PROF.

VIRGINIA PLUMMER (Orcid ID : 0000-0003-3214-6904)

PROF. JINGPING ZHANG (Orcid ID : 0000-0003-1136-3993)

Accepted Article
Article type : Original Article

Burnout and its association with resilience in nurses: a cross-sectional study

Nurse burnout and resilience

Yu-fang Guo, Yuan-hui Luo, Louisa Lam, Wendy Cross, Virginia Plummer and Jing-ping

Zhang

Yu-Fang Guo, PhD, RN, College of Nursing, HeBei University, Baoding, Hebei, China;

Yuan-hui Luo, RN, Nursing Psychology Research Center of Xiangya Nursing School, Central

South University, Changsha, Hunan, China;

Louisa Lam, PhD, RN, BNSc, MPH, Lecture, School of Nursing and Midwifery, Faculty of

Medicine, Nursing and Health Sciences, Monash University, Melbourne Victoria, Australia;

Wendy Cross, PhD, Med, RN, Professor, Associate Dean, Faculty of Medicine, Nursing and

Health Sciences, Monash University, Melbourne Victoria, Australia;

Virginia Plummer, PhD, RN, BN, Associate Professor, Faculty of Medicine, Nursing and

Health Sciences, Monash University, Melbourne Victoria, Australia;

Jing-Ping Zhang, PhD, RN, Professor, Associate Dean, Nursing Psychology Research Center

of Xiangya Nursing School, Central South University, Changsha, Hunan, China.

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/jocn.13952
This article is protected by copyright. All rights reserved.
 *Correspondence: Jing-Ping Zhang, PhD, RN, Professor, Associate Dean, Nursing
Accepted Article Psychology Research Center of Xiangya Nursing School, Central South University, 172 Tong

Zi Po Road, Changsha 410013, Hunan, China. Email: jpzhang1965@163.com Telephone: +

86 731 82650264; fax: + 86 731 82650266.

Acknowledgement

The authors thank the participating hospitals and nurse participants, and also head nurses and

directors of hospitals for their assistance.

Funding

This study received no funding from any agency in the public, commercial or not-for-profit

sectors.

Conflict of interest

No conflict of interest has been declared by the authors.

Contributions

Study design: YFG, JPZ;

Data collection and analysis: YFG, YHL, LL, WC, VP;

Manuscript preparation: YFG, YHL, LL, WC, VP, JPZ.

This article is protected by copyright. All rights reserved.

 Abstract
Accepted Article
Aims and objectives. To investigate the prevalence and extent of burnout on nurses and its

association with personal resilience.

Background. With the worldwide shortage of nurses, nurse burnout is considered one of the

main contributing factors and has been the focus of studies in recent years. Given the well-

documented high level of burnout among nurses, resilience is expected to be a significant

predictor of nurse burnout. The association between burnout and resilience has not previously

been investigated extensively.

Design. A cross-sectional survey design was selected.

Methods. 1061 nurses from 6 separate three-level hospitals in Hunan Province, China

returned self-reported questionnaires from March to June 2015. Data were collected using a

socio-demographic sheet, Maslach Burnout Inventory-General Survey (MBI-GS) and the

Connor-Davidson Resilience Scale (CD-RISC).

Results. Nurses experienced severe burnout symptoms and showed a moderate level of

resilience. Three metrics of burnout had significantly negative correlations with the total

score and following variables of resilience. Linear regression analysis showed resilience,

especially strength, demographic characteristics (exercise, alcohol use and marital status) and

job characteristics (income per month, ratio of patients to nurses, shift work and professional

rank) were the main predictors of the three metrics of burnout.

Conclusion. The findings of this study may help nurse managers and hospital administrators

to have a better understanding of nurse burnout and resilience. The significantly negative

relationship between burnout symptoms and resilience has been demonstrated, and this

informs the role of resilience in influencing burnout.

This article is protected by copyright. All rights reserved.

 Relevance to clinical practice. Adaptable and effective interventions for improving
Accepted Article resilience are needed to relieve nurses’ burnout and reduce workplace stress. Moreover, nurse

managers and hospital administrators should establish an effective management system to

cultivate a healthy workplace, adopt positive attitudes and harmonious relationships.

Key words: burnout, nurse, nurse practitioners, nursing, resilience, stress

What does this paper contribute to the wider global clinical community?

• This study demonstrates that Chinese nurses experience severe burnout syndrome and

show a moderate level of resilience.

• Level of nurse burnout may be alleviated by promoting factors that affect nurses’

burnout as identified in this study.

• Nursing managers and hospital administrators should take effective measures to

cultivate nurses’ resilience, improve their work conditions and help them live a

healthy life.

Introduction

Globally, the current widespread shortage in nursing and the high level of burnout have

received great attention from nurse managers and researchers for the past three decades

(Poghosyan et al. 2010). A large number of studies have attempted to explore the significant

predictors that can explain burnout variation among nurses, such as job stress, work-family

conflict, working environment and personality characteristics (Leineweber et al. 2014, Emold

This article is protected by copyright. All rights reserved.

 et al. 2011). Burnout affects not only nurses’ job satisfaction and performance, but also the
Accepted Article quality of clinical care and patients’ well-being (Van Bogaert et al. 2013a).

