Journal of Affective Disorders 324 (2023) 309–316

Contents lists available at ScienceDirect

Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

Research paper

Effects of work-family conflict and anxiety in the relationship between

work-related stress and job burnout in Chinese female nurses: A chained
mediation modeling analysis
Liang Yuan a, 1, Yili Li b, 1, Hong Yan a, Chenchang Xiao c, Dan Liu a, Xin Liu a, Yue Guan a,
Bin Yu a, *
a
Department of Epidemiology and Health Statistics, School of Public Health, Wuhan University, Wuhan, China
b
Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, China
c
Department of Medicine, City College, Wuhan University of Science and Technology, Wuhan, China

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Job burnout among nurses has been a challenging problem in recent years globally and in China.
Nurse Work-related stress, work-life interference and mental health have been shown to be associated with nurse job
Work-related stress burnout. However, the underlying mechanisms remain not fully understood. This study aims to examine the
Work-family interference
complex relationships linking work-related stress to nurse burnout among Chinese nurses.
Anxiety symptoms
Job burnout
Methods: Study data were collected from female nurses (n = 2172) in cities of Wuhan, Shiyan and Jingzhou,
Hubei Province of China. Job burnout was used as outcome variable, work-related stress was the predictor, work-
life interference and anxiety symptoms were mediators. Mediation and chained mediation modeling analysis
were used for data analysis.
Results: The association between work-related stress and job burnout was significantly mediated by work-family
conflict (indirect effect[95%CI] = 0.05[0.05,0.06]) and anxiety symptoms (indirect effect = 0.42[0.36,0.49]),
respectively. Further, a chained mediation mechanism was observed with work-family conflict and anxiety
symptoms consecutively mediated the relationship between work-related stress and job burnout (indirect effect
= 0.02[0.01,0.02]).
Limitations: The data were collected in one province in central China, so it needs caution when generalizing the
study findings to other regions within or outside of China.
Conclusion: Work-related stress exerts effects on job burnout through work-family conflict and anxiety symptoms
among female nurses in China. Work-related stress-based burnout prevention must consider both work-family
conflict and mental health problems.

1. Introduction
Job burnout is an occupational phenomenon defined as a syndrome
resulting from chronic workplace stress and has been recognized as a
serious health issue by the World Health Organization (WHO) (WHO,
2019). Job burnout among nurses has gained much attention from re­
searchers. Nurses' burnout may cause decreased quality of nursing and
increased intention to leave, contributing to a severe nurse shortage
(Poghosyan et al., 2010). A systematic review and meta-analysis re­
ported that 11.23 % of nurses globally ever experienced burnout
symptoms (Woo et al., 2020). A recent Chinese study examined the
prevalence of job burnout among 1056 nurses in Liaoning Province and
found that 20.5 % of these nurses suffered from burnout, and 72.9 %
reported at least one symptom of burnout (Guo et al., 2021). A cross-
sectional study in Eastern China indicated that about 64.0 % of nurses
experienced job burnout (Wang et al., 2019). Thus, it is of great signif­
icance to investigate the factors and underlying mechanisms contrib­
uting to job burnout among nurses in China.

* Corresponding author.
E-mail address: binyu1029@whu.edu.cn (B. Yu).
1
These authors contributed equally to this work.

https://doi.org/10.1016/j.jad.2022.12.112
Received 19 March 2022; Received in revised form 12 September 2022; Accepted 23 December 2022
Available online 28 December 2022
0165-0327/© 2022 Elsevier B.V. All rights reserved.
L. Yuan et al.
1.1. Effects of work-related stress on job burnout
There are many factors contributing to the job burnout among
nurses, particularly the work-related stress. According to the multidi­
mensional model of Maslach, burnout is a prolonged response to chronic
stress (Maslach et al., 2001). Several reports have shown that nurses
experienced moderate or higher levels of stress, which may be mainly
from the poor work environment, inadequate staffing and management
support, shift work, lack of resources, bad colleague relationships, etc.
(Fiske, 2018; Gu et al., 2019; Labrague et al., 2018; Sauer and McCoy,
2017; Zhang et al., 2020). All these stressors can lead to multiple adverse
outcomes among nurses, especially burnout syndrome (Ganesan et al.,
2019; Tahghighi et al., 2017). Previous studies in some developed
countries have shown that job stress significantly influenced burnout
level (Cañadas-de la Fuente et al., 2018; Dall'Ora et al., 2020; Tuna and
Baykal, 2014). Studies in China also showed that heavily work-related
stress could negatively affect job burnout (Li et al., 2021; Luan et al.,
2017). One aim of the study is to investigate the relationship and un­
derlying mechanism between work-related stress and job burnout
among Chinese nurses.
1.2. Work-family conflict may mediate the relationship between work-
related stress and job burnout
In addition to the direct effect, work-related stress may exert effects
on job burnout through thirty-party factors. One of them is work-family
conflict, which is prevalent among nurses (Yildiz et al., 2021). As a form
of role conflict, work-family conflict is an irreconcilable clash of the
pressure of work and family (Greenhaus and Beutell, 1985). According
to the spillover-crossover model, stress in the workplace may spill over
into the family field, thus affecting their emotions, attitudes and be­
haviors in family life, eventually triggering work-family conflict
(Rodríguez-Muñoz et al., 2014). Further, the work-family conflict may
increase the job burnout. Several national studies among nurses have
found that the conflicts between work and life caused a variety of
adverse outcomes, like low commitment, sluggishness, burnout, and
turnover (S et al., 2019; Sr et al., 2018; Yildiz et al., 2021). Thus, it is
likely that the work-family conflict may mediate the relationship be­
tween the work-related stress and job burnout in nurse population.
1.3. Anxiety may mediate the relationship between work-related stress
and job burnout
Alternatively, anxiety may serve as a mediator between work-related
stress and job burnout. As a psychologically unpleasant state, anxiety is
usually associated with stress-related challenges. According to affective
event theory (AET), external challenges can influence one's attitudes and
behaviors by changing the mood or emotion of an individual (Weiss and
Beal, 2005). This theory suggests that nurses' emotional responses may
mediate the association between their stress in work and burnout. One
study has indicated that Chinese nurses are more likely to suffer from
anxiety and have a higher level of anxiety than the general population
(Wei et al., 2009). Moreover, some studies found that anxiety symptoms
were positively correlated with burnout and impaired the physical and
mental health of nurses (Colville et al., 2017; Gomes et al., 2017;
Pokhrel et al., 2020). A survey conducted in Rome showed that anxiety
may have a mediating effect between psychological stress and burnout
among adolescent athletes (Gustafsson et al., 2017). So, it is likely that
anxiety symptoms may mediate the relationship between the work-
related stress and job burnout in nurse population.
1.4. Potential chained mediation mechanism
Based on the evidence above, it is likely that work-family conflict and
anxiety may mediate the relationship between work-related stress and
job burnout, respectively. Meanwhile, many studies have investigated
310
Journal of Affective Disorders 324 (2023) 309–316
the relationship between work-family conflict and poor mental health.
For example, one study found that female nurses who experienced
greater work-family conflict were more likely to suffer from psycho­
physical health conditions (Gustafsson et al., 2017; Zurlo et al., 2020).
Another study has shown that work-family conflict had a positive effect
on anxiety symptoms (Modaresnezhad et al., 2021). Thus, it is likely that
work-family conflict and anxiety may mediate the linkage from work-
related stress to job burnout consecutively (Fig. 1). However, to the
best of our knowledge, few studies have investigated this issue.
1.5. Purposes of this study
The purpose of this study was to investigate (1) the level of job
burnout in Chinese female nurses; (2) the mediation mechanism in
which work-family conflict and anxiety may mediate the relationship
between work-related stress and job burnout respectively, and (3) the
potential chained mediation mechanism in which work-family conflict
and anxiety consecutively mediate the relationship between work-
related stress and job burnout. Findings of the study will provide evi­
dence deepening our understanding of the mechanism underlying job
burnout among Chinese nurses, and provide information for future
effective prevention and intervention programs.
2. Materials and methods
2.1. Participants and sampling
Participants in the study were: (1) female registered nurses who were
on duty during the survey; (2) having at least six months of clinical
nursing experience and >1 month of night shift experience. Nurses in an
internship or advanced training were excluded. There were 11 tertiary
grade A hospitals in three cities (Wuhan, Shiyan, and Jingzhou) of Hubei
Province of China enrolled. Cluster sampling approach was used to re­
cruit participants. Only nurses who agreed to participate and signed the
informed consent were enrolled. A total of 2392 nurses were surveyed,
and 2172 valid questionnaires were eventually returned with a survey
response rate of 90.8 %.
2.2. Data collection
Data were collected from November 2017 to January 2018. The
paper questionnaires were mailed to the nurse managers of each hospital
and the nurse managers would hand out to all female nurses. This survey
was anonymous, confidential, and voluntary. The study was approved
by the Ethics Committee of Wuhan University, School of Medicine.
2.3. Measurement
2.3.1. Work-related stress
The Nurse Stress Inventory (NSI) was adopted to evaluate the work-
related stress among Chinese nurses (Li and Liu, 2000). The NSI consists
Fig. 1. Chained mediation of work-family conflict and anxiety symptoms in the
relationship between work-related stress and job burnout.
Note: *P < 0.05, **P < 0.001.
L. Yuan et al. Journal of Affective Disorders 324 (2023) 309–316

