Putting Patients at Risk: The Effect of Health Care Provider Burnout on Patient Care in the Operating Room—A Narrative Review

Prevalence of Burnout

Many studies reported a high prevalence of burnout in the OR (Table 2). In a large Italian cross-sectional survey of 1009 participants, nearly 40% experienced emotional exhaustion and 26% depersonalization, with 44% scoring low in personal accomplishment.³³ The link between work-related traumatic events and depersonalization is well established.¹⁷ Surgical areas face significant burnout risk, with one survey reporting an 83% burnout rate due to social isolation.¹⁰ Another study found that 73.5% of surgeons experienced burnout, and 93.7% were stressed.⁸ Similarly, burnout was prevalent in the French neurosurgical community, with no significant differences between residents and neurosurgeons.³⁴

Burnout among anesthesiologists has been extensively studied. In the United States, a survey of 5295 anesthesiology residents and first-year graduates found that 51% were burnt out, 32% distressed, and 12% depressed.³⁵ An Italian study of 859 anesthesiologists reported a 10.2% incidence of high-degree burnout, marked by emotional exhaustion, depersonalization, and low personal accomplishment.³⁶ A recent study of 2698 US anesthesiologists found high burnout rates, with many considering leaving their jobs due to burnout and staffing shortages.³⁷ In China, a 69% burnout rate among 2873 anesthesiologists was reported.³⁸ Similarly, a US post-COVID-19 cross-sectional study indicated that 67.7% of anesthesiologists were at high risk for burnout and 18.9% had burnout syndrome,³⁷ and in Pakistan, 39% of anesthesiologists experienced emotional exhaustion, 68.4% depersonalization, and 50.3% burnout in personal achievement.³⁹

Other subgroups within the OR workforce also face increased burnout risk. A French study found that OR nurses had the highest prevalence of psychological disorders during COVID-19, with 64% experiencing anxiety, 45% depression, and 45% PTSD.¹⁴ Likewise, research in China revealed that OR nurses exposed to specific or multiple work-related traumatic events were at high risk for burnout.¹⁷

Burnout prevalence rates varied slightly across countries, peaking during the pandemic. Irish surgical physicians and American OR nurses reported the highest levels at 83%¹⁰ and 70.5%,⁷ respectively. In France, studies found burnout rates between 36% and 49%, focusing on anxiety, depression, and insomnia among surgical staff.^9,34,40 Similarly, studies from Poland⁴¹ and the US³⁵ reported rates of 32% and 51%, respectively, showing slight global variations in burnout among health care professionals (Table 2).

Several studies explored sex differences in surgeon burnout. Wang et al⁴² found that 38% of female residents experienced sex-based discrimination, much higher than the 14% reported by male residents. In addition, 25% of female residents reported being sexually harassed during training, compared with only 1% of males.⁴² Nearly half of the participants experienced or witnessed sex-based discrimination and bias, leading to burnout.⁴² Similarly, female surgeons experienced higher stress levels during COVID-19 compared with their male counterparts (n=335), even after adjusting for parental and training status (P<0.001).⁴³ Another study identified that being female was a significant risk factor for mental health compromise in the OR.⁹

COVID-19 Pandemic

The pandemic had a global impact and notably impacted the OR wait times and increased the socioeconomic burden.⁴⁴ However, only one study in this review compared burnout before and during the pandemic, surveying 954 surgeons globally.⁴⁵ The total burnout score was reported as mean (SD) 18.05±5.41 prepandemic and 19.33±6.51 during the pandemic (P<0.001).⁴⁵ In total, 66.5% felt that their roles had been diminished, and 41% were reassigned to nonsurgical tasks.⁴⁵ During the pandemic, in the US, a 70.5% burnout rate was reported among nurses,⁷ while in Ireland, 83% of surgical staff were at increased risk of burnout.¹⁰ Similarly, in Argentina, a study of 302 physicians found high levels of stress (93.7%), burnout (73.5%), anxiety (44%), and depression (21.9%) during the pandemic.⁸

Physicians and nurses were significantly affected by the pandemic. In France, Vallée et al found that insufficient training among young surgeons was linked to mental health disorders.⁹ French orthopedic surgeons experienced 39% burnout, affecting their quality of life.⁴⁰ Some resident surgeons reported shame⁴⁶ and depression,⁴⁷ while others conversely felt accomplishment.⁴⁸ Stress levels decreased with enhanced safety measures,⁴⁹ but some faced income loss and fear of infecting patients and their own families with COVID-19.¹²

