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ORIGINAL ARTICLES

Factors Related to Job Burnout Among Community Nurses in Changchun, China

Hu, Hai-Xia; Liu, Li-Ting; Zhao, Feng-Jun; Yao, Yao-Yao; Gao, Yu-Xia; Wang, Gui-Ru

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doi: 10.1097/jnr.0000000000000072
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Abstract

Introduction

Job burnout is a continuous response to emotional and interpersonal stress in the workplace over an extended period. Job burnout consists of three dimensions: emotional exhaustion, depersonalization, and personal accomplishment (Maslach, Schaufeli, & Leiter, 2001). This concept, first proposed in 1974 by American clinical psychologist Freudenberger, has been widely applied by nurses, teachers, and other professionals (Freudenberger, 1974; Jordan, Fenwick, Slavin, Sidebotham, & Gamble, 2013; Özkan & Özdevecioğlu, 2013).

In recent years, increasing national policy support for healthcare and deep reformation of the medical system have led to the establishment of health service goals. Community nurses are an important component of the community health service (CHS) system. These nurses are responsible for primary healthcare in communities. In addition, community nurses play an important role in the country’s reasonable allocation of medical resources. They carry out the CHS’s “six in one” functions (i.e., prevention, medicine, healthcare, rehabilitation, health education, and technical guidance of family planning). Job burnout among community nurses reduces job satisfaction and increases turnover. Moreover, job burnout has been shown to severely impact nursing service quality and professional development (Miller, 2011).

In 2010, Hooper, Craig, Janvrin, Wetsel, and Reimels (2010) surveyed nurses working in the emergency and other departments (oncology, intensive care, and kidney division) in the United States. Among emergency department nurses, 59.2% had midrange burnout, and 22.4% had severe burnout. Nurses in other departments had higher rates of more severe burnout. In 2011, Bagaajav, Myagmarjav, Nanjid, Otgon, and Chae detected job burnout in 87% of medical staff in a study in Mongolia, with stress induced by an imbalanced effort–reward model the most important cause (Bagaajav et al., 2011).

Hudek-Knežević, Maglica, and Krapić (2011) showed that job burnout in nurses is related to personality traits, workplace stress from the hospital (role conflict and work overload), and working attitudes. In 2013, Khamisa, Peltzer, and Oldenburg conducted a systematic review of the factors related to burnout that explored the relationships among work-related stress, burnout, and job satisfaction (Khamisa et al., 2013). Wu, Zou, and Liu (2011) researched job burnout among community nurses in Beijing, China. Their reported rates of severe burnout because of emotional exhaustion, depersonalization, and personal accomplishment were 30.5%, 19.8%, and 43.2%, respectively.

There are some published reports related to burnout among community nurses working in China. However, none of these reports have specifically examined the situation in Changchun, Jilin Province (Chen, He, Zou, & Hu, 2012; Gong, Huang, & Li, 2013). This survey explores a region and factors related to job burnout that differ from the survey of Wu et al. (2011). The sample size is adequate to reflect the current situation of burnout among community nurses in Changchun. Findings from this research fill gaps in the academic understanding of community-nurse burnout in Changchun.

Methods

Sample Design

There are 48 CHS centers, 50 CHS stations, and 767 registered nurses (RNs) in Changchun. We used a convenience sampling method and administered a questionnaire survey to 420 RNs at 33 CHS centers and 32 CHS stations in Changchun from July 1 to August 30, 2011.

Community nurses who met the following criteria were invited to participate: (a) holds a certificate of practice, (b) has more than 1 year of work experience in community care, and (c) provides informed consent and volunteers to participate in the study. We excluded from the study community nurses who were not working during the survey period (i.e., on vacation, at school, or on maternity leave).

Research Tools

Sociodemographic survey

Several additional variables were included in the sociodemographic survey to explore factors related to burnout in community nurses. Five domestic experts on CHSs examined and verified the items on the survey instrument. Instrument items included gender, age, marital status, educational level, professional title, years of employment, employment status, interpersonal relationship status, job satisfaction, continuing education opportunities, level of English-language proficiency, and monthly income. The items “doctor–nurse difficulties,” “nurse–nurse difficulties,” and “nurse–patient difficulties” refer to instances in which the nurse had difficulty in her relationship with doctors, other nurses, or patients, respectively.

