Correlation Among Workplace Burnout, Resilience, and Well-Being in Nursing Staff: A Cross-Sectional Study in Taiwan

ABSTRACT Background Because nurses often work in medical environments characterized by high workloads and high levels of stress and pressure, they are particularly vulnerable to workplace burnout and their well-being may suffer. Related studies on burnout, resilience, and well-being have focused primarily on teachers, social workers, and students, with few studies addressing the situation faced by nursing staff. It is important to understand the factors affecting the well-being of nursing staff. Purpose This study explores the status quo and correlations among nursing-staff demographic characteristics, workplace burnout, well-being-related resilience, and the predictive factors of well-being in nurses. Methods A cross-sectional, descriptive, correlational research design and purposive sampling were used in this study. Nursing staff who had worked for more than 6 months at a medical center in central Taiwan were recruited as participants, with data from 289 participants collected. A structured questionnaire was used to collect data on demographic characteristics, workplace burnout, resilience, and well-being. Results The average scores for workplace burnout, resilience, and well-being were 40.40/(0- to 100-point scale), 26.79/(10- to 50-point scale), and 43.25/(24- to 96-point scale), respectively. The result of the regression analysis explained about 51.6% of the variance in well-being. Furthermore, resilience (28.4%), self-perceived health (14.3%), workplace burnout (4.5%), exercise frequency (1.8%), job title (1.2%), interpersonal pressure relief resilience (0.9%), and marital status (0.5%) were other important predictive factors of well-being in the participants. Conclusions/Implications for Practice Medical institutions should provide appropriate resilience-enhancing countermeasures to reduce workplace burnout as well as pay greater attention to the exercise frequency, self-perceived health, job title, and marital status of their nurses to help them achieve physical, mental, and overall well-being.


Introduction
Burnout reflects a condition of perceived failure or exhaustion caused by failure to meet the expected workload in terms of energy, strength, and resources (Efıl et al., 2022).Scholars have suggested that burnout is rooted in long-term work pressures and a lack of appropriate relief (Han & Kwak, 2022).Burnout may cause people to lack the necessary energy to work or reduce their work willingness (Nabizadeh-Gharghozar et al., 2020).Alsayed et al. (2022) suggested that excessive working time is the primary contributing factor to workplace burnout.Importantly, Cheng et al. (2007) found that the actual time workers put into work is often underestimated/ underreported.However, as high-pressure workers, nurses are continually placed in high-pressure and high-risk working environments and constantly assigned to work multiple shifts, which is likely to lead to burnout (Kern et al., 2021).
In terms of self-perceived mental health, satisfaction is the most significant factor explaining changes in personal wellbeing (Søvold et al., 2021).The higher a staff's well-being, the higher their productivity and working performance (Abdullah et al., 2021).Workplace burnout and boredom are often the social and psychological results of a nurse's working environment, which can influence their well-being (Chen et al., 2022).
Resilience is a complex and dynamic process that enables nurses to adapt proactively to stressors and adversity (Cooper et al., 2020).
In a high-pressure working environment, medical staffs with better resilience are better able to maintain their personal and professional well-being (Hsiao et al., 2019).Improving nurse resilience helps nurses reduce emotional exhaustion, increase work engagement, overcome workplace challenges, and cope with adversity (F.Yu et al., 2019).
As nurses are often in high-pressure medical environments and perform shift work for long periods, their well-being often declines over time (Alsayed et al., 2022).However, studies on workplace burnout, resilience, and well-being in nurses are scarce in the literature.Thus, this study was designed to pursue the following: (a) understand the basic demographics and current workplace burnout, resilience, and well-being status of nursing staff; (b) investigate the correlations among these variables; and (c) investigate the significant predictors of well-being.

