Burnout in Nursing: A Theoretical Review

Dall’Ora et al.
Human Resources for Health (2020) 18:41

https://doi.org/10.1186/s12960-020-00469-9
REVIEW Open Access
Burnout in nursing: a theoretical review

Chiara Dall’Ora1*, Jane Ball2, Maria Reinius2 and Peter Griffiths1,2
Abstract
Background: Workforce studies often identify burnout as a nursing ‘outcome’. Yet, burnout itself—what constitutes
it, what factors contribute to its development, and what the wider consequences are for individuals, organisations,
or their patients—is rarely made explicit. We aimed to provide a comprehensive summary of research that
examines theorised relationships between burnout and other variables, in order to determine what is known (and
not known) about the causes and consequences of burnout in nursing, and how this relates to theories of burnout.
Methods: We searched MEDLINE, CINAHL, and PsycINFO. We included quantitative primary empirical studies
(published in English) which examined associations between burnout and work-related factors in the nursing
workforce.
Results: Ninety-one papers were identified. The majority (n = 87) were cross-sectional studies; 39 studies used all
three subscales of the Maslach Burnout Inventory (MBI) Scale to measure burnout. As hypothesised by Maslach, we
identified high workload, value incongruence, low control over the job, low decision latitude, poor social climate/
social support, and low rewards as predictors of burnout. Maslach suggested that turnover, sickness absence, and
general health were effects of burnout; however, we identified relationships only with general health and sickness
absence. Other factors that were classified as predictors of burnout in the nursing literature were low/inadequate
nurse staffing levels, ≥ 12-h shifts, low schedule flexibility, time pressure, high job and psychological demands, low
task variety, role conflict, low autonomy, negative nurse-physician relationship, poor supervisor/leader support, poor
leadership, negative team relationship, and job insecurity. Among the outcomes of burnout, we found reduced job
performance, poor quality of care, poor patient safety, adverse events, patient negative experience, medication
errors, infections, patient falls, and intention to leave.
Conclusions: The patterns identified by these studies consistently show that adverse job characteristics—high
workload, low staffing levels, long shifts, and low control—are associated with burnout in nursing. The potential
consequences for staff and patients are severe. The literature on burnout in nursing partly supports Maslach’s
theory, but some areas are insufficiently tested, in particular, the association between burnout and turnover, and
relationships were found for some MBI dimensions only.
Keywords: Burnout, Nursing, Maslach Burnout Inventory, Job demands, Practice environment
* Correspondence: [email protected]
1
School of Health Sciences, and Applied Research Collaboration Wessex,
Highfield Campus, University of Southampton, Southampton SO17 1BJ, UK
Full list of author information is available at the end of the article
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Dall’Ora et al. Human Resources for Health (2020) 18:41 Page 2 of 17
Introduction employees’ health and job performance as outcomes

