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. Author manuscript; available in PMC: 2024 Jan 1.
Published in final edited form as: Dimens Crit Care Nurs. 2023 Sep-Oct;42(5):248–254. doi: 10.1097/DCC.0000000000000598

A National Survey of Stress and Burnout in Critical Care Nurses: A pre-pandemic study

Delwin Millan Villarante 1,2, Sharon C O’Donoghue 3, Monica Medeiros 4, Erin Milton 5, Kayley Walsh 6, Ashley L O’Donoghue 7,8, Leo Celi 9,10,11, Margaret Hayes 12,13, Justin Dilibero 14
PMCID: PMC10403271  NIHMSID: NIHMS1901379  PMID: 37523722

Abstract

Background:

Critical care nurses (CCN) experience a higher level of stress and burnout than nurses in other specialties. About 50% of CCNs are mildly stressed and almost 20% are moderately stressed. Prolonged periods of stress can lead to burnout, which has been shown to have deleterious effects on quality and patient safety.

Objectives:

The purpose of this study is to determine the prevalence of burnout among a national sample of CCNs and the association with environmental factors.

Methods:

A national survey of critical care nurses working in the United States was implemented using an exploratory descriptive design. The anonymous survey was developed iteratively according to best practices of survey design. The survey included the Perceived Stress Scale (PSS) and the Copenhagen Burnout Inventory (CBI) Tool. Pre and pilot testing were conducted with critical care nurse specialists and the survey was revised based on their feedback. An anonymous link was distributed to respondents using convenience sampling through social media and further disseminated via snowball sampling.

Results:

Two hundred and seventy nurses responded to the survey. The mean PSS score in the study population was 18.5 (SD = 6.4), indicating moderate stress. The mean CBI score was 61.9 (SD = 16.5), indicating moderate burnout. Our study found that the overall health of the work environment was one of the most important factors associated with both stress and burnout

Conclusions:

This study has demonstrated the relationship between the health of the work environment and burnout among critical care nurses. It is imperative that healthcare organizations evaluate and implement strategies to optimize the health of the work environment to mitigate burnout and its negative sequalae on the nurse, patient, and system.

Keywords: Burnout, Stress, Occuptional Stress, Healthy Work Environment, Critical Care Nursing

Critical care nurses (CCN) experience a higher level of stress and burnout than other nursing specialties1, with half of CCNs reported to be mildly stressed and almost one - fifth moderately stressed.2,3 Prolonged periods of stress can lead to burnout, which has been shown to have deleterious effects on quality of care and patient safety.4

Psychological stress is defined as the presence of external demands that exceeds an individual’s adaptive abilities.5 Perceived psychological stress occurs when an individual judges that situational demands exceed his or her resources.6 Short-term stress has been shown to have some benefits such as improving focus; however, chronic stress has many negative effects including insomnia, fatigue, irritability, anxiety, and depression.5

Considerable job stress is a major factor in the high rates of nursing burnout,7,8 and nursing workplace stress is predicted to only increase over the next few years.9–12 The National Institute for Occupational Safety and Health (n.d., p.06) defines job stress as “the harmful physical and emotional responses that occur when the requirements of the job do not match the capabilities, resources, or needs of the worker.”13 Perceived job stress is linked to the occurrence of burnout.14

Burnout is a syndrome characterized by emotional exhaustion, depersonalization, and reduced professional efficacy, resulting from chronic workplace stress.15 Burnout is an important contributor of health outcomes and is included in the International Classification of Diseases (ICD-11) as an occupational hazard (World Health Organization, 2022).15 Burnout affects workers across industries and is especially common among healthcare workers, particularly those working in critical care.1,5

Burnout has been shown to decrease self-esteem and increase feelings of frustration, anger, anxiety, and fear, which impair a clinician’s ability to provide optimal patient care.16,17 These feelings have been associated with negativity towards patients, coworkers, and the job in general and frequently manifest as unprofessional behavior towards coworkers and patients.18 Additionally, burnout has been shown to increase the risk of substance use disorders and suicide.5

