Introduction
While individuals may harbor dreams and ambitions for their work lives, factors such as economic constraints, social status, gender, religious beliefs, sexual orientation, or race may hinder their realization [1]. Stigma surrounding mental illness is also a significant factor. Over the past few decades, public perception of psychiatric hospitals has remained negative. The image of a “psychiatric hospital” often conjures up that of a large, custodial institution, typically located in the suburbs [2]. Psychiatric nurses, as mental health professionals, are also affected by stigmatization. Research has found widespread negative perceptions of psychiatry among members of other medical professions [3], reflecting the lower social status of psychiatric nurses and their lack of sufficient respect and recognition. Moreover, psychiatric nurses exposed to workplace violence and similar environments suffer significant harm to their physical and mental well-being [4]. Therefore, providing psychiatric nurses with sufficient incentives, ensuring their perception of decent work, and enhancing job satisfaction are crucial for improving the quality of psychiatric care, maintaining patient safety, and promoting patient recovery.
Employment is often a prerequisite for individuals to sustain income, and the rewards of work can impact their social status and economic strength. However, research reports indicate the presence of Effort-Reward Imbalance (ERI) among psychiatric nurses [5], characterized by an imbalance in the reciprocal relationship where individuals invest high effort and low reward reflects [6]. Particularly in psychiatric healthcare settings, challenges such as working with difficult patient populations, limited resources, uncompensated efforts, violence, and aggression can lead to this imbalance [7]. Past studies have shown that such imbalance can trigger anger, depression, and perceptions of unfairness, consequently resulting in physical ailments and mental disorders [8]. Therefore, for psychiatric nurses, maintaining a balance between effort and reward in their work is an urgent issue that needs to be addressed. We hypothesize that there is a negative correlation between effort-reward imbalance and decent work.
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In recent years, the concept of decent work has garnered significant attention and is closely linked to a series of initiatives by the International Labour Organization (ILO) aimed at respecting workers’ rights. At the macro level, decent work refers to ensuring that workers can work under conditions of freedom, fairness, safety, and dignity by promoting employment, strengthening social protection, safeguarding workers’ basic rights, and engaging in tripartite dialogue among governments, employers, and workers’ organizations [9]. At the individual level, decent work is a composite concept encompassing five key aspects: physically and interpersonally safe working conditions, hours that permit free time and sufficient rest, organizational values aligned with family and social values, fair compensation, and access to adequate healthcare [10]. Ensuring nurses’ perception of decent work is beneficial for both individual nurses and organizations. On one hand, safeguarding nurses’ decent work reduces burnout and intention to resign, enhancing their enthusiasm and stability in their roles [11]. On the other hand, a decent work environment fosters nurses’ work immersion, thereby enhancing their professional competence and service quality [12]. Additionally, decent work inspires nurses’ grit, enabling them to demonstrate higher adaptability and resilience when facing work pressures and challenges [13]. Therefore, considering the profound impact of burnout on nurses and organizations, we hypothesize that nurses’ burnout is negatively correlated with their perception of decent work.
Burnout refers to a syndrome that develops under prolonged work stress, encompassing three dimensions: emotional exhaustion, depersonalization, and reduced personal accomplishment [14]. Emotional exhaustion reflects the state of emotional fatigue and the degree of loss of enthusiasm for work. Depersonalization reflects the extent to which an individual adopts a negative, detached, or indifferent attitude towards clients. Reduced personal accomplishment reflects the degree to which an individual negatively evaluates the significance and value of their work [15]. In May 2019, the World Health Organization(WHO) included “burnout” in the International Classification of Diseases(ICD), highlighting the prevalence and severity of burnout [16]. Existing research indicates that burnout negatively impacts both physical and psychological health. Physiologically, burnout is associated with continuous autonomic nervous system activation, dysfunction of the sympathoadrenal medullary axis, elevated cortisol levels, changes in brain structure and function, metabolic syndrome, cardiovascular diseases, musculoskeletal disorders, respiratory diseases, and health issues such as headaches and infections [17, 18]. Psychologically, burnout is associated with anxiety and depression, and it affects an individual’s well-being [19, 20]. Therefore, we hypothesize that burnout is negatively correlated with the well-being of psychiatric nurses.