The past decades have seen a growing research and arising from burnout [7].
policy interest around how work organisation character- Subsequent models of burnout differ from Maslach’s
istics impact upon different outcomes in nursing. Several in one of two ways: they do not conceptualise burnout
studies and reviews have considered relationships be- as an exclusively work-related syndrome; they view
tween work organisation variables and outcomes such as burnout as a process rather than a state [10].
quality of care, patient safety, sickness absence, turnover, The job resources-demands model [11] builds on the
and job dissatisfaction [1–4]. Burnout is often identified view of burnout as a work-based mismatch but differs
as a nursing ‘outcome’ in workforce studies that seek to from Maslach’s model in that it posits that burnout de-
understand the effect of context and ‘inputs’ on velops via two separate pathways: excessive job demands
outcomes in health care environments. Yet, burnout it- leading to exhaustion, and insufficient job resources
self—what constitutes it, what factors contribute to its leading to disengagement. Along with Maslach and
development, and what the wider consequences are for Schaufeli, this model sees burnout as the negative pole
individuals, organisations, or their patients—is not al- of a continuum of employee’s well-being, with ‘work en-
ways elucidated in these studies. gagement’ as the positive pole [12].
The term burnout was introduced by Freudenberger in Among those who regard burnout as a process,
1974 when he observed a loss of motivation and reduced Cherniss used a longitudinal approach to investigate the
commitment among volunteers at a mental health clinic development of burnout in early career human services
[5]. It was Maslach who developed a scale, the Maslach workers. Burnout is presented as a process characterised
Burnout Inventory (MBI), which internationally is the by negative changes in attitudes and behaviours towards
most widely used instrument to measure burnout [6]. clients that occur over time, often associated with
According to Maslach’s conceptualisation, burnout is a workers’ disillusionment about the ideals that had led
response to excessive stress at work, which is charac- them to the job [13]. Gustavsson and colleagues used
terised by feelings of being emotionally drained and this model in examining longitudinal data on early car-
lacking emotional resources—Emotional Exhaustion; by eer nurses and found that exhaustion was a first phase
a negative and detached response to other people and in the burnout process, proceeding further only if nurses
loss of idealism—Depersonalisation; and by a decline in present dysfunctional coping (i.e. cynicism and disen-
feelings of competence and performance at work—re- gagement) [14].
duced Personal Accomplishment [7]. Shirom and colleagues suggested that burnout occurs
Maslach theorised that burnout is a state, which occurs when individuals exhaust their resources due to long-
as a result of a prolonged mismatch between a person and term exposures to emotionally demanding circumstances
at least one of the following six dimensions of work [7–9]: in both work and life settings, suggesting that burnout is
not exclusively an occupational syndrome [15, 16].
1) Workload: excessive workload and demands, so that This review aims to identify research that has exam-
recovery cannot be achieved. ined theorised relationships with burnout, in order to
2) Control: employees do not have sufficient control determine what is known (and not known) about the
over the resources needed to complete or factors associated with burnout in nursing and to deter-
accomplish their job. mine the extent to which studies have been underpinned
3) Reward: lack of adequate reward for the job done. by, and/or have supported or refuted, theories of
Rewards can be financial, social, and intrinsic (i.e. burnout.
the pride one may experience when doing a job).
4) Community: employees do not perceive a sense of Methods
positive connections with their colleagues and Design
managers, leading to frustration and reducing the This was a theoretical review conducted according to
likelihood of social support. the methodology outlined by Campbell et al. and Pare
5) Fairness: a person perceiving unfairness at the et al. [17, 18]. Theoretical reviews draw on empirical
workplace, including inequity of workload and pay. studies to understand a concept from a theoretical per-
6) Values: employees feeling constrained by their job spective and highlight knowledge gaps. Theoretical re-
to act against their own values and their aspiration views are systematic in terms of searching and
or when they experience conflicts between the inclusion/exclusion criteria and do not include a formal
organisation’s values. appraisal of quality. They have been previously used in
nursing, but not focussing on burnout [19]. While no
Maslach theorised these six work characteristics as reporting guideline for theoretical reviews currently ex-
factors causing burnout and placed deterioration in ists, the PRISMA-ScR was deemed to be suitable, with
some modifications, to enhance the transparency of each to check for agreement in data extraction. In line
reporting for the purposes of this review. The checklist, with the theoretical review methodology, we did not for-
which can be found as Additional file 2, has been modi- mally assess the quality of studies [19]. However, in Add-
fied as follows: itional file 3, we have summarised the key aspects of
quality for each study, covering generalisability (e.g. a mul-
– Checklist title has been modified to indicate that the tisite study with more than 500 participants); risk of bias
checklist has been adapted for theoretical reviews. from common methods variance (e.g. burnout and corre-
– Introduction (item 3) has been modified to reflect lates assessed with the same survey. This bias arises when
that the review questions lend themselves to a there is a shared (common) variance because of the com-
theoretical review approach. mon method rather than a true (causal) association be-
– Selection of sources of evidence (item 9) has been tween variables); evidence of clustering (e.g. nurses nested
modified to state the process for selecting sources of in wards, wards nested in hospitals); and evidence of stat-
evidence in the theoretical review. istical adjustment (e.g. the association between burnout
– Limitations (item 20) has been amended to discuss and correlates has been adjusted to control for potentially
the limitations of the theoretical review process. influencing variables). It should be noted that cells are
– Funding (item 22) has been amended to describe shaded in green when the above-mentioned quality stan-
sources of funding and the role of funders in the dards have been met, and in red when they have not. In
theoretical review. the ‘Discussion’ section, we offer a reflection on the com-
mon limitations of research in the field and present a
All changes from the original version have been graphic summary of the ‘strength of evidence’ in Fig. 1.
highlighted.
Data synthesis
Literature search Due to the breadth of the evidence, we summarised
A systematic search of empirical studies examining extracted data by identifying common categories
burnout in nursing published in journal articles since through a coding frame. The starting point of the
1975 was performed in May 2019, using MEDLINE, coding frame was the burnout multidimensional the-
CINAHL, and PsycINFO. The main search terms were ory outlined by Maslach [7]. We then considered
‘burnout’ and ‘nursing’, using both free-search terms and whether the studies’ variables fit into Maslach’s cat-
indexed terms, synonyms, and abbreviations. The full egorisation, and where they did not, we created new
search and the total number of papers identified are in categories. We identified nine broad categories: (1)
Additional file 1. Areas of Worklife; (2) Workload and Staffing Levels;
We included papers written in English that measured (3) Job Control, Reward, Values, Fairness, and Com-
the association between burnout and work-related fac- munity; (4) Shift Work and Working Patterns; (5)
tors or outcomes in all types of nurses or nursing assis- Psychological Demands and Job Complexity; (6) Sup-
tants working in a healthcare setting, including hospitals, port Factors: Working Relationships and Leadership;
care homes, primary care, the community, and ambu- (7) Work Environment and Hospital Characteristics;
lance services. Because there are different theories of (8) Staff Outcomes and Job Performance; and (9) Pa-
burnout, we did not restrict the definition of burnout ac- tient Care and Outcomes. In the literature, categories
cording to any specific theory. Burnout is a work-related 1–7 were treated as predictors of burnout and cat-
phenomenon [8], so we excluded studies focussing ex- egories 8 and 9 as outcomes, with the exception of
clusively on personal factors (e.g. gender, age). Our aim missed care and job satisfaction which were treated
was to identify theorised relationships; therefore, we ex- both as predictors and outcomes.
cluded studies which were only comparing the levels of When the coding frame was finalised, CDO and MLR
burnout among different settings (e.g. in cancer services applied it to all studies. Where there was disagreement, a
vs emergency departments). We excluded literature re- third reviewer (JEB) made the final decision.
views, commentaries, and editorials.
Results
Data extraction and quality appraisal The database search yielded 12 248 studies, of which
The following data were extracted from included studies: 11 870 were rapidly excluded as either duplicates
country, setting, sample size, staff group, measure of or titles and/or abstract not meeting the inclusion
burnout, variables the relationship with burnout was criteria. Of the 368 studies accessed in full text,
tested against, and findings against the hypothesised re- 277 were excluded, and 91 studies were included
lationships. One reviewer (MEB) extracted data from all in the review. Figure 2 presents a flow chart of the
the studies, with CDO and JEB extracting 10 studies study selection.
Fig. 1 Graphical representation of strength of relationships with burnout
The 91 studies identified covered 28 countries; four (n = 82). Eight studies surveyed nurses at a national level,
studies included multiple countries, and in one, the regardless of their work setting.
country was not reported. Most were from North Amer- Sample sizes ranged from hundreds of hospitals
ica (n = 35), Europe (n = 28), and Asia (n = 18). (max = 927) with hundreds of thousands of nurses
The majority had cross-sectional designs (n = 87, 97%); (max = 326 750) [20] to small single-site studies
of these, 84 were entirely survey-based. Three studies were with the smallest sample being 73 nurses [21] (see
longitudinal. Most studies were undertaken in hospitals Additional file 3).
Fig. 2 Study selection flow chart
The relationships examined are summarised in [24], and one used the burnout subscale of the
Table 1. Professional Quality of Life Measure (ProQoL5) scale,
which posits burnout as an element of compassion
Measures of burnout fatigue [25]. Two studies used idiosyncratic measures
Most studies used the Maslach Burnout Inventory of burnout based on items from other instruments
Scale (n = 81), which comprises three subscales [20, 26].
reflecting the theoretical model: Emotional Exhaus-
tion, Depersonalisation, and reduced Personal Accom-
plishment. However, less than half (47%, n = 39) of Factors examined in relation to burnout: an overview
the papers measured and reported results with all The studies which tested the relationships between
three subscales. Twenty-three papers used the Emo- burnout and Maslach’s six areas of worklife—workload,
tional Exhaustion subscale only, and 11 papers used control, reward, community, fairness, and values—typic-
the Emotional Exhaustion and Depersonalisation sub- ally supported Maslach’s theory that these areas are pre-
scales. In nine studies, the three MBI subscales were dictors of burnout. However, some evidence is based
summed up to provide a composite score of burnout, only on certain MBI dimensions. High scores on the
despite Maslach and colleagues advising against such Areas of Worklife Scale [27] (indicating a higher degree
an approach [22]. of congruence between the job and the respondent) were
Five studies used the Copenhagen Burnout Inven- associated with less likelihood of burnout, either directly
tory (CBI) [23]. This scale consists of three dimen- [28, 29] or through high occupational coping self-
sions of burnout: personal, work-related, and client- efficacy [30] and presence of civility norms and co-
related. Two studies used the Malach-Pines Scale worker incivility [31].
Table 1 Summary of studies’ results