of 35 items with five subscales: nursing profession and clinical duty; Table 1
workload and time; working environment and resources; patient care; Characteristics of the study sample.
management and interpersonal relationship. Each item is measured Variables Categories N or mean % or SD
using a four-point Likert scale from 1 = no stress to 4 = severe stress.
Hospital location Wuhan 1521 70.0
Total score is computed with a higher score indicating greater stress. The Jingzhou 303 14.0
Cronbach's α was 0.96. Shiyan 348 16.0
Age (in years) ≤25 583 26.8
2.3.2. Work-family conflict 26–30 702 32.3
31–35 420 19.3
The Chinese version of the Multidimensional Work-Family Conflict ≥36 467 21.5
Scale (WFCS) was adopted to evaluate the work-family conflict (Carlson Mean (SD) 30.8 7.5
et al., 2000). The WFCS consists of 18 items, with two subscales: work Marital status Married 1380 63.5
interference with family (WIF), and family interference with work Unmarried 772 35.5
Others 20 0.9
(FIW). WIF refers to the demands and obligations of the work role as a
Education < College 544 25.0
negative impact on family life. FIW means that the conflict arising from College or above 1628 75.0
family obligations disturbs personal work. Each item is measured using a Nursing levels Licensed practical nurse 687 31.6
five-point Likert scale, ranging from “1 = never” to “4 = always”. Total Registered nurse 895 41.2
score is computed with a higher score indicating greater work-family Nurse in charge or above 590 26.2
Employment type Formal employment nurse 420 19.3
conflict. The Cronbach's α was 0.92. Contract employed nurse 1638 75.4
Others 114 5.2
2.3.3. Anxiety symptoms Years of working ≤5 867 39.9
The Zung Self-rating anxiety scale (SAS) was adopted to evaluate the 6–10 590 27.2
11–15 294 13.5
subjective feelings of anxiety in the past week (Zung, 1971). The SAS
>15 421 19.4
consists of 20 items, and each item is measured using a four-point Likert Mean (SD) 5.07 2.55
scale that ranges from “1 = rarely” to “5 = always”. To calculate an Annual income (RMB) ≤50,000 749 34.5
index score, the total score of the 20 items was multiplied by 1.25 and 50,001–70,000 720 33.1
retained the integer part. A high index score indicates a high level of 70,001–100,000 445 20.5
258 11.9
anxiety. The Cronbach's α was 0.84 in the study.
≥100,001
Department Internal medicine 443 20.4
Surgery 369 17.0
2.3.4. Job burnout Obstetrics and gynecology 296 13.6
The job burnout subscale of a Chinese version of the Professional Pediatrics 398 18.3
Others 666 30.7
Quality of Life Scale (ProQOL-CN) was adopted to measure the burnout
among nurses (Stamm, 2010). The burnout subscale consists of 10 items,
and each item is assessed using a five-point Likert scale, ranging from “1 3.2. Levels of job burn out across the study sample
= never” to “5 = always”. To calculate a standard score, the total score of
10 items was first converted into a Z score and then the T score was Results in Table 2 show that there were statistically significant dif­
calculated (T = 10Z + 50). In this study, 25%T and 75%T were taken as ferences in the level of job burnout across groups of age (F = 15.064, P <
the threshold so that the subscale score of 19 or less denotes a low level 0.001), marital status (F = 13.788, P < 0.001), nursing levels (F =
of burnout; a score of 19–56 notes average level; and 56 and above 13.325, P < 0.001), years of working (F = 9.127, P < 0.001), years of
suggests high levels. The Cronbach's α was 0.72. unit (F = 4.996, P < 0.001) and department (F = 7.706, P < 0.001).

