Summary of findings
Occupational stress is defined as a reaction that may occur when an individual's job demands and pressures do not match their knowledge, capacity, and ability to cope.1 The symptoms of occupational stress may vary and can manifest in many forms such as compassion fatigue, a reduced capacity and interest in being empathetic towards the suffering of others,2 and psychological signs such as anxiety or depression. Common occupational stressors in the health care industry can increase health care workers’ risk of distress. When health care workers are unable to manage high job stress on a regular basis, they are likely to experience burnout. Burnout, as a response to prolonged exposure to chronic occupational stressors, is generally characterized as emotional exhaustion, depersonalization, and decreased personal accomplishment.3
There is a large amount of literature reporting on the high prevalence of occupational stress and burnout in emergency departments (EDs) globally.4 A number of studies state that between 26% and 82% of ED nurses and physicians report burnout,5-8 which is higher than in other specialties.9 Additional studies also found that 85% of ED nurses reported at least one symptom of secondary traumatic stress,10 86% of ED nurses reported moderate to high levels of compassion fatigue,8 and 52% of ED staff reported moderate to severe anxiety.11 This phenomenon is closely related to occupational stressors such as high ED service demands, overcrowding, work overload, lack of control, exposure to traumatic events, and resource shortages.7,12,13 Other occupational stressors in EDs include working in a chaotic and consistently changing working environment that demands rapid critical decision making and response to life-and-death situations.14 With limited information about patient history, ED staff are required to perform quick assessments and manage a wide range of complex clinical situations.15 It is well documented that ED staff face assaults by either patients or patients’ family members more frequently than other specialties.16,17 As overcrowding and access block affect many EDs, staff are required to be flexible and adaptable to accommodate changing workloads. Occupational stress levels can also be intensified by interpersonal issues between colleagues and inadequate manager support.18,19 As a consequence of chronic exposure to these unavoidable occupational stressors, ED staff report higher incidents of occupational stress and burnout.7,20
High occupational stress and burnout have detrimental effects not only on individual staff, but also on patient safety and an organization's financial profile. Prolonged exposure to these occupational stressors can place staff at risk of depression, anxiety, musculoskeletal pain, fatigue, sleep disturbances, and cardiovascular diseases.21-23 Exposure to stress on a repetitive basis without adequate coping strategies can lead to maladaptive behaviors such as smoking, alcohol or substance abuse, and suicide.24,25 In addition, burnout has negative impacts on social relationships with co-workers. A qualitative study exploring the experience of occupational stress on ED nurses found that high levels of emotional and mental fatigue led to bullying, aggression, interpersonal confrontations, and low staff morale within the workplace.26 Besides these negative impacts on staff, burnout can also cause harm to patients and impact on organizational safety. A systematic review by Hall and colleagues27 found that staff burnout has a significant negative association with patient safety. The impact of burnout on the organization includes reduced productivity, increased absenteeism, poor staff retention, and high training costs, which lead to economic loss to the organization and community.6,27 Given the devastating effects of occupational stress on staff, patients, and the organization, it is essential to promote staff well-being and manage occupational stress in emergency health service staff.28-30
Existing stress management interventions primarily focus on either organizational-directed interventions or individual-focused interventions. Organizational-directed interventions are strategies used to modify organizational factors or implement policy and procedure changes to reduce sources of stress generated by the job or organization. Examples include changes to staff on-call periods and reduced working hours or workloads to minimize workplace stress.31-33 Individual-focused interventions refer to strategies focusing on promoting the individual's tolerance or coping abilities to manage workplace stress. Common individual strategies include mindfulness techniques, cognitive-behavioral therapy, or education to improve individuals’ communication skills or coping strategies.34,35
Mindfulness is an awareness training that encourages the individual to pay attention to the present moment and respond non-judgmentally.36 It allows an individual to be open and accepting, instead of reacting to a stressful situation. Mindfulness-based stress reduction interventions have been extensively reviewed in many systematic reviews in various populations,37-41 including health care workers,42-45 with positive stress reduction outcomes. In comparison, cognitive behavior therapy is a psychotherapy used to change and replace negative thoughts and behaviors with more positive and constructive solutions.46 In addition to its main usage in reducing depression and anxiety,47,48 cognitive behavior therapy is also used in stress reduction49 and suicide prevention.50 Educational interventions include training or programs designed for specific purposes, such as promoting staff wellness,51 self-care,52 lifestyle changes,53 effective communication,54 resilience, and stress management.55
A preliminary search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews, and the JBI Database of Systematic Reviews and Implementation Reports was conducted and no current or ongoing systematic reviews on this topic were identified. Although there are published systematic reviews,56-61 including Cochrane reviews,62,63 that address occupational stress management among health care workers, none of these reviews focus on ED staff specifically. The meta-analysis results in the most recent Cochrane review62 suggested that individual-focused interventions such as cognitive behavioral training, and mental (e.g. meditation) and physical relaxation (e.g. massage) decreased stress compared with no intervention. However, the majority of organizational-directed interventions included in the review had no clear effect on stress reduction apart from low-quality evidence suggesting that changing work schedules may reduce stress.62 One recent systematic review's64 primary aim was to summarize ED stressors; however, the review only included one peer-reviewed ED stress reduction intervention study. In addition, studies with fewer than 50 participants were excluded.64 Therefore, the objective of this review was to determine the effectiveness of interventions to reduce occupational stress, and/or burnout in all staff who work in the emergency department.
What is the effectiveness of interventions to reduce occupational stress and/or burnout among ED staff?
The review considered studies that included all health personnel working in EDs, such as physicians, nurses, and allied health and administrative staff. Any hospital setting providing emergency care, irrespective of size, was considered for inclusion, such as large tertiary hospitals or small rural remote hospitals. There was no restriction regarding participants’ educational levels or years of clinical experience.
This review included studies that evaluated any type of individual-focused or organizational-directed workplace interventions designed to manage occupational stress or burnout (acute or chronic) in the ED environment. There was no restriction regarding the content, length, and/or frequency of the intervention. Individual-focused interventions included 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 included changes in resources, working environment, work tasks, workload, and/or shift length. There were no limits to frequency, intensity, or duration of interventions. Studies utilizing singular or multi-faceted interventions were included.
This review considered studies that compared the intervention of interest to a different intervention or no intervention.
This review included studies with perceived or biological measures of occupational stress and burnout as the primary outcome measures.3 For studies to be included in the review, the occupational stress needed to be measured using a validated tool such as, but not limited to, the Perceived Stress Scale,65 the Mental Health Professionals Stress Scale,66 the Survey of Recent Life Experiences,67 and Maslach Burnout Inventory.68
The secondary outcomes included perceived or biological measures of compassion fatigue,69 or other psychological measurements (e.g. anxiety, depression). The types of measurement tools for these outcomes included the Compassion Fatigue self-test,70 the Hospital Anxiety and Depression Scale,71 the Depression Anxiety Stress Scale,72 and the State-Trait Anxiety Inventory.73
Types of studies
This review considered experimental, quasi-experimental, and other types of quantitative study designs for inclusion, such as randomized controlled trials (RCTs), before-and-after studies, and interrupted time-series studies. Single group studies with pre-test/post-test designs were also included. In addition, analytical observational studies including prospective and retrospective cohort studies, case-control studies, and analytical cross-sectional studies were considered for inclusion. If the study design used mixed methods, only the quantitative data were included.
This systematic review was conducted in accordance with the JBI methodology for systematic reviews of effectiveness74 and an a priori protocol.75
The search strategy aimed to find both published and unpublished studies. A three-step search strategy was utilized in this review. An initial limited search of PubMed and CINAHL was undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the articles. The search strategy, including all identified keywords and index terms, was adapted for each included information source and was initially undertaken on November 1, 2018, for papers published in English from January 1, 2008, until November 1, 2018. This time frame was selected because the preliminary search found most relevant studies had been published after 2008. An updated search was undertaken on February 1, 2019, prior to drafting the review. The full search strategies are provided in Appendix I. Finally, the reference lists of all studies selected for critical appraisal were screened for additional studies.
The databases searched included CINAHL via EBSCO, Cochrane Central Register of Controlled Trials via Cochrane Collaboration, Embase via EBSCO, PubMed via EBSCO, Scopus via Elsevier Science, PsycINFO via EBSCO, and Web of Science via Web of Science.
The search for unpublished studies included MedNar, Google Scholar, ProQuest Dissertations and Theses, and Conference Proceedings.
Following the search, all identified citations were uploaded into EndNote X9 (Clarivate Analytics, PA, USA) and duplicates were removed. Studies were selected by screening titles and abstracts against the inclusion criteria, with potentially relevant studies retrieved in full and assessed by two independent reviewers (HX, KK). Reasons for exclusion of full-text studies were recorded (Appendix II). No disagreements arose between the reviewers; therefore, a third reviewer was not required.
Assessment of methodological quality
Two reviewers (HX, KK) independently assessed the eligible studies that met the review inclusion criteria for methodological validity prior to inclusion in the review. The standardized critical appraisal instruments for experimental and quasi-experimental studies from the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia)74 were used according to the study design. Authors of papers were contacted twice to request missing or additional data for clarification, where required. Five authors responded and provided additional data. We were unable to contact four authors due to lack of published contact details. Any disagreements were resolved through consensus without needing to consult a third reviewer. Regardless of methodological quality, all studies were included for data extraction and synthesis.