On the other hand, nurses showed gradual burnout due to ongoing tension, exacerbated by unprofessional behavior,⁵⁰ equipment shortages, anxiety, and difficult tasks.¹⁸ In one study, 45% of French OR nurses reported PTSD during COVID-19,¹⁴ and faced exhaustion, lack of support, professional challenges, and organizational obstacles, including insufficient pandemic-related guidelines.¹⁸

Stress Factors for Burnout

Various stress factors potentiating burnout were identified, including personality and professional practice,^34,40 internal/external environment⁵¹ plus organizational, interpersonal, occupational, and individual factors.⁵⁰ In a US survey, 51% of anesthesiology residents and first-year graduates reported burnout, 32% distress, and 12% depression, with heavy workload and student debt increasing risk, while workplace resources and work-life balance reduced it.³⁵ Similarly, 79% of vascular surgery residents (N=284) reported a negative workplace,⁴² and anesthesiologists cited job dissatisfaction, long hours, poor sleep, and poor physical health as burnout drivers.^38,52 Post-COVID-19, a US study found burnout worsened by staffing shortages and lack of support,³⁷ while workload and city of practice were stressors in Pakistan.³⁹ Nurses faced stress from night shifts, equipment shortages, inadequate training,⁹ 24-hour shifts,⁸ anxiety, emotional exhaustion,⁵⁵ COVID-19 patient interactions,⁶² musculoskeletal issues,⁶⁰ and disruptive behavior.⁶⁴

Burnout stress factors varied by country. In Iran, organizational issues and personal factors like musculoskeletal disorders were significant.^60,62 Studies from France, Poland, Iran, India, and the US highlight stressors such as high workload, organizational indifference, and poor work-life balance, leading to higher burnout rates among surgical staff.^{17,37,41,50,57,58} In Spain, 17.3% of OR nurses experienced high burnout levels associated with personality traits (neuroticism and depression) and being single/divorced males, suggesting potential risk groups for early detection.⁵³ Similarly, a Taiwanese study of 612 nurses found higher burnout in those who were younger than 43 years old and single.⁵⁶

Burnout and Patient Safety

Few studies directly link burnout to patient safety incidents. Instead, they examine individual or organizational aspects that could lead to safety events. One study analyzed 89 critical events in a year and found a connection between the lack of debriefing and communication failures in the OR.⁶⁷ Nearly half of these OR-related events occurred outside of the OR, varying in severity from cardiac arrest to communication breakdowns.⁶⁷

OR events were indirectly linked to patient safety concerns. For example, anesthesia delays and missing items, occurring in 19% of cases, and prolonged surgery times.⁷⁶ Surgeons and anesthesiologists influenced timely OR turnover times,⁷⁵ and communication failures (reported by 65% of surgeons) disrupted surgical flow.⁷⁸ In addition, staff turnover was found to interrupt teamwork, as reported by 73% of surgeons.⁷¹

OR Efficiency, Workflow, and Solutions

Several studies revealed inefficiencies in OR scheduling,⁸⁰ surgical flow disruptions,⁷⁸ OR turnover times⁷⁵ and room characteristics.⁷⁹ One study explored performance-shaping factors and human error,⁷⁴ while another aimed to reduce OR delays with novel surgical applications.⁷⁶ OR design has been linked to stress levels in surgical teams, highlighting the importance of patient flow, organization, and equipment access.⁶⁹

Interestingly, 79% of surgeons considered using a second surgeon (dual surgeon operation) as a viable solution; 89% believed it would reduce fatigue, 84% felt it would boost confidence, 77% thought it would enhance decision-making, 69% expected fewer technical errors, and 66% saw the potential for better communication and teamwork.⁷⁰

Behavioral techniques have been tested to improve mental well-being and job performance. A study of nearly 1000 participants, 28% of whom were anesthesiologists, found that meditation improved mood and reduced negative emotions in the OR.⁸² Another study found that meditative breathing helped to improve nurses’ mental well-being and job performance,⁶⁸ while intraoperative music did not negatively affect performance.⁵⁹ Three studies also reported solutions: a data-driven surgical scheduling system,⁸⁰ music therapy to reduce stress⁷⁷ and organizational strategies focusing on leadership and support.⁵⁴

Lasting Effects of COVID-19

The COVID-19 pandemic significantly impacted the OR workforce, exacerbating distress due to virus risk, quarantine, social stigma, and family concerns,⁸³ compounded by surgical cancellations that caused workflow disruptions and a backlog that extended long after pandemic conditions ended.¹¹

Postpandemic research found that 67.7% of US anesthesiologists were at high risk for burnout, with 18.9% experiencing burnout syndrome and 78.4% reporting persistent staffing shortages.³⁷ Not surprisingly, 36.0% planned to leave their jobs within 2 years.³⁷ Coronaphobia contributed significantly to stress and family suffering,⁸⁴ the impact of which extended beyond the health care professional and resulted in reciprocal and cumulative family suffering.⁸⁴

