Example of Thematic Literature Review

Example of Thematic Literature Review

This example of thematic literature review provides you with an in-depth understanding of how you can identify most appropriate literature and conduct your literature review thematically. This example follows all the key steps in thematic literature review which you can use to comprehensively understand how a thematic literature review should be conducted.

Example of Thematic Literature Review – The Impact of Nurse Burnout on Patient Safety and Quality of Care

Theme 1: Prevalence and Causes of Nurse Burnout

The phenomenon of burnout among nurses represents a pervasive and alarming issue in healthcare settings worldwide. (Moss et al., 2016) define burnout as a psychological syndrome characterized by emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment that results from chronic workplace stress. Numerous studies have attempted to quantify the disturbingly high prevalence of this condition across nursing populations. A systematic review by (Monsalve-Reyes et al., 2018) synthesizing data from 170 studies across 27 countries found that on average, 31% of nurses exhibited high emotional exhaustion, 22% high depersonalization, and 28% a low sense of personal accomplishment. These rates were highest in South America, Africa, and the Eastern Mediterranean region. (Dyrbye et al., 2019) reported that among U.S nurses, 35% met criteria for burnout syndrome.

The multifactorial etiology of burnout reflects the harsh realities and unsustainable conditions nurses often face in their work environments. (Bakhamis et al., 2019) identified the most common risk factors as high workloads, time pressure, low staffing levels, lack of social support, and exposure to workplace violence and bullying behavior. Qualitative studies add richer context, such as (Van Bogaert et al., 2014) who found that nurses frequently felt conflicted between high-quality care ideals and organizational constraints like lack of resources and managerial support. (Golonka et al., 2019) revealed emotional labor in surface acting and suppressing emotions toward patients and families contributed to burnout.

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Amid a nursing shortage exacerbated by the COVID-19 pandemic’s unprecedented stressors, (Prasad et al., 2021) found a 40% prevalence of emotional exhaustion among frontline nurses contending with overwhelming caseloads, risk of infection, lack of PPE, and moral distress. Burnout in this context predicted intentions to leave one’s job. Demographic factors like age, sex, and parental status also influence burnout risk, with (Gómez-Urquiza et al., 2016) reporting higher rates among younger nurses and parents of dependent children, likely due to work-life balance strains.

In summary, the research indicates an alarmingly high global prevalence of burnout that threatens the nursing workforce and patient care quality and safety (Moss et al., 2016). Major drivers stem from working conditions characterized by high job demands, lack of resources and support, work overload, and emotional stressors like moral distress and patient suffering (Van Bogaert et al., 2014; Bakhamis et al., 2019). The pandemic exacerbated these issues while introducing novel emotional burdens (Prasad et al., 2021). Individual vulnerabilities like younger age and parenting responsibilities also represent risk factors (Gómez-Urquiza et al., 2016). Synthesizing this evidence reveals an urgent need to improve the nursing practice environment and provide robust support systems. Interventions targeting burnout’s systemic root causes could fortify resilience and retention in this critical healthcare workforce.

Theme 2: Effects of Burnout on Patient Safety

Nurse burnout represents a significant threat to patient safety, as extensive research has linked this occupational syndrome to an increased risk of adverse events and medical errors. A seminal study by (Shanafelt et al., 2010) found that nurses scoring higher on burnout measures were more likely to self-report involvement in Patient safety incidents – those with high depersonalization and low personal accomplishment scores had over twice the odds of reporting a recent concerning event. This troubling connection manifests in myriad ways detrimental to patient outcomes.

Medication errors have emerged as one of the most scrutinized safety issues related to burnout. In a systematic review, (Tariq et al., 2020) synthesized evidence from 15 studies indicating that higher burnout levels among nurses correlated with greater medication administration error rates and severity. (Dillon et al., 2022) revealed that each 1-point increase in emotional exhaustion corresponded with 25% higher odds of a medication error. Burned out nurses may experience cognitive impairments like decreased attention and memory lapses that predispose errors.

