Burnout among healthcare workers (HCWs) in intensive care units (ICUs) is a persistent occupational health concern and a recognized determinant of compromised healthcare delivery. Defined as a triad of emotional exhaustion, depersonalization, and reduced personal accomplishment, burnout arises from prolonged exposure to occupational stressors within high-acuity clinical environments (1–3). ICU professionals face unique stressors, including high patient turnover, life-sustaining interventions, ethical dilemmas, and shift work, which collectively predispose them to greater psychological strain compared to other healthcare settings (4, 5). The repercussions are substantial—burnout contributes to diminished job performance, increased risk of medical error, compromised patient safety, and elevated rates of workforce attrition, which further destabilize already strained ICU staffing systems (6–8).

The literature identifies multiple and interrelated drivers of ICU burnout. Organizational and work-related stressors—such as excessive workloads, chronic understaffing, and limited clinical autonomy—are principal contributors (9–12). These are often exacerbated by structural challenges, including high patient acuity, administrative inefficiencies, and inadequate institutional support (13, 14). Additionally, socio-demographic factors such as younger age, female sex, and limited professional tenure have been associated with heightened burnout vulnerability, although findings remain heterogeneous across populations (8, 15). Emotional stressors, particularly frequent exposure to suffering, moral injury, and ethically complex care scenarios, further amplify risk—especially among ICU nurses, who consistently report higher levels of emotional exhaustion than their physician counterparts (16–18). Although protective factors—such as peer support, access to mental health resources, resilience training, and workload redistribution—have demonstrated benefit in attenuating burnout, their uptake and integration into ICU systems remain inconsistent and under-resourced (18, 19). Recent meta-analyses emphasize the relative efficacy of systemic interventions over individual-level strategies, underscoring the need for structural change (20).

Despite increasing research on ICU burnout, critical gaps persist. Most studies are crisis-focused, particularly COVID-19-related, with limited exploration of routine, post-pandemic ICU contexts. The Knowledge, Attitude, Practice (KAP) framework remains underutilized in assessing how HCWs’ knowledge and beliefs influence burnout-related behaviors. Furthermore, few large-scale, multi-center studies integrate socio-demographic, occupational, and behavioral dimensions to identify high-risk groups. The role of mental health resources in shaping KAP outcomes is poorly defined, and the generalizability of existing findings is constrained by small, single-center samples (21, 22).

Despite growing global recognition of burnout among ICU healthcare workers, critical knowledge gaps remain, particularly in the context of China. Most previous research has primarily investigated acute, crisis-driven burnout scenarios—such as those associated with the COVID-19 pandemic—yet limited evidence exists regarding the determinants of burnout under routine clinical circumstances. Moreover, there is a notable lack of large-scale studies employing theoretically grounded behavioral frameworks, such as Knowledge–Attitude–Practice (KAP), to systematically understand and address preventive behaviors in daily ICU practice. Specifically within China, research remains scarce on how institutional support mechanisms interact with demographic, occupational, and professional characteristics to shape burnout-related outcomes among ICU healthcare workers. Therefore, this multicenter cross-sectional investigation delineates burnout-related KAP among ICU personnel operating under routine post-pandemic conditions in Yancheng, Jiangsu, and elucidates the demographic, occupational, and institutional correlations of suboptimal profiles, with the aim of providing evidence to guide targeted system-level interventions.

Among 3,342 HCWs across multiple healthcare facilities in Yancheng, Jiangsu, most were aged 25–34 (40.0%) or 35–44 (32.0%), with only 5.9% ≥ 55 years, indicating a young workforce. Females predominated (70.0%), and 50.0% were single, 40.0% married/partnered. Household sizes were moderate, with 32.0% having four members and 30.0% three. Income showed 35.0% earning $51,000–$100,000, but 24.9% preferred not to disclose. Most were permanent employees (60.0%) and nurses (60.0%), with 40.0% having 1–5 years ICU experience, 20.0% each at 6–10 and 11–20 years. Rotating shifts were prevalent (49.9%), medical ICUs common (35.0%), and 50.0% reported no access to workplace mental health resources, with 40.0% confirming access and 10.0% unsure, highlighting a critical support gap (Table 1). The unsure responses may reflect variability in awareness or availability of mental health services across the regional network’s facilities. Figure 1 illustrates the distribution of KAP responses, showing high recognition of burnout causes (e.g., 84.0% identified long shifts as a contributor), strong perception of its impact (e.g., 82.8% viewed burnout as a serious problem), and a preference for informal coping strategies (e.g., 96.0% took breaks).

