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Burnout, Perceived Stress, and Job Satisfaction Among Trauma Nurses at a Level I Safety-Net Trauma Center

Munnangi, Swapna, PhD; Dupiton, Lynore, MSN, RN; Boutin, Anthony, MD, FACEP; Angus, L. D., George, MD, MPH, FACS

doi: 10.1097/JTN.0000000000000335

Nurses are at the forefront of our health care delivery system and have been reported to exhibit a high level of burnout. Burnout and stress in trauma nurses at a safety-net hospital can negatively impact patient care. Safety-net hospitals are confronted with unique social, financial, as well as resource problems that can potentially make the work environment frustrating. The purpose of this study was to explore the levels of burnout, stress, and job satisfaction in nurses providing care to trauma patients at a Level I safety-net trauma center. A cross-sectional survey design was used to investigate principal factors including personal and professional demographics, burnout, perceived stress, and job satisfaction. Trauma nurses working at a Level I safety-net trauma center are stressed and exhibited moderate degree of burnout. The extent of emotional exhaustion experienced by the nurses varied with work location and was highest in surgical intensive care unit nurses. The level of job satisfaction in terms of opportunities for promotion differed significantly by race and the health status of the nurses. Satisfaction with coworkers was lowest in those nurses between the ages of 60–69 years. Female nurses were more satisfied with their coworkers than male nurses. In addition, the study revealed that significant relationships exist among perceived stress, burnout, and job satisfaction. Work environment significantly impacts burnout, job satisfaction, and perceived stress experienced by trauma nurses in a safety-net hospital. Nursing administration can make an effort to understand the levels of burnout and strategically improve work environment for trauma nurses in order to minimize stressors leading to attrition and enhance job satisfaction.

Departments of Surgery (Drs Munnangi and Angus) and Emergency Medicine (Ms Dupiton and Dr Boutin), Nassau University Medical Center, East Meadow, New York.

Correspondence: Swapna Munnangi, PhD, Department of Surgery, Nassau University Medical Center, 2201 Hempstead Turnpike, East Meadow, NY 11554 (

The authors declare that they have no competing interests.

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Trauma nurses face significant stress in responding to life-threatening injuries while effectively empathizing with the emotional suffering of both the patient and their family (Hinderer et al., 2014). As a result of prolonged exposure to stressful working environments, nurses also experience higher levels of burnout than other health care professionals (Karkar, Dammang, & Bouhaha, 2015 ; Thorsen, Tharp, & Meguid, 2011). Burnout is characterized by high emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment in professionals who provide direct care to others (Maslach & Jackson, 1996). It represents an internal response to stressors in the environment (Adriaenssens, De Gucht, & Maes, 2015). Many factors contribute to nurse dissatisfaction, turnover, and burnout including staff shortages, acuity of care, and working conditions including long shifts (Stimpfel, Sloane, & Aiken, 2012) as well as personality hardiness (Daines, 2000). The key is to identify and hopefully intervene in the spiral that eventually leads to the syndrome of burnout simply because a nurse's ability to cope, work, and even thrive in the current health care environment has a significant effect on his or her overall job satisfaction and may further impact patient care including patient dissatisfaction (Sabo, 2006 ; Stimpfel et al., 2012). Indeed, there is ample evidence to support a negative association between burnout and empathy among nurses (Wilkinson, Whittington, Perry, & Eames, 2017).

Public safety-net hospitals face multiple challenges in recruiting and retaining trauma nurses as the majority of those institutions offer salaries that are lower than the more well-funded organizational entities, and the needs of the patients are often greater and more labor intensive (Harper, Castrucci, Bharthapudi, & Sellers, 2015). In addition, hospitals that provide a “safety-net” for the uninsured and underinsured often face financial burdens and strained resources that further contribute to frustration, stress, and burnout of frontline staff (Hayashi, Selia, & McDonnell, 2009).

Burnout, stress, and job satisfaction are critical understudied facets of trauma nursing, particularly at safety-net hospitals where staffing may be problematic. Moreover, institutions with high patient-to-nurse ratios contributing to burnout have shown an increase in the likelihood of dying and failure to rescue rates (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002), decrease in organizational productivity, and increase in job turnover rates (Khamisa, Oldenburg, Peltzer, & Ilic, 2015), thereby affecting overall patient outcomes. A better understanding of relationships among these measures is especially important in the safety-net hospital context, with the majority of existing literature focusing on well-funded organizational entities. Across hospital or facility types, public safety-net hospitals have been perceived as providing lower quality of care relative to other facility types (Ross et al., 2007 ; Werner, Goldman, & Dudley, 2008). Furthermore, studies have shown that severe burnout in nurses affects job satisfaction and may result in poor care leading to organizational loss (Adwan, 2014 ; Farahbod, Chegini, Eramsadati, & Mohtasham-Amiri, 2015 ; Flinkman, Laine, Leino-Kilpi, Hasselhorn, & Salantera, 2008), which in turn provides a significant opportunity for improvement in corporate employee retention and recruitment. Given the perceived burnout and stress in the environment of trauma nursing (Farahbod et al., 2015), this study seeks to explore the degree of burnout, stress, and job satisfaction among nurses who take care of trauma patients in a Level I safety-net trauma center. In addition, relationships among these measures as well as differences in terms of various personal and professional factors were examined. This study may provide a foundation for designing appropriate intervention strategies to improve job satisfaction and minimize burnout in high-stress nursing environments.