2.4. Statistical analysis
Descriptive analyses (e.g., mean, standard deviation, frequency,
percentage, etc.) were used to present the sample characteristics. One-
factor Analysis of Variance (One-Way ANOVA) was used to analyze
the difference in the means of multiple groups. Pearson correlation
analysis was used to analyze the correlation between variables. Media­
tion and chained mediation modeling analysis were used to investigate
the association between work-related stress, work-family conflict, anx­
iety symptoms and job burnout. The SPSS PROCESS macro (version 3.3)
compiled by Hayes was used for analysis (Hayes, 2013). All mediation
analyses were controlled for age, marital status, hospital location,
nursing levels, years of working, and department. All statistical analyses
were performed using SPSS (version 26.0, IBM Corp). Type I error was
set at P < 0.05 (two-sided) for all statistical analyses.
3. Result
3.1. Characteristics of the study sample
Among the total sample of 2172 female nurses with a mean age of
30.8 ± 7.5 years, more than half were married, three quarters had a
college or above education, three out of four were contract employed
nurses, and 41.2 % were registered nurses. More details could be found
in Table 1.
3.3. Correlations among work-related stress, work-family conflict,
anxiety symptoms and job burnout
Results in Table 3 show that work-related stress and its subconstructs
(i.e., the nursing profession and clinical duty, workload and time,
working environment and resources, patient care, and management and
interpersonal relationship) were positively correlated with work-family
conflict, including work interference with family, and family interfer­
ence with work, with correlation coefficients ranging from 0.35 to 0.57.
Work-family conflict and its two subconstructs (i.e., work interference
with family, and family interference with work) were positively corre­
lated with anxiety symptoms (coefficient ranging from 0.41 to 0.50) and
job burnout (coefficients ranging from 0.37 to 0.51). Anxiety symptoms
were positively correlated with job burnout (r = 0.53).
3.4. Mediation modeling
Results in Table 4 indicated that work-family conflict significantly
mediated the association between total work-related stress and job
burnout (work-related stress → work-family conflict: 0.35[0.33,0.37],
work-family conflict → job burnout: 0.15[0.13,0.17], work-related
stress → job burnout: 0.07[0.06,0.08], indirect effect = 0.05
[0.05,0.06], proportion of indirect effect = 0.43[0.36,0.54]). Anxiety
symptoms significantly mediated the association between total work-
related stress and job burnout (indirect effect = 0.42[0.36,0.49],

311
L. Yuan et al. Journal of Affective Disorders 324 (2023) 309–316

Table 2 proportion of indirect effect = 0.42[0.36,0.49]). Further analyses show

Levels of burnout across the study sample, mean (SD). that work interference with family and family interference with work
Variables Burnout F P mediated the association between work-related stress and job burnout,
while anxiety symptoms mediated the association between work-related
Total 26.23
(5.74) stress and job burnout. More details can be found in Table 4.
Hospital location
Wuhan 26.15 2.76 0.063 3.5. Chained mediation modeling of job burnout
(5.68)
Jingzhou 25.90
(5.13)
Results in Fig. 2 shows that indirect effect with a coefficient[95%CI]
Shiyan 26.85 = 0.04[0.03,0.06] of total work-related stress on job burnout level was
(6.42) found to be statistically significant. A review of the direct effects of
Age 15.06 <0.001 mediators on job burnout showed that the effects of work-family conflict
25.01
≤25
with a coefficient = 0.10[0.08,0.12] and anxiety symptoms with a co­
(5.60)
26–30 26.39 efficient = 0.18[0.15,0.20]. Additionally, total work-related stress was
(5.47) significantly associated with work-family conflict, with a coefficient =
31–35 27.46 3.52[0.33,0.37], which in turn was associated with anxiety with a co­
(5.48) efficient = 0.28[0.25,0.32], which further associated with job burnout
26.25
with a coefficient = 0.18[0.15,0.20]. The chained two-step indirect ef­
≥36
(5.59)
Marital status 13.79 <0.001 fect of total work-related stress → work-family conflict → anxiety
Married 26.67 symptoms → job burnout was 0.02[0.01,0.02]. All the above-mentioned
(5.76) results revealed that serial multiple mediations were present. Mean­
Unmarried 25.37
while, similar results were observed for the subconstructs of the
(5.60)
Others 28.45 respective variables (see supplementary results).
(6.48)
Education 1.50 0.221 4. Discussion
< College 25.94
(5.86)
College or above 26.33
Job burnout among nurses has been a challenging problem in
(5.69) nursing management. The study investigated the level of burnout among
Nursing levels 13.33 <0.001 Chinese female nurses, and examined the complicated relationships
Licensed practical nurse 25.32 between work-related stress, work-family conflict, anxiety symptoms,
(5.64)
and job burnout using the chained mediation modeling analysis. The
Registered nurse 26.84
(5.40) findings of the study add new data, deepening our understanding of the
Nurse in charge or above 26.37 mechanisms underpinning the relationship between work-related stress
(6.21) and job burnout, and provide new evidence for future effective inter­
Employment 3.03 0.049 vention and prevention programs targeting job burnout among nurses.
type
Formal employment 25.98
nurse (5.58) 4.1. Level of burnout in Chinese nurses
Contract employed nurse 26.37
Others (5.80) The study results showed that the mean of the summated scores of
25.02
the burnout subscale was 26.1 (SD = 5.5), which was at a moderate
(5.30)
Years of working 9.13 <0.001 level, similar to the burnout score of Korean nurses and higher than that
≤5 25.44 of American nurses (Lee et al., 2021; Storm and Chen, 2021). The rea­
(5.56) sons of the job burnout in Chinese nurses are complex. First of all, China
6–10 26.73 has a large population and the ratio of nurses to 1000 population is 2.3,
(5.49)
11–15 27.33
which is significantly lower than the range of 7.9 to 17.5 in developed
(6.52) countries(Drennan and Ross, 2019).Thus, Chinese nurses are more
>15 26.37 prone to experience long working hours, heavy workloads, mandatory
(5.66) shifts, and encounter emergencies and interpersonal conflicts, contrib­
Annual income 2.30 0.076
uting to the strained nurse-patient relationship(Gao et al., 2012; Wu
≤50,000 26.55
(6.20) et al., 2014). In this context, experiences of workplace violence are
50,001–70,000 26.25 common among Chinese nurses, which may discourage their enthusiasm
(5.53) for nursing and promotes burnout (Jiao et al., 2015; Zhang et al., 2017).
70,001–100,000 26.22 Next, the profession of nursing has not been valued. Compared to phy­
(5.44)
≥100,001 25.67
sicians, nurses have a relatively lower social status, and sometimes fail
(5.36) to be respected by patients, resulting in a long-standing effort-reward
Department 7.71 <0.001 imbalance in the nursing profession (Liu et al., 2019; Zhang et al., 2017).
Internal medicine 25.89 The study results showed that those nurses aged 31–35 years, with
(5.51)
11–15 years of working, married, contract-based nurses, and pediatric
Surgery 26.29
(5.20) nurses experienced a higher level of burnout. Previous studies have
Obstetrics and 26.06 shown that unmarried nurses under the age of thirty were more likely to
gynecology (4.78) experience burnout, and their burnout levels tend to be higher than the
Pediatrics 27.46 married, which is different from this study (Molina-Praena et al., 2018;
(6.13)
Others 25.06
Yu et al., 2020). The reasons may be complex. One possible reason is that
(5.43) young and contract-based nurses usually take on more tedious primary
care in the clinic but their remuneration and benefits are relatively low,
which makes them more dissatisfied with the job (Hayes et al., 2012;