PTSD in OR staff is understudied; however, the Protec-Cov study reported that 18% of French doctors had significant post-COVID PTSD symptoms due to increased workload and isolation,¹³ and the HERO study of 2038 health care workers found younger workers and nurses had more PTSD symptoms compared with their older and physician counterparts during the COVID-19 pandemic.⁸⁵ In intensive care settings, PTSD prevalence soared from 3.3% to 24% prepandemic to 16% to 73.3% postpandemic,⁸⁶ with a rate of 24.3% reported in a 2023 survey of health care workers.¹⁵ These professionals faced unique risk factors such as constant confrontation with death, fear of infecting patients and family members, care unpredictability, COVID-19-related insecurity,⁸⁶ increased workload, lack of professional recognition, and isolation due to lockdowns.¹³

Postpandemic, one third of hospital doctors suffering from PTSD felt they needed psychological support, yet only 31% of these received it.¹³ Effective communication, protection, resources, and social support are crucial for mitigating long-term PTSD, highlighting the need for early intervention and support.^15,86

The pandemic’s impact extends beyond immediate stress, with many health care workers experiencing persistent psychological distress. Ongoing support systems, such as access to mental health services and peer support groups, are crucial for addressing these long-term effects.⁸⁷ In addition, organizational policies that prioritize staff well-being, such as flexible work schedules and adequate rest periods, can help mitigate the ongoing impact of the pandemic.⁸⁸ For example, hospitals can implement regular mental health check-ins and provide access to confidential counseling services.⁸⁸ These system-level strategies can help lower job stress and promote quality of life for health care professionals working in high-stress environments.⁸⁹

High-risk Populations

In our review, surgeons, anesthesiologists, and nurses were the primary groups experiencing burnout, with sex-related factors appearing to play a notable role. Female surgeons reported experiencing higher levels of sex-based discrimination, bias, and sexual harassment compared with their male counterparts,⁴² and reported greater stress.⁴³ Factors such as sex-based hierarchies in the OR, alongside potential pay gaps and reduced autonomy, may contribute to these experiences.⁹⁰ Research on female neurosurgeons suggested that burnout risk is linked to being a resident and having fewer children,⁹¹ while a broader range of elements, including work duties, experience, age, sex, and marital status, also play a role.⁹² Interestingly, our review noted a finding of higher burnout risk among single or divorced males,⁵³ while other studies have indicated higher burnout rates and lower satisfaction among female family physicians.^93,94 Despite differing findings on specific risk factors, there is consensus that female physicians often carry a greater burden of responsibilities outside of work.⁹³ As female medical students now outnumber males, yet remain underrepresented in surgical specialties,⁹⁵ the increasing number of female applicants to surgical residencies underscores the growing urgency of addressing sex equity within the OR.⁹⁶

While targeted interventions may help address specific at-risk groups, broader, systemic changes are needed to tackle the deep-rooted cultural and societal sex-based challenges faced in the OR. Addressing these issues requires fundamental organizational and cultural shifts to create a more supportive and equitable work environment for all OR professionals.

Impact on Patient Safety

Occupational stress and burnout are known to significantly impair cognitive function, leading to decreased attention, reduced problem-solving abilities, depression, and compromised decision-making.^89,97,98 This impairment directly elevates the risk of surgical errors and compromises patient safety.²⁵ Analysis of surgical errors has revealed a complex interplay of contributing factors, encompassing individual clinician pressures like time constraints, interruptions, and exhaustion, alongside systemic issues such as communication breakdowns, staffing inconsistencies, organizational lapses in specimen handling, medical record inaccuracies, and errors in clinical judgment.⁹⁸

These connections are further illustrated by studies demonstrating that physician and nurse burnout are associated with an increase in the risk of medical errors.²⁵ Systematic reviews evaluating older studies have reported that surgeon burnout is associated with a 2.5-fold increase in risk of medical errors and poorer patient safety,⁹⁹ while a meta-analysis showed a 66.4% probability that high burnout levels lead to worse safety outcomes.²⁵ A second meta-analysis of 5234 records found burnout was linked to increased patient safety events, lower patient satisfaction, and diminished care quality.¹⁰⁰