Hypothesised by Observed Refuted** Number of studies supporting
Maslach’s theory the relationship
1. Areas of worklife
Areas of worklife (high score on Areas of Worklife √ √ 4 out of 4
Scale)
2. Workload and staffing levels
High workload √ √* (definitive for EE 12 out of 13
only)
Nurse staffing levels (low/inadequate) √* 12 out of 15
Time pressure √* (definitive for EE 3 out of 3
only)
3. Job control, reward, values, fairness, community
Low control over the job √ √* 5 out of 7
Low reward √ √* 3 out of 3
Low value congruence √ √* (definitive for EE 7 out of 8
and DEP)
4. Shift work and working patterns
Night work √
Overtime √
Number of hours worked per week √
≥ 12-h shifts √*(definitive for EE 4 out of 4
only)
Low schedule flexibility √* (definitive only 1 out of 1
for EE)
5. Demands and job complexity
Job and psychological demands √* (definitive for EE 8 out of 8
only)
Low task variety √* 4 out of 4
High patient complexity √* 4 out of 4
Role conflict √* (definitive for EE 4 out of 4
only)
Low autonomy √* 4 out of 6
Low decision latitude √ √* 4 out of 4
6. Support factors: working relationships and
leadership
Negative nurse-physician relationship √* 10 out of 12
Low supervisor/leader support √* 12 out of 12
Leadership styles that are not authentic and √* (definitive only 14 out of 14
transformational for EE)
Negative team relationship √* 14 out of 15
7. Work environment and hospital characteristics
Negative work environment (global scale) √* (definitive for EE 11 out of 11
only)
Low Structural/organisation empowerment √* (definitive for EE 7 out of 7
only)
Limited Participation in hospital affairs (including √* 2 out of 3
policy and research)
No development opportunities √
Low pay √
High job insecurity √* 1 out of 1
Table 1 Summary of studies’ results (Continued)

