ReviewDeterminants and prevalence of burnout in emergency nurses: A systematic review of 25 years of research
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.
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