312
L. Yuan et al. Journal of Affective Disorders 324 (2023) 309–316

Table 3
Correlation among work-related stress, work-family conflict, anxiety symptoms, and job burnout among female nurses.
Variables Mean (SD) 1 2 3 4 5 6 7 8 9 10

1.Work-related stress 84.03 (21.22)

2.Nursing profession and clinical duty 18.21 (4.69) 0.81**
3.Workload and time 13.64 (4.10) 0.82** 0.70**
4.Working environment and resources 6.72 (2.66) 0.75** 0.55** 0.63**
5.Patient care 27.58 (7.55) 0.89** 0.61** 0.63** 0.58**
6.Management and interpersonal relationship 17.88 (6.34) 0.85** 0.56** 0.55** 0.57** 0.69**
7.Work-family conflict 47.95 (13.23) 0.57** 0.50** 0.50** 0.43** 0.47** 0.46**
8.Work interference with family 27.60 (7.78) 0.57** 0.51** 0.54** 0.42** 0.48** 0.42** 0.92**
9.Family interference with work 20.35 (6.78) 0.46** 0.38** 0.35** 0.35** 0.37** 0.43** 0.90** 0.65**
10.Anxiety symptoms 48.95 (10.89) 0.46** 0.38** 0.34** 0.34** 0.41** 0.43** 0.50** 0.49** 0.41**
11.Job burnout 26.23 (5.74) 0.45** 0.43** 0.41** 0.36** 0.35** 0.36** 0.49** 0.51** 0.37** 0.53**

* P < 0.05.
**
P < 0.001.

Table 4
Mediation modeling of the complex associations between work-related stress, work-family conflict, anxiety symptoms and job burnout among female nurses, co­
efficients [95 % confidence interval].
Variables X on M M on Y X on Y controlling M Indirect effect Proportion of the indirect effect

M: Work-family conflict
X: Total work-related stress 0.35[0.33,0.37] 0.15[0.13,0.17] 0.07[0.06,0.08] 0.05[0.05,0.06] 0.43[0.36,0.54]
X: Nursing profession and clinical duty 1.39[1.29,1.49] 0.16[0.14,0.18] 0.30[0.25,0.35] 0.22[0.19,0.25] 0.42[0.36,0.51]
X: Workload and time 1.62[1.50,1.73] 0.16[0.15,0.18] 0.30[0.24,0.36] 0.27[0.23,0.30] 0.47[0.40,0.56]
X: Working environment and resources 2.13[1.94,2.32] 0.18[0.16,0.19] 0.40[0.31,0.49] 0.38[0.33,0.43] 0.49[0.41,0.58]
X: Patient care 0.83[0.76,0.89] 0.18[0.16,0.20] 0.12[0.08,0.15] 0.15[0.13,0.17] 0.56[0.47,0.69]
X: Management and interpersonal relationship 0.97[0.89,1.05] 0.18[0.16,0.20] 0.15[0.12,0.19] 0.17[0.15,0.20] 0.53[0.44,0.66]

M: WIF
X: Total work-related stress 0.21[0.19,0.22] 0.27[0.24,0.30] 0.07[0.05,0.08] 0.06[0.05,0.06] 0.46[0.38,0.57]
X: Nursing profession and clinical duty 0.84[0.78,0.90] 0.28[0.25,0.31] 0.28[0.23,0.33] 0.24[0.21,0.27] 0.46[0.38,0.55]
X: Workload and time 1.02[0.96,1.09] 0.29[0.26,0.31] 0.27[0.21,0.33] 0.30[0.26,0.34] 0.53[0.45,0.64]
X: Working environment and resources 1.21[1.10,1.33] 0.31[0.28,0.34] 0.40[0.31,0.48] 0.38[0.33,0.44] 0.49[0.42,0.59]
X: Patient care 0.49[0.45,0.53] 0.32[0.29,0.35] 0.11[0.08,0.14] 0.16[0.14,0.18] 0.59[0.50,0.73]
X: Management and interpersonal relationship 0.52[0.47,0.56] 0.31[0.28,0.34] 0.16[0.13,0.20] 0.16[0.14,0.19] 0.50[0.42,0.62]

M: FIW
X: Total work-related stress 0.15[0.13,0.16] 0.18[0.15,0.22] 0.09[0.08,0.11] 0.03[0.02,0.06] 0.22[0.17,0.29]
X: Nursing profession and clinical duty 0.55[0.49,0.61] 0.21[0.18,0.25] 0.40[0.35,0.45] 0.12[0.09,0.14] 0.23[0.18,0.29]
X: Workload and time 0.59[0.53,0.66] 0.23[0.19,0.26] 0.43[0.38,0.49] 0.13[0.12,0.16] 0.24[0.19,0.30]
X: Working environment and resources 0.92[0.82,1.02] 0.24[0.21,0.28] 0.55[0.47,0.64] 0.22[0.18,0.27] 0.29[0.23,0.3]
X: Patient care 0.34[0.30,0.37] 0.24[0.21,0.28] 0.18[0.15,0.21] 0.08[0.07,0.10] 0.31[0.24,0.40]
X: Management and interpersonal relationship 0.45[0.41,0.49] 0.23[0.20,0.27] 0.21[0.18,0.26] 0.11[0.09,0.13] 0.33[0.25,0.42]