At the organizational level, burnout has led to poor work performance, and an increase in turnover.5,19 Burnout has been associated with lower patient satisfaction scores, an increased incidence of errors and hospital acquired infections, and an increased 30-day mortality.20

Although, the incidence of burnout and its contributing factors have been established, there is a paucity of research on mitigation strategies. Action is needed at both the personal and organizational levels. Strategies for reducing burnout at the personal level include self-recognition of stress and burnout and implementation of self-care strategies: ensuring adequate sleep, engaging in routine exercise, participating in mindfulness and mediation practices, balancing responsibilities, and avoiding unhealthy behaviors.21 Strategies at the organizational level include establishing and maintaining a healthy work environment (HWE), improving flexibility of scheduling, providing longitudinal feedback on patient outcomes, providing resiliency training and promoting self-care, mindfulness, and cognitive-based therapy.19,21

Establishment of a HWE as an organizational strategy has been shown to increase engagement, decrease burnout, improve retention, and contribute to optimal patient outcomes.22 Six components are needed to establish a HWE: skilled communication, true collaboration, effective decision-making, appropriate staffing, meaningful recognition, and authentic leadership.19 A better understanding of the level of stress and burnout related to the workplace environment could provide potential interventions to improve nurses’ well-being and patients’ outcomes.

The purpose of this study is to determine the prevalence of burnout among a national sample of CCNs and its association with available resources and environmental factors. Specific aims of the study include to: determine the perceived burnout among CCNs, explore the relationship of perceived stress and perceived burnout, and characterize the association of self-reported resources and environmental factors with perceived burnout among CCNs.

METHODS

This study was reviewed by the Institutional Review Board (IRB) of Rhode Island College, who determined that the research was exempt from continuing review (approval number 1920–1918, December 18, 2019, “Assessing Stress and Burnout among Critical Care Nurses”). A statement of informed consent was distributed with the survey questions and participants acknowledged consent prior to accessing the survey. Procedures were followed in accordance with the ethical standards of the responsible committee on human experimentation (institutional or regional) and with the Helsinki Declaration of 1975.

Survey design

An anonymous survey was developed iteratively according to best practices of survey design.23 Participants were required to acknowledge consent electronically before they were given access to the survey questions. The survey included demographic questions such as education level, years in current unit, work schedule; work place questions, such as break schedule, availability of a wellness space at the institution; questions on the availability of institutional strategies to alleviate stress and burnout, and questions on the health of their work environment based on the AACN standards for establishing and maintaining a HWE were included.19 Nurses rated their units’ performance for each standard on a five-point Likert scale where 5 was positive and 1 was negative. A score of ≥ 3 was representative of a HWE. The survey also included the Perceived Stress Scale (PSS), a 10 question tool used to assess stress.24,25 Scores range from 0 to 40 with higher score indicating higher level of stress. Scores lower than 13 indicate lower stress and scores, between 14 to 26 are considered moderate stress. While scores 26 to 40 indicate high stress. Also, the Copenhagen Burnout Inventory Tool (CBI) was used, a 17 question tool measuring burnout in three domains; personal burnout, work related burnout, and client related burnout.26 Scores range from 0–100. Scores of 50 to 74 are moderate. Scores 75 to 99 are high and a score of a 100 is severe. Pre and pilot27 testing were conducted with critical care nurse specialists and the survey was iteratively revised based on their feedback.

Survey Distribution

An anonymous link was distributed to respondents using Qualtrics.28 The initial survey link was distributed to a convenience sample using social media (Facebook, e-mail, and Twitter). Each potential subject was asked to forward the survey to a colleague, so the survey was further distributed through snowball sampling.29 The survey was open for four months from March 13th to May of 2020. Three reminder notices were sent over the course of the study period.

Statistical Analysis

Means and standard deviations (SD) were used for continuous variables and counts and percentages for categorical variables. Tests of differences were conducted using chi-squared tests for categorical variables. P≤0.05 was considered statistically significant, and all tests were two-tailed. Stata SE version 16.1 (StataCorp) was used for statistical analysis.