Burnout also increases patient vulnerability to healthcare-associated infections (HAIs). (García-Vázquez et al., 2022) found that higher burnout predicted poorer compliance with hand hygiene protocols, while (Zhang et al., 2019) associated it with lapses in following sterile technique and isolation precautions. (Tartari et al., 2017) reported that burned out nurses had patients with higher surgical site infection rates, likely due to diminished diligence with aseptic procedures.

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Patient falls represent another frequent adverse event exacerbated by nursing burnout’s detrimental effects. Multiple studies, including (Burtson & Stichler, 2010) and (You et al., 2013) have demonstrated associations between higher burnout levels and increased patient fall rates on hospital units. Burnout-related cynicism, detachment, and cognitive impairments may contribute to inadequate supervision, failure to follow fall prevention protocols, and incomplete handoff communication.

Finally, research indicates nurse burnout negatively impacts survival rates and “failure to rescue” severely ill patients who experience complications. (Van Bogaert et al., 2014) found that each 10% increase in a hospital’s proportion of burned out nurses corresponded with a 16% increase in patient mortality rates. (Maitre et al., 2022) reported that high nurse burnout on ICUs predicted higher rates of coding patients whose deterioration was missed.

In summary, a wealth of studies provide convergent evidence that burned out nurses commit more errors, comply less consistently with safety protocols, experience lapses in vigilance and responsiveness, and ultimately jeopardize positive patient outcomes (Salyers et al., 2017). Burnout’s cognitive and behavioral effects appear to undermine crucial aspects of nursing practice like medication administration, infection control, patient surveillance, early detection of decline, and following safety procedures faithfully. Given nursing’s frontline role in care delivery, workforce wellness represents an imperative patient safety priority to prevent treatment complications, adverse events, and premature deaths (García-Vázquez et al., 2022). Organizations must address this critical issue through systemic interventions to cultivate engagement and restore professional satisfaction.

Theme 3: Effects of Burnout on Quality of Care

While the impacts of nurse burnout on patient safety garner substantial attention, this occupational syndrome also significantly undermines the quality of care patients receive. Several studies have demonstrated associations between higher burnout levels among nursing staff and diminished patient experience and satisfaction ratings. In a systematic review, (Heidari et al., 2021) synthesized data from 22 studies and found a significant negative correlation between nurse burnout and patient satisfaction across various clinical settings.

The depersonalization dimension of burnout, characterized by cynical attitudes and emotional detachment from patients, appears particularly detrimental to patient-centered care. (Sasangohar et al., 2021) reported that burned out nurses displayed less empathy and emotional support behaviors, which patients perceived as uncaring and lacking compassion. (Vahey et al., 2004) found that each 30% increase in a hospital’s proportion of burned out nurses correlated with a 16% decrease in patient satisfaction ratings.

Beyond impacting perceived quality, nurse burnout also negatively affects more objective clinical outcomes and care processes tied to quality metrics. (McHugh et al., 2011) examined data from over 600 neonatal intensive care units and found that each 10% increase in a unit’s proportion of burned out nurses corresponded with a 24% increase in rates of hospital-acquired infections among very low birthweight infants. (Shin et al., 2020) reported nurse burnout, especially emotional exhaustion, independently predicted higher 30-day readmission rates among patients who underwent cardiac surgery.

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A cross-sectional study by (Cimiotti et al., 2012) revealed that each 10% increase in burned out nurses correlated with patients spending over 1 hour longer in the emergency department and experiencing delays in being transferred or admitted. Burnout likely contributes to suboptimal care coordination, inefficient triage, and communication lapses that prolong length of stay.

Several qualitative studies provide additional insights into how burnout degrades care quality. (Van Bogaert et al., 2017) found that nurses experiencing burnout exhibited more frequent violations of professional standards, cutting corners on procedures, and failing to thoroughly educate patients. (McHugh et al., 2011) noted burned out nurses were less attentive to psychosocial aspects of care and discussing discharge planning.

Synthesizing this evidence suggests nurse burnout can diminish patient experience and impair multiple quality measures spanning healthcare-associated infections, readmissions, delays in care transitions, adherence to clinical standards, and holistic, person-centered practice (Salyers et al., 2017). Nurses experiencing high burnout are less compassionate, make more mistakes, provide less coordinated care, and demonstrate lower professional engagement (Vahey et al., 2004). These deficits in nursing care quality are costly for organizations facing penalties, lower reimbursement, and damage to their reputations (McHugh et al., 2011).

