Life in the OR can come with a heavy burden on staff. Fast-paced shifts and routinely high stakes regularly create situations that are pressured, safety-critical, and emotionally taxing. There's little room for error and little time to spare.

Meanwhile, surgical care is changing rapidly to meet demands for efficiency and cost-effectiveness, placing extra pressure on systems and teams. Staff shortages and high turnover compound daily challenges; newcomers need to become productive as quickly as possible, while teams must adapt to regular changes and integrate increasingly complex technology into their workflows. Supervision burdens are growing. Documentation is complex and laborious. Then there was COVID…

This article takes a hard look at the impact of burnout in surgical care, exploring the critical relationship between staff well-being and performance in the OR. We look at strategies to help reduce the burden on our teams, building supportive infrastructures that improve collaboration, encourage growth, and promote a healthier, more sustainable work environment.

A Parallel Pandemic

Burnout in healthcare has reached critical levels. In 2022, the CDC declared a “mental health crisis” facing healthcare workers, with 46% of respondents reporting symptoms of burnout the previous year. Up from 32% in 2018, this offers a glimpse into the impact of the COVID-19 pandemic on our workforce, with researchers describing “a parallel pandemic” of psychosocial trauma in staff [1].

In the OR, burnout hits especially hard. A landmark study of members of the American College of Surgeons found that 40% of responding surgeons screened positive for burnout [2] with more recent estimates putting this closer to 50% for attending surgeons and nearly 70% for residents [3]. In nursing, rates of over 50% have been repeatedly reported, exacerbated by unprecedented patient volume and understaffing during the pandemic [4]. Prevalence is similarly high in anesthesiology, with rates approaching 40%, and surgical technology, where over 60% regularly experience high levels of emotional exhaustion [5, 6].

High levels of burnout are seen in the OR, with rates around 50% measured across all professional groups.

Rates of burnout measured in the OR reflect those seen in other high-risk clinical settings like the ICU. Unless our teams can work in these environments in a state of well-being, it is hard to see how they can meet the unprecedented challenges facing hospitals today. A 2023 case study in OR nurses emphasized that their well-being at work “underpins and drives effective teamwork, and not the other way round.” In other words, staff well-being is seen as a prerequisite for a positive and productive OR, rather than a product of it [7].

The Cost of Burnout

These numbers give a snapshot of a deep-rooted problem that is now the focus of a number of high-profile initiatives and programs. Burnout is recognized by the World Health Organization as a workplace phenomenon caused by chronic, unmanaged stress. It is characterized by a triad of emotional exhaustion, depersonalization (cynicism or mental detachment), and a reduced sense of personal accomplishment. The syndrome has severe consequences that negatively impact workers’ health and quality of life, including high rates of substance abuse, absenteeism, depression, illness, and suicide.

Beyond its immediate impact on clinicians, burnout severely affects the quality and safety of patient care. Large-scale studies have demonstrated a direct association between burnout scores and the likelihood of committing a major medical error. In the ICU, for example, the level of burnout in nurses and doctors is an independent predictor of patients dying [8]. In surgery, it is also associated with poorer clinical outcomes and reduced patient satisfaction [9].

The other significant cost of burnout is to our workforce. Burnout among doctors costs the U.S. healthcare system an estimated $4.6 billion annually [10]. Nurses suffering from burnout are significantly more likely to experience low job satisfaction, reduced productivity, and increased intention to leave–resulting in higher turnover and reduced retention [11]. In 2023, the vacancy rate of perioperative RNs was about 16% (nearly tripling from 6% in 2014). What’s more, first-year turnover among OR nurses was almost 30% in 2023, taking an average of 98 days to fill an open OR nurse position [12]. This creates a vicious cycle of stress and understaffing, directly impacting a hospital's capacity for surgical care provision and perioperative services.

"We know that a large number of experienced OR nurses left the profession during the pandemic, and these losses made existing shortages worse … staff shortages fuel stress and burnout, which leads to more staff leaving, and the cycle continues.”

- James Stobinski, Ph.D., RN, CNOR, Director of Education for the National Institute of First Assisting (accessed via ortoday.com)

Beyond Burnout: Moral Injury and Administrative Harm

The profound cost of burnout has led to several large-scale initiatives from agencies such as The Joint Commission, American College of Surgeons, and American Nurses Association. However, the surge of interest and research has also been accompanied by a growing concern that it is becoming a catchall for all distress experienced by healthcare workers, masking important drivers of well-being and opportunities for intervention.

The term “burnout” can be problematic for clinical staff, suggesting a failure of resilience that is particularly unhelpful (and untrue) in perioperative care. In the OR, we often take pride in our ability to work well under pressure and meet high demands; the concept of chronic workplace stress often fails to grasp the lived reality of day-to-day experiences.

When clinicians are directly asked, the negative feelings that can lead to burnout often don't come directly from stress or overwork but rather from a repeated conflict between what we see happen and what we know should happen. Healthcare staff frequently report feeling demoralized by systems that put profit and performance ahead of patients and staff. Repeated exposure to things that do not align with deep-held values creates a deep sense of distress, and can lead to what has been termed “moral injury.” This might include delivering poor-quality care due to understaffing or seeing a patient harmed due to a lack of resources. Moral injury can lead to anger, depression, PTSD, and intention to leave, overlapping but distinct from what is often talked about under the term burnout.

