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Relationship between head nurse leadership and nurses’ burnout: parallel mediation of job demands and job resources among clinical nurses

BMC Nursing volume 24, Article number: 354 (2025) Cite this article

Abstract

Background

Many elements in the workplace contribute to nurses’ burnout experiences, affecting patient safety and the healthcare organizations’ efficiency. Leaders’ presence and conduct are the most potent “master” factors in every work setting. Although previous studies have shown that head nurse leadership, job demands, job resources, and job burnout are significantly related, the interaction mechanism remains unclear. This study investigates the parallel mediating roles of job demands and job resources between head nurse leadership and job burnout in nursing staff.

Methods

A cross-sectional, anonymous, and confidential online survey was conducted from March to June 2024 to collect data from 579 registered nurses in four hospitals in Hunan provinces. The independent variable was head nurse leadership, the mediating variables were job demands and resources, and the dependent variable was job burnout. Parallel mediation analysis was performed using the PROCESS macro in SPSS.

Results

This study found that head nurse leadership negatively relates to nurses’ burnout. The parallel mediation analysis suggests that job resources and job demands play parallel roles in the relationship between head nurse leadership and job burnout. As predicted, head nurse leadership weakened job burnout through job resources and contributed to job burnout through job demands.

Conclusion

This study finding highlights the importance of head nurse leadership in decreasing nurses’ job burnout and reveals two potential mechanisms through which head nurse leadership is related to nurses’ burnout. By understanding the role of head nurse leadership, job demands, and job resources, interventions can be targeted to improve nurses’ mental health.

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Background

Burnout occurs when individuals experience prolonged emotional and interpersonal pressures in the workplace. It is a complex phenomenon that consists of three key components: emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment [1]. Burnout is prevalent among healthcare professionals, especially among nurses [2, 3]. In a national survey, over two-thirds of registered nurses in the United States indicated suffering from burnout [4]. Burnout among nurses reached 64.5% in China and 60% in South Korea and Japan [5, 6]. As the workloads on hospital systems and physicians have escalated, the pressures placed on nurses have also intensified [7, 8]. Burnout, a response to work-related stresses, promotes chronic stress in nurses and presents as a variety of mental and physical health problems, such as headaches, exhaustion, irritability, and difficulty concentrating [9, 10]. If neglected, burnout can trigger many personal repercussions, such as anxiety and sleep issues, which impact mental health [11]. Furthermore, some studies reveal that individuals experiencing severe burnout may have suicidal tendencies [12, 13]. Job burnout also reduces work efficiency and undermines decision-making, reactivity, and critical thinking skills [14, 15]. Burnout eventually leads to increased medical errors, missed nursing care, and decreased patient satisfaction [16]. Therefore, to protect nurses’ well-being and relieve burnout among nurses, identifying the underlying factors of burnout has remained a vital research theme in nursing management.

There has been a growing focus on the emotional and physical well-being of nurses, with extensive research on burnout, and the Job Demands-Resources (JD-R) model serving as the most widely used framework for understanding occupational stress and its relationship with employee health [17]. The central assumption of the JD-R model is that each employment is related to two broad categories of work characteristics: job demands and job resources [18]. Job demands refer to the elements of a job requiring extended physical or mental work, thereby having certain physiological and psychological costs [19]. Job resources are “those physical, psychological, social, or group aspects of the job that are either/or (1) functional to accomplish work goals, (2) shorten job demands and physiological and psychological costs, and (3) motivate personal growth, learning, and development” [20]. The JD-R model emphasizes two key pathways: the motivating pathway and the health deterioration pathway. ​The motivational pathway suggests that engagement with work and job resources foster positive outcomes and reduce burnout, while excessive job demands lead to burnout and negative health impacts [21, 22]. Various job demands and resources are identified as predictors of burnout in nurses.​ A meta-analysis found that job demands, such as workplace conflicts, role conflict, and role ambiguity are significant contributors to burnout. Key job resources such as autonomy, social support, and access to adequate personnel are crucial in alleviating burnout [23]. Recently, researchers have expanded the JD-R model to encompass factors beyond job demands and resources, including personal resources, empowerment, work-family conflict, and so on [18, 24]. These enhancements provide a more thorough understanding of the evolution and effect of occupational burnout. Notably, the model also underscores the crucial role of managers in reconciling job demands and job resources in the workplace [25, 26]. Leadership is the process of motivating a group to achieve a goal, and it can significantly influence employee performance, serving as a key predictor of an organization’s success or failure [27, 28].