Job burnout scale

The Maslach Burnout Inventory (MBI) was used in our survey. This scale has been translated into many versions that are widely used in China and have a high reliability and validity, indicating that this scale is applicable for use on nurses (Feng, Luo, & Ye, 2004). The MBI includes 22 items and is divided into three dimensions: emotional exhaustion (five items), depersonalization (nine items), and low personal accomplishment (eight items). Each item is scored using a 5-point Likert scale, with 1 representing “almost never,” 2 representing “a few times,” 3 representing “sometimes,” 4 representing “most of the time,” and 5 representing “almost every day.”

The dimensions of emotional exhaustion and depersonalization used a positive scoring system, with higher scores representing a higher degree of burnout. The low personal accomplishment dimension used a reverse scoring system, with lower scores representing a lower degree of personal accomplishment. Critical values used to assess the dimensions included emotional exhaustion > 11 points, depersonalization > 25 points, and low personal accomplishment > 16 points (Gao, Wang, Yu, Yin, & Wang, 2012).

Cronbach’s α coefficient, which is used to measure the internal consistency of a tool, was used to analyze the reliability of the scale. If the Cronbach’s α was >.7, then the scale was considered to be reliable. Prior research has found the overall MBI to have a Cronbach’s α of .901, with scores for MBI subscales as follows: .925 for emotional exhaustion, .913 for depersonalization, and .883 for low personal accomplishment. This scale demonstrates a high level of internal consistency.

Survey

The research team consisted of four groups, with two researchers in each group. Investigators were trained on both the research technique and on a common set of words and phrases they would use to provide directions. From July 1 to August 30, 2011, investigators distributed the questionnaire survey to 420 RNs who met the research criteria at 33 CHS centers and 32 CHS stations in Changchun. They retrieved 435 questionnaires, of which 420 were valid. The response rate was 93.33%.

Statistics

Epidata 3.1 software was used to upload the data into the computer. SPSS 13.0 for Windows was used to perform the statistical analyses, including normality testing, statistical description, one-factor analysis of variance, and multiple regression analysis.

Results

Sociodemographic Profile

Sociodemographic data are shown in Table 1. All of the respondents were women. Most participants were either ≤30 or 31–40 years old, had worked in their profession for ≥11 years, had an associate degree or a lower level of education, and had not taken the College English Test. There were 174 nurses, 104 senior nurses, and 142 chief nurses or above. In terms of employment status, 57.4% of the participants worked in formal establishments. Most were satisfied with their continuing education opportunities and felt that it was easy to deal with interpersonal relationships. Most participants (47.9%) earned a monthly salary in the 2001–3000 RMB range.

TABLE 1
TABLE 1:
Demographics-Based Comparison of Burnout Dimension Scores (N = 420)

Community Nurse Job Burnout Condition and Extent

Table 2 shows the dimension scores for community nurse job burnout. There were 362 (86.2%) community nurses with job burnout. The detection rate of burnout was high.

TABLE 2
TABLE 2:
Participant Job Burnout Dimension Scores (N = 420)

The Relationship Between Demographic Variables and Burnout Dimension Scores

Table 1 analyzes differences in burnout dimension scores among participants with different demographic characteristics. Correlation factors that were identified as affecting the job burnout of community nurses in Changchun included age, marital status, educational level, professional title, employment status, years of employment, job satisfaction, continuing education opportunities, interpersonal relationship difficulties, and monthly income. Participants younger than 30 years old had lower scores compared with those older than 30 years old. Married participants had higher scores in the emotional exhaustion dimension, whereas unmarried participants had higher scores in the low personal accomplishment dimension.

The scores of participants with a junior college degree were the highest. Those who were senior nurses and nurses working at formal organizations earned relatively high scores. The scores of participants who had worked for ≥ 11 or 4–10 years were relatively high. Participants who were community nurses and who were not satisfied with nursing had the highest job burnout scores. Participants who reported no interpersonal relationship difficulties had lower job burnout scores. Participants with lower monthly incomes, especially those with incomes less than 1000 RMB, were more likely to feel exhausted with their jobs.

Multiple Stepwise Regression Analysis of Factors Related to Job Burnout in Community Nurses

Variable selection

Multiple regression analysis was used to control the interactions among factors affecting job burnout in community nurses and to identify the main factors. The total job burnout score was the dependent variable. Independent variables included sociodemographic information such as age, marital status, educational level, professional title, employment status, years of employment, job satisfaction, continuing education opportunities, interpersonal relationship difficulties, and monthly income.