The well-being of nurses in their profession has be defined as their positive evaluation of their contributions to nursing work and the nursing profession, enabling nurses to be in the best possible state at any given time, with the ability to adapt to and overcome adversity as much as possible [21]. Research has found a close correlation between nursing quality and performance and well-being [22]. Moreover, from a long-term perspective, workplace well-being is conducive to reducing nurses’ burnout and enhancing job efficiency and satisfaction [23, 24]. Therefore, safeguarding the well-being of nurses is crucial for both nurses themselves and their patients. Another study suggests that when employees’ basic needs are met, their well-being also improves [24]. Hence, we hypothesize that nurses’ perception of decent work is positively correlated with well-being.
The Job Demands-Resources (JD-R) model provides theoretical support for understanding these variables. This model emphasizes the interaction between an individual’s demands and resources in the work environment and how these interactions affect job performance, attitudes, and well-being. In this model, job demands are defined as aspects of the job that require physical and psychological effort, such as workload, role conflict, and time pressure. Job resources are positive factors that help individuals achieve work goals, reduce the physiological and psychological costs of job demands, and promote personal growth and development, such as job autonomy, colleague support, and performance feedback [25, 26]. Within the JD-R framework, we hypothesize that the effort-reward imbalance for psychiatric nurses’ influences well-being through two pathways. The Deterioration Pathway: In this pathway, effort-reward imbalance increases burnout, which in turn reduces well-being. The Enhancement Pathway: In this pathway, a strong perception of decent work, as a reflection of good job resources, can mitigate the impact of burnout and enhance nurses’ well-being. Hence, we hypothesize that effort-reward imbalance among psychiatric nurses’ influences well-being, with burnout and decent work mediating this relationship.
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Previous studies have explored the relationships between certain variables, such as the positive correlation between effort-reward imbalance and burnout [27], the negative correlation between effort-reward imbalance, burnout, and well-being [20, 28], and the impact of decent work on nurses’ burnout [11]. However, there is a lack of research examining the relationship between effort-reward imbalance, well-being, decent work, and burnout, particularly among psychiatric nurses. Therefore, this study aims to examine the relationship between effort-reward imbalance, well-being, burnout, and decent work among psychiatric nurses. It also provides theoretical support and practical guidance for improving the working environment, conditions, job satisfaction, and professional development of psychiatric nurses.
Methods
Study design
This study employed a quantitative cross-sectional survey design, rigorously adhering to the guidelines outlined in the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. The research was conducted in February 2024 at two psychiatric specialty hospitals in Hangzhou and Huzhou cities, located in Zhejiang Province, China. These hospitals shared similarities in healthcare standards and operational models.
Sample
Sample size calculation utilized the G-Power 3.196 linear multiple regression algorithm. With an effect size of 0.15, α value of 0.05, and regression coefficient of 0.05, at a significance level of 0.05, and an expected power (1 - β error probability) of 0.95. The study encompassed 23 variables, including 6 socio-demographic characteristics and 13 dimensions related to the scale. The calculation indicated a minimum sample size requirement of 234 nurses. Considering a potential 20% rate of invalid questionnaires, at least 257 nurses were needed to meet the minimum sample size.
The inclusion criteria for participants were as follows: (1) Registered nurses; (2) Minimum of one year of experience in psychiatric healthcare; (3) Informed consent and willingness to participate in the study. Exclusion criteria included: (1) Nurses on leave; (2) Interns or trainees; (3) Administrative or logistical nursing staff.
The study gathered a total of 410 questionnaires. After excluding 13 invalid responses, 397 questionnaires were ultimately included in the analysis, resulting in an effective rate of 96.8%.
Measurements
Demographic information
Demographic characteristics encompass gender, age, educational background, experience in psychiatric work, professional title, marital status.
Effort-reward imbalance scale
In this study, the Chinese version of the Effort-Reward Imbalance (ERI) Scale was used to investigate the effort-reward situation among psychiatric nurses. Developed by Siegrist [29], this scale has been widely used in the Chinese occupational population with demonstrated reliability and validity [30]. The scale comprises 23 items, representing three dimensions: “Effort” (6 items, scores ranging from 6 to 30), “Reward” (11 items, scores ranging from 11 to 55), and “Overcommitment” (6 items, scores ranging from 6 to 24). We calculated the Effort-Reward Ratio (ERR) to assess the imbalance between effort and reward. The ERR is calculated as (Effort Score / Reward Score) × (11 / 6), where a higher ERR indicates a more severe imbalance. In this study, the Cronbach’s α coefficient for this scale was calculated as 0.939.
