The effect of sleep quality and depressive symptoms on the relationship between burnout and health-related productivity loss in nurses working in intensive care: a cross-sectional study from the Chinese nurses’ health cohort study (TARGET)

Burnout is highly prevalent among ICU nurses and compromises physical and psychological well-being, leading to productivity loss. However, limited evidence exists regarding the pathways through which burnout influences productivity, particularly the role of sleep disturbance and depression. Few studies have examined the mechanisms through which burnout affects health-related productivity in intensive care unit (ICU) nurses. This study addresses this gap by investigating the sequential mediating role of sleep quality and depressive symptoms in the relationship between burnout and health-related productivity loss. A cross-sectional study. Baseline data from the Chinese Nurses’ Health Cohort Study, collected between December 2020 and February 2024, included 3,491 ICU nurses. Burnout, health-related productivity loss, sleep quality and depressive symptoms were assessed using the Maslach Burnout Inventory–Human Services Survey, Stanford Presenteeism Scale, Pittsburgh Sleep Quality Index and Patient Health Questionnaire-9. Chain mediation analysis was conducted using the SPSS PROCESS macro, and subgroup analyses were performed. Data from 3,491 ICU nurses were analyzed. Subgroup analyses showed female nurses aged 18–30 years, with a master’s degree or above, senior titles, contract positions, clinical roles, and 6–10 years of experience reported higher productivity loss. Productivity loss correlated with burnout, poor sleep quality, and depressive symptoms. Mediation analysis using Bootstrap resampling (5,000 iterations) revealed that burnout had a significant total effect on productivity loss (β = 0.1019, 95% CI [0.0963, 0.1076]). The direct effect remained significant after accounting for mediators (β = 0.0587, 95% CI [0.0527, 0.0647]). The sequential indirect effect through sleep quality and depressive symptoms was significant (β = 0.0422, 95% CI [0.0395, 0.0469]), indicating that burnout impaired sleep quality, which increased depressive symptoms and ultimately contributed to greater productivity loss. The relationship between burnout and health-related productivity is mediated by sleep quality and depressive symptoms. Interventions reducing burnout, improving sleep quality, and preventing depression may help mitigate productivity loss. The study protocol for TARGET was registered with the China Clinical Trial Registry (registration number: ChiCTR2100043202, February 8, 2021, https://trialsearch.who.int/Default.aspx ).