Frontiers in Psychiatry 元分析：心理韧性与护士职业倦怠呈中等负相关

摘要

背景：

职业倦怠是护理领域中常见且严重的职业心理健康问题，而心理韧性是一种可改变的因素，可能与较低的倦怠水平相关。这种关联在从实习护士到注册护士的教育到实践过渡过程中是否同样成立尚不清楚，且最具可比性的既往荟萃分析排除了护理学生和中文文献。

目的：

我们旨在汇总护士和护理实习生中韧性与倦怠的关联。预先设定了两个共同主要结局：韧性与情绪耗竭（EE）的相关性，以及概念匹配的实习护士与注册护士在总体倦怠上的比较。次要结局为人格解体和个人成就感。

方法：

检索了九个数据库，其中五个英文数据库和四个中文数据库，检索时间从建库至2026年，各数据库内未应用语言过滤器；纳入资格限于以英文或中文发表的研究报告。符合条件的研究为横断面研究，报告了经过验证的韧性测量工具与护士或护理实习生倦怠之间的相关性。两名评价者独立筛选、提取数据并评价质量（AHRQ 11项量表）。采用随机效应模型（REML；metafor）通过Fisher's z法汇总相关系数，并进行亚组、敏感性和小样本研究分析。

结果：

共分析78项职业倦怠研究（29,292名参与者）；五项学业倦怠研究不在范围内。韧性与情绪耗竭呈负相关（r = − 0.36，95% CI = − 0.42至− 0.31；k = 49；I² = 95%），与总体倦怠（− 0.44）和人格解体（− 0.30）呈负相关，与个人成就感呈正相关（+ 0.43）。在概念匹配的比较（总体倦怠）中，注册护士的关联在数值上强于实习护士（r = − 0.46 vs. − 0.28；Q_between p = 0.025）；由于仅有五项实习护士研究且敏感性分析不稳定，这一差异是初步的。在留一法、模型选择和PET-PEESE分析中，估计值均稳定，且在九项AHRQ评分≥ 8的研究中并未减弱（r = − 0.43，− 0.59至− 0.24）；未检测到漏斗图不对称（Egger's p = 0.49）。

结论：

心理韧性是护士倦怠中等程度、一致的保护性相关因素，但反映高异质性的宽预测区间意味着其实际获益可能因环境而异。韧性建设应补充而非替代组织措施。该相关因素在注册护士中是否强于实习护士仍属初步结论。

系统综述注册：

https://www.crd.york.ac.uk/PROSPERO/view/CRD420261427008，标识符CRD420261427008。

1 引言

职业倦怠是一种与工作相关的心理综合征，源于长期职业压力。其经典定义包含三个维度：情绪耗竭（情感和身体资源的枯竭）、去人格化或愤世嫉俗（对受护者采取疏离、冷漠的回应），以及个人成就感降低（在工作中感到无效能）（）。护士工作在情感要求高、病情危重程度高的照护一线，职业倦怠在这一群体中很常见。它不仅损害护士自身的身心健康，也损害其所提供照护的安全性和质量。

护士职业倦怠是一个全球性问题。一项涵盖30多个国家94项研究的荟萃分析估计，过去十年中合并职业倦怠患病率约为30%，且这一患病率在2019冠状病毒病（COVID-19）大流行期间有所上升（）。其后果也有充分记录。最近一项综合85项研究、涵盖超过288,000名护士的分析将护士职业倦怠与患者安全较差、患者满意度较低和照护质量下降联系起来（）。因此，识别能够保护护士免于职业倦怠的可改变因素已成为研究和劳动力政策的优先事项。

心理韧性是在逆境、压力或创伤面前积极适应的能力。它已成为这样一种保护因素，并且由于可以通过培训加以培养，它是贯穿护理职业生涯的一个合理干预靶点。然而，护理职业生涯并非千篇一律。护理实习生（处于临床实习或实践阶段的学生）面临首次临床接触以及已有充分描述的过渡期或现实冲击（–），而注册护士则面临已确立执业中慢性、累积性的压力源。韧性在这两个阶段、在从教育到实践的过渡中是否具有同等保护作用，直接关系到何时以及针对谁应优先开展韧性培养教育。

既往综述已开始量化韧性与职业倦怠之间的联系，但仍存在一个关键空白。最直接可比的荟萃分析（）汇总了29项研究中护士的相关性（总体r ≈ − 0.41）。然而，该综述仅检索了四个英文数据库，截止到2022年初，仅限于英语，而且最重要的是，排除了护理学生和实习生。因此，它无法检验这种保护性关联在从教育到实践的过渡中是否存在差异。此前尚无任何综合研究将临床暴露的护理实习生与注册护士一并纳入，或正式检验韧性—职业倦怠关联的组间差异。大量中文证据也基本缺席于国际综合研究，这引发了关于完整性和语言偏倚的担忧。

