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Still an Epidemic

The Burnout Syndrome in Hospital Registered Nurses

Bakhamis, Lama, MS; Paul, David P. III, DDS, PhD, MBA, MA; Smith, Harlan, PhD; Coustasse, Alberto, DrPH, MD, MBA, MPH

doi: 10.1097/HCM.0000000000000243

The number of registered nurses (RNs) in the United States is roughly 3 times the number of physicians and surgeons, making RNs a critically important component of the US health care system. Registered nurse burnout—the state of emotional exhaustion in which the individual feels overwhelmed by work to the point of feeling fatigued, unable to face the demands of the job, and unable to engage with others—is a real concern, having been reported in many hospitals. The purpose of this research was to examine the causes and consequences of burnout syndrome among RNs in US hospitals and its role in the RN shortage in hospitals. The methodology involved a review of the literature and semistructured interviews. Seven primary databases, 2 websites, and 43 articles were consulted in this project. Findings indicated that burnout syndrome in RNs can be analyzed in terms of 4 clusters of characteristics: individual, management, organizational, and work. The consequences of burnout syndrome have increased RN turnover rates, poor job performance, and threats to patient safety. Burnout syndrome was more prevalent in hospitals with a higher number of patients per nurse and among younger RNs. Registered nurse burnout in hospitals has negatively impacted the quality of care, patient safety, and the functioning of staff workers in the health care industry.

Author Affiliations: Healthcare Administration Program, Lewis College of Business, Marshall University (Mrs Bakhamis); Department of Marketing and International Business, Monmouth University (Dr Paul); and Lewis College of Business, Marshall University (Drs Smith and Coustasse), South Charleston, West Virginia.

Correspondence: Alberto Coustasse, DrPH, MD, MBA, MPH, Lewis College of Business, Marshall University, 100 Angus E. Peyton Dr, South Charleston, WV 25303 (

IN 2014, ACCORDING to the US Bureau of Labor Statistics, 2.8 million registered nurses (RNs) worked in the US health care system, 1.708 million of whom were employed in hospitals.1 But only 708 300 physicians and surgeons were employed in the US health care system during 2014.2 Registered nurses are thus critical in providing health care to US citizens. The number of employed RNs, moreover, has been on the rise: the US Department of Labor forecasts that the nursing workforce will grow 16% between 2010 and 2024.3

The supply of RNs relative to the size of the US population, however, remains low, and the shortage has recently grown to more than a million, double that of just a few years ago.4 As of 2010, there were 921 RNs for every 100 000 US citizens. Registered nurses density varies significantly across states as well, ranging from 1247.7 RNs per 100 000 individuals in South Dakota to 677 RNs per 100 000 populations in Idaho.5 According to Carayon and Gurses,6 low levels of staffing, when combined with the aging US population and changes in the health care environment (eg, more emphasis on containing costs), have meant that RNs are experiencing a heavier, more demanding workload than ever before.

The result for some RNs has been burnout—a state of emotional exhaustion where the individual feels overwhelmed by work to the point of feeling fatigued, unable to face the demands of the job, and unable to engage with others.7 The affected individual may develop a sense of cynical detachment from work and view others, especially patients, as objects. As fatigue, exhaustion, and detachment coalesce, affected individuals often become ineffective at work of the loss of the ability to contribute meaningfully. The incidence of burnout in RNs has been shown to be as high as 70%.7

Registered nurses not only experience challenging work conditions involving long hours and little appreciation, but are also paid relatively poorly: RN wages average between $3400 and $7700 per month, depending on the hospital and its location.8 These stressors have contributed to high rates of burnout among new nurses: up to 65% of those in the study reviewed have left their jobs as a result, which has contributed to a nursing shortage.9 This shortage is significant, and the situation is likely to become worse. There will be an estimated 1.2 million vacancies in nurse positions between 2014 and 2020, and more than 55% of current RNs are 50 years or older and expect to retire within 5 to 10 years.10 On the demand side of the health care system, an aging population will exacerbate the nursing shortage: the number of hospital patients has increased in the last 10 years and is expected to increase in the next 30 years. The numbers gap between RNs and patients will likely continue to grow.11

The American psychologist, Herbert Freudenberger, first used the term “burnout” in the 1970s to describe the result of unyielding stress and high standards experienced by people working in hospitals.12 However, the leading measure of burnout syndrome is the Maslach Burnout Inventory (MBI),13 which tracks the incidence of burnout along 3 main dimensions: emotional exhaustion, depersonalization, and inefficacy.10,14,15 Emotional exhaustion refers to the overwhelming exhaustion that can come from constant work under demanding conditions. Depersonalization refers to the sensation of being detached and insensate to the care and treatment of patients. When an RN becomes detached from his or her job, this could contribute to destructive feelings that lead to negative impacts on the effectiveness or quality of services provided to patients.16 The Inefficacy scale captures the impact of burnout on the person's sense of accomplishment and achievement on the job. Maslach et al17 have identified inefficacy as a situation in which one's sense of personal achievement on the job is minimal and note that this dimension is the most complex of the three.

