Review
Determinants and prevalence of burnout in emergency nurses: A systematic review of 25 years of research

https://doi.org/10.1016/j.ijnurstu.2014.11.004Get rights and content

Abstract

Background

Burnout is an important problem in health care professionals and is associated with a decrease in occupational well-being and an increase in absenteeism, turnover and illness. Nurses are found to be vulnerable to burnout, but emergency nurses are even more so, since emergency nursing is characterized by unpredictability, overcrowding and continuous confrontation with a broad range of diseases, injuries and traumatic events.

Objectives

This systematic review aims (1) to explore the prevalence of burnout in emergency nurses and (2) to identify specific (individual and work related) determinants of burnout in this population.

Method

A systematic review of empirical quantitative studies on burnout in emergency nurses, published in English between 1989 and 2014.

Data sources

The databases NCBI PubMed, Embase, ISI Web of Knowledge, Informa HealthCare, Picarta, Cinahl and Scielo were searched.

Results

Seventeen studies were included in this review. On average 26% of the emergency nurses suffered from burnout. Individual factors such as demographic variables, personality characteristics and coping strategies were predictive of burnout. Work related factors such as exposure to traumatic events, job characteristics and organizational variables were also found to be determinants of burnout in this population.

Conclusions

Burnout rates in emergency nurses are high. Job demands, job control, social support and exposure to traumatic events are determinants of burnout, as well as several organizational variables. As a consequence specific action targets for hospital management are formulated to prevent turnover and burnout in emergency nurses.

Introduction

Several studies show that a positive experience of the work environment (low strain) is related to work engagement and professional commitment, while a negative perception (high strain) is related to a state of depletion of resources, called ‘burnout’ (Ahola et al., 2009). In the early '70s of the last century, Freudenberger defined burnout as ‘the extinction of motivation or incentive, especially where one's devotion to a cause or relationship fails to produce the desired results’ (Freudenberger, 1974). Shortly after, Christina Maslach defined burnout as a psychological state resulting from prolonged emotional or psychological stress on the job (Maslach and Jackson, 1981a, Maslach and Jackson, 1981b, Maslach et al., 2001). Maslach sees burnout as an internal emotional reaction (illness) caused by external factors, resulting in loss of personal and/or social resources: ‘Burnout is the index of the dislocation between what people are and what they have to do. It represents erosion in values, dignity, spirit, and will—an erosion of the human soul. It's a malady that spreads gradually and continuously over time, putting people into a downward spiral from which it's hard to recover’ (Maslach and Leiter, 1997).

Burnout, as defined by Maslach, has three dimensions. The first dimension of the burnout syndrome is “emotional exhaustion”. When the emotional reserves are depleted, employees feel that they are no longer able to provide work of good quality. They have feelings of extreme energy loss and a sense of being completely drained out of emotional and physical strength (Maslach and Jackson, 1981a, Maslach and Jackson, 1981b). The second dimension “depersonalization” is defined as the development of negative attitudes, such as cynicism and negativism, both in thinking as well as in behavior, in which coworkers and service recipients are approached with derogatory prejudices and treated accordingly (Maslach and Jackson, 1981a, Maslach and Jackson, 1981b). The third aspect is “lack of personal accomplishment”. This is defined as lack of feelings regarding both job and personal competence and failure in achieving goals (McDonald-Fletcher, 2008, Maslach and Jackson, 1981a, Maslach and Jackson, 1981b). There is a general consensus in the literature that emotional exhaustion is the central or core dimension of burnout (Gaines and Jermier, 1983, Sonnentag et al., 2010).

The consequences of burnout are multiple. Apart from a decrease in the quality of care (in case of health care jobs), a relationship was found between burnout and the occurrence of musculoskeletal disorders, depression, obesity, insomnia, alcohol intake and drug abuse (Poghosyan et al., 2010a, Sorour and El-Maksoud, 2012, Iacovides et al., 1999, Moustaka and Constantinidis, 2010). Burnout also has a negative impact on the quality of life of the employee, with more intra-relational conflicts and aggression (Wu et al., 2011). Finally, burnout can also lead to a significant economic loss through increased absenteeism, higher turnover rates and a rise in health care costs (Borritz et al., 2006).

