Burnout is defined by the Maslach Burnout Inventory (MBI) as encompassing three primary dimensions: a loss of enthusiasm for work (emotional exhaustion, EE), negative feelings and cynical attitudes (depersonalization, DP), and low sense of personal accomplishment (low personal accomplishment, PA) (WHO, 2024; Maslach and Jackson, 1981; Maslach et al., 2001; Maslach and Leiter, 2016). This encompasses not only perception but also a decline in performance. The prevalence of burnout among nurses has reached epidemic levels, prompting a widespread focus on this issue (Owuor et al., 2020; Woo et al., 2020). In comparison to other healthcare professionals, nurses are more susceptible to burnout, due to their proximity to patients and the frequency of their interpersonal interactions (Westergren and Lindberg, 2023). A number of studies have indicated that burnout is a prevalent issue among nurses (Owuor et al., 2020; Woo et al., 2020). A meta-analytic study revealed that 31% of nurses exhibited high EE, while 24 and 38% of subjects demonstrated high DP and low PA, respectively (Molina-Praena et al., 2018). A study conducted in Shandong, China, revealed that 63.8% of nurses employed in general hospitals exhibited at least one symptom of burnout. Furthermore, 34.4% of the nurses in the study met the criteria for high EE, 42.2% for high DP, and 26.1% for low PA (Sun et al., 2018).

The adverse effects of nurse burnout have been documented in the literature, including an impact on nurses’ well-being, a negative effect on nurse turnover rates, and a potential threat to patient safety (Sullivan et al., 2022). Furthermore, burnout can result in suboptimal job performance (Adriaenssens et al., 2017) and a degradation in the quality of care or service provided by the nursing staff (Cañadas-De la Fuente et al., 2015). The ramifications of burnout are detrimental to nurses, patients, and healthcare institutions. Consequently, it is imperative to identify risk factors for burnout in nurses and to implement targeted interventions to prevent its occurrence.

Previous research has identified the primary risk factors for nurse burnout as being associated with stressful work environments and heavy workloads, including prolonged work hours (Woo et al., 2020; Chen and Meier, 2021). More recent studies have focused on the issue of sleep problems. Empirical evidence from both the general population and healthcare professionals indicates that the presence of sleep problems, such as insufficient sleep and poor sleep quality, may increase the odds of burnout (Wang et al., 2020; Saintila et al., 2024). Given the nature of the nurses working conditions, which often include shift work and extended hours, sleep problems are highly prevalent among nurses. This is accompanied by alterations in sleep architecture and a reduction in the quality and quantity of sleep hours (Yazdi et al., 2014; Geiger-Brown et al., 2012; Miguez-Torres et al., 2021; Wang et al., 2020). A meta-analysis comprising 12 studies has revealed a significant positive correlation between sleep problems and burnout among nurses (Membrive-Jiménez et al., 2022). In addition, both sleep duration and sleep quality have been linked to an elevated risk of burnout in surveys of nurses (Membrive-Jiménez et al., 2022; Chin et al., 2015). Although these studies provide preliminary insights into the potential relationship between sleep problems and burnout among nurses, they have also identified several key research gaps.

Firstly, sleep problems can be characterized by multiple subtypes, including poor sleep quality, high sleep latency, short sleep duration, impaired sleep efficiency, daytime dysfunction, the use of sleep medication and nine types of sleep disturbances (Cho et al., 2015; Becker et al., 2018). Nevertheless, few studies have examined the differences in the associations between various subtypes of sleep problems and burnout. This prevents psychologists from acknowledging whether and to what extent specific sleep problems subtypes are greater risk factors for burnout than others. Therefore, further research is required to examine the unique effects of all potential sleep problems subtypes on burnout among nurses, with a view to obtaining a more accurate understanding of the associations involved.

Secondly, it is not uncommon for individuals to present with multiple subtypes of sleep problems concurrently (Blunden et al., 2004; Owens et al., 2014). Additionally, a significant number of participants have indicated that they have experienced more than one subtype of sleep problem (Roth et al., 2006). Moreover, a study indicated that nurses may be susceptible to the cumulative effects of various types of sleep problems (Ma et al., 2024). It is therefore unclear whether individuals presenting with multiple subtypes of sleep problems are at an elevated risk of burnout relative to those exhibiting a single sleep problem. To date, no study has investigated whether nurses presenting with multiple types of sleep problems are more likely to engage in burnout than those presenting with a single type of sleep problem. Furthermore, there has been no prior study that has investigated the cumulative effect of multiple subtypes of sleep problems on burnout among clinical nurses, making such an investigation a clear research priority.

