Community Ment Health J (2015) 51:733737

DOI 10.1007/s10597-014-9818-4

BRIEF COMMUNICATION

Predictors of Burnout Among Nurses in Taiwan

Huan-Fang Lee Miaofen Yen Susan Fetzer
Tsair Wei Chien

Received: 10 January 2014 / Accepted: 10 December 2014 / Published online: 24 December 2014
Springer Science+Business Media New York 2014

Abstract Nurse burnout is a crucial issue for health care

professionals and impacts nurse turnover and nursing
shortages. Individual and situational factors are related to
nurse burnout with predictors of burnout differing among
cultures and health care systems. The predictors of nurse
burnout in Asia, particularly Taiwan, are unknown. The
purpose of this study was to investigate the predictors of
burnout among a national sample of nurses in Taiwan. A
secondary data analysis of a nationwide database investigated the predictors of burnout among 1,846 nurses in
Taiwan. Hierarchical regression analysis determined the
H.-F. Lee
Department of Nursing, Institute of Allied Health Sciences,
National Cheng Kung University, Tainan City, Taiwan
H.-F. Lee
Nursing Department, Chi-Mei Medical Center, Tainan City,
Taiwan
M. Yen (&)
Department of Nursing, National Cheng Kung University,
Tainan City, Taiwan
e-mail: miaofen@mail.ncku.edu.tw
M. Yen
Institute of Allied Health Sciences, National Cheng Kung
University, Tainan City, Taiwan
S. Fetzer
Department of Nursing, University of New Hampshire, Durham,
NC, USA
T. W. Chien
Business Management Department, Chi Mei Medical Center,
Tainan City, Taiwan
T. W. Chien
Chia Nan University of Pharmacy and Science, Tainan City,
Taiwan

relationship between predictors and burnout. Predictors of

Taiwanese nurse burnout were age, physical/psychological
symptoms, job satisfaction, work engagement, and work
environment. The most significant predictors were physical/psychological symptoms and work engagement. The
variables explained 35, 39, and 18 % of the emotional
exhaustion, personal accomplishment, and depersonalization variance for 54 % of the total variance of burnout.
Individual characteristics and nurse self-awareness, especially work, engagement can impact Taiwanese nurses
burnout. Nurse burnout predictors provide administrators
with information to develop strategies including education
programs and support services to reduce nurse burnout.
Keywords

Burnout
Nurse
Predictors

Introduction
Burnout is far more common among healthcare workers
than among other professional groups (Iglesias et al. 2010;
Spence Laschinger et al. 2009). Nurse burnout leads to
predicted turnovers that result in manpower shortages and
crucial staffing issues. In Taiwan, with nearly 40 % of the
nations nurses not practicing, 89 % of hospitals surveyed
reported that it was difficult to recruit nurses (Lu 2013).
Jourdain and Chenevert (2010) have noted that burnout
within the nursing profession is an especially important
factor when there is a shortage of nurses.
Nurse burnout has been investigated since the 1970s in
Western countries. However, only two studies have
investigated nurse burnout in Taiwan. Hsieh et al. (2004)
explored the relationships between characteristics, coping
strategies, and burnout among 147 psychiatric nurses.
However, both studies of Taiwanese nurses used limited

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734

samples and failed to identify predictors of burnout.

Researchers have suggested that larger sample sizes,
expanding the data collection area, and exploring different
working environments are needed to investigate burnout
differences across health care systems and countries (Lin
et al. 2009; Maslach et al. 2001).
Burnout is defined as experiencing a state of emotional
exhaustion similar to the extinguishing of a candle.
According to Maslach (1982), consisting of three dimensions: emotional exhaustion, depersonalization, and a
reduced sense of personal accomplishment. Emotional
exhaustion occurs when individuals overextend themselves
and feel emotionally overwhelmed. Depersonalization
refers to treating the patient as an object with an attitude of
indifference. A reduced sense of personal accomplishment
occurs when individuals think of themselves negatively,
consider themselves failures, and believe themselves to be
inadequate in work-related situations.
According to Maslach et al. (2001), individual factors,
including age, marital status, and length of employment, in
addition to situational factors including hospital type and
work unit, can affect nurse burnout. Nurse self-awareness
has also been found to be related to burnout, including
physical/psychological symptoms, work environment, job
satisfaction, and work engagement (Gonzalez-Roma et al.
2006; Hanrahan et al. 2010; Kanai-Pak et al. 2008;
Schaufeli and Bakker 2004; Weng et al. 2011).
Age is the most consistent demographic variable related
to burnout; however, reports have been inconsistent (Iglesias
et al. 2010; Maslach et al. 2001; Poncet et al. 2007; Wang
et al. 2010). Whitmer et al. (2009) indicated that problemsolving capacity and self-reliance are different between
individuals born from 1965 to 1980 (generation X) and those
born from 1981 to 2000 (generation Y). Generation X individuals who have stronger problem-solving capacities are
more self-reliant. They work hard at their jobs and strive for
work accomplishments. However, challenging workloads
with family care responsibilities place them in stressful situations. Generation Y individuals have been cared for by
overprotective parents. They expect immediacy and value
speed more than accuracy. Researchers have reported that
generation Y nurses experience burnout more frequently
than do older nurses (Lin et al. 2009; Maslach et al. 2001;
Meeusen et al. 2010; Poncet et al. 2007). Maslach et al.
(2001) noted that work experience was confounded with age
when evaluating burnout. The work experience of younger
nurses is usually less than the experience of older staff. The
relationship between burnout and age among Taiwanese
nurses is unknown.
Most studies have reported that critical care nurses
experience higher levels of burnout (Cho et al. 2009;
Poncet et al. 2007; Taylor and Barling 2004). However, the
greatest percentages of nurses in hospitals practice in

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Community Ment Health J (2015) 51:733737

general medical-surgical units. Aiken et al. (2002) found

that nurses who work in general units have a high level of
burnout because of higher patient-to-nurse ratios, failureto-rescue rates, and patient mortality.
Nurses self-awareness of physical and psychological
symptoms, work environment, job satisfaction, and work
engagement has also been shown to be related to nurse
burnout (Gonzalez-Roma et al. 2006; Hanrahan et al. 2010;
Korkeila et al. 2003; Weng et al. 2011). Physical and
psychological symptoms, such as being tense and easily
irritated, having difficulty sleeping, and experiencing
feelings of helplessness and depression are similar to the
characteristics of burnout (Hsu et al. 2010; Klersy et al.
2007; Poncet et al. 2007; Spence Laschinger and Leiter
2006). Korkeila et al. (2003) indicated that depression is
associated with a high level of emotional exhaustion, with
a reported odds ratio of 6.9.
In summary, individual and situational factors can result
in burnout and negative nurse self-awareness. Although
research related to nurse burnout has been conducted in
Western countries, a lack of understanding remains
regarding burnout among nurses in Asia. The influence of
these predictors among nurses in Taiwan is unknown. The
aim of this study was to investigate the predictors of
burnout among nurses across Taiwan.

Methods
A secondary data analysis was conducted to investigate the
predictors of burnout among nurses in Taiwan. The data
were obtained from the NURSE-Outcomes study, a
nationwide survey of nurse workload and patient outcomes
in Taiwan conducted from 2008 to 2010.
Description of the NURSE-Outcomes Database
The NURSE-Outcomes study collected data using a proportional stratified random sample of the 483 hospitals in
Taiwan. Thirty-five hospitals participated, including four
medical centers, nine regional hospitals, and 22 district
hospitals accredited by the Taiwan Joint Commission. The
hospitals were stratified by geographic location as north or
south. Of the 1,896 nurses invited to provide data, 1,846
completed questionnaires.
Measurements
Data from five instruments completed during the NURSEOutcomes were obtained. The Maslach Burnout Inventory
Human Service Survey (MBIHSS)Chinese version is a
20-item scale measuring burnout and was tested by Lee et al.
(2013) on Taiwanese nurses. The 7-point Likert scale rates

734

samples and failed to identify predictors of burnout.