Although there have been numerous studies on the predictors of nurse burnout around

the world, e.g. America (Cimiotti et al. 2012), Europe (Van Bogaert et al. 2013b), Australia

(Singh et al. 2015), Japan (Sasaki et al. 2009). There is limited knowledge of the association

between burnout and resilience among nurses worldwide, especially in mainland China. The

purpose of the study was to explore the levels of burnout and resilience among Chinese

nurses, and describe the relationship between these two variables.

Background

Burnout is defined as a psychological syndrome of emotional exhaustion, cynicism and

reduced professional efficacy, which is experienced in response to chronic job stressors

(Schaufeli et al. 1996). Studies show that nursing is one of the human service professions

especially susceptible to the burnout syndrome worldwide (Gascon et al. 2013). There is

evidence that nurses have a high level of burnout symptoms. McHugh et al. (2011) examined

survey data from 95,499 American nurses and found high job dissatisfaction and burnout

among nurses who were directly caring for patients in hospitals and nursing homes.

Laschinger et al. (2009) investigated 612 Canadian staff nurses and found that 47.3% of staff

nurses experienced severe burnout symptoms. Kitaoka and Masuda (2013) reviewed studies

in Japan and summarised that approximately 36% of human services professionals, such as

nurses, exhibited burnout compared to 18% of civil servants, and 12% of company

employees.

In mainland China, the rate of nurse burnout is also high across the nation. Zhou et al.

(2015) investigated 1100 nurses from Hunan province and found that 34.9% had burnout

symptoms, which was similar to the percentage of nurses nationwide (35.5%). Liu et al.

This article is protected by copyright. All rights reserved.

 (2012) conducted a study with 1104 Chinese nurses and reported that 37% of nurses
Accepted Article experienced a high level of burnout. Burnout is now becoming a common and serious

problem which can lead to ill health for nurses, lower job satisfaction, and higher nursing

staff turnover and as a consequence, reduced quality of clinical care for patients (Schaufeli &

Buunk 2003). Oyeleye et al. (2013) found that nurse burnout has a significant relationship

with workplace incivility, turnover intention, health, help-seeking behaviours, life satisfaction

and self-esteem. Understanding nurse burnout and related factors has become critical for

nurse managers and hospital administrators.

Numerous studies were conducted to explore the influencing factors on nurse burnout.

According to Maslach et al. (2001), two groups of factors that appear to be associated with

burnout are situational factors, including job characteristics, occupational characteristics and

organizational characteristics, and individual factors, including demographic characteristics,

personality characteristics and work attitudes. Studies have shown that despite the significant

impact of situational factors (e.g. experience, workload and role conflict), individual factors

(e.g. age, marital status and personality characteristics) contributed as unique qualities to

nurse burnout (Khamisa et al. 2015). Some studies have found that the types of personality

characteristics could indicate which kinds of people may be more susceptible to burnout

(Alarcon et al. 2009).

Personal resilience is considered as a dynamic process that can positively adjust to

adversity and moderate potential damages due to harmful events (Norris et al. 2008, Jackson

et al. 2007). The ability to maintain good functioning after stress exposure appears more

common than previously thought (Bonanno 2004). Empirical evidence shows that resilience

could help individuals adopt coping strategies to minimize distress (Mallak 1998) and

develop problem-solving skills (Rushton et al. 2016). Several studies suggest that resilience is

the resource of an individual to move on in a productive way from traumatic or stressful

This article is protected by copyright. All rights reserved.

 experiences (Tugade & Fredrickson 2004). Research on resilience in nurses shows that it is a
Accepted Article necessary quality for overcoming the negative effects of workplace adversity and challenges

through the development of personal strengths (Tusaie & Dyer 2004). Resilience is found to

protect against work-related stress and a crucial component for nurses’ well-being and mental

and physical health (McDonald et al. 2013).

Several studies have been conducted to investigate the relationship between resilience

and burnout, however, few involved nurses (Moon et al. 2013, Mealer et al. 2014). Nurse

burnout is not simply an organisational challenge or an issue for policy makers. It has become

a global issue. Understanding nurse burnout and its association with resilience is an important

way to improve the mental and physical health among nurses and the quality of clinical care

provided to patients. To our knowledge, few studies have been conducted to explore the

influencing function of resilience on nurse burnout in mainland China.

According to the psychological stress system (Jiang, 1993), job stress is considered as a

stressor, which could lead to nurse burnout. During this process, several individual and

environmental factors (e.g. personality, self-efficacy, social support) intermediate the

function of stress on burnout. In this study, burnout is recognized as a stress-related

psychological change, and resilience is treated as an individual characteristic. The aims of the

study were to explore the states of burnout and resilience and the influence of resilience on

burnout in Chinese nurses by using a large sample size and standard measurements.

This article is protected by copyright. All rights reserved.

 Methods
Accepted Article
Study design

The aim of this study was to investigate the relationship between burnout and resilience

among nurses in mainland China. A cross-sectional survey design was used in this study.

This study is part of a larger study on the relationship among stress, resilience and burnout

and results on stress will be reported elsewhere.