Design and Sample
A cross-sectional and correlational research approach was used, and nurses at a medical center in central Taiwan were recruited as participants.Data collection and analysis took place from May 1, 2021, to January 20, 2022.Convenience sampling was used to conduct analysis.The inclusion criteria were nurses who (a) held a nurse or registered nurse license (Ministry of Examination, ROC, 2023), (b) were currently engaged in nursing work, and (c) were either a nursing staff or an assistant head nurse with a service length of at least 6 months.The exclusion criteria were as follows: (a) a service length of less than 6 months, (b) being a specialist nurse, (c) holding an administrative or educational position (i.e., head nurses and nursing teachers), and (d) not completing the questionnaire.The minimum sample size was calculated using the statistical G*Power software Version 3.0.10.Using this tool, the researchers performed multiple linear regressions and specifically fixed the model R 2 deviation from zero (α = .05,p = .8,and effect size = 0.13; Ghods et al., 2022), with the calculation results indicating the need for data from at least 178 participants.Considering a possible 45% attrition rate (Emani et al., 2020), the total sample size was set to 300.Two hundred eighty-nine participants submitted valid questionnaires and 11 submitted invalid questionnaires (i.e., one nursing assistant, one supervisor, and seven specialist nurses), giving a valid response rate in this study of 96.33%.

Instruments
To explore the correlations among workplace burnout, resilience, and well-being in this sample, the following tools were used: a demographic characteristics questionnaire, a workplace burnout scale, a resilience scale, and a well-being scale.

Workplace burnout scale
The workplace burnout scale of Yeh et al. (2008) was used in this study to measure self-perceived overall burnout.The scale asks respondents to subjectively assess the frequency of various problems during the previous week and covers 21 items in the four dimensions of personal burnout, work-related burnout, client-related burnout, and overcommitment to work.This scale is scored on a 5-point Likert scale, with 4 = always, 3 = often, 2 = sometimes, 1 = seldom, and 0 = never.The four domains are scored separately.In terms of the personal burnout, work-related burnout, and overcommitment-to-work dimensions, the results were calculated by multiplying the original scores by 5 to achieve a score range between 0 and 100.
For the client-related burnout dimension, the result was calculated by the original score Â25÷6 to also achieve a score range between 0 and 100 points.Higher dimension scores are associated with a higher degree of burnout.The Cronbach's alpha coefficients ranged between .90 and .92for "personal burnout," "work-related burnout," and "client-related burnout" and .84 for "overcommitment to work."The content validity index was above .79(Yeh et al., 2008).The results indicate that the scale had good internal consistency and validity and is a valid tool for evaluating workplace burnout.In this study, the Cronbach's α of the overall workplace burnout scale was .93.

Resilience scale
Utilizing X. Yu and Zhang's (2007) Resilience Scale for Medical Staff, the resilience of medical staff was divided into 10 items in four dimensions, including the meaning of work, difficulties in acceptance, emotional adjustment, and interpersonal pressure relief.Scoring is based on a 5-point Likert scale (1 = very inconsistent, 5 = very consistent), with a total score range of 10-50 points.Hsiao et al. (2019) previously applied this scale to medical staff from a teaching demonstration hospital in southern Taiwan, finding a Cronbach's α coefficient of internal consistency of .91 and a scale fitness of goodness of fit index = .973,indicating good reliability and validity.In this study, the Cronbach's α of the scale was .90.

Well-being scale
The well-being scale of Lin (2000) was used in this study.This scale includes 24 items in the four dimensions of positive emotions, interpersonal relationships, self-affirmation, and physical and mental health, with items scored on a 4-point scale (1 = very inconsistent, 4 = very consistent) and higher total scores associated with higher overall well-being.The Cronbach's α values of the subscales were positive emotions = .87,interpersonal relationships = .84,self-affirmation = .82,physical and mental health = .79,and overall scale = .93,and the correlation coefficient of criterion-related validity was .77-.86 (Lin, 2000).In this study, the Cronbach's α for the overall scale was .93.

Statistical Analysis
After coding, the collected data were analyzed using descriptive statistics, including frequency, percentage, mean, and standard deviation, on the Chinese version of IBM SPSS 23.0 (IBM Inc., Armonk, NY, USA).Inferential statistical analyses were conducted using independent t tests, Pearson product-difference correlation, one-way analysis of variance, and multiple stepwise regression analysis.The residual and error term of the regression model were examined using the Kolmogorov-Smirnov test.The results revealed that the values correspond to a normal distribution (Kolmogorov-Smirnov = 0.12, p > .05).For all statistical analyses, p < .05 was used to indicate statistical significance.