The prevalence of burnout, assessed by use of a self-report instrument in a general working population in Western countries, ranges from 13% to 27% (Norlund et al., 2010, Lindblom et al., 2006, Kant et al., 2004, Houtman et al., 2000, Aromaa and Koskinen, 2004). Nurses are known to be at higher risk for the development of burnout then other occupations (Maslach, 2003, Gelsema et al., 2006). Research showed that nurses indeed report high levels of work related stress (Hasselhorn et al., 2003, Smith et al., 2000, Clegg, 2001, McVicar, 2003) and that 30% to 50% reach clinical levels of burnout (Aiken et al., 2002, Poncet et al., 2007, Gelsema et al., 2006). According to several authors, the demands that burden the nurses (in terms of work setting, task description, responsibility, unpredictability and the exposure to potentially traumatic situations) and the resources they can rely on, are strongly related to the content of their job and their nursing specialty (Browning et al., 2007, Ergun et al., 2005, Eriksen, 2006, Kipping, 2000, Mealer et al., 2007). Emergency (ER) nursing is a specialty that differs from other nursing specialties: work in emergency departments is hectic, unpredictable and constantly changing. ER-nurses are confronted with a very broad range of diseases, injuries and problems. Moreover, due to the hectic work conditions and overcrowding, emergency nurses often have to move from one urgency to another, with often little recovery time (Alexander and Klein, 2001, Gates et al., 2011). As a consequence, rates of burnout are found to be very high in emergency nursing settings (Hooper et al., 2010, Potter, 2006).

Section snippets

Aim

The aim of the present review is (1) to examine the level of burnout in ER-nurses and (2) to identify specific determinants of burnout in these nurses, including various individual and work-related factors.

Search methods

The databases NCBI PubMed, Embase, ISI Web of Knowledge, Informa HealthCare, Picarta, Cinahl and Scielo were searched in June 2014 for original research publications that were written or published in the last 25 years (1989–2014) in English, concerning exposure to occupational stress and its

Study population and study design

All of the 17 reviewed studies, except one (Van der Ploeg and Kleber, 2003), had a cross-sectional design. Self-report questionnaires were used for every study. The initial sample sizes ranged from 57 to 945 respondents (Median: 228) with response rates varying from 25.8% to 100%. Most of the researchers approached entire emergency care units. Two authors collected their data at conferences (Walsh et al., 1998, Browning et al., 2007). The mean percentage of female respondents in the studies was

Discussion

In the present study the research on burnout, conducted in the past 25 years in ER-nurses, was examined. This review focuses on (1) the prevalence of burnout in nurses working in ER-settings and (2) the identification of the determinants of burnout in terms of individual factors (demographic characteristics, personality factors, coping strategies and job attitudes) and work related factors (exposure to traumatic incidents, job characteristics and organizational factors). We analyzed the results

Implications for nursing

Although several studies suffer from methodological weaknesses and flaws, the present systematic review offers ideas for burnout prevention and nurse retention policy in ER-nurses. Interventions could focus on (1) the promotion of adequate professional autonomy (in terms of clinical decision making, interdisciplinary consultation and collaboration), (2) the creation of a good team spirit and sufficient peer support in ER-departments, (3) qualitative leadership of nursing supervisors (in terms

Conflict of interest

No conflict of interest has been declared by the author(s).

Funding statement

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

References (98)

  • A. Squires et al.

    A systematic survey instrument translation process for multi-country, comparative health workforce studies

    Int. J. Nurs. Stud.

    (2013)
  • H. Stathopoulou et al.

    Anxiety levels and related symptoms in emergency nursing personnel in Greece

    J. Emerg. Nurs.

    (2011)
  • B. Swider et al.

    Born to burnout: a meta-analytic path model of personality, job burnout, and work outcomes

    J. Vocation. Behav.

    (2010)
  • E. Adali et al.

    Burnout among nurses in intensive care units, internal medicine wards and emergency departments in Greek hospitals

    ICUs Nurs. Web J.

    (2002)
  • L. Aiken et al.

    Hospital nurse staffing and patient mortality, nurse burnout, and job satisfaction

    JAMA

    (2002)
  • D. Alexander et al.

    Impact of accident and emergency work on mental health and emotional well-being

    Br. J. Psychiatry

    (2001)
  • S. Ariapooran

    Compassion fatigue and burnout in Iranian nurses: the role of perceived social support

    Iran. J. Nurs. Midwifery Res.

    (2014)
  • A. Aromaa et al.

    Health and Functional Capacity in Finland: Baseline Results of the Health 2000 Examinations Survey

    (2004)
  • A. Bakker et al.