Study population and sample

A convenience sample of nurses was recruited from six third-level hospitals in Hunan

province. In mainland China, hospitals are classified as three levels based on their staffing,

equipment and technology. The higher the level, the more sophisticated the facility. In this

study, three hospitals were located in a provincial capital city and three hospitals were located

in prefecture level cities. All six hospitals were general hospitals. The inclusion criteria were:

(1) registered nurses or licensed practical nurses; (2) who provided direct care to residents; (3)

and were Chinese speakers. According to the inclusion criteria, head nurses and directors

from each hospital gave permission to recruit nurses. After the study information session,

nurses who had interests in participating could contact the researchers to participate in the

study. Data were collected from March to June 2015.Three trained researchers distributed

1400 questionnaires to clinical nurses, of which 1061 completed the questionnaire. This

equated to a response rate of 75.78%.

This article is protected by copyright. All rights reserved.

 Instruments
Accepted Article
The questionnaires contained a socio-demographic section, Maslach Burnout Inventory-

General Survey (MBI-GS) and the Connor-Davidson Resilience Scale (CD-RISC).

Socio-demographic variables included age, gender, highest education level, marital

status, children, income per month, shift work, employment type, length of service,

professional rank, cigarette use, alcohol use, exercise, the name of the department, the

number of nurses and beds in their department.

Nurses’ job burnout was measured by MBI-GS. This scale was developed by Maslach

and Jackson (1981) and consists of 16 items over three metrics: emotional exhaustion (five

items), cynicism (five items) and reduced professional efficacy (six items). The items were

scored on a Likert scale from 0 (never) to 6 (everyday) (Schaufeli et al. 1996). The MBI-GS

does not compute a total score for burnout to reflect the burnout state. The higher the scores

on the three metrics, the higher level of burnout indicated. The Chinese version of the MBI-

GS, developed by Li & Shi (2003), also has a good validity and reliability. In this study,

Cronbach alpha coefficients for EE, CY and RPE were 0.93, 0.83 and 0.82, respectively.

The CD-RISC was used to measure nurses’ resilience level (Connor & Davidson 2003).

This scale comprises 25 items over three metrics (tenacity, strength and optimism) that assess

resilience or capacity to change and cope with adversity. Nurses were asked to rate each item

with reference to the previous month. A 5-point Likert scale was used (0 = not true at all, 4 =

true all the time). The total score ranges from 0 to 100, with higher scores indicating higher

levels of resilience. The Cronbach alpha coefficients of the Chinese version were 0.91 for the

total score, 0.88, 0.80 and 0.60 for the three factors (Yu & Zhang 2007). In this study, the

Cronbach alpha coefficients of resilience and its three metrics were 0.921, 0.869, 0.833 and

0.597, respectively.

This article is protected by copyright. All rights reserved.

 Ethical consideration
Accepted Article
Ethical approval was obtained from the Institutional Review Board (IRB) of Xiangya Nursing

School, Central South University. The objectives and procedures were explained to the

participants. They were assured that participation in this study was voluntary and anonymous,

and declining to participate would not have any impact on their work and life. All data were

held secure, confidential and accessed only by the research team.

Data analyses

SPSS 23.0 and Amos 23.0 (SPSS Inc., Chicago, IL, USA) were used for data analysis. The

scores for burnout symptoms, resilience and its metrics showed normal distributions

(checked by Kolmogorov-Smirnov test). Descriptive statistics, including frequency,

percentage, mean and standard deviations, were used to analyse the demographic

characteristics, burnout and resilience. Correlations between burnout and resilience were

tested by Pearson correlation. Multiple Linear regression analysis was used to identify the

influence of resilience and other socio-demographic variables on burnout. Stepwise

regression analysis was used to minimize the multicollinearity effect. Harman’s single factor

analysis and the confirmatory factor analysis were used to test the common methods

variance. All statistical tests were two-sided (α=0.05).

Results

Characteristics of participants

As stated, a total of 1061 nurses participated in the survey. Nearly all were female (97.7%),

the mean age was 29.34 years (SD 6.17), and the mean length of service was 8.13 years (SD

6.99). Participants represented many specialty departments (Table 1). Almost two-thirds

This article is protected by copyright. All rights reserved.

 (691/1061) of nurses reported the ratio of patients to nurses in their departments was higher
Accepted Article than 10:4. Other socio-demographic characteristics are shown in Table 2.

Descriptive results of burnout and resilience

As shown in Table 3, the mean scores for emotional exhaustion, cynicism and reduced

professional efficacy were 2.56 (SD 1.26), 2.20 (SD 1.14), 2.18 (SD 1.12), respectively. The

average total score for resilience was 63.77 (SD 12.80), and the mean scores for tenacity,

strength and optimism were 32.12 (SD 7.20), 21.89 (SD 4.51), 9.76 (SD 2.42), respectively,

suggesting that, generally, nurses had a moderate level of resilience.

Correlations between burnout and resilience

Correlations between burnout and resilience are detailed in Table 4. The total score and

following variables (tenacity, strength and optimism) of resilience showed significant

relationships with emotional exhaustion, cynicism and reduced professional efficacy

(p<0.001). Increasing the scores of resilience and its metrics were negatively correlated with

burnout symptoms, however the correlations were weak, with all of the values for the

correlation coefficients between 0.2 and 0.4 (Hu et al 2004).