Nurse managers are essential in healthcare departments, managing the main workforce group in leading direct care units: the nursing staff. It should be noted that the daily work of nursing managers often involves organizing, planning work, and managing resources [29]. Leaders’ top-down influence may also create structural changes in resource and demand that affect huge groups [30]. Head nurse leadership might be considered a higher-order job resource or demand that simultaneously affects many people [31]. Building on the ideas of Tummers and Bakker and integrating JR-R theory with Einarsen’s conceptualization of leadership [32, 33], we argue that head nurse leadership might generate extra demands or resources. Therefore, leadership could be a moderator that directly influencing job demands and resources. For example, when workers face an elevated workload, supervisors may alleviate this job demand by identifying organizational priorities and recognizing which tasks can be safely disregarded [34]. By allowing workers to choose their work schedule and location, leaders can augment job resources through increased job autonomy [35]. Effective leadership is shown by granting nurses autonomy, exhibiting compassion and empathy, and ensuring an adequate nurse-patient ratio, which may reduce stress and physical burdens while improving job satisfaction [36]. However, leadership among nurse managers varies significantly among organizations; unsatisfactory or unfavorable workplace conditions marked by insufficient leadership skills, a shortage of nursing personnel, and high stress levels impede the quality of nursing performance [37, 38]. Many scholars pointed to a lack of attention paid by researchers, hospital administrators, and policymakers to unit-level management. They called for more systematic studies on nurse manager leadership and management skills and practices that affect nurses’ occupational mental health.

To date, the associations between head nurse leadership, job demands, and resources with burnout among nurses have not been explored. It is also unclear how job demands and resources mediate the effect of head nurse leadership on job burnout. Thus, underpinning the JD-R theory as the foundation of this study, this study aimed to examine the relationship between head nurse leadership, job demands, job resources, and job burnout among nurses in China and to investigate the role of job demands and job resources in mediating the relationships between head nurse leadership and job burnout among nurses in China. We hypothesized that (1) higher leadership levels in nurse managers are associated with lower levels of job burnout among nurses. (2) Job demands and job resources would mediate the association between head nurse leadership and burnout.

Methods

Design and participants

A cross-sectional survey was performed using a convenience sample approach among nurses from four hospitals in Changsha, Hunan Province, from March to June 2024. The inclusion criteria were registered nurses who comprehended the survey’s objective, consented, and participated willingly, with more than one year of experience in the department. The exclusion criteria included nurses with psychiatric disorders or those on extended leave (e.g., maternity leave).

The appropriate sample size for hierarchical regression analysis was determined using G*power. Taking into consideration an effect size (f) of 0.15 (median), a power (1 − β) of 0.95, a significance level (α) of 0.05, and a total of 31 variables. A theoretical minimum sample size of 229 is required.

With the help of the nursing department, 610 target nurses received the call to participate via a link on the WeChat platform. The questionnaire is composed of research purpose, informed consent, data confidentiality, questionnaire information, etc. After reviewing the study’s objectives and contents, the nurses decided to join or not, and they were free to leave at any moment. Lastly, we used the Wenjuanxing platform (https://www.wjx.cn/) to gather 579 valid surveys (response rate: 94.9%). Since every question was marked as required, no information was missing.

Measurements

Demographic variables

A demographic questionnaire was utilized in this study to collect the characteristics of participants, including gender, age, marital status, educational level, length of nursing work, income, professional title, current working department, and department head nurse’s education.