Decent work perception scale
The Decent Work Perception Scale (DWPS), developed by Chinese scholars [31], was employed in this study to assess the perception of decent work among psychiatric nurses. This scale has been previously utilized in the nursing population and demonstrates good reliability and validity [11]. It consists of 16 items organized into five dimensions: Work Rewards (4 items), Work Position (3 items), Work Atmosphere (3 items), Work Development (3 items), and Work Recognition (3 items). Responses were rated on a 5-point Likert scale ranging from “1” (strongly disagree) to “5” (strongly agree), with total scores ranging from 16 to 80. Higher scores indicate a stronger perception of decent work. In this study, the Cronbach’s α coefficient for DWPS was determined to be 0.949.
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Maslach burnout inventory-general survey
This study used the Chinese version of the Maslach Burnout Inventory-General Survey (MBI-GS) to investigate burnout among psychiatric nurses. The scale was developed by Maslach and has been cross-culturally adapted by Chinese scholars Chaoping Li [32]. It has been widely used among nurse populations. The scale includes three dimensions: emotional exhaustion, depersonalization, and reduced personal accomplishment, with a total of 15 items. Each item is assessed using a 7-point Likert scale, with scores ranging from 0 (never) to 6 (everyday) based on the nurse’s personal experiences. The personal accomplishment dimension is scored in reverse. Higher MBI-GS scores indicate higher levels of burnout. In this study, the Cronbach’s α coefficient for the Maslach-GS was 0.923.
General well-being schedule scale
This study used the General Well-Being Schedule Scale(GWBSS), developed by the National Center for Health Statistics in the United States [33], to assess the well-being of psychiatric nurses. The scale has been adapted by Chinese scholars and extensively used in China, demonstrating robust reliability and validity [34]. Comprising 18 items, the scale evaluates six dimensions: health worry, energy level, satisfying interesting life, mood (depressive or cheerful), emotional–behavioral control, and relaxed versus tense–anxious. For scoring, items 2, 5, 6, and 7 are rated on a 5-point scale, items 15–18 on a 10-point scale, while the remaining items are scored using a 6-point system. Additionally, items 1, 3, 6, 7, 9, 11, 13, 15, and 16 are reverse-scored. A higher total score on the scale indicates higher subjective well-being. In this study, the Cronbach’s α coefficient for this scale was calculated as 0.791.
Data collection
This study used electronic questionnaires for the survey. Before implementation, researchers created electronic links containing the consent form, instructions, and questionnaire content. Nurses could proceed to the next step only after reading and agreeing to the informed consent form. The instructions emphasized the purpose of the questionnaire, the guiding principles for answering questions, and important notes and explanations. Researchers trained data collectors on questionnaire distribution, focusing on the methods for completing the questionnaire, the principles of informed consent, the study’s purpose and significance, the instructions for completing the questionnaire, and familiarity with the questionnaire items. Two research assistants, after unified training, were responsible for distributing the questionnaires, with one researcher dedicated to quality supervision during the data collection process. First, team members communicated with the heads of the nursing departments of the two hospitals via email and meetings. After obtaining permission to conduct the survey, the research assistants sent the electronic questionnaire links to the nurses. Before completing the questionnaire, nurses were informed about the purpose and significance of the study, all potential risks, and emergency contact information. Nurses could freely choose to participate or decline to participate in the study, and they could withdraw at any time during the study without any consequences. Upon completion, the data were stored in a secure electronic folder accessible only to the researchers and authorized personnel with the password.
Data analysis
The questionnaire responses were automatically generated in spreadsheet format to ensure consistency in answers. We conducted a search for data anomalies (e.g., 12121212, 11111111) and subsequently removed them. Data analysis was performed using SPSS 26.0 and the PROCESS Macro. Harman’s single-factor test was employed to check for common method bias. Descriptive statistics were utilized to analyze the demographic characteristics of the study participants and the mean scores of variables. The relationships between variables were examined through Pearson correlation analysis. PROCESS v4.0 was used to assess the mediating roles of nurses’ burnout and decent work in the relationship between effort-reward imbalance and well-being. Bootstrap resampling generated 5,000 samples for mediation analysis, and a 95% confidence interval was applied for significance assessment of path coefficients. A p-value of < 0.05 was considered statistically significant.
