JAN JOURNAL OF ADVANCED NURSING

ORIGINAL RESEARCH

Nurse burnout and its association with occupational stress in a

cross-sectional study in Shanghai
Zhenyu Xie, Aolin Wang & Bo Chen

Accepted for publication 11 December 2010

Correspondence to Bo Chen: X I E Z . , W A N G A . & C H E N B . ( 2 0 1 1 ) Nurse burnout and its association with

e-mail: chenb@fudan.edu.cn occupational stress in a cross-sectional study in Shanghai. Journal of Advanced
Nursing 67(7), 1537–1546. doi: 10.1111/j.1365-2648.2010.05576.x
Zhenyu Xie BSc MPH
Doctor-in-Charge
Pudong Center for Disease Control and
Abstract
Prevention, Shanghai, China Aim. This paper is a report of a study investigating nurse burnout and its associ-
ation with occupational stressors in Shanghai, China.
Aolin Wang BSc Background. Burnout is described as feelings of emotional exhaustion, deperson-
Medical Student alization and reduced personal accomplishment. Measuring burnout among nurses
School of Public Health, Fudan Uinversity, and its association with occupational stressors are important in providing appro-
Shanghai, China priate intervention to reduce stress and burnout.
Method. In total, 527 nurses from 41 hospitals in Shanghai returned self-
Bo Chen MD PhD FFPH
reported questionnaires in June 2008. Their burden of burnout was measured by
Lecturer
School of Public Health, Fudan University, the Chinese version of ‘Maslach Burnout Inventory’, and their stress by the
Shanghai, China Chinese version of ‘job content questionnaire’ and ‘effort-reward imbalance
questionnaire’.
Results. Most nurses (74Æ76%) had a Demand/Control ratio higher than 1 and
27Æ13% had an Effort/Reward ratio higher than 1. The nurses showed a high
level of emotional exhaustion, moderate level of depersonalization, and low level
of reduced personal accomplishment. Linear regression analyses showed higher
burden of stress and burnout among nurses at younger age, or on shift duty or
from higher grade hospitals. Both the job content questionnaire and effort-reward
imbalance questionnaire models had good predictive powers of the nurses’
burnout, especially the effort-reward imbalance questionnaire model is more
powerful than the other in predicting two Maslach Burnout Inventory subscales
of emotional exhaustion and depersonalization.
Conclusion. Nurses in Shanghai were suffering from high levels of burnout,
which was strongly associated with work-related stress. Interventions in reducing
occupational stress are needed to reduce the burden of burnout in Chinese
nurses.