为弥补这些空白，我们开展了一项系统综述与meta分析，目标有三。第一，我们在护理实习生与注册护士中合并了心理韧性与职业倦怠之间的相关性，以情绪耗竭作为职业倦怠的主要维度。第二，我们开展了据我们所知首个概念匹配的组间比较（亚组差异检验），以考察这一关联在从教育到实践的过渡期中的差异。第三，我们通过检索截至2026年的九个中英文数据库来拓宽证据基础，在检索阶段不设语言限制，但将纳入资格限定为以英文或中文发表的报告。我们基于资源保存理论和过渡冲击文献提出的方向性假设是：韧性在两组中均与职业倦怠呈负相关，但该关联在注册护士中强于护理实习生：注册护士已巩固了职业认同、应对技能库以及资源“车队”，特质韧性被认为正是通过这些发挥其保护作用，而仍在经历过渡冲击并获取职业资源的实习生，可能尚未将韧性充分转化为保护。

2 方法

2.1 注册与报告

本系统综述与meta分析已在国际系统综述前瞻性注册库（PROSPERO；注册号CRD420261427008，于2026年6月17日注册）中前瞻性注册，并按照系统综述与meta分析首选报告条目（PRISMA 2020）声明进行报告（）。文献检索在方案正式注册前已开始，注册在任何数据分析开展之前完成；最终检索更新日期为2026年6月19日，稿件于2026年6月26日提交。方案得到遵循，仅有一项有记录的修订并已透明报告：由于职业倦怠的实习生研究几乎从不报告情绪耗竭，预先设定的组间检验（最初指定基于情绪耗竭）改为在总倦怠上进行，该构念在两组中均有充足数据（第3.4节）；所有其他分析均遵循注册方案。由于本研究综合的是先前已发表、去标识化的汇总数据，故无需伦理批准。

2.2 纳入标准（PECOS）

纳入标准采用PECOS原则构建。

参与者（P）包括两个临床暴露组：（A）护理实习生（处于临床实习/实践阶段的学生）和（B）临床实践中的注册护士；尚未进入实习阶段的临床前期学生被排除，因为工作相关倦怠不适用，其他卫生专业人员（如医生、护理助理、助产士）的混合样本若无法分解至护士也被排除。暴露（E）为心理韧性，采用任何经过验证的韧性测量工具进行测量（如Connor–Davidson韧性量表[CD-RISC 25/10/2]（）、Brief Resilience Scale、Wagnild和Young韧性量表[RS-14/RS-25]、成人韧性量表，以及经过验证的中文改编版）；韧性测量工具作为预先指定的调节因素和敏感性因素进行检验。比较（C）为护理实习生（A组）与注册护士（B组）；对于效应量合并，不需要比较组，组别作为主要调节因素。结局（O）为职业（工作相关）倦怠，测量学业或学习相关倦怠的研究（如非临床学生中的Maslach倦怠量表（MBI）–学生调查）不在本综述范围内，被排除于主要分析之外（另行报告）。在职业倦怠内部，预先指定的结局层级避免了歧义：主要结局为韧性与情绪耗竭（EE）的相关性，EE是核心的、报告最一致的倦怠维度，也是在各种测量工具和两个组之间最具可比性的构念，并且是整体综合的锚点。次要结局为韧性与以下各项的相关性：（i）总体或全局倦怠（各研究测量工具所操作的总体倦怠得分，如MBI总分、中文Maslach倦怠量表（CMBI）总分、哥本哈根倦怠量表[CBI]总分、职业生活质量量表（ProQOL）倦怠分量表倦怠分量表、Oldenburg[OLBI]总分），（ii）去人格化/愤世嫉俗（DP），以及（iii）个人成就感（PA）。每个结局在单独的荟萃分析中合并，负向计分的维度（EE、DP、总分）与正向计分的PA从不合并为一个估计值。由于各测量工具（MBI–人类服务调查（MBI-HSS）/MBI–通用调查（MBI-GS）/MBI–学生调查（MBI-SS）、CMBI、CBI、ProQOL、OLBI）对倦怠的操作化方式不同（最突出的是“总体倦怠”，各测量工具之间并不相同），因此对每项研究记录倦怠测量工具，并将其作为预先指定的调节因素和敏感性限制（仅MBI）进行检验。符合条件的研究设计（S）为横断面或观察性相关性研究，报告韧性与倦怠之间的零阶Pearson（或Spearman）相关系数（r），或提供足以推导该系数的统计量。为明确起见，护理实习生被定义为正在接受监督下临床实习的注册前护理学生；未进入实习阶段的临床前期学生和已毕业、在独立实践中执业的持证护士不被归类为实习生（后者作为注册护士纳入，B组）。每个实习生和学生样本的职业与学业分类见补充表S4。

