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System-Level Improvements in Work Environments Lead to Lower Nurse Burnout and Higher Patient Satisfaction

Brooks Carthon, J. Margo PhD, APRN, FAAN; Hatfield, Linda PhD, NNP-BC, FAAN; Brom, Heather PhD, APRN; Houton, Mary BSN, RN, CMSRN, CRN; Kelly-Hellyer, Erin MSN, RN-BC; Schlak, Amelia BSN, RN; Aiken, Linda H. PhD, FAAN, FRCN

Author Information
Journal of Nursing Care Quality: January/March 2021 - Volume 36 - Issue 1 - p 7-13
doi: 10.1097/NCQ.0000000000000475


In 2017, the National Academy of Medicine created the Action Collaborative for Clinician Well Being and Resilience in response to growing concerns over health care provider burnout and associated threats to patient care.1 Health care provider burnout is a mounting public health crisis with up to half of all physicians and 1 in 3 nurses reporting high burnout.1–3 While gaining recent national attention, burnout has long been a topic of discussion.4 Burnout is characterized by feelings of negativism or increased mental distance from one's job.5,6 Among hospital-based nurses, there are increasing worries about heavier workloads, increased patient acuity, time pressures, and limited resources.7,8 These stressors are believed to contribute not only to burnout but also to other job-related outcomes including high rates of absenteeism,9 job turnover, and intention to leave their current place of employment.10,11

Burnout among nurses may also pose threats to patient safety and quality.12,13 In a study of more than 95 000 nurses, McHugh and colleagues14 found that nurses caring for patients in hospitals and nursing homes were more burned out than nurses in other care settings. In addition, patient satisfaction was lower in hospitals where more nurses were burned out.14 Similarly, in a study of 7067 nurses working in 161 hospitals, Cimiotti and colleagues15 found significant associations between high levels of nurse burnout and increased incidence of hospital associated infections. In addition, White and colleagues16 examined burnout among 687 direct care registered nurses practicing in 540 nursing homes. They found that 30% of the nurses experienced high burnout and nurses with high burnout were 5 times more likely to leave necessary care incomplete, such as adequate patient surveillance, teaching, and care planning.16

Although burnout among nurses is now well recognized, less is known on how to address the problem. A recent review and meta-analysis of interventions to reduce burnout suggest that individual and organizational interventions can make a difference.3 Most of the strategies that health care systems are implementing appear to largely target individuals and include interventions such as mindfulness courses, wellness retreats, resiliency training, culinary medicine classes, or brief emotional support teams.17–19 However, more evidence is needed to support interventions equally focused on health care systems that take into account important organizational factors, such as working conditions, managerial support, or the adequacy of resources that may lead to burnout.3,20

In this study, we examined the relationship between nurse burnout and patient satisfaction and evaluated how hospital organizational factors, specifically the nurse work environment, influence these outcomes.14 Our focus on the nurse work environment builds on a robust literature base that suggests that nurse and patient outcomes improve when nurses have support from hospital administrators, collegial working relationships with physicians, adequate staffing levels, and involvement with decision making regarding nursing practice.21,22 Nurses in these environments are more engaged in decision making regarding their practices at the organizational level and are in positions to address changes that may be linked to adverse patient events.23–27 In contrast, practice environments marked by clinical inefficiency, top-down decision making, and limited nurse engagement in governance are markers for health care system dysfunction and may contribute to adverse outcomes for nurses and patients.23,28,29

In this study, we explored the relationships between burnout, patient satisfaction, and organizational features of the work environment. Using data from 463 hospitals in 4 states, this study sought to (1) evaluate whether higher levels of nurse burnout were associated with lower patient satisfaction and (2) determine whether improvements in the work environment were associated with lower nurse burnout and higher patient satisfaction.



We conducted an analysis of cross-sectional data on hospitals in 4 states (California, Florida, New Jersey, and Pennsylvania) using 3 linked data sets from 2016. Using a common hospital identifier, the following data sources were linked together: (1) patient satisfaction ratings obtained from Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, (2) the American Hospital Association Annual Survey, and (3) the RN4CAST-US, a survey of hospital nurses. The University of Pennsylvania's Institutional Review Board approved this study.