Keywords: burnout, China, effort–reward imbalance, job content questionnaire,

Maslach Burnout Inventory, nurses, stress

 2011 Blackwell Publishing Ltd 1537

Z. Xie et al.
Introduction
Burnout is defined as a psychological syndrome of emotional
exhaustion, depersonalization and reduced personal accom-
plishment that occurs among individuals who work with
other people, particularly in conflicting or otherwise critical
situations (Maslach & Schaufeli 1993). It is reported that
more than 100 symptoms and possible consequences are
associated with burnout, ranging from anxiety to lack of zeal
(Schaufeli & Enzmann 1998). Especially worth noticing is
that burnout among nurses is a serious condition that
threatens their own health and that of their patients. Halbe-
sleben et al. (2008) has found out that burnout was associated
with the perception of lower patient safety. The extension of
burnout in nursing is high and is receiving worldwide
attention (Wu et al. 2007, Garrosa 2008, Schulz et al. 2009).
Duquette et al.’s (1994) review paper identified three
groups of factors that appear to be linked to burnout in
nursing: organizational factors such as occupational stres-
sors, ‘buffering’ factors such as coping strategies and demo-
graphic factors such as age, nursing grade and experience.
Among these factors, prolonged stress at work is claimed to
lead to burnout (Freudenberger 1974), especially when the
demands of work and individual capacities are imbalanced
(Wu et al. 2007). Researchers suggested that some elements
of occupational stress are significantly associated with burn-
out in different professions, such as teachers (Unterbrink
et al. 2007), judges and procurators (Tsai et al. 2009).
Nursing is considered as a risk profession with high levels
of stress and burnout. In current healthcare settings, nurses
are particularly at risk for burnout given the increased patient
acuity and the worsening nursing shortage. Aiken et al.
(2002) showed that nurses in hospitals with high patient-
to-nurse ratios are more likely to experience burnout and job
dissatisfaction. China confronts one of the world’s most
severe nursing shortages. According to China’s Ministry of
Health (2003), the number of registered nurses was
10:10,000 of the population from 1997 to 2002, while this
number was 74Æ49:10,000 in Japan and 83:10,000 in
Australia at the same time (WHO 2002, Zeng 2009).
Understanding nurses’ burnout level and its relationship with
occupational stressors is of importance to reduce the health
risks among nurses and increase the quality of health services.
As pointed out by Zeng (2009), stress and burnout in
nursing have been studied extensively for more than two
decades; however, their relationship among nurses in main-
land China remains largely unknown. To our knowledge,
there are less than ten studies in English literatures discussing
the stress–burnout interactions among Chinese nurses, most
of which were data from Taiwan or Hong Kong. This study
1538
was designed to investigate nurse burnout and its association
with occupational stressors in Shanghai, a largest city in
China facing the challenge of overcrowded population and
nursing shortage.
The study
Aim
The aim of the study was to investigate nurse burnout and its
association with occupational stressors in Shanghai, China.
Design
A cross sectional design was used to investigate the level of
stress and burnout in nurses.
Participants and settings
Participants were nurses from 21 hospitals in the Pudong
district of Shanghai city. All hospitals in China are classified
as three grades based on the facility, equipment and staffing.
The higher the grade, the more sophisticated the facility.
Local small communities usually have primary hospitals
(Grade I), while large communities or the centre of some
middle town are generally equipped with larger hospitals
named community hospitals (Grade II). Grade III hospitals
are usually located in large cities and called general hospitals.
There were around 2500 nurses from 41 hospitals (29 Grade
I, 9 Grade II and 3 Grade III) at Pudong district at the time of
the survey (June 2008). We selected half of the Grade I (14)
and Grade II (4) hospitals in random and all three Grade III
hospitals as the sampling pool. Approximately 20–30% of
nurses from each hospital, giving a total of 550 nurses, were
invited to participate in the survey.
Data collection
Data were collected using self-reported questionnaires under
the instruction of trained investigators in June 2008. There
were 527 nurses completed the questionnaires, giving a
response rate of 95Æ8%.
Personal and job characteristics, including age, height and
weight for calculating body mass index (BMI), education,
marital status, personal salary, family income, smoking and
alcohol drinking habit, whether or not doing exercise
frequently, hospital type, department, technical rank, work
experience, working hours per week, and whether or not
doing shift work, were all tabulated for further association
analyses.
 2011 Blackwell Publishing Ltd
JAN: ORIGINAL RESEARCH
Occupational stress
Two standardized questionnaires were used to measure the
occupational stress: the Chinese version of the ‘job content
questionnaire’ (C-JCQ) based on the Karasek’s JCQ model
and the Chinese version of the ‘effort-reward imbalance
questionnaire’ (C-ERI) based on the Siegrist’s ERI model (Dai
et al. 2008).
The 22-item JCQ questionnaire consists of three scales
including five items of ‘psychological demand’, nine items of
‘job control’ and eight items of ‘workplace social support’.
The ‘job control’ scale is the sum of two subscales: ‘skill
discretion’ measured by six items and ‘decision authority’
measured by three items. The ‘workplace social support’ scale
is the sum of two subscales: ‘coworker support’ measured by
four items and ‘supervisor support’ measured by four items.
Items were scored on a five-point scale ranging from 0 (never)
to 4 (always). The value of the demand-control ratio (D/C
ratio) was also assessed to evaluate the balance between
psychological demand and job control. The D/C ratio was
calculated as follows: demand/control · correction factor
(factor correcting for the difference in the numbers of items
of the two scales). A score of D/C ratio greater than 1
indicates a high-risk imbalance condition for high job
demand and low self-control. In this study, the Cronbach’s
a value for total 22 items was 0Æ788. The Cronbach’s a values
for ‘job demand’, ‘job control’ and ‘workplace social support’
were 0Æ671, 0Æ794 and 0Æ795 respectively. The measure
showed acceptable internal consistency.
The 22-item ERI questionnaire consists of three scales
including six items of ‘job effort’, 11 items of ‘job reward’
and five items of ‘overcommitment’. Items were scored on a
five-point Likert scale ranging from 0 (no) to 4 (yes, I am very
distressed). The value of the effort–reward ratio (E/R ratio)
was also assessed to evaluate the balance between job effort
and reward. The E/R ratio was calculated as follows: effort/
reward · correction factor (factor correcting for the differ-
ence in the numbers of items of the two scales). A score of
E/R ratio greater than 1 indicates a high-risk imbalance
condition for high cost and low gain. In this study, the
Cronbach’s a value for total 22 items was 0Æ903. The
Cronbach’s a values for ‘job effort’, ‘job reward’ and
‘overcommitment’ were 0Æ871, 0Æ864 and 0Æ812 respectively.
The measure showed a better internal consistency.
Job burnout
The Chinese version of the 19-item of the ‘Maslach Burnout
Inventory’ (C-MBI) revised by Boles et al. (2000) was used to
measure the three domains of burnout: emotional exhaustion
(seven items), depersonalization (five items) and reduced
personal accomplishment (seven items) (Dai et al. 2008).
 2011 Blackwell Publishing Ltd
Stress and burnout in nurses
Items were scored on a seven-point scale ranging from 0
(never) to 6 (every day). All items of ‘personal accomplish-
ment’ were reversely coded. Higher scores reflect greater
emotional exhaustion, depersonalization, and fewer personal
accomplishments. In this study, the Cronbach’s a value for
total 19 items was 0Æ789. The Cronbach’s a values for
‘emotional exhaustion’, ‘depersonalization’ and ‘personal
accomplishment’ were 0Æ852, 0Æ762 and 0Æ749 respectively.
Ethical considerations
The study was approved by the appropriate Ethics Commit-
tees. All participants gave written informed consent.
Data analyses
Data analysis was performed using SPSS 12.0 (SPSS Inc.,
Chicago, IL, USA) and STATA/SE 8.0 for windows (StataCorp
LP, College Station, TX, USA). All statistical tests were
two-sided (a = 0Æ05). To examine the association between
nurse burnout and occupational stressors, crude and
adjusted linear regression analyses were first conducted to
identify the predictors of each burnout dimension (emotional
exhaustion, depersonalization and reduced personal accom-
plishment). In the crude analysis, personal and job charac-
teristics together with JCQ and ERI indices were forced into
the linear regression model one by one (single-variable
model). The adjusted analysis was then performed forcing all
tabulated variables into the regression model (multi-variable
model).
The upper tertile scores for psychological demand, effort
and overcommitment as well as the lower tertile scores for
job control, workplace social support and reward were
defined high-risk conditions. The dichotomized D/C ratio (or
E/R ratio) with a cut-point of 1Æ00 was defined as a high-risk
condition for imbalance. Burnout indices including emotional
exhaustion, depersonalization and personal accomplishment
were defined as dichotomized variables with a cut-point at
the two-third percentile score.
Logistic regression was then adopted to estimate the
association between nurse burnout and occupational stress.
After controlling for all confounding factors of tabulated
personal and job characteristics, logistic regression was
applied to determine the statistical significance of the associ-
ation between three dimensions of nurse burnout and the
independent effect of each occupational stress scale, including
psychological demand, job control, D/C ratio, workplace
social support, job effort, job reward, E/R ratio, overcom-
mitment. The odds ratio (OR) and its 95% confidence interval
(95%CI) were provided in the logistic regression analyses.
1539
Z. Xie et al.

Table 1 Personal and job characteristics among nurses

Results
Personal Job
All participating nurses were female. The mean age of the 527 characteristics N (%) characteristics N (%)
participants was 32Æ11 years, and the mean duration of their
Age Shift work
work experience was 10Æ05 years. Other personal and job
<30 240 (45Æ5) No 177 (33Æ59)
characteristics are given in Table 1. Table 2 shows the level 30–39 196 (7Æ2) Yes 350 (66Æ41)
of occupational stress and burnout in nurses. The mean JCQ >39 91 (17Æ3) Hospital type
scales were 18Æ50 for psychological demand, 29Æ14 for job BMI (kg/m2) Grade I 130 (24Æ67)
control, and 28Æ84 for workplace social support. The mean <25Æ0 487 (92Æ4) Grade II 149 (28Æ27)
D/C ratio was 1Æ17 and 394 participants (74Æ76%) had a ‡25Æ0 40 (7Æ6) Grade III 248 (47Æ06)
Education Department
value higher than 1, indicating that the majority of the nurses
Highschool or 197 (37Æ38) Internal 318 (60Æ34)
had a high-risk imbalance condition for high job demand and below medicine
low self-control. The mean ERI scales were 18Æ92 for job Junior college 269 (51Æ04) Surgery 141 (26Æ76)
effort, 44Æ86 for job reward and 15Æ65 for overcommitment. Senior college 61 (11Æ57) Others 68 (12Æ90)
The mean E/R ratio was 0Æ82, and 137 participants (26Æ05%) Marital status Technical rank
Married 358 (67Æ93) Junior 421 (79Æ89)
had a value higher than 1, indicating that some of the nurses
Unmarried 166 (31Æ50) Intermediate 100 (18Æ98)
had a low-risk imbalance condition for high cost and low Others 3 (0Æ57) Senior 6 (1Æ14)
gain. The mean MBI scales were 28Æ48 for emotional Salary (CN Yuans/ Work experience
exhaustion, 11Æ39 for depersonalization and 34Æ79 for per- month) (Years)
sonal accomplishment. <2000 83 (15Æ75) <5 214 (40Æ61)
All linear regression results are presented in Table 3. 2000–4000 387 (73Æ43) 5–15 173 (32Æ83)
>4000 57 (10Æ82) >15 140 (26Æ57)
Nurses’ emotional exhaustion was inversely associated with
Family income Working hours
increased age, enhanced technical rank and work experience, (CN Yuans/month/person) per week
improved job control, workplace social support and job <1000 27 (5Æ12) £40 445 (84Æ44)
reward, but positively associated with unmarried status, 1000–3000 264 (50Æ09) >40 82 (15Æ56)
larger hospital (from Grade I hospital to Grade III hospital), 3000–5000 146 (27Æ70)
>5000 90 (17Æ08)
shift work, increased psychological demand, job effort and
Alcohol drinking
overcommitment in single-variable models. The multi-vari- No 519 (98Æ48)
able model of stepwise analysis after controlling potential Yes 8 (1Æ52)
confounders listed in Tables 1 and 2 diminished most Smoking
associations, where enhanced emotional exhaustion was still No 527 (100Æ00)
significantly related to increased job effort and overcommit- Exercise
No 441 (83Æ68)
ment, reduced workplace social support, younger age and
Yes 86 (16Æ32)
lower education.
Nurses’ depersonalization was inversely associated with
increased age and BMI, alcohol drinking, enhanced technical support and job reward, but inversely associated with
rank and work experience, improved job control, workplace unmarried status, larger hospital, and shift work in single-
social support and job reward, but positively associated with variable models. The multi-variable model after controlling
unmarried status, larger hospital, shift work, increased all confounders diminished most associations, where
psychological demand, job effort and overcommitment in enhanced family income, psychological demand, job control
single-variable models. The multi-variable model after con- and reward were still associated with enhanced personal
trolling potential confounders diminished most associations, accomplishment. Larger hospital and higher technical rank
where enhanced depersonalization was still significantly were associated with reduced personal accomplishment in
related to reduced age, alcohol drinking, technical rank and multi-variable analysis.
job reward. At the same time, higher salary and overcom- The ORs of nurses’ burnout increase with occupational
mitment also contributed to higher scores of depersonaliza- stress are presented in Table 4. All logistic regression results
tion. in Table 4 were adjusted for nurses’ personal and job
Nurses’ enhanced personal accomplishment was positively characteristics including age, BMI, education, marital status,
associated with increased age, family income, work experi- salary, family income, alcohol drinking, exercise, hospital
ence, psychological demand, job control, workplace social type, department, technical rank, work experience, working

1540  2011 Blackwell Publishing Ltd

JAN: ORIGINAL RESEARCH Stress and burnout in nurses

Table 2 Occupational stress and burnout scores among nurses (OR = 1Æ00, 1Æ19, 1Æ71, P for trend = 0Æ034) and job reward
(OR = 1Æ00, 1Æ33, 2Æ47, P for trend <0Æ001).
Occupational stress and burnout Mean ± SD
Occupational stress assessed by D/C ratio and E/R ratio
JCQ was also associated with two dimensions of nurses’ burnout
Psychological demand 18Æ50 ± 2Æ65
including emotional exhaustion and depersonalization, where
Job control 29Æ14 ± 4Æ15
D/C ratio 1Æ26 ± 0Æ38
D/C ratio greater than 1 showed 4Æ70-fold higher emotional
D/C ratio > 1Æ00, N (%) 394 (74Æ76) exhaustion and 2Æ69-fold higher depersonalization than the
Workplace social support 28Æ84 ± 4Æ95 nurses with D/C ratio lower than 1, and E/R ratio greater
ERI than 1 showed 4Æ15-fold higher emotional exhaustion and
Job effort 18Æ92 ± 5Æ37 5Æ49-fold higher depersonalization than the nurses with E/R
Job reward 44Æ86 ± 8Æ11
ratio lower than 1.
E/R ratio 0Æ82 ± 0Æ74
E/R ratio > 1Æ00, N (%) 137 (26Æ05)
Overcommitment 15Æ65 ± 2Æ86
Discussion
MBI
Emotional exhaustion 28Æ48 ± 9Æ45
Depersonalization 11Æ39 ± 6Æ15 Stress and burnout level
Personal accomplishment 34Æ79 ± 8Æ14
In this study, the mean score of job strain index (D/C ratio)
was found to be 1Æ26, and a value greater than 1 was found in
74Æ76% of the nurses investigated. These figures were much
hours per week and shift work. Crude regression results higher than those in most publications, in which a D/C ratio
(Data not shown) were similar to the adjusted results shown was usually reported to be lower than 1. Typically, in some
in Table 4. large-sample cross-sectional studies, women of working age
Generally, stronger and more consistent effects were found had a D/C ratio lower than 0Æ81 (Tsutsumi et al. 2001, Sanne
with regard to the ERI indices for nurses’ burnout, and with et al. 2005). While most of the literature did not give the
regard to emotional exhaustion and depersonalization than information of D/C ratio in terms of nurses, an E/R ratio
personal accomplishment. There were dose-response rela- indicating imbalanced job effort and reward was more
tionships between dichotomized emotional exhaustion and frequently applied in the literature. The E/R ratio of 0Æ82 in
psychological demand (OR per tertile adjusting potential this study was higher than that of Belgian (Stordeur &
confounding factors = 1Æ00, 1Æ85, and 4Æ99, P for trend D’Hoore 2007), German (Schulz et al. 2009) and Canadian
<0Æ001), and job control (OR = 1Æ00, 1Æ21, 2Æ09, P for trend (Spence Laschinger & Finegan 2008) nurses, but similar to
<0Æ001), and workplace social support (OR = 1Æ00, 1Æ10, that of Dutch (Schreuder et al. 2010) and Japanese (Kikuchi
2Æ13, P for trend <0Æ001), and job effort (OR = 1Æ00, 3Æ21, et al. 2010) nurses. It is therefore shown that the nurses in
10Æ71, P for trend <0Æ001), and job effort (OR = 1Æ00, 2Æ11, this study experienced higher levels of stress where high
4Æ15, P for trend <0Æ001), and overcommitment (OR = 1Æ00, psychological demand could not be evened out by self-
3Æ96, 11Æ12, P for trend <0Æ001). The dose-response control, and heavy job effort could not be compensated with
relationships were also observed with regard to dichotomized proper reward.
depersonalization and its associations with psychological The nurses in this study showed a high level of emotional
demand (OR = 1Æ00, 1Æ52, 3Æ15, P for trend <0Æ001), exhaustion (mean score: 28Æ48, 4Æ07 divided by seven items,
workplace social support (OR = 1Æ00, 1Æ30, 2Æ40, P for trend indicating that half of the nurses felt emotionally exhausted
<0Æ001), job effort (OR = 1Æ00, 2Æ36, 3Æ49, P for trend at least once per week), moderate levels of depersonalization
<0Æ001), job reward (OR = 1Æ00, 2Æ48, 5Æ49, P for trend (mean score: 11Æ39, 2Æ28 divided by five items, indicating over
<0Æ001), and overcommitment (OR = 1Æ00, 2Æ44, 3Æ59, P for half of nurses felt depersonalized at least once per month),
trend <0Æ001). Occupational stress had lower effects on but low level of reduced personal accomplishment (mean
personal accomplishment compared with emotional exhaus- score: 34Æ79, 4Æ97 divided by seven items, indicating that
tion and depersonalization. Reduced personal accomplish- around half of the nurses believed to have personally
ment was found to be associated with enhanced accomplished something a few times per week or every
psychological demand (OR = 1Æ00, 0Æ53, 0Æ56, P for tren- day). The results indicated that the burnout burden in the
d = 0Æ028). Enhanced personal accomplishment was found to nurses were mainly on the subscales of emotional exhaustion
be associated with decreased job control (OR = 1Æ00, 1Æ44, and depersonalization, but not reduced personal accomplish-
2Æ18, P for trend <0Æ001), workplace social support ment.

 2011 Blackwell Publishing Ltd 1541

Z. Xie et al.

Table 3 Single- and multi-variable linear regression coefficients between burnout indexes and personal (or occupational) stressors
Emotional exhaustion Depersonalization Personal accomplishment
   
Personal or occupational stressors Single Multi Single Multi Single Multi

Age§ 0Æ20*** 0Æ13*** 0Æ29*** 0Æ23*** 0Æ20*** 0Æ17**

BMI§ 0Æ03 – 0Æ07 – 0Æ04 –
Education 0Æ07 0Æ07* 0Æ07 – 0Æ02 –
Marital status 0Æ09* – 0Æ18*** – 0Æ13** –
Salary 0Æ03 – 0Æ00 0Æ14** 0Æ08 –
Family income 0Æ01 – 0Æ05 – 0Æ12** 0Æ11*
Alcohol drinking 0Æ00 – 0Æ09* 0Æ08* 0Æ04 –
Exercise 0Æ06 – 0Æ02 – 0Æ02 –
Hospital type 0Æ20*** – 0Æ19*** – 0Æ10* 0Æ15**
Department 0Æ04 – 0Æ04 – 0Æ04 –
Technical rank 0Æ13** – 0Æ23*** 0Æ11* 0Æ06 0Æ10*
Work experience 0Æ09* – 0Æ19*** – 0Æ16*** –
Working hours per week 0Æ08# – 0Æ07# – 0Æ01 –
Shift work 0Æ19*** – 0Æ21*** – 0Æ09* –
Psychological demand§ 0Æ42*** – 0Æ22*** – 0Æ09* 0Æ15**
Job control§ 0Æ12** – 0Æ12** – 0Æ21*** 0Æ18***
Workplace social support§ 0Æ21*** 0Æ09** 0Æ18*** – 0Æ12** –
Job effort§ 0Æ62*** 0Æ39*** 0Æ31*** – 0Æ06 –
Job reward§ 0Æ43*** – 0Æ42*** 0Æ36*** 0Æ11* 0Æ12**
Overcommitment§ 0Æ59*** 0Æ35*** 0Æ28*** 0Æ12** 0Æ06 –
R2 0Æ50*** 0Æ28*** 0Æ12***
Adjusted R2 0Æ50*** 0Æ27*** 0Æ11***

*P < 0Æ05; **P < 0Æ01; ***P < 0Æ001; #P < 0Æ1.