排除标准：（1）综述、质性研究、干预/实验性研究（RCT/类实验）、病例报告、会议摘要、社论和通讯；（2）测量概念上不同的构念（仅心理韧性）而非一般心理韧性（单独分析，不合并）或共情疲劳（ProQOL倦怠分量表在报告时按倦怠测量处理）的研究；（3）未报告可提取的相关系数和样本量的研究（回归/SEM/ORs无法推导出零阶r）；（4）重复队列，包括同一队列以不同语言发表：疑似重复者通过比对作者重叠、样本量、城市/医院、数据收集期、工具以及报告系数的模式与全文进行裁定，仅保留最完整的报告；（5）未以英文或中文发表的报告，这两种语言是综述团队能够在不翻译的情况下评估全文并提取数据的语言；（6）掠夺性或非同行评审来源，按来源类型而非声望操作性定义为（a）科普或消费者健康期刊，（b）文摘或摘要汇编，（c）符合掠夺性实践客观指标的开源渠道，以及（d）明显偏离领域的（如中等教育）期刊——所有合法的同行评审期刊，包括较低层次的期刊，均被保留，仅通过质量亚组和敏感性分析加以处理；（7）尽管尝试了馆际互借和联系作者仍无法获取全文的报告。

2.3 信息来源与检索策略

从建库至2026年6月19日检索了九个数据库：PubMed（n = 1,236）、Embase（n = 1,039）、Web of Science（n = 2,087）、Cumulative Index to Nursing and Allied Health Literature（CINAHL）（n = 1,428）和Cochrane Library（n = 147）（英文）；以及中国知网（CNKI，n = 127）、万方（n = 364）、维普（n = 130）和SinoMed/CBM（n = 328）（中文），去重前共获得6,886条记录。检索结合了三个概念模块（心理韧性 × 护士 × 倦怠），使用数据库特定的受控词表（MeSH、Emtree、CINAHL主题词）和自由文本词（所有九个数据库的完整检索策略见补充附录A）。检索未限制研究设计，并在全文筛选阶段应用以最大化敏感性。对纳入研究和相关综述的参考文献列表进行了手工检索（后向滚雪球），并进行了前向引文追踪。九个数据库中均未应用语言过滤器，其中四个数据库收录中文文献，中文报告与英文报告以相同检索词查找和获取。语言仅作为纳入标准进入综述，因为团队只能可靠地以英文和中文评估全文并提取数据。在全文阶段没有报告因语言原因被排除（图1）。

图1

2.4 研究选择与数据提取

将记录导入文献管理软件，去重后由两名评价者独立依据纳入标准进行筛选，先按标题/摘要筛选，再按全文筛选；分歧通过讨论或第三名评价者解决。筛选流程总结于PRISMA 2020流程图（图1）。作为去重的一部分，我们使用上述匹配程序专门筛查了跨语言孪生文献（同一队列以中文和英文分别发表）；若同一队列被多次报告，则保留更完整的报告，而实际上为不同样本的同作者聚类（例如Guo 2018/2019与Ríos-Risquez/García-Izquierdo研究，其在样本量、系数和DOI上均不同）则分别保留。

两名评价者独立将以下信息提取至预先试用的电子表格中：第一作者、发表年份、国家/地区、机构/专业、人群（护士 vs. 护理学生）、抽样方法、样本量、心理韧性测量工具、职业倦怠测量工具，以及心理韧性与职业倦怠之间的相关系数（总分及各分量表）。若研究仅报告回归系数、中介/SEM路径系数或比值比而未报告零阶相关系数，则从相关表中查找双变量r；既未报告r也无法转换为可转换统计量的研究被排除。差异均对照原文进行核对。少数研究报告的是Spearman系数而非Pearson系数；这些研究被与Pearson系数合并，并在预先设定的敏感性分析中排除，结果未对合并估计产生实质性改变。若未直接报告零阶Pearson r，则使用标准转换方法推导（例如从标准化回归系数推导），并将需要此类推导的研究数量记录在提取表中。

2.5 偏倚风险（质量）评估

纳入的横断面研究的方法学质量由两名评价者独立使用美国医疗保健研究与质量局（AHRQ）11项横断面检查表进行评估；根据注册方案，总分将研究分为高质量（–）、中等质量（, ）或低质量（≤ 5）。同时使用JBI分析性横断面研究关键评估检查表作为二次评估。分歧通过共识解决。每个结局的合并证据的总体确定性采用GRADE方法进行评级（）。在全文手稿中，“高质量”指此AHRQ阈值（总分≥ 8）；若研究按来源类型（索引期刊、核心期刊或学位论文）描述，则使用“核心来源”一词以区分这两种含义。质量以两种方式进入分析：在亚组差异检验中比较三个AHRQ等级，并将主要结局重新合并，分析分别限制于得分≥ 8的研究和得分≥ 6的研究。按来源类型的限制与上述结果一并报告，且不属于质量限制。

2.6 统计分析

分析在 R（版本 ≥ 4.3）中使用 metafor 包进行（）。效应量指标为心理韧性与职业倦怠之间的 Pearson 相关系数（r）。由于 r 有界且其方差取决于其大小，每个 r 均被转换为 Fisher's z（相关性 meta 分析的标准方法）（），在 z 尺度上合并，再转换回 r 以便解释。鉴于预期的临床和方法学异质性，a priori 采用随机效应模型（限制性最大似然法 [REML]）。分别计算了韧性与以下各项的合并估计值：(i) 总体职业倦怠，(ii) 情绪耗竭，(iii) 去人格化/玩世不恭，以及 (iv) 个人成就感；个人成就感维度（一个正向计分的构念）单独分析，未与情绪耗竭/去人格化维度合并。