Multiple stepwise regression analysis of related factors

Multiple stepwise regression analysis identified job satisfaction (satisfied), marital status (unmarried), educational level (junior college), and interpersonal relationship difficulties (doctor–nurse, nurse–patient, and nurse–nurse difficulties) as important explanatory factors of job burnout (Table 3).

TABLE 3
TABLE 3:
Multiple Stepwise Regression Analysis on Factors Related to Job Burnout in Participants

Discussion

The Job Burnout Rate Among Community Nurses in Changchun is High

This study identified 362 (86.2%) of the participants as experiencing job burnout. This rate is higher than the job burnout rates reported by Li, Li, and Shi (2007; 69.1%) and Sun, Wang, and Xu (2011; 70.1%). These two previous studies were performed in other parts of China and may reflect regional differences in wages, benefits, and individual subjective well-being.

The job burnout rate found in this study was also significantly higher than that reported by Aiken et al. (2011) from their study of 98,116 nurses in nine countries surveyed between 1999 and 2009. They reported a job burnout rate in South Korea and Japan of 30%–60%. Differences between the findings of Aiken et al. and this study may be related to the lower salary, poorer working environment, small sample size, and differences in the emotional attitudes of nurses in this study.

Emotional Exhaustion Dimension was the Highest Among the Job Burnout Dimensions for Community Nurses

Emotional exhaustion means that individuals feel exhausted because they cannot deal easily with problems at work. Causes of the high score in the emotional exhaustion dimension in this study included low level of education, limited capabilities and skills, and inability to deal effectively with problems at work.

The depersonalization dimension earned the lowest score. Depersonalization refers to the adoption of negative and indifferent attitudes toward others (Feng et al., 2004; Zhang, Li, & Xu, 2008). The finding of this study indicates that the work attitude of participants was active, with high enthusiasm and readiness to perform their healthcare duties. At present, China is performing “high-quality nursing service” activities at CHS institutions, which is improving the service attitude and quality of community nurses.

Low personal accomplishment refers to an individual’s ability to perceive the value of their work when they work alone as well as work in cooperation with others. The score for this dimension (2.67 ± 0.91 points) was at the medium level. This result is similar to the finding of Zhang et al. (2008). The low educational background of the community nurses (mainly associate junior college graduates) and their low social status reduced their sense of value and led to our finding of a relatively high degree of job burnout.

Correlation Factors that Affect Job Burnout in Community Nurses

Job burnout in nurses is the result of long-term interactions in an individual’s psychological and social environment (Bühler & Land, 2003). The factors that correlated with job burnout in community nurses in Changchun included age, marital status, educational level, professional title, employment status, years of employment, job satisfaction, continuing education opportunities, interpersonal relationship difficulties, and monthly income.

Age, Marital Status, and Educational Level

Burnout in community nurses relates to their age, marital status, and educational level. We identified no statistically significant differences in the emotional exhaustion dimension of participants in different age groups. The scores of participants who were younger than 30 years old were lower than those who were older than 30 years old. This result may be because of the negative effects of increasing age on the energy level and physical condition of nurses.

We found that marital status had a significant effect on the dimensions of emotional exhaustion and personal accomplishment. Married participants earned higher scores in the emotional exhaustion dimension, and unmarried participants had higher scores in the low personal accomplishment dimension. Married nurses often face stress from both work and family and perceive that their self-worth is not properly reflected. Furthermore, married nurses may differ in their individual capabilities to withstand strain. Research by Crawford, Lepine, and Rich (2010) showed that family and age are factors that influence the formation of burnout.

The participants had different educational backgrounds and different personal and social expectations, which caused the statistically significant differences in the emotional exhaustion and overall job burnout dimension scores. The scores for junior college nurse participants were the highest. This result was similar to the findings of Luo, Ye, and Feng (2005), which showed that nurses with associate degrees are more likely to burn out because of the restrictions related to their abilities and degrees.

Professional Title, Labor Properties, and Years of Employment

The job burnout conditions were different in nurses who had different professional titles, labor properties, and years of employment. There were statistically significant differences in the emotional exhaustion dimension of nurses who had different professional titles and employment status. These results were similar to those of Zhang et al. (2008).

