Working in an emergency department (ED) is associated with high levels of stress.1 Multiple organizational factors such as overcrowding, excessive workload, staff shortages and budget constraints may lead to occupational stress.2 Staff stress levels can be further escalated after exposure to traumatic events or staff conflicts with inadequate support from colleagues or supervisors.3,4
Emergency department staff face unique stressors that are different from those in other specialties. Emergency department staff need to make time-critical decisions and provide prompt treatment to patients at their most acute stage of illness, often with limited knowledge of the patient's history.5 Staff are confronted with a broad range of illnesses and injuries in the complex ED environment, often facing consistent distractions or interruptions.6 They are required to perform in a chaotic and high-acuity setting while having to be consistently alert and agile to quickly identify and respond to life-and-death situations.7 Unlike other specialty areas, some parts of EDs (i.e. fast track area, waiting room) do not have standardized nurse/patient ratios, which can result in the ED becoming busy very quickly. Furthermore, some additional challenges that ED staff face on a regular basis include: a greater risk of exposure to workplace violence and the need to consistently juggle patient flow to compensate for bed management pressure in over-occupied hospitals.8 Consequently, high prevalence of work-related stress is reported among ED staff.9,10
Previous data have demonstrated that the prevalence of occupational stress and burnout is increasing in Australia,11 with a similar trend observed globally.12 The majority of work-related mental stress in Australia is due to work pressure.11 Australia's economic cost of occupational stress mental disorders is estimated to be over AUD12 billion each year.13 Emergency department staff report higher levels of stress than other hospital based specialities.14,15 Across a number of studies, between 26% to 66% of staff reported occupational stress, emotional exhaustion and burnout, depending on the specific professional group and organizational contexts.9,16,17 Prolonged exposure to workplace stress may have a negative impact on the psychological and physiological wellbeing of ED staff.18 The inability to cope with stress may also result in compromised quality of care for the patient, reduced productivity, absenteeism, high staff turnover and large economic costs to the healthcare system.9,17,19 Ensuring workforce longevity is an emerging issue for emergency health services.8,14 Given the negative impact of occupational stress on both staff and patients, there is a growing focus on the importance of promoting psychological wellbeing and managing stress among ED staff.20
A preliminary search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews and the JBI Database of Systematic Reviews and Implementation Reports (JBISRIR) was conducted on ED staff stress reduction interventions. Whilst systematic reviews do exist, they relate to stress and burnout prevention and management, each focused solely on either doctors,21-25 nurses,26,27 medical students28 or a combination of healthcare workers,29,30 rather than all staff working within emergency healthcare environments. One Cochrane review by Ruotsalainen et al.30 published in 2016 investigated interventions preventing occupational stress for all healthcare workers. When comparing the included studies in Ruotsalainen et al.'s review with the studies that were found in a preliminary search conducted for this review, many of the ED-specific studies were not included.31,32 The reason for this was that the review by Ruotsalainen et al.30 included only randomized controlled trials that investigated individual-focused interventions such as cognitive-behavioral interventions, physical or mental relaxation. In addition, the review did not break down the effectiveness of interventions by professional specialty, which makes it difficult to generalize these findings to the emergency environment. Basu conducted a systematic review that summarized the organizational stressors that may be present in the ED and made brief recommendations for clinical implications based on non-ED focused studies.33 The review included only one peer-reviewed study by Cooke et al. using 12-week aromatherapy and massage sessions as a stress reduction intervention among ED nurses in a single department. Again, many of the studies found in the preliminary search for this proposed review were not included. The current proposed review will consider a range of study designs and interventions to ensure all research investigating interventions to reduce stress and burnout for all staff working in the emergency environment are included.
Stress reduction interventions among healthcare workers tend to be categorized as either organizational-directed interventions (i.e. rostering) or individual-focused interventions (i.e. mindfulness).25 Depending on the type of stress, different interventions may be used. For example, debriefing is often used for acute stress whereas mindfulness-based interventions (MBIs) tend to be used for chronic stress prevention and management. Mindfulness-based interventions using various approaches appear to be the most commonly studied.25 One systematic review investigating interventions to prevent and reduce physician burnout reported that MBIs can effectively reduce stress compared with other interventions.25 The length and format of MBIs training vary from a few weeks of face-to-face formal training programs such as mindfulness-based stress reduction34 to mindfulness meditation practice that can be accessed via a website or an app.35
Over the past few years, research on stress management in EDs has increased, with more experimental and cohort studies being published from 2016 to 2018, which have not been included in past systematic reviews.36-41 Emergency departments have investigated various types of strategies, which include either organizational-directed interventions or individual-focused interventions. Individual-focused interventions such as mindfulness36,40 or specific training programs37-39,41 are widely used in many EDs to prevent or reduce workplace related stress by promoting coping and resilience skills. For example, Braganza et al. conducted a “oneED” program in one Australian ED by combining a one-day face-to-face mindfulness workshop and 12 months of ongoing mindfulness activities such as a “4-min pause” within the clinical area.36 Therefore, a systematic review to determine the effectiveness of interventions to reduce occupational stress and burnout specifically for staff working in the ED environment is required. This review will also present recommendations for stakeholders to develop stress prevention and coping initiatives for this specific population. Given the unique and highly stressful working environment and increasing role overload on ED employees, developing a review focusing on the specific ED population would provide highly relevant and deeper insights into this growing field of interest.