    Job resources buffer the impact of job demands on burnout

    J. Occup. Health Psychol.

    (2005)
  • A. Bakker et al.

    The relationship between the big five personality factors and burnout: a study among volunteer counselors

    J. Soc. Psychol.

    (2006)
  • J. Ball et al.

    RN4CAST Nurse Survey in England

    (2012)
  • M. Bernaldo-De-Quiros et al.

    Psychological consequenced of aggression in pre-hospital emergency care: cross sectional survey

    Int. J. Nurs. Stud.

    (2014)
  • M. Borritz et al.

    Burnout as a predictor of self-reported sickness absence among human service workers: prospective findings from three year follow up of the PUMA study

    Occup. Environ. Med.

    (2006)
  • V. Brenninkmeijer et al.

    How to conduct research on burnout: advantages and disadvantages of an unidimensional approach to burnout

    Occup. Environ. Med.

    (2003)
  • L. Browning et al.

    Nursing specialty and burnout

    Psychol. Health Med.

    (2007)
  • R. Burke et al.

    Burnout, work satisfactions and psychological wellbeing among nurses in Turkish hospitals

    Eur. J. Psychol.

    (2010)
  • J. Campos et al.

    Maslach Burnout Inventory—student survey: Portugal–Brazil cross-cultural adaptation

    Rev. Saúde Pública

    (2012)
  • A. Clegg

    Occupational stress in nursing: a review of the literature

    J. Nurs. Manage.

    (2001)
  • S. Collins et al.

    Working with the psychological effects of trauma: consequences for mental health-care workers—a literature review

    J. Psychiatr. Mental Health Nurs.

    (2003)
  • E. Donnelly et al.

    Occupational risk factors in the emergency medical services correspondence

    Prehospital Disaster Med.

    (2009)
  • F. Ergun et al.

    Quality of life of oncology nurses

    Cancer Nurs.

    (2005)
  • W. Eriksen

    Practice area and work demands in nurses’ aides: a cross-sectional study

    BMJ Public Health

    (2006)
  • V. Escribà-Agüir et al.

    Psychosocial work environment and burnout among emergency medical and nursing staff

    Int. Arch. Occup. Environ. Health

    (2006)
  • V. Escriba-Agüir et al.

    Psychological well-being and psychosocial work environment characteristics among emergency medical and nursing staff

    Stress Health

    (2007)
  • L. Flynn et al.

    Organizational traits, care processes, and burnout among chronic hemodialysis nurses

    West. J. Nurs. Res.

    (2009)
  • H. Freudenberger

    Staff burn-out

    J. Soc. Issues

    (1974)
  • J. Gaines et al.

    Emotional exhaustion in a high stress organization

    Acad. Manage. J.

    (1983)
  • D. Gates et al.

    Violence against nurses and its impact on stress and productivity

    Nurs. Econ.

    (2011)
  • T. Gelsema et al.

    A longitudinal study of job stress in the nursing profession: causes and consequences

    J. Nurs. Manage.

    (2006)
  • M. Gillespie et al.

    Burnout among nursing staff in accident and emergency and acute medicine: a comparative study

    J. Clin. Nurs.

    (2003)
  • N. Goalder et al.

    Mental health nurse burnout and stress: options for prevention

    Handover

    (2008)
  • J.R.B. Halbesleben et al.

    Nurse burnout and patient safety outcomes: nurse safety perception versus reporting behavior

    West. J. Nurs. Res.

    (2008)
  • H. Hasselhorn et al.

    Working Conditions and Intent to Leave the Profession among Nursing Staff in Europe

    (2003)
  • J. Häusser et al.

    Ten years on: a review of recent research on the Job Demand-Control (-Support) Model and psychological well-being

    Work Stress

    (2010)
  • I. Houtman et al.

    Psychische Vermoeidheid en Werk

    (2000)
  • A. Iacovides et al.

    Burnout in nursing staff: is there a relationship between depression and burnout?

    Int. J. Psychiatry Med.

    (1999)
  • H. Imai et al.

    Burnout and work environments of public health nurses involved in mental health care

    Occup. Environ. Med.

    (2004)
  • I. Kant et al.

    Burnout in de werkende bevolking? resultaten van de Maastrichtse Cohort Studie. (Burnout Among the Working Population. Results of the Maastricht Cohort Study)

    Gedrag en Organisatie

    (2004)
  • R. Karasek et al.

    Healthy Work: Stress, Productivity, and the Reconstruction of Working Life

    (1990)
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