Head nurse leadership

The head nurse leadership scale developed by Huang Chunmei was used to evaluate the head nurse’s leadership [39]. Six characteristics make up this scale: decisiveness, influence, charisma, affinity, foresight, and strength of control. The 44 items were evaluated using a 5-point Likert scale (1 = never, 2 = rarely, 3 = partially, 4 = often, and 5 = always). A higher total score indicates more effectiveness in the head nurse’s leadership. The scale’s Cronbach’s alpha was 0.961.

Job demand-resource

Chinese researcher Li Jie created the employment demand-resource scale [40], which consists of two parts. The first section is the Job Demands Questionnaire, which consists of 19 questions and covers six dimensions: shifting work, surroundings, psychological and emotional demands, workload, and time management. Each item has a negative phrase, and a 5-point Likert scale is used to rate it (1 = never, 5 = almost always). The higher the overall score, the greater the work demands. The second section consists of the Job Resources Questionnaire, which has 15 questions and covers five dimensions: social support, decision-making involvement, job control, incentives, and skill diversity. Items with negative phrasing are scored positively, and those with positive phrasing are scored inversely. Notably, a higher score indicates fewer job resources. Cronbach’s alpha for the scale was 0.893.

Job burnout

The survey utilized the Chinese version of the Occupational Burnout Scale, revised by Chinese researchers such as Li Chaoping [40]. The scale comprises three dimensions: emotional exhaustion (5 items), depersonalization (4 items), and reduced personal accomplishment (6 items), totaling 15 items. It employs a 7-point Likert scale, where 0 to 6 correspond to “never,” “almost never,” “rarely,” “sometimes,” “often,” “quite often,” and “very frequently,” respectively. The reduced personal accomplishment dimension is reverse-scored, while the other items are scored positively. Higher scores indicate more severe feelings of occupational burnout. The overall Cronbach’s α coefficient of the scale is 0.903.

Statistical analysis

The outcomes were downloaded from Questionnaire Star and evaluated using SPSS 25.0 statistical software. Descriptive statistics, including frequency and percentage, were used to characterize sample demographics and occupational attributes. Pearson was used to describe the correlations among research variables, At the same, multivariate linear hierarchical regression analysis was performed to examine the possible predictive influence of head nurse leadership, work demand, and job resources on job burnout. The results of the Harman one-way test for common method bias indicate that if the first-factor explanation rate is below 40%, the data in this study does not exhibit significant common method bias. The mediation effect analysis was conducted using Hayes’ SPSS macro program, PROCESS, employing the Bootstrap method with 5000 resamples to calculate the 95% confidence interval. The mediation effect is deemed significant if none of the results include 0. Differences were considered statistically significant at P < 0.05.

Results

Test of common method bias

Harman’s single-factor analysis was used to check for common methodological bias. The results indicated that 15 factors had eigenvalues of more than 1, and the first one interpreted 26.97% of the variability. This result is below the threshold of 40%, suggesting that there was no serious problem with common-method bias in this study.

Characteristics of participants

This study showed that almost all the nurses were female; most participants (71.7%) were married, aged 31–40 (42.2%). Most nurses (52.3%) held a practitioner nurse title or lower, while 47.7 held a senior nurse title or above. Regarding education level, 80 (13.8%) had junior high school education, 439 (75.8%) had a bachelor’s degree, and 60 (10.4%) had a master’s degree or above. See Table 1 for more detailed demographic information.

Table 1 Demographic characteristics of the sample
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Correlations between variables

Pearson correlation analysis demonstrated that the correlation coefficient between the total score of head nurse leadership and the total score of job burnout of 579 nurses was (r = − 0.183, P < 0.001), job demands (r = − 0.142, P < 0.001), and job resources (r = − 0.316, P < 0.001). The correlation coefficient between the total score of job demands and the total score of job burnout was r = 0.491, and the correlation coefficient between the total score of job resources and job burnout was r = 0.364, all P < 0.001. As shown in Table 2. These significant correlations in the expected direction presented initial support for the postulated relations.