Researchers have suggested that larger sample sizes,
expanding the data collection area, and exploring different
working environments are needed to investigate burnout
differences across health care systems and countries (Lin
et al. 2009; Maslach et al. 2001).
Burnout is defined as experiencing a state of emotional
exhaustion similar to the extinguishing of a candle.
According to Maslach (1982), consisting of three dimensions: emotional exhaustion, depersonalization, and a
reduced sense of personal accomplishment. Emotional
exhaustion occurs when individuals overextend themselves
and feel emotionally overwhelmed. Depersonalization
refers to treating the patient as an object with an attitude of
indifference. A reduced sense of personal accomplishment
occurs when individuals think of themselves negatively,
consider themselves failures, and believe themselves to be
inadequate in work-related situations.
According to Maslach et al. (2001), individual factors,
including age, marital status, and length of employment, in
addition to situational factors including hospital type and
work unit, can affect nurse burnout. Nurse self-awareness
has also been found to be related to burnout, including
physical/psychological symptoms, work environment, job
satisfaction, and work engagement (Gonzalez-Roma et al.
2006; Hanrahan et al. 2010; Kanai-Pak et al. 2008;
Schaufeli and Bakker 2004; Weng et al. 2011).
Age is the most consistent demographic variable related
to burnout; however, reports have been inconsistent (Iglesias
et al. 2010; Maslach et al. 2001; Poncet et al. 2007; Wang
et al. 2010). Whitmer et al. (2009) indicated that problemsolving capacity and self-reliance are different between
individuals born from 1965 to 1980 (generation X) and those
born from 1981 to 2000 (generation Y). Generation X individuals who have stronger problem-solving capacities are
more self-reliant. They work hard at their jobs and strive for
work accomplishments. However, challenging workloads
with family care responsibilities place them in stressful situations. Generation Y individuals have been cared for by
overprotective parents. They expect immediacy and value
speed more than accuracy. Researchers have reported that
generation Y nurses experience burnout more frequently
than do older nurses (Lin et al. 2009; Maslach et al. 2001;
Meeusen et al. 2010; Poncet et al. 2007). Maslach et al.
(2001) noted that work experience was confounded with age
when evaluating burnout. The work experience of younger
nurses is usually less than the experience of older staff. The
relationship between burnout and age among Taiwanese
nurses is unknown.
Most studies have reported that critical care nurses
experience higher levels of burnout (Cho et al. 2009;
Poncet et al. 2007; Taylor and Barling 2004). However, the
greatest percentages of nurses in hospitals practice in

123

Community Ment Health J (2015) 51:733737

general medical-surgical units. Aiken et al. (2002) found

that nurses who work in general units have a high level of
burnout because of higher patient-to-nurse ratios, failureto-rescue rates, and patient mortality.
Nurses self-awareness of physical and psychological
symptoms, work environment, job satisfaction, and work
engagement has also been shown to be related to nurse
burnout (Gonzalez-Roma et al. 2006; Hanrahan et al. 2010;
Korkeila et al. 2003; Weng et al. 2011). Physical and
psychological symptoms, such as being tense and easily
irritated, having difficulty sleeping, and experiencing
feelings of helplessness and depression are similar to the
characteristics of burnout (Hsu et al. 2010; Klersy et al.
2007; Poncet et al. 2007; Spence Laschinger and Leiter
2006). Korkeila et al. (2003) indicated that depression is
associated with a high level of emotional exhaustion, with
a reported odds ratio of 6.9.
In summary, individual and situational factors can result
in burnout and negative nurse self-awareness. Although
research related to nurse burnout has been conducted in
Western countries, a lack of understanding remains
regarding burnout among nurses in Asia. The influence of
these predictors among nurses in Taiwan is unknown. The
aim of this study was to investigate the predictors of
burnout among nurses across Taiwan.