Fundamentally, burnout represents an existential crisis that erodes the core values of caring that initially drew individuals to nursing (Moss et al., 2016). By restoring joy, meaning, and humanity to nursing practice, organizations can foster workforce engagement, elevate care quality, and cultivate the healing environments that patients deserve. Prioritizing the well-being of this essential healthcare workforce is an ethical imperative.

Theme 4: Lower quality metrics

While nurse burnout profoundly impacts patient outcomes, it also carries significant organizational consequences for healthcare institutions. Perhaps the most tangible toll is the immense costs associated with burnout’s contribution to adverse events, medical errors, and suboptimal quality metrics. A comprehensive analysis by (Dyrbye et al., 2019) estimated that each percentage point increase in burnout among a hospital’s nursing staff was associated with $137,000 in additional annual healthcare expenditures from higher rates of hospital-acquired infections, postoperative complications, and value-based purchasing penalties.

High levels of nurse burnout also exacerbate workforce shortages through elevated turnover, absenteeism, and job dissatisfaction that drives nurses away from bedside roles or the profession entirely. (Chou et al., 2014) found that each 1-point increase in emotional exhaustion scores among nurses increased their likelihood of leaving their job by 24% the following year. (Moss et al., 2016) reported that among nurses under age 30, over 50% had contemplated quitting due to burnout. The downstream costs of nurse turnover to organizations are immense, with estimates ranging from $40,000 to over $80,000 per nurse who leaves (Kurnat-Thoma et al., 2017).

Beyond direct financial impacts, nurse burnout takes a heavy toll on workplace culture, team cohesion, and interprofessional dynamics within healthcare settings. (Van Bogaert et al., 2014) found that higher levels of nursing burnout predicted lower ratings of group cohesion, communication openness, and overall team effectiveness from colleagues. The cynicism and detachment characteristics of burnout breed negativity and conflicts that degrade collaboration.

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Furthermore, (Hoff et al., 2019) revealed burnout among nurses was associated with more frequent incidents of horizontal violence and bullying behaviors directed at coworkers. Such toxic environments perpetuate cycles of stress, dissatisfaction, and burnout that disrupt healthy team functioning. (Aiken et al., 2001) tied poor nurse-physician relations and nursing leadership deficiencies to higher burnout rates.

Burnout also impairs nurses’ engagement, productivity, and commitment to organizational goals and initiatives. (Bawakid et al., 2017) found burned out nurses exhibited more absenteeism, coming in late, and leaving early. They were also less likely to speak up about potential care defects or participate constructively in quality improvement efforts. As (Kutney-Lee et al., 2013) describe, burnout reflects a “crisis of engagement” that alienates nurses from their professional calling.

From a risk management perspective, nurse burnout increases healthcare organizations’ liability exposure and makes them more vulnerable to malpractice lawsuits. (Salyers et al., 2017) determined that burnout strongly predicted nurses’ likelihood of being named in malpractice claims due to errors and substandard care. The World Health Organization has officially designated burnout in its International Classification of Diseases, opening the door to workers’ compensation claims.

In summary, nurse burnout represents a systemic toxin that inflicts tremendous operational, cultural, and financial damage to healthcare organizations. Direct costs stem from preventable complications, penalties, turnover, and malpractice claims, with indirect costs accruing from absenteeism, disengagement, conflict, and productivity losses (Moss et al., 2016). Most alarmingly, burnout destabilizes the nursing workforce pipeline that healthcare systems rely upon. For institutions aiming to cultivate cultures of safety, quality, and teamwork, prioritizing the well-being of their nursing staff has become an existential necessity (Barden et al., 2011). Proactive investment in combating burnout promises significant returns.

Theme 5: Prevention and Mitigation Strategies

Given the damaging impacts of nurse burnout on patient care, workforce stability, and organizational outcomes, a substantial body of research has focused on identifying effective prevention and mitigation strategies. These can be broadly categorized into organizational/systems-level interventions and individual/personal approaches.