Setting and sample


The sample included all adult nonfederal acute care hospitals in California, Florida, New Jersey, and Pennsylvania that reported HCAHPS data and had 10 or more nurses respond to the RN4CAST-US (n = 463). Nursing hospital characteristics were derived from the 2016 RN4CAST-US, which is a large mail-based survey that utilized a modified Dillman approach.30 Home addresses were obtained from state boards of nursing and surveys were sent to the homes of a random sample of nurses in the 4 states. The survey yielded a 26% response rate31,32 and represented more than 95% of hospitals in these 4 states.33 The survey employed a double sampling approach so that after the initial survey was completed, a second sample of nonrespondents was conducted to evaluate the nonresponse bias of the main survey.31,32 This resurvey included a random sample of 1400 nonrespondents using more frequent reminders and incentives.32,34,35

No significant differences were found between those who responded to the first survey compared with those who responded to the second.32 Additional details of the survey methodology are presented elsewhere.32,33 On the survey, nurses were asked to indicate the address of their hospital and their responses were aggregated to the hospital level to characterize each hospital's level of nurse burnout, nurse work environment, and other nurse characteristics. There were 14 772 nurses in the 463 study hospitals with an average of 31.9 nurse respondents per hospital (range: 10-145). The 2016 American Hospital Association survey provided information on hospital structural characteristics including bed size, teaching status, technology status, urban status, and state.


The publicly available HCAHPS data were used to measure patient satisfaction in 2016. The HCAHPS survey is composed of 32 questions and is a National Quality Forum–endorsed measure of the patient experience in hospitals. Data were risk adjusted and aggregated to the hospital level.36

Variables and measures

Nurse burnout (measured at the hospital level)

Nurse burnout was measured by the emotional exhaustion subscale of the Maslach Burnout Inventory as emotional exhaustion is considered the strongest dimension of burnout.37 The 9 items of this subscale, which assess how often nurses feel symptoms of burnout, were included in the 2016 RN4CAST-US survey. Nurses are considered to have high burnout if they had a score of 27 or more on the emotional exhaustion subscale,38 which is consistent with how burnout has been measured in the literature.14,15,39 The emotional exhaustion variable was aggregated to the hospital level to describe the proportion of high burnout nurses in each hospital. For descriptive purposes, the aggregated measure of nurse burnout was categorized into quartiles. Hospitals in the lowest quartile were categorized as “low burnout hospitals” and those in the highest quartile as “high burnout hospitals.”

Nurse work environment (measured at the hospital level)

The nurse work environment was based on nurse responses to the Practice Environment Scale of the Nursing Work Index, which is a validated measure and endorsed by the National Quality Forum.22,40 The Practice Environment Scale of the Nursing Work Index is a 31-item instrument comprising 5 subscales: Nurse Participation in Hospital Affairs; Nursing Foundations for Quality of Care; Nurse Manager Ability, Leadership and Support of Nurses; Staffing and Resource Adequacy; and Collegial Nurse-Physician Relations.41 The 5 subscales were aggregated to the hospital level and then averaged to create 1 continuous measure of the nursing work environment per hospital. As is the validated practice, the work environment was divided into quartiles with the lowest quartile categorized as a poor work environment, the middle 2 quartiles as a mixed work environment, and the highest quartile as the best work environment.41

Patient satisfaction (measured at the hospital level)

The HCHAPS survey comprised 29 questions that assess the patient's hospital experience and allow for risk adjustment based on the mix of patients. The survey is administered via mail only, telephone only, mixed (mail and telephone), or interactive voice response. Responses are aggregated to the hospital level and adjusted for patient mix variables (education, self-rated health, length of time from discharge to survey completion, language spoken, age, service line, interaction of age and surgical service line, and interaction of age and maternity service line).36 We used 3 of the 10 HCHAPS publicly reported measures including 2 global measures that assessed patients' perception of overall hospital quality and 1 individual item specific to nursing. The first global item asks patients to provide an overall hospital rating from 0 to 10 and the second global item asks patients whether they would recommend the hospital. The individual item asks how well nurses communicate. The HCAHPS measures are reported as “top box” scores. The top box is the proportion of patients rating the hospital 9 or 10 (high) for the overall hospital rating, definitely yes for whether patients would recommend the hospital, and always for whether nurses communicated well.36


Nursing characteristics were derived from the RN4CAST-US survey and aggregated to the hospital level, which included age, sex, years as a nurse, and years at current hospital. Hospital structural characteristics were obtained from the American Hospital Association survey and included bed size, teaching status, technology status, and state. Bed size was categorized as 100 beds or less, 101 to 250 beds, and more than 250 beds. Teaching status was categorized as none, minor (1:4 medical resident/fellows to bed), and major (>1:4 medical resident/fellows to bed). High technology hospitals were identified as those with the capacity to perform open heart surgery and/or organ transplant. Urban/rural designation was based on Core Based Statistical Area codes.

Data analysis

Descriptive statistics were used to describe the differences in nursing characteristics, hospital characteristics, and patient satisfaction across quartiles of burnout. Chi-square tests were employed for categorical data, except where cell size was less than 5 and Fisher exact test was utilized. Analysis of variance was employed to test for differences across quartile of burnout for continuous data. Next, a series of linear regressions was estimated to examine the relationship between nurse burnout and patient satisfaction. For ease of interpretation, burnout was treated as a continuous variable in all regression models and reflected a 10% increase in the proportion of nurses who were burned out. We first fit unadjusted models (model 1) that estimated the association between burnout and each patient satisfaction outcome (separately). The results in model 1 represent the change in patient satisfaction for every 10% increase in burnout. The second series of models (model 2) adjusted for hospital characteristics (bed size, teaching status, technology status, state, and urban/rural location). Finally, the third series of models (model 3) adjusted for hospital characteristics and the work environment. In these final models, the results represent the change in patient satisfaction when the work environment improves from poor to mixed or mixed to best. All statistical analyses were completed in STATA Version 14.2 (StataCorp LLC, College Station, Texas) and significance was set at P value of less than .05.


Sample characteristics

Supplemental Digital Content Table 1, available at:, displays the nurse and hospital characteristics of the total sample and by quartile of burnout. On average, 31.4% of nurses reported high burnout. Among hospitals in the lowest quartile of burnout, 16.0% of nurses reported high burnout, compared with 49.0% of nurses in the highest quartile of burnout hospitals (P < .001). Hospitals with poor work environments also had the highest burnout (n = 58, 50%), whereas, hospitals with good work environments less frequently had high burnout (n = 5, 4.3%; P < .001). There were no significant differences with regard to other nurse and hospital characteristics across quartiles of burnout.

Patient satisfaction by level of burnout

The Table displays the patient satisfaction measures overall and by quartile of burnout. Satisfaction ratings ranged from 68.5% to 76.4%. Two of 3 outcomes (Overall Hospital Rating of 9 or 10 and Recommend Hospital) had significant relationships with burnout and as burnout increased, patient satisfaction decreased. For example, there was almost a 5 percentage point difference in the mean percentage of patients who would definitely recommend the hospital between those cared for in hospitals with low burnout (72.0%) and those cared for in hospitals with high burnout (67.3%; P < .001). In contrast, whether nurses always communicated well did not vary significantly between low and high burnout hospitals (eg, 76.7% vs 75.6%, P = .106).

Table. - Distribution of Patient Satisfaction by Level of Hospital Nurse Burnouta
Patient Satisfaction All Hospitals (n = 463), M (SD) Low Burnout (n = 121), M (SD) Second Quartile (n = 112), M (SD) Third Quartile (n = 119), M (SD) High Burnout (n = 111), M (SD) Pb
Patients gave a rating of 9 or 10 68.5 (7.4) 69.8 (8.3) 69.9 (6.9) 68.1 (6.6) 65.9 (7.0) <.001
Patients would definitely recommend 70.1 (8.6) 72.0 (9.6) 71.6 (8.0) 69.3 (7.8) 67.3 (8.1) <.001
Nurses always communicated well 76.4 (4.2) 76.7 (4.6) 76.9 (4.4) 76.4 (3.9) 75.6 (3.9) .106
aMean (M) represents hospital-level percentage of patients reporting the given outcome and SD represents standard deviation.
bP values generated from analysis of variance.

Association between patient satisfaction and burnout

To examine the association between burnout, patient satisfaction, and the work environment, a series of linear regression models was fit. In the first series of models, the association between burnout and each patient satisfaction measure was estimated. A 10% increase in the proportion of nurses with high burnout was associated with 0.4% to 1.3% lower patient satisfaction ratings. For example, a 10% increase in burnout was associated with lower ratings of patients definitely recommending the hospital by 1.3 percentage points (P < .001). If a hospital improved from the highest quartile of burnout to the lowest quartile (a 33% decrease in burnout), its patient satisfaction could improve by almost 4 percentage points (1.3 × 3). Similarly, a 10% increase in burnout was associated with lower ratings of patient satisfaction with nurse communication by 0.35 percentage points (P = .018). If a hospital improved from the highest quartile of burnout to the lowest quartile, its patient satisfaction with nursing communication could improve by more than 1 percentage point (0.4 × 3).