Only one variable entered into the regression models.

All the variables were forced into the multi-variables regression models.
§
Age, BMI, psychological demand, job control, social support, job effort, job reward and overcommitment were forced into the models as
continuous variables, the others as categorical variables.

Most interestingly, we found that the type of hospital in

Stress and burnout in relation to nurses’ personal and job
characteristic
The stress subscales of the JCQ and ERI indexes were mainly
associated with age, reduced personal or family income,
hospital type, working hours per week and rotation shift (data
not shown). These personal and job-related characteristics
(old age, low grade hospital type and no shift work) were also
associated with lower emotional exhaustion and depersonal-
ization, together with greater personal accomplishment.
Older nurses are usually equipped with rich experience in
handling challenging situations and higher ranking that earns
them more respect from others, better economic reward, and
less requirement of shift work. Therefore, they are believed to
have lower level of workload stress and burnout (Brewer &
Shapard 2004, Wu et al. 2007, Garrosa et al. 2009). Higher
working hours per week and taking rotation shift will directly
increase the workload or disturb the daily life schedule, and
have been reported to be associated with high level of stress
and burnout (van Wijk 1997, Makowiec-Dabrowska et al.
2000, van der Heijden et al. 2008).
which the nurses worked was closely related to work-related
stressors (data not shown) and burnout. General hospitals
(Grade III) presented higher scores in terms of psychological
demand, effort, overcommitment, emotional exhaustion, and
depersonalization, but lower scores in personal accomplish-
ment. The fact that over half of the nurses in general hospitals
were suffering from burnout was also reported by two other
studies conducted in Shanghai (Wang et al. 2008, Feng et al.
2004). This phenomenon that nurses in larger hospitals
showing heavier burden of stress and burnout may be
explained by the competition at a higher level in those hospitals
compared with others. It is common knowledge that people in
China are accustomed to visiting a doctor even when they are
not suffering from serious disease. This leads to a large number
of outpatients and a fast rotation of inpatients in those general
hospitals. In fact, China is undergoing reforms in the medical
sector which aim at reducing the workload in larger hospitals
and better allocating the medical resources of different
hospitals. It is expected that these reforms will alleviate the
work-related stress and burnout of both nurses and doctors.

1542  2011 Blackwell Publishing Ltd

JAN: ORIGINAL RESEARCH Stress and burnout in nurses

Table 4 Associations of the tertiles of JCQ (or ERI) indexes with burnout indexes (Logistic regression analyses)
Emotional exhaustion Depersonalization Personal accomplishment
JCQ or ERI tertile AOR (95%CI) AOR (95%CI) AOR (95%CI)

JCQ
Psychological demand 1 1Æ00 1Æ00 1Æ00
2 1Æ85 (1Æ06–3Æ23)** 1Æ52 (0Æ86–2Æ69) 0Æ53 (0Æ32–0Æ89)*
3 4Æ99 (3Æ01–8Æ26)*** 3Æ15 (1Æ88–5Æ29)*** 0Æ56 (0Æ35–0Æ89)*
P for trend§ <0Æ001 <0Æ001 0Æ028
Job control 1 1Æ00 1Æ00 1Æ00
2 1Æ21 (0Æ76–1Æ94) 0Æ95 (0Æ58–1Æ56) 1Æ44 (0Æ89–2Æ33)
3 2Æ09 (1Æ28–3Æ38)** 1Æ28 (0Æ77–2Æ14) 2Æ18 (1Æ33–3Æ57)**
P for trend§ <0Æ001 0Æ208 <0Æ001
D/C ratio £1Æ00 1Æ00 1Æ00 1Æ00
>1Æ00 5Æ05 (2Æ92–8Æ73)*** 2Æ61 (1Æ62–4Æ23)*** 1Æ23 (0Æ80–1Æ88)
Workplace social support 1 1Æ00 1Æ00 1Æ00
2 1Æ10 (0Æ68–1Æ77) 1Æ30 (0Æ77–2Æ18) 1Æ19 (0Æ73–1Æ92)
3 2Æ13 (1Æ33–3Æ41)** 2Æ40 (1Æ44–3Æ99)*** 1Æ71 (1Æ07–2Æ75)*
P for trend§ <0Æ001 <0Æ001 0Æ034
ERI
Job effort 1 1Æ00 1Æ00 1Æ00
2 3Æ21 (1Æ83–5Æ64)*** 2Æ36 (1Æ37–4Æ07)** 0Æ93 (0Æ58–1Æ49)
3 10Æ71 (6Æ04–18Æ99)*** 3Æ49 (2Æ00–6Æ06)*** 0Æ96 (0Æ59–1Æ57)
P for trend§ <0Æ001 <0Æ001 0Æ784
Job reward 1 1Æ00 1Æ00 1Æ00
2 2Æ11 (1Æ29–3Æ45)** 2Æ48 (1Æ45–4Æ25)** 1Æ33 (0Æ82–2Æ16)
3 4Æ15 (2Æ48–6Æ92)*** 5Æ49 (3Æ14–9Æ61)*** 2Æ47 (1Æ50–4Æ06)***
P for trend <0Æ001 <0Æ001 <0Æ001
E/R ratio £1Æ00 1Æ00 1Æ00 1Æ00
>1Æ00 5Æ51 (3Æ63–8Æ36)*** 3Æ18 (2Æ12–4Æ76)*** 1Æ32 (0Æ88–1Æ98)
Overcommitment 1 1Æ00 1Æ00 1Æ00
2 3Æ96 (2Æ18–7Æ19)*** 2Æ44 (1Æ39–4Æ27)** 0Æ99 (0Æ60–1Æ63)
3 11Æ12 (6Æ27–19Æ74)*** 3Æ59 (2Æ10–6Æ13)*** 0Æ83 (0Æ51–1Æ34)
P for trend§ <0Æ001 <0Æ001 0Æ944

*P < 0Æ05; **P < 0Æ01; ***P < 0Æ001; #P < 0Æ1.