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This cross-sectional survey study was conducted at Nassau University Medical Center. Nassau University Medical Center is a 500-bed tertiary care teaching hospital and a Level I safety-net trauma center in Nassau County, New York. Nassau County is included in the New York City Metropolitan Statistical Area. Nassau University Medical Center's trauma center treats approximately 1,650 trauma admissions per year. This study was approved by the institutional review board at Nassau University Medical Center. The study participants were nurses working in various units that provide direct care to trauma patients in the trauma center. These units included the emergency department (ED), surgical intensive care unit (SICU), and the medical intensive care unit (MICU). Nurses from the burn intensive care unit were excluded from the study.

Principal factors selected for investigation include personal and professional demographics, burnout, perceived stress, and job satisfaction. Age category, sex, race, marital status, childbearing status, and health status were the personal demographic variables collected. Years of work experience, hours worked per week, and unit of work were the professional demographic variables collected. Three standard survey questionnaires were used to collect data in this study—Maslach Burnout Inventory questionnaire, abridged Job Descriptive Index, and Perceived Stress Scale. Maslach Burnout Inventory—Human Services form that comprises 22 items was used to measure burnout in three areas: emotional exhaustion, depersonalization, and personal accomplishment. Each item can be answered on a 7-point Likert scale ranging from 0 to 6. A combination of high scores for emotional exhaustion and depersonalization and lower scores for personal accomplishment are indicative of burnout (Maslach & Jackson, 1996). The Job Descriptive Index is a survey instrument in which individuals provide responses indicating their feelings regarding satisfaction with their present job with respect to various facets that are scored as subscales. The five subscales include work, supervision, relationship with coworkers, pay, and promotion. Each subscale has a total score ranging from 0 to 15 (Balzer et al., 1997 ; Stanton et al., 2002). Higher scores in each subscale are indicative of higher satisfaction (Russell et al., 2004). Perceived Stress Scale is a commonly used 10-item questionnaire to determine levels of perceived stress. It is a self-administered tool that measures the degree of stress as appraised by the participant. Perceived Stress Scale scores can range from 0 to 40. Higher scores indicate higher perceived stress (Cohen, Kamarck, & Mermelstein, 1983). In addition, basic information related to personal and professional demographic characteristics was also included in the questionnaire. No personal identifying information was requested on the questionnaires. An envelope consisting of a cover letter with the three part questionnaire was distributed to the target population by the nursing administrators in the respective units. Cover letter contained the directions for completing the survey and the assurance for anonymity and confidentiality. The study was promoted by posters and nursing administrators encouraged nurse participation at staff meetings stressing that the survey is anonymous and voluntary. The completed questionnaire envelopes were dropped off by nurses at specific locations in the hospital.

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Descriptive statistics were used to summarize demographic characteristics of data in the study. The student t test was used to determine differences between two groups, and analysis of variance with Tukey test for post hoc analysis was used for comparison across multiple groups. Pearson correlations were used to determine the relationships among various dimensions of burnout, perceived stress, and job satisfaction subscales. Statistical significance was determined using a p value. A p value of less than .05 was considered statistically significant in this study. SAS 9.4 was used for statistical analysis.

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Of the 83 nurses who were providing early care to trauma patients, 75 participated in this research study by answering the questionnaires. The response rate, therefore, was 90.36%. Demographic characteristics of the respondents are outlined in Table 1. The majority of the survey respondents were female (81.33%), White (45.33%), and married (56%). Thirty-six percent of the respondents were between 50 and 59 years of age. Health problems were reported by 44% of the nurses. The mean scores for the levels of burnout components, perceived stress, and job satisfaction subscales are presented in Table 2.





