Wang et al.

BMC Public Health (2024) 24:688 BMC Public Health

https://doi.org/10.1186/s12889-024-18223-4

RESEARCH Open Access

Factors associated with burnout among

frontline nurses in the post-COVID-19
epidemic era: a multicenter cross-sectional
study
Shitao Wang1*†, Guoshuai Luo2†, XiangQian Ding3†, Xuelu Ma1, Fei Yang4, Mengen Zhang1, Guangxin Sun1,
Fei Wang1, Liping Zhu5, Shuo Wang2 and Zongyou Li1

Abstract
Background The COVID-19 pandemic has significantly increased the risk of burnout among frontline nurses.
However, the prevalence of burnout and its associated factors in the post-pandemic era remain unclear. This research
aims to investigate burnout prevalence among frontline nurses in the post-pandemic period and pinpoint associated
determinants in China.
Methods From April to July 2023, a cross-sectional study was carried out across multiple centers, focusing on
frontline nurses who had been actively involved in the COVID-19 pandemic. The data collection was done via an
online platform. The Maslach Burnout Inventory-Human Services Survey was utilized to evaluate symptoms of
burnout. A multivariable logistic regression analysis was used to pinpoint factors associated with burnout.
Results Of the 2210 frontline nurses who participated, 75.38% scored over the cut-off for burnout. Multivariable
logistic regression revealed that factors like being female [odds ratio (OR) = 0.41, 95%CI = 0.29–0.58] and exercising
1–2 times weekly[OR = 0.53, 95%CI = 0.42–0.67] were protective factors against burnout. Conversely, having 10
or more night shifts per month[OR = 1.99, 95%CI = 1.39–2.84], holding a master’s degree or higher[OR = 2.86, 95%
CI = 1.59–5.15], poor health status[OR = 2.43, 95% CI = 1.93–3.08] and [OR = 2.82, 95%CI = 1.80–4.43], under virus
infection[OR = 7.12, 95%CI = 2.10-24.17], and elevated work-related stress[OR = 1.53, 95% CI = 1.17-2.00] were all
associated with an elevated risk of burnout.
Conclusion Our findings indicate that post-pandemic burnout among frontline nurses is influenced by several
factors, including gender, monthly night shift frequency, academic qualifications, weekly exercise frequency, health
condition, and viral infection history. These insights can inform interventions aimed at safeguarding the mental well-
being of frontline nurses in the post-pandemic period.

†
Shitao Wang, Guoshuai Luo and XiangQian Ding are co-first authors
and contributed equally.
*Correspondence:
Shitao Wang
[email protected]
Full list of author information is available at the end of the article

© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use,
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Wang et al. BMC Public Health (2024) 24:688 Page 2 of 8

Keywords Burnout, COVID-19, Nurse, Post-pandemic, Prevalence

Introduction (1) Descriptive characteristics of nurses: This

Nurse burnout is a well-documented work-related included job title, gender, employment status,
stress syndrome characterized by emotional exhaus- monthly frequency of night shifts, qualification,
tion, depersonalization, and reduced personal age, weekly frequency of exercise, personality
accomplishment [1]. Research from 2012 indicated traits, health status, history of virus infection,
a heightened prevalence of burnout among frontline economic pressures, lifestyle, work-related stress,
nurses [2], which is consistent with the results of a and concerns regarding potential infection.
study conducted in 2018 [3]. Various factors, including Considering that these descriptive characteristics
exposure to violence [4], excessive workload [5], Post- may be related to the burnout of frontline nurses,
Traumatic Stress Disorder [6] and insomnia [7], con- and these specific responses can more accurately
tribute to this phenomenon. The implications of nurse reveal the relationship between these descriptive
burnout are profound, potentially leading to a decline characteristics and the burnout of frontline
in the quality of patient care [8]. The emergence of the nurses, they were selected for this survey. Burnout
COVID-19 pandemic further exacerbated the issue of Assessment: Burnout was evaluated using the
nurse burnout [9, 10]. During the pandemic, elevated Maslach Burnout.
stress levels and exposure to traumatic events were (2) Inventory-Human Services Survey (MBI-HSS), a
notably correlated with an increased risk of burnout validated instrument for assessing burnout among
in frontline nurses [11–14]. In addition, poor staffing healthcare professionals [17–19]. This tool has
ratios are a significant concern, with research indicat- demonstrated correlations with the quality of care
ing that a nurse-to-patient ratio exceeding 1:2 ampli- [20]. Comprising 22 items, respondents rate each
fies the risk of burnout for nurses in intensive care on a 7-point scale, from 0 (Never) to 6 (Every day).
units [15, 16]. The epidemic has led to a surge in burn- The scale evaluates three domains: emotional
out among frontline nurses, thereby increasing the exhaustion, depersonalization, and reduced
probability of unfavorable nursing incidents. personal achievement. Cut-off scores of > 26, >9,
Although factors contributing to nurse burnout were and < 33 are indicative of clinically significant
extensively studied during the pandemic, the post-epi- emotional exhaustion, depersonalization, and
demic prevalence and determinants of burnout among reduced personal achievement, respectively [21].
frontline nurses remain unclear. This study aims to Being at high risk of burnout in at least one of the
ascertain the prevalence and underlying causes of three domains is deemed as experiencing burnout
burnout among frontline nurses in China in the after- [22]. The Cronbach’s α for the Chinese version
math of the COVID-19 pandemic. of the MBI-HSS stood at 0.830 [23], signifying a
substantial degree of internal consistency.
Methods
Study design
A cross-sectional study was conducted between April Statistical analyses
and July 2023, subsequent to the COVID-19 pandemic Statistical analyses were conducted using IBM SPSS
in China. The study population comprised frontline Statistics 23.0 and GraphPad Prism 9.0 software.
nurses holding valid professional qualification certifi- Frequency distributions were treated as categorical
cates. Descriptive characteristics of the nurses were variables and compared between groups using the chi-
gathered via the Wenjuanxing platform (https://www. square test. To adjust for multiple testing, the Bon-
wjx.cn). Initially, we signed up for the Wenjuanxing ferroni correction was applied, with a p-value < 0.004
platform and subsequently imported the questionnaire (0.05/14) deemed statistically significant. Multivariate
content into it. This process enabled us to obtain a link regression analyses were employed to examine the
to the questionnaire. We then disseminated this link to relationship between nurses’ descriptive characteris-
the nurses’ mobile phones through WeChat (a widely- tics and burnout, setting the significance threshold at
used social application in China with over 1 billion p < 0.004 (0.05/14). Variables selected for the adjusted
active users), facilitating timely completion of the analysis encompass job title, gender, employment sta-
survey. tus, monthly frequency of night shifts, qualification,
age, weekly frequency of exercise, personality trait,
Instruments and measures health status, virus infection, economic pressure,
The following measures and questions were collected:
Wang et al. BMC Public Health (2024) 24:688 Page 3 of 8

lifestyle, work pressure, and concern about potential the work environment and the specific phase of the
infection. pandemic play pivotal roles in these divergent out-
comes. Additionally, some studies that exclusively
Results gauge burnout by assessing emotional exhaustion tend
Description of nurse characteristics to report a lower prevalence. Lastly, the use of different
A total of 2,210 nurses from 27 provinces across China assessment instruments can also introduce variability
participated in the survey. Of these, 41.31% held the in results. Moreover, the readiness of health systems,
position of nurse-in-charge, and a significant major- potential understaffing in health organisations, work-
ity, 80.27%, were female. Permanent employment was load, and other organisational factors also significantly
reported by 31.04% of the respondents, while 45.02% contribute to this discrepancy.
undertook between 5 and 10 night shifts monthly. The Our research indicates that gender plays a role in
predominant age bracket was 25 to 36 years, encom- burnout among frontline nurses, with females show-
passing 51.99% of the participants, and 66.20% held an ing a lower prevalence compared to males. This obser-
undergraduate degree with with a specialisation. More vation aligns with certain previous studies [30, 31].
nurses’ characteristics are provided in Table 1. The Another significant factor associated with burnout
distribution of risk factors related to nurse burnout identified in this study is the frequency of night shifts
across the entire sample is detailed in Table 2. per month. Specifically, nurses working more than
10 night shifts monthly are at a considerably height-
Burnout prevalence and associated risk factors ened risk of burnout. Understaffing could be the pri-
The prevalence of burnout among frontline nurses in mary cause for the increased frequency of night shifts
this study was 75.38% (1,666 out of 2,210). The regres- observed among certain nurses. This correlation
sion analysis concerning nurses’ descriptive char- between the number of night shifts and elevated MBI
acteristics is illustrated in Fig. 1. After adjusting for scores is supported by earlier findings [32, 33]. Fur-
multiple testing (as seen in Table 3), factors like being thermore, our study discerned a link between burnout
female and exercising 1–2 times weekly were found and educational qualifications. Interestingly, nurses
to be protective against burnout. Conversely, having possessing graduate degrees appear more susceptible
five or more night shifts monthly, holding a master’s to burnout, a trend previously observed among medi-
degree or higher, poor health status, under virus infec- cal educators [34]. The primary reason that nurses
tion, and elevated work-related stress were all associ- with advanced educational qualifications are more
ated with an elevated risk of burnout. susceptible to burnout is due to their excessive work-
load, coupled with the additional responsibility of con-
Discussion ducting scientific research, a requirement not typically
This study evaluated burnout and its associative fac- imposed on nurses with lower education levels.
tors among frontline nurses after the COVID-19 pan- Our research indicates that engaging in moderate
demic. Our findings pinpointed several determinants exercise (once to twice a week) post-epidemic can con-
linked to burnout in frontline nurses, including gen- siderably reduce burnout risk among frontline nurses,
der, monthly frequency of night shifts, qualification, corroborating the outcomes of a recent study [35].
weekly exercise frequency, health status, and history Intriguingly, we did not identify a direct correlation
of viral infection. Along with our study, an increasing between extremely high or low exercise frequencies
body of research has pinpointed factors that affect the and burnout prevalence. While several reports high-
risk of burnout among nurses in the post-pandemic light a strong relationship between poor health status
era. These studies can offer valuable insights for inter- and burnout [36, 37], our findings align with these,
ventions aimed at mitigating nurse burnout after the though another study detected no impact of health sta-
pandemic [24]. tus on the Maslach Burnout total score [38]. The dis-
Regular exercise can effectively curb the incidence crepancy across studies might stem from geographical
of occupational burnout among oncologists [25]. Our differences in research areas. Notably, our compre-
research indicates that after the COVID-19 pandemic, hensive survey spanned 27 provinces and exclusively
75.38% of nurses experienced burnout symptoms, focused on frontline nurses, unlike other studies. In
encompassing emotional exhaustion, depersonaliza- our study, a nurse’s viral infection status emerged as
tion, and reduced personal achievement. These results a critical factor linked to burnout. Understandably,
is consistent with a survey undertaken in China during frontline nurses infected with the virus often grapple
the pandemic [12] but are notably higher than findings with compromised health, amplifying their burnout
from other countries [26–29]. Several factors might risk. This aligns with our earlier observation regard-
account for this discrepancy: Primarily, variations in ing the association between poor health and increased
Wang et al. BMC Public Health (2024) 24:688 Page 4 of 8

Table 1 Nurses’ descriptive characteristics

Descriptive Characteristic N %
Job title
Nurse (and below) 523 23.67
Nurse practitioner 774 35.02
Nurse-in-charge (and above) 913 41.31
Gender
Male 436 19.73
Female 1774 80.27
Employment status
Permanent employment 686 31.04
Temporary employment 1524 68.96
Frequency of night shifts per month
<5 830 37.56
5 ∼ 10 995 45.02
>10 385 17.42
Qualification
Specialty (and below) 516 23.35
Undergraduate college 1463 66.20
Master (and above) 231 10.45
Age
≤ 25 379 17.15
26 ∼ 35 1149 51.99
36 ∼ 45 488 22.08
> 45 194 8.78
Frequency of exercise per week
Never 1002 45.34
1–2 800 36.20
3(and above) 408 18.46
Personality trait
Introvert 1159 52.44
Extroversion 1051 47.56
Health status
Good 1048 47.42
General 909 41.13
Chronic disease 253 11.45
Virus infection
Under infection 134 6.06
Recovery 1863 84.29
No infection 213 9.64
Economic pressure
Yes 1614 73.03
No 596 26.97
Living style
Living alone 424 19.19
Living with family 1506 68.14
Living with colleagues 280 12.67
Working pressure
Yes 1632 73.85
No 578 26.15
Concern about potential infection
Yes 1116 50.50
No 1094 49.50
Wang et al. BMC Public Health (2024) 24:688 Page 5 of 8

Table 2 Distribution of risk factors across nurse burnout in the overall sample(emotional exhaustion > 26, depersonalisation > 9,
reduced personal achievement < 33)
Descriptive Characteristic Job burnout χ2 P
Yes No
Job title 6.156 0.046
Nurse (and below) 395(17.87%) 128(5.79%)
Nurse practitioner 605(27.38%) 169(7.65%)
Nurse-in-charge (and above) 666(30.14%) 247(11.18%)
Gender 45.439 <0.001
Male 383(17.33%) 53(2.40%)
Female 1283(58.05%) 491(22.22%)
Employment status 5.954 0.015
Permanent employment 540(24.43%) 146(6.61%)
Temporary employment 1126(50.95%) 398(18.01%)
Frequency of night shifts per month 52.283 <0.001
<5 565(25.57%) 265(11.99%)
5 ∼ 10 767(34.71%) 228(10.32%)
>10 334(15.11%) 51(2.31%)
Qualification 47.909 <0.001
Specialty(and below) 396(17.92%) 120(5.43%)
Undergraduate college 1055(47.74%) 408(18.46%)
Master (and above) 215(9.73%) 16(0.72%)
Age 7.938 0.047
≤ 25 300(13.57%) 79(3.57%)
26 ∼ 35 873(39.50%) 276(12.49%)
36 ∼ 45 347(15.70%) 141(6.38%)
> 45 146(6.61%) 48(2.17%)
Frequency of exercise per week 49.071 <0.001
Never 801(36.24%) 201(9.10%)
1–2 535(24.21%) 265(11.99%)
3(and above) 330(14.93%) 78(3.53%)
Personality trait 4.859 0.028
Introvert 896(40.54%) 263(11.90%)
Extroversion 770(34.84%) 281(12.71%)
Health status 113.998 <0.001
Good 684(30.95%) 364(16.47%)
General 756(34.21%) 153(6.92%)
Chronic disease 226(10.23%) 27(1.22%)
Virus infection 46.174 <0.001
Under infection 131(5.93%) 3(0.14%)
Recovery 1361(61.58%) 502(22.71%)
No infection 174(7.87%) 39(1.76%)
Economic pressure 5.613 0.018
Yes 1238(56.02%) 376(17.01%)
No 428(19.37%) 168(7.60%)
Living style 35.980 <0.001
Living alone 357(16.15%) 67(3.03%)
Living with family 1079(48.82%) 427(19.32%)
Living with colleagues 230(10.41%) 50(2.26%)
Working pressure 12.706 <0.001
Yes 1262(57.10%) 370(16.74%)
No 404(18.28%) 174(7.87%)
Concern about potential infection 13.566 <0.001
Yes 804(36.38%) 312(14.12%)
No 862(39.00%) 232(10.50%)
Wang et al. BMC Public Health (2024) 24:688 Page 6 of 8