For the analyses in all participants, tertile cut points were as follows: psychological demand: <18, 18–19, >19; job control: >30, 27–30,
<27; social support: >30, 27–30, <27; job effort: <17, 17–21; >21; job reward: >49, 42–49, <42; overcommitment: <15, 15–16, >16.

Adjusted odds ratio (95% confidence interval), adjusted for age, BMI, education, marital status, salary, family income, alcohol drinking,
exercise, hospital type, department, technical rank, work experience, working hours per week and shift work.
§
P for trend reflects Mantel-Haenszel Chi-square distribution of categorized burnouts indexes among the tertiles of JCQ (or ERI) indexes.

Relationship between stress and burnout
In this study, in both the MBI subscales of emotional
exhaustion and depersonalization, the ERI model showed
higher predictive power (higher ORs and lower P values)
than the JCQ models. Although both the JCQ and ERI
models were found to be useful in understanding the relation
between occupational stress and adverse health effects, they
both have shortcomings. The JCQ model has a good
description of the work environment, but does not take into
account the individual differences such as the variant reaction
under the same stressful situation. The ERI model takes inter-
individual differences into consideration, but excludes any
measurement of task-level control. Similar to our findings in
the study, Calnan et al. (2004) & Dai et al. (2008) have
reported a better predictive power of the ERI model than the
JCQ model when discussing work-related burnout or dis-
eases. To overcome the difference between the JCQ and ERI
models, a recent trend is combining both models in assessing
job stress (Ota et al. 2005, Dai et al. 2008, Tsai et al. 2009),
or future studies should develop a new model that covers the
main aspect in both the JCQ and ERI model, and refine some
of the items (Griep et al. 2009).
We also found that all the six subscales in the JCQ and ERI
models had strong correlations with the MBI subscales of
emotional exhaustion and depersonalization, some of which
were also, to a certain extent, associated with personal
accomplishment. This weak association between stress and

