Abstract
Background: Burnout, defined as emotional exhaustion, depersonalization, and a sense of low personal accomplishment, impacts 1 in 3 registered nurses (RNs) in addition to patients and health care organizations across the United States. Despite a plethora of research on the drivers of RN burnout, there is a gap in current health services research relevant to the direct costs (i.e., costs directly linked to a healthcare resource or service) and indirect costs (i.e. social and cultural consequences) of RN burnout. The purpose of this dissertation was to comprehensively describe both the direct and indirect costs of RN burnout for a health care organization. Aim 1 of the study sought to evaluate the direct costs of RN burnout-attributed turnover. Aim 2 explored the cultural, indirect costs of RN burnout in an Emergency Department (ED).
Methods: Using a multi-modal approach, direct RN burnout costs were assessed using Markov modeling approaches (i.e., decision analysis), and indirect costs were evaluated through an 18-month ethnography. Data collection and analysis were informed by the Social Ecological Model (SEM). A Markov model was used to evaluate direct costs of RN burnout-attributed turnover (Aim 1) in a hospital with baseline, status quo burnout prevalence rates, compared to one with a burnout intervention program. Ethnographic fieldwork (Aim 2) was conducted over 18 months through participant observations and in-depth interviews semi-structured interviews in a level one, academic medical center ED. Inductive and deductive coding strategies were used to analyze the fieldnotes and interviews to identify emerging categories and themes
Results: Our results show that RN burnout imparts significant economic burdens to a health care organization. Aim 1 of the study found that, in modeling burnout up to 10 years, RN burnout costs $11,592 per RN per year employed in a hospital. RNs spent more time in burnout in the status quo scenario (i.e., hospital with higher RN burnout) than the hospital with a burnout reduction program (1.5 years vs. 1.1 years of employment), as well as less time employed at the hospital (2.9 years vs 3.5 years of employment). Aim 2 findings revealed multi-level costs to RNs, patients, team members, and the health care system as demonstrated through an explanatory model, the Muir Pathway of Burnout. Individual impacts of burnout included RN withdrawal and a loss of professional identity; interpersonal impacts included loss of team cohesion and inadequate RN training; on a systems-level RN burnout was perceived as a cultural norm which detracted from necessary interventions and in turn compromised the ostensibly valued culture of patient safety. Aim 2 findings also revealed how a significant change, exhibited through a physical move in the ED, exacerbated existing RN burnout and turnover intent.
Conclusion: RN burnout imparts significant direct and indirect costs to a health care organization, supporting the need for hospital investment in burnout interventions. The Pathway of Burnout can help health care leaders identify where RNs are within the Pathway of Burnout and then inform when, and how, to implement relevant interventions. The comprehensive findings from this dissertation can inform future large-scale, national studies evaluating RN burnout costs to support RN burnout policy development and implementation.