异质性通过 Q 检验和 I² 统计量进行量化（按注册的分级标准解释：0%–25% 为低，26%–50% 为中等，51%–100% 为高）（13），并报告了 95% 预测区间。本综述的核心推断步骤是进行正式的亚组差异检验（Q_between），比较护理实习生（A 组）与注册护士（B 组）之间的韧性与职业倦怠关联。由于职业倦怠实习生研究很少报告情绪耗竭维度（k = 1），组间检验在总体职业倦怠上进行（这是对注册方案的一项有记录的修订，原方案指定的是情绪耗竭）。由于主要分析仅限于职业倦怠，此比较在设计上构念匹配（两组均测量工作相关职业倦怠）。其他预设亚组分析考察了：地区（中国 vs. 其他）、韧性测量工具、职业倦怠测量工具以及调查时期（COVID-19 前 vs. 后）。在可用研究 ≥10 项时，采用 meta 回归探索连续调节变量（发表年份、样本量；平均年龄和女性百分比报告过于不一致，无法建模）。敏感性分析包括留一法分析和固定效应与随机效应估计值的比较。发表偏倚（当研究 ≥ 10 项时）通过漏斗图检查和 Egger 回归检验进行评估，若检测到不对称则应用剪补法。森林图、留一法图和漏斗图均在 metafor 中生成。统计显著性设定为 p < 0.05（异质性和偏倚检验为 p < 0.10）。这些注册的 I² 分级标准不同于传统的 Cochrane 阈值；我们将其保留为预注册标准，并且为避免过度依赖 I²，对每个合并估计值均突出报告 τ² 和 95% 预测区间。小样本研究效应还通过 PET-PEESE 进行了额外检验。

3 结果

3.1 研究筛选与特征

在筛选出的记录中，有84篇横断面报告符合系统综述的纳入标准。其中83篇报告了心理韧性与职业倦怠之间可提取的零阶相关，其特征见表1（14–96）；剩余1项研究因报告了内部不一致、无法核实的总体倦怠系数而被排除在定量合成之外。由于本综述关注职业（工作相关）倦怠，这83项研究中有5项在护生中开展并测量了学业（学习相关）倦怠；因其超出范围，被排除在主要分析之外，并在第3.6节中单独报告。因此，主要分析纳入了78项职业倦怠研究，共29,292名参与者（样本量：25–1,627），其特征总结于表1。研究发表于2009年至2026年间，在中国（n = 26）和其他国家或地区（n = 52）开展。大多数样本为注册护士（B组，k = 72）；临床暴露的护理实习生（A组）贡献了6项职业倦怠研究。一个单独的道德韧性亚组（k = 2）与主要心理韧性合并分析分开进行。韧性最常采用CD-RISC系列测量（k = 51；CD-RISC-25/CD-RISC-10/CD-RISC-2），其次是Brief Resilience Scale（k = 9）、Wagnild and Young Resilience Scale（k = 5）和其他经过验证的工具（k = 13，包括两个坚韧性量表和两个工作韧性量表）。倦怠主要采用Maslach Burnout Inventory系列评估（MBI-GS、MBI-HSS、MBI-other、MBI-SS；k ≈ 49）；其余研究使用CBI、ProQOL、OLBI/OBI或单维耗竭测量。在可分析的研究中，60篇发表于2020年或之后（COVID-19大流行期间或之后），18篇发表于此前。在78项研究中，方法学质量（AHRQ 11项）高者13项，中等38项，低27项（平均≈6.2/11）；完整的条目级评价见补充表S1。低评级比例较高反映了该清单对横断面自我报告设计的结构性局限，其中关于评估者盲法、随访和随机抽样的条目很少能满足。78项研究中有13项得分≥8分，其中9项报告了情绪耗竭系数。因此，我们在主要分析（见下文）以及敏感性分析（第3.6节）中按研究质量分层报告合并估计值。所有结局的GRADE证据确定性为低至极低，因严重不一致性和偏倚风险而降级（结果总结；表2）。

表 1

纳入研究的特征及 AHRQ 方法学质量（k = 83；主要职业倦怠分析，k = 78）。

N，样本量；r_total，心理韧性与总体倦怠的相关性；r_EE，心理韧性与情绪耗竭的相关性；r_DP，心理韧性与去人格化的相关性；r_PA，心理韧性与个人成就感的相关性；空白单元格 = 未报告；AHRQ，医疗保健研究与质量局 11 项评分（质量评级为高 [≥ 8]、中等 [6–7] 或低 [≤ 5]）；CD-RISC，Connor–Davidson 心理韧性量表；MBI，Maslach 倦怠量表；CBI，哥本哈根倦怠量表。

^a

A 组 = 实习护士；B 组 = 注册护士。

^b

学业倦怠研究（护理学生，归入 A 组），在第 3.6 节单独报告，未纳入 78 项研究的职业倦怠分析。包含期刊和地区的完整版本见补充表 S3。

表 2

GRADE 证据概要。

GRADE，即推荐分级的评估、制定与评价；CI，置信区间；PI，预测区间；EE，情绪耗竭；DP，去人格化；PA，个人成就感。因偏倚风险、不一致性（高 I²）而降低证据确定性。

