Burnout is a reaction to the imbalance between work-related demands and personal resources, and it is manifested through the three dimensions: emotional exhaustion (EE), depersonalization (DP), and reduced personal accomplishment (PA) [1, 2], which represent basic personal stress, interpersonal environment, and the self-evaluation dimensions of burnout, respectively [3]. Healthcare professionals often suffer from burnout [4, 5]. According to a systematic review published in 2018, the prevalence rates of EE, DP, and reduced PA were 27.4%–99.6%, 13.3%–98.0%, and 25.1%–99.3%, respectively, in primary care (PC) providers in low- and middle-income countries [6]. High job burnout is frequent among PC providers in China [4]. A national survey conducted for 10,626 primary healthcare doctors revealed that 41% of the respondents felt highly exhausted; 37%, highly depersonalized; and 34%, a low sense of PA.

Burnout can have many negative effects on an individual and organization. Long-term burnout can damage an individual’s physical and mental health [7], and burnout in health professionals is related to low job commitment [8], high turnover intention [9–11], and poor work performance [12–15]. Provider job burnout is associated with adverse events, including medical errors, reduction in quality of care [16, 17], and poor patient satisfaction [18, 19], and job burnout is affected by many factors.

In general, job burnout is associated with socioeconomic status. Men are more likely to suffer from job burnout than women [5, 20], and age is associated with job burnout symptoms [21]. Compared with married people, unmarried people have higher levels of job burnout. Moreover, high levels of education are risk factors for job burnout [22], and job burnout rate in medical staff in the eastern region is higher than the job burnout rates in the central and western regions.

Job characteristics, including professional title, professional status, and working hours per week, can be tightly related to job burnout. These job characteristics can help us understand the relationship between specialization levels, responsibilities, role positioning, workload, and burnout across different practice types. A survey in Turkey published in 2021 found that burnout level decreased with increasing academic title, and attending physicians were the most exhausted [23]. Working over 40 h per week was the most important risk factor for burnout in PC physicians in Oman [24]. In rural China, primary healthcare workers with middle- or high-ranking professional titles had high degrees of job burnout [25]. Compared with doctors and nurses, pharmacists suffer a higher degree of job burnout. Working for over 40 h per week is related to high levels of burnout.

However, previous studies on the job burnout in medical staff in primary health facilities focused on burnout in different types of health technicians (physicians, nurses, community health workers, midwives, and pharmacists) and its influencing factors. However, this study places greater emphasis on exploring the differences in job burnout among individuals in different positions within the same institution. On the one hand, as a populous country, China faces challenges of uneven distribution of primary healthcare human resources, with rural areas experiencing shortages in meeting primary healthcare service demands. The supply-demand imbalance of primary healthcare services is a common issue in other developing countries around the world. On the other hand, China has a large population, and there is a significant disparity in medical resources between urban and rural areas, with generally low capacity for primary medical services. In addition to the need for rational allocation of medical resources, improving management efficiency is also crucial. Therefore, unlike developed countries with relatively abundant medical resources or other developing countries with less pressure on primary healthcare issues, conducting this study within the context of China has unique value.

The present study focused on job burnout in primary health facilities in China, determined the deep possible reasons of different positions, especially administrative positions. The main objective is to identify the underlying causes, particularly in administrative roles, and explore targeted intervention measures. Hence, the aims of this study were 1) to measure the prevalence of job burnout in different managers in China and 2) to identify the associated factors of job burnout for different positions.

Table 1 shows the characteristics of the participants. The majority of the participants were females (65.49%), and participants aged 50 (7.51%) had the least number. Most of the participants were living with a partner (78.88%). Approximately 69.83% of the participants received low levels of education, and only 3.55% of the participants had high-ranking professional titles. Physicians accounted for 46.98% of the participants surveyed; nurses, 28.20%; others, 17.07%; and pharmacists, 7.76%. Most of the participants were practicing more than 40 h per week (93.16%), and 37.00%, 24.24%, and 38.75% were from eastern, central, and western China, respectively. General staff accounted for 79.83% of the participants surveyed; middle managers, 13.53%; and senior managers, 6.64%. Significant differences in the majority of these characteristics were found among the three types of participants (p < 0.05). Overall, the proportion of the burnout cases was 52.01% (48.61% experienced moderate burnout and 3.40% suffered from severe burnout). The proportions of burnout cases in the three groups were 54.69%, 50.81%, and 51.98%. The proportion of serious burnout cases in the three groups were 3.03%, 3.71%, and 3.37%.

Table 2 shows the scores in each dimension and the weighted sum score of job burnout. The mean score for burnout among the respondents was 1.60, and the median was 1.55, which met the criterion of moderate burnout. The comparison among the dimensions of burnout indicated that the degree of EE was relatively higher than DP and reduced PA in the current sample. The results of t-tests showed no difference in the weighted sum score of job burnout but indicated a significant differences in each dimension of job burnout among the three types of participants. Compared with senior managers and general staff, middle managers had higher levels of EE (2.13, 2.08, and 1.88) and lower levels of reduced PA (1.48, 1.73, and 1.80). Compared with senior and middle managers, the general staff had higher levels of DP (1.03, 0.91, and 1.00), higher levels of reduced PA (1.80, 1.73, and 1.48), and lower levels of EE (1.88, 2.08, and 2.13). Compared with middle managers and general staff, senior managers had lower levels of DP (0.93, 1.00, and 1.03).

Table 3 shows the results of the multilevel regression analysis of the factors associated with burnout and its three subcomponents among different positions. Health workers with medium-ranking professional titles had higher levels of burnout, EE, and DP in the middle managers and general (p < 0.05), whereas those from the senior managers showed no difference (p > 0.05). Senior managers had higher levels of reduced PA, whereas middle managers and the general staff showed no difference (p > 0.05). Compared with physicians, pharmacists in middle manager and general staff positions showed low degrees of burnout, EE, and DP (p < 0.05), whereas pharmacists in senior manager positions, showed no difference (p > 0.05). Other types of workers in senior manager positions showed high levels of reduced PA (p < 0.05), whereas those in middle manager and general staff positions showed low levels of reduced PA (p > 0.05). Workload of no less than 40 h per week was associated with low level of reduced PA in senior manager, middle manager, and general staff positions (p > 0.05) but high level of EE (p > 0.05).

Female providers in the middle manager and general staff positions showed low levels of burnout (p < 0.05), whereas those in senior manager positions showed no difference (p > 0.05). Senior managers in the 30–49 age group experienced high levels of reduced PA, whereas providers in general staff positions at the same age group showed lower levels of reduced PA and providers in middle manager positions showed no difference (p > 0.05). Unmarried providers in senior manager and general staff positions indicated high levels of DP (p < 0.05). High level of education was related to high levels of burnout, EE, and DP in middle managers (p < 0.05). By contrast, providers in senior manager positions and with highest level of education (undergraduates) showed no difference from providers with the lowest level of education (junior college or below). Providers in the general staff positions showed lower levels of reduced PA, whereas those in senior manager and middle manager positions showed no difference (p > 0.05). Compared with participants from eastern China, participants from central China showed lower levels of burnout, EE, and DP, particularly those in middle manager and general staff positions (p < 0.05). Senior managers from central China showed no difference (p > 0.05).

This study measured job burnout among different positions in China and identified associated factors of job burnout for different positions. More than half of providers in different positions suffered from moderate burnout. Different levels of job burnout in different positions. Middle managers showed the highest levels of personal stress, and general staff showed the lowest interpersonal and self-evaluation dimensions of burnout. Job duty, job capability, job treatment, and career advancement in different positions may be potential factors for these results.

The job duty of different positions, which can be reflected in the content of work goals and job requirements, can be the main and direct reason for job burnout in different positions. Senior managers of hospitals are concerned about the normal operations and sustainable development of their respective hospitals [34]. Middle managers of hospitals, such as directors of departments, are the implementors of hospitals’ strategic goals and policies. They focus on the realization of development goals, such as department discipline construction, talent training, and medical quality [35–38]. They need to face the dual pressure of realizing hospital strategies and their own development, and thus are more emotionally exhausted than workers in the other two positions. The general staff has more repetitive tasks but less job autonomy [39]. This situation may lead to reduced PA.

Difference in job capability may lead to differences in job burnout. First, a large portion of the time of senior managers is spent on communication. They can handle interpersonal problems well. Thus, the level of DP is lower in these workers. Most middle managers received good professional education and have good professional and communication skills. Therefore, they not only get recognition for diagnosis and treatment activities but also are recognized by senior managers and supported by general staff when conducting management activities. Hence, middle managers have a high level of PA. Finally, The general staff has the characteristics of weak professional ability, less work experience, and weak human communication ability. In addition, patients usually hold a distrustful attitude toward them [40]. Thus, compared with middle and senior managers, the general staff had higher levels of DP and reduced PA. Previous studies have shown that by strengthening the training of professional knowledge and communication skills for the general staff, their professional competence and communication skills can be enhanced [41], and thus their job burnout can be reduced [17].

The job treatment of different positions can be represented the value of an individual’s work. It may be an underlying factor for the EE of middle managers and reduced PA of general staff. The workload and level of difficulty experienced by middle managers are not lower than those of senior managers, but a clear gap between the two groups has been found. This gap leads to their low motivation to work and serious negative emotions. Thus, they have higher levels of EE. The general staff have a heavy workload, but their job treatment is generally low, and thus their sense of personal achievement is low [20]. Adjusting the job treatment of middle managers and general staff not only can increase their enthusiasm to work but also can stabilize the management team.

The career development system is unsound, and this situation may explain the high levels of EE in middle managers and reduced PA in the general staff. First, promotion is usually a step-up from a low-level position to a high-level position. Middle and senior managers constitute a small part of an organization and are thus relatively few. This condition directly limits promotion opportunities for middle managers and general staff [42]. Second, owing to the difficulty in achieving promotion and related requirements, middle managers and the general staff need to undergo strict assessments if they want to be promoted. Middle managers, as backbones of businesses, face increasing pressure for promotion. They have higher levels of EE than senior managers and general staff. Therefore, under the premise of limited opportunities for promotion, the career development system needs to be improved for the stability of management teams [43].

The study findings also indicate that certain individual and job characteristics play significant roles in the burnout experienced by rural primary healthcare doctors. Compared to females, males are more prone to experiencing burnout, possibly due to their strong motivation and sense of achievement. Healthcare professionals aged 40 and above are more susceptible to burnout compared to those below 40, which could be attributed to increased demands in balancing family and work responsibilities, as well as limited career development opportunities. Individuals with higher educational qualifications exhibit higher levels of job burnout, possibly because of their higher expectations for career advancement [44]. On the other hand, healthcare professionals with intermediate professional titles experience greater pressure for promotion compared to those with junior or senior titles; this might be attributed to their strong desire to change their status and achieve success at this career stage [45]. Primary healthcare doctors who work an average of over 50 h per week are most likely to experience job burnout, highlighting the imbalance between the number of primary healthcare workers and their workload, leading to extended working hours for primary healthcare doctors [46]. Additionally, burnout is more severe in western regions compared to eastern and central regions, which may be due to the uneven distribution of medical resources among these areas.