Ethical Considerations
Data collection in this study adhered to relevant ethical principles.Before implementation, the institutional review board reviewed and approved (No. 201123) the research, and the researcher recruited eligible nursing staff through Outlook.Potential candidates were permitted to read the anonymous research questionnaire instructions in the email and decide independently whether to complete the questionnaire.Those who agreed to participate filled in the Google Form to complete the questionnaire by themselves, and respondents who completed and submitted the questionnaire were given a stored-value gift card.The study collected data in a strictly confidential and anonymous manner, and participant identification information was coded to preclude the chance of data disclosure and ensure the confidentiality of participant data and privacy.The follow-up data analyses used statistics to analyze overall responses, and the results were used for academic research only.To protect the rights and interests of the research subjects, no specific personal answers were presented.

Demographic Characteristics, Workplace Burnout, Resilience, and Well-Being
The questionnaires were distributed to 300 nursing staff, and 289 valid responses were retrieved and used in subsequent analysis (valid return rate: 96.33%).The age of participants ranged between 23 and 65 years and averaged 40.56 (SD = 14.04) years.Nearly all of the participants (97.2%) were female, most (62.6%) were single, and 85.1% lived with family members.Most had completed a university education (83.4%) and currently had no children (62.3%).Most worked as registered nurses (81.7%) in internal or surgical departments (55.7%).Most worked on a monthly fixed-shift system (67.8%), and most rated their self-perceived health as extremely poor (45.3%;Table 1).
In addition, workplace burnout was significantly and negatively correlated with overall well-being, positive emotions, interpersonal relationships, self-affirmation, and physical and mental health ( p < .01);personal burnout was negatively correlated with overall well-being, positive emotions, interpersonal relationships, self-affirmation, and physical and mental health ( p < .01);work-related burnout was negatively correlated with overall well-being, positive emotions, interpersonal relationships, self-affirmation, and physical and mental health ( p < .01);client-related burnout was significantly and negatively correlated with overall well-being, positive emotions, interpersonal relationships, self-affirmation, and physical and mental health ( p < .01);and overcommitment burnout was significantly correlated with overall well-being, positive emotions, interpersonal relationships, self-affirmation, and physical and mental health ( p < .01).
Furthermore, resilience was positively correlated with overall well-being, positive emotions, interpersonal relationships, selfaffirmation, and physical and mental health ( p < .01);meaning of work was positively correlated with overall well-being, positive emotions, interpersonal relationships, self-affirmation, and physical and mental health ( p < .01);difficulties in acceptance was positively correlated with overall well-being, positive emotions, interpersonal relationships, self-affirmation, and physical and mental health ( p < .01);emotional adjustment was positively correlated with overall well-being, positive emotions, interpersonal relationships, self-affirmation, and physical and mental health ( p < .01);and interpersonal pressure relief was positively correlated with overall wellbeing, positive emotions, interpersonal relationships, selfaffirmation, and physical and mental health ( p < .01;Table 3).

Critical Predictors of Well-Being in Nurses
Resilience was found to have the highest explanatory power in this study, explaining 28.4% of the overall variance, followed by good self-perceived health (14.3%), lower work-related burnout (4.5%), exercise frequency of 1-2 times/week (1.8%), holding a job title of assistant head nurse or nurse team leader (1.2%), better interpersonal pressure relief resilience (0.9%), and being married (0.5%).The variables above effectively explained 51.6% of the total variance in well-being in this sample ( p < .001;Table 4).