M: Anxiety symptoms
X: Total work-related stress 0.24[0.22,0.26] 0.21[0.19,0.23] 0.07[0.06,0.08] 0.05[0.04,0.06] 0.42[0.36,0.49]
X: Nursing profession and clinical duty 0.87[0.78,0.96] 0.22[0.20,0.24] 0.33[0.28,0.37] 0.19[0.16,0.23] 0.37 [0.32,0.43]
X: Workload and time 0.92[0.81,1.02] 0.23[0.21,0.25] 0.36[0.31,0.41] 0.21[0.18,0.25] 0.37[0.32,0.44]
X: Working environment and resources 1.37[1.21,1.54] 0.24[0.22,0.26] 0.45[0.37,0.53] 0.33[0.27,0.39] 0.42[0.36,0.50]
X: Patient care 0.58[0.53,0.64] 0.24[0.22,0.26] 0.12[0.09,0.17] 0.14[0.12,0.17] 0.53[0.46,0.62]
X: Management and interpersonal relationship 0.73[0.67,0.80] 0.24[0.22,0.26] 0.15[0.11,0.18] 0.18[0.15,0.21] 0.54[0.47,0.63]

Note: (1) Age, marital status, hospital location, nursing levels, years of working, and department were included as covariates; (2) WIF: work interference with family;
FIW: family interference with work.

Rudman et al., 2010; Shang et al., 2014). The more work obligations
they engage in, the more they feel stressed, which may increase the
likelihood of burnout (Asiedu et al., 2018). Additionally, compared to
other departments, nurses in pediatrics are with high work intensity,
high skill level, and have a high incidence of workplace violence in
China (Zhang et al., 2018).
4.2. Mediation effects of work-family conflict and anxiety symptoms
One important finding of this study was the effect of work-family
conflict and anxiety symptoms in mediating the relationship between
work-related stress and job burnout. Work-family conflict and anxiety
are two important risk factors related to burnout syndrome (Wang et al.,
2012; Zhang et al., 2020). Work-family conflict partially mediated the
effects of work-related stress on nurse burnout, which was consistent
with findings from studies among Chinese teachers and clinical
nurturing nurses (Ji and Yue, 2020). We also found that the mediating
effect of work interfering with family was significantly stronger than the
mediating effect of family interfering with work. It may be related to the
fact that the majority of our sample was young and unmarried female
nurses. These nurses just transited from students, which was a
demanding and stressful process. Meanwhile, these young nurses may
take on more clinical primary care (Hayes et al., 2012; Rudman et al.,
2010). The more work obligations they engage in, the harder they meet
their family-related demands when they go back home, therefore, they
are more prone to feel stressed, which in turn increases the risk of
burnout (Asiedu et al., 2018).
Additionally, the findings of this study indicate that anxiety partially

313
L. Yuan et al.
mediated the relationship between work-related stress and job burnout.
Nurses with a higher level of stress in nursing are more likely to expe­
rience anxiety symptoms, which in turn increases the risk of burnout.
Stress is prevalent in nursing, and the prolonged work-related stress
from the profession, patient care, responsibility would negatively affect
the emotional and psychological states (e.g., anxiety) of nurses, which
causes burnout syndrome (Creedy et al., 2017; Lin et al., 2020).
4.3. Chained mediation mechanisms of work-family conflict and anxiety
symptoms
Another key finding is the chained mediations mechanism in which
work-related stress-nurse burnout relation is mediated by work-family
conflict and anxiety symptoms, consecutively. The chained mediation
mechanism was also observed in studies among other populations
(Smith et al., 2019; Sun et al., 2021; Zhang et al., 2020). Work-family
conflict can increase anxiety symptoms, an immediate risk factor for
burnout. The chained mediation mechanism supports the significance of
a harmonious family in the prevention of job burnout for female nurses
in China. To reduce the conflict between work and family, a better work
environment and organizational climate will play an important role. The
study also compared the effects of five dimensions of work-related stress
in the mediation and chained mediation modeling mechanisms. Among
the five dimensions, patient care is more likely to exert its effect on nurse
burnout through work-family conflict and anxiety symptoms, followed
by management and interpersonal relationship. The stress of patient
care is mainly originated from accidents at work, patients' demand, and
nursing proficiency, while the stress of management and interpersonal
relationship mainly include the lack of respect from others, excessive
criticism from leaders, and lack of support from colleagues. As we
mentioned in the method, the nurses in the study were selected from
tertiary hospitals, which mainly admit patients with critical illnesses.
Thus, the requirements for nurses are higher and patient care is more
difficult. Further, most of the nurses in our study were young with short
working years, they may lack experience in performing care and getting
along with colleagues and patients. Additionally, with the increasing
demand for medical care, hospitals have mainly focused on the com­
petency of nurses and neglected to build team support, so nurses tend to
be filled with pieces of training and exams in their spare time, which
may leave them lacking time to bond with colleagues. When all stressors
converge, it squeezes nurses' time for family life and endangers their
mental health, causing nurse burnout (Khamisa et al., 2015).
While for the chained mediation mechanism, the five dimensions of
work-related stress also played different roles. The stress of the nursing
profession and clinical duty, workload and time, coupled with working
environment and resources were associated with work-family conflict,
while the stress of patient care coupled with management and inter­
personal relationship were associated with anxiety symptoms. In China,
patients usually prefer to seek health care in large public hospitals even
if they do not have serious diseases (Xie et al., 2011). Therefore, there
are a large number of outpatient visits and a high volume of inpatients in
these tertiary hospitals, which makes nurses spend most of their effort on
nursing. Nurses may feel stress both physically and psychologically and
may have a higher likelihood of conflicts with their families when they
return home, jeopardizing their mental health with persistent anxiety
symptoms, further erupting into burnout (Pan et al., 2015). Compared to
other domains, patient care, and management and interpersonal rela­
tionship are all related to frequent and close communication with pa­
tients and colleagues. These dimensions of work-related stress not only
affected the level of burnout indirectly through work-family conflict and
anxiety symptoms but also exerted a significant direct effect on burnout.
4.4. Implications
The findings of this study can be used to inform interventions to
prevent burnout among Chinese nurses if further confirmed in a
314
Journal of Affective Disorders 324 (2023) 309–316
longitudinal study. Considering the important role of work-family con­
flict and anxiety symptoms in mediating the relationship between work-
related stress and job burnout, future intervention programs may target
improving the working environment and interpersonal relationships in
the departments. Group-based interventions and context-specific mea­
sures have been proven to be effective in increasing well-being and
mitigating burnout of the staff team (Alabi et al., 2021). Thus, focusing
on stressors in practice environments like monotonous tasks and poor
collaborative relationships with colleagues may be a primary strategy
for burnout prevention. Typical measures include organizing support
groups, conducting mindfulness-based courses, implementing stress
management programs and conflict-resolution training. Additionally,
given to the substantial impact of family and mental health on burnout,
psychological consultation and marital counseling should also be
considered to help nurses solve their problems at the stage of work-
family conflict and anxiety, before proceeding to more severe psycho­
somatic diseases.
4.5. Limitations
The study has some limitations. First, the study was cross-sectional,
so causal relationships can't be established. Secondly, the data were
collected in one province in central China, so it needs caution when
generalizing the study findings to other regions within or outside of
China. Third, the assessment of variables was based on self-report, recall
bias could not be ruled out. Despite these limitations, the study is the
first to examine the complex relationship among work-related stress,
work-family conflict, anxiety symptoms, and job burnout using a
chained mediation modeling analysis. The findings of this study provide
preliminary data to support future research on the etiology and inter­
vention of burnout syndrome among a large number of nurses in China.
Submission declaration
All authors declare that the work described has not been published
previously, it is not under consideration for publication elsewhere and
that its publication is approved by all authors.
Contributors
Yili Li designed the study and wrote the protocol. Hong Yan and
Chenchang Xiao managed the participant recruitment and data acqui­
sition. Dan Liu, Xin Liu, and Yue Guan collected and preprocessed some
of the data. Liang Yuan managed the literature research, analyses and
wrote the first draft of the manuscript. Bin Yu provided the critical
revision of the manuscript. All authors contributed to and have
approved the final manuscript.
Role of the funding source
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Conflict of interest
The authors declare that there are no conflict of interests，we do not
have any possible conflicts of interest.
Acknowledgements
We thank all the participants for their contribution to this study.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.jad.2022.12.112.
L. Yuan et al. Journal of Affective Disorders 324 (2023) 309–316

