2.1 Study design and participants

Using a multistage random sample process, based on the country's geographic location and rate of economic development, one province (municipality) was selected from each of the three regions: eastern (Zhejiang), central (Heilongjiang) and western (Chongqing). The sample is representative since these three provinces have varying capacities for economic, cultural and medical services. The National Health Commission of China provided data indicating that, taking into account variations in percentage among provinces, the ratio of nurses at the tertiary, secondary and primary hospital levels is around 12:8:1. Finally, we selected 21 public hospitals (16:4:1) and seven hospitals from each province. A random number table was used to randomly select 250 nursing staff members from each hospital. Before beginning the inquiry, each investigator had standardized training, and they were all eligible to function as investigators when the time came. The management, medical conflict resolution and human resources departments of the participating institutions granted permission for the study to be carried out.

This study was approved by the Ethics Committee of the Second Affiliated Hospital of Harbin Medical University (approval number: KY2020-197). The Ethics Committee authorized every research technique. Participants gave their free and informed permission to take part in the investigation. Online and private paper-and-pencil survey-gathering techniques often provide respondents with the confidentiality they want and are unaffected by recurrent or inconsequential responses (Gosling et al., 2004).

Respondents who did not correctly complete the questionnaire, nurses with mental or psychological disorders, part-time nurses, interns or nurses on leave during the survey were excluded.

2.2 Measurement instruments

The questionnaire consisted of the following two parts: (1) General demographic characteristics such as gender, age, marital status, child status, unit grade, unit type, department, years engaged in nursing work, educational background, current technical title, position, post-staffing type, monthly income level, work shift type, daily working hours in recent months, working days per week, overtime times, night shift times and sleep quality. (2) The occupational burnout of nurses was measured using the Maslach Burnout Inventory-Human Service Survey (MBI-HSS) (Li et al., 2003). This scale is widely used by scholars in various professional service groups, including nurses, managers, teachers, students, doctors, etc (Liu et al., 2018). There are 22 items on the scale composed of three dimensions: EE, DP and PA. The scale is scored according to 0–6 points, with a total of seven levels. The participant's overall score for each dimension is represented by the composite score on each scale. On the emotional fatigue measure, participants with scores of 0–18, 19–26 and ≥27 showed mild, moderate and severe degrees of emotional weariness respectively. On the depersonalization dimension, those who scored 0–5, 6–9 and >9, respectively, showed low, moderate and high degrees of depersonalization. In the facet of lack of achievement, those scoring ≥40, 34–39 and 0–33, respectively, had a high, moderate and low degree of lack of personal success. The items in this dimension were reverse coded. In this investigation, the Cronbach's alpha scale was 0.737. The subscales of EE, DP and PA have Cronbach's alphas of 0.898, 0.753 and 0.842, in that order.

2.3 Data collection

From March to July 2021, data were gathered using the “wen juan xing” online survey app. Nurses working in hospitals were required to provide their unit names, which allowed us to aggregate data from hospitals and analyse nurses' burnout levels. Respondents completed an anonymous questionnaire and distributed 5250 questionnaires. A total of 4865 valid questionnaires – or an effective rate of 92.67% – were kept after removing those with missing data, partial completion, repetitive omissions and multiple choice questions. Participants had to meet three requirements in order to be considered for inclusion: (1) they had to be Registered nurses; (2) they had to work at a hospital for a minimum of 1 year and (3) they had to provide their informed permission and volunteer to fill out the questionnaires. Hospital-based nursing students were not included.

2.4 Data analysis

Statistical analyses were performed using IBM SPSS statistics software (version 24.0). K–S tests were used to confirm that the continuous variables had normal distributions. For the demographic data, descriptive statistics were computed, such as numbers (n), percentages (%), medians and interquartile ranges (IQR). The Kruskal–Wallis H test and Kolmogorov–Smirnov Z test were used to examine group differences in continuous variable measurements. The least significant difference post-comparison method was used for multiple comparisons between groups. Multicollinearity was investigated for every research variable. Linear logistic regression was used to analyse the factors influencing nurses' job burnout. The level of statistical significance was set at p < 0.05.

3.1 Demographic characteristics of respondents

Table 1 lists the demographic characteristics of the respondents. A total of 4865 nurses participated in the survey. Among them, 2.6% were men, and 97.4% were women; aged 26–35 made up the majority of them (n = 2371, 48.7%), most of the respondents were unmarried (n = 3476, 71.4%) and 65.1% of the nurses (n = 3168) had no children.