Participants who were senior nurses or were nurses working in formal organizational systems had higher emotional exhaustion scores. This may be because of senior nurses being more likely to be married and have children, inferring that they had higher demands on their energy and physical strength. Furthermore, nurses in this category are at a particularly critical time in their career and serve in key positions in their units. Therefore, senior nurses face the dual stresses of work and family, which lead to job burnout.

Nurses typically show less enthusiasm toward their work when they are employed at formal organizations. Gao et al. (2012) studied job burnout among nurses in the Tianjin district and found higher position title to be associated with lower levels of burnout, which differs from the results of this study. This study found statistically significant differences in the emotional exhaustion and depersonalization dimensions among participants in different years-of-employment categories. Nurses who had worked for more than 11 years and for 4–10 years had higher scores than the other nurses. These nurses typically work longer hours, leading to job burnout.

Work Satisfaction and Continuing Education Opportunities

There were significant differences in the dimensions of job burnout and overall burnout among participants based on job satisfaction and continuing education opportunities. Participants who were not satisfied with nursing earned the highest scores on job satisfaction, indicating that this group had the most serious level of job burnout. This may be associated with lower social status and relatively low wages. This result is similar to those of Xie, Xu, and Liu (2007). Nurses who like their jobs, who are cheerful, and who have a strong willingness to work respond more actively to daily work and difficulties and report a lower rate of job burnout. Therefore, the relevant departments should take active measures to enhance the enthusiasm of nurses in the workplace to reduce job burnout.

Interpersonal Relationship Difficulties and Monthly Income

Differences in interpersonal relationship difficulties significantly affected the dimensions of job burnout and overall job burnout. Participants who reported having no difficulties in their interpersonal relationships earned lower scores for job burnout. Previous studies have shown that interpersonal relationship difficulties influence the formation of burnout (Wright, 2011). Differences in monthly income had a statistically significant effect on the emotional exhaustion dimension. Nurses with different monthly incomes, especially those with incomes below 1000 RMB, are more likely to feel exhausted in the workplace.

Explanatory Factors for Job Burnout

Stepwise regression found that job satisfaction, marital status, educational level, and interpersonal relationship difficulties all significantly influenced job burnout. A survey by Meeusen, van Dam, Brown-Mahoney, van Zundert, and Knape (2010) that addressed burnout and job satisfaction among 425 Dutch nurse anesthetists showed a negative relationship between job burnout and job satisfaction and a 27% rate of job satisfaction. In this study, unmarried nurses had the highest scores. This may be related to their younger age, lack of stable marital relationships, and a lack of psychological support. Huang (2012) surveyed county hospital nurses in China and found no significant difference between educational level and burnout, considering that nursing primarily requires technological skills that do not require a high level of education. These results differ from those of this study.

This study supports that stresses from interpersonal relationships and job burnout are positively correlated. We found that level of interpersonal relationship difficulties relates positively to level of burnout severity, which is a result similar to those of previous studies of nurse burnout and related factors (Deng, Liu, & Xiang, 2010). A study on burnout among French doctors in 2011 showed that work–family conflicts, salary, and interpersonal tension, including low interpersonal cooperation abilities, led to burnout (Doppia, Estryn-Béhar, Fry, Guetarni, & Lieutaud, 2011). The reasons for burnout in nurses are similar, indicating that interpersonal relationships also affect nursing staff (Doppia et al., 2011).

In summary, this study identified a high rate of job burnout among community nurses in Changchun. We suggest that the relevant departments should take action to develop supportive policies, create fair and reasonable opportunities for advancement, improve benefits, increase job satisfaction, and arouse enthusiasm among community nurses working in Changchun. Hospital-related departments should encourage nurses to pursue further education opportunities. In addition, these departments should adopt measures to encourage community nurses to participate actively in training to improve their professional skills. Psychological care should be provided. Relevant departments should monitor the various work and family-derived stresses that affect community nurses and then provide these nurses with psychological and policy support to facilitate their effective response to these stresses. The results of this survey only reflect the incidence of burnout among community nurses in Changchun, China. The National Health Ministry and Ministry of Finance established goals for improving the benefits, job satisfaction, and enthusiasm of community nurses in 2011. Therefore, cohort studies should be implemented to support related health departments to formulate appropriate principles and policies for community health workers.

Acknowledgment

We thank Medjaden Bioscience Limited for assisting in the preparation of this manuscript.

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Keywords:

community nurses; job burnout

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