Communication, a key human factor contributing to medical errors⁶⁵ and a factor contributing to 43% of malpractice claims in the United States,¹⁰¹ has dire consequences in the OR if not managed effectively.¹⁰² When communication fails, harm is caused to patients, staff, and hospitals, along with longer stays and wasted resources.¹⁰³ Stressed and emotionally drained staff may exhibit poor communication skills, leading to misunderstandings, misinterpretations, and a breakdown in teamwork.⁹⁸ A significant proportion (15%) of communication failures in surgical settings involve purpose failures, indicating a breakdown in the intended message.¹⁰¹ Communication errors have also been linked to increased stress and excessive noise in the OR,¹⁰² and inadequate staffing and increased staff turnover linked to poor teamwork.⁷¹ Interestingly, the best communication skills in the OR were found in nurses, staff older than 51 years, and those with >21 years of work experience.¹⁰⁴

Surgery demands extensive teamwork and coordination,¹⁰⁵ and lower burnout rates are associated with better patient safety culture, job satisfaction, and working conditions.⁶⁶ Interestingly, poor teamwork, manifested by disrespect, rudeness, and disagreements on patient care, can contribute to patient harm by escalating team tension and diminishing operational efficiency.¹⁰¹ Similarly, high staff turnover can significantly affect patient outcomes. In a recent retrospective study of National Health Service acute trusts in England (2010–2019), higher turnover rates of nurses and senior doctors were associated with increased risks of patient mortality within 30 days of emergency admissions.¹⁰⁶ Specifically, a 1 SD increase in nurse turnover was associated with a 0.052 percentage point increase in all-cause emergency admission mortality (95% CI: 0.037-0.067), and a 1 SD increase in senior doctor turnover was associated with a 0.019 percentage point increase in emergency mortality (95% CI: 0.006-0.033).¹⁰⁶ The study, analyzing data from ~236,000 nurses, 41,800 senior doctors, and 8.1 million admitted patients, revealed a significant correlation between staff turnover and patient mortality.¹⁰⁶ Importantly, staff turnover has been linked to burnout.^26,97

Staff experiencing burnout may be less likely to report errors, voice concerns, or participate in safety initiatives. Importantly, the risk of significant harm to patients increases when medical errors go unreported.⁹⁸ By implementing strategies and policies to mitigate burnout, health care institutions have the potential to enhance communication, improve leadership and support of staff, and ensure adequate resources to provide safe and effective care.¹⁰⁷

Improving Efficiency

In 2011, surgery hospitalizations accounted for 48% of total hospital costs in the US,¹⁰⁸ highlighting the potential for efficiency improvements in the OR to reduce costs, boost productivity, and free up provider time.¹⁰⁹ One approach proposed is using a parallel flow pathway, where care in the induction room continues while the OR is cleaned, which reduces turnover time and increases daily OR cases without compromising patient safety.¹⁰⁹

Studies have also identified wasted time and resources in the OR, with surgical waste comprising 20% of supply costs and circulating nurses spending 26% of their time outside the OR.¹¹⁰ In a survey of over 1500 US nurse practitioners, 70% reported burnout or depression, with 58% attributing it to bureaucratic tasks like charting and paperwork.¹¹¹

Solutions that improve time management and decrease waste, such as procedure packs, hold value. Customizable surgical packs, which are tailored to specific interventions, can enhance efficiency and reduce costs by ensuring only necessary tools are available.¹¹² Similarly, integrating digital solutions, such as patient flow and automation of surgical pathways to provide real-time location systems that claim to increase OR utilization by 12.5% within 2 years and reduce waitlists—could positively influence efficiency and reduce costs.¹¹³

High-stakes Environment

Beyond the significant influence of systemic factors, the intrinsic nature of working in the OR carries a substantial emotional weight that contributes to burnout.³⁴ The constant exposure to critical and often life-threatening patient conditions, the emotional toll of witnessing suffering and, at times, mortality, and the inherent pressure associated with preventing errors in high-stakes procedures can lead to significant psychological distress.³⁴ Health care professionals in the OR often bear the responsibility for critical decisions under time constraints, and the emotional aftermath of both successful and unsuccessful interventions can accumulate over time, contributing to emotional exhaustion and depersonalization.^17,28,38 While systemic improvements are crucial for building resilience, acknowledging and addressing the direct emotional impact of these inherent aspects of OR work is equally important for a comprehensive understanding of burnout in this setting.

System-based Solutions

To effectively mitigate burnout and enhance patient safety in the OR, a comprehensive approach focusing on system-based solutions is essential. Promoting a culture of psychological safety, where staff feel supported and comfortable raising concerns without fear of reprisal, is vital for open communication and proactive problem-solving.^{24,25,101,105} In addition to strong leadership that prioritizes staff well-being, health systems can create a culture where burnout is recognized and addressed proactively.¹⁰⁷ This foundation enables the implementation of other critical system changes.