3.2 主要结局：心理韧性与情绪耗竭

在49项职业倦怠研究中，心理韧性与情绪耗竭呈负相关：合并 r = − 0.36（95%置信区间[CI] = − 0.42至− 0.31；更精确值 = − 0.364，− 0.418至− 0.306；p < 0.001；图 2）。异质性较高（I² = 95%），95%预测区间（− 0.67至+ 0.05）表明，尽管平均关联为中等程度，但单个环境中的真实关联可能从强到接近无关联不等。仅限注册护士（B组，k = 48）时，估计值基本不变（r = − 0.37，95% CI = − 0.42至− 0.31；I² = 94%）。仅限AHRQ清单评为高质量（即总分8分或以上）的研究时，剩余九项情绪耗竭研究，其关联即便有差异也更强：r = − 0.43，95% CI = − 0.59至− 0.24，I² = 97%。仅剔除低分研究（AHRQ ≥ 6）后得 r = − 0.37，95% CI = − 0.45至− 0.29，k = 30。AHRQ等级并非显著调节因素，Q = 1.37，df = 2，p = 0.51，因此合并结果不依赖于较低质量的研究。

图 2

3.3 次要倦怠结局

心理韧性与总体倦怠呈负相关（k = 44；r = − 0.44，95% CI = − 0.48至− 0.39；I² = 92%；PI = − 0.69至− 0.10；补充图 S1），与去人格化/愤世嫉俗（DP；k = 41；r = − 0.30，95% CI = − 0.35至− 0.24；I² = 91%）呈负相关，与个人成就感（PA；k = 41；r = + 0.43，95% CI = + 0.38至+ 0.48；I² = 91%；符号已统一，使PA越高=成就感越大）呈正相关。此处，N 为所有纳入研究中唯一参与者的总数，每项研究仅计一次；各结局所基于的参与者人数（EE = 18,473；总体倦怠 = 15,163；DP = 14,792；PA = 14,795）是该总数的子集，因为大多数研究报告了部分而非全部维度，且不打算合计为 N（表 2）。

因此，心理韧性与两个“负性”倦怠维度（EE、DP）呈负相关，与个人成就感呈正相关，与所有组成部分均呈现保护性模式一致。

3.4 关键比较：护理实习生与注册护士（组别调节因素）

由于主分析仅限于职业倦怠，实习护士与注册护士的比较在设计上概念匹配：两组均测量工作相关倦怠（补充表S2）。对于总倦怠这一在两组中均有充足数据的结局，注册护士显示出数值上更强的关联（r = − 0.46，k = 39，95% CI = − 0.50 至 − 0.41），而实习护士为（r = − 0.28，k = 5，95% CI = − 0.42 至 − 0.13）；Q_between = 5.04，df = 1，p = 0.025。这一差异应被解读为初步性和假设生成性的，原因有三。第一，实习护士组仅基于五项研究，且实习护士组的留一法分析显示，合并的实习护士估计值在r = − 0.21 至r = − 0.33 之间变动，取决于剔除哪一项单一研究。第二，倦怠测量工具本身是一个显著的调节变量（见第3.5节），因此职业阶段对比部分与工具组合相混杂；在组别加工具的元回归中，组间差异持续存在但被减弱（β = − 0.19，p = 0.040）。第三，唯一一项使用单维度仅情感耗竭量表的实习护士研究，按照预先设定的规则，被视为在本分析中贡献了一个总体倦怠指标；若将其重新归入情感耗竭维度，则实习护士组减少至四项研究，差异变为不显著（p = 0.083）。基于情感耗竭的比较无法直接进行，因为只有一项职业倦怠实习护士研究将情感耗竭作为多维工具的子量表报告；因此组间检验被预先修改为总倦怠（第2.6节）。该模式在方向上与从教育到实践过渡过程中保护性关联增强相一致，但在统计上较为脆弱，需要在更大的实习护士样本中加以确认。

3.5 调节变量与亚组分析（情感耗竭）

所有亚组和调节变量结果总结于表 3。

表 3

亚组和调节变量分析（心理韧性与情感耗竭）。

在EE上，实习护士与注册护士的比较无法估计，因为只有一项职业倦怠的实习护士研究报告了EE。所有估计值均为韧性—情绪耗竭关联的估计值，但组间比较除外，该比较针对的是总体倦怠（在两组中均有足够数据的构念匹配结局）。在韧性工具亚组中，两项使用构念分歧量表（坚韧性和工作特定韧性）的研究未显示，并在构念纯化敏感性分析（第3.6节）中加以考察；其余亚组计数之和等于49项研究的分析总数。

k，研究数量；r，合并Pearson相关系数（随机效应，REML）；95% CI，95%置信区间；I²，异质性统计量；Q_between，亚组间异质性检验；R²，研究间方差被解释的比例。