 2011 Blackwell Publishing Ltd 1543

Z. Xie et al.
What is already known about this topic
• Younger nurses present higher levels of work-related
stress and stronger feeling of burnout.
• Occupational stress is one of the possible reasons for job
burnout.
• Mainland China confronts severe nursing shortage, but
the impact on stress and its negative outcomes are
largely unknown.
What this paper adds
• Nurses from higher grade hospitals in Shanghai have
higher burden of work-related stress and burnout.
• Both the job content questionnaire (JCQ) and effort-
reward imbalance questionnaire (ERI) models have
good predictive powers to the nurses’ burnout,
especially the ERI model has better power than the JCQ
model in predicting two MBI subscales of emotional
exhaustion and depersonalization.
• The strongest predictors of emotional exhaustion by
stress models are psychological demand in the JCQ
model together with the job effort and overcommitment
in the ERI model. The strongest predictor of
depersonalization is job reward in the ERI model.
Implications for practice and/or policy
• Interventions to alleviating work-related stress are
especially needed in nurses at young age, on shift duty,
and from high-grade hospitals.
• Interventions at individual level may have better effects
than those at workplace level in preventing stress and
burnout.
• Three stress subscales of psychological demand, job
effort and overcommitment are key points for
intervention in preventing emotional exhaustion, as well
as job reward in preventing depersonalization.
reduced personal accomplishment could explain the low level
of this type of burnout in nurses, although a lack of job
control and unsatisfied job reward did present strong
correlations with reduced personal accomplishment. The
emotional exhaustion was the most severe burnout in our
study and had the strongest association with most stress
subscales. Amongst them, extrinsic job effort and psycholog-
ical demand, together with the intrinsic overcommitment,
were the most important predictors, indicating that future
coping strategies should focus on how to reduce these
subscales of work-related stress. The subscales of demand,
1544
effort and overcommitment were also strong predictors of
depersonalization, but their predictive powers were lower
than job reward, indicating that this type of burnout was
strongly related to the intrinsic difference of individuals.
Another interesting finding in our study is that in both the
MBI subscales of emotional exhaustion and depersonalization,
the predictive power of job control was much lower than that
of psychological demand. However, in the subscale of personal
accomplishment, job control showed a better predictive power
than demand. Recent publications have underscored the
importance of low job control for a range of health outcomes
(Bosma et al. 1998, Shen et al. 2005). Whether these adverse
effects caused by low job control were the result of the reduced
personal accomplishment will be an interesting topic.
Implications for practice
This study highlights the need for stress interventions for
Chinese nurses, especially for the young nurses from general
hospitals where the workload was much higher than that of
the more experienced nurses or that of those from Grade I or
Grade II hospitals. According to our findings, Chinese nurses
mainly exhibited the burden of burnout by a symptomatic
aspect (emotional exhaustion) rather than in terms of the
attitude components (depersonalization and reduced personal
accomplishment), the key interventions are intended to
relieve those emotional symptoms experienced by nurses.
Also considering that the ERI model was better than the JCQ
model in predicting nurses’ burnout, interventions at indi-
vidual level will be suspected to have better effects than those
at a workplace level. The different types of burnout were
better predicted by the different stress subscales. Our data
highlight the importance of three stress subscales of demand,
effort and overcommitment in preventing emotional exhaus-
tion, as well as job reward in preventing depersonalization.
Limitations
Several limitations are noted in this study. First, all nurses
were from a highly developed and densely populated district
in Shanghai. The generalization involved in our findings
should be taken with caution. Secondly, this study had a high
response rate, but only 20–30% nurses from each hospital
were invited to participate in the investigation. The question-
naire was delivered to the nurses on duty. When the total
number of answered questionnaires from one hospital reached
the quota of 20–30% of all nurses, the investigation stopped.
Therefore, the study participants were not selected in random
and their characteristics may be different from those who did
not participate. Thirdly, the JCQ and ERI models used in this
 2011 Blackwell Publishing Ltd
JAN: ORIGINAL RESEARCH
study were mainly job-person fit. Situational factors such as
the demand-control imbalance and the effort–reward disequi-
librium are more discussed than personal factors such as
stress-hardy personality and individual coping strategies,
which are considered to have buffering effects on burnout.
In this way, our conclusions may be restricted in scope.
Conclusion
Nurses from a district in Shanghai were found to experience a
high level work-related stress and burnout, especially those of
a young age, on shift duty or working at high-ranking
hospitals. Both the stress models of the JCQ and ERI
questionnaires made good predictions concerning the nurses’
burnout, especially in the two MBI subscales of emotional
exhaustion and depersonalization. The strongest predictors of
emotional exhaustion by stress models were the psychological
demand in the JCQ model together with the job effort and
overcommitment in the ERI model, indicating their impor-
tance in preventing emotional exhaustion. These three stress
subscales were also strong predictors of depersonalization,
but their predictive power was lower than that of job reward,
indicating the importance of better reward in preventing
depersonalization. Overall, the ERI model was more profi-
cient than the JCQ model in predicting work-related burnout,
which shows that the interventions at an individual level will
be more effective than at a workplace level.
Acknowledgements
The authors are thankful to all the nurses who participated
this work, and to Professor Junmin Dai from Fudan
University who gave great contributions to the study design
and data collection, and to Doctor Liming Yang, Tao Lin and
Yunbiao Huang from Pudong Center for Disease Control and
Prevention who gave critical helps in administrative support.
Funding
This work was supported by a grant (08GWQ003) from
Shanghai Municipal Health Bureau.
Conflict of interest
No conflict of interest has been declared by the authors.
Author contributions
ZX and BC was responsible for the study conception and
design. ZX, AW and BC performed the data collection, ZX
 2011 Blackwell Publishing Ltd
Stress and burnout in nurses
and AW performed the data analysis. AW and BC was
responsible for the drafting of the manuscript. BC made
critical revisions to the paper for important intellectual
content, provided statistical expertise, obtained funding and
supervised the study. ZX provided administrative, technical
or material support. ZX and AW contributed equally to this
study.
References
Aiken L.H., Clarke S.P., Sloane D.M., Sochalski J. & Silber J.H.
(2002) Hospital nurse staffing and patient mortality, nurse burn-
out, and job dissatisfaction. JAMA 288(16), 1987–1993.
Boles J.S., Dean D.H., Ricks J.M., Short J.C. & Wang G. (2000) The
dimensionality of the Maslach Burnout Inventory across small
business owners and educators. Journal of Vocational Behaviour
56, 12–34.
Bosma H., Peter R., Siegrist J. & Marmot M. (1998) Two alternative
job stress models and the risk of coronary heart disease. American
Journal of Public Health 88(1), 68–74.
Brewer E.W. & Shapard L. (2004) Employee burnout: a meta-ana-
lysis of the relationship between age or years of experience. Human
Resource Development Review 3, 102–123.
Calnan M., Wadsworth E., May M., Smith A. & Wainwright D.
(2004) Job strain, effort–reward imbalance, and stress at work:
competing or complementary models? Scandinavian Journal of
Public Health 32(2), 84–93.
Dai J.M., Collins S., Yu H.Z. & Fu H. (2008) Combining job stress
models in predicting burnout by hierarchical multiple regressions:
a cross-sectional investigation in Shanghai. Journal of Occupa-
tional and Environmental Medicine 50(7), 785–790.
Duquette A., Kérouac S., Sandhu B.K. & Beaudet L. (1994) Factors
related to nursing burnout: a review of empirical knowledge. Issues
in Mental Health Nursing 15(4), 337–358.
Feng Y., Luo H. & Ye Z.H. (2004) Job burnout of nurses. Chinese
Mental Health Journal 18(7), 477–479.
Freudenberger H.J. (1974) Staff burnout. Journal of Social Issues 30,
159–165.
Garrosa E., Moreno-Jiménez B., Liang Y. & González J.L. (2008)
The relationship between socio-demographic variables, job
stressors, burnout, and hardy personality in nurses: an explor-
atory study. International Journal of Nursing Studies 45(3), 418–
427.
Garrosa E., Rainho C., Moreno-Jimenez B. & Monteiro M.J. (2010)
The relationship between job stressors, hardy personality, coping
resources and burnout in a sample of nurses: a correlational study
at two time points. International Journal of Nursing Studies 47(2),
205–215.
Griep R.H., Rotenberg L., Vasconcellos A.G., Landsbergis P.,
Comaru C.M. & Alves M.G. (2009) The psychometric properties
of demand-control and effort-reward imbalance scales among
Brazilian nurses. International Archives of Occupational and
Environmental Health 82(10), 1163–1172.
Halbesleben J.R., Wakefield B.J., Wakefield D.S. & Cooper L.B.
(2008) Nurse burnout and patient safety outcomes: nurse safety
perception versus reporting behavior. Western Journal of Nursing
Research 30(5), 560–577.
1545
Z. Xie et al.