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Results
Common method bias test
This study used a questionnaire survey to collect data. Due to the substantial number of questionnaire items and the extended duration for completion, and in order to mitigate common method bias, the data were subjected to Harman’s single-factor test. The results of the unrotated principal component factor analysis indicated the presence of ten factors with eigenvalues greater than 1. The first factor accounted for 32.64% of the total variance, falling below the 40% critical threshold. Therefore, it can be inferred that this study is not significantly affected by common method bias.
Sociodemographic characteristics
Table 1 presents the characteristics of the participants. Among them, 366 were female nurses, while 31 were male nurses, with ages ranging from 22 to 55 years, averaging 36.18 ± 8.17 years. The majority of participants had 5–15 years of work experience, accounting for 41.8%. Additionally, 367 participants held a bachelor’s degree, comprising 92.4% of the sample. The predominant professional title was supervisor nurse, with 170 individuals, representing 42.8%. Furthermore, 73.0% of the participants were married.
Table 1
Sociodemographic characteristics of the sample (N = 397)
Variables | N | % |
|---|---|---|
Gender | ||
Male | 31 | 7.8 |
Female | 366 | 92.2 |
Educational Background | ||
Short-cycle Courses | 24 | 6.0 |
Bachelor’s degree | 367 | 92.4 |
Master’s degree or above | 6 | 1.5 |
Experience in psychiatric work | ||
<5 | 74 | 18.6 |
5–15 | 166 | 41.8 |
16–25 | 99 | 24.9 |
> 25 | 58 | 14.6 |
Professional title | ||
Registered nurses | 30 | 7.6 |
Senior nurse | 137 | 34.5 |
Supervisor nurses | 170 | 42.8 |
Cochief nurses or above | 60 | 15.1 |
Marital status | ||
Married | 290 | 73.0 |
Unmarried | 96 | 24.2 |
Others | 11 | 2.8 |
Descriptive statistics of variables
In this study, psychiatric nurses scored an average of 0.92 ± 0.28 on effort-reward imbalance, 30.47 ± 13.46 on burnout, 55.68 ± 10.84 on decent work, and 84.12 ± 15.33 on well-being. The scores for each dimension are presented in Table 2.
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Table 2
Correlation analysis of effort-reward imbalance, decent work, burnout, and well-being
M ± SD | Effort-Reward imbalance | Decent work | Burnout | Well-being | |
|---|---|---|---|---|---|
Effort-Reward imbalance | 0.92 ± 0.28 | 1 | |||
Decent work | 55.68 ± 10.84 | -0.564** | 1 | ||
Burnout | 30.47 ± 13.46 | 0.603** | -0.541** | 1 | |
Well-being | 84.12 ± 15.33 | -0.541** | 0.511** | -0.691** | 1 |
Pearson correlation analysis
In this study, Pearson correlation analysis was conducted to examine the relationships among effort-reward imbalance, burnout, decent work, and well-being among psychiatric nurses, as presented in Table 2. The results revealed negative correlations between effort-reward imbalance scores and decent work (r =-0.564, p < 0.001), well-being (r =-0.541, p < 0.001). Additionally, a positive correlation was found between effort-reward imbalance and burnout (r = 0.603, p < 0.001). A negative correlation was found between decent work and burnout (r =-0.541, p < 0.001). Furthermore, a positive correlation was observed between decent work and well-being (r = 0.511, p < 0.001). Finally, burnout was negatively correlated with well-being (r=-0.691, p < 0.001).
Mediation effect analysis
Table 3 presents the results of the relationship analysis among various variables. Effort-reward imbalance demonstrates a direct negative impact on well-being (β=-0.141, p = 0.003) and decent work (β=-0.373, p < 0.001). Furthermore, it exerts direct positive effects on burnout (β = 0.603, p < 0.001). Burnout exhibits a negative direct effect on decent work (β=-0.316, p < 0.001) and well-being (β=-0.526, p < 0.001). Additionally, decent work shows a positive direct effect on well-being (β = 0.147, p = 0.001).