The linear regression results among burnout, resilience and socio-demographic

variables

In this study, the three metrics of burnout comprised the dependent variables, while the

social-demographic variables, resilience and its three metrics comprised the independent

‘
variables. Stepwise regression analysis was used and the values for the alpha to enter and ’
‘ the alpha to remove ’ were 0.05 and 0.10, respectively. Table 5 shows the linear
regression results for the association among burnout, resilience and socio-demographic

characteristics. Results indicate that a low level of strength, little exercise, low income, a high

ratio of beds to nurses, shift work, separation or divorce and alcohol use were the main

This article is protected by copyright. All rights reserved.

 predictors of a high level of emotional exhaustion (F=19.204, p<0.001, R2=0.114, adjusted
Accepted Article R2=0.109), 10.9% of the variance in emotional exhaustion was explained by strength,

exercise, income, ratio of beds to nurses, shift work, marital status and alcohol use; a low

score for resilience, little exercise and shift work were the main predictors of a high level of

cynicism (F=44.988, p<0.001, R2=0.114, adjusted R2=0.112), 11.2% of the variance in

cynicism was explained by resilience, exercise and shift work; low levels of strength and

professional rank were the main predictors of a high level of reduced professional efficacy

(F=73.014, p<0.001, R2=0.123, adjusted R2=0.121), 12.1% of the variance in reduced

professional efficacy was explained by strength and professional rank.

Harman’s single factor analysis and the confirmatory factor analysis about the common

method variance

Common method variance is defined as the variance that is attributable to the measurement

method rather than to the construct of interest (Bagozzi & Yi 1991). Studies show that

common method variance is a potential problem in cross-sectional studies (Podsakoff et al.

2003, Krishnaveni & Deepa 2013). Thus, the Harman’s single factor analysis and the

confirmatory factor analysis were used to test the common method variance in this study. The

Harman’s single factor analysis was used to check whether variance in the data could be

largely attributed to a single factor (Chang et al. 2010), while the confirmatory factor analysis

was used to test whether the factors were related to the measures (Kline 2010).

Factor analysis showed that only 23.0 % of the variance could be explained by a single

factor, which was less than 50.0%, thus the data did not suffer from the common method

variance. Moreover, the confirmatory factor analysis showed that the single-factor model did

not fit the data well, χ2=1597.2, P<0.001, Goodness-of-Fit Index (GFI) =0.851, Comparative

This article is protected by copyright. All rights reserved.

 Fit Index (CFI) =0.835, Tucker-Lewis Index (TLI) =0.811, Standardized Root Mean-square
Accepted Article Residual (SRMR) =0.0749, Root Mean Square Error of Approximation (RMSEA) =0.102.

The results of these two analyses suggest that the common method variance does not

confound the interpretation of the results.

Discussion

Given that the worldwide challenge of nurse burnout leads to a nursing shortage, the findings

of this study provided an alternative way to relieve nurse burnout. In this study, resilience,

especially strength, showed a strong relationship with burnout, which enriches the existing

knowledge about the influencing factors of burnout.

Status of burnout and resilience

Throughout this study, the scores of emotional exhaustion, cynicism, reduced professional

efficacy were slightly higher than those in other studies (Hansen et al. 2009, Laschinger et al.

2009). Compared with the Chinese norm (Li & Shi 2003) (EE: 2.16, CY: 1.45, RPE: 1.84),

there was a significant difference in each metric (p<0.001), the scores of EE, CY, RPE in this

study were higher. Compared with the European norm (EE: 1.48, CY: 1.48), scores on EE,

CY in this study were also significantly higher (p<0.001) (Schutte et al. 2000). According to

the comparison, burnout in the Chinese nurses has worsened in recent years. This might have

some relationship with the severe nursing shortage in China and the increasing workload in

public hospitals. China’s Ministry of Health (2003) reported that the number of registered

nurses was 10:10,000 population from 1997 to 2002, while this number was 83:10,000 in

Australia and 74.49:10,000 in Japan at the same time (WHO 2002, Zeng 2009). Despite the

fact that China cultivated thousands of nurses over these years, the nursing shortage is an

obvious problem. Moreover, under the critical requirement of Chinese health policy and the

ever-increasing number of patients, Chinese nurses need more time and capacity to cope with

This article is protected by copyright. All rights reserved.

 clinical workloads. In addition, there are no casual or on-call nurses for sick leave and
Accepted Article holiday relief (Zhou et al. 2015). These factors affect their enthusiasm for work and the work-

family relationship, which can cause burnout and a decline in the quality of clinical care.

The findings of this study showed that nurses had a moderate level of resilience, with the

average total score for resilience 63.77 (SD 12.80). Similar results were reported in studies

undertaken in other countries. Hegney et al. (2015) reported that the mean score for resilience

for Australian nurses was 70.02, somewhat lower than nurse leaders and community samples.

Mealer et al. (2012) found that over 70% of nurses have a moderate level of resilience in

America. Previous research has also predicted that improving the resilience state of nurses

will result in increasing job satisfaction, serving to ameliorate the international nursing

turnover rate (Hart et al. 2014). In China, the ongoing challenges, demands and frustrations

that impact nurses each day often cause adverse effects, such as reduced nursing efficiency,

poor quality of care and decreased job performance. Therefore, nurse managers need to

implement managerial interventions, such as education about resilience and constructing a

harmonious and healthy working environment, to improve nurses’ resilience skills and

behaviours in response to heavy workloads.