韧性工具未显著调节EE关联（Q_mod，p = 0.31；CD-RISC r = − 0.34，k = 34；Brief Resilience Scale (BRS) r = − 0.45，k = 5；Wagnild and Young RS r = − 0.25，k = 3；其他 r = − 0.48，k = 5），地区也未显著调节（中国与其他：p = 0.74；中国 − 0.35，k = 22；其他 − 0.37，k = 27）。倦怠工具是显著的调节变量（Q_mod，p = 0.003，R² ≈ 21%）：单维度EE测量显示出最强的关联（r = − 0.55，k = 4），而MBI-GS（r = − 0.25，k = 12）和MBI-HSS（r = − 0.28，k = 12）较弱，使该工具成为异质性的一个显著来源。在移除重复队列后，COVID-19时期不再是显著的调节变量（p = 0.056），大流行后研究倾向于显示出比大流行前研究（r = − 0.28，k = 15）更强的关联（r = − 0.40，k = 34）；由于缺乏统计学显著性并非等效性的证据，这应被解读为不确定，而非表明不存在时期效应。在预先设定的连续型元回归中，韧性—EE关联与发表年份（p = 0.07）或样本量（p = 0.80）无显著相关，未提供连续尺度上小研究效应的证据。仅包含三项或四项研究的亚组（例如Wagnild and Young和单维度EE分层）置信区间较宽，应相应谨慎解读。

3.6 敏感性分析与稳健性

主要EE估计值在所有敏感性分析中均保持稳定（表 4）。

表 4

敏感性分析（韧性与情绪耗竭）。

所有估计均为随机效应（REML）模型；每行均展示主要EE估计以供比较。报告了两种不同的限制条件，二者不可互换。AHRQ各行基于11项清单评分的方法学质量限制分析，而核心来源行基于发表来源类型限制分析，即被索引期刊、核心期刊及学位论文，不涉及质量评分。在78项职业倦怠研究中，13项AHRQ评分≥8，其中9项报告了情绪耗竭系数，因此该行是表中精度最低的。

EE，情绪耗竭；CD-RISC，Connor–Davidson韧性量表；r，合并相关系数；95% CI，95%置信区间；k，研究数量。

留一法分析使合并r保持在较窄范围内（− 0.352至− 0.369；图 3）。固定效应与随机效应估计几乎相同（r = − 0.358 vs. − 0.364）。小样本校正估计与主要结果一致：PET给出的校正r = − 0.32（95% CI = − 0.45至− 0.18），PEESE给出r = − 0.35（− 0.42至− 0.27），均为明显负值。当合并范围限制为CD-RISC工具（r = − 0.34，k = 34）、AHRQ评分≥8的研究（r = − 0.43，k = 9）、AHRQ评分≥6的研究（r = − 0.37，k = 30）以及核心来源报告，即被索引或核心期刊及学位论文（r = − 0.34，k = 45）时，所有结论均成立。最后一项基于来源类型而非方法学质量限制分析，两种标准在表 4中分别报告。构念纯化，即排除使用坚韧性或工作特异性韧性量表的研究，仅保留一般心理韧性工具，也使估计基本不变，表明合并关联并非由构念分歧量表驱动。作为对总体倦怠的预防性敏感性分析，排除一项研究（Gao 2023），其总体倦怠系数与人格解体系数相同且无法与原始来源再次核实，使合并估计基本不变（r = − 0.43，k = 43），且实习护士与注册护士之间的差异仍显著（Q_between p = 0.028）。

图 3

3.6.1 学业倦怠亚组（超出主要范围，单独报告）

五项被排除的测量学业倦怠的护生研究显示出相似幅度的关联（韧性–学业耗竭r = − 0.36，k = 3），但学业倦怠与职业倦怠是不同的构念，未进行合并。

3.7 发表偏倚

对于主要EE结局，未检测到漏斗图不对称的统计学证据（Egger回归检验z = − 0.69，p = 0.49），且剪补法未填补任何缺失研究（校正后r仍为− 0.36；图 4）。然而，这些检验在极端异质性下效能较低且有效性有限，因此未检测到不对称并不能证明不存在发表或检索偏倚；作为进一步核查，小样本校正的PET-PEESE估计（第3.6节）仍明显为负。

图 4

4 讨论

这项对78项职业倦怠横断面研究（29,292名参与者）的meta分析发现，护士和临床暴露的护理实习生的心理韧性与倦怠之间存在中等且一致的负相关。韧性与情绪耗竭（合并r = − 0.36）、总体倦怠（− 0.44）和去人格化（− 0.30）呈负相关，与个人成就感呈正相关（+ 0.43）。这些关联的方向和大小与最具可比性的既往综合研究（总体r = − 0.41；耗竭− 0.27；去人格化− 0.23）高度一致。由于我们的证据基础约大三倍、涵盖多语言且更新至2026年，这一一致性印证并更新了此前的估计。我们纳入的文献（78项研究）完全处于相关性护理综合研究的常规范围内，且范围与其他近期高影响力综述相当（97，98）。