Hypothesised by Observed Refuted** Number of studies supporting
Maslach’s theory the relationship
Model of nursing care √
Specialised hospital/ward type √
Magnet hospital √
8. Staff outcomes and job performance
Intention to leave √* 19 out of 19
Turnover √ √
Low job performance √* 2 out of 2
Missed care √*** 3 out of 3
Sickness absence √ √* 3 out of 4
Poor general health √ √* (definitive for EE 4 out of 4
only)
Mental health issues (including depression) √* 5 out of 5
Job dissatisfaction √*** 10 out of 11
9. Patient care and outcomes
Poor quality of care √* 7 out of 8
Poor patient safety √* 5 out of 5
Adverse events √* 3 out of 3
Patient negative experience (including √* 2 out of 2
dissatisfaction and verbal abuse)
Medication errors √* 2 out of 2
Infections √* 3 out of 3
Pressure ulcers √
Patient falls √* 2 out of 2
*Partial evidence (e.g. relationship established with some but not all burnout subscales)
**Refuted when there is consistent evidence that a hypothesised relationship does not exist (e.g. large studies with no confidence intervals shown if
no association)
***Observed in multiple directions
The majority of studies looking at job characteris- Workload and staffing levels
tics hypothesised by the Maslach model considered Workload and characteristics of jobs that contribute to
workload (n = 31) and job control and reward (n = 10). workload, such as staffing levels, were the most fre-
While only a few studies (n = 9) explicitly examined the quently examined factor in relation to burnout. Thirty
hypothesised relationships between burnout and commu- studies found an association between high workload and
nity, fairness, or values, we identified 39 studies that burnout.
covered ‘supportive factors’ including relationships with Of these, 13 studies looked specifically at measures
colleagues and leadership. of workload as a predictor of burnout. Workload was
A large number of studies included factors that fall out- associated with Emotional Exhaustion in five studies
side of the Maslach model. Six main areas were identified: [32–36], with some studies also reporting a relation-
ship with Depersonalisation, and others Cynicism.
Working patterns and shifts working (n = 15) Janssen reported that ‘mental work overload’ pre-
Features inherent in the job such as psychological dicted Emotional Exhaustion [37]. Three studies con-
demand and complexity (n = 24) cluded that workload is associated with both
Job support from working relationships and Emotional Exhaustion and Depersonalisation [38–40].
leadership (n = 39) Kitaoka-Higashiguchi tested a model of burnout and
Hospital or environmental characteristics (n = 28) found that heavy workload predicted Emotional Ex-
Staff outcomes and job performance (n = 33) haustion, which in turn predicted Cynicism [41]. This
Patient outcomes (n = 17) was also observed in a larger study by Greengrass
Individual attributes (personal or professional) et al. who found that high workload was associated
(n = 16) with Emotional Exhaustion, which consequently
predicted Cynicism [42]. One study reported no was significantly related to control over practice setting
association between workload and burnout compo- [63]; two studies reported no effect of job control on
nents [43], and one study found an association be- burnout [44, 64].
tween manageable workload and a composite burnout Reward predicted Cynicism [35] and burnout on a
score [44]. composite score [44]. Shamian and colleagues found that
Further 15 studies looked specifically at nurse staffing a higher score in the effort and reward imbalance scale
levels, and most reported that when nurses were caring was associated with Emotional Exhaustion, and higher
for a higher number of patients or were reporting staff- scores in the effort and reward imbalance scale were as-
ing inadequacy, they were more likely to experience sociated with burnout measured by the CBI [65].
burnout. No studies found an association between better Value congruence refers to a match between the re-
staffing levels and burnout. quirements of the job and people’s personal principles
While three studies did not find a significant association [7]. Value conflicts were related with a composite score
with staffing levels [32, 45, 46], three studies found that of burnout [44], and one study concluded that nurses
higher patient-to-nurse ratios were associated with Emo- with a high value congruence reported lower Emotional
tional Exhaustion [47–49], and in one study, higher Exhaustion than those with a low value congruence,
patient-to-nurse-ratios were associated with Emotional and nurses with a low value congruence experienced
Exhaustion, Depersonalisation, and Personal Accomplish- more severe Depersonalisation than nurses with a high
ment [50]. One study concluded that Emotional value congruence [66]. Low value congruence was a
Exhaustion mediated the relationship between patient-to- predictor of all three MBI dimensions [35] and of burn-
nurse ratios and patient safety [51]. Akman and colleagues out measured with the Malach-Pines Burnout Scale
found that the lower the number of patients nurses were [67]. Two studies considered social capital, defined as a
responsible for, the lower the burnout composite score social structure that benefits its members including
[52]. Similar results were highlighted by Faller and col- trust, reciprocity, and a set of shared values, and they
leagues [53]. Lower RN hours per patient day were associ- both concluded that lower social capital in the hospital-
ated with burnout in a study by Thompson [20]. predicted Emotional Exhaustion [33, 36]. A single study
When newly qualified RNs reported being short- showed fairness predicted values, which in turn pre-
staffed, they were more likely to report Emotional Ex- dicted all MBI Scales [35]. Two studies looked at com-
haustion and Cynicism 1 year later [54]. In a further munity, and one found that community predicts a
study, low staffing adequacy was associated with Emo- composite score of burnout [44], while the other found
tional Exhaustion [55]. Similarly, Leineweber and col- no relationships [35].
leagues found that poor staff adequacy was associated While not directly expressed in the terms described by
with Emotional Exhaustion, Depersonalisation, and Per- Maslach, other studies demonstrate associations with
sonal Accomplishment [56]. Leiter and Spence Laschin- possible causal factors, many of which are reflected in
ger explored the relationship between staffing adequacy Maslach’s theory.
and all MBI subscales and found that Emotional Exhaus- In summary, there is evidence that control over the
tion mediated the relationship between staffing adequacy job is associated with reduced burnout, and value con-
and Depersonalisation [57]. Time pressure was investi- gruence is associated with reduced Emotional Exhaus-
gated in three studies, which all concluded that reported tion and Depersonalisation.
time pressure was associated with Emotional Exhaustion
[58–60]. Working patterns and shift work