Predictors of burnout

In this study, resilience, especially strength, showed a significant association with emotional

exhaustion, cynicism and reduced professional efficacy. Resilience has been referred to as the

ability of individuals to bounce back or cope successfully despite adverse circumstances

(Rutter 2008). The development of resilience among nurses has been associated with

increased quality of life, better health and effective use of adaptive coping strategies

(Gillespie et al. 2007). Strength is defined as a dimension of resilience focusing on the

individual’s capacity for recovering and becoming strong after setbacks and past experiences

This article is protected by copyright. All rights reserved.

 (Yu & Zhang 2007). Studies show that strength, as stress-related growth in health psychology
Accepted Article and positive psychology, reflects the process of disruption-reintegration (Frazier et al. 2004).

Nurses who have a high level of strength usually regard change as a normal part of life rather

than as a threat to life. They achieve new integration and further growth positively and

develop less burnout after striving against adverse work experiences.

Demographic characteristics including exercise, alcohol use and marital status also

significantly influenced nurses’ emotional exhaustion and cynicism. Studies have found that

physical exercise offers well-recognised cardiovascular, metabolic effects that improve self-

esteem, self-knowledge of body image, cognitive functions and socialization, as well as

reduction of stress and anxiety (Paluska & Schwenk 2000). Chen (2004) reported that

participating in a physical activity program could reduce nurses’ physical and emotional

stress, avoid burnout and remain active in clinical practice much longer. Alcohol

consumption is considered as a negative coping strategy towards hardiness and frustration.

Studies report that substance abuse (e.g. alcohol, cigarettes) among health care professionals

has a strong relationship with depression and burnout (Cares et al. 2015). Severe and

persistent alcohol consumption could impact nurses’ lifestyles, work schedules and affect

their job performance and quality of clinical care. It appears that a harmonious relationship

between nurses and their partners provides important support for nurses as they deal with

stress or difficulty. Button (2008) reported that social support from family members, friends

or society could moderate the relationships among health care-related occupational stress and

the mental-physical health of nurses, and good social support resulted in an enjoyable quality

of life and positive attitudes towards work.

Moreover, the results of this study showed that some job related characteristics, such as

income, professional rank, the ratio of patients to nurses and shift work, were predictors of

nurses’ emotional exhaustion, cynicism and reduced professional efficacy. Empirical studies

This article is protected by copyright. All rights reserved.

 have identified that low income and professional rank, high ratios of patients to nurses, and
Accepted Article frequent shift work were the main causes of nurses’ job stress (Garcia-Izquierdo & Rios-

Risquez, 2012). The more stressors in nurses’ working lives, the more burnout is caused.

Maslach et al. (2001) concluded that burnout is a prolonged response to chronic emotional

and interpersonal stressors on the job. Studies show that effective interventions in reducing

nurses’ job stress could lighten their burnout and improve job satisfaction and quality of care

(Frogeli et al. 2016). It is clear that nurse managers need to take these job characteristics into

account when they implement effective measures to prevent or alleviate nurse burnout.

Limitations of the study

Three critical limitations are noted in this study. First, because of the cross-sectional study

design, it is not intended to understand causal relationships. Second, a convenience sample

was used in this study, resulting in findings that may not necessarily be representative. Third,

the study sample was only selected from Hunan province, which may limit the generalisation

of the findings. A wider geographical range is recommended. It is also recommended that

future studies be conducted by using longitudinal research methods and randomized sampling.

Conclusion

This study provides empirical evidences regarding burnout and resilience among Chinese

nurses. The findings of this study can enrich our knowledge of the role of resilience in

influencing nurse burnout at a cross-sectional level. In this study, resilience, especially

strength, and some demographic (exercise, alcohol use and marital status) and job

characteristics (income per month, ratio of patients to nurses, shift work and professional

rank) were the main predictors of burnout symptoms. In order to alleviate nurse burnout

effectively, nurse managers should note the value of resilience and take effective

management to increase nurse resilience. Moreover, establishing a positive working condition

This article is protected by copyright. All rights reserved.

 and advocating a healthy life style are also recommended. The more improvements that can
Accepted Article be implemented, the fewer nurses will experience burnout.

Relevance to clinical practice

To date, concern about alleviating burnout for nurses is growing. This study suggests that

nurses in China have high levels of burnout and moderate levels of resilience. Improving

resilience and job factors, cultivating a healthy life style as well as enjoying harmonious

relationship with family and friends will lead to a reduction in burnout. Nurse Managers and

hospital administrators should take measures to cultivate nurses’ resilience (e.g. learning

healthy coping strategies, adopting positive attitudes and using positive language). Moreover,

they need to develop new and useful workforce management strategies to decrease the

frequency of work shifts and the ratio of patients to nurses. An incentive system is also

needed to stimulate nurses. In addition, education about social communication strategies and

developing healthy behaviours should be considered. For nurse managers, formulating an

effective management system is also important in relieving nurse burnout.

References

Alarcon G, Eschleman KJ & Bowling NA (2009) Relationship between personality

variables and burnout:a meta-analysis. Work & Stress 23(3), 244-263.

Bagozzi RP & Yi Y (1991) Multitrait-multimethod matrices in consumer research. Journal of

Consumer Research, 17,426-439.

Bonanno GA (2004) Loss, trauma, and human resilience. American Psychologist 59, 20-28.

Button L (2008) Effect of social support and coping strategies on the relationship between

health care related occupational stress and health. Journal of Research in Nursing 13(6),

498-524.

This article is protected by copyright. All rights reserved.