References Liu, J., Zheng, J., Liu, K., Liu, X., Wu, Y., Wang, J., You, L., 2019. Workplace violence
against nurses, job satisfaction, burnout, and patient safety in Chinese hospitals.
Nurs. Outlook 67, 558–566. https://doi.org/10.1016/j.outlook.2019.04.006.
Alabi, R.O., Hietanen, P., Elmusrati, M., Youssef, O., Almangush, A., Mäkitie, A.A., 2021.
Luan, X., Wang, P., Hou, W., Chen, L., Lou, F., 2017. Job stress and burnout: a
Mitigating burnout in an oncological unit: a scoping review. Front. Public Health 9,
comparative study of senior and head nurses in China. Nurs. Health Sci. 19,
677915. https://doi.org/10.3389/fpubh.2021.677915.
163–169. https://doi.org/10.1111/nhs.12328.
Asiedu, E.E.A., Annor, F., Amponsah-Tawiah, K., Dartey-Baah, K., 2018. Juggling family
Maslach, C., Schaufeli, W.B., Leiter, M.P., 2001. Job burnout. Annu. Rev. Psychol. 52,
and professional caring: role demands, work-family conflict and burnout among
397–422. https://doi.org/10.1146/annurev.psych.52.1.397.
registered nurses in Ghana. Nurs. Open 5, 611–620. https://doi.org/10.1002/
Modaresnezhad, M., Andrews, M.C., Mesmer-Magnus, J., Viswesvaran, C., Deshpande, S.,
nop2.178.
2021. Anxiety, job satisfaction, supervisor support and turnover intentions of mid-
World Health Organization (WHO), 2019. Burn-out an “Occupational Phenomenon”:
career nurses: a structural equation model analysis. J. Nurs. Manag. 29, 931–942.
international classification of diseases. https://www.who.int/mental_health/evide
https://doi.org/10.1111/jonm.13229.
nce/burn-out/en accessed 12 December 2021.
Molina-Praena, J., Ramirez-Baena, L., Gómez-Urquiza, J.L., Cañadas, G.R., De la
Cañadas-de la Fuente, G.A., Albendín-García, L., Cañadas, G.R., San Luis-Costas, C.,
Fuente, E.I., Cañadas-De la Fuente, G.A., 2018. Levels of burnout and risk factors in
Ortega-Campos, E., de la Fuente-Solana, E.I., 2018. Nurse burnout in critical care
medical area nurses: a meta-analytic study. Int. J. Environ. Res. Public Health 15,
units and emergency departments: intensity and associated factors. Emergencias 30,
E2800. https://doi.org/10.3390/ijerph15122800.
328–331.
Pan, Y., Yang, X.h., He, J.P., Gu, Y.H., Zhan, X.L., Gu, H.F., Qiao, Q.Y., Zhou, D.C., Jin, H.
Carlson, D.S., Kacmar, K.M., Williams, L.J., 2000. Construction and initial validation of a
M., 2015. To be or not to be a doctor, that is the question: a review of serious
multidimensional measure of work-family conflict. J. Vocat. Behav. 56, 249–276.
incidents of violence against doctors in China from 2003–2013. J. Public Health 23,
https://doi.org/10.1006/jvbe.1999.1713.
111–116. https://doi.org/10.1007/s10389-015-0658-7.
Colville, G.A., Smith, J.G., Brierley, J., Citron, K., Nguru, N.M., Shaunak, P.D., Tam, O.,
Poghosyan, L., Clarke, S.P., Finlayson, M., Aiken, L.H., 2010. Nurse burnout and quality
Perkins-Porras, L., 2017. Coping with staff burnout and work-related posttraumatic
of care: cross-national investigation in six countries. Res. Nurs. Health 33, 288–298.
stress in intensive care. Pediatr. Crit. Care Med. 18, e267–e273. https://doi.org/
https://doi.org/10.1002/nur.20383.
10.1097/PCC.0000000000001179.
Pokhrel, N.B., Khadayat, R., Tulachan, P., 2020. Depression, anxiety, and burnout among
Creedy, D.K., Sidebotham, M., Gamble, J., Pallant, J., Fenwick, J., 2017. Prevalence of
medical students and residents of a medical school in Nepal: a cross-sectional study.
burnout, depression, anxiety and stress in australian midwives: a cross-sectional
BMC Psychiatry 20, 298. https://doi.org/10.1186/s12888-020-02645-6.
survey. BMC Pregnancy Childbirth 17, 13. https://doi.org/10.1186/s12884-016-
Rodríguez-Muñoz, A., Sanz-Vergel, A.I., Demerouti, E., Bakker, A.B., 2014. Engaged at
1212-5.
work and happy at home: a spillover–crossover model. J. Happiness Stud. 15,
Dall'Ora, C., Ball, J., Reinius, M., Griffiths, P., 2020. Burnout in nursing: a theoretical
271–283. https://doi.org/10.1007/s10902-013-9421-3.
review. Hum. Resour. Health 18, 41. https://doi.org/10.1186/s12960-020-00469-9.
Rudman, A., Omne-Pontén, M., Wallin, L., Gustavsson, P.J., 2010. Monitoring the newly
Drennan, V.M., Ross, F., 2019. Global nurse shortages-the facts, the impact and action for
qualified nurses in Sweden: the Longitudinal Analysis of Nursing Education (LANE)
change. Br. Med. Bull. 130, 25–37. https://doi.org/10.1093/bmb/ldz014.
study. Hum. Resour. Health 8, 10. https://doi.org/10.1186/1478-4491-8-10.
Fiske, E., 2018. Nurse stressors and satisfiers in the NICU. Adv. Neonatal Care 18,
S, M., K, N., Y, I., H, H., A, T., H, O., J, I., 2019. Gender division of labor, burnout, and
276–284. https://doi.org/10.1097/ANC.0000000000000514.
intention to leave work among young female nurses in Japan: a cross-sectional study.
Ganesan, S., Magee, M., Stone, J.E., Mulhall, M.D., Collins, A., Howard, M.E., Lockley, S.
Int. J. Environ. Res. Public Health 16. https://doi.org/10.3390/ijerph16122201.
W., Rajaratnam, S.M.W., Sletten, T.L., 2019. The impact of shift work on sleep,
Sauer, P.A., McCoy, T.P., 2017. Nurse bullying: impact on nurses' health. West. J. Nurs.
alertness and performance in healthcare workers. Sci. Rep. 9, 4635. https://doi.org/
Res. 39, 1533–1546. https://doi.org/10.1177/0193945916681278.
10.1038/s41598-019-40914-x.
Shang, J., You, L., Ma, C., Altares, D., Sloane, D.M., Aiken, L.H., 2014. Nurse
Gao, Y.-Q., Pan, B.-C., Sun, W., Wu, H., Wang, J.-N., Wang, L., 2012. Anxiety symptoms
employment contracts in Chinese hospitals: impact of inequitable benefit structures
among Chinese nurses and the associated factors: a cross sectional study. BMC
on nurse and patient satisfaction. Hum. Resour. Health 12, 1. https://doi.org/
Psychiatry 12, 141. https://doi.org/10.1186/1471-244X-12-141.
10.1186/1478-4491-12-1.
Gomes, A.R., Faria, S., Vilela, C., 2017. Anxiety and burnout in young athletes: the
Smith, T.D., DeJoy, D.M., Dyal, M.-A.A., Huang, G., 2019. Impact of work pressure, work
mediating role of cognitive appraisal. Scand. J. Med. Sci. Sports 27, 2116–2126.