Methods
A secondary data analysis was conducted to investigate the
predictors of burnout among nurses in Taiwan. The data
were obtained from the NURSE-Outcomes study, a
nationwide survey of nurse workload and patient outcomes
in Taiwan conducted from 2008 to 2010.
Description of the NURSE-Outcomes Database
The NURSE-Outcomes study collected data using a proportional stratified random sample of the 483 hospitals in
Taiwan. Thirty-five hospitals participated, including four
medical centers, nine regional hospitals, and 22 district
hospitals accredited by the Taiwan Joint Commission. The
hospitals were stratified by geographic location as north or
south. Of the 1,896 nurses invited to provide data, 1,846
completed questionnaires.
Measurements
Data from five instruments completed during the NURSEOutcomes were obtained. The Maslach Burnout Inventory
Human Service Survey (MBIHSS)Chinese version is a
20-item scale measuring burnout and was tested by Lee et al.
(2013) on Taiwanese nurses. The 7-point Likert scale rates

Community Ment Health J (2015) 51:733737

how often the subject experiences burnout, from never = 0

to every day = 6. Three subscales were used to measure
emotional exhaustion (eight items), poor sense of personal
accomplishment (eight items), and depersonalization (four
items). In the Lee et al. (2013) study, the Cronbachs a values
were 0.85, 0.91, 0.86, and 0.65 for the total scale, emotional
exhaustion, reduced personal accomplishment, and depersonalization, respectively, and the validity scores included a
goodness of fit index (GFI) of 0.92, adjusted goodness of fit
index (AGFI) of 0.90 and root mean square error of
approximation (RMSEA) of 0.05.
The Brief Symptom Rating Scale (BSRS-5)Chinese
version developed by Lee et al. (2003) uses five items to
screen physical/psychological symptoms on a 5-point
scale, ranging from 1 = never to 5 = very serious, with
higher scores indicating poorer physical and psychological
health status. The Cronbachs a values reported by Lee
et al. (2003) ranged from 0.77 to 0.90.
The Mueller/McCloskey Satisfaction Scale (MMSS)
measures nurses job satisfaction on a 5-point scale over
eight domains: satisfaction with extrinsic rewards, scheduling, family/work balance, coworkers, interaction, professional opportunities, praise/recognition, and control/
responsibility (Mueller and McCloskey 1990). The Chinese
version uses a scale from 1 = never satisfied to 5 = very
satisfied, with a reported Cronbachs a of 0.89 (Li et al.
2002).
The Utrecht Work Engagement Scale (UWES-9) measures the work-related state of fulfillment and consists of
nine items used to assess work engagement (Schaufeli et al.
2006). The 7-point scale ranges from 1 = never to
7 = very serious, with a higher score reflecting greater
engagement. The original Cronbachs a was 0.92 (Schaufeli et al. 2006), and the value in the current study was
0.91.
The Nursing Work Index-Revised (NWI-R) (Aiken and
Patrician 2000) measures the practice environment on four
dimensions. A 4-point Likert scale is used to measure selfawareness of work environment, from 1 = never agree to
4 = agree totally, with higher scores indicating positive
self-awareness. The original Cronbachs a was from 0.84
to 0.97 (Aiken and Patrician 2000). For the current study,
only 15 items from three dimensions, autonomy, control
over practice, and doctor-nurse relationships, were analyzed with Cronbachs a from 0.80 to 0.87.

735

variables and burnout, a two-step hierarchical regression

analysis was performed. In step 1, the demographic variables were entered; the nurse self-awareness variable was
entered in step 2. The tolerance value was used to check
the collinarity problem. The value of tolerance in the current study was closed to one, indicating there was no collinarity problem (Wu 2009). The data were analyzed using
the Statistical Package for the Social Sciences (Version 17)
(SPSS/IBM Inc., Chicago, IL, USA).

Results
98 % (n = 1,814) of the 1,846 nurses were female, and
74 % (n = 1,372) were unmarried. The mean subject age
was 29 years (SD 5.26). There was nearly equal representation from northern and southern Taiwan. Half of the
subjects (n = 938, 50.8 %) practiced in medical units.
Nurses who worked in regional or district hospitals
(p \ 0.001) and in northern Taiwan (p = 0.002) reported
lower levels of personal accomplishment. There were no
significant differences in the burnout subscales with respect
to the area of practice or gender. The nurses who were not
married had higher scores on the three burnout subscales,
indicating they experienced higher levels of burnout.
Except for age and NWI-R score, there were significant
correlations among all variables (p \ 0.001). Physical/
psychological symptoms were the highest correlate of
emotional exhaustion (r = 0.48); work engagement was
the highest correlate of personal accomplishment and
depersonalization (r = -0.615, r = -0.326, respectively).
Work engagement was the variable most strongly correlated with the total burnout score among variables related
to nurse self-awareness (r = -0.633).
The significant categorical and continuous variables were
included in the linear regression model to predict total
burnout and the subscales of emotional exhaustion, personal
accomplishment, and depersonalization. The explained
variances were 54, 35, 39, and 18 %, respectively. Work
engagement explained the greatest variance in the total
burnout score; personal accomplishment, depersonalization,
and physical/psychological symptoms explained the most
variance in emotional exhaustion.

Statistical Analyses

Discussion

Descriptive statistics were used to describe subject characteristics. Differences were examined using t tests or
analysis of variance (ANOVA). Pearson correlations were
used to examine the association among continuous data. To
investigate the relationship between all significant

Among the Taiwanese nurses in this study, geographical

location, hospital type, marital status, and age were significantly related to burnout. Age was negatively related to
burnout, with younger nurses reporting greater burnout
than older nurses. These findings are similar to those of

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736

previous studies (Maslach et al. 2001; Meeusen et al. 2010;

Poncet et al. 2007). The mean age of nurses in the current
study represented generation Y individuals. The differences between unmarried and married nurses burnout
subscale scores were significant; however, the mean scores
differed only slightly (range 12.9 points). Therefore, it
was expected that marital status would not be significant in
step 2 of the hierarchical regression. The significant mean
difference in scores may have been due to the large sample
size.
Physical/psychological symptoms were the strongest
predictor of emotional exhaustion in this nationwide sample. The findings were similar to those of Van der Doef
et al. (2012), who noted that East African nurses who
reported having more somatic complaints also reported
more emotional exhaustion. Therefore, chronic environmental stressors in the workplace may contribute to physical/psychological symptoms such as anxiety, insomnia,
and depression, and these symptoms contribute to emotional exhaustion. A strong positive correlation was identified between work engagement and a sense of personal
accomplishment. Work engagement has been considered
the opposite of burnout and a protective factor against
burnout (Prins et al. 2010; Schaufeli et al. 2002). The
current study supports the findings of other studies (Demerouti et al. 2010; Prins et al. 2010) that noted that
individuals with more engagement had higher personal
accomplishment. When work engagement is low, there is
little opportunity for personal or professional accomplishment. Therefore, the lack of accomplishment leads to less
desire for work engagement. Work engagement explained
the most variance in burnout, personal accomplishment,
and depersonalization among nurses in Taiwan. These
findings are consistent with those of previous studies of
European and South African nurses, who also had higher
burnout scores with less work engagement (Demerouti
et al. 2010; Prins et al. 2010).

Conclusions
Personal characteristics can be used to predict nurse burnout
among Taiwanese nurses. Younger nurses with compromised physical/psychological symptoms are at risk of emotional exhaustion. Work engagement is a strong predictor of
a sense of personal accomplishment. Strategies are needed to
improve physical/psychological symptoms and work
engagement among nurses in Taiwan to avoid burnout.
Acknowledgments This study was funded by the Department of
Health, Executive Yuan, R. O. C. (TAIWAN) (DOH099-TD-M-11397025).

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Community Ment Health J (2015) 51:733737

Ethical Standard This study was received ethical approval from
National Cheng Kung University Hospital review board (No. 96E6245).

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