 Cares A, Pace E, Denious J & Crane LA (2015) Substance use and mental illness among
Accepted Article nurses: workplace warning signs and barriers to seeking assistance. Substance Abuse 36,

59-66.

Chang SJ, van Witteloostujin A & Eden L (2010) From the editors: common method variance

in international business research. Journal of International Business Studies 41(2), 178-

184.

Chen T (2004) A study of stress, regular physical activity and health-related fitness of

nursing school students in south Taiwan. Spalding University, Doctoral Dissertation.

Cimiotti JP, Aiken LH, Sloane DM & Wu ES (2012) Nurse staffing, burnout, and health

care-associated infection. American Journal of Infection Control 40(6), 486-490.

Connor KM & Davidson JRT (2003) Development of a new resilience scale: the Connor-

Davidson Resilience Scale (CD-RISC). Depress and Anxiety 18(2), 76-82.

Emold C, Schneider N, Meller I & Yagil Y (2011) Communication skills, working

environment and burnout among oncology nurses. European Journal of Oncology

Nursing 15(4), 358-363.

Frazier P, Tashiro T, Berman M, Steger M & Long J (2004) Correlates of levels and patterns

of posttraumatic growth among sexual assault survivors. Journal of Consulting and

Clinical Psychology 72, 19-30.

Frogeli E, Djordjevic A, Rudman A, Livheim F & Gustavsson P (2016) A randomized

controlled pilot trial of acceptance and commitment training (ACT) for preventing

stress-related ill health among future nurses. Anxiety, Stress & Coping: An International

Journal 29(2), 202-218.

This article is protected by copyright. All rights reserved.

 Garcia-Izquierdo M & Rios-Risquez MI (2012). The relationship between psychosocial job
Accepted Article stress and burnout in emergency departments: an exploratory study. Nursing Outlook

60(5), 322-329.

Gascon S, Leiter MP, Andr´es E, Santed MA, Pereira JP, Cunha MJ, et al (2013) The role of

aggressions suffered by healthcare workers as predictors of burnout. Journal of Clinical

Nursing 22(21–22), 3120–3129.

Gillespie BM, Chaboyer W, Wallis M & Grimbeck P (2007) Resilience in the operating room:

developing and testing of a resilience model. Journal of Advanced Nursing 59,427-438.

Hansen N, Sverke M & Nᾶswall K (2009) Predicting nurse burnout from demands and

resources in three acute care hospitals under different form of ownership: a cross-

sectional questionnaire survey. International Journal of Nursing Studies 46, 96-107.

Hart PL, Brannan JD & Chesnay MD (2014) Resilience in nurses” an integrative review.

Journal of Nursing Management 22, 720-734.

Hegney DG, Rees CS, Eley R, Osseiran-Moisson R & Francis K (2015) The contribution of

individual psychological resilience in determining the professional quality of life of

Australia nurses. Frontiers in Psychology 6, 1-8.

Hu LP, Liu HG, Li ZJ & Mao JD (2004) Research design and statistical analysis of

laboratory medicine. Bei Jing, People’s Military Medical Press.

Jackson D, Firtko A & Edenborough M (2007) Personal resilience as a strategy for surviving

and thriving in the face of workplace adversity: a literature review. J Adv Nurse 60, 1-9.

Jiang, Q.J., 1993. Medical Psychology. China Science Publishing & Media Ltd, Beijing.

This article is protected by copyright. All rights reserved.

 Khamisa N, Oldenburg B, Peltzer K & Ilic D (2015) Work related stress, burnout, job
Accepted Article satisfaction and general health of nurses. International Journal of Environmental

Research and Public Health 12, 652-666.

Kitaoka K & Masuda S (2013) Academic report on burnout among Japanese nurses. Japan

Journal of Nursing Science 10, 273-279.

Kline RB (2010) Principles and practice of structural equation modelling (3 rd ed.). New

York, New York: Guildford Press.

Krishnaveni R & Deepa R (2013) Controlling common method variance while measuring the

impact of emotional intelligence on well-being. Vikalpa, 38(1),41-47.

Laschinger SHK, Leiter M, Day A & Gilin D (2009) Workplace empowerment, incivility,

and burnout: impact on staff nurse recruitment and retention outcomes. Journal of

Nursing Management 17,302-311.

Leineweber C, Westerlund H, Chungkham H, Lindqvist R, Runesdotter S & Tishelman C

(2014) Nurses’ practice environment and work-family conflict in relation to burnout: a

multilevel modelling. PLoS One 9(5), 1-9.

Li CP & Shi K (2003) The influence of distributive justice and procedural justice on job

burnout. ACTA Psychological Sinica 35(5), 677-683.

Liu K, You LM, Chen SX, Hao YT, Zhu XW, Zhang LF & Aiken LH (2012) The

relationship between hospital work environment and nurse outcomes in Guangdong,

China: a nurse questionnaire survey. Journal of Clinical Nursing 21, 1476-1485.

Mallak LA (1998) Measuring resilience in health care provider organizations. Health

Manpow Manage 24(4-5), 148-152.

This article is protected by copyright. All rights reserved.

 Maslach C & Jackson SE (1981) The measurement of experienced burnout. J Occup Behav 2,
Accepted Article 99-103.

Maslach C, Schaufeli WB & Leiter MP (2001) Job burnout. Annu. Rev. Psychol. 52, 397-422.