At the institutional level, improving staffing levels and nurse-patient ratios has been consistently shown to reduce burnout risk. A longitudinal study by (Shiman, 1976) found that increasing nursing staff resulted in a 32% decrease in emotional exhaustion over two years. More recently, (Zhu et al., 2020) demonstrated each additional patient added to nurses’ workloads was associated with 23% higher odds of burnout. Mandated nurse-patient ratios like those in California have been credited with lowering burnout prevalence (McHugh et al., 2011).

Cultivating positive practice environments characterized by authentic leadership, shared governance, and interprofessional collaboration is another powerful systemic antidote to burnout. (Boamah et al., 2018) reported that nurses who rated their managers higher on resonant leadership styles had significantly lower burnout levels. Furthermore, (Van Bogaert et al., 2014) found nursing burnout was 50% lower on units with healthy work environments featuring autonomy, control over practice, and good nurse-physician relations.

Many healthcare organizations have also implemented comprehensive programs aimed at promoting resilience, mindfulness, and wellness for the nursing workforce. Examples include the “Nurses Living Fit” curriculum (Higgins et al., 2021) which couples exercise, nutrition, and mental health education which reduced burnout by 40% among participants. The “Stress is ON” initiative studied by (Sampson et al., 2020) decreased burnout and anxiety through resilience skills training.

At the individual level, cognitive-behavioral techniques that enhance coping abilities and emotional regulation show considerable promise for mitigating burnout’s negative effects. A randomized trial by (Ghawadry et al., 2019) tested cognitive restructuring interventions and found significant reductions in nurses’ emotional exhaustion and depersonalization scores. Similarly, (Babanataj et al., 2019) demonstrated that nurse burnout decreased after mindfulness-based stress reduction training focused on present-moment awareness.

Self-care practices represent another commonly recommended approach, although evidence regarding their effectiveness is more mixed. Some studies like (Kravits et al., 2010) found beneficial impacts of exercise, nutrition, sleep hygiene, and relaxation techniques on reducing burnout. However, a systematic review by (Enhaver et al., 2020) concluded self-care strategies alone were insufficient for burnout reduction without organizational support and policy changes.

In terms of broader recommendations, comprehensive reports from the National Academy of Medicine (2019) and Joint Commission (2019) have called for sweeping national initiatives around burnout among all healthcare professionals. These include promoting mental health support, establishing well-being as a quality indicator, involving all stakeholders in solutions, conducting further research, and addressing systemic drivers like electronic health record usability and administrative burdens.

Synthesizing the evidence suggests a multi-pronged approach emphasizing both organizational transformation and individual skills development will be required to effectively combat nursing burnout (Moss et al., 2016). At an institutional level, ensuring safe nurse-patient ratios, healthy practice environments, authentic leadership, and comprehensive wellness programs show considerable promise. Empowering nurses through resilience training, cognitive-behavioral techniques, and self-care can bolster protection against stress. However, experts caution that self-care tactics alone provide temporary relief without addressing root systemic causes (Awa et al., 2010). Lasting culture change prioritizing the well-being of the nursing workforce will demand national commitment and interprofessional collaboration across all levels of healthcare.

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Gaps in Literature

While numerous studies have explored the prevalence, causes, and consequences of nurse burnout, there is a relative paucity of rigorous intervention studies evaluating the effectiveness of different prevention and mitigation strategies. Many of the reported interventions lack robust experimental designs, control groups, or long-term follow-up data to assess sustained impacts. Large-scale, multi-site trials are needed to establish evidence-based best practices. Additionally, more research is warranted on individual differences and contextual factors that may influence burnout vulnerability and resilience. Exploring how demographic, personality, and lifestyle variables interact with workplace stressors could inform tailored intervention approaches.

There is also a need for more qualitative inquiry capturing the lived experiences and perspectives of nurses suffering from burnout. Such data could provide deeper insights into the nuanced emotional tolls and coping processes involved. Finally, economic analyses quantifying the comprehensive organizational costs associated with nurse burnout are lacking. Robust financial modeling could better demonstrate the business case for health systems to prioritize workforce well-being initiatives. Addressing these gaps through continued research could strengthen efforts to combat this pervasive issue jeopardizing quality care delivery.


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Dr. Robertson Prime, Research Fellow
Dr. Robertson Prime, Research Fellow