The differences in levels of perceived stress, burnout dimensions, and job satisfaction subscales by personal and professional demographic characteristics of nurses are shown in Table 3. No significant differences in perceived stress scores were observed in nurses when stratified by age, sex, race, marital status, work location, and whether they had children. However, the perceived stress scores were significantly higher in nurses who reported health problems relative to those who did not (17.03 ± 4.33 vs. 14.52 ± 6.12; p < .05). The average scores for the personal accomplishment and depersonalization dimensions of burnout did not significantly differ by any of the studied personal or professional demographic characteristics of the nurses. The emotional exhaustion levels varied significantly on the basis of the work location of nurses. Highest emotional exhaustion levels were observed in the SICU nurses, followed by ED and MICU nurses. Nurses working in the SICU experienced significantly higher levels of emotional exhaustion than the nurses working in the MICU (32.09 ± 13.27 vs. 16.17 ± 14.81; p < .05). Analysis of variance showed no significant differences in the overall job satisfaction of nurses with their job in general, work on present job, pay, and supervision when stratified by personal and professional demographic characteristics. The levels of satisfaction with the opportunities for promotion differed significantly by race and the health status of the nurses. Asian nurses showed higher satisfaction with the opportunities for promotion than nurses who were White (7.33 ± 2.57 vs. 4.90 ± 2.19; p < .05). Nurses with health problems expressed higher levels of satisfaction with the opportunities for promotion relative to those who did not (6.72 ± 2.77 vs. 5.16 ± 2.11; p < .05; Table 3).



Satisfaction with coworkers varied by age and was lowest in those between the ages of 60 and 69 (7.33 ± 2.42) years. Post hoc analysis revealed that nurses in the age group of 30–39 years were more satisfied with their coworkers than nurses between the ages of 60 and 69 (11.28 ± 3.54 vs. 7.32 ± 2.42; p < .05) years. Female nurses were more satisfied with their coworkers than male nurses (10.39 ± 3.69 vs. 7.25 ± 2.53; p < .05). Higher satisfaction with coworkers was also observed in nurses without children compared with those with children (12.44 ± 3.10 vs. 9.06 ± 3.53; p < .05). Nurses working in the MICU were more satisfied with their coworkers than ED nurses and SICU nurses (p < .05).

Pearson correlations were used to examine the relationships among various dimensions of burnout, perceived stress score, and job satisfaction subscales (Table 4). Perceived stress scores correlated negatively with personal accomplishment (r = −.233; p < .05), satisfaction of the nurses with work on their present job (r = −.335; p < .05), and supervision (r = −.277; p < .05). Nurses with higher perceived stress scores had higher depersonalization (r = .331; p < .05) and higher emotional exhaustion (r = .523; p < .05). The nurses with higher personal accomplishment scores had lower emotional exhaustion (r = −.231; p < .05) and higher satisfaction with work on their present job (r = .310; p < .05). A negative correlation was observed between emotional exhaustion and satisfaction with work on their present job (r = −.450; p < .05) and overall job satisfaction in general (r = −.270; p < .05). Nurses with higher emotional exhaustion scores also had higher levels of depersonalization (r = .548 p < .05) and were more satisfied with their coworkers (r = .362; p < .05). Nurses with lower satisfaction with work on their present job had higher levels of depersonalization (r = −.262; p < .05) and higher satisfaction with their job in general (r = .420; p < .05). Depersonalization scores also positively correlated with the nurse's satisfaction with coworkers (r = .498; p < .05). Nurses with higher satisfaction with their pay had lower satisfaction with the supervision they received (r = −.302; p < .05). The levels of satisfaction with the opportunities for promotion did not correlate significantly with any of the studied measures (Table 4).



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To the best of our knowledge, this is the first comprehensive study examining the prevalence and relationships among burnout, job satisfaction, and perceived stress in trauma nurses at a Level I safety-net trauma center. The higher than average perceived stress score observed in our study sample may have increased the trauma nurses susceptibility to stress-induced illness (Cohen et al., 1983 ; Cohen & Janicki-Deverts, 2012 ; Laal, 2010 ; Milliken, Clements, & Tillman, 2007). Moreover, in our study sample, nurses who reported health problems had higher perceived stress scores. Perhaps personal health problems may have impacted perceived health scores (Danna & Griffin, 1999). Therefore, it is imperative from an organizational perspective to provide opportunities for trauma nurses to use coping strategies that can assist them to lead a healthier work life. Given those findings, it would also be desirable to consider personal health issues in job assignments if such issues are brought to the attention of nurse manager by the nurse.

The stress that trauma nurses experience in a demanding safety-net trauma center work environment with enhanced expectations of patient care often has great professional implications (Danna & Griffin, 1999) and can be conducive to advent of burnout (Maslach, Schaufeli, & Leiter, 2001 ; McVicar, 2003). In light of this, it is not surprising that trauma nurses in our study sample exhibited moderate degree of burnout using cut-off scores for health professionals. Indeed, the average scores were similar to those obtained for American medical workers (Maslach & Jackson, 1996 ; Poghosyan, Aiken, & Sloane, 2009). Despite absence of significant differences in the personal accomplishment and depersonalization levels in terms of the various personal and professional characteristics studied, a significant difference was noted in the emotional exhaustion level by location of work. Essentially, the study revealed that the nurses working in SICU were more emotionally exhausted than the MICU nurses. One possible explanation for this could be that the trauma patients in the SICU are usually more critical than those in MICU. Indