A cross-sectional study exploring the relationship between burnout, absenteeism, and job performance among American nurses

Professional burnout [1] is alarmingly prevalent among U.S. nurses with studies reporting rates of 35–45% [2‐7]. Burnout is a syndrome characterized by feelings of energy exhaustion, cynicism related to one’s job, and reduced professional efficacy that stems from chronic work-related stress [8]. Excessive workload, inadequate staffing, values conflicts, inadequate rewards, and poor work environment (e.g., insufficient autonomy, lack of administrative support, poor physician-nurse relationships) increase the risk of burnout among nurses [3, 4, 9‐17]. Studies suggest the consequences of burnout among nurses include lower willingness to lead, suboptimal quality of patient care, lower inpatient satisfaction ratings, more health care-associated infections, and increased patient mortality ratios [3, 4, 18‐21].

Previous studies also suggest nurses with burnout are more likely to be dissatisfied with their job and intend to or actually leave their place of employment [3, 22‐28]. Few studies, however, have examined the potential impact of nurse burnout on absenteeism and work performance [29]. Systematic reviews of articles published between 1950 and 2016 on absenteeism and presenteeism (impaired performance at work) [30] and between 1986 and 2006 on absenteeism [31] in nurses identified only two studies examining the relationship between burnout and presenteeism. One study of 73 registered nurses reported that higher levels of burnout were associated with worse supervisor rated job performance and more self-reported absences [32]. In the second study of 258 nurses working in the Netherlands, a bi-directional relationship was found between burnout and presenteeism [33]. We identified another study of 404 nurses working in an institution for people with learning difficulties where the emotional exhaustion domain of burnout was associated with higher self-reported absenteeism [34], and in a 1989 study of 106 nurses working in long-stay settings, emotional exhaustion predicted absences in the subsequent 12 months [35]. Important limitations of previous studies, however, include being conducted more than a decade ago or outside the U.S., having small sample sizes of nurses from a single specialty or practice setting, using only the emotional exhaustion domain of burnout, or being unable to account for potential confounding factors such as mood disorders and fatigue [32‐35].

To further our knowledge about the relationship between burnout and self-reported absenteeism and job performance among nurses, we conducted a national survey of U.S. nurses using validated measures. We hypothesized that nurses who had burnout would be more likely to report absenteeism and lower job performance than nurses without burnout.

We adhered to Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines and methodology.

In this national study of U.S nurses, over a third had substantial symptoms of burnout, and, similar to the findings reported in a study conducted in the Netherlands [33], those with burnout were more likely to self-report poor work performance. We did not find a statistically significant association between burnout and absenteeism. However, absence from work due to personal illness was uncommon in this sample, and the wide confidence interval around this effect estimate [58] does not allow a clinically important association between burnout and absenteeism to be excluded. A previous study conducted in Europe suggested burnout predicts subsequent absenteeism among nurses [35]. Among non-health care employees, burnout as well as poor work performance has been shown to be a predictor of future work absences in longitudinal studies [40, 59]. In sum, these findings suggest burnout remains prevalent among nurses and likely impacts work perfromance.

Nurses in our cohort who had symptoms of burnout were also more likely to have reduced on the work performance, independent of fatigue and other factors. Poor work performance may have a greater negative impact on patient care (as the nurse is not replaced on their shift) [60] and be more costly than absenteeism [61]. A previous study of inpatient nurses in North Carolina found an association between presenteeism and patient falls and medication errors, with estimated costs of $1346 per nurse annually in North Carolina (2009), or if extrapolated to all nurses in the U.S., just under $2 billion annually [60].

In this cohort, 16% reported missing at least 1 day at work in the past month due to a personal health issue. In a study of over 6000 nurses from seven countries the reported prevalence of missing work over the past 3 months ranged from 10% (South Korea) to 74% (Iceland), and was 56% among nurses working in the US [62]. In that international study, older nurses were less likely to report absenteeism, whereas nurses who worked full-time, had overtime, and perceived staffing to be inadequate on their unit were more likely to report absenteeism after controlling for country and hospital clustering.

Findings from this study suggest organizational investment in strategies aimed at reducing burnout among nurses is needed, and if successful, likely to have a positive return on investment and benefit nursing-sensitive quality of care indicators. Such strategies should take aim at the environment that nurses work in and work-related contributors to stress [3, 9], rather than solely focus on individual strategies to deal with stress. Intervention studies with appropriate control groups are needed to inform evidence-based organizational strategies to address nurse burnout and related issues.

This study has several limitations. First, the response rate was 26.2%. Although this is typical of national surveys, our findings are vulnerable to response bias. Our responders, however, were fairly typical of US nurses with respect to age, sex, highest academic degree related to nursing, and work hours [63, 64]. Furthermore the prevalence of burnout in this cohort was similar to that found in previous studies of nurses [2, 3], suggesting our findings may be comparable. Second, we explored a limited number of personal and professional characteristics hypothesized to be associated with absenteeism and work performance. There are likely to be additional factors beyond those measured in this study that also influence these outcomes. Third, we did not collect objective data on absenteeism or work performance. We did, however, use a validated measure with demonstrated concordance with employee archival measures of absenteeism, daily diary reports, and supervisor ratings [36‐38, 41].

Strengths of this study include use of the criterion standard burnout assessment instrument (the Maslach Burnout Inventory) and statistical adjustment for symptoms of depression and fatigue. Future research should explore additional factors likely to impact absenteeism and work performance, leverage employer data on absences and job performance, use longitudinal study designs, and further explore the effects of absenteeism on the colleagues impacted by the nurses who are absent [65].

In conclusion, in this study of U.S. nurses we found nearly 1 in 3 had symptoms of burnout, and burnout doubled the odds of low work performance. One in six self-reported absenteeism in the last month due to a personal illness. Although we did not find a statistically significant relationship between burnout and absenteeism, one in six self-reported absenteeism in the last month due to a personal illness. To improve work performance, organizations should address work-related stressors contributing to nurse burnout and absenteeism.