韧性与情绪耗竭的负相关报告最为一致（r = − 0.36，95% CI = − 0.42至− 0.31；k = 49），且当仅限于注册护士时，该估计几乎相同（− 0.37）。这超过了对照meta分析中耗竭的合并相关性（− 0.27），可能是因为我们更广泛地纳入了中国队列和疫情后研究，其中该关联往往更强。若干通路与这一横断面关联相符（尽管尚未被其证实）：有韧性的人往往报告更适应的应激反应，且韧性与认知重评和主动应对相关，这可能限制情绪耗竭，也与求助行为和调动社会支持相关。由于设计为横断面，这些机制是假设而非已确立的通路。在实践中，韧性强化项目（例如正念、认知重评和同伴支持）是减少耗竭努力中一个合理的组成部分，可纳入执业前课程和继续专业发展，同时应认识到其获益可能因环境而异。

这种保护性模式在所有倦怠成分中均保持一致。韧性与两个负向维度——耗竭和去人格化——呈负相关，与个人成就感呈正相关（+ 0.43）。与去人格化的关联较弱（− 0.30），这与既往研究一致。去人格化可能更多由组织和关系因素驱动，如工作场所无礼行为和人员配置，而非个体适应能力；而成就感则与韧性所建立的自我效能感密切相关。

我们主要的预设问题是，这种关联的强度在教育到执业的过渡阶段是否存在差异。由于分析仅限于职业倦怠，比较在设计上实现了概念匹配：两组测量的都是工作相关倦怠，从而避免了学术与职业之间的混杂因素。在总体倦怠上，注册护士显示出比护理实习生数值上更强的关联（r = − 0.46 对 − 0.28；Q_between p = 0.025）。这与基于资源保存理论和过渡冲击文献的假设一致，即韧性在注册护士中运作于一个更为稳固的职业身份和资源结构之内，而对于仍在积累职业资源、并面临首次临床接触的强烈新奇感的实习生而言，它可能只是若干相互竞争的影响之一。然而，这一信号是脆弱的：它仅基于五项实习生研究，实习生估计值在留一法下不稳定，在调整倦怠测量工具后减弱，并且如果重新归类一项研究就会变得不显著（第3.4节）。因此，我们将其视为初步的、产生假设的结果，并将我们在此的贡献定位为方法学上的——据我们所知，这是首个针对该关联在职业阶段间进行概念匹配的组间比较——而非一个已确立的效应。在实际意义上，这一模式与分阶段定制的方法相容（对实习生提供过渡冲击和期望管理支持，对执业护士提供持续强化），但确认这一点将需要样本量充足的实习生样本。

Heterogeneity was high (I² ≈ 95%), as is typical for correlational meta-analyses, and we examined several moderators of the exhaustion association. The burnout instrument was a significant source of heterogeneity (Q_mod p = 0.003, R² ≈ 21%): single-dimension exhaustion scales gave the strongest associations (− 0.55), whereas MBI-GS (− 0.25) and MBI-HSS (− 0.28) gave weaker ones. This points to the need for measurement harmonization. By contrast, the resilience instrument and region were not significant moderators, and the COVID-19 period was no longer significant after removal of the duplicate cohort (p = 0.056); because absence of evidence is not evidence of absence, these null moderator results (which may reflect limited power) should not be read as demonstrating equivalence. More importantly, the wide prediction interval for emotional exhaustion (− 0.67 to + 0.05) means that in some settings the true association could be close to zero: the pooled value is a benchmark, not a parameter that applies uniformly, and resilience interventions cannot be assumed to be equally effective across all contexts and populations. Policymakers, managers, and clinicians should therefore treat resilience-building as one locally evaluated element of a broader strategy rather than as a guaranteed lever.

The review has several strengths. It was prospectively registered with PROSPERO. The nine-database bilingual search, run without a language filter and covering the Chinese as well as the English literature, assembled one of the largest and most current evidence bases for this association to date, recovering a substantial Chinese literature absent from earlier syntheses. Emotional exhaustion was treated, a priori, as the primary and most comparable outcome. The synthesis provides what is, to our knowledge, the first formal between-group comparison across the education-to-practice transition, supported by a broad set of robustness checks. The primary estimate was stable under leave-one-out and under fixed- versus random-effects models, and it held in the analyses that address quality directly. Restricting to CD-RISC-only studies gave − 0.34, restricting to the nine studies scoring AHRQ ≥ 8 gave − 0.43, and dropping the low-scoring studies, AHRQ ≥ 6, gave − 0.37; a further restriction to core-source reports, a criterion of source type rather than of quality, gave − 0.34. The high-quality subset is small, and its confidence interval correspondingly wide, but the association in it is no weaker than in the full pool. Egger’s test (p = 0.49) and trim-and-fill (no studies imputed) showed no evidence of publication or small-study bias.