Two reviewers independently extracted data from the included studies using the standardized JBI data extraction tool in JBI SUMARI.74 The extracted data included specific details about the populations, methods, interventions, and outcomes of significance to the review question and objective. At this stage, a further three authors76-78 were contacted to request missing or additional data, with all providing additional data that was used in the review.
Where possible, meta-analysis was performed using RevMan V5.3.5 (Copenhagen: The Nordic Cochrane Centre, Cochrane). Heterogeneity was assessed statistically using the standard chi squared (x2) and I2 tests. Analyses were performed using a fixed-effects model. Choice of this model was based on the guidance of Tufanaru et al.79 and also due to the small number of included studies in the meta-analysis and presence of low heterogeneity (I2<25%).80 Effect sizes were expressed as standardized mean differences (SMDs) for continuous data and their 95% confidence intervals (CIs) were calculated for analysis. Where statistical pooling was not possible, the findings are presented in narrative form including tables and figures to aid in data presentation.
Assessing certainty in the findings
The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach for grading the certainty of evidence was followed81 and a Summary of Findings was created using GRADEpro GDT Version 4 (McMaster University, ON, Canada). The Summary of Findings presents the following information where appropriate: outcomes, impact, number of participants and studies, a ranking of the certainty of the evidence based on the risk of bias, directness, heterogeneity, precision, and risk of publication bias of the review results.
The results of the search are presented in a PRISMA82 flow diagram (Figure 1). A total of 6399 records were found following the search of databases and gray literature sites. Following the removal of duplicates, 81 full texts were retrieved for review. Sixty-seven papers were excluded after reviewing the full texts as they did not meet the inclusion criteria for this review (Appendix II). Some of the reasons for study exclusion at this stage included ineligible population, outcomes not included in the review, or ineligible study designs. In total, 14 articles met the inclusion criteria and were included in this review.
Tables 1 and 2 summarize the critical appraisal results of the included studies. All studies were included in the review regardless of methodological quality; however, some methodological issues were identified. The four RCTs included lacked either true randomization, concealment of treatment assignment to treatment allocator, blinding of participants to treatment assignment, or blinding of those delivering treatment. Only one study83 reported in-depth details of the randomization process. It was unknown if true randomization was achieved in the remaining three studies84-86 due to limited reporting of the process. A similar issue was identified for concealment to treatment assignment. Apart from one study,83 treatment allocators appeared not to be blinded,84-86 which increases the risk of allocation bias. Due to the nature of the interventions being investigated, it was not uncommon for participants to know to which group they were being allocated; hence, it was not always possible to blind participants. Blinding of those delivering the treatment was either unclear or not undertaken in three studies. The methodological quality of the 10 quasi-experimental studies54,76-78,87-92 were assessed using the JBI quasi-experimental critical appraisal assessment tool.74 Only one quasi-experimental study78 used a comparison group; the remaining nine studies were single-group studies utilizing pre- and post-test design without a comparator.
Characteristics of included studies
All included studies measured either stress and/or burnout levels in staff working in the emergency department. Appendix III provides a summary of the study characteristics. Out of the 14 studies, 12 were published between 2016 and 2019, with the remaining two studies published in 2011 and 2013. The geographical locations included the United States (n = 4),78,89-91 Europe (n = 4),77,83,87,92 Australia (n = 2),76,84 Asia (n = 2),85,86 the Middle East (n = 1),54 and Africa (n = 1).88 The sample sizes within the included studies varied widely from 14 to 392 participants. In total, there were 1033 participants across the 14 included studies. A large proportion of study participants were either exclusively ED nurses (n = 6)54,76,85,86,89,91 or ED physicians (n = 4).78,83,84,88 Two studies included both ED physicians and nurses as participants (n = 2).77,87 Two studies involved all ED staff including allied health as well as non-clinical administrative staff (n = 2).76,92 One study included ED nurses and emergency medical technicians (n = 1).90
The types of study designs included quasi-experimental studies (n = 8),54,77,78,87-91 RCTs (n = 4),83-86 and the quasi-experimental component of a mixed-methods design (n = 2).76,92 As this systematic review focused on effectiveness, only quantitative data from both mixed-methods studies were included in the review. Both individual-focused interventions (n = 10)54,76,83-89,91 and organizational-directed interventions (n = 4)77,78,90,92 were investigated across the studies. There were considerably large variations regarding content, length, and intensity of the interventions investigated in the included studies.
All studies included in the review used self-reported psychometric tools to measure outcomes. The Maslach Burnout Inventory,54,76,78,83,87,90,92 the Perceived Stress Scale,84,87,91 and the Professional Quality of Life Scale88,89 were the most commonly used tools. The majority of the studies measured both stress and burnout (n = 6),76,83,84,87-89 or either stress (n = 3)77,85,91 or burnout (n = 5)54,78,86,90,92 alone. One study also measured depression.92 None of the included studies measured compassion fatigue and anxiety. Apart from one study88 that measured outcomes before and three months after the intervention period, all other studies54,76,77,83-87,89-92 measured outcomes before and immediately after the intervention. One study83 included additional follow-up at six months, and one study78 measured an ongoing program one year later.
The findings of the review are presented as individual-focused (10 studies) and organization-directed interventions (four studies).
Six studies (n = 6) investigated educational interventions and four studies (n = 4) investigated mindfulness-based interventions (MBIs) to reduce stress and burnout in ED.
Two RCTs83,86 and four quasi-experimental studies54,87-89 investigating the effectiveness of an educational program to reduce occupational stress were included.3 There was variation in terms of program content, intensity, and length across all six studies. One study by Kharaghani et al.54 implemented communication skills training without clearly reporting the program content, intensity, and length. The remaining five studies provided more detailed information about the design of their programs.
Flarity et al.89 delivered compassion fatigue resiliency education in a single, four-hour interactive group seminar. In addition, the program offered participants a range of multimedia resources including seminar handouts, DVDs, CDs, and access to a website with educational resources regarding compassion fatigue. The remaining studies offered training on a more regular basis and over longer periods. Mache et al.83 implemented 90 minutes of mental health promotion training weekly for 12 weeks. The training was provided by qualified psychologists with the focus on actual work situations and problems, coping strategies, and colleague support. Caponnetto et al.87 provided autogenic training, a form of relaxation therapy involving self-hypnosis, twice a month for 16 weeks. Each session lasted 180-minutes and was guided by psychologists. Two additional studies had similar training intensity and length (twice a week for six months), but with different educational topics. El-Shafei et al.88 delivered a Worksite Wellness Education program, which incorporated two 30- to 45-minute educational sessions weekly for six months. The program focused on improving the wellness knowledge skills and coping strategies of participants by covering topics such as work-related stress, smoking and substance abuse, malpractice, exposure to patient mortality, and infectious disease. Wei et al.86 tested an active intervention that was delivered by nurse managers. Participants in the intervention group received training 30 minutes twice a week during meetings for six months covering a range of work-related coping skills such as communication, confliction, and emotion control.
The Maslach Burnout Inventory and the Professional Quality of Life scale were used to measure outcomes in six of these studies.54,83,86-89 The Maslach Burnout Inventory tool was broken down and reported as three subscales: emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA). Other psychometric tools used to measure stress and/or burnout in the six included studies that investigated educational interventions included Perceived Stress Scale, Perceived Stress Questionnaire, Copenhagen Psychosocial Questionnaire, Utrecht Work Engagement Scale, and Emotion Regulation Skills Questionnaire-27.
All studies reported statistically significant decreases in stress and/or burnout levels in the participants after delivery of their interventions.54,83,86-89 The RCT by Mache et al.83 investigating a mental training program reported between-group effects, with the intervention group demonstrating highly statistically significant reduction in perceived stress levels at the end of the program (Mann Whitney U = 527; P<0.01), at 12 weeks (Mann Whitney U = 643; P<0.01), and six months later (Mann Whitney U = 669; P = 0.1), compared to the waiting list group. A highly statistically significant effect was also reported when investigating the impact of the program on burnout (P<0.01). Over time, the effect size for the outcome of EE decreased slightly (at end of the program: Cohen's d = 0.61; 12 weeks post intervention: Cohen's d = 0.50: P<0.01). Similarly, Caponnetto et al.87 noticed a statistically significant stress reduction from pre- to post-test in their study (t(27) = 7.72, P<0.001), and a statistically significant burnout reduction in both EE subscale (t(27) = 5.64, P<0.001) and DP subscale (t(27) = 6.67, P<0.001). El-Shafei et al.88 also reported that both stress and burnout were significantly reduced following their intervention. For the outcome of stress, pre-test mean was 31.12 (standard deviation [SD] = 5.22) with post-test mean of 28.87 (SD = 5.84; P<0.001), and for burnout the pre-test mean was 29.98 (SD = 4.54; P< 0.001) with post-test mean of 23.75 (SD = 5.93; P<0.001). The study undertaken by Flarity et al.89 reported there was a statistically significant increase in compassion satisfaction (subscale of compassion fatigue scale) (P = 0.004), decrease in burnout (P≤0.001), and decreased stress symptoms (P = 0.001) from baseline scores, following attendance at a resiliency program. Results from Wei et al.86 showed that both EE and DP reduced significantly in the intervention group compared with the control group (P<0.01). Kharaghani et al.54 also reported statistically significant differences in burnout reduction by comparing average burnout scores before (mean ± SD: 57/82 ± 12/44, P<0.001) and after training (40/87 ± 5/95, P<0.001) using the Maslach Burnout Inventory.
All six studies54,83,86-89 reported statistically significant reductions in burnout scores following delivery of their interventions. Two studies86,87 reported significant reductions in EE and DP scores, while one study54 reported a significant decrease in EE scores. Another study89 reported significant improvement in compassion satisfaction, while four studies83,87-89 reported significant reductions in stress symptoms. Despite the overall positive results, it should be noted that across the studies there were considerable differences in intervention content, delivery, timing, and outcome measurements.
Two RCTs,84,85 one quasi-experimental study,91 and one mixed-methods study76 investigated MBIs for individuals. The content, frequency, and length of the intervention varied across the studies. Three of the four MBI studies used either repeated brief guided meditation sessions91 or weekly mindfulness workshops.84,85 The study by Rooney91 provided 20 brief guided meditation sessions to ED nurses after they completed their clinical shift. Kwok85 delivered a one-and-a-half-hour program once a week over four weeks, addressing mindfulness, emotion regulation, distress tolerance, and interpersonal relationships (MEDI program), to ED nurses in the intervention group. Ireland et al.84 delivered weekly one-hour mindfulness training workshops to the intern medical officers in the intervention group for 10 weeks. For these two RCTs, Kwok85 did not provide any intervention to the control group while Ireland et al.84 provided an extra hour break per week to the control group (as an “active” control). Only Braganza et al.76 used multi-modular forms of mindfulness activities, which included a one-day mindfulness workshop plus mindfulness-themed flyers, a “four-minute pause” during morning medical handover (i.e. two-to-three-minute videos about mindfulness and 90-second guided meditations), and weekly 30-minute “drop-in” sessions for six months, led by the program coordinator and delivered to all ED staff. Again, different lengths of guided meditation sessions were reported between the studies from four minutes76 to one hour.84 All the sessions were delivered face-to-face at the participants’ workplaces. Two studies84,91 used the same stress-measurement tool (Perceived Stress Scale) to measure outcomes; however, the remaining studies utilized various other tools including Kessler-10 Psychological Distress Scale,76 Maslach Burnout Inventory,76 Copenhagen Burnout Inventory,84 and Revised Medical Personnel Stress Survey85 to measure stress and/or burnout.
Three out of four studies76,84,91 reported a statistically significant reduction in stress levels after delivery of their intervention although only one study84 reported a reduction in burnout scores. Of these, the RCT by Ireland et al.84 reported a significant stress reduction (F = 5.88, P = 0.007, η2 = 0.28) and a reduction in burnout; however, the result was not statistically significant (F = 2.88, P = 0.072, η2 = 0.16) following intervention delivery. The single-group, pre- and post-quasi-experimental study by Rooney91 reported a reduction of stress scores following the intervention. The participants who attended one mindfulness session reported a 9.52% stress score reduction, while the ones who did not attend any sessions reported a 1.61% reduction. The rate of stress score reduction increased to 43.23% for those who attended three sessions. Braganza and colleagues76 also observed a significant reduction of stress scores by a mean difference of 1.8 points (95% CI, 0.3 to 3.4, P = 0.022) at the follow-up assessment. However, there were no changes to burnout levels (Maslach Burnout Inventory: EE subscale, P = 0.981; DP subscale, P = 0.498; PA subscale, P = 0.663). In contrast to the above findings, another RCT with a small sample size (n = 14) by Kwok85 reported no difference in stress measurements when comparing results for the intervention group against the control group.
Two RCTs84,85 of the four MBI studies were pooled in a meta-analysis using a fixed-effects model due to low heterogeneity and the small number of included studies (Figure 2).79 One study76 that utilized a quasi-experimental design was unable to be included in the meta-analysis. The fourth study91 was excluded from the meta-analysis as it did not report means and SDs. The meta-analysis showed an overall statistically non-significant difference between the intervention and control groups on the outcome of stress (n = 58, SMD −0.32; 95% CI, −0.84 to 0.20, P = 0.23; heterogeneity: x2 = 0.01, P = 0.93, I2 = 0%).
Three quasi-experimental studies77,78,90 and one mixed-methods study92 investigated organizational-directed interventions. There was variation between the studies in respect to interventions, duration, intensity, and number of study sites. The study by d’Ettorre et al.77 introduced a range of extensive organizational improvement interventions such as goals to improve occupational safety and wellness, which involved employees in decision making and improving communication with management staff. Schneider et al.92 attempted to improve ED work conditions by developing and implementing solutions to address work stressors during 10 regular multi-professional meetings. Greenwald et al.78 introduced telemedicine shifts to allow senior ED physicians to work from home on weekends to reduce burnout. In contrast, Pascual90 focused on team development to alleviate staff burnout by adopting a management model (Training Within Industry90). The project aimed to eliminate unnecessary processes, streamline ED flow, and improve team coordination through strategies such as staff training and champions.
The duration of these organizational-directed interventions varied from 90 days90 to seven months.92 The telemedicine shift study by Greenwald et al.78 was held on an ongoing basis. The study by d’Ettorre et al.77 did not specifically report the length of the intervention period, but the overall study time frame was over two years. Only Schneider et al.92 stated that meetings were held at three-week intervals while another two studies77,90 did not report any information about the intervention time frame. Two studies90,92 were conducted at a single site while another two studies77,78 involved multiple EDs. The Maslach Burnout Inventory was used in three studies,78,90,92 while one study77 used the Multidimensional Validated Tool.
In terms of outcomes, only d’Ettorre et al.77 measured stress reduction. The pre- and post-test results from this quasi-experimental, single-group study demonstrated a stress reduction from medium to low using a multidimensional validated tool among both physicians (Pre 22.75 vs. Post 15.37; P<0.05) and nurses (Pre 25.12 vs. Post 15.75; P<0.05). Three studies78,90,92 measured burnout. Two studies reported that staff burnout levels worsened after introducing the interventions. One study78 reported no change to the overall burnout levels. Schneider et al.92 reported small but non-significant increases of EE (mean Pre 4.19 [SD 0.94] vs. Post 4.21 [SD 1.03]; P = 0.855) and depressive symptoms (mean Pre 1.90 [SD 1.48] vs. Post 2.22 [SD 1.53]; P = 0.119) with a statistically significant increase of DP over one year (mean Pre 3.18 [SD 1.23] vs. Post 3.54 [SD 1.22]; P = 0.027). Similarly, Pascual90 also reported an increase of EE by an average of 4.74 points (t (26) = 2.56; P = 0.017) among all participants, while an increase of PA by an average of 3.20 points (t (9) = 2.57; P = 0.030) was detected among emergency medical technicians only. The authors were unable to determine a cause for these findings. Greenwald et al.78 reported no difference to overall burnout levels (Wilk's lambda = 0.96, F (3, 34) = 0.42, P = 0.74) between physicians who worked telemedicine shifts and physicians who worked regular clinical schedules. Although there was a reduction in EE score (−4.8 vs. 1.0; P = 0.04) for telemedicine physicians, there was no difference in PA (−1.2 vs. 1.4; P = 0.24) or DP (−2.2 vs. −0.4; P = 0.36). Meta-analysis was unable to be conducted due to the different types of organizational interventions utilized in the included studies. Overall, results of organizational-directed interventions demonstrated inconsistent findings, with some studies reporting reduced stress levels77 and some studies an increase in burnout levels.90,92
Certainty of evidence
The overall quality of evidence for all included interventional studies was low according to the GRADE81 criteria. The level of evidence was downgraded due to limitations in study designs, indirectness of evidence, and publication bias. In the four RCTs, issues such as the lack of allocation concealment and blinding also increased risk of bias and reduced the level of evidence. Furthermore, indirectness of evidence as a result of varied content, length, and frequency of interventions was observed in the included studies. Consequently, the overall certainty of results was reduced. Publication bias could not be eliminated as both small negative and positive studies were included in the review.
This review provides a comprehensive synthesis of current research to determine the effectiveness of interventions to reduce stress and burnout among ED staff. The review included 14 studies that investigated individual-focused and organizational-directed interventions with two studies suitable for the meta-analysis. It is important to highlight that most of the included studies were conducted within the past three years, which reflects an increasing awareness and promotion of ED staff wellness. Although there is growing interest in occupational stress management in EDs, the lack of high-quality research in this area remains an issue, and additional rigorous studies are needed.
Effectiveness of interventions
The results of this review demonstrate that individual-focused interventions may be more effective in occupational stress and/or burnout reduction than organizational-directed interventions for staff working in the ED. However, results were limited due to the small number of low-quality studies that investigated organizational-directed interventions. The educational interventions may lead to small but significant reductions in occupational stress and burnout for individual ED staff. This finding is similar to other systematic reviews59,93 that reported training interventions or self-care workshops were effective in reducing stress and/or burnout in a broader population of health care workers. More specifically, this systematic review identified that MBIs had the most significant effect, with three studies reporting statistically significant effects and only one study85 finding no effect. However, it is important to note that this final study had a small sample size of only 14 participants. The findings of this review support other reports76,84,91 within the literature that suggest that MBIs can assist ED staff in developing attention and awareness, improving mental well-being and capacity to cope with stress, as well as have wider implications for the health service, patient safety, and quality of care.94 Support from the organization is integral to embedding educational programs and promoting the development of these skills in staff working in the ED.
The effectiveness of organizational-directed interventions was based on the results of four quasi-experimental studies. Overall, these studies reported organizational-directed interventions reduced stress levels, but either had no effect or increased burnout levels. It is worth noting that two studies reported that implementing organizational interventions increased the levels of staff burnout. As highlighted in a previous study,92 burnout deterioration can be related to other complex issues such as a staff's disappointment towards leadership, organizational management, or change fatigue.95 Another factor that can impact on burnout is the lack of staff willingness to engage with intervention measures due to poor mental well-being.96 Therefore, it is important for organizations to consider these complex issues when implementing a stress-reduction program.
This review provides some evidence for educational interventions in reducing both occupational stress and burnout for staff working in the ED. However, it is also worth considering that all the included educational interventional studies delivered varied educational content and had different approaches to their intervention. Consequently, it is difficult to ascertain which educational content and teaching approaches were the most effective.
Organizational-directed interventions versus individual-focused interventions
Previous systematic reviews57,60 have found that organizational-directed interventions are less commonly adopted than individual-focused interventions. The majority of previous studies within the literature investigating organizational interventions aimed to reduce access block, improve departmental performance in key performance indicators, or target other environmental issues in EDs, rather than focusing on ED staff stress or burnout reduction.97-99 Effective stress reduction is unlikely to be achieved by implementing solely individual-focused interventions without addressing the root health care system causes.100 Staff stress levels may improve over time by managing environmental issues.101 Therefore, it is important for organizations to take more ownership of high staff burnout issues by implementing strategies to reduce stressful working environments and promote staff mental health.
Throughout the literature there is a lack of acknowledgement and ownership of the issue of health care worker burnout by organizations. A multi-institutional survey by Dyrebe and colleagues102 found that burnout was seen as a personal failure and stigmatized among medical students rather than as an outcome of chronic occupational hazard exposure. Meanwhile, the challenge of implementing organizational interventions needs to be acknowledged. Organizational interventions require additional resources to facilitate large-scale changes and a longer assessment period to evaluate effectiveness.103 However, this may be unrealistic or difficult to achieve for some departments with limited resources and budget constraints. As a comparison, individual-focused interventions teaching clinicians to manage their own stress levels are easier to implement. This may account for the number of included studies in this review that investigated individual-focused interventions. Therefore, assessing and considering the specific needs of ED staff before implementing any individual-focused or organizational-based intervention is essential to ensure the best outcomes for the organization and health care staff.
Review strengths and limitations
This review has several limitations. Firstly, limiting the search between 2008 and 2019, and to English language papers only may have excluded some studies. Secondly, there are methodological limitations in some of the RCT studies included in the review. Almost all included RCTs were associated with risk of allocation bias, performance bias, and detection bias by not blinding the participants and treatment allocators. There were also some limitations with the quasi-experimental studies that are intrinsic to the study design (e.g. single group studies, limited follow-up measures). Thirdly, almost all included studies had small sample sizes without sample size calculations, which reduced statistical power and confidence in reliability and the ability to generalize the results. Fourthly, only three studies78,83,88 assessed either medium or long-term (three months to one year) post-intervention effects. Insufficient amount of long-term follow-up (e.g. more than one year) has been identified as a limitation in other systematic reviews on similar topics.57,60 This deficit limits confidence in sustainability of any change following delivery of the interventions. Long-term outcome measurements can provide valuable insights if the interventions have a long-term effect on participants and/or participants can integrate the interventions into their lives over time. The potential benefits or necessity of periodical intervention re-exposure to maximize or sustain its effects, or the frequency of re-exposure is also unknown.60 Regardless of the above limitations, this review contributes to the current knowledge base on occupational stress reduction interventions for staff in the ED.
Occupational stress and burnout impact on the well-being of ED staff; therefore, it is imperative that ED staff have access to evidence-based interventions to eliminate stress and prevent burnout. This review has found that both educational interventions and MBIs have potential to reduce occupational stress and burnout in staff working in the ED. However, the certainty of evidence was considered as low per the GRADE criteria due to limitations in study designs, indirectness of evidence, and publication bias. Therefore, the strength of the recommendations from this review is limited due to the heterogeneity across the studies and quality of the included studies. More research is recommended, particularly high-quality RCTs with larger sample sizes and measurement of long-term effects to improve knowledge in this field.
Recommendations for practice
According to the JBI Grades of Recommendations,81 the recommendations for practice are limited. This review has found that individual-focused interventions including both educational interventions and MBIs can potentially reduce stress and burnout among ED staff and should be considered as tools for reducing ED staff occupational stress. Individual-based interventions seem to be more cost-effective to implement with fewer resources required. In addition, individual-focused interventions are easily adaptable. Consideration should be given to having these interventions implemented by local wellness champions and clinicians, which may produce more beneficial effects and long-term sustainability. Organizational-directed interventions such as communication interventions, multi-disciplinary meetings, and management models also have the potential to reduce ED staff stress, but can increase burnout. However, implementing large-scale, organizational-directed interventions would require additional resources and involve more stakeholders than individual-based interventions. Organizations need to consider the timing and impact of these interventions to avoid change fatigue and change resistance from staff. Strategies need to be implemented to ensure future projects can be easily adapted to a variety of circumstances to provide safe and beneficial effect.
Recommendations for research
There are several recommendations for future research. Firstly, further high-quality RCTs are needed to address the risk of bias highlighted in studies included in this review. Secondly, as most of the included studies in this review had small sample sizes without sample size calculations, future studies with larger sample sizes are required. Thirdly, some qualitative research into barriers and facilitators around these types of interventions would further support the findings of this review. Finally, a scoping review would assist to determine the breadth of studies on this topic and guide future research.
Appendix I: Search strategy
Searched on November 1, 2018
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PsycINFO (OvidSP [Wolters Kluwer])
Searched on November 1, 2018
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Web of Science
Searched on November 1, 2018
Searched on November 1, 2018
Searched on November 1, 2018
ProQuest Dissertations & Theses
Searched on November 1, 2018
Searched on November 1, 2018
Reference check of included key articles:
Searched on November 1, 2018
Appendix II: Studies ineligible following full-text review
- 1. Airosa F, Andersson SK, Falkenberg T, Forsberg C, Nordby-Hörnell E, Öhlén G, et al. Tactile massage and hypnosis as a health promotion for nurses in emergency care – a qualitative study. BMC Complement Altern Med 2011;11(1):83.
- 1. Reason for exclusion: Ineligible study design, qualitative study
- 2. Ajeigbe DO. Nurse-physician teamwork in the emergency department [thesis]. Los Angeles (CA): University of California; 2012.
- 2. Reason for exclusion: Did not measure outcomes relevant to the review
- 3. Ettorre G, Greco M. Healthcare work and organizational interventions to prevent work-related stress in Brindisi, Italy. Saf Health Work. 2015;6(1):35-8.
- 3. Reason for exclusion: Did not meet inclusion criteria
- 4. Arnold J, Tango J, Walker I, Waranch C, McKamie J, Poonja Z, et al. An evidence-based, longitudinal curriculum for resident physician wellness: the 2017 Resident Wellness Consensus Summit. West J Emerg Med. 2018;19(2):337-41.
- 4. Reason for exclusion: Ineligible study design
- 5. Battaglioli N, Ankel F, Doty CI, Chung A, Lin M. Executive summary from the 2017 Emergency Medicine Resident Wellness Consensus Summit. West J Emerg Med. 2018;19(2):332-6.
- 5. Reason for exclusion: Did not meet inclusion criteria
- 6. Blanco Donoso LM, García Rubio C, Moreno Jiménez B, de la Pinta MLR, Moraleda Aldea S, Garrosa E. Brief intervention based on ACT and mindfulness: pilot study with nursing staff in intensive care unit and emergency services. Rev Int Psicol Ter Psicol. 2017;17(1):57-63.
- 6. Reason for exclusion: Full text not in English
- 7. Braunschneider H. Preventing and managing compassion fatigue and burnout in nursing. ESSAI 2013;11(1):11.
- 7. Reason for exclusion: Ineligible study type
- 8. Brazil VA, Greenslade JH,Brown AF. Enhancing capacity for intern training in the emergency department: the MoLIE project. Med J Aust. 2011;194(4):165-8.
- 8. Reason for exclusion: Did not measure outcomes relevant to the review
- 9. Breslin T, McInerney J, Sheehan J, Natin D,Codd M. Stress in an Irish inner city emergency department revisited (2000-2006). Ir J Psychol Med. 2010;27(3):135-7.
- 9. Reason for exclusion: No clear intervention described, no clear study design
- 10. Bronson K. Using mindfulness to decrease burnout and stress among nurses working in high intensity areas. Dissertation Abstracts International: Section B: The Sciences and Engineering 2018;79(5-B(E)): No-Specified.