Table 2 Mean, standard deviation, and correlations
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Parallel mediation analysis results

Table 3; Fig. 1 show the regression analysis results in the mediating effect model under the control of gender, education level, department, and income. The first result of these tests suggested that head nurse leadership scores had a negative and significant effect on job burnout scores (− 0.031, P < 0.01). Secondly, the mediating variables job demands scores and job resource scores were negatively influenced by the head nurse leadership scores (β = − 0.027, p < 0.05; β = − 0.049, p < 0.001). Thirdly, job demands and resources scores significantly mediated job burnout scores (β = 0.490, p < 0.001; β = 0.256, p < 0.01). This result indicates that job demands and resources mediated the relationship between head nurse leadership and job burnout, confirming the hypothesis.

Table 3 Results of the parallel mediation analysis
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Fig. 1
figure 1

Parallel mediation pathway model. Note: *P < 0.05, **P < 0.01, ***P < 0.001

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In these analyses, we observed the mediating effects of job demands and job resources conflict on the relationship between head nurse leadership and burnout. Table 4 shows that the direct effect was − 0.027, and the effect size was 44%; the total indirect effect of head nurse leadership and job burnout was − 0.034, and the effect size was 56%. This shows a significant mediating role in the relationship between head nurse leadership and job burnout. Specifically, the mediating effect consisted of the indirect effects from two pathways. (1) The mediating effect of job demands was 0.02 (95% CI: − 0.032 – − 0.008). The effect size was 33%. (2) The mediating effects of job resources were 0.014 (95% CI: − 0.026 – − 0.004). The effect size was 23%. Both indirect effect paths were significant.

Table 4 Bootstrap analysis of parallel mediation effects
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Discussion

This study aimed to enhance understanding of how head nurse leadership influences job characteristics by examining job demands and resources among a sample of nurses. ​Our findings suggest potential mechanisms through which nurse managers mitigate nurse burnout, offering valuable insights for interventions and a fresh perspective on the factors leading to burnout in nurses. Consistent with the hypothesis, higher levels of head nurse leadership are inversely correlated with burnout among nurses. Job demands and job resources partially mediated the association between head nurse leadership and burnout. Job demand as a risk factor and job resource as an alleviating factor should be addressed to decrease nurses’ job burnout.

Researchers have explored negative mental states in nurses, such as job burnout. Many factors could cause job burnout in nurses, such as work environment, hours worked, workload, and so on [41, 42]. This study found that head nurse leadership was one of the risk factors for job burnout, consistent with previous literature. For instance, a survey of over 40,000 healthcare employees found that a 1-point improvement in leadership scores was associated with a 7% decrease in burnout likelihood [43]. Furthermore, a systematic review of nursing leadership highlighted that positive leadership styles boost nurses’ well-being in the workplace [44]. Multiple linear regression analysis showed that the relationship between head nurse leadership and burnout remained significant even after adjusting for confounding variables. This strongly suggested that head nurse leadership could be associated with burnout. Recognizing the significance of strong leadership in burnout prevention may inform targeted interventions and organizational strategies. Transformational leadership, emphasizing individualized support, visionary inspiration, and ethical modeling, enhances team cohesion through trust-building and goal alignment, while fostering psychological resilience against burnout [45]. Transactional leadership reinforces this through structured accountability systems and performance-based rewards, effectively reducing role ambiguity and occupational stress [46]. Empirical evidence demonstrates transformational leadership’s consistent negative correlation with burnout rates [45, 47], particularly when integrated with transactional elements to create ambidextrous leadership capabilities [48]. Head nurse leadership development should adopt multilevel strategies, including curricular integration, progressive training, and embedded evaluation. First, integrating transformational-transactional competencies into medical and nursing curricula builds foundational leadership skills, and identifies interdisciplinary leadership talents with innovation potential. Action learning, using clinical simulations and problem-based scenarios, follows this to enhance the application of leadership principles in real-world contexts. Incorporating leadership evaluation into annual assessments promotes continuous improvement. Based on these evaluations, tiered training systems aligned with career paths can provide targeted skill development.