The purpose of this research was to examine the causes and consequences of burnout among RNs in US hospitals in order to identify potential solutions to this problem.

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The methodology for this qualitative study was a literature review, which was conducted by L.B. and validated by A.C., who was a second reader for the research's inclusion criteria. H.S. and D.P.P. then reviewed and revised the manuscript. The electronic databases of PubMed, Academic Search Premier, ProQuest, EBSCO Host, CINAHL, and Google Scholar were searched for the terms “Burnout” OR “Burnout syndrome” AND “Maslach theory” AND “Registered nurses” OR “hospital” OR “turnover” OR “Consequences.” The official websites of the Centers for Medicare & Medicaid Services and the American Nurses Association were also utilized for this study.

The search was limited to articles published between 2000 and 2017 in the English language. Original articles, reviews, and research studies using primary and secondary data were included. A total of 53 articles were reviewed; 43 of these were utilized in this research. Two semistructured interviews, conducted with RNs having 32 years of experience, were used to complement the research results. One of the RNs (J. Studney) was a clinical informatics nurse specialist, and the second RN (M. Ball) worked in the intensive care unit. The questions used in these interviews can be found in the Appendix.

The conceptual framework of this study was adapted from Yao, Chu, and Li (2010).18 The causes and consequences of burnout among RNs can be analyzed in terms of 4 clusters of characteristics: individual, management, organizational, and work. The research data have shown that RN experiences within each cluster of characteristics contribute to the presence of burnout. The results have been increased RN turnover rates, poor job performance, and threats to patient safety (Figure).



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Studies utilizing the MBI

The MBI, as noted earlier, highlights the dimensions of emotional exhaustion, depersonalization, and inefficacy. This research indicates that emotional exhaustion is the most easily noticeable among many nurses.17 Most of the individuals reporting being burned out link it to exhaustion, brought on by emotional stress, including distress and frustration.19,20

Tunc and Kutanis21 reported that RNs who had experienced depersonalization claimed that it might be caused by excessive job demands that have led them to disengage from their work. Depersonalization also occured in RNs who have experienced emotional exhaustion and has contributed to the occurrence of job dissatisfaction.

Poghosyan et al,22 using the MBI, conducted a study in 2010 across 6 countries: the United States, Japan, Germany, the United Kingdom, Canada, and New Zealand. Its purpose was to examine the impact of burnout syndrome among RNs in hospitals on the quality of care provided in diverse countries. The research sample consisted of 54 846 RNs. The researchers showed that the highest rate of RN burnout was in Japan at 79.9%, whereas the lowest burnout rate was 9.4% in New Zealand. Germany had the second highest burnout rate at 30%. The burnout rate reported in the US sample was 18.8%, whereas the rates for Canada and the United Kingdom were, respectively, 14.4% and 12.8%. Most of the RNs in the research sample stated that burnout syndrome affected their ability to take good care of patients, thereby increasing the risks to patient safety.

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This research now turns to other studies that focus on how clusters of characteristics at 4 levels (individual, management, organization, and work) influence the incidence of burnout (Table).



Gilles et al23 noted that RN burnout can be traced to some individual characteristics such as age, sex, and self-fulfillment. Erickson and Grove24 found that the rate of burnout among RNs younger than 30 years was 43.6%, whereas the rate of burnout among RNs older than 30 years was 37.5%. However, the authors found that the RNs younger than 30 years were less likely than those older than 30 years to hide their true emotions.

Management characteristics influencing RN burnout include the lack of proper clinical supervision, failure to offer resources, and mandated overtime.25 Olds and Clarke26 found that exhaustion linked to extended work hours led to burnout. Of 5532 RNs included in this study, 4045 worked more than 35 hours per week as paid volunteers, whereas the remaining 1487 RNs had mandated, unpaid, overtime.

Organizational characteristics that cause RN burnout have included an excessive workload, staff shortages, and a low nurse-to-patient ratio.27 According to Sharma et al,28 roughly 80% of the RNs sampled complained that they had no time for rest because of a heavy workload. Forty-two percent of the RNs in this sample said they suffered from severe stress, and 45% of the RNs were tired of their jobs. In summary, the RNs in this study identified increases in workload, the nursing shortage, time constraints, poor management, and lack of team support as key factors leading to burnout.

Weiner29 noted a strong relationship between a high patient-to-nurse ratio (ie, >8:1) and preventive medical errors, which led to burnout syndrome. For example, for every RN added to staff, Weiner found that there was a 7% decrease in mortality. The mortality rate was highest among those patients who had the least access to RNs.

Work characteristics that caused burnout syndrome among RNs included the work environment and team relationships. McHugh et al30 reported that in their study 24% of the RNs were dissatisfied with their occupation, 34% of the RNs suffered from burnout syndrome, and 37% of the RNs eventually decided to work in nonnursing positions because of the poor and stressful work environment.

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Research shows that RN burnout has been associated with a poor level of patient care, patient dissatisfaction, an increased number of medical errors, higher infection rates, and higher mortality rates.31

Olds and Clarke26 reported that 9.6% of RNs in their sample had a contaminated needle stick or serious injury, 15.1% provided the wrong treatment or dose to their patients, 19.8% had caused injuries to their patients from falls, 32.8% had experienced work-related harms, and 35.2% got infections.

According to Konwinski,32 the RN turnover rate within the first year of work ranged from 35% to 61%. The author also demonstrated that there was a direct relationship between turnover rates and workload increases, bullying within the work environment, emotional exhaustion, loss of job control, a poor work environment, and lack of engagement.

In another study,33 54% of RNs intended to leave their job because of reasons linked to burnout syndrome. Such turnover has a strong negative impact on the quality of health care provided. For example, the study by Hunt34 showed that RN turnover resulted in a decreased quality of care, an increase in the incidence of medical errors, more lost patients, and higher costs. In a hospital reviewed by Hunt, there was an estimated financial loss of $300 000 for every percentage increase in nurse turnover annually.

The study by McHugh et al30 showed that patient outcomes have been negatively affected by RN burnout in several ways: mortality rates in the hospitals studied increased by 19.4%, there was a 6.5% increase in patient readmission rates, and 36% of RNs missed essential changes with their patient's situation and/or failed to report important patient information when changing their shifts.

Stimpfel et al35 assessed the association between the patient-to-nurse ratio and burnout. They reported that nurses with large numbers of patients, such as more than 8 per RN, have less time to communicate with patients, which in turn delayed needed care and led to medical errors.

Cimiotti et al36 discovered that hospital-acquired infections were associated with RN burnout. Their study, involving a sample of 7075 RNs in 160 hospitals, showed that the rates of surgical site infections and urinary tract infections were positively related to the incidence of RN burnout. For example, the hospitals with the highest burnout rates had the highest infection rates: a 10% increase in the burnout rate was associated with increases of 1 urinary tract infection and 2 surgical site infections for every 1000 patients. Fennessey37 noted that RNs suffering from burnout felt less motivated to work and tend to be less careful with patients, which resulted in more medical errors and decreased their work efficiency.

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The aim of this study was to examine the causes and consequences of RA burnout in US hospitals, in order to identify solutions to this problem. The results of the literature review suggested that burnout has led to the development of mental and physical difficulties in RNs, such as low self-esteem, rejection, anxiety, and depression. The literature review also suggests that burnout syndrome among RNs is present all over the world.

Among the identified factors that were attributed to RN burnout, the results indicated that the working environment, shift work, and workloads—all of which are controlled by hospital management—were biased against nurses. Hospital management often is nonclinical in nature and decides the number of nurses to employ, what nurses would work off-time shifts such as the night shift, and the working conditions for RNs. This lack of autonomy has contributed to the profession's burnout rates.38 One consequence of this burnout among hospital RNs is a growing shortage of RNs in hospitals, and the problem is getting worse: RN recruitment has been the second most important factor in hospital human resources departments every year between 2015 and 2017, the fourth most important consideration among chief nursing executives (up from seventh in 2013), and fifth most important concerns of hospital execurives (up from ninth in 2013)39; in 2017, more than 80% of 130 health care facilities from 29 states surveyed had an RN vacancy rate of 80% or greater, compared with 50% in 2013.40

This research also points out that burnout affects not only RN job performance, but also mental and physical health. Some of the consequences of burnout among the RNs included in the reviewed studies included severe headaches, sleeping complications, high blood pressure, and cardiovascular illness. These health issues, caused in part by high patient-to-nurse ratios (ie, >8:1), have contributed in turn to higher medical error rates and a lower quality of patient care.

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Limitations and practical implications

The limitations of this review included search strategies used and the quality of the databases searched, which could affect the quality, availability, and numbers of articles found in this research. Further, researchers' biases and publications' biases could also affect the results of the study.

Registered nurse burnout has been an important issue impacting the US health care system and has not yet been resolved. After reviewing many studies on this topic, the Magnet Hospital Recognition Program began offering a way forward.41 Positive outcomes such as a better work enviroment, lower mortality rates, and improved patient care have been documented in hospitals participating in this program. Magnet Hospitals, indeed, are known for attracting quality RNs and retaining them because of exceptional work environments, thus leading to high levels of job satisfaction. Implementing the Magnet Hospital Recognition Program in health care facilities appears to be a good first step in reducing the incidence of RN burnout.41

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Burnout among RNs in hospitals has become a worldwide phenomenon that negatively impacts the quality of care, the safety of patients, and the working staff. Solving the burnout problem continues to be difficult. This study's focus on the causes and consequences of RN burnout represents a contribution in the continuing search for more complete solutions.

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burnout syndrome; hospitals; Maslach theory; registered nurses; turnover

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