- 10. Reason for exclusion: Unable to separate ED data from the overall results with a mixed group of participants
- 11. Brooks DM, Bradt J, Eyre L, Hunt A, Dileo C. Creative approaches for reducing burnout in medical personnel. Art Psychother. 2010;37(3):255-63.
- 11. Reason for exclusion: Ineligible population, not ED specific
- 12. Brown L, Benage M, Tran A, Chapman D. Impact of scribes upon emergency physician self-assessed authenticity. Ann Emerg Med. 2014;64(4):S44.
- 12. Reason for exclusion: Full text not available. Unable to contact author due to lack of published contact details
- 13. Calder-Sprackman S, Kumar T, Gerin-Lajoie C, Kilvert M, Sampsel K. Ice cream rounds: the adaptation, implementation, and evaluation of a peer-support wellness rounds in an emergency medicine resident training program. CJEM. 2018;20(5):777-80.
- 13. Reason for exclusion: Ineligible study design
- 14. Carney D, Mongelluzzo J, Foster A, Fee C, Ekman E. Understanding emotions: combating burnout with empathy during emergency medicine residency. Ann Emerg Med. 2017;70(4):S148-S9.
- 14. Reason for exclusion: Did not measure outcome
- 15. Carroll M, Chung A. Talk it out: a novel use of training groups with emergency medicine residents. West J Emerg Med. 2018;19(4.1).
- 15. Reason for exclusion: Conference study protocol, did not publish outcomes, author did not respond to requests for additional data
- 16. Chesak S. Integration and impact of stress management and resiliency training (smart) in a nurse residency program: a feasibility study. J Altern Complement Med. 2013;20(5).
- 16. Reason for exclusion: Ineligible population, not ED specific
- 17. Chinai S, Bird S, Lesperance D, Maranda S, Balasubramaniam M, Haskins B, et al. Effect of an empathy curriculum on emergency medicine resident burnout and patient perception of empathy: a randomized controlled trial. West J Emerg Med. 2016;17:S12.
- 17. Reason for exclusion: Full text not available. Unable to contact author due to lack of published contact details
- 18. Choi WJ, Cho SH, Cho NS, Kim GS. Effect of an education program on violence in the emergency department. J Korean Soc Emerg Med. 2005;16(2):221-8.
- 18. Reason for exclusion: Did not measure outcomes relevant to the review
- 19. Chung A, Battaglioli N, Lin M, Sherbino J. JGME-ALiEM hot topics in medical education: an analysis of a virtual discussion on resident well-being. J Grad Med Educ. 2018;10(1):36-42.
- 19. Reason for exclusion: Ineligible study type
- 20. Chung AS. Mindfulness in emergency medicine. Ann Emerg Med. 2015;66(4):S162.
- 20. Reason for exclusion: Did not measure outcome
- 21. Chung AS, Felber R, Han E, Mathew T, Rebillot K, Likourezos A. A high-impact mindfulness in emergency medicine curriculum for medical students. Ann Emerg Med. 2017;70(4):S166-S7.
- 21. Reason for exclusion: Did not measure outcomes relevant to the review
- 22. Chung AS, Felber R, Han E, Mathew T, Rebillot K, Likourezos A. A targeted mindfulness curriculum for medical students during their emergency medicine clerkship experience. West J Emerg Med. 2018;19(4):762-6.
- 22. Reason for exclusion: Did not measure outcomes relevant to the review
- 23. Coleman SM. Developing a nurse retention program aimed at reducing nursing turnover [D.N.P.]. Ann Arbor: Walden University; 2018.
- 23. Reason for exclusion: Ineligible study design, qualitative study
- 24. Cooke M, Holzhauser K, Jones M, Davis C, Finucane J. The effect of aromatherapy massage with music on the stress and anxiety levels of emergency nurses: comparison between summer and winter. J Clin Nurs. 2007;16(9):1695-703.
- 24. Reason for exclusion: Published more than 10 years ago
- 25. Copeland D, Liska H. Implementation of a post-code pause: extending post-event debriefing to include silence. J Trauma Nurs. 2016;23(2):58-64.
- 25. Reason for exclusion: Did not measure outcomes relevant to the review
- 26. Crewe CD. The Watson Room: managing compassion fatigue in clinical nurses on the front line. Dissertation Abstracts International: Section B: The Sciences and Engineering. 2017;77(10-B(E)):No-Specified.
- 26. Reason for exclusion: Ineligible setting
- 27. Cunningham T, Bartels J, Grant C, Ralph M. Mindfulness and medical review: a grassroots approach to improving work/life balance and nursing retention in a level I trauma center emergency department. Journal Emerg Nurs. 2013;39(2):200-2.
- 27. Reason for exclusion: Did not measure outcome
- 28. d’Ettorre G, Maselli C, Greco M, Pellicani V. Assessment and management of job stress in emergency nurses: a preliminary study. Int J Emerg Ment Health. 2016;18(4).
- 28. Reason for exclusion: Did not clearly describe the intervention, limited data regarding post intervention stress
- 29. d’Ettorre G, Pellicani V. Assessing and managing job stress in emergency departments: which targets for improvement interventions? Occup Environ Med. 2018;75:A324-A5.
- 29. Reason for exclusion: Ineligible study design, not experimental
- 30. Dong KA, Dance E, Blouin D, Yarema M, Williams J, Rowe BH. Evaluation of a structured wellness curriculum for emergency medicine residents. CJEM. 2010;12(3):253.
- 30. Reason for exclusion: Did not measure outcomes relevant to the review
- 31. Dowers C, Vohra T, Goyal N, Miller J. The effect of a resident wellness program on burnout and ITE scores. West J Emerg Med. 2017;18:S29-S30.
- 31. Reason for exclusion: Full text not available. Unable to contact author due to lack of published contact details
- 32. Farahmand S, Vafaeian M, Vahidi E, Abdollahi A, Bagheri-Hariri S, Dehpour AR. Comparison of exogenous melatonin versus placebo on sleep efficiency in emergency medicine residents working night shifts: a randomized trial. World J Emerg Med. 2018;9(4):282-7.
- 32. Reason for exclusion: Did not measure outcomes relevant to the review
- 33. Fleming H, Wagers B, Whitaker N, Kronenfeld K, Walthall J. Development and implementation of a brief, structured trauma debrief. Acad Emerg Med. 2016;23:S288.
- 33. Reason for exclusion: Full text not available. Unable to contact with author due to lack of published contact details
- 34. Gorgas DL, Greenberger S, Bahner DP, Way DP. Teaching emotional intelligence: a control group study of a brief educational intervention for emergency medicine residents. West J Emerg Med. 2015;16(6):899-906.
- 34. Reason for exclusion: Did not measure outcomes relevant to the review
- 35. Halpern J, Gurevich M, Schwartz B, Brazeau P. Interventions for critical incident stress in emergency medical services: a qualitative study. J Stress Health. 2009;25(2):139-49.
- 35. Reason for exclusion: Ineligible study design, qualitative study
- 36. Heron SL, Wurster R, Sanders T, Shayne P, Liebzeit J, Gomes P, et al. Assessment of a curriculum on wellness for first year residents in emergency medicine. Acad Emerg Med. 2011;18(5):S168-S9.
- 36. Reason for exclusion: Did not measure outcomes relevant to the review
- 37. Holt M, Reed M, Woodruff SI, DeMers G, Matteucci M,Hurtado SL. Adaptation of screening, brief intervention, referral to treatment to active duty military personnel in an emergency department: findings from a formative research study. Mil Med. 2017;182(7):e1801-e7.
- 37. Reason for exclusion: Ineligible study design, qualitative study
- 38. Hosseinabadi R, Karampourian A, Beiranvand S, Pournia Y. The effect of quality circles on job satisfaction and quality of work-life of staff in emergency medical services. Int Emerg Nurs. 2013;21(4):264-70.
- 38. Reason for exclusion: Did not measure outcomes relevant to the review
- 39. Hutson Hendy D. Compassion fatigue in emergency department nurses. Dissertation Abstracts International: Section B: The Sciences and Engineering 2017;78(4-B(E)):No-Specified.
- 39. Reason for exclusion: Did not measure outcomes relevant to the review
- 40. Kim YA, Park JS. Development and application of an overcoming compassion fatigue program for emergency nurses. J Korean Acad Nurs. 2016;46(2):260-70.
- 40. Reason for exclusion: Full text is not in English
- 41. Krywko DM, Bourne CL. The EM•Ppowered InitiativeTMp: Can a two-week selective be effective in promoting wellness and professional development? Ann Emerg Med. 2017;70(4):S36.
- 41. Reason for exclusion: Did not measure outcomes relevant to the review
- 42. Lavoie-Tremblay M, Sounan C, Trudel JG, Lavigne GL, Martin K, Lowensteyn I. Impact of a pedometer program on nurses working in a health-promoting hospital. Health Care Manag (Frederick). 2014;33(2):172-80.
- 42. Reason for exclusion: Ineligible population, not ED specific
- 43. Lee SM, Sung KM. The effects of violence coping program based on middle-range theory of resilience on emergency room nurses’ resilience, violence coping, nursing competency and burnout. J Korean Acad Nurs. 2017;47(3):332-44.