Status of Workplace Burnout, Resilience, and Well-Being in the Sample
In terms of workplace burnout, this study found that personal burnout ranked the highest, and client-related burnout ranked the lowest.The participants were under long-term  pressure in the workplace and faced multiple role pressures (Rehder et al., 2021;Ślusarz et al., 2022).Furthermore, interpersonal interactions, workload, long working hours, task flexibility, insufficient education and training, and limited resources in working units have all been found to contribute to nursing staff being under more physical and mental pressure and to chronic exhaustion (Alsayed et al., 2022;Lee & Chang, 2022;Nabizadeh-Gharghozar et al., 2020).In this study, the average score for client-related burnout was the lowest, which may relate to personal characteristics, work enthusiasm, and peer support (Slowiak & DeLongchamp, 2022;F. Yu et al., 2019) In terms of resilience, in this study, the average score for meaning of work was the highest, followed by difficulties in acceptance, with interpersonal pressure relief earning the lowest score.The participants' high resilience in terms of meaning of work may be attributable to their cognizance that their work helps patients both directly and indirectly, which gives their work meaning (Hsiao et al., 2019).The participants exhibited relatively good resilience with regard to difficulties in acceptance, which is consistent with Hsiao et al. (2019) and Wei et al. (2019).Nursing staff in supervisory positions usually have higher recognition of their profession and are more likely to accept various difficulties and challenges in their work or to face these with humorous or optimistic attitudes (Hsiao et al., 2019;Wei et al., 2019).However, resilience to interpersonal pressure relief ranked the lowest in this study, which may be attributable to nursing staff failing to take the initiative to share with colleagues their experiences of workplace adversity in facing changes, high work pressure, and inadequate team cooperation (Lee & Chang, 2022;Wei et al., 2019).Therefore, it is suggested that unit supervisors regularly observe the interpersonal interactions of their nurses and the difficulties they face in clinical settings and also guide senior staff to foster a more-positive work environment within the unit.Moreover, hospitals should consider providing appropriate training to strengthen mindfulness and relaxation, emotional regulation, problem solving, and resourcefulness among the nursing staff.These skills are beneficial to developing good interpersonal resilience, which should help enhance well-being in nurses (Kunzler et al., 2022;Labrague, 2021).
Another finding in this study was that the average well-being score for interpersonal relationships was relatively high, suggesting that nursing staff have the characteristics necessary to care for others and enjoy helping others, which can make others feel happy (Lin, 2000).However, the average well-being score for physical and mental health was the lowest of all, suggesting that job demands regularly exceed acceptable pressure, leading to negative impacts on physical and mental health status (Johari & Omar, 2019).Chen et al. (2022) and Labrague (2021) found that shift work exposes nurses to abnormal work and rest patterns as well as poor dietary habits, which indirectly affects the secretion and regulation of hormones in the body and causes changes to sleep patterns.Moreover, excessively long working hours and heavy workloads increase the risk of physical and mental burnout and further affect physical and mental health (Portero de la Cruz et al., 2020).
Influencing Factors of Nursing Staff's Basic Demographic Data, Workplace Burnout, Resilience, and Well-Being This study found that married participants performed better than their single peers in terms of overall well-being and the subdimensions of positive emotions and self-affirmation and that marital status explained 0.5% of the variance in well-being.This is consistent with the wider body of research (Grover & Helliwell, 2019).Nurses in happy marriages tend to receive important support from their spouse when facing pressures and difficulties (Grover & Helliwell, 2019).Furthermore, the participants with religious beliefs were found to have better overall well-being and physical and mental health than their nonreligious peers, which is consistent with Harris and Tao (2022).
Nurses with religious beliefs may maintain a more-stable and positive mood when facing setbacks in the workplace.
In terms of self-affirmation well-being, the participants with more than three children performed better than their peers without children.The findings of prior studies indicate that children are an important source of family happiness and that children can help reduce parental feelings of work-related emotional overload and burden.Nursing staff with children have higher life satisfaction and well-being than nurses without children (Kobyakova et al., 2021).Moreover, nursing staff with children of their own can more readily establish partnerships with work colleagues, understand patient care needs, and provided appropriate suggestions and support, which improve both self-affirmation and well-being status.On the contrary, nursing staff without children are less likely to discuss parenting with their colleagues because of their young age and lack of experience in family care.Thus, nursing staff without children are more prone to exhibit poorer stress management adjustment ability, which may aggravate workplace burnout and reduce their sense of happiness (Efıl et al., 2022;Rehder et al., 2021).