In terms of working conditions, 77.5% of the nurses worked in public hospitals (n = 3769), and 81.7% (n = 3974) of nurses worked in general hospitals. Among the 4865 respondents, 25.8% (n = 1254) came from internal medicine, 30.2% (n = 1467) had been engaged in nursing for 6–10 years and most had a bachelor's degree (n = 3353, 68.9%) and were nurses (n = 1751, 36.0%). More than half of the nurses were on contract (n = 2846, 58.5%) and only worked day shifts (n = 2506, 51.5%). The proportion of nurses with a monthly income ranging from 3001 to 5000 yuan was the highest, accounting for 41.9% (n = 2038). Most nurses work 7–8 h in the past month (n = 2929, 60.2%). A total of 46.2% (n = 2250) said that their sleep quality in the past month had only reached the general level.

3.2 The overall situation of job burnout among nurses

The nurses exhibited low PA, moderate DP and moderate EE, as Table 2 demonstrates. In addition, the total burnout level average score was 2.69 ± 0.70, the score of DP dimension was the lowest, which was 0.96 ± 1.11, followed by EE and personal achievement, which were 2.22 ± 1.34 and 4.30 ± 1.29 respectively.

Of the respondents, 50.7% had moderate or high EE, 32.8% had moderate or high DP and emotional alienation, and 80.4% had moderate or low personal achievement. The results also showed that the scores of EE and DP of nurses in this study were lower than the norm (Maslach et al., 1993), and the scores of low sense of achievement were higher than the norm (p < 0.05).

3.3 Characteristics of participants in relation to job burnout

4.1 Current situation of each dimension of job burnout among nurses

A previous study confirmed that nurses' job burnout not only affects the quality of nursing but also leads to an increase in nurses' turnover intention (Liu et al., 2018). Lower patient satisfaction is correlated with high levels of burnout and job unhappiness among nurses, which suggests issues with the quality of treatment. The present state of nurse work burnout and strategies for lowering its incidence have emerged as major areas of interest for the organizational behaviour and human resource management study (Aiken et al., 2002). Therefore, it is important to take measures to reduce nurses' EE and DP and improve PA.

4.2 Differences of different demographic characteristics of nurses in various dimensions of job burnout

In terms of age, through pairwise comparison, it can be seen that the EE and DP factor scores of nurses in the age group under the age of 25 are greater than those in the age group over the age of 36, and the PA is lower than those in the age group over the age of 36. It was also found that the lower the working years, technical titles and positions of nurses, the easier it was for them to experience lower levels of EE, DP and PA. This may be because nurses under the age of 25 years who have fewer working years are in the early stages of career development and cannot skilfully cope with changes in the working environment and stress factors, and a stable colleague relationship has not been established; therefore, they have received relatively little social support. In addition, the sense of a gap caused by the conflict between ideal work goals and reality produces helplessness, which leads to a loss of personal achievement.

Married nurses with children scored relatively high in EE and DP. In addition to undertaking work tasks, married nurses with children must also play a variety of roles in the family, such as supporting the older people and raising children. To master the balance between work and family conflicts, they make use of more physical strength and energy. This irregular shift caused them to spend less time with their families and receive less emotional support. In addition, nurses who have experienced divorce or widowhood may suffer more severe emotional trauma, lack support from their families and be prone to negative self-evaluations. Additionally, the data indicated that compared to single nurses, married nurses had a higher risk of experiencing occupational burnout. This is consistent with Sabbah's research results (Sabbah et al., 2012). Based on a comprehensive analysis of existing research on the subject, work–family conflict emerges when the demands of one role impede the fulfilment of those of another, or when the demands of one role necessitate particular behaviours that complicate the accomplishment of the demands of another; or when one role's requirements cause strain from participation in another role. Owing to busy work and limited personal energy, role conflicts between family and work often make it difficult for nurses to achieve a balance. Therefore, nurses should avoid bringing negative emotions such as fatigue and anxiety to their families because of long-term exposure to high-pressure environments.

In terms of unit types, the research discovered that although the DP level was lower in general and speciality hospitals, the EE and PA levels of nurses at community health care centres were higher. The development of grassroots medical and health services may be mostly carried out collectively, and their work effect is a long process that needs to be gradually highlighted. However, community nursing work that needs to go deeply into the family requires greater patient compliance. The difficulty of work and the non-cooperation of residents lead to the gradual loss of professional values and professional beliefs and doubt the significance of their work. It is noteworthy that this research discovered a greater degree of job burnout among ICU nurses, which might be attributed to the following factors. First, ICU patients' condition was critical and changed rapidly; they not only faced basic nursing work but also carried out various special treatments because the work content was more complex and the workload was greater. Second, ICU nurse staffing did not keep up with patient volume, and the nursing human resources were seriously insufficient, which has become a common problem in the medical field. Third, compared to other departments, ICU patients are in critical condition. Nurses often perform many nursing operations, but patients do not improve or die more frequently, which makes them feel frustrated. Fourth, there are many types of medical equipment in the ICU wards, and the environment is relatively closed and narrow. Working in this environment for a long time makes it easy to feel irritable and unable to concentrate (Hu et al., 2021).