The mediation analysis indicated that job demands partially mediated the relationship between head nurse leadership and burnout, with ineffective leadership increasing job demands and the risk of burnout. This established association aligns with previous research conducted in the field. Toxic leadership exacerbates stress by increasing job demands and hindering recovery processes [49]. Conversely, transformational leadership fosters a supportive environment that enhances resilience and lowers burnout risk [50]. Given the healthcare industry’s manpower shortages and increasing job demands [42, 51], high-quality leader-member relationships, along with support and appreciation from leaders, can help nurses reframe challenges and improve job satisfaction [52, 53]. However, sustained exposure to high job demands environments may critically impair nurses’ cognitive functioning through chronic activation of stress response pathways [54]. Evidence shows that prolonged occupational stress disrupts the hypothalamic-pituitary-adrenal axis, elevating cortisol levels, which impair prefrontal cortex executive functions and contribute to cognitive decline [55]. This neurocognitive erosion undermines nurses’ capacity to perceive leadership and engage with workplace support, despite the availability of job resources [56]- a phenomenon consistent with the Conservation of Resources Theory’s prediction of depleted psychological capital in chronically stressed individuals [57]. While nurse managers possess partial agency to modulate job demands within their teams through task delegation and workflow adjustments, their ability to enact systemic change remains constrained by organizational hierarchies and resource allocation policies [58]. This necessitates collaborative intervention from institutional administration to implement organization-wide job demand controls based on staffing ratios and workload auditing systems. Crucially, the efficacy of such interventions depends on establishing systematic monitoring mechanisms to assess nurses’ perceived job demands, coupled with real-time resource reallocation processes.

This study enhances existing literature by demonstrating how head nurse leadership negatively impacts nurses’ job burnout through the mediating role of job resources, as explained by the JD-R theory [59]. In particular, positive nurse manager leadership as a specific form of job resource facilitates nurse job crafting as a motivational process, decreasing job burnout. Supporting evidence includes Sabei’s research, which highlighted the importance of management skills and sufficient resources in alleviating burnout among emergency staff [60], and Chen Shu-chuan’s findings that managerial support and job resources significantly reduce burnout, overshadowing personal resources [61]. Additionally, about half of nursing job resources relate to leadership factors such as supervisory support and transformational leadership [23]. The current findings suggest that high job resources are associated with low burnout levels among nurses, underscoring the need for nurse managers to provide effective support and foster positive work environments to mitigate burnout [20]. We therefore motivate nurse managers to offer the most effective internal and external supportive resources for nurses, including organizing work environments, fostering harmonious leadership-member relationships and inter-member relationships, and improving reward systems to mitigate burnout as much as possible.

This model provided a pathway of the relationship among head nurse leadership, job demands, job resources, and burnout of Chinese nurses. Namely, head nurse leadership may lead to burnout through the parallel mediating effects of job demands and resources. Our results not only revealed the possible mechanism underlying the relationship between head nurse leadership and burnout but also provided practical intervention to promote burnout problems in nurses. Consequently, simultaneous and comprehensive intervention (both decrease job demand or increase job resources) could help reduce job burnout more so than head nurse leadership alone.