stress and work-family conflict on firefighter burnout. Arch. Environ. Occup. Health
https://doi.org/10.1111/sms.12841.
74, 215–222. https://doi.org/10.1080/19338244.2017.1395789.
Greenhaus, J.H., Beutell, N.J., 1985. Sources of conflict between work and family roles
Sr, D., K, D., S, B., R, S., M, Schubert, S, D.G., M, Simon, 2018. Work schedule flexibility
<sup/>. AMR 10, 76–88. https://doi.org/10.5465/amr.1985.4277352.
is associated with emotional exhaustion among registered nurses in Swiss hospitals:
Gu, B., Tan, Q., Zhao, S., 2019. The association between occupational stress and
a cross-sectional study. Int. J. Nurs. Stud. 82 https://doi.org/10.1016/j.
psychosomatic wellbeing among Chinese nurses: a cross-sectional survey. Medicine
ijnurstu.2018.03.019.
(Baltimore) 98, e15836. https://doi.org/10.1097/MD.0000000000015836.
Stamm, B., 2010. The Concise Manual for the Professional Quality of Life Scale
Guo, Y., Hu, S., Liang, F., 2021. The prevalence and stressors of job burnout among
undefined.
medical staff in Liaoning, China: a cross-section study. BMC Public Health 21, 777.
Storm, J., Chen, H.-C., 2021. The relationships among alarm fatigue, compassion fatigue,
https://doi.org/10.1186/s12889-021-10535-z.
burnout and compassion satisfaction in critical care and step-down nurses. J. Clin.
Gustafsson, H., Sagar, S.S., Stenling, A., 2017. Fear of failure, psychological stress, and
Nurs. 30, 443–453. https://doi.org/10.1111/jocn.15555.
burnout among adolescent athletes competing in high level sport. Scand. J. Med. Sci.
Sun, Y., Liu, F., Wang, Y., Zhou, M., Yang, B., Cao, F., 2021. Mindfulness improves health
Sports 27, 2091–2102. https://doi.org/10.1111/sms.12797.
worker’s occupational burnout: the moderating effects of anxiety and depression.
Hayes, A.F., 2013. Introduction to mediation, moderation, and conditional process
Int. Arch. Occup. Environ. Health 94, 1297–1305. https://doi.org/10.1007/s00420-
analysis: a regression-based approach. In: Introduction to Mediation, Moderation,
021-01685-z.
And Conditional Process Analysis: A Regression-based Approach. Guilford Press,
Tahghighi, M., Rees, C.S., Brown, J.A., Breen, L.J., Hegney, D., 2017. What is the impact
New York, NY, US.
of shift work on the psychological functioning and resilience of nurses? An
Hayes, L.J., O’Brien-Pallas, L., Duffield, C., Shamian, J., Buchan, J., Hughes, F.,
integrative review. J. Adv. Nurs. 73, 2065–2083. https://doi.org/10.1111/
Laschinger, H.K.S., North, N., 2012. Nurse turnover: a literature review - an update.
jan.13283.
Int. J. Nurs. Stud. 49, 887–905. https://doi.org/10.1016/j.ijnurstu.2011.10.001.
Tuna, R., Baykal, Ü., 2014. The relationship between job stress and burnout levels of
Ji, D., Yue, Y., 2020. Relationship between kindergarten organizational climate and
oncology nurses. Asia Pac. J. Oncol. Nurs. 1, 33–39. https://doi.org/10.4103/2347-
teacher burnout: work-family conflict as a mediator. Front. Psychiatry 11, 408.
5625.135818.
https://doi.org/10.3389/fpsyt.2020.00408.
Wang, Q.-Q., Lv, W.-J., Qian, R.-L., Zhang, Y.-H., 2019. Job burnout and quality of
Jiao, M., Ning, N., Li, Y., Gao, L., Cui, Y., Sun, H., Kang, Z., Liang, L., Wu, Q., Hao, Y.,
working life among chinese nurses: a cross-sectional study. J. Nurs. Manag. 27,
2015. Workplace violence against nurses in Chinese hospitals: a cross-sectional
1835–1844. https://doi.org/10.1111/jonm.12884.
survey. BMJ Open 5, e006719. https://doi.org/10.1136/bmjopen-2014-006719.
Wang, Y., Chang, Y., Fu, J., Wang, L., 2012. Work-family conflict and burnout among
Khamisa, N., Oldenburg, B., Peltzer, K., Ilic, D., 2015. Work related stress, burnout, job
Chinese female nurses: the mediating effect of psychological capital. BMC Public
satisfaction and general health of nurses. Int. J. Environ. Res. Public Health 12,
Health 12, 915. https://doi.org/10.1186/1471-2458-12-915.
652–666. https://doi.org/10.3390/ijerph120100652.
Wei, Z., Rong, D., Qiu, Y., 2009. Investigation of medical staff’s moodiness health in
Labrague, L.J., McEnroe-Petitte, D.M., Leocadio, M.C., Van Bogaert, P., Cummings, G.G.,
Shenzhen special zone. Chin. J. Health Psychol. 17, 1306–1308.
2018. Stress and ways of coping among nurse managers: an integrative review.
Weiss, H.M., Beal, D.J., 2005. Reflections on affective events theory. In: Research on
J. Clin. Nurs. 27, 1346–1359. https://doi.org/10.1111/jocn.14165.
Emotion in Organizations. Emerald, Bingley, pp. 1–21. https://doi.org/10.1016/
Lee, H., Baek, W., Lim, A., Lee, D., Pang, Y., Kim, O., 2021. Secondary traumatic stress
S1746-9791(05)01101-6 (MCB UP).
and compassion satisfaction mediate the association between stress and burnout
Woo, T., Ho, R., Tang, A., Tam, W., 2020. Global prevalence of burnout symptoms among
among Korean hospital nurses: a cross-sectional study. BMC Nurs. 20, 115. https://
nurses: a systematic review and meta-analysis. J. Psychiatr. Res. 123, 9–20. https://
doi.org/10.1186/s12912-021-00636-w.
doi.org/10.1016/j.jpsychires.2019.12.015.
Li, X., Jiang, T., Sun, J., Shi, L., Liu, J., 2021. The relationship between occupational
Wu, H., Liu, L., Sun, W., Zhao, X., Wang, J., Wang, L., 2014. Factors related to burnout
stress, job burnout and quality of life among surgical nurses in Xinjiang,China. BMC
among Chinese female hospital nurses: cross-sectional survey in Liaoning Province of
Nurs. 20, 181. https://doi.org/10.1186/s12912-021-00703-2.
China. J. Nurs. Manag. 22, 621–629. https://doi.org/10.1111/jonm.12015.
Li, X.M., Liu, Y.J., 2000. Job stressors and burnout among staff nurses. Chin. J. Nurs. 11,
Xie, Z., Wang, A., Chen, B., 2011. Nurse burnout and its association with occupational
4–8.
stress in a cross-sectional study in Shanghai. J. Adv. Nurs. 67, 1537–1546. https://
Lin, Y.-E., Tseng, C.-N., Wang, M.-F., Wu, S.-F.V., Jane, S.-W., Chien, L.-Y., 2020. Anxiety
doi.org/10.1111/j.1365-2648.2010.05576.x.
and work stress among newly employed nurses during the first year of a residency
programme: a longitudinal study. J. Nurs. Manag. 28, 1598–1606. https://doi.org/
10.1111/jonm.13114.