Association between patient satisfaction, burnout, and the work environment

The final set of models explored the extent to which burnout and patient satisfaction are explained by the work environment because it is a modifiable feature of hospitals that could become an intervention. Once accounting for the nurse work environment, burnout was no longer significantly associated with any of the 3 patient satisfaction outcomes. There also was a significant and positive association between the work environment and patient satisfaction. For example, the estimate of 6.08 indicates that the percentage of patients who would “definitely recommend” the hospital was more than 6 percentage points higher in good compared with mixed work environments and 12 percentage points higher in good compared with poor work environments (see Supplemental Digital Content Table 2, available at:


The aim of this study was to evaluate the relationship between nurse burnout, patient satisfaction, and the work environment. We found that across 463 hospitals, 1 in 3 nurses experiences high burnout and that burnout was significantly and negatively associated with patient satisfaction. Conversely, hospitals with the best work environments were also those with the lowest burnout and highest patient satisfaction.

Our examination of patient satisfaction and nurse burnout is particularly timely as satisfaction is increasingly viewed as a quality indicator and directly linked to reimbursement through the Value Based Purchasing Program (VBP).42 Authorized by the Affordable Care Act and implemented in 2012, VBP adjusts payments to hospitals to incentivize quality of care. The program is funded by reducing Medicare base operating payments by 2% and redistributing these funds to hospitals that perform well on their Total Performance Score. Patient satisfaction comprises 30% of the Total Performance Score and is calculated from HCAHPS survey data. In our sample hospitals with the highest levels of burnout, nearly half of the nurses reported high burnout. Many of these hospitals also had poor work environments. Our findings suggest that high burnout hospitals may decrease their levels of burnout and improve patient satisfaction ratings through system-level investments in the nurse work environment. For example, we found that compared with hospitals with poor work environments, hospitals improving the work environment from poor to best resulted in an increase in patient satisfaction by up to 12 percentage points. This could translate to a change in payment by tens of thousands of dollars if a hospital moved from a poor to a good practice environment as the FY 2018 VBP cycle resulted in $1.9 billion distributed across 1550 high performing hospitals.43

Health care systems are just beginning to initiate system-level efforts to improve burnout but most of this work to date has focused on physicians.3 For example, in their study of 166 physicians across 34 clinics, Linzer and colleagues44 found that improvements in workflow, such as automated prescribing systems and more time with patients resulted in decreased burnout. Attention to system-level interventions to reduce burnout is in line with recent initiatives including the National Academy of Medicine's Action Collaborative on Clinician Well-being and Resilience that emphasizes developing organization-wide initiatives to foster well-being, engaging all clinicians, including nurses, in designing and implementing health information technology, and creating positive work environments.1,45

We note that there are a few limitations to our study. Because of the cross-sectional study design, we are unable to assert causality to our findings. Our sample included hospitals in 4 states raising questions about generalizability. However, these are 4 populous states and represent more than 20% of all hospital admissions, thus increasing confidence that these results could be applicable across a wide range of settings.46

A solution to burnout and improving patient satisfaction

Many hospitals achieve better work environments by attaining Magnet designation. For example, a study by Lasater and colleagues47 of 323 Magnet and 2698 non-Magnet hospitals showed that hospitals with Magnet status performed better on VBP metrics including the Total Performance Score and Patient experience. Another study by Stimpfel and colleagues48 on 212 pairs of Magnet hospitals matched to non-Magnet hospitals found that patients in Magnet hospitals gave their hospitals the highest rating, were more likely to recommend the hospital, and reported more favorable nurse communication than non-Magnet hospitals. While Magnet designation has been closely tied to improved patient outcomes, only 9% of hospitals are Magnet designated and the process itself can be costly and resource intensive to attain.49 Nonetheless, hospitals can still achieve Magnet-like qualities through investments in the work environment. This includes fostering relationships between nurses, administrators, and physicians, and ensuring that nurses have decision-making authority in their practice and adequate resources and time to do their work.


We identified relationships between high nurse burnout, lower patient satisfaction, and the nurse work environment. Our findings provide evidence to support system-level improvements in the nurse work environment to improve both patient and nurse outcomes.


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burnout; health care systems; nurses; patient satisfaction; work environment

Supplemental Digital Content

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