- 43. Reason for exclusion: Full text is not in English
- 44. Leung A, Puri G, Chen B, Gong Z, Chan E, Feng E, et al. Novel role of physician navigators on performance indicators in the emergency department. CJEM. 2017;19:S47.
- 44. Reason for exclusion: Did not measure outcomes relevant to the review
- 45. Lewis J, Schoenfeld D, Dubosh N, Ullman E. Participation in an emergency medicine bootcamp increases self-confidence at the start of residency. West J Emerg Med. 2017;18:S22.
- 45. Reason for exclusion: Did not measure outcomes relevant to the review
- 46. Lucas BP, Trick WE, Evans AT, Mba B, Smith J, Das K, et al. Effects of 2- vs 4-week attending physician inpatient rotations on unplanned patient revisits, evaluations by trainees, and attending physician burnout: a randomized trial. JAMA. 2012;308(21):2199-207.
- 46. Reason for exclusion: Ineligible population, not ED specific
- 47. Lynch J, Prihodova L, Dunne PJ, O’Leary C, Breen R, Carroll A, et al. Mantra meditation programme for emergency department staff: a qualitative study. BMJ Open. 2018;8(9):e020685.
- 47. Reason for exclusion: Ineligible study design, qualitative study
- 48. Margolis M, Roger AE. System restricts nurses’ overtime. ED Manag. 2010;22(10):117.
- 48. Reason for exclusion: Ineligible study type
- 49. Mason S, O’Keeffe C, Carter A, O’Hara R, Stride C. An evaluation of foundation doctor training: a mixed-methods study of the impact on workforce well-being and patient care [the Evaluating the Impact of Doctors in Training (EDiT) study]. HS&DR. 2013;1(15).
- 49. Reason for exclusion: Did not measure outcomes relevant to the review
- 50. Mueller G, Hunt B, Wall V, Rush R, Jr, Molof A, Schoeff J, et al. Intensive skills week for military medical students increases technical proficiency, confidence, and skills to minimize negative stress. J Spec Oper Med. 2012;12(4):45-53.
- 50. Reason for exclusion: Ineligible population, military medical students
- 51. Nordberg A, Carreiro S, Chai PR, Carey J, Bird S. Bringing emergency wellness and encouraging lifelong learning (be well)-an innovative wellness elective model. Acad Emerg Med. 2017; 24:S285.
- 51. Reason for exclusion: Conference study protocol, did not publish outcomes
- 52. Orly S, Rivka B, Rivka E, Dorit S-E. Are cognitive–behavioral interventions effective in reducing occupational stress among nurses? Appl Nurs Res. 2012;25(3):152-7.
- 52. Reason for exclusion: Wrong population, not ED specific
- 53. Paetow G, Schiller J, Chung A, Hart D. Storytelling: a novel wellness initiative for emergency medicine residents. West J Emerg Med. 2017;18:S66-S7.
- 53. Reason for exclusion: Did not measure outcomes relevant to the review
- 54. Philippon AL, Bokobza J, Hurbault A, Bloom B, Riou B, Duguet A, et al. The death in simulation randomized trial: effect of simulated patient death on emergency worker's anxiety. Ann Emerg Med. 2015;66(4):S139.
- 54. Reason for exclusion: Ineligible study type
- 55. Rainey J, Klyce V, Neugarten C, Chien J, Williams S, Fukumoto K, et al. ROAR: resident ovation and appreciation rewards, on the path to wellness in emergency medicine. West J Emerg Med. 2017;18:S71.
- 55. Reason for exclusion: Did not measure outcomes relevant to the review
- 56. Rowe BH, Lashyn T, Villa-Roel C, Singh M, Couperthwaite S, Bullard M, et al. Randomized controlled trial of volume-based staffing in an urban emergency department. CJEM. 2012;14:S1.
- 56. Reason for exclusion: Does not meet inclusion criteria
- 57. Schmidt M, Haglund K. Debrief in emergency departments to improve compassion fatigue and promote resiliency. J Trauma Nurs. 2017;24(5):317-22.
- 57. Reason for exclusion: Ineligible study type
- 58. Schmitz G, Clark M, Heron S, Sanson T, Kuhn G, Bourne C, et al. Strategies for coping with stress in emergency medicine: early education is vital. J Emerg Trauma Shock. 2012;5(1):64-9.
- 58. Reason for exclusion: Ineligible study type
- 59. Shepherd M, Chang M, Huddleston P. The effects of interventions to reduce noise on patient satisfaction scores and stress levels on nursing units during the renovation of the emergency department within an acute care setting. Ochsner J. 2018;18(1):e14.
- 59. Reason for exclusion: Ineligible population, not ED specific
- 60. Smith J, Derr C, Wilson J. Individual competition as a novel approach to population health management: a corporate wellness model designed in an emergency department residency program. Ann Emerg Med. 2016;68(4):S95.
- 60. Reason for exclusion: Did not measure outcomes relevant to the review
- 61. Sung SM, Sung KM. The effects of violence coping program based on middle-range theory of resilience on emergency room nurses’ resilience, violence coping, nursing competency and burnout. J Korean Acad Nurs. 2017;47(3):332-44.
- 61. Reason for exclusion: Full text is not in English
- 62. Sutherland KA, Pham C, La Riviere C, Weldon E. Mentorship in Canadian emergency medicine residency training programs: a needs assessment. CJEM. 2017;19:S34.
- 62. Reason for exclusion: Ineligible study type
- 63. Tuckey MR, Scott JE. Group critical incident stress debriefing with emergency services personnel: a randomized controlled trial. Anxiety Stress Coping. 2014;27(1):38-54.
- 63. Reason for exclusion: Ineligible population, fire fighters
- 64. Valentin B, Grottke O, Skorning M, Bergrath S, Fischermann H, Rortgen D, et al. Cortisol and alpha-amylase as stress response indicators during pre-hospital emergency medicine training with repetitive high-fidelity simulation and scenarios with standardized patients. Scand J Trauma Resusc Emerg Med. 2015;23:31.
- 64. Reason for exclusion: The aim of study did not meet the requirement of the review
- 65. Walthall JDH, Chisholm CD, Rodgers KG, Cooper D, Wilbur LG. Preemptive wellness: an emergency medicine residency support network retreat. Ann Emerg Med. 2012;60(5):S170.
- 65. Reason for exclusion: Did not measure outcomes relevant to the review
- 66. Wen LS, Baca JT, O’Malley P, Bhatia K, Peak D, Kimo Takayesu J. Implementation of small-group reflection rounds at an emergency medicine residency program. CJEM. 2013;15(3):175-7.
- 66. Reason for exclusion: Did not measure outcomes relevant to the review
- 67. Zaeri N, Zaeri S. Effects of valerian extract on the anxiety of nurses at emergency departments. Avicenna J Phytomed. 2015;5:149-50.
- 67. Reason for exclusion: Full text not available. Attempted to contact author twice and did not respond to requests for additional data
Appendix III: Characteristics of included studies
Dr Mary-Anne Ramis (Queensland Centre for Evidence Based Nursing and Midwifery: A JBI Centre of Excellence) and Mr Luke Burgess (Queensland Centre for Evidence Based Nursing and Midwifery: A JBI Centre of Excellence) for their assistance with manuscript development.
Mr Michael Fagg (University of Queensland) for providing technical assistance with defining search terms.
The review was conducted in partial fulfilment of the requirements for the degree of Doctor of Philosophy at the University of Queensland, Brisbane, Australia for HX.
1. World Health Organization. Occupational health: stress at the workplace. n.d. [cited 10 Aug 2018]. Available from: http://www.who.int/occupational_health/topics/stressatwp/en/
2. Adams RE, Boscarino JA, Figley CR. Compassion fatigue and psychological distress among social workers: a validation study. Am J Orthopsychiatry
2006; 76 (1):103–108.
3. Maslach C, Leiter MP. The truth about burnout
: how organizations cause personal stress and what to do about it. San Francisco, CA: Jossey-Bass; 1997.
4. Loeppke R, Heron R, Bazas T, Beaumont D, Spanjaard H, Konicki DL, et al. Global trends in occupational medicine: results of the International Occupational Medicine Society Collaborative Survey. J Occup Environ Med
2017; 59 (3):e13–e16.
5. Xiao Y, Wang J, Chen S, Wu Z, Cai J, Weng Z, et al. Psychological distress, burnout
level and job satisfaction in emergency medicine
: a cross-sectional study of physicians in China. Emerg Med Australas
2014; 26 (6):538–542.
6. Weigl M, Schneider A. Associations of work characteristics, employee strain and self-perceived quality of care in emergency departments: a cross-sectional study. Int Emerg Nurs
7. Adriaenssens J, De Gucht V, Maes S. Determinants and prevalence of burnout
in emergency nurses: a systematic review of 25 years of research. Int J Nurs Stud
2015; 52 (2):649–661.
8. Hooper C, Craig J, Janvrin DR, Wetsel MA, Reimels E. Compassion satisfaction, burnout
, and compassion fatigue among emergency nurses compared with nurses in other selected inpatient specialties. J Emerg Nurs
2010; 36 (5):420–427.
9. Shanafelt TD, Boone S, Tan L, Dyrbye LN, Sotile W, Satele D, et al. Burnout
and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med
2012; 172 (18):1377–1385.