Table 3
Analysis of direct effects and total effect between variables
Effect | Item | β | SE | t | P | LLCI | ULCL |
|---|---|---|---|---|---|---|---|
Direct effects | ERR→DW | -0.373 | 1.937 | -7.521 | < 0.001 | -18.378 | -10.761 |
ERR→BO | 0.603 | 1.945 | 15.016 | < 0.001 | 25.382 | 33.030 | |
ERR→ WB | -0.141 | 2.598 | -2.996 | 0.003 | -12.893 | -2.677 | |
DW→ WB | 0.147 | 0.063 | 3.286 | 0.001 | 0.083 | 0.332 | |
BO→ WB | -0.526 | 0.053 | -11.374 | < 0.001 | -0.703 | -0.496 | |
BO→DW | -0.316 | 0.040 | -6.370 | < 0.001 | -0.333 | -0.176 | |
Total effect | ERR→WB | -0.541 | 2.334 | -12.787 | < 0.001 | -34.439 | -25.260 |
As Fig. 1 shows, the results of the mediation analysis indicate that burnout mediates the relationship between effort-reward imbalance and well-being (95% CI [-0.386, -0.257]). Similarly, decent work also serves as a mediator between effort-reward imbalance and well-being (95% CI [-0.100, -0.012]). Additionally, burnout and decent work served as chain mediators in the relationship between effort-reward imbalance and well-being (95% CI [-0.050, -0.006]) (See Table 4). The confidence intervals for all these mediation effects do not include 0, confirming the existence of sequential mediation effects. Furthermore, the mediated effect accounts for 73.94% of the total effect.
Fig. 1
The mediation of burnout and decent work in the relationship between effort-reward imbalance and well-being
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Table 4
Analysis of indirect effects between variables
Effect | Item | β | BootSE | BootLLCI | BootULCL |
|---|---|---|---|---|---|
Indirect effects | ERR→DW→WB | -0.055 | 0.022 | -0.100 | -0.012 |
ERR→BO→WB | -0.317 | 0.033 | -0.386 | -0.257 | |
ERR→BO→ DW→ WB | -0.028 | 0.011 | -0.050 | -0.006 | |
Total | -0.400 | 0.037 | -0.473 | -0.325 |
Discussions
This study conducted a survey among nurses from two psychiatric hospitals in Zhejiang Province to investigate the relationships among effort-reward imbalance, burnout, decent work, and well-being, aiming to further validate theories in JD-R model. The findings revealed a direct impact of effort-reward imbalance on nurses’ well-being. Additionally, burnout and decent work were found to mediate the relationship between effort-reward imbalance and well-being.
The results of this study indicate a positive correlation between the effort-reward imbalance and burnout among psychiatric nurses, aligning with our hypothesized outcomes. Similar conclusions have been drawn from previous research [35]. This finding holds significant practical implications as psychiatric nurses often encounter challenges such as collaborating with difficult patient populations, limited resources, violence, and aggression [7]. Nurses must focus not only on the physical symptoms of their patients but also on their mental state and behavior. The continuously high job demands deplete the physical and mental resources of psychiatric nurses, making them more susceptible to burnout. Therefore, hospital management should pay close attention to the work environment and resource allocation for psychiatric nurses, ensuring they have sufficient support and resources to cope with the challenges they face in their work.
Additionally, this study’s findings reveal a negative correlation between burnout and the perception of decent work among psychiatric nurses. Notably, another study has shown that decent work can influence burnout; specifically, decent work as a job resource can alleviate burnout [11]. This suggests a potential bidirectional relationship between decent work and burnout: on one hand, a good working environment and perception of decent work can reduce burnout; on the other hand, when nurses are in a state of burnout, their perception of decent work may be diminished, further exacerbating the negative effects of burnout. Therefore, managers should take a multi-faceted approach to actively prevent and intervene in the burnout of psychiatric nurses, to maintain their perception of decent work and overall job satisfaction.