McDonald G, Jackson D, Wilkes L & Vickers HM (2013) Personal resilience in nurses and

midwives: effects of a work-based educational intervention. Contemporary Nurse: A

Journal of the Australian Nursing Profession 45(1), 134-143.

McHugh MD, Kutney-Lee A, Cimiotti JP, Sloane DM & Aiken LH (2011) Nurses’

widespread job dissatisfaction, burnout, and frustration with health benefits signal

problems for patient care. Health Affairs (Millwood) 30(2), 202-10.

Mealer M, Conrad D, Evans J, Jooste K, Solyntjes J, Rothbaum B & Moss M (2014)

Feasibility and acceptability of a resilience training program for intensive care unit

nurses. American Journal of Critical Care 23(6),e97-e105.

Mealer M, Jones J, Newman J, McFann KK, Rothbaum B & Moss M (2012) The presence of

resilience is associated with a healthier psychological profile in intensive care unit (ICU)

nurses: results of a national survey. International Journal of Nursing Studies 49(3), 292-

299.

Moon IO, Park SK & Jung JM (2013) Effects of resilience on work engagement and burnout

of clinical nurses. J Korean Acad Nurs Adm 19(4),525-535.

Norris FH, Stevens SP, Pfefferbaum B, Wyche KF & Pfefferbaum RL (2008) Community

resilience as a metaphor, theory, set of capacities, and strategy for disaster readiness. Am

J Community Psychol 41, 127-150.

This article is protected by copyright. All rights reserved.

 Oyeleye O, Hanson P, O’Connor N & Dunn D (2013) Relationship of workplace incivility,
Accepted Article stress, and burnout on nurses’ turnover intentions and psychological empowerment. The

Journal of Nursing Administration 43(10), 536-542.

Paluska SA & Schwenk TL (2000) Physical activity and mental health. Sports Med. 29(3),

167-180.

Podsakoff PM, MacKenzie SB, Podsakoff NP & Lee JY (2003) Common method biases in

behavioural research: a critical review of the literature and recommended remedies.

Journal of Applied Psychology, 88(5),879-903.

Poghosyan L, Clarke PS, Finlayson M & Aiken HL (2010) Nurse burnout ad quality of care:

cross-national investigating in six countries. Research in Nursing & Health 33, 288-298.

Rushton CH, Batcheller J, Schroeder K & Donohue P (2016) Burnout and resilience among

nurses practicing in high-intensity settings. American Journal of Critical Care 24(5),

412-420.

Rutter M (2008) Developing concepts in developmental psychopathology. In Developmental

Psychopathology and Wellness: Genetic and Environmental Influences (J.J. Hudziak

ed.), pp.3-22. American Psychiatric Publishing, Washington, DC.

Sasaki M, Kitaoka-Higashiguchi K, Morikama Y & Nakagawa H (2009) Relationship

between stress coping and burnout in Japanese hospital nurses. Journal of Nursing

Management 17, 359-365.

Schaufeli WB & Buunk BP (2003) Burnout: an overview of 25 years of research and

theorizing. In: Schabracq M.J., Winnubst J.A.M. & Cooper C.L., editors. Handbook of

Work and Health Psychology. Wiley: Chichester. pp. 383–425.

This article is protected by copyright. All rights reserved.

 Schaufeli WB, Leiter MP, Maslach C & Jackson SE (1996) Maslach Burnout Inventory-
Accepted Article General Survey (MBI-GS). In MBI Manual. 3rd edition. Edited by Maslach C., Jackson

S.E. & Leiter M.P., Palo Alto CA: Consulting Psychologists Press 19-26.

Schutte N, Toppinen S, Kalimo R & Schaufeli W (2000) The factorial validity of the Maslach

Burnout Inventory-General Survey (MBI-GS) across occupational groups and nations.

Journal of Occupational and Organizational Psychology 73(1), 53-66.

Singh C, Cross W & Jackson D (2015) Staff burnout- a comparative study of metropolitan

and rural mental health nurses within Australia. Issue in Mental Health Nursing 36(7),

528-537.

Tugade M & Fredrickson B (2004) Resilience individuals use emotions to bounce back from

negative emotional experiences. Journal of Personality and Social Psychology 86, 320-

333.

Tusaie K & Dyer J (2004) Resilience: a historical review of the construct. Holistic Nursing

Practice 18, 3-10.

Van Bogaert P, Clarke S, Wouters K, Franck E, Willems R & Mondelaers M (2013a) Impacts

of unit-level nurse practice environment, workload and burnout on nurse-reported

outcomes in psychiatric hospitals: a multilevel modelling approach. International

Journal of Nursing Studies 50(3), 357-365.

Van Bogaert P, Kowalski C, Weeks SM, Van Heusden D & Clarke SP (2013b)The

relationship between nurse practice environment, nurse work characteristics, burnout

and job outcome and quality of nursing care: a cross-sectional survey. International

Journal of Nursing Studies 50, 1667-1677.

This article is protected by copyright. All rights reserved.

 World Health Organization (WHO) (2002) Imbalances in the health workforce: briefing
Accepted Article paper. Retrieved fro, http://www.who.int/hrh/documents/en/imbalances_briefing.pdf. On

18 February 2016.

Yu XN & Zhang JX (2007) Factor analysis and psychometric evaluation of the Connor-

Davidson Resilience Scale (CD-RISC) in Chinese people. Social Behavior and

Personality 35(1), 19-30.