Several limitations qualify these findings. First, all included studies were cross-sectional, which precludes causal inference; reverse causation (lower burnout permitting higher self-rated resilience) and common-method variance (both constructs self-reported) cannot be excluded. Second, heterogeneity was very high (I² ≈ 91%–95%) and only partly explained (burnout instrument R² ≈ 21%). The pooled point estimate should therefore be read as a benchmark rather than a population parameter, alongside the prediction interval, which for emotional exhaustion (− 0.67 to + 0.05) indicates that the true association could be near-null in some settings. Accordingly, GRADE certainty is low to very low: observational designs, downgraded for serious inconsistency and risk of bias (Table 2). Third, the intern arm was small (k = 5 for total burnout) and unstable, so the between-group difference is preliminary and is not robust to reasonable reclassification of a single study; occupational-burnout intern studies also rarely reported emotional exhaustion, so the EE-based comparison could not be performed. Fourth, eligibility was limited to reports published in English or Chinese, so evidence published in other languages could not be appraised, and some Chinese non-core-source studies could not be retrieved in full text and were excluded; Egger’s test detects only within-pool small-study asymmetry and is blind to systematically unretrieved literature, so residual retrieval and language bias cannot be excluded, although the main analysis already incorporates substantial Chinese full-text evidence, and small-study-adjusted PET-PEESE estimates remained clearly negative. Fifth, the personal-accomplishment dimension required transparent sign harmonization across studies that reported reduced accomplishment.

As resilience is modifiable through training (workplace resilience-training trials and meta-analyses report small-to-moderate reductions in distress) (99, 100), these findings translate into concrete, stage-specific recommendations.

In the prelicensure curriculum, rather than a stand-alone lecture, resilience competencies (cognitive reappraisal, help-seeking, realistic expectation-setting) should be embedded in clinical-placement preparation and in structured postplacement debriefs and reflective practice, where they match the demands interns actually face. Across the education-to-practice transition, resilience and reality-shock inoculation should be integrated into transition-to-practice or nurse-residency and preceptorship programs for newly graduated nurses, grounded in transition-shock theory (, ) and the novice-to-expert trajectory (). For management and retention, because depersonalization is driven more by organizational than individual factors, individual resilience-building must be paired with system-level action on workload, staffing, civility, and psychological safety; under Conservation of Resources and Job Demands–Resources theory (101, 102), resilience is a personal resource that may complement, but cannot substitute for, reductions in job demands.

Ethical caveat. Framing burnout prevention mainly as individual resilience risks placing responsibility for a structural problem on practitioners. Our recommendations therefore treat resilience interventions as a complement to, not a substitute for, organizational reform. Future research should prioritize longitudinal and intervention designs that can establish temporal precedence, report emotional-exhaustion effect sizes for nursing interns specifically, use concept-matched (occupational) burnout measures across career stages, and adopt standardized instruments to reduce measurement-driven heterogeneity.

5 Conclusion

In this meta-analysis of 78 studies of occupational burnout (29,292 nurses and nursing interns), psychological resilience was a moderate and consistent protective correlate of burnout (emotional exhaustion r = − 0.36; total burnout r = − 0.44). The estimates were stable across extensive sensitivity, small-study-adjusted, and subgroup analyses, but they carry low-to-very-low GRADE certainty and a wide prediction interval owing to high heterogeneity, so the practical benefit of resilience is likely to vary across settings. On the concept-matched between-group comparison (total burnout), registered nurses showed a numerically stronger association than nursing interns (Q_between p = 0.025); this is a preliminary, hypothesis-generating signal, based on only five intern studies and not robust to sensitivity analyses, that the value of resilience may strengthen across the education-to-practice transition, and it needs confirmation in adequately powered intern samples. Resilience-building may be a reasonable but not universally sufficient component of a broader strategy—tentatively transition support for interns and sustained reinforcement for practicing nurses—and should complement, not replace, organizational measures to reduce burnout.

Statements

Data availability statement

The original contributions presented in the study are included in the article/Supplementary Material. Further inquiries can be directed to the corresponding author.

Author contributions

XC: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. YZ: Data curation, Investigation, Project administration, Writing – review & editing. FZ: Conceptualization, Data curation, Writing – review & editing. XZ: Conceptualization, Data curation, Supervision, Writing – review & editing.

Funding

The author(s) declared that financial support was not received for this work and/or its publication.

Conflict of interest

The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Generative AI statement

The author(s) declared that generative AI was not used in the creation of this manuscript.

Any alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyt.2026.1920134/full#supplementary-material

SUPPLEMENTARY APPENDIX A

Search strategies and results across the nine databases.

SUPPLEMENTARY TABLE S1

AHRQ item-level quality appraisal of included studies.

SUPPLEMENTARY TABLE S2

Group × burnout-construct cross-tabulation.

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Keywords

burnout, education-to-practice transition, emotional exhaustion, meta-analysis, nurses, nursing interns, nursing students, psychological resilience

Citation

Chen X, Zhang Y, Zhang F and Zhu X (2026) Psychological resilience and burnout in nursing interns versus registered nurses: a systematic review and meta-analysis. Front. Psychiatry 17:1920134. doi: 10.3389/fpsyt.2026.1920134

Received

26 June 2026

Revised

08 September 2026

Accepted

10 September 2026

Published

14 October 2026

Volume

17 - 2026

Updates

Copyright

© 2026 Chen, Zhang, Zhang and Zhu.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Xiaomei Chen, yfy6641279@fy.ahmu.edu.cn

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