Moreover, the results of this study identified registered nurses and assistant head nurses, including nurse team leaders, as having better overall well-being, interpersonal relationships, and self-affirmation than regular nurses, accounting for 1.2% of the variance in well-being.A possible reason is that nursing staff with higher professional titles and positions have better clinical work experiences, are more familiar with their working environments, and can deal with problems between medical staff and patients and interpersonal relationships in a more sophisticated manner (Kunzler et al., 2022;Søvold et al., 2021).
In this study, working fixed shifts was shown to be significantly and positively correlated with self-affirmation and well-being.This finding echoes that of Rosa et al. (2019), who found that working flexible shifts can significantly affect the psychological status of nursing staff.The well-being of the participants who worked either fixed day or night shifts was higher than those who worked either mixed day and night shifts or flexible shifts.A possible reason may be that working fixed shifts makes it easier to arrange their nonwork time (Ahn & Kwon, 2020;Chen et al., 2022;Søvold et al., 2021).
In addition, the participants who exercised once or twice per week had better physical well-being and mental health than those self-reporting as never exercising, which echoes the findings of studies conducted in other countries (Portero de la Cruz et al., 2020).Exercise status explained 1.8% of the variance in well-being in this study.The reasons for not exercising include frequent shift work leading to physical and mental burnout and irregular lifestyle patterns and burnout caused by excessive workloads, which reduced interest in exercise indirectly (Portero de la Cruz et al., 2020).Therefore, adjusting shift work patterns may help nurses better arrange fixed rest and exercise times to improve their well-being.
The self-perceived health of the participants was found to significantly and positively correlate with overall well-being and the subdimensions of positive emotions, interpersonal relationships, self-affirmation, and physical and mental health, explaining 14.3% of the total variance in well-being.This result is similar to previous studies (Ahn & Kwon, 2020;Chen et al., 2022;Søvold et al., 2021).Higher self-perceived health was correlated with higher well-being, and lower self-perceived health was correlated with lower well-being.Some participants perceived their organization as unfair in allocating resources and felt more helpless because of nursing staff shortages.They may have also felt pressure to care for seriously ill patients.These reasons may together cause nursing staff to feel poor self-perceived health and, consequently, a lower degree of well-being.
Workplace burnout was found in this study to significantly and positively correlate with overall well-being and the subdimensions of positive emotions, interpersonal relationships, self-affirmation, and physical and mental health, which explain 4.5% of the total variance.Moreover, workplace burnout and boredom are often physiological and psychological consequences of working in high-pressure working environments, which affects overall well-being (Søvold et al., 2021).A harmonious interpersonal relationship in the workplace and family support can help reduce work stressors and improve well-being.Even inexperienced nursing staff under even greater workplace burnout can still obtain well-being in the workplace if they receive positive feedback and support during their care work (Rehder et al., 2021).
The following research limitations should be considered when making inferences from this study.The cross-sectional research approach used in this study explores well-being performance at a specific point in time only and is not predictive of longitudinal change.Second, as the participants in this study were recruited from one medical center in central Taiwan only, the findings may not be applied to all nursing staff.Future studies may extend the investigation to other medical and nursing units to extend generalizability.Moreover, the results of this study suggest that workplace burnout and Table 3 Relationship Among Demographic Characteristics, Workplace Burnout, Resilience, and Well-Being (N = 289), Continued resilience directly impact well-being in nurses, supporting the findings of prior research that found a mediating effect of resilience on workplace burnout and mental health in nurses (Labrague, 2021).However, this study did not test the relationship among resilience, workplace burnout, and well-being.Therefore, future studies should investigate level of nursing staff workplace burnout to provide a reference for developing effective strategies for reducing stress (based on individual and systemic factors) and turnover intention and enhancing well-being.

Conclusions and Recommendations
In this study, resilience was identified as the best predictor of well-being in nurses.In particular, interpersonal pressure relief resilience was positively correlated with overall well-being.The results of this study may be referenced by medical institutions to strengthen well-being in nurses through measures such as providing exercise and nutrition recommendations, regularly monitoring for workplace burnout, and increasing psychological counseling and tutor support resources (Rogers, 2016).In addition, nurses may be informed of the factors affecting their well-being to facilitate their own burnout-amelioration efforts.Finally, countermeasures to enhance resilience should be provided to help nursing staff achieve physical, mental, and overall well-being.

Table 1
Participant Demographic Characteristics (N = 289), Continued Note.Nurse: Only those who pass the junior examination can obtain a nurse license.Registered nurse: Only those who pass the senior examination can obtain a registered professional nurse license.The Journal of Nursing ResearchShau-Tion TZENG et al.