Zeng Y (2009) Review of working-related stress in mainland Chinese nurses. Nursing &

Health Sciences 11(1), 90-97.

Zhou WJ, He GP, Wang HH, He Y, Yuan Q & Liu D (2015) Job dissatisfaction and burnout

of nurses in Hunan China: a cross-sectional survey. Nursing & Health Sciences 17, 444-

450.

Table 1 Nursing departments (N=1061)

Departments N (%)

Medical 302(28.5%)

Surgical 319 (30.1%)

Gynecology 97(9.1%)

Paediatric 57(5.4%)

Outpatient services 51 (4.8%)

Emergency departments 75 (7.1%)

Operating room 76 (7.2%)

ICU 84 (7.9%)

This article is protected by copyright. All rights reserved.

 Table 2 Socio-demographic characteristics (N=1061)
Accepted Article
Socio-demographic characteristics M (SD)/N (%)

Age 29.34 (6.17)

The length of service 8.13 (6.99)

Gender

Male 24(2.3%)

Female 1037(97.7%)

Highest education level

Diploma 6 (0.6%)

Associate degree 214 (20.2%)

Bachelor degree 805 (75.9%)

Master degree 34 (3.2%)

Doctoral degree 2 (0.2%)

Marital status

Single 424 (40.0%)

Married 624 (58.8%)

Divorced or separated 12 (1.1%)

Widowed 1 (0.1%)

Have any children

No 531 (50.0%)

Yes 530 (50.0%)

Income per month

< 3000 yuan (US, $500) 156 (14.7%)

3001-5000 yuan (US, $500-$ 830) 497 (46.8%)

This article is protected by copyright. All rights reserved.

 5001-7000 yuan (US, $830-$ 1160) 292 (27.5%)
Accepted Article 7001-9000 yuan (US, $1160-$ 1500) 87 (8.2%)

>9001 yuan (US, $1500) 29 (2.7%)

Shift work

No 218 (20.5%)

Yes 843 (79.5%)

Employment type

Formal employed nurse 415 (39.1%)

Personal agent nurse 378 (35.6%)

Contract employed nurse 268 (25.3%)

Professional rank

Junior RN 324 (30.5%)

Senior RN 479 (45.1%)

Nurse in charge 218 (20.5%)

Associate professor nurses 40 (3.8%)

Cigarette use

No 1043 (98.3%)

Yes 18 (1.7%)

Alcohol use

No 1014 (95.6%)

Yes 47 (4.4%)

Exercise

No 556 (52.4%)

Yes 505 (47.6%)

This article is protected by copyright. All rights reserved.

 Table 3 Mean and standard deviations of variables of nurse burnout and resilience (N=1061)
Accepted Article
Variables M SD Min. Max.

Burnout

Emotional exhaustion 2.56 1.26 0.00 6.00

Cynicism 2.20 1.14 0.00 6.00

Reduced professional efficacy 2.18 1.12 0.00 5.50

Resilience

Tenacity 32.12 7.20 0.00 52.00

Strength 21.89 4.51 3.00 32.00

Optimism 9.76 2.42 2.00 16.00

The total score 63.77 12.80 8.00 99.00

This article is protected by copyright. All rights reserved.

 Table 4 Pearson’s correlations (P-values) between nurse burnout and resilience (N=1061)
Accepted Article
Emotion Cynicism Reduced Tenacity Strength Optimism The total

exhaustion professional score

efficacy

Emotion exhaustion 1.000

Cynicism 0.653 1.000

(P<0.001)

Reduced professional efficacy 0.083 0.129 1.000

(P=0.007) (P<0.001)

Tenacity -0.229 -0.285 -0.272 1.000

(P<0.001) (P<0.001) (P<0.001)

Strength -0.279 -0.299 -0.340 0.770 1.000

(P<0.001) (P<0.001) (P<0.001) (P<0.001)

Optimism -0.237 -0.236 -0.235 0.614 0.646 1.000

(P<0.001) (P<0.001) (P<0.001) (P<0.001) (P<0.001)

The total score -0.271 -0.311 -0.317 0.951 0.909 0.763 1.000

(P<0.001) (P<0.001) (P<0.001) (P<0.001) (P<0.001) (P<0.001)

This article is protected by copyright. All rights reserved.

 Table 5 Multiple linear regression coefficients among burnout, resilience and socio-
Accepted Article demographic variables (N=1061)

Dependent variables Independent Variables B Beta t p

Emotional exhaustion Strength -0.068 -0.244 -8.244 <0.001

Exercise -0.285 -0.113 -3.765 <0.001

Income per month -0.157 -0.114 -3.574 <0.001

Ratio of beds to nurses 0.176 0.067 -2.269 0.023

Shift work 0.285 0.090 2.910 0.004

Marital status 0.225 0.092 2.792 0.005

Alcohol use 0.388 0.064 2.141 0.033

Cynicism The total score of resilience -0.026 -0.295 -9.975 <0.001

Exercise -0.220 -0.097 -3.263 0.001

Shift work 0.249 0.087 2.982 0.003

Reduced professional Strength -0.084 -0.337 -11.637 <0.001

efficacy

Professional rank -0.117 -0.085 -2.932 0.003

Note: B is the unstandardized coefficients, Beta is the standardized coefficients

This article is protected by copyright. All rights reserved.