This study provides comprehensive insight into burnout KAP among 3,342 HCWs across a regional network of healthcare facilities in Yancheng, Jiangsu, China. The findings extend current literature by identifying specific demographic and occupational predictors of burnout-related KAP, while also revealing gaps in institutional support. Compared to existing global evidence, our data both corroborates and diverges from prior studies, highlighting new perspectives on burnout dynamics in routine, post-pandemic ICU contexts.

The workforce profile revealed a young, predominantly female cohort with a high representation of nurses and mid-career professionals in permanent positions. Access to mental health resources was limited, with 50.0% of HCWs reporting no access, 40.0% confirming access, and 10.0% unsure, consistent with Table 1. The unsure responses may reflect variability in awareness or availability across facilities, underscoring the need for standardized resource dissemination in the regional network. This gap aligns with global concerns regarding insufficient psychological support in critical care settings, particularly in resource-constrained systems. This staffing structure aligns with previous studies indicating that ICU environments globally are often characterized by nurse-dominant, female-majority teams (32, 33). The prevalence of mid-career staff suggests either effective workforce retention or evolving institutional policies in Chinese ICUs that favor continuity and experience accumulation. Interestingly, while the workforce stability appears strong, only 40% of HCWs reported access to mental health resources, echoing widespread concerns regarding the insufficient integration of psychological support within critical care infrastructure (34, 35). Compared to high-income countries where institutional wellness programs are increasingly standardized (36), the persistent resource gap in our setting underscores the disparity in structural support across healthcare systems. This deficit is especially significant given the acknowledged role of organizational interventions in reducing burnout risk and improving resilience among HCWs (37, 38).

Regarding knowledge of burnout, our findings align with previous studies showing that HCWs readily identify workload-related contributors such as long shifts, high patient acuity, and emotional strain (11, 39). However, critical gaps persist in awareness of formal prevention strategies, institutional training initiatives, and actual burnout prevalence. This disconnects between recognition and mitigation knowledge reflects global patterns, particularly in US and European studies, where systemic inertia often delays meaningful intervention (40). Our study adds to this literature by highlighting similar trends in a non-Western ICU context, where stress may be normalized, and institutional solutions underdeveloped. Novel in our findings is the widespread uncertainty surrounding burnout prevalence among peers—a potential result of cultural reticence, insufficient organizational transparency, or the internalization of high stress as normative. This phenomenon has been underreported in prior burnout studies, and its identification here underscores the importance of open discourse and burnout surveillance mechanisms as precursors to systemic reform (12, 41, 42).

Notably, gender, marital status, household size, income, and ICU type were non-significant predictors of KAP outcomes, contrasting with studies linking female sex or specific ICU types (e.g., medical ICUs) to higher burnout risk (43, 44). This discrepancy may reflect contextual factors in the Yancheng healthcare network. Uniformly high workloads across ICU types could minimize differences in burnout vulnerability. Similarly, cultural norms in China, where professional demands often supersede personal circumstances, may reduce the influence of gender or marital status on burnout perceptions. The income’s non-significance may stem from the 24.9% non-disclosure rate, limiting statistical power. These findings suggest that institutional and cultural factors may overshadow demographic influences in this cohort, warranting further exploration in multi-center studies to clarify context-specific drivers.

Attitudinally, HCWs in this study demonstrated strong recognition of burnout’s adverse effects on patient care and staff well-being, a pattern echoed in global evidence (45, 46). The widespread endorsement of institutional support, peer dialog, and structured interventions reaffirms the centrality of systemic responses to burnout prevention (47, 48). However, only moderate self-efficacy in recognizing burnout and considerable uncertainty regarding stigma suggest persisting internal and cultural barriers to effective identification and discussion. These findings align with previous studies identifying stigma and lack of formal training as key deterrents to early recognition (47). Interestingly, participants overwhelmingly rejected the notion that burnout enhances professional identity view that diverges from earlier narratives portraying stress endurance as a marker of professional commitment (49, 50).