Additionally, the study findings revealed a positive correlation between psychiatric nurses’ perception of decent work and their sense of well-being. This aligns with previous research, further emphasizing the significance of decent work in enhancing overall employee well-being [36]. Decent work entails establishing a secure, supportive, and conducive work environment for employees. In psychiatric settings, a safe and supportive work environment can mitigate the impact of work stressors such as violence and intimidation on nurses, thereby enhancing their well-being [37]. Moreover, decent work emphasizes fair compensation, including competitive wages, benefits, and opportunities for career advancement. Adequate financial remuneration acknowledges psychiatric nurses’ expertise, skills, and contributions, alleviating financial strain and enhancing overall well-being. Benefits such as health insurance, paid leave, and employee assistance programs further support nurses’ physical and mental health, fostering a sense of well-being. Therefore, psychiatric healthcare institutions should strive to create a decent work environment to ensure that psychiatric nurses can provide optimal patient care.
Finally, this study reveals that the imbalance between effort and reward for psychiatric nurses affects their well-being, with burnout and the perception of decent work serving as mediators in this relationship. These findings are consistent with the JD-R [26]. Specifically, psychiatric nurses often encounter emotionally demanding and complex work environments, where they not only handle numerous medical tasks but also manage patients’ emotional fluctuations and unpredictable behaviors. This high-pressure work environment can lead to feelings of effort-reward imbalance [38]. When psychiatric nurses perceive an imbalance between their effort and reward, they may experience frustration, disappointment, and excessive stress [27]. Over time, this continuous pressure leads to burnout, which further impacts their perception of decent work and reduces their overall well-being. This indicates a deterioration pathway where high job demands and low rewards deplete nurses’ physical and mental resources, lowering their well-being. Moreover, burnout not only reduces nurses’ work efficiency but also changes their perception of work [39, 40]. They may feel that their work is undervalued, leading to a diminished sense of decent work. Conversely, a strong perception of decent work, as a reflection of good job resources, can mitigate the impact of burnout and enhance nurses’ well-being. Therefore, managers need to promote the perception of decent work among psychiatric nurses, alleviate the effects of effort-reward imbalance and burnout, and enhance their well-being.
Implication
This study holds significant practical implications for psychiatric nursing. Firstly, managers should prioritize achieving a balance between psychiatric nurses’ efforts and rewards to ensure they receive due recognition and compensation. This can be accomplished through the establishment of equitable salary structures, offering opportunities for career advancement, and implementing reward systems [41]. Secondly, both managers and healthcare institutions need to strengthen the support system for psychiatric nurses, fostering a more harmonious and supportive work environment. This includes providing psychological counseling and emotional support services, establishing support groups and in-house social platforms, and enhancing patient and family understanding and respect for nurses’ work [42]. Moreover, creating a decent work environment is crucial, whereby managers ensure psychiatric nurses have appropriate equipment, optimize workflow and compensation mechanisms, promote respect for nurses, and bolster various welfare benefits.
Limitation
The study has several limitations. Firstly, its cross-sectional design precludes establishing causal relationships among variables. Therefore, future research could employ longitudinal designs to explore the causality between effort-reward imbalance and well-being. Secondly, although the electronic questionnaire emphasized anonymity and voluntariness, it still cannot entirely eliminate confounding factors such as nurses’ social expectations and recall biases. Future studies could employ qualitative research methods for further exploration. Lastly, the sample primarily consisted of psychiatric nurses, predominantly female with undergraduate degrees. Future studies could further investigate variations in variables among different genders and educational backgrounds.
Conclusion
The present study elucidates the impact of effort-reward imbalance on well-being and confirms the mediating roles of burnout and decent work. These findings provide a critical foundation for enhancing the work environment and welfare of psychiatric nurses. Psychiatric hospital management should focus on providing adequate support, fair compensation, reasonable work schedules, and professional development opportunities. By improving these key factors, the negative effects of effort-reward imbalance and burnout can be mitigated, creating a more supportive and well-being-oriented work environment for psychiatric nurses.
Acknowledgements
We sincerely thank all the nurses who participated. Additionally, we extend our gratitude to Huzhou Third Municipal Hospital for their support in data collection.
Declarations
Ethics approval and consent to participate
This study strictly adhered to the principles of the Helsinki Declaration. Ethical approval for the research was obtained from the Ethics Review Committee of the Affiliated Mental Health Center & Hangzhou Seventh People’s Hospital, Zhejiang University School of Medicine (Approval No. 2024-009). Informed consent was obtained from all participants in this study.
Consent for publication
No applicable.
Competing interests
The authors declare no competing interests.
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