10. Dominguez-Gomez E, Rutledge DN. Prevalence of secondary traumatic stress among emergency nurses. J Emerg Nurs
2009; 35 (3):199–204. quiz 273-4.
11. Alharthy N, Alrajeh OA, Almutairi M, Alhajri A. Assessment of anxiety level of emergency health-care workers by Generalized Anxiety Disorder-7 Tool. Int J Appl Basic Med Res
2017; 7 (3):150–154.
12. Johnston A, Abraham L, Greenslade J, Thom O, Carlstrom E, Wallis M, et al. Review article: Staff perception of the emergency department working environment: integrative review of the literature. Emerg Med Australas
2016; 28 (1):7–26.
13. Xu H, Johnston ANB, Greenslade JH, Wallis M, Elder E, Abraham L, et al. Stressors and coping strategies of emergency department nurses and doctors: a cross-sectional study. Australas Emerg Care
14. Flowerdew L, Brown R, Russ S, Vincent C, Woloshynowych M. Teams under pressure in the emergency department: an interview study. Emerg Med J
2012; 29 (12):e2.
15. Franklin A, Liu Y, Li Z, Nguyen V, Johnson TR, Robinson D, et al. Opportunistic decision making and complexity in emergency care. J Biomed Inform
2011; 44 (3):469–476.
16. Gillespie GL, Bresler S, Gates DM, Succop P. Posttraumatic stress symptomatology among emergency department workers following workplace aggression. Workplace Health Saf
2013; 61 (6):247–254.
17. Kowalenko T, Gates D, Gillespie GL, Succop P, Mentzel TK. Prospective study of violence against ED workers. Am J Emerg Med
2013; 31 (1):197–205.
18. Di Somma S, Paladino L, Vaughan L, Lalle I, Magrini L, Magnanti M. Overcrowding in emergency department: an international issue. Intern Emerg Med
2015; 10 (2):171–175.
19. Lavoie S, Talbot LR, Mathieu L, Dallaire C, Dubois MF, Courcy F. An exploration of factors associated with post-traumatic stress in ER nurses. J Nurs Manag
2016; 24 (2):174–183.
20. Patterson J, Gardner A. Burnout
rates in pediatric emergency medicine
physicians. Pediatr Emerg Care
2020; 36 (4):192.
21. Hamilton S, Tran V, Jamieson J. Compassion fatigue in emergency medicine
: the cost of caring. Emerg Med Australas
2016; 28 (1):100–103.
22. Ruggiero JS, Avi-Itzhak T. Sleep patterns of emergency department nurses on workdays and days off. J Nurs Res
2016; 24 (2):173–180.
23. Wentzel D, Brysiewicz P. The consequence of caring too much: compassion fatigue and the trauma nurse. J Emerg Nurs
2014; 40 (1):95–97.
24. Rose JS, Campbell M, Skipper G. Prognosis for emergency physician with substance abuse recovery: 5-year outcome study. West J Emerg Med
2014; 15 (1):20–25.
25. Austin AE, van den Heuvel C, Byard RW. Physician suicide. J Forensic Sci
2013; 58: (Suppl 1): S91–S93.
26. Wolf LA, Perhats C, Delao AM, Clark PR. Workplace aggression as cause and effect: emergency nurses’ experiences of working fatigued. Int Emerg Nurs
27. Hall LH, Johnson J, Watt I, Tsipa A, O’Connor DB. Healthcare staff wellbeing, burnout
, and patient safety: a systematic review. PLoS One
2016; 11 (7):e0159015.
28. Battaglioli N, Ankel F, Doty CI, Chung A, Lin M. Executive summary from the 2017 emergency medicine
resident wellness consensus summit. West J Emerg Med
2018; 19 (2):332–336.
29. Jelinek GA. The developing challenge of clinical longevity. Emerg Med Australas
2012; 24 (2):201–202.
30. Lee Y-K, Lee C-C, Chen C-C, Wong C-H, Su Y-C. High risk of ‘failure’ among emergency physicians compared with other specialists: a nationwide cohort study. Emerg Med J
2013; 30 (8):620–622.
31. Martini S, Arfken CL, Balon R. Comparison of burnout
among medical residents before and after the implementation of work hours limits. Acad Psychiatry
2006; 30 (4):352–355.
32. Brainch N, Schule P, Laurel F, Bodic M, Jacob T. Psychiatric Emergency services - can duty-hour changes help residents and patients? Psychiatr Q
2018; 89 (4):771–778.
33. Rickard G, Lenthall S, Dollard M, Opie T, Knight S, Dunn S, et al. Organisational intervention to reduce occupational stress and turnover in hospital nurses in the Northern Territory, Australia. Collegian
2012; 19 (4):211–221.
34. Allen R, Watt F, Jansen B, Coghlan E, Nathan EA. Minimising compassion fatigue in obstetrics/gynaecology doctors: exploring an intervention for an occupational hazard. Australas Psychiatry
2017; 25 (4):403–406.
35. Hersch RK, Cook RF, Deitz DK, Kaplan S, Hughes D, Friesen MA, et al. Reducing nurses’ stress: a randomized controlled trial of a web-based stress management program for nurses. Appl Nurs Res
36. Kabat-Zinn J. Full catastrophe living. New York, NY: Delta Publishing; 1990.
37. Lynch J, Prihodova L, Dunne PJ, Carroll Á, Walsh C, McMahon G, et al. Mantra meditation for mental health in the general population: a systematic review. Eur J Integr Med
38. Janssen M, Heerkens Y, Kuijer W, van der Heijden B, Engels J. Effects of mindfulness
-based stress reduction on employees’ mental health: a systematic review. PLoS One
2018; 13 (1):e0191332.
39. Jamieson SD, Tuckey MR. Mindfulness
interventions in the workplace: a critique of the current state of the literature. J Occup Health Psychol
2017; 22 (2):180–193.
40. Luken M, Sammons A. Systematic review of mindfulness
practice for reducing job burnout
. Am J Occup Ther
2016; 70 (2):7002250020p1-p10.
41. Khoury B, Sharma M, Rush SE, Fournier C. Mindfulness
-based stress reduction for healthy individuals: a meta-analysis. J Psychosom Res
2015; 78 (6):519–528.
42. Rudaz M, Twohig MP, Ong CW, Levin ME. Mindfulness
and acceptance-based trainings for fostering self-care and reducing stress in mental health professionals: a systematic review. J Contextual Behav Sci
2017; 6 (4):380–390.
43. Burton A, Burgess C, Dean S, Koutsopoulou GZ, Hugh-Jones S. How effective are mindfulness
-based interventions for reducing stress among healthcare professionals? A systematic review and meta-analysis. Stress Health
2017; 33 (1):3–13.
44. Smith SA. Mindfulness
-based stress reduction: an intervention to enhance the effectiveness of nurses’ coping with work-related stress. Int J Nurs Knowl
2014; 25 (2):119–130.
45. Irving JA, Dobkin PL, Park J. Cultivating mindfulness
in health care professionals: a review of empirical studies of mindfulness
-based stress reduction (MBSR). Complement Ther Clin Pract
2009; 15 (2):61–66.
46. Beck JS. Cognitive behavior therapy: basics and beyond. 2nd ed.New York, NY: The Guilford Press; 2011.
47. Twomey C, O’Reilly G. Effectiveness of a freely available computerised cognitive behavioural therapy programme (MoodGYM) for depression: meta-analysis. Aust N Z J Psychiatry
2017; 51 (3):260–269.
48. Naidu VV, Giblin E, Burke KM, Madan I. Delivery of cognitive behavioural therapy to workers: a systematic review. Occup Med (Lond)
2016; 66 (2):112–117.
49. Hopkinson MD, Reavell J, Lane DA, Mallikarjun P. Cognitive behavioral therapy for depression, anxiety, and stress in caregivers of dementia patients: a systematic review and meta-analysis. Gerontologist
2018; 59 (4):343–362.
50. Guille C, Zhao Z, Krystal J, Nichols B, Brady K, Sen S. Web-based cognitive behavioral therapy intervention for the prevention of suicidal ideation in medical interns: a randomized clinical trial. JAMA Psychiatry
2015; 72 (12):1192–1198.
51. Ross S, Liu EL, Rose C, Chou A, Battaglioli N. Strategies to enhance wellness in emergency medicine
residency training programs. Ann Emerg Med
2017; 70 (6):891–897.
52. Lloyd C, Campion DP. Occupational stress and the importance of self-care and resilience: focus on veterinary nursing. Ir Vet J
53. Kaspin LC, Gorman KM, Miller RMJPhm. Systematic review of employer-sponsored wellness strategies and their economic and health-related outcomes. Popul Health Manag
2013; 16 (1):14–21.
54. Kharaghani M, Fard AS, Sahebalzamani M. The effect of communication skills training on decreasing the nurses’ burnout
in hospital emergency wards of Tehran University of Medical Sciences on 2015. IJABR
55. Sood A, Sharma V, Schroeder DR, Gorman B. Stress Management and Resiliency Training (SMART) program among department of radiology faculty: a pilot randomized clinical trial. Explore (NY)
2014; 10 (6):358–363.
