Nurse Burnout: A Patient Safety Crisis

By Shannon Firth

Nurse burnout was consistently tied to reduced patient safety and satisfaction, and lower quality of care, a meta-analysis involving decades of data indicated.

In the evaluation of 85 studies with 288,581 nurses from 32 countries, occupational burnout was associated with:

-Lower safety climate or culture: standardized mean difference (SMD) of -0.68 (95% CI -0.83 to -0.54)

-Lower patient satisfaction ratings: SMD -0.51 (95% CI -0.86 to -0.17)

-Lower nurse-assessed quality of care: SMD -0.44 (95% CI -0.57 to -0.30)

The findings persisted regardless of nurses' age, sex, work experience, and geography, according to Tait Shanafelt, MD, of Stanford University School of Medicine in California, and colleagues.

"The emotional exhaustion and depersonalization dimensions of burnout, more so than personal accomplishment, were observed to be the most closely associated with patient safety," the authors wrote.

Co-author Lambert Zixin Li, MPhil, a PhD candidate at the Stanford University Graduate School of Business, said by email that "despite decades of organizational and national quality improvement efforts, the association between nurse burnout and quality of care has become more negative over the years, implying the urgency of interventions."

"A small reduction in nurse burnout may have simultaneous effects on many patient outcomes," Li added.

Burnout mitigation efforts often focus on helping nurses more effectively cope with stress, Shanafelt said by email.

The current findings "should provide powerful motivation for governments and organizations that care about quality of care to act," he said. "We need to get serious about addressing the structural problems in the work environment that cause nurse distress rather than simply trying to teach nurses to better tolerate a broken system."

The meta-analysis included studies published from 1994 to 2024 with a median sample size of 458 individuals. The study population consisted of nurses from over 5,300 hospitals, with a mean age of 34 years. The majority were female (82.7%) and white (70.9%). Also, 42% had a bachelor's degree or higher, and the mean length of work experience was 10.4 years. The mean prevalence rate of burnout was 30.7% based on study-specific cutoffs, the authors said.

Nurses in any speciality were eligible for inclusion in the current analysis, such as registered nurses and nurse practitioners, but midwives, nursing assistants, nursing students, and combined samples of nurses and physicians were excluded.

Shanafelt's group also identified an association between nurse burnout and lower safety grades (SMD -0.53, 95% CI -0.72 to -0.34) as well as burnout and an increase in the frequency of:

-Nosocomial infections: SMD -0.20 (95% CI -0.36 to -0.04)

-Patient falls: SMD -0.12 (95% CI -0.22 to -0.03)

-Medication errors: SMD -0.30 (95% CI -0.48 to -0.11)

-Adverse events or patient safety incidents: SMD -0.42 (95% CI -0.76 to -0.07)

-Missed care or care left undone: SMD -0.58 (95% CI -0.91 to -0.26)

Burnout was not tied to patient mortality, frequency of patient abuse, patient complaints, or pressure ulcers. Li suggested that null results for certain measures may have been due to low statistical power.

Shanafelt suggested that higher levels of education might mitigate certain negative effects of nurse burnout.

While the link between nurse burnout and quality of care was not tempered by nurses' educational level (P=0.97), the association between nurse burnout and lower patient safety was weaker among nurses with a higher share of college degrees (meta-regression coefficient 0.52, 95% CI 0.15-0.89, P=0.006), the authors noted.

"When making clinical decisions, an individual's level of distress may influence their judgement. However, their training may help mitigate this effect and protect patients," said Shanafelt, who emphasized the need for investing in more nurse training and continued professional development.

Limitations of the meta-analysis included the heterogeneity of the analyzed studies, and the fact that most of the studies had cross-sectional designs, which prevented the researchers from determining a causal relationship between nurse burnout and outcomes.