Strengths and limitations of the study

Our study had some strengths. First, to the best of our knowledge, this is the first study to investigate the impact of head nurse leadership upon burnout among Chinese nurses via the parallel mediating effects of job demand and job resources. Through these studies, we may not only further explore the influencing aspect of nurses’ burnout, but also give a reference for hospital management to develop effective management measures. Second, adjusting for covariates allowed us to incorporate major potential confounders and better account for the association between head nurse leadership and job burnout among nursing staff. Also, several limitations in the current study need to be mentioned. First, due to the cross-sectional study design, we cannot establish causal relationship between the variables. More robust and dynamic data about the relationship between head nurse leadership, job demands, job resources, and job burnout over time could be obtained by future researchers through longitudinal or experimental study. Second, the subjects of the present study were all from Hunan province. Due to the cultural context and differences in supervisor-subordinate dynamics between different regions and countries, it is essential to exercise caution when extrapolating these findings to a more diverse and global healthcare context. Therefore, more multi-center studies are required to assess the generalizability of these findings to nursing populations across various cohorts and in other nations. Third, our respondents completed the self-reported survey with mobile devices, which might lead to self-reported biases and social desirability response bias, as some participants may have provided inaccurate responses. Additionally, this study primarily utilized quantitative methods. A more objective approach, such as observational methods or a qualitative approach, would complement the findings by exploring the underlying factors and dynamics that shape the influence of nurse leadership on burnout among nursing staff.

Conclusion

This study revealed that job demands and resources mediate the association between head nurse leadership and burnout among nurses, and nurses with lower levels of head nurse leadership might be at high risk for burnout. These findings have important implications for the early detection, prevention, and treatment of burnout symptoms among nurses. The present study’s findings highlight that nurse managers play a role in influencing nurses’ well-being, as they shape their working environment through their job character. Organizations should plan adequate training activities to improve head nurse leadership and set positive examples. At the same time, the effects of job demand and job resources should be comprehensively considered when implementing the intervention.

Data availability

The datasets collected and analyzed in this study are not publically accessible but can be obtained from the corresponding author upon reasonable request.

Abbreviations

JD-R:

Job demands-resources

CI:

Confidence interval

LLCI:

Lower Limit of the Confidence Interval

ULCI:

Upper Limit of the Confidence Interval

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Acknowledgements

The authors are grateful to all the participants of this study for their involvement.

Funding

The Chinese Nursing Association (grant number: ZHKY202306); The Natural Science Foundation of Hunan Province (grant number: 2023JJ30764); The National Natural Science Foundation of China (grant number: 82371553).

Author information

Authors and Affiliations

  1. School of Nursing, Hunan University of Chinese Medicine, Changsha, China

    He Jiaqing

  2. Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital of Central, South University, 139 Renmin Middle Road, Changsha, Hunan, 410011, China

    Tian Yusheng, Yang Jiaxin & Elihuruma Eliufoo

  3. National Clinical Research Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China

    Tian Yusheng & Yang Jiaxin

  4. Department of Psychiatry, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China

    Tian Yusheng & Yang Jiaxin

  5. Hunan Central South University Xiangya Stomatological Hospital, Hunan, China

    Yang Min

  6. Department of Nursing, Hunan Provincial People’s Hospital, 61 Jiefang West Road, Changsha, Hunan, 410005, China

    Zhai Mimi & Li Yamin

Authors
  1. He Jiaqing
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  2. Tian Yusheng
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Contributions

Conceived and designed the research: Y-m L. Wrote the paper: J-q H. Analyzed the data: J-q H and Y-s T. Revised the paper: M-m Z, J-x Y, EE, and MY. The authors read and approved the final manuscript.

Corresponding author

Correspondence to Li Yamin.

Ethics declarations

Ethics approval and consent to participate

This study was conducted in compliance with the declaration of Helsinki ethical approval. Ethical approval for this study was obtained from the Ethics Committee of The Second Xiangya Hospital of Central South University (LYF20230048), and applicable ethical standards and regulations followed all procedures. Informed consent was obtained from all participants before the commencement of data collection. The nurses who participated were assured of the confidentiality and anonymity of their responses.

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Not applicable.

Competing interests

The authors declare no competing interests.

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Jiaqing, H., Yusheng, T., Mimi, Z. et al. Relationship between head nurse leadership and nurses’ burnout: parallel mediation of job demands and job resources among clinical nurses. BMC Nurs 24, 354 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12912-025-03006-y

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Keywords

BMC Nursing

ISSN: 1472-6955

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