In terms of monthly income, nurses officially employed in public hospitals (public institutions) are treated as civil servants who are more stable and provide better welfare benefits than contract nurses. The burnout level of nurses working day and night shifts was higher than that of nurses working day shifts only. The worse the sleep quality, the more likely it was to experience burnout. Some scholars have pointed out that factors leading to fatigue include the quantity and quality of sleep and rest, working time processes and work intensity, which is consistent with our result (Krueger, 1989). Compared with full-time day-shift nurses, shift nurses have a higher probability of poor sleep, irregular work and rest, sleeping during work and physical fatigue, while night shift work focuses on condition observation, operation and treatment, so their personal sense of achievement cannot be improved. The longer the usual daily working hours in recent months and the more overtime work, the higher the corresponding rest and sleep time cannot be adequately guaranteed, and sleep quality is the premise to ensuring good mood, improving personal sense of achievement and good social behaviour. Lack of sleep can lead to changes in psychological functions, such as irritability, anxiety, depression, other negative emotions and loss of interest in work. Some studies have found that the sleep problems of nursing students are higher than those of the general population (Hu et al., 2021; Mulyadi et al., 2021), which reminds us to some extent that attention should be paid to the rationality of nurse scheduling, avoiding long-term continuous work, and doing a good job in the psychological debugging of nurses to improve their sleep quality.

4.3 Effective measures and countermeasures to prevent and alleviate job burnout

The survey's findings indicated that nurses are more vulnerable to burnout from their jobs. To preserve the physical and mental well-being of the nursing group, guarantee the standard of nursing care and sustain the advancement of nursing professions, proactive and efficacious interventions against EE, depersonalization and decreased personal accomplishment should be implemented. Therefore, this study proposes the following measures and suggestions to prevent job burnout among nurses:

First, previous studies have pointed out that the employment process is an interactive process between professionals and occupations (Safari et al., 2022), so we should not only consider the influence of external factors but also the problem of job burnout from the cognitive aspect of professionals (Rasmussen et al., 2016). Therefore, in order to firmly establish a positive concept of employment, this study recommends that nurses learn stress management techniques, monitor their own emotional changes over time, pay attention to the quality of their sleep and seek out professional or social support when juggling work and personal obligations.

Second, owing to the continuous improvement in nursing in China (Zhao et al., 2021), professional requirements for nurses are also increasing. According to Maslow's demand theory, medical and health institutions should not only improve the professional requirements of nurses but also provide them with corresponding care (Giuffrida & Davila, 2024; Zhan et al., 2021). For example, paying attention to the physiological and psychological needs of nurses to reduce their stressors, arranging shifts scientifically, ensuring that nurses have sufficient rest time and regular work and rest, attaching great importance to the interest needs of nurses and actively striving for policy support to safeguard and protect their professional rights and interests. In addition, it should be ensured that the career promotion channel for nurses is unblocked, provide social support for nurses to a certain extent and implement necessary psychological interventions and organizational adjustments to reduce and prevent nurses' job burnout. Those nurses who are new to the field and have little experience should get special care. They should receive salaries and benefits or help in making career plans, provide more psychological attention to married nurses who work in the operating room and provide psychological guidance when necessary to help them eliminate negative emotions. The training provided should focus on the multidimensional development of basic nursing knowledge, nursing skills and nurse–patient interpersonal relationships to improve nurses' job efficiency, quality of life and work quality.

Third, the competent medical and health departments and hospital managers should strengthen the publicity of nursing through policy-making and other ways (Chiu et al., 2021; Salvage & White, 2019) and advocate for the whole society, including the families of patients and nurses, to understand and respect the nursing profession to improve their social status and social support and maintain family harmony. Improving the working environment of nurses (Blau et al., 2023), building a harmonious nurse–patient relationship, creating a healthy working atmosphere and reducing the employment pressure on nurses from the perspective of professional social cognition (White et al., 2019).

4.4 Limitations

There are several restrictions on our investigation. Initially, a cross-sectional design was used in this research to examine the variables influencing work burnout in nurses at this point in their careers. Without a longitudinal survey, the causal relationships between variables cannot be explained. Therefore, further longitudinal studies are required to address this issue. Second, the sample size of male nurses was small, and male nurses were fewer than female nurses in hospitals. It is suggested that future research can start from effective means to alleviate nurses' job burnout, deeply study the internal mechanism and intervention path of job burnout, put forward practical methods to prevent or alleviate nurses' job burnout and find means to include more male nurses.