In summary, there is evidence that high workload is Shift work and working patterns variables were consid-
associated with Emotional Exhaustion, nurse staffing ered by 15 studies. Overall, there was mixed evidence on
levels are associated with burnout, and time pressure is the relationship between night work, number of hours
associated with Emotional Exhaustion. worked per week, and burnout, with more conclusive re-
sults regarding the association between long shifts and
Job control, reward, values, fairness, and community burnout, and the potential protective effect of schedule
Having control over the job was examined in seven stud- flexibility.
ies. Galletta et al. found that low job control was associ- Working night shifts was associated with burnout
ated with all MBI subscales [40], as did Gandi et al. [61]. (composite score) [68] and Emotional Exhaustion [62],
Leiter and Maslach found that control predicted fairness, but the relationship was not significant in two studies
reward, and community, and in turn, fairness predicted [69, 70]. Working on permanent as opposed to rotating
values, and values predicted all MBI subscales [35]. Low shift patterns did not impact burnout [71], but working
control predicted Emotional Exhaustion only for nurses irregular shifts did impact a composite burnout score
working the day shift [62], and Emotional Exhaustion [72]. When nurses reported working a higher number of
shifts, they were more likely to report higher burnout the job was associated with a reduced likelihood to ex-
composite scores [68], but results did not generalise in a perience Depersonalisation [71]. Higher task clarity was
further study [69]. One study found working that over- associated with reduced levels of Emotional Exhaustion
time was associated with composite MBI score [73]. On- and increased Personal Accomplishment [58].
call requirement was not significantly associated with Patient characteristics/requirements were investigated
any MBI dimensions [71]. in four papers. When nurses were caring for suffering
The number of hours worked per week was not a sig- patients and patients who had multiple requirements,
nificant predictor of burnout according to two studies they were more likely to experience Emotional Exhaus-
[25, 53], but having a higher number of weekly hours tion and Cynicism. Similarly, caring for a dying patient
was associated with Emotional Exhaustion and Deper- and having a high number of decisions to forego life-
sonalisation in one study [70]. Long shifts of 12 h or sustaining treatments were associated with a higher like-
more were associated with all MBI subscales [74] and lihood of burnout (measured with a composite score)
with Emotional Exhaustion [49, 75]. A study using the [76]. Stress resulting from patient care was associated
ProQoL5 burnout scale found that shorter shifts were with a composite burnout score [73]. Patient violence
protective of burnout [25]. also had an impact on burnout, measured with CBI [81],
Having higher schedule flexibility was protective of as did conflict with patients [76].
Emotional Exhaustion [46], and so was the ability to Role conflict is a situation in which contradictory,
schedule days off for a burnout composite score [76]. competing, or incompatible expectations are placed on
Having more than 8 days off per month was associated an individual by two or more roles held at the same
with lower burnout [69]. Stone et al. found that a posi- time. Role conflict predicted Emotional Exhaustion [41],
tive scheduling climate was protective of Emotional Ex- and so it did in a study by Konstantinou et al., who
haustion only [77]. found that role conflict was associated with Emotional
In summary, we found an association between ≥ 12-h Exhaustion and Depersonalisation [34]; Levert and col-
shifts and Emotional Exhaustion and between schedule leagues reported that role conflict correlated with Emo-
flexibility and reduced Emotional Exhaustion. tional Exhaustion, Depersonalisation, and Personal
Accomplishment. They also considered role ambiguity,
Psychological demands and job complexity which correlated with Emotional Exhaustion and Deper-
There is evidence from 24 studies that job demands and sonalisation, but not Personal Accomplishment [39].
aspects intrinsic to the job, including role conflict, au- Andela et al. investigated the impact of emotional dis-
tonomy, and task variety, are associated with some burn- sonance, defined as the mismatch between the emotions
out dimensions. that are felt and the emotions required to be displayed
Eight studies considered psychological demands. The by organisations. They reported that emotional disson-
higher the psychological demands, the higher the likeli- ance is a mediator between job aspects (i.e. workload,
hood of experiencing all burnout dimensions [72], and patient characteristics, and team issues) and Emotional
high psychological demands were associated with higher Exhaustion and Cynicism. Rouxel et al. found that per-
odds of Emotional Exhaustion [62, 78]. Emotional de- ceived negative display rules were associated with Emo-
mands, in terms of hindrances, had an effect on burnout tional Exhaustion [64].
[67]. One study reported that job demands, measured Autonomy related to Emotional Exhaustion and Deper-
with the Effort-Reward Imbalance Questionnaire, were sonalisation [60], and in another study, it only related to
correlated with all burnout dimensions [79], and simi- Depersonalisation [43]. Low autonomy impacted Emo-
larly, Garcia-Sierra et al. found that demands predict tional Exhaustion via organisational trust [82]. Autonomy
burnout, measured with a composite scale of Emotional correlated with burnout [67]. There was no effect of au-
Exhaustion and Cynicism [80]. According to one study, tonomy on burnout according to two studies [58, 63].
job demands were not associated with burnout [73], and Low decision-making at the ward level was associated with
Rouxel et al. concluded that the higher the job demands, all MBI subscales [77]. Decision latitude impacted Per-
the higher the impact on both Emotional Exhaustion sonal Accomplishment only [36], and in one study, it was
and Depersonalisation [64]. found to be related to Emotional Exhaustion [78]. High
Four studies looked at task nature and variety, quality decision latitude was associated with Personal Accom-
of job content, in terms of skill variety, skill discretion, plishment [41] and low Emotional Exhaustion [33].
task identity, task significance, influenced Emotional Ex- Overall, high job and psychological demands were as-
haustion through intrinsic work motivation [37]. Skill sociated with Emotional Exhaustion, as was role conflict.
variety and task significance were related to Emotional Patient complexity was associated with burnout, while
Exhaustion; task significance was also related to Personal task variety, autonomy, and decision latitude were pro-
Accomplishment [60]. Having no administrative tasks in tective of burnout.
Working relationships and leadership awareness, balanced processing, an internalised moral