56. Wiederhold BK, Cipresso P, Pizzioli D, Wiederhold M, Riva G. Intervention for physician burnout
: a systematic review. Open Med (Wars)
2018; 13 (1):253–263.
57. Panagioti M, Panagopoulou E, Bower P, Lewith G, Kontopantelis E, Chew-Graham C, et al. Controlled interventions to reduce burnout
in physicians: a systematic review and meta-analysis. JAMA Intern Med
2017; 177 (2):195–205.
58. Clough BA, March S, Chan RJ, Casey LM, Phillips R, Ireland MJ. Psychosocial interventions for managing occupational stress and burnout
among medical doctors: a systematic review. Syst Rev
2017; 6 (1):144.
59. Busireddy KR, Miller JA, Ellison K, Ren V, Qayyum R, Panda M. Efficacy of interventions to reduce resident physician burnout
: a systematic review. J Grad Med Educ
2017; 9 (3):294–301.
60. West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout
: a systematic review and meta-analysis. Lancet
2016; 388 (10057):2272–2281.
61. Lee HF, Kuo CC, Chien TW, Wang YR. A meta-analysis of the effects of coping strategies on reducing nurse burnout
. Appl Nurs Res
62. Ruotsalainen JH, Verbeek JH, Marine A, Serra C. Preventing occupational stress in healthcare workers. Cochrane Database Syst Rev
63. Ruotsalainen J, Serra C, Marine A, Verbeek J. Systematic review of interventions for reducing occupational stress in healthcare workers. Scand J Work Environ Health
2008; 34 (3):169–178.
64. Basu S, Qayyum H, Mason S. Occupational stress in the ED: a systematic literature review. Emerg Med J
2017; 34 (7):441–447.
65. Cohen S. Perceived Stress Scale. 1994 [cited 26 Feb 2019]. Available from: http://www.mindgarden.com/documents/PerceivedStressScale.pdf
66. Cushway D, Tyler PA, Nolan P. Development of a stress scale for mental health professionals. Br J Clin Psychol
1996; 35 (2):279–295.
67. Kohn PM, Macdonald JE. The Survey of Recent Life Experiences: a decontaminated hassles scale for adults. J Behav Med
1992; 15 (2):221–236.
68. Maslach C, Jackson SE, Leiter MP. Zalaquett CP, Wood RJ. Maslach Burnout
Inventory. Evaluating stress: a book of resources
3rd ed.Lanham, MD, US: Scarecrow Education
; 1997. 191–218.
69. Figley C. Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. New York, NY: Brunner-Routledge; 1995.
70. Figley CR, Stamm BH. Stamm BH. Psychometric review of compassion fatigue self-test. Sidran Press, Measurement of stress, trauma and adaptation
. Lutherville, MD:1996.
71. Snaith RP. The hospital anxiety and depression scale. Health Qual Life Outcomes
2003; 1 (29):1–4.
72. Lovibond SH, Lovibond PF. Manual for the depression anxiety stress scales. 2nd ed.Sydney: Psychology Foundation; 1995.
73. Spielberger CD, Gorsuch RL, Lushene R, Vagg PR, Jacobs GA. Manual for the state-trait anxiety inventory. Palo Alto, CA: Consulting Psychologists Press; 1983.
74. Tufanaru C, Munn Z, Aromataris E, Campbell J, Hopp L. Aromataris E, Munn Z. Chapter 3: Systematic reviews of effectiveness. JBI, JBI Reviewer's Manual [Internet]
75. Xu HG, Kynoch K, Tuckett A, Eley R, Newcombe P. Effectiveness of interventions to reduce occupational stress among emergency department staff: a systematic review protocol. JBI Database System Rev Implement Rep
2019; 17 (4):513–519.
76. Braganza S, Young J, Sweeny A, Brazil V. oneED: Embedding a mindfulness
-based wellness programme into an emergency department. Emerg Med Australas
2018; 30 (5):678–686.
77. d’Ettorre G, Greco MR. Assessment and management of work-related stress in hospital emergency departments in Italy. J Med Pract Manage
2016; 31 (5):280–283.
78. Greenwald P, Willis L, Gogia K, Clark S, Mital RC, Sharma R. Burnout
: do emergency department doctors doing telehealth fare differently? Acad Emerg Med
79. Tufanaru C, Munn Z, Stephenson M, Aromataris E. Fixed or random effects meta-analysis? Common methodological issues in systematic reviews of effectiveness. Int J Evid Based Healthc
2015; 13 (3):196–207.
80. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ
2003; 327 (7414):557–560.
81. Schünemann H, Brożek J, Guyatt G, Oxman A, editors. Handbook for grading the quality of evidence and the strength of recommendations using the GRADE approach [Internet]. Updated October 2013. The GRADE Working Group. [cited 26 Feb 2019]. Available from: https://gdt.gradepro.org/app/handbook/handbook.html
82. Moher D, Liberati A, Tetzlaff J, Altman DG. the PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med
2009; 6 (6):e1000097.
83. Mache S, Bernburg M, Baresi L, Groneberg D. Mental health promotion for junior physicians working in emergency medicine
: evaluation of a pilot study. Eur J Emerg Med
2018; 25 (3):191–198.
84. Ireland MJ, Clough B, Gill K, Langan F, O’Connor A, Spencer L. A randomized controlled trial of mindfulness
to reduce stress and burnout
among intern medical practitioners. Med Teach
2017; 39 (4):409–414.
85. Kwok KO. The effects of an intervention program (MEDI) on reducing occupational stress in emergency department nurses [dissertation]. California School of Professional Psychology. Hong Kong: Alliant International University; 2011.
86. Wei R, Ji H, Li J, Zhang L. Active intervention can decrease burnout
in ED nurses. J Emerg Nurs
2017; 43 (2):145–149.
87. Caponnetto P, Magro R, Inguscio L, Cannella MC. Quality of life, work motivation, burn-out and stress perceptions benefits of a stress management program by autogenic training for emergency room staff: a pilot study. Ment Illn
2018; 10 (2):67–70.
88. El-Shafei DA, Abdelsalam AE, Hammam RAM, Elgohary H. Professional quality of life, wellness education
, and coping strategies among emergency physicians. Environ Sci Pollut Res Int
2018; 25 (9):9040–9050.
89. Flarity K, Gentry JE, Mesnikoff N. The effectiveness of an educational program on preventing and treating compassion fatigue in emergency nurses. Adv Emerg Nurs J
2013; 35 (3):247–258.
90. Pascual AA. Training within industry in the emergency department: team development to improve patient care and alleviate staff burnout
[dissertation]. Dissertation Abstracts International: Section B: The Sciences and Engineering. 2018; 78(9-B(E)).
91. Southeastern Louisiana University, Rooney J. Trialing an evidence-based guided meditation project to reduce perceived stress in emergency department nurses: a DNP project [dissertation]. 2017.
92. Schneider A, Wehler M, Weigl M. Effects of work conditions on provider mental well-being and quality of care: a mixed-methods intervention study in the emergency department. BMC Emerg Med
2019; 19 (1):1.
93. Fox S, Lydon S, Byrne D, Madden C, Connolly F, O’Connor P. A systematic review of interventions to foster physician resilience. Postgrad Med J
2018; 94 (1109):162–170.
94. Lynch J, Prihodova L, Dunne PJ, O’Leary C, Breen R, Carroll A, et al. Mantra meditation programme for emergency department staff: a qualitative study. BMJ Open
2018; 8 (9):e020685.
95. Nielsen K, Miraglia M. What works for whom in which circumstances? On the need to move beyond the ‘what works?’ question in organizational intervention
research. Hum Relat
2016; 70 (1):40–62.
96. von Thiele Schwarz U, Nielsen KM, Stenfors-Hayes T, Hasson H. Using kaizen to improve employee well-being: results from two organizational intervention
studies. Hum Relat
2017; 70 (8):966–993.
97. Crawford K, Morphet J, Jones T, Innes K, Griffiths D, Williams A. Initiatives to reduce overcrowding and access block in Australian emergency departments: a literature review. Collegian
2014; 21 (4):359–366.
98. Morley C, Unwin M, Peterson GM, Stankovich J, Kinsman L. Emergency department crowding: a systematic review of causes, consequences and solutions. PLoS One
2018; 13 (8):e0203316.
99. Yarmohammadian MH, Rezaei F, Haghshenas A, Tavakoli N. Overcrowding in emergency departments: a review of strategies to decrease future challenges. J Res Med Sci
2017; 22 (1):23.
100. Lown M, Lewith G, Simon C, Peters D. Resilience: What is it, why do we need it, and can it help us? Br J Gen Pract
101. Hassan TB. Sustainable working practices and minimizing burnout
in emergency medicine
. Br J Hosp Med (Lond)
2014; 75 (11):617–619.
102. Dyrbye LN, Eacker A, Durning SJ, Brazeau C, Moutier C, Massie FS, et al. The impact of stigma and personal experiences on the help-seeking behaviors of medical students with burnout
. Acad Med
2015; 90 (7):961–969.
103. Egan M, Bambra C, Thomas S, Petticrew M, Whitehead M, Thomson H. The psychosocial and health effects of workplace reorganisation. 1. A systematic review of organisational-level interventions that aim to increase employee control. J Epidemiol Community Health
2007; 61 (11):945–954.