van der Heijden B.I., Demerouti E. & Bakker A.B. (2008) Work-home
interference among nurses: reciprocal relationships with job
demands and health. Journal of Advanced Nursing 62(5), 572–584.
Kikuchi Y., Nakaya M., Ikeda M., Narita K., Takeda M. & Nishi M.
(2010) Effort-reward imbalance and depressive state in nurses.
Occupational Medicine (Lond) 60(3), 231–233.
Makowiec-Dabrowska T., Krawczyk-Adamus P., Sprusinska E. &
Jozwiak Z.W. (2000) Can nurses be employed in 12-hour shift
systems? International Journal of Occupational Safety and Ergo-
nomics 6(3), 393–403.
Maslach C. & Schaufeli W.B. (1993) Historical and conceptual
development of burnout. In Professional Burnout: Recent
Developments in Theory and Research (Schaufeli W.B., Maslach
C. & Marek T., eds), Taylor & Francis, Washington, DC, pp.
397–422.
Ministry of Health (2003) Enhancing Nursing Management. Minis-
try of Health, Beijing.
Ota A., Masue T., Yasuda N., Tsutsumi A., Mino Y. & Ohara H.
(2005) Association between psychosocial job characteristics and
insomnia: an investigation using two relevant job stress models–the
demand-control-support (DCS) model and the effort-reward
imbalance (ERI) model. Sleep Medicine 6(4), 353–358.
Sanne B., Mykletun A., Dahl A.A., Moen B.E. & Tell G.S. (2005)
Testing the Job Demand-Control-Support model with anxiety and
depression as outcomes: the Hordaland Health Study. Occupa-
tional Medicine (Lond) 55(6), 463–473.
Schaufeli W.B. & Enzmann D. (1998) The Burnout Companion
to Study and Research: A Critical Analysis. Taylor & Francis,
London.
Schreuder J.A., Roelen C.A., Koopmans P.C., Moen B.E. & Groot-
hoff J.W. (2010) Effort-reward imbalance is associated with the
frequency of sickness absence among female hospital nurses: a
cross-sectional study. International Journal of Nursing Studies
47(5), 569–576.
Schulz M., Damkroger A., Heinz C., Wehlitz L., Lohr M., Driessen
M., Behrens J. & Wingenfeld K. (2009) Effort-reward imbalance
and burnout among German nurses in medical compared with
psychiatric hospital settings. Journal of Psychiatric and Mental
Health Nursing 16(3), 225–233.
Shen H.C., Cheng Y., Tsai P.J., Lee S.H. & Guo Y.L. (2005)
Occupational stress in nurses in psychiatric institutions in Taiwan.
Journal of Occupational Health 47(3), 218–225.
Spence Laschinger H.K. & Finegan J. (2008) Situational and dispo-
sitional predictors of nurse manager burnout: a time-lagged anal-
ysis. Journal of Nursing Management 16(5), 601–607.
Stordeur S. & D’Hoore W. (2007) Organizational configuration of
hospitals succeeding in attracting and retaining nurses. Journal of
Advanced Nursing 57(1), 45–58.
Tsai F.J., Huang W.L. & Chan C.C. (2009) Occupational stress and
burnout of lawyers. Journal of Occupational Health 51(5), 443–
450.
Tsutsumi A., Kayaba K., Tsutsumi K. & Igarashi M. (2001) Asso-
ciation between job strain and prevalence of hypertension: a cross
sectional analysis in a Japanese working population with a wide
range of occupations: the Jichi Medical School cohort study.
Occupational and Environmental Medicine 58(6), 367–373.
Unterbrink T., Hack A., Pfeifer R., Buhl-Griesshaber V., Muller U.,
Wesche H., Frommhold M., Scheuch K., Seibt R., Wirsching M. &
Bauer J. (2007) Burnout and effort-reward-imbalance in a sample
of 949 German teachers. International Archives of Occupational
and Environmental Health 80(5), 433–441.
van Wijk C. (1997) Factors influencing burnout and job stress among
military nurses. Military Medicine 162(10), 707–710.
Wang S.Z., Zhao Q. & Li S.G. (2008) A survey of job burnout
of clinical nurses. Chinese Nursing Research 22(9A.), 2292–2293.
(In Chinese).
Wu S., Zhu W., Wang Z., Wang M. & Lan Y. (2007) Relationship
between burnout and occupational stress among nurses in China.
Journal of Advanced Nursing 59(3), 233–239.
World Health Organization (WHO) (2002) Imbalances in the health
workforce: briefing paper. Retrieved from http://www.who.int/
hrh/documents/en/imbalances_briefing.pdf. on 31 December 2010.
Zeng Y. (2009) Review of work-related stress in mainland Chinese
nurses. Nursing and Health Sciences 11(1), 90–97.

The Journal of Advanced Nursing (JAN) is an international, peer-reviewed, scientific journal. JAN contributes to the advancement of
evidence-based nursing, midwifery and health care by disseminating high quality research and scholarship of contemporary relevance
and with potential to advance knowledge for practice, education, management or policy. JAN publishes research reviews, original
research reports and methodological and theoretical papers.

For further information, please visit JAN on the Wiley Online Library website: www.wileyonlinelibrary.com/journal/jan

Reasons to publish your work in JAN:

• High-impact forum: the world’s most cited nursing journal and with an Impact Factor of 1Æ518 – ranked 9th of 70 in the 2010
Thomson Reuters Journal Citation Report (Social Science – Nursing). JAN has been in the top ten every year for a decade.
• Most read nursing journal in the world: over 3 million articles downloaded online per year and accessible in over 7,000 libraries
worldwide (including over 4,000 in developing countries with free or low cost access).
• Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jan.
• Positive publishing experience: rapid double-blind peer review with constructive feedback.
• Early View: rapid online publication (with doi for referencing) for accepted articles in final form, and fully citable.
• Faster print publication than most competitor journals: as quickly as four months after acceptance, rarely longer than seven months.
• Online Open: the option to pay to make your article freely and openly accessible to non-subscribers upon publication on Wiley
Online Library, as well as the option to deposit the article in your own or your funding agency’s preferred archive (e.g. PubMed).

1546  2011 Blackwell Publishing Ltd