More Evidence Burnout Ups Risk for Errors: Critical Care Nurses

Diana Swift

May 04, 2021

Critical care nurses (CCNs) across the country reported high levels of stress, depression, and anxiety even before the onset of the COVID-19 pandemic, and these factors correlated with an increase in self-reported medical errors, a cross-sectional study of American CCNs found.

The national survey-based study, conducted by the Ohio State University College of Nursing in Columbus, was published online May 1 in the American Journal of Critical Care.

The survey, conducted between August 2018 and August 2019, reveals that 39.8% of CCNs reported depressive symptoms and 53.2% reported anxiety symptoms. Furthermore, 61% of CCNs surveyed ranked their physical health at 5 or lower on a scale of 1 to 10, and 51% scored their mental health at 5 or lower. Only 39.8% reported experiencing a high quality of professional life.

Bernadette J. Mazurek Melnyk, PhD

Bernadette J. Mazurek Melnyk, PhD, APRN-CN, Ohio State University's chief wellness officer and dean of the College of Nursing, led the study of members in the American Association of Critical-Care Nurses. Among 771 respondents, 92% were women, and the mean age was 39.9 years, with 57.8% in the age range 25 to 44 years. Ethnically, the cohort was 83.4% non-Hispanic white, and 91.4% reported working more than 8 hours a day. Worked days lasted 12 hours or more for 68.2%, with an additional 22.3% working 9 to 12 hours.

"They're exhausted after three 12-hour shifts a week and some even go off to work at other centers as well," Melnyk told Medscape Medical News. "This interferes with concentration and judgment."

"These are working hours that are not allowed in the aviation industry or the railway industry," added Nancy Blake, PhD, RN, FAANP, chief nursing office at Harbor-UCLA Medical Center in Torrance, California. "And when there's shortage of nursing staff, someone will get called back in the next day after a shift."

In the current study, nurses' physical and mental well-being was assessed by validated instruments, including the Generalized Anxiety Disorder Questionnaire-2, the Patient Health Questionnaire-2, the Professional Quality of Life Scale, and the Perceived Stress Scale-4.

According to Melnyk, her nurses commonly report physical health problems such as musculoskeletal disability from lifting and shifting patients, as well as high blood pressure and cholesterol, poor nutrition and binge eating, deconditioning due to lack of recreational exercise, and disturbed sleep. "We think that as nurses, they should be adhering to nutritional and activity guidelines, but they aren't," she said.

On the positive side, nurses who perceived their workplace as very supportive of their well-being (score of 6 or more out of 10) were twice as likely to have better physical health (odds ratio [OR], 2.16; 95% CI, 1.33 - 3.52). The observed relationship between greater perceived support for staff wellness and better health remained after adjusting for nurses' age, sex, race/ethnicity, marital status, education, and hours of work per day or shift.

Unwanted Recipe for Errors

Overall, 61% of respondents admitted to making medical errors in the past 5 years. Nurses in poor physical and mental health reported making significantly more mistakes than those in better health, with ORs of 1.31 (95% CI, .96 - 1.78) for physical health and 1.62 (95% CI, 1.17 - 2.29) for depression.

That translated to errors for 67% of nurses with higher stress scores vs 56.5% of those reporting no or little stress. "These errors can include mistakes in dosage or scheduling of dosing and missteps when doing procedures," Melnyk said. Added Blake, "Under stress, nurses can even mix up patients."

The study's findings confirm those of an earlier national study of the general nursing population by Melnyk's group, which showed that nurses with worse health were 26% to 71% more likely to commit medical errors. Here, too, there was a significant relationship between greater perceived worksite wellness and better health. And among physicians, similar burnout this been linked to double the rate of medical errors.

The Pandemic Effect

Although the survey by Melnyk and colleagues was conducted before the COVID-19 pandemic, burnout has only worsened since. According to UCLA's Blake, the peak of the pandemic increased the workloads of already stressed CCNs by necessitating higher patient-to-nurse ratios.

"I think it's fair to say some nurses are now reaching their breaking point. The worst thing has been caring for dying patients whose families can't visit them and being the nurse in the room who watches the family members crying on the other end of the iPad not being able to say goodbye to their loved ones," she said.

Seeking to redress this situation, Blake's center recently implemented a program called Helping Healers Heal, in which someone checks in on nurses and engages them in one-on-one debriefing sessions and discussions. "We also have a psychologist who normally deals with medical residents but has put together some programs for nurses' well-being," she said.

Despite such measures, the center has seen a small spike in nurse turnover, which is expected to rise with the looming retirement of the baby boomer cohort. "But turnover has been much higher in hospitals across the country. Some nurses say they can't go back into the hospital setting, they're going try for a job in a pharmaceutical company or get out of nursing altogether. We anticipate a future nurse shortage," Blake said.

For Jessica Curtisi, RN, PCCN, who works in Wexner Medical Center's intensive care unit, similar support has allowed her to manage the intense emotions evoked by her work. "At my lowest point last year, leaving the profession briefly crossed my mind. What keeps me here is a sense of duty. If I don't stay and care for these patients, who will?" she said.

Staying on has been made easier by taking advantage of employee assistance with counseling, mindfulness coaching, and even pet therapy. "Counseling has allowed [me] to vent my emotions without fear to someone who really wants to listen," Curtisi said. "It's helped me to understand my own natural coping mechanism, which was to bottle up my emotions. Mindfulness coaching has helped me to feel the intense emotions of my work without burning out and keeping me from going about my day to day."

Call to Action

The study investigators warn, "[H]ospital leaders and healthcare systems need to prioritize the health of their nurses by resolving system issues, building wellness cultures, and providing evidence-based wellness support and programming, which will ultimately increase the quality of patient care and reduce the incidence of preventable medical errors."

Melnyk herself put it more plainly. "We need to fix this stuff and do more than we're doing about conditions that contribute to burnout and depression. The health of our clinicians has a huge impact on healthcare quality, safety, staff turnover, and cost."

The authors have disclosed no relevant financial relationships.

Am J Crit Care. 2021;30:176-84. Abstract

Diana Swift is a medical journalist based in Toronto. She can be reached at

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