burnout risk. Furthermore, job-related stress was iden- that health-related quality of life, another measure of
tified as a burnout risk, echoing another study’s find- personal health, exhibited a strong correlation with
ings [39]. Interestingly, a prior study demonstrated burnout [40]. Nevertheless, further investigations are
essential to validate these insights.
Table 3 Factors associated with burnout risk(emotional Although our multicenter study rigorously assessed
exhaustion > 26, depersonalisation > 9, reduced personal the associations between various factors and post-
achievement < 33 ) pandemic burnout among frontline nurses, there
Descriptive Characteristic Adjusted OR (95% Cat- Over- are several limitations to consider: (1) Our research
CI) egory all focused solely on China, potentially not capturing
p value p value the unique experiences and mental health trajecto-
Gender ries of frontline nurses in other cultural or national
Male 1 <0.001 contexts; (2) Although we endeavored to encompass
Female 0.412(0.294–0.579)a 0.000 a diverse sample across multiple provinces, dispari-
Frequency of night shifts
ties in healthcare settings, the pandemic’s impact, and
per month
socioeconomic nuances across these regions might
<5 1 <0.001
impede the wider applicability of our findings; (3) Even
5 ∼ 10 1.410 (1.120–1.776) 0.004
>10 1.985 (1.389–2.837)b 0.000
though we adjusted for numerous demographic ele-
Qualification
ments, potential unaccounted confounders might still
Specialty (and below) 1 <0.001
sway the identified correlations between burnout and
Undergraduate college 0.858(0.643–1.146) 0.300 the variables examined; (4) In certain provinces, the
Master (and above) 2.860 (1.587–5.153)c 0.000 sample sizes were comparatively limited, which could
Frequency of exercise per potentially introduce bias into the outcomes; (5) Some
week descriptive characteristics of nurses (weekly frequency
Never 1 <0.001 of exercise, personality traits, health status) were
1–2 0.528(0.417–0.668)d 0.000 self-reported.
3(and above) 0.981(0.705–1.364) 0.907
Health status Conclusion
Good 1 <0.001 Our research reveals a higher prevalence of burn-
General 2.434(1.926–3.075)e 0.000 out among frontline nurses in the post-COVID-19
Chronic disease 2.819(1.796–4.426)f 0.000 epidemic era. We identified several influencing fac-
Virus infection tors, including gender, monthly night shift frequency,
No infection 1 0.001 educational qualification, weekly exercise frequency,
Under infection 7.120(2.097–24.170)g 0.002 health status, and viral infection status. These insights
Recovery 0.775(0.518–1.161) 0.216 are invaluable for strategizing interventions to manage
Working pressure and alleviate burnout among frontline nurses in the
No 1 0.002 aftermath of the COVID-19 pandemic.
Yes 1.530(1.169–2.002)h 0.002
a
OR: Adjustment for job title, employment status, frequency of night shifts
per month, qualification, age, frequency of exercise per week, personality
trait, health status, virus infection, economic pressure, living style, working
pressure and concern about potential infection; bOR: Adjustment for job title,
gender, employment status, qualification, age, frequency of exercise per week,
personality trait, health status, virus infection, economic pressure, living style,
working pressure and concern about potential infection; cOR: Adjustment for
job title, gender, employment status, frequency of night shifts per month, age,
frequency of exercise per week, personality trait, health status, virus infection,
economic pressure, living style, working pressure and concern about potential
infection; dOR: Adjustment for job title, gender, employment status, frequency
of night shifts per month, qualification, age, personality trait, health status, virus
infection, economic pressure, living style, working pressure and concern about
potential infection; eOR,fOR: Adjustment for job title, gender, employment
status, frequency of night shifts per month, qualification, age, frequency of
exercise per week, personality trait, virus infection, economic pressure, living
style, working pressure and concern about potential infection; gOR: Adjustment
for job title, gender, employment status, frequency of night shifts per month,
qualification, age, frequency of exercise per week, personality trait, health
status, economic pressure, living style, working pressure and concern about
potential infection; hOR: Adjustment for job title, gender, employment status,
frequency of night shifts per month, qualification, age, frequency of exercise
per week, personality trait, health status, virus infection, economic pressure,
living style and concern about potential infection
Wang et al. BMC Public Health (2024) 24:688 Page 7 of 8

Fig. 1 Forest plot for logistic regression analysis of the factors of burnout among frontline nurses
2
Abbreviations Laboratory of Biological Psychiatry, Institute of Mental Health, Tianjin
COVID-19 Coronavirus disease Anding Hospital, Mental Health Center of Tianjin Medical University,
MBI-HSS Maslach Burnout Inventory-Human Services Survey Tianjin, China
3
Department of Neurosurgery, Qilu Hospital of Shandong University,
Acknowledgements Jinan, China
4
The authors thank all nurses for their time and cooperation in the survey. Department of Neurology, Affiliated Hospital of North Sichuan Medical
College, Nanchong, China
5
Author contributions Ya’an People’s Hospital, Sichuan University, Yaan, China
G.L. and S.W. conceived and designed the study. X.D. wrote the first draft. M.Z.
and G.S. critically revised the first draft. Z.L., F.W., X.M., F.Y., L.Z. and Shuo.W. Received: 11 December 2023 / Accepted: 28 February 2024
conducted data extraction, initial analysis and supervised data analysis. All
authors reviewed and approved the final manuscript.

Funding
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