RESULTS

Demographics Description

Two hundred and seventy nurses responded to this national survey (Please see figure 1). The majority of nurses surveyed were educated at the bachelor’s degree or higher (89.3%; n = 241), 28.5% (n=77) worked on their current unit for less than five years and 40.7% (n=110) worked permanent days. Most nurses reported working in an academic teaching hospital (62.2%, n = 168) and most nurses reported that their hospital was not Magnet designated (65.6%, n = 177; Please see supplemental table 1).

Figure 1.

Figure 1.

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Locations of Survey Respondents.

Work Environment

Most nurses reported their place of work would be considered a HWE (71.5%; n = 193). However, they also reported “rarely” or “never” getting a lunch break (58.2%, n = 157), or any break (78.9%, n = 213). Only 39.3% (n = 106) of nurses who reported having a wellness space and of those only 77 responded to the question of whether they used it. Of those 77, only 9 (11.7%) reported actually using the wellness space.

Stress and Burnout

The mean PSS score in our study population was 18.5 (SD = 6.4) indicating moderate stress (Please see figure 2). Nurses who worked at institutions with wellness spaces had significantly lower PSS scores (16.8, SD = 6.2) than nurses without dedicated wellness spaces (19.6, SD = 6.3, p < 0.001). Nurses with a HWE had significantly lower PSS scores (17.6, SD = 6.5) than nurses without a HWE (20.8, SD = 5.6, p < 0.001). Nurses who worked at a Magnet designated hospital had significantly lower PSS scores (17.3, SD = 6.8) than nurses who worked at non-magnet hospitals (19.2, SD = 6.2, p = 0.02). There was no statistically significant difference in PSS scores across experience levels, educational attainment, years in current unit, shift, whether nurses got lunch breaks or any breaks, or whether the hospital was an academic teaching hospital.

Figure 2.

Figure 2.

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Distribution of Percieved Stress Scores.

The mean CBI score was 61.9 (SD = 16.5) indicating moderate burnout (Please see figure 3). Nurse’s level of burnout on the CBI scale decreased with experience: nurses with 0–5 years of experience had the highest burnout level (66.5, SD = 14.7), compared to nurses with over 20 years of experience who had the least (54.8, SD = 18.7, p < 0.001). Nurses who received lunch breaks “sometimes”, “usually”, or “always” reported less burnout (58.9, SD = 17.3) than nurses who received lunch breaks “rarely” or “never” (64.0, SD = 15.6, p = 0.01). Nurses with wellness spaces at work had less burnout (56.9, SD = 16.7) than nurses without a wellness space (65.1, SD = 15.6, p < 0.001). Nurses who had a HWE had less burnout (59.2, SD = 16.5) than nurses without a HWE (68.7, SD = 14.3, p < 0.001). Nurses who worked at an academic teaching hospital experienced higher levels of burnout (63.5, SD = 16.0) than nurses who did not work at one (59.2, SD = 17.0, p = 0.04). Nurses who worked at hospitals that were Magnet designated had lower levels of burnout (56.6, SD = 18.1) than nurses who did not (64.7, SD = 14.8). There were no statistically significant differences in the CBI scores by educational attainment or shift.

Figure 3.

Figure 3.

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Distribution of Copenhagen Burnout Inventory Scores.

DISCUSSION

The purpose of this study was to determine the prevalence of burnout among a national sample of CCNs and the association between available resources and environmental factors. Our sample of critical care nurses indicated experiencing moderate stress and burnout.

The growing problem of stress and burnout among healthcare professionals in critical care has been well established. However, there remains an important literature gap in terms of the contributing and mitigating factors in the development of stress and burnout in ICU professionals30 and ways to mitigate them.31 Swamy and colleagues32 reported that critical care nurses have the highest burnout rate of all nurse specialties with the condition affecting between a third and more than half of nurses working in the ICU. Findings of our study are consistent with the literature stating the pervasiveness of burnout on critical care nurses. In addition, our study demonstrated that between personal, client and work-related factors, work related factors were the strongest contributor to burnout.