Overall, evidence from 39 studies supports that having perspective, and transparency—predicted higher em-
positive support factors and working relationships in powerment, which in turn predicted lower levels of
place, including positive relationships with physicians, Emotional Exhaustion and Cynicism a year later [54].
support from the leader, positive leadership style, and Authentic leadership had a negative direct effect on
teamwork, might play a protective role towards burnout. workplace bullying, which in turn had a direct positive
The quality of the relationship with physicians was in- effect on Emotional Exhaustion [88]. Effective leadership
vestigated by 12 studies. In two studies, having negative predicted staffing adequacy, which in turn predicted
relationships with physicians was associated with all Emotional Exhaustion [57, 85]. Authentic leadership pre-
MBI dimensions [77, 83]; quality of nurse-physician rela- dicted all areas of worklife, which in turn predicted all
tionship was associated with Emotional Exhaustion and MBI dimensions of burnout [30], and a similar pathway
Depersonalisation, but not PA [50]. Two studies found was identified by Laschiner and Read, although authentic
an association with Emotional Exhaustion only [55, 84], leadership impacted Emotional Exhaustion only and it
and one concluded that quality of relationship with phy- was also through civility norms and co-worker incivility
sicians indirectly supported PA [36]. This was also found [31]. Emotional Exhaustion mediated the relationship
by Leiter and Laschinger, who found that positive nurse- between authentic leadership and intention to leave the
physician collaborations predicted Personal Accomplish- job [89]. ‘Leader empowering behaviour’ had an indirect
ment [57, 85]. When burnout was measured with effect on Emotional Exhaustion through structural em-
composite scores of MBI and a not validated scale, two powerment [29], and empowering leadership predicted
studies reported an association with nurse-physician re- trust in the leader, which in turn was associated with
lationship [20, 76], and two studies found no associa- burnout composite score [87]. Active management-by-
tions [56, 63]. exception was beneficial for Depersonalisation and Per-
Having support from the supervisor or leader was con- sonal Accomplishment, passive laissez-faire leadership
sidered in 12 studies, which found relationships with dif- negatively affected Emotional Exhaustion and Personal
ferent MBI dimensions. A relationship between low Accomplishment, and rewarding transformational lead-
support from nurse managers and all MBI subscales was ership protected from Depersonalisation [90]. Contrary
observed in one study [77], while two studies reported it to this, Madathil et al. found that transformational lead-
is a protective factor from Emotional Exhaustion only ership protected against Emotional Exhaustion, but not
[58, 83], and one that it was also associated with Deper- Depersonalisation, and promoted Personal Accomplish-
sonalisation [86]. Kitaoka-Higashiguchi reported an as- ment [43]. Transformational leadership predicted posi-
sociation only with Cynicism [41], and Jansen et al. tive work environments, which in turn predicted lower
found it was only associated with Depersonalisation and burnout (composite score) [44]. Positive leadership af-
Personal Accomplishment [60]. Van Bogaert and col- fected Emotional Exhaustion and Depersonalisation [56]
leagues found that support from managers predicted low and burnout measured with a non-validated scale [20].
Emotional Exhaustion and high Personal Accomplish- Teamwork and social support were also explored. Co-
ment [84], but in a later study, it only predicted high worker cohesion was only related to Depersonalisation
Personal Accomplishment [36]. Regarding the relation- [58]; team collaboration problems predicted negative
ship with the manager, it had a direct effect on Deper- scores on all MBI subscales [38], and workplace support
sonalisation, and it moderated the effect of time protected from Emotional Exhaustion [72]. Similarly,
pressure on Emotional Exhaustion and Depersonalisa- support received from peers had a protective effect on
tion [59]; a protective effect of a quality relationship with Emotional Exhaustion [60]. Collegial support was related
the head nurse on a composite burnout score was also to Emotional Exhaustion and Personal Accomplishment
reported [76]. Two studies using different burnout scales [39], and colleague support protected from burnout [67].
found an association between manager support and re- Interpersonal conflict affected Emotional Exhaustion
duced burnout [25, 67]. Low trust in the leader showed through role conflict, but co-worker support had no ef-
a negative impact on burnout, measured with a compos- fect on any burnout dimensions [41], and similarly, co-
ite score [87]. Two further studies focused on the per- worker incivility predicted Emotional Exhaustion [31],
ceived nurse manager’s ability: authors found that it was and so did bullying [88]. Poor team communication was
related to Emotional Exhaustion [46], and Emotional Ex- associated with all MBI dimensions [40], staff issues pre-
haustion and Personal Accomplishment [50]. dicted burnout measured with a composite score [73],
Fourteen studies looked at the leadership style and and so did verbal violence from colleagues [68]. One
found that it affects burnout through different pathways study found that seeking social support was not associ-
and mechanisms. Boamah et al. found that authentic ated with any of the burnout dimensions, while another
leadership—described as leaders who have high self- study found that low social support predicted Emotional
Exhaustion [37], and social support was associated with another study found that having promotion opportun-
lower Emotional Exhaustion and higher Personal Ac- ities was not related to burnout [79]. Moloney et al.
complishment [21]. Vidotti et al. found an association found that professional development was not related to
between low social support and all MBI dimensions [62]. burnout [67]. Two studies considered pay. In one study,
no effect was found on any MBI dimension [73], and a
Work environment and hospital characteristics very small study (n = 78 nurses) reported an effect of
Eleven studies were considering the work environment satisfaction with pay on Emotional Exhaustion and De-
measured with the PES-NWI scale [91], where higher personalisation [34]. Job insecurity predicted Deperson-
scores indicate positive work environments. Five studies alisation and PA [79].
comprising diverse samples and settings concluded that When the hospital adopted nursing models of care ra-
the better rated the work environment, the lower the ther than medical models of care, nurses were more likely
likelihood of experiencing Emotional Exhaustion [32, 47, to report high levels of Personal Accomplishment [57, 85].
49, 51, 92], and four studies found the same relationship, However, another study found no significant relationship
but on both Emotional Exhaustion and Depersonalisa- [20]. Regarding ward and hospital type, Aiken and Sloane
tion [50, 66, 93, 94]; only one study concluded there is found that RNs working in specialised AIDS units re-
an association between work environment and all MBI ported lower levels of Emotional Exhaustion [98]; how-
dimensions [95]. Negative work environments affected ever, ward type was not found to be significantly
burnout (measured with a composite score) via job dis- associated with burnout in a study on temporary nurses
satisfaction [96]. One study looked at organisational [53]. Working in different ward settings was not associ-
characteristics on a single scale and found that a higher ated with burnout, but working in hospitals as opposed to
rating of organisational characteristics predicted lower in primary care was associated with lower Emotional Ex-
Emotional Exhaustion [82]. Environmental uncertainty haustion [71]. Working in a small hospital was associated
was related to all MBI dimensions [86]. with a lower likelihood of Emotional Exhaustion, when
Structural empowerment was also considered in rela- compared to working in a community hospital [63].
tion to burnout: high structural empowerment led to Faller’s study also concluded that working in California
lower Emotional Exhaustion and Cynicism via staffing was a significant predictor of reduced burnout.
levels and worklife interference [54]; in a study using a When the hospitals’ investment in the quality of care
similar methodology, structural empowerment affected was considered, one study found that having foundations
Emotional Exhaustion via Areas of Worklife [29]. The for quality of care was associated with reduced Emo-
relationship between Emotional Exhaustion and Cyni- tional Exhaustion only [50], but in another study, foun-
cism was moderated by organisational empowerment dations for quality of care were associated with all MBI
[40], and organisational support had a protective effect dimensions [83]. Working in a Magnet hospital was not
on burnout [67]. Hospital management and organisa- associated with burnout [53].
tional support had a direct effect on Emotional Exhaus- In summary, having a positive work environment (gen-
tion and Personal Accomplishment [84]. Trust in the erally work environments scoring higher on the PES-
organisation predicted lower levels of Emotional Exhaus- NWI scale) was associated with reduced Emotional
tion [82] and of burnout measured with a composite Exhaustion, and so was higher structural empowerment.
MBI score [87]. However, none of the organisational characteristics at
Three studies considered whether policy involvement the hospital level was consistently associated with