315
L. Yuan et al.
Yildiz, B., Yildiz, H., Ayaz Arda, O., 2021. Relationship between work-family conflict and
turnover intention in nurses: a meta-analytic review. J. Adv. Nurs. 77, 3317–3330.
https://doi.org/10.1111/jan.14846.
Yu, J., Song, H., Shi, H., Wang, K., 2020. Association between work-family conflict and
overall well-being among chinese nurse leaders. J. Nurs. Manag. 28, 1498–1503.
https://doi.org/10.1111/jonm.13084.
Zhang, H., Ye, Z., Tang, L., Zou, P., Du, C., Shao, J., Wang, X., Chen, D., Qiao, G., Mu, S.
Y., 2020. Anxiety symptoms and burnout among Chinese medical staff of intensive
care unit: the moderating effect of social support. BMC Psychiatry 20, 197. https://
doi.org/10.1186/s12888-020-02603-2.
316
Journal of Affective Disorders 324 (2023) 309–316
Zhang, L., Wang, A., Xie, X., Zhou, Y., Li, J., Yang, L., Zhang, J., 2017. Workplace
violence against nurses: a cross-sectional study. Int. J. Nurs. Stud. 72, 8–14. https://
doi.org/10.1016/j.ijnurstu.2017.04.002.
Zhang, Y.-Y., Han, W.-L., Qin, W., Yin, H.-X., Zhang, C.-F., Kong, C., Wang, Y.-L., 2018.
Extent of compassion satisfaction, compassion fatigue and burnout in nursing: a
meta-analysis. J. Nurs. Manag. 26, 810–819. https://doi.org/10.1111/jonm.12589.
Zung, W.W., 1971. A rating instrument for anxiety disorders. Psychosomatics 12,
371–379. https://doi.org/10.1016/S0033-3182(71)71479-0.
Zurlo, M.C., Vallone, F., Smith, A.P., 2020. Work-family conflict and psychophysical
health conditions of nurses: gender differences and moderating variables. Jpn. J.
Nurs. Sci. 17, e12324 https://doi.org/10.1111/jjns.12324.