Practices reported by ICU staff revealed a strong preference for informal coping mechanisms—such as taking breaks (96.0%), peer discussions (78.9%), and exercise (76.8%)—over formal approaches like counseling (32.0%) or managerial engagement (53.8%). This trend mirrors Western findings where HCWs favor self-initiated strategies due to stigma or access barriers. In the Chinese ICU context, additional cultural and organizational factors likely contribute (50, 51). Mental health stigma, prevalent in China, may deter HCWs from seeking counseling due to fears of professional judgment. Hierarchical hospital structures may discourage managerial discussions, as staff perceive such actions as risking career advancement. Limited visibility and availability of confidential counseling services, with only 40.0% reporting access, further exacerbate underutilization. These barriers suggest the need for culturally sensitive interventions, such as anonymous counseling platforms, leadership-driven stigma reduction campaigns, and mandatory mental health literacy training integrated into staff onboarding across all facilities in the Yancheng network (52–54, 59, 60).

Our regression models identified consistent predictors of favorable KAP outcomes: mid-career age groups, clinical roles (especially nurses and physicians), ICU experience between 1 and 20 years, rotating shift work, and access to mental health resources. These findings support prior research showing that clinical exposure and institutional support are key to effective burnout recognition and prevention (46, 55, 56). Conversely, temporary and contract HCWs were inadequate knowledge, less positive in attitude, and less engaged in preventive practices—a novel and concerning finding. This subgroup likely experiences marginalization in institutional support systems, emphasizing the need for inclusive policy interventions. Notably, variables such as gender, marital status, household size, income, and ICU type did not predict KAP outcomes, contradicting some studies but possibly reflecting contextual stability within our regional multi-institutional cohort.

By applying a KAP framework in a large, post-COVID ICU setting, this study addresses several critical gaps in existing burnout literature and contributes novel evidence to the field. First, it shifts the focus beyond acute crisis settings—such as pandemics—to examine the persistent, systemic stressors contributing to chronic burnout under routine clinical operations. This distinction is vital for designing sustainable interventions. Second, it links behavioral burnout outcomes with granular sociodemographic and occupational predictors, allowing for precision in intervention targeting—an approach often lacking in broader prevalence-focused studies. Third, it brings to light disparities in knowledge, attitudes, and preventive behaviors among non-permanent HCWs, a group routinely excluded from institutional wellness programs despite elevated vulnerability. This inclusion enhances the equity and inclusivity of burnout research. Lastly, the large sample size and multi-domain KAP design offer a robust methodological contribution, making this study one of the few to comprehensively assess burnout cognition and behavior at scale within a high-risk ICU environment in a non-Western context.

The regional focus on Yancheng, Jiangsu, limits the generalizability of findings to other healthcare systems, particularly those with differing organizational cultures or resource availability. Chinese ICUs often operate within hierarchical structures, which may discourage formal support-seeking due to perceived professional risks or mental health stigma, a factor less prominent in Western settings with standardized wellness programs. Resource constraints in China’s public hospitals may exacerbate gaps in mental health support compared to high-income countries. These cultural and systemic factors likely influenced the preference for informal coping and low counseling uptake observed, underscoring the need for context-specific interventions. Multi-center studies spanning diverse regions are needed to enhance the applicability of findings.

The multicenter design of this study was confined to 10 hospitals within a single city, Yancheng, Jiangsu. Consequently, the findings are context-specific and may not be readily generalizable to ICUs in other Chinese provinces or to healthcare systems with different organizational structures and resource availability. The cross-sectional nature of the study design inherently precludes causal inferences and an analysis of temporal trends in burnout. Although a high response rate of 74.3% was achieved, the potential for selection bias cannot be fully dismissed, as non-respondents might systematically differ from participants (e.g., in terms of workload, motivation, or burnout severity). The exclusive use of self-reported data for KAP is a limitation due to potential recall and social-desirability biases. Lastly, the evaluation of mental health resource accessibility relied entirely on participant self-report, lacking external validation of the quality or scope of these services.

This study reveals that ICU staff in a post-pandemic, multi-institutional context in Yancheng, Jiangsu, experience substantial burnout, with knowledge, attitudes, and practices influenced by clinical role, ICU experience, shift schedules, and institutional support availability. Temporary and contract staff demonstrated lower KAP scores, highlighting structural vulnerabilities. The predominance of informal coping strategies points to cultural and organizational barriers to formal support engagement. These findings, while robust within the regional context, underscore the need to standardize mental health support, enhance burnout training, and integrate non-permanent staff into wellness initiatives. The KAP framework provides a scalable tool for behavioral monitoring, but broader studies are needed to generalize findings across diverse healthcare systems.