Closely related to moral injury is the concept of “administrative harm,” caused by repeated exposure to the outcomes of decision-making influenced purely by financial incentives and corporate interests. These types of organizational decisions can cause frustration and disillusionment for staff, prioritizing short-term gains while neglecting longer-term impacts on patient care and staff well-being.

"Burnout, demoralization, and administrative harm are much more than hot topics of the day ... they are a clear and present danger to the future of health care, and we ignore them at our peril.”

- Joseph R. Betancourt, MD, MPH, President of the Commonwealth Fund (accessed via commonwealthfund.org)

Building Trust and Support

Along with an understanding of the scale of the problem, it has become well-established that burnout rates are strongly related to key individual and workplace-related factors. Initiatives designed to improve resilience and coping, such as mindfulness and resilience training, can be effective; however, researchers have emphasized that while supporting individual resilience is worthwhile, it is inadequate to address the organizational factors that are often prime movers of burnout. Generic human resources approaches can even increase feelings of disconnect between staff and management [13].

Organizational factors have repeatedly shown the most significant impact on OR staff well-being, in particular, initiatives focused on enforcing manageable workloads and ensuring equitable scheduling. Lack of trust in management, poor senior support, unpredictable workloads, and overwork due to understaffing all lower staff morale and resilience, driving burnout and turnover. Effective approaches to wellness seek to tackle these factors directly despite the organizational challenges involved.

The role of leaders in promoting well-being has been repeatedly emphasized, with structured approaches such as wellness-centered leadership prioritizing transparency, compassion, and meaningful engagement with staff [14]. Building trust through equitable practices is crucial to a positive work environment, and wellness-centered leaders can cultivate relationships and drive changes by representing diversity, integrity, and self-awareness to their teams. In many work environments, we still have a long way to go.

"When nurses believe their schedules are fair and equitable, demonstrate best practices, and ensure their individual and unit’s needs are met, this builds trust and satisfaction.”

— ChrysMarie Suby, RN MS, President-CEO Labor Management Institute, Inc. (accessed via ortoday.com)

Technology That Drives Confidence

Along with the role of leaders, the potential for technological solutions to improve well-being marks an important development. Over recent years, a growing cause of stress has been related to the workload associated with documentation and legacy electronic health record (EHR) software. In the OR, staff are required to access and document a multitude of data to ensure compliance with regulations, maintain records, and prepare each case in accordance with each surgeon's preferences. Routine patient documentation can take nurses as many as 200 clicks per patient, leaving less time for direct patient care [15]. Systems that enable teams to reduce the time they spend accessing and recording information can reduce the cognitive load for each shift, enabling clinical staff to spend more time on patient-directed activities. In a 2021 survey, 53% of the nurses who responded said their work environment could be improved and burnout levels reduced through more straightforward documentation and better information access [16].

In addition to streamlining processes, technology has an important role in building confidence and preparedness. Confidence is central to mental well-being, boosting resilience and driving performance. It is intimately connected to feelings of preparedness and stress that are often based on the perceived evaluation of other people, especially in a hierarchical environment like the OR.

Feeling unprepared negatively impacts both confidence and performance in the OR. In an American Journal of Surgery study, 89% ranked preparation as a very important strategy to improve surgical performance in critical situations [17]. Junior staff are particularly exposed to feeling underprepared, lacking familiarity with their work colleagues and institutions and personal experiences contributing to resilience. New OR staff frequently report considerable stress caused by fear of looking unprepared to surgeons and other team members.

"Confidence is probably the most important resource in human well-being and performance […] the greatest source of anxiety is the fear of the negative evaluation of other people.”

- Professor Ian Robertson. Professor of Psychology and Co-Director Global Brain Health Institute (accessed 10 Dec, 20204, via edition.cnn.com)

Improving the OR Together

Platforms such as Incision Assist can help improve confidence by providing teams with surgeon-specific, case-relevant information in an easily accessible format. In a recent case study, 90% of Assist users reported feeling better prepared, more confident, and less stressed. Improved wellness provides a platform that drives a cycle of continuous improvement, reflected in improved operational performance, such as reduced turnover times, as well as improved staff satisfaction. Hospitals are using Assist to introduce new workflows to their OR teams, such as those based around robotic platforms, reducing stress among more seasoned staff caused by new or unfamiliar technology. Assist is also used to supplement and strengthen orientation programs, providing a high-impact resource to both preceptors and newcomers. The application of team-focused interventions to optimize onboarding has been used elsewhere to significantly reduce OR staff turnover [17].

Burnout in surgical care is not inevitable—it’s a challenge we can meet with thoughtful solutions and meaningful action. By simplifying access to team-critical information, tools like Assist can enhance preparedness and boost confidence, helping teams drive improvements in their daily work from a position of empowerment and support. Through prioritizing staff well-being, fostering trust, and leveraging technology, we can work together to create high-performing OR environments that enable both staff and patients to thrive.

To learn more about how Incision Assist is supporting perioperative teams, visit incision.care/products/assist.