had an effect on burnout. Two studies on the same sam- burnout.
ple found that having the opportunity to participate in
policy decisions was associated with reduced burnout Staff outcomes and job performance
(all subscales) [57, 85], and one study did not report re- Nineteen studies considered the impact of burnout on
sults for the association [20]. Emotional Exhaustion me- intention to leave. Two studies found that Emotional Ex-
diated the relationship between nurses’ participation in haustion and Cynicism had a direct effect on turnover
hospital affairs and their intention to leave the job [97]; intentions [28, 99], and four studies reported that only
a further study did not found an association between Emotional Exhaustion affected intentions to leave the
participation in hospital affairs and Emotional Exhaus- job [21, 32, 37, 100], with one of these indicating that
tion, but only with Personal Accomplishment [50]. Emotional Exhaustion affected also intention to leave
Lastly, one study investigated participation in research the organisation [32], but one study did not replicate
groups and concluded it was associated with reduced such findings [101] and concluded that only Cynicism
burnout measured with a composite score [76]. was associated with intention to leave the job and nurs-
There was an association between opportunity for caring. Similarly, one study found that Cynicism was dir-
eer advancement and all MBI dimensions [77]; however, ectly related to intention to leave [35]. A further study
found that Emotional Exhaustion affected turnover in- Emotional Exhaustion and Personal Accomplishment
tentions via job satisfaction [88], and one article reported were associated with perceived health [70]. Final-year
that Emotional Exhaustion mediated the effect of au- nursing students who experienced health issues were
thentic leadership on intention to leave [89]. Emotional more likely to develop high burnout when entering the
Exhaustion was a mediator between nurses’ involvement profession [26]. When quality of sleep was treated both
with decisions and intention to leave the organisation as a predictor and outcome of burnout, relationships
[97]. Burnout measured on a composite score was asso- were found in both instances [106].
ciated with a higher intention to leave [96]. Laeeque Focussing on mental health, one study found that
et al. reported that burnout, captured with CBI, related burnout predicted mental health problems for newly
to intention to leave [81]; Estryn-Behar et al. used the qualified nurses [30], and Emotional Exhaustion and
same scale to measure burnout and found that high Cynicism predicted somatisation [42]. Depressive symp-
burnout was associated with higher intention to leave in toms were predictive of Emotional Exhaustion and De-
all countries, except for Slovakia [102]. Burnout, mea- personalisation, considering therefore depression as a
sured with the Malach-Pines Scale, was associated with predictor of burnout [108]. Rudman and Gustavsson also
intention to quit, and stronger associations were found found that having depressive mood and depressive ep-
for nurses who had higher perceptions of organisational isodes were common features of newly qualified
politics [103]. Burnout (Malach-Pines Scale) predicted nurses who developed or got worse levels of burnout
both the intention to leave the job and nursing [67]. throughout their first years in the profession [26].
Three studies investigated the relationship between Tourigny et al. considered depression as a predictor
burnout and intention to leave; one of these aggregated and found it was significantly related to Emotional
all job outcomes in a single variable (i.e. job satisfaction, Exhaustion [107].
intention to leave the hospital, applied for another job, Eleven studies considered job satisfaction: of these,
and intention to leave nursing) and reported that Deper- three treated job satisfaction as a predictor of burnout
sonalisation and Personal Accomplishment predict job and concluded that higher levels of job satisfaction were
outcomes [84]; they replicated a similar approach and associated with a lower level of composite burnout
found the same associations [36]. They later found that scores [52, 96] and all MBI dimensions [94]. According
all MBI dimensions were associated with leaving the to two studies, Emotional Exhaustion and Cynicism pre-
nursing profession [104]. Only one study in a sample of dicted job dissatisfaction [54, 101], while four studies re-
106 nurses from one hospital found an association be- ported that Emotional Exhaustion only was associated
tween Depersonalisation and turnover within 2 years with increased odds to report job dissatisfaction [73, 82,
[105]. 88, 100]; one study reported that Cynicism only was as-
Two studies looked at the effect of burnout on job sociated with job dissatisfaction [99]. Rouxel et al. did
performance: one found a negative association between not find support in their hypothesised model that Emo-
burnout (measured with CBI) and both task perform- tional Exhaustion and Depersonalisation predicted job
ance and contextual performance [106]. Only Emotional satisfaction [64].
Exhaustion was associated with self-rated and In summary, considering 39 studies, there is conflict-
supervisor-rated job performance of 73 RNs [21]. Missed ing evidence on the direction of the relationship between
care was investigated in three studies, and it was found burnout and missed care, mental health, and job satis-
to be both predictor of Emotional Exhaustion [32], an faction. An association between burnout and intention
outcome of burnout [20, 103]. to leave was found, although only one small study re-
Four studies considered sickness absence. When RNs ported an association between burnout and turnover. A
had high levels of Emotional Exhaustion, they were more moderate relationship was found for the effect of burn-
likely to experience short-term sickness absence (i.e. 1– out on sickness absence, job performance, and general
10 days of absence), which was obtained from hospital health.
administrative records. Similarly, Emotional Exhaustion
was associated with seven or more days of absence in a Patient care and outcomes
longitudinal study [105]. Emotional Exhaustion was sig- Among the patient outcomes of burnout, quality of care
nificantly associated with reported mental health absen- was investigated by eight studies. Two studies in diverse
teeism, but not reported physical health absenteeism, samples and settings reported that high Emotional Ex-
and sickness absence from administrative records [21]. haustion, high Depersonalisation, and low Personal Ac-
One study did not find any meaningful relationships be- complishment were associated with poor quality of care
tween burnout and absenteeism [107]. [109, 110], but one study found that only Personal Ac-
Emotional Exhaustion was a significant predictor of complishment was related to better quality of care at the
general health [73], and in a further study, both last shift [104]; Emotional Exhaustion and Cynicism
predict low quality of care [54]; two articles reported Individual characteristics
that Emotional Exhaustion predicts poor nurse ratings In total, 16 studies, which had examined work character-
of quality of care [82, 84]. A high burnout composite istics related to burnout, also considered the relationship
score predicted poor nurse-assessed quality of care [96]. between characteristics of the individual and burnout.
In one instance, no associations were found between any Relationships were tested on demographic variables, in-
of the burnout dimensions and quality of care [36]. cluding gender, age, and family status; on personality as-
Five studies considered aspects of patient safety: burn- pects; on work-life interference; and on professional
out was correlated with negative patient safety climate attributes including length of experience and educational
[111]. Emotional Exhaustion and Depersonalisation were level. Because our focus on burnout is as a job-related
both associated with negative patient safety grades and phenomenon, we have not reported results of these
safety perceptions [112], and burnout fully mediated the studies into detail, but overall evidence on demographic
relationship between depression and individual-level and personality factors was inconclusive, and having
safety perceptions and work area/unit level safety per- family issues and high work-life interference was associ-
ceptions [108]. Emotional Exhaustion mediated the rela- ated with different burnout dimensions. Being younger
tionship between workload and patient safety [51], and a and not having a bachelor’s degree were found to be as-
higher composite burnout score was associated with sociated with a higher incidence of burnout.
lower patient safety ratings [113].
Regarding adverse events, high DEP and low Personal Discussion
Accomplishment predicted a higher rate of adverse events This review aimed to identify research that had exam-
[85], but in another study, only Emotional Exhaustion pre- ined theorised relationships with burnout, in order to
dicted adverse events [51]. When nurses were experien- determine what is known (and not known) about the
cing high levels of Emotional Exhaustion, they were less factors associated with burnout in nursing and to deter-
likely to report near misses and adverse events, and when mine the extent to which studies have been underpinned
they were experiencing high levels of Depersonalisation, by, and/or have supported or refuted, theories of burn-
they were less likely to report near misses [112]. out. We found that the associations hypothesised by
All three MBI dimensions predicted medication errors Maslach’s theory between mismatches in areas of work-