The objective of this study is to examine the associations between sleep problems and burnout in a large and representative sample of nurses from Fujian Province, China. Additionally, the study aims to investigate the unique and cumulative effects of different subtypes of sleep problems on three dimensions of burnout among Chinese nurses and identify the influence of depressive symptoms on this relationship (Chen and Meier, 2021).

To our knowledge, this is the first study to examine the relationship between sleep problems and three dimensions of burnout in a sample of 744 nurses from China, exploring global issues down to specific problems, and considering both unique and cumulative effects. After controlling for sociodemographic and occupational characteristics, in addition to depression, this study demonstrated that nurses experiencing sleep problems were more likely to develop high EE, high DP and low PA. Additionally, “feel too cold” and “have pain” were found to be risk factors for high EE. Moreover, “daytime dysfunction” was identified as a risk factor for low PA. Further, we found that nurses with three or more sleep problems were twice as likely to develop high DP and low PA than those with no sleep problems.

In the current study, the overall prevalence of burnout was 67.7%, which is higher than that found in a study of Chinese nurses (Sun et al., 2018). In addition, this result is much higher than the overall prevalence of burnout symptoms among nurses of 11.23% reported in a meta-analysis of 61 studies (Woo et al., 2020). Regarding the three dimensions of burnout, the prevalence of high EE (6.9%) and high DP (23.4%) were within the respective ranges of 5.6–69.6% and 1.1–39.1%, respectively, reported in a previous meta-analysis (Galanis et al., 2021). However, the prevalence of low PA (63.2%) was significantly higher than the range of 0–52.2%. This may be related to the investigation of different healthcare systems, working conditions and epidemiological severity, as well as the utilization of different assessment methods and cut-offs for burnout. Furthermore, we had to take into account the impact of the COVID-19 pandemic; increased workload, fear of infection, segregation of work and lack of understanding of some patients may have contributed to high EE, high DP, and low PA (Bruyneel et al., 2021).

Consistent with previous studies (Wang et al., 2021), the results of this study indicated that the risk of all three dimensions of burnout was higher in nurses with sleep problems than in those without. This remained the case even after taking into account participant characteristics, including depression. This may highlight the potential importance, even in the presence of other well-recognized risk factors, of assessing nurses for sleep problems in burnout prevention and intervention.

In terms of sleep problem subtypes, we found that “feel too cold” and “have pain” were significant risk factors for high EE after adjusting for a comprehensive number of confounders. Zborowska et al. (2021) demonstrated that EE is significantly influenced by disturbed sleep and environmental factors. The identification of factors such as feeling too cold and having pain in this study is consistent with the notion that environmental and physical discomfort can affect EE. This may be because feeling cold or aching while sleeping is related to sleep deprivation (e.g., frequent nocturnal awakenings, difficulty falling asleep and disrupted sleep continuity) (Finan et al., 2013). In addition, sleep is associated with emotional processing and affect regulation (Yoo et al., 2007). Neuroimaging evidence show hyper-responsiveness in the sleep-deprived amygdala, indicating increased emotional intensity after sleep deprivation (Yoo et al., 2007; Trockel et al., 2020). These finding suggest that sleep deprivation caused by feeling cold or pain (Finan et al., 2013), may lead to impaired mood and affect regulation, thus contributing to emotional exhaustion (Trockel et al., 2020; Stewart and Arora, 2019). Further, it can be reasonably deduced that nurses who are suffering from high levels of EE as a direct result of discomfort such as feeling the cold or experiencing pain may find themselves experiencing a reduction in their ability to concentrate and an increased tendency to make errors at work (Buysse et al., 1989). This can have a significant impact on patient safety and the efficiency of the workflow in question. Furthermore, chronic pain or discomfort has the potential to result in increased absenteeism among nursing staff, which in turn can lead to a decline in morale, cohesion and ultimately, the atmosphere in the workplace.