The review will consider studies that include all staff working in EDs, including doctors, nurses, allied health and administrative staff.
This review will evaluate any type of individual-focused or organizational-directed workplace intervention designed to manage occupational stress or burnout (acute or chronic) in the ED environment. Individual-focused interventions will include but not be limited to: mindfulness-based interventions (e.g. wellness programs), cognitive-behavioral based interventions, stress reduction interventions, pharmacological/herbal interventions, lifestyle interventions (e.g. changes to diet and exercise) and educational programs for improving resiliency or communication skills. Organizational-directed interventions will include but not be limited to changes in: resources, the working environment, work tasks, workload and/or shift length. There are no limits to the frequency, intensity and duration of interventions. Studies utilizing multi-faceted interventions will also be included.
This review will consider studies that compare an intervention to another intervention or no comparator (i.e. no intervention).
This review will include, but not be limited to, studies with the following outcome measures: perceived or biological measures of occupational stress, such as: burnout,42 compassion fatigue,43 or other psychological measurements (e.g. anxiety, depression). For studies to be included in the review, the occupational stress must be measured by a validated tool including but not limited to: the Perceived Stress Scale,44 Mental Health Professionals Stress Scale,45 Survey of Recent Life Experiences,46 Maslach Burnout Inventory,47 Hospital Anxiety and Depression Scale,48 Depression Anxiety Stress Scale,49 and State-Trait Anxiety Inventory.50
Types of studies
This review will consider both experimental and quasi-experimental quantitative study designs for inclusion such as: randomized controlled trials, non-randomized controlled trials, before and after studies and interrupted time-series studies. In addition, analytical observational studies including prospective and retrospective cohort studies, case-control studies and analytical cross-sectional studies will be considered for inclusion.
The proposed systematic review will be conducted in accordance with the Joanna Briggs Institute methodology for systematic reviews of effectiveness evidence.51
The search strategy will aim to locate both published and unpublished studies. An initial limited search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews and JBISRIR was undertaken to identify articles on the topic. The search strategy, including all identified keywords and index terms, will be adapted for each included information source. Databases PubMed, CINAHL, Embase, Cochrane Register of Controlled Trials, PsycINFO, Scopus and ISI: Web of Science will be searched using database subject headings and keywords (e.g. stress, burnout, physician/doctor, nurse, health personnel, emergency department, emergency room). Grey literature databases searches will include: MedNar, Google Scholar, ProQuest Dissertation and Theses, and Conference Proceedings. The specific search strategy for PubMed is outlined in Appendix I. In addition, the reference lists of all studies selected for critical appraisal will be manually screened for additional studies. The search timeframe will be from 2008 to the present and only articles in English will be considered for inclusion. The rational for commencing the search from 2008 is to include all relevant and recent studies in this area. From the preliminary search, we found that the majority of studies on this topic have been published within the past 10 years.
Following the search, all identified citations will be collated and uploaded into EndNote X9 (Clarivate Analytics, PA, USA) and duplicates removed. Study selection will be divided in two stages: i) titles and abstracts will be screened by two independent reviewers for assessment against the inclusion criteria for the review; potentially relevant studies will be retrieved in full; and ii) the full text of selected citations will be assessed in detail against the inclusion criteria by two independent reviewers. Reasons for exclusion of full text studies that do not meet the inclusion criteria will be reported in the systematic review. Any disagreements that arise between the reviewers at each stage of the study selection process will be resolved through discussion, or with a third reviewer. The results of the search will be reported in full in the final systematic review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram.52
Assessment of methodological quality
Eligible studies will be critically appraised by two independent reviewers for methodological validity prior to include into the review by using standardized critical appraisal instruments from the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI).51 Any disagreements that arise will be resolved through consensus. A third reviewer will be consulted if necessary. All studies, regardless of their methodological quality, will undergo data extraction and synthesis, where possible. A record of all included studies will be kept, which include the title, author, location and database where they were found. The results of critical appraisal will be reported in narrative form and in a table.
Data will be extracted from studies included in the review by two independent reviewers using the standardized data extraction tool from JBI SUMARI.51 The data extracted will include specific details about the populations, methods, interventions, and outcomes of significance to the review questions and objective. Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Authors of papers will be contacted to request missing or additional data, where required.
Quantitative data will, where possible, be pooled in statistical meta-analysis using RevMan Version 5.3.5 (Copenhagen: The Nordic Cochrane Centre, Cochrane). Effect sizes will be expressed as either odds ratios (for dichotomous data) and weighted (or standardized) mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard chi-squared x2 and I2 and also explored using subgroup analyses based on the different study designs and outcomes or themes that may be revealed in this review. Where statistical pooling is not possible, the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate.
Assessing certainty in the findings
The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach for grading the certainty of evidence will be followed53 and a Summary of Findings (SoF) will be created using GRADEpro (McMaster University, ON, Canada). The SoF will present the following information where appropriate: absolute risks for the treatment and control, estimates of relative risk, and a ranking of the quality of the evidence based on the risk of bias, directness, heterogeneity, precision and risk of publication bias of the review results.
The review is conducted in partial fulfilment of the requirements for the Doctor of Philosophy at the University of Queensland, Brisbane, Australia, for HX.
Appendix I: Proposed search strategy for MEDLINE
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