in one study [109], but Van Bogaert et al. found that life and burnout were generally supported.
only high levels of Depersonalisation were associated Research consistently found that adverse job charac-
with medication errors [104]. High scores in Emotional teristics—high workload, low staffing levels, long shifts,
Exhaustion and Depersonalisation predicted infections low control, low schedule flexibility, time pressure, high
[109]. Cimiotti et al. found that Emotional Exhaustion job and psychological demands, low task variety, role
was associated with catheter-associated urinary tract in- conflict, low autonomy, negative nurse-physician
fections and surgical site infections [114], while in an- relationship, poor supervisor/leader support, poor lead-
other study, Depersonalisation was associated with ership, negative team relationship, and job insecurity—
nosocomial infections [104]. Lastly, patient falls were were associated with burnout in nursing.
also explored, and Depersonalisation and low Personal However few studies used all three MBI subscales in
Accomplishment were significant predictors in one study the way intended, and nine used different approaches to
[109], while in a further study, only Depersonalisation measuring burnout.
was associated with patient falls [104]. There was no as- The field has been dominated by cross-sectional stud-
sociation between burnout and hospital-acquired pres- ies that seek to identify associations with one or two fac-
sure ulcers [20]. tors, rarely going beyond establishing correlation. Most
Considering patient experience, Vahey et al. concluded studies were limited by their cross-sectional nature, the
that higher Emotional Exhaustion and low Personal Ac- use of different or incorrectly applied burnout measures,
complishment levels were associated with patient dissat- the use of common methods (i.e. survey to capture both
isfaction [93], and Van Bogaert et al. found that burnout and correlates), and omitted variables in the
Emotional Exhaustion was related to patient and family models. The 91 studies reviewed, while highlighting the
verbal abuse, and Depersonalisation was related to both importance of burnout as a feature affecting nurses and
patient and family verbal abuse and patient and family patient care, have generally lacked a theoretical ap-
complaints [104]. proach, or identified mechanisms to test and develop a
In summary, evidence deriving from 17 studies points theory on the causes and consequences of burnout, but
to a negative effect of burnout on quality of care, patient were limited in their testing of likely mechanisms due to
safety, adverse events, error reporting, medication error, cross-sectional and observational designs.
infections, patient falls, patient dissatisfaction, and family For example, 19 studies showed relationships between
complaints, but not on pressure ulcers. burnout and job satisfaction, missed care, and mental
health. But while some studies treated these as predictors While we used a reproducible search strategy search-
of burnout, others handled as outcomes of burnout. This ing MEDLINE, CINAHL, and PsycINFO, it is possible
highlights a further issue that characterises the burnout that there are studies indexed elsewhere and we did not
literature in nursing: the simultaneity bias, due to the identify them, and we did not include grey literature. It
cross-sectional nature of the evidence. The inability to es- seems unlikely that these exist in sufficient quantity to
tablish a temporal link means limits the inference of caus- substantively change our conclusions.
ality [115]. Thus, a factor such as ‘missed care’ could lead
to a growing sense of compromise and ‘crushed ideals’ in Conclusion
nurses [116], which causes burnout. Equally, it could be Patterns identified across 91 studies consistently show
that job performance of nurses experiencing burnout is re- that adverse job characteristics are associated with burn-
duced, leading to increased levels of ‘missed care’. Both out in nursing. The potential consequences for staff and
are plausible in relation to Maslach’s original theory of patients are severe. Maslach’s theory offers a plausible
burnout, but research is insufficient to determine which is mechanism to explain the associations observed. How-
most likely, and thereby develop the theory. ever incomplete measurement of burnout and limited
To help address this, three areas of development research on some relationships means that the causes
within research are proposed. Future research adopting and consequences of burnout cannot be reliably identi-
longitudinal designs that follow individuals over time fied and distinguished, which makes it difficult to use
would improve the potential to understand the direction the evidence to design interventions to reduce burnout.
of the relationships observed. Research using Maslach’s
theory should use and report all three MBI dimensions;
Supplementary information
where only the Emotional Exhaustion subscale is used, Supplementary information accompanies this paper at https://doi.org/10.
this should be explicit and it should not be treated as be- 1186/s12960-020-00469-9.
ing synonymous to burnout. Finally, to move our theor-
etical understanding of burnout forward, research needs Additional file 1: MEDLINE via OVID, CINAHL with full text via EBSCO,
and PsycINFO via EBSCO.
to prioritise the use of empirical data on employee be-
Additional file 2: PRISMA-ScR Checklist.
haviours (such as absenteeism, turnover) rather than
Additional file 3: Studies’ settings, sample sizes, burnout and correlates
self-report intentions or predictions. measurement, and appraisal of quality.
Addressing these gaps would provide better evidence
of the nature of burnout in nursing, what causes it and
Abbreviations
its potential consequences, helping to develop evidence- MBI: Maslach Burnout Inventory; CBI: Copenhagen Burnout Inventory;
based solutions and motivate work-place change. With ProQoL5: Professional Quality of Life Measure
better insight, health care organisations can set about re-
Acknowledgements
ducing the negative consequences of having patient care We would like to thank Jane Lawless who performed the second screening
provided by staff whose work has led them to become of the provisionally included papers.
emotionally exhausted, detached, and less able to do the
job, that is, burnout. Authors’ contributions
CDO led the paper write-up at all stages, designed and conducted the
search strategy, completed the initial screening of papers, co-developed the
Limitations coding frame, and applied the coding frame to all studies. JB conceived the
Our theoretical review of the literature aimed to summar- review, co-developed the coding frame, applied the coding frame to all stud-
ies, and contributed substantially to drafting the paper at various stages. MR
ise information from a large quantity of studies; this extracted all the data from studies and produced evidence tables. PG con-
meant that we had to report studies without describing ceived the review and contributed substantially to the drafting of the paper
their context in the text and also without providing esti- at various stages. All authors read and approved the final manuscript.
mates (i.e. ORs and 95% CIs). In appraising studies, we
Funding
did not apply a formal quality appraisal instrument, al- Not applicable
though we noted key omissions of important details. How-
ever, the results of the review serve to illustrate the variety Availability of data and materials
Not applicable
of factors that may influence/result from burnout and
demonstrate where information is missing. We did not Ethics approval and consent to participate
consider personality and other individual variables when Not applicable
extracting data from studies. However, Maslach and Leiter
recently reiterated that although some connections have Consent for publication
Not applicable
been made between burnout and personality characteris-
tics, the evidence firmly points towards work characteris- Competing interests
tics as the primary drivers of burnout [8]. The authors declare that they have no competing interests.
Author details 25. Hunsaker S, Chen HC, Maughan D, Heaston S. Factors that influence the
1
School of Health Sciences, and Applied Research Collaboration Wessex, development of compassion fatigue, burnout, and compassion satisfaction
Highfield Campus, University of Southampton, Southampton SO17 1BJ, UK. in emergency department nurses. J Nurs Scholarsh. 2015;47(2):186–94.
2
Department of Learning, Informatics, Management and Ethics, Karolinska 26. Rudman A, Gustavsson JP. Early-career burnout among new graduate
Institutet, Tomtebodavägen 18a, 17177 Solna, Sweden. nurses: a prospective observational study of intra-individual change
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Received: 4 December 2019 Accepted: 24 March 2020 27. Leiter MP, Maslach C. Areas of worklife survey manual. Centre for
Organizational Research and Development, Acadia University, Wolfville. 2006.
28. Boamah SA, Laschinger H. The influence of areas of worklife fit and work-life
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Dall’Ora et al.

Human Resources for Health (2020) 18:41

REVIEW Open Access

Burnout in nursing: a theoretical review

Introduction employees’ health and job performance as outcomes

Fig. 1 Graphical representation of strength of relationships with burnout

Fig. 2 Study selection flow chart

Table 1 Summary of studies’ results

Table 1 Summary of studies’ results (Continued)

Working relationships and leadership awareness, balanced processing, an internalised moral

99. Spence Laschinger HK, Leiter M, Day A, Gilin D. Workplace empowerment,

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