The present study also demonstrated that nurses with daytime dysfunction were more likely to develop low PA. This is analogous to a study of nurses in the UK (Yang et al., 2020), which showed that poor sleep quality and daytime dysfunction were associated with increased burnout, including low PA. Similarly, another study (Shi et al., 2023) identified a positive correlation between daytime dysfunction and high EE and DP and low PA in medical residents undergoing standardized residency training. It is noteworthy that Shi (Shi et al., 2023) observed that the proposed models linking sleep disorders, primarily daytime dysfunction, and burnout include two main hypotheses. The first hypothesis posits that burnout results from exhaustion of the body, mind, and spirit, which can be reversed by healthy sleep. The second hypothesis suggests that chronic stress hyperactivates the hypothalamic–pituitary–adrenal axis, thereby mediating both burnout and sleep loss (Stewart and Arora, 2019). It can thus be inferred that the experience of daytime dysfunction can result in a reduction in PA, which in turn can lead to a decline in work productivity and effectiveness in nursing tasks, ultimately impacting the quality of patient care. Moreover, nurses who are experiencing daytime dysfunction may also experience a reduction in their quality of life due to increased fatigue and a diminished capacity to engage in daily activities, which can affect their overall well-being and work-life balance. In our study, the relationship between daytime dysfunction and DP was not significant after adjusting for the influence of depression. One potential explanation for this is that the correlation between daytime dysfunction and depersonalization may be mediated by the status of depressive symptoms.

We also found that, compared with those with no sleep problems, nurses with three or more subtypes of sleep problems were associated with a twofold risk of developing high DP and low PA. This finding is consistent with the cumulative risk model, which postulates that individuals often encounter multiple independent risk factors rather than a single factor, and that the occurrence of additive risk factors intensifies the likelihood of unexpected outcomes (Sameroff, 2000). To date, our study is the first to report the cumulative effect of multiple sleep problem subtypes on nurse burnout. Notwithstanding the observation in our study that other subtypes of sleep problems are not significantly associated with any dimension of burnout, their cumulative effect on burnout remains substantial. Therefore, a comprehensive assessment of nurses’ sleep problems is needed facilitate the timely prevention and effective reduction of nurse burnout.

The findings of this study contribute to the existing evidence base for clinical practice. The findings suggest that sleep-focused burnout prevention and intervention programs may be an effective strategy for reducing burnout among nurses. Firstly, this study indicates the existence of discrete subtypes of sleep problems among nurses, highlighting the need for future research on sleep problem subtypes, targeted prevention and intervention rather than a one-size-fits-all approach to reducing burnout among nurses. In addition, it is recommended that particular attention be paid to sleep disturbances (e.g., “feeling too cold” and “having pain”) and daytime dysfunction, as they play an important role in the development of high EE or low PA in nurses. Hospital administrators can play a crucial role in mitigating the negative health effects associated with poor sleep by educating nurses about sleep hygiene. They should emphasize the importance of maintaining good sleep hygiene and provide strategies to improve sleep quality. Key recommendations include maintaining a consistent sleep schedule, creating a conducive sleep environment, and avoiding caffeine and electronic devices before bedtime. Furthermore, although there was no significant association between other subtypes of sleep problems and all three dimensions of burnout, their cumulative effect and burnout remained significant. This highlights the necessity for a comprehensive assessment of sleep problem subtypes among nurses in order to facilitate the timely prevention and effective reduction of burnout.

A few limitations of the study should be noted when considering its contributions to existing research and the design of future studies. First, the cross-sectional nature of the study design precludes the possibility of inferring specific causal relationships. Second, although participants in this study were anonymous, identification may have biased their questionnaire responses, and our study variables were measured using self-reported data, which may introduce biases. Third, as potential factors contributing to burnout, we only assessed depression and no other factors, particularly job strain (Metlaine et al., 2017). Fourth, the recruitment of nurses from a single geographical location, namely Quanzhou City in China, may have restricted the generalizability of the findings to other urban settings. Finally, the present study was conducted with a sample of nurses in tertiary hospitals only, which may limit the generalizability of the results to other primary and secondary hospitals.

Despite the above limitations, this is the first study to test the relationship between sleep problems and three dimensions of burnout among Chinese nurses, exploring global issues down to specific problems, and considering both unique and cumulative effects. The findings indicated that compared with those without sleep problems, nurses with sleep problems, especially those with multiple subtypes of sleep problems, were more likely to experience burnout. In the present study, we found that feeling cold or painful during sleep predicted higher EE, and poor daytime function predicted lower PA. A previous study suggested that sleep hygiene interventions may have beneficial effects on burnout (Brubaker et al., 2020). These findings may guide future research to design prevention and intervention tailored to nurses with distinct sleep problem subtypes, which may be a way forward in combating burnout. In addition, focusing on the cumulative effects of sleep problems may provide an overall picture of the relationship between sleep problems and burnout in nurses. Future studies are needed to further confirm our findings in a longitudinal design.