Ergonomic human factor improvements, such as optimized equipment layout and reduced noise levels, can significantly decrease physical and mental strain on OR staff.^{58,63,102,114,115} Adjustable workstations, strategically placed equipment, and noise-reducing materials can create a more efficient and less stressful work environment.^{23,58,112,115,116}

Team-based simulation training can enhance communication, motivation, and coordination skills, reducing the likelihood of errors and improving teamwork.^117,118 These simulations allow OR teams to practice complex scenarios, identify communication breakdowns, and refine their collaborative skills in a safe and controlled setting.^117,118

Furthermore, the integration of digital tools, such as electronic trigger tools, checklists, and real-time feedback systems, can improve surgical process adherence, minimize errors, and streamline workflows.^98,119 Ideas, such as the digital OR and black box technology, are broadening the horizon on integration of technology in the OR.^120–122 Innovative solutions can reduce administrative burden, improve information flow, and provide timely feedback to OR staff, enhancing efficiency and reducing the potential for human error.^119–121 However, implementing innovative digital solutions in the OR still faces barriers, including the need for extensive interdisciplinary collaboration, standardized data protocols, increased acceptance of video recording, and robust ethical and legal frameworks for patient data protection.¹²²

Preventing Burnout

Context-specific interventions tailored to each country’s health care system are essential for mitigating burnout and promoting well-being among health care professionals worldwide.⁸⁸

Strategies, such as reducing workload, limiting duty hours, ensuring adequate staffing, and offering flexible schedules, can improve job satisfaction and reduce burnout.¹²³ In addition, individual-focused interventions, including stress management and mindfulness, have also enhanced well-being.^87,88

Our review highlights the importance of addressing stress and working conditions to improve safety attitudes and patient outcomes in the OR. Effective strategies include providing adequate training and protective equipment, managing disruptive behavior, and fostering psychological safety in the OR.⁸⁸ In addition, integrating process groups into surgical training can help manage work-related stress and improve mental health.¹²⁴ In response to burnout, the CDC’s National Institute for Occupational Safety and Health has introduced the WellBQ questionnaire and Impact Wellbeing Guide to support hospital leaders in improving employee mental health.¹²⁵

Expert Opinion

This section provides a novel perspective of how experts view this issue from a clinical standpoint, and how effective practices can reduce burnout and improve care quality. Combining research insights with clinical perspectives, we highlight the critical need for systemic changes to support health care workers and ensure high-quality care.

In today’s health care environment, the link between human resource management (HRM) and the well-being of health care professionals is increasingly critical. Health care institutions rely on dedicated staff to care for individuals during illness and vulnerability, making staff well-being essential for quality care. Despite this, high rates of burnout, anxiety, depression, and other psychological disorders are prevalent, a problem worsened by the COVID-19 pandemic.

Our review highlights the strategic importance of effective HRM. Practices related to retention, such as training, workload management, work-life balance, and overall well-being, are crucial for preventing burnout. Implementing these practices requires collaboration among top management, line managers, HR specialists, employee representatives, and external consultants to create a supportive environment. However, challenges persist in implementing HRM practices due to organizational issues; top management often prioritizes financial and quality metrics over HRM. Medical professionals in line management roles frequently lack the necessary managerial skills, and traditional abusive training cultures further exacerbate the problem. In addition, HRM specialists often lack the credibility needed to be strategic assets.

The pandemic has intensified pressures on health care workers, making it urgent to address these issues holistically. Psychological problems affect decision-making, focus, and empathy, compromising patient safety, especially in sensitive areas such as the OR. Investing in mental and emotional well-being is essential for maintaining high-quality care and a supportive work environment.

Training and retaining health care professionals is costly and challenging. Addressing the loss of staff due to burnout and psychological issues is crucial. Although numerous performance indicators exist, reliable metrics for assessing psychological well-being and its impact on care quality are lacking. Re-evaluating working conditions, shift schedules, and protocols is necessary to manage burnout effectively. By focusing on both immediate stressors and long-term strategies for worker well-being, we can ensure that health care professionals have the support they need to deliver optimal care while maintaining their own health.

Limitations

This review has several limitations. The focus on English language studies from 2018 to 2024 may introduce language and publication bias, excluding relevant research outside this scope. Significant heterogeneity in study designs, OR populations, burnout measurement tools, and reported outcomes prevented a meta-analysis, limiting findings to broad trends and qualitative insights. The underrepresentation of studies from low-income and middle-income countries limits generalizability beyond high-income settings. In addition, few studies directly measured patient safety outcomes, relying instead on associated risk factors. Lastly, international prevalence comparisons are complicated by differences in measurement tools, cultural perceptions, and health care systems.