Swamy and colleagues (2020) suggested that “...burnout increases the risk of clinician turnover and compounds health system costs through decreased efficiency and productivity and staff shortages” (p.381).32 Now more than ever it is imperative to work towards implementation of evidenced-based research to address burnout. Groups that are most at risk and thus most likely to benefit from intervention and burnout prevention, need to be identified. A study evaluating health care providers’ (HCP) perceived support from personal, hospital, and system resources found that “HCPs found the most useful resources for stress management were hospital, not personal resources. HCPs who reported more support from hospital resources experienced fewer psychological distress symptoms and were less likely to quit.” (p. 321).33 It is therefore important for health care systems to understand what mitigations from an organizational viewpoint can be implemented to prevent stress and burnout in their employees.

Our study found that the overall health of the work environment was one of the most important contributors associated with both stress and burnout. These findings are consistent with the literature where a HWE was shown to increase engagement, decrease burnout, improve retention, and contribute to optimal patient outcomes.34 Other factors associated with burnout in our study included having less experience, fewer years on the current unit, not receiving lunch, not receiving other breaks, working in a hospital not designated as a Magnet institution, not having a wellness space, and working in an academic medical center. Although the presence of a wellness center was associated with lower burnout, the majority of nurses who reported having a wellness center did not utilize the space. This may suggest that other environmental factors associated with organizations offering a wellness space may account for this finding. Assessment of these factors were beyond the scope of this study and further research is needed in this area.

In comparison to burnout, experience levels, years in current unit, receiving lunch or other breaks, and working in an academic medical center was not associated with perceived stress. This finding may indicate that even factors not perceived as stressful may still contribute to burnout.

It is important to note that the data we have gathered reflected pre pandemic working conditions. Research published since the pandemic has revealed that nurses and physicians have experienced increased levels of stress, and burnout since the COVID-19 pandemic.35. Evaluation of differences in stress and burnout before and after the start of the pandemic was beyond the scope of this study. Future research is necessary to inform our understanding of these differences and to guide the identification of targeted strategies to improve related outcomes. Finally, it should be noted that respondents to this study needed to have access to internet, social medial or e-mail in order to participate in our online survey which may have limited our ability to reach respondents without access to such resources.

CONCLUSION

This study has demonstrated the relationship between the health of the work environment and burnout among critical care nurses. In light of the COVID-19 pandemic, these factors have only increased. It is imperative that healthcare organizations evaluate and implement strategies to optimize the health of the work environment in order to mitigate burnout and its negative sequalae on the nurse, patient and system levels. In addition, this study did not account for potential post pandemic changes and did not explore potential disparities in levels of stress and burnout that may be present across race, gender and culture. We are currently completing a follow up study to explore such differences.

Supplementary Material

Table 1

Acknowledgements:

The authors would like to thank all those that completed the survey.

No grant or financial support was used for this study.

Footnotes

There are no conflicts of interest to disclose.

Contributor Information

Delwin Millan Villarante, Solution Reliability, Connected Care, Philips Healthcare, Cambridge, MA; Critical Care, Beth Israel Deaconess Medical Center, Boston, MA.

Sharon C. O’Donoghue, Nurse Specialist, Professional Development, Beth Israel Deaconess Medical Center, Boston, MA.

Monica Medeiros, Rehabilitation Services, Beth Israel Deaconess Medical Center, Boston, MA.

Erin Milton, Rehabilitation Services, Spaulding Rehab, Boston, MA.

Kayley Walsh, The Center for Healthy Aging, Beth Israel Lahey Hospital, Boston, MA.

Ashley L. O’Donoghue, Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, MA; Department of Medicine, Harvard Medical School, Boston, MA.

Leo Celi, Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge MA; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Ma; Department of Biostatistics, Harvard T.H. Chan School of Public Health.

Margaret Hayes, Director, Medical Intensive Care Units, Division of Pulmonary, Critical Care, and Sleep Medicine; Department of Medicine, Beth Israel Deaconess Medical Center.

Justin Dilibero, Chair, Graduate Department, Zvart Onanian School of Nursing, Rhode Island College, Providence, RI.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Table 1
NIHMS1901379-supplement-Table_1.docx (17.9KB, docx)

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