Nurses are Burned Out. Can Quality Measures Help?

More than half of nurses are burned out. The consequences are severe. 

Even before the COVID-19 pandemic, nurses around the country reported feeling overworked and burned out. Burnout, characterized by energy depletion or exhaustion, job-related feelings of negativism or cynicism, and reduced professional efficacy, is not unique to nurses, with other types of health professionals and industries also experiencing high rates. The phenomenon is so common that the World Health Organization (WHO) included burnout in the International Classification of Diseases (ICD-11) as an occupational phenomenon. In a recent survey, the American Nurses Association (ANA) found that 62% of nurses report symptoms of burnout. 

Levels of nurse burnout vary across settings of care. For instance, oncology nurses report higher rates of emotional exhaustion and depersonalization, which are common measures of burnout, than primary care and palliative care nurses; however; oncology nurses have lower rates of burnout than their emergency department colleagues. Overall, nurses working in hospitals report higher levels of burnout and are more likely to leave their jobs due to workplace stress. 

The consequences of nurse burnout are severe, as burnout has been associated with degradation in  quality-of-care outcomes, including hospital-acquired infections and patient experience of care. 

What are the causes of nurse burnout? 

Several factors contribute to workplace stress for nurses. Compared with other health care workers, nurses experience more frequent, direct, and emotionally-charged contact with a large volume of patients. Nurses also report inadequate staffing, lack of communication from physicians, and poor organizational leadership as key reasons for burnout.

Nurses identify inadequate staffing as a top contributing factor to burnout. A landmark hospital-based study revealed that each additional patient assigned to a nurse increases the odds of patient death by 7%. Burnout and inadequate staffing are a vicious cycle. Burnout is one of the strongest predictors of nurses abandoning their career or leaving their jobs, contributing to greater workloads for the nurses who remain. The inadequate staffing that comes as a result of burnout causes more burnout and contributes to additional turnover, increasing costs and disrupting care.  In 2018, most nurses felt regularly burned out in their jobs, with close to half of nurses considering leaving the profession entirely.

The reasons for inadequate nurse staffing are widely debated. Some argue that the growing demand for nurses has outpaced the supply. In 2019, more than 80,000 qualified applicants were turned away due to nursing schools’ limited resources. However, the Health Resources and Services Administration (HRSA) projects that the US supply of nurses will ultimately  exceed demand, leading to a nation-wide excess of 293,800 nurses by 2030. 

Alternatively, nurses have claimed that hospitals are intentionally understaffing to cut costs. National Nurses United, the largest union and professional association of registered nurses in the U.S., stated in a 2021 press release that, “Hospitals intentionally understaff every unit, every shift with fewer numbers of nurses than is actually required to safely and optimally care for the numbers of admitted patients and their severity of illness. Hospitals do this to maximize profits and excess revenue.”

Several states have adopted nurse staffing laws that aim to improve patient care and decrease nurse burnout. In 1999, California passed a law that established unit-specific, minimum nurse-to-patient staffing ratios. Since then, California has experienced an increase in nurse staffing, decreased burnout and turnover, and a reduction in preventable deaths. 

What role can quality measurement play in addressing nurse burnout?

Multifaceted and creative approaches are necessary to reduce nurse burnout, especially to address factors that are not easily measured, such as engagement and collaboration with physicians. While improved monitoring or quality-based incentives alone will not solve nurse burnout, leveraging quality measures may be part of the solution.

Quality measurement strategies for nurse burnout may be most effective in the hospital setting since evidence tying burnout to patient outcomes (eg, mortality, surgical site infection) is strongest in hospital-based studies. In addition, existing hospital value-based payment programs present an opportunity to leverage quality measurement incentives.

One promising avenue to consider is to focus on patient outcomes, specifically outcomes (and patient-reported outcomes) correlated with inadequate staffing, including health care-acquired infections and patient experience. This strategy aligns with the Centers for Medicare & Medicaid Services’ (CMS) goals and directly tackles priority patient safety concerns. In 2004 the National Quality Forum (NQF) endorsed 15 nursing-sensitive consensus standards. The standards target the acute care hospital setting and include several key patient outcome measures, some of which are included in hospital quality-based programs. 

^aThis is not a comprehensive list of all programs that include similar measures. 

Patient-reported outcome performance measures (PRO-PMs) were not included on NQF’s nursing-sensitive consensus standards, likely due to the lack of PRO-PMs in the early 2000’s. PRO-PMs have become more prominent since the 2004 NQF report, and are integrated into hospital value-based payment programs through the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospital Survey. The addition of patient experience survey measures, like CAHPS, could provide an added benefit to the nurse-sensitive measure set. 

System-centered quality measures may be the missing link. System-centered quality measures may address the concern that focus on these measures could inadvertently increase nurse burnout by placing extra pressure on nurse performance. NQF’s nursing-sensitive consensus standards included a set of measures that assess nursing staff turnover, skill mix, and nurse care hours per patient for registered nurses (RN), licensed practical nurses (LPN), licensed vocational nurses (LNV), and unlicensed assistive personnel (UAP):   

• Turnover: Number of voluntary uncontrolled separations during the month for RNs and advanced practice nurses, LVN/LPNs, and nurse assistants/aides

• Skill Mix: Percentage of RN, LVN/LPN, UAP, and contract hours to total nursing hours 

• Nursing Care Hours per Patient Day: Number of RN care hours per patient day, number of nursing staff hours per patient day

In addition to these three measures, NQF’s nursing-sensitive consensus standards included a composite measure of survey questions on the practice environment completed by staff registered nurses. Several of these measures are endorsed by NQF, and the ANA is committed to working with CMS to advance Nursing Care Hours per Patient Day and Skill Mix measures into the HIQR program.  

Since several patient outcome measures are already integrated into key hospital programs, the addition of these system-centered measures could prove useful for understanding nurse staffing and addressing burnout. Unfortunately, adding new quality measures adds administrative burden to hospitals. Future solutions will need to strike the right balance between hospital accountability for adequate nurse staffing and additional administrative burn out. 

About the Quality Outlook Commentary Series

Breakthrough treatments in cancer care, including precision therapies tailored to specific patient factors, are driving rapid changes in the definitions of oncology quality and value. Efforts to implement value-based care models in oncology must meet the demands of evolving science, new best care practices, and shifting patient priorities. Quality measures must be up-to-date and relevant. Payment models must recognize the challenges and costs of managing complex patient populations with diverse needs. In this JCP blog series, Quality Outlook, Discern Health will explore key issues in oncology quality and value through posts focused on measurement, value-based payment, and quality improvement.

About Rachael Peroutky, MSPH
Rachael Peroutky, MSPH, is a Senior Project Manager at Discern Health, part of Real Chemistry. Rachael has expertise in quality improvement projects and policy in the oncology and cardio-metabolic space. In her role, Rachael oversees qualitative research projects in the quality and value-based care space and hosts engagements with health care stakeholders through workshop meetings, interviews, and webinars. She has experience evaluating the design and implementation of health policies in domestic and global contexts. 

About Tess Donckels
Tess Donckels, MSPH, is a Senior Project Manager at Discern Health, part of Real Chemistry. In this role, she oversees quantitative and qualitative health care projects, including evaluation of quality of care in chronic disease and development of value-based care strategies to close gaps in care and reduce time to diagnosis. Prior to joining Discern Health, Tess performed health policy analysis for the Bloomberg American Health Initiative while earning her MSPH. Previously, she worked as a Research Associate at Seattle Children’s Research Institute and the University of Washington, where she carried out decision-making and addiction neuroscience research.

About Sarena Ho
Sarena Ho,  is a Project Analyst at Discern Health, part of Real Chemistry. With a background in public health and health policy, she brings strong research and policy analysis skills to the Discern team. Prior to joining Discern, Sarena worked on issues related to violence prevention and rehabilitation at Johns Hopkins School of Public Health as well as global health and immunizations at CDC. At Discern, Sarena supports efficient completion of client projects related to oncology, immunizations, behavioral health, and quality improvement. 

About Katie Schultz
Katie Schultz is a Project Analyst at Discern Health, part of Real Chemistry. She brings both public health and anthropological perspectives to her work. Prior to joining Discern, Katie worked with the Maryland Department of Health on research related to stigma, and she also has experience in public health ethnographic research globally. Katie supports projects across a variety of therapeutic areas including the development of educational resources on health care quality and value-based care.

About Sara Khan Shirsekar
Sara Khan Shirsekar is a Project Analyst at Discern Health, part of Real Chemistry, and has supported and managed client projects by conducting research on value-based care initiatives and quality measurement within the healthcare industry. Her recent work involved the creation of a strategic plan for hospitals to prioritize post-acute and long-term care. Prior to joining Discern, Sara worked as an intern for both the Maryland Hospital Association and Congressman Elijah E. Cummings. Sara continues to bring her expertise in policy analysis to ensure success within the value-based marketplace.  

Blog Editor

About Tom Valuck, MD, JD
Tom Valuck is a Partner at Discern Health, part of Real Chemistry. He is a thought leader on health care system transformation and helps lead the firm’s focus on achieving better health and health care outcomes at a lower cost. Tom’s work at Discern includes facilitating the exploration of next-generation measurement and accountability models for health care delivery systems. He also helps clients develop strategies to achieve success within the value-based marketplace. 

About Discern Health
Discern Health, part of Real Chemistry, uses research and strategic advisory services to help our clients improve health and health care through value-based payment and delivery models. These models align performance with incentives by rewarding doctors, hospitals, suppliers, and patients for working together to improve quality while lowering total costs. Real Chemistry is an independent provider of analytics-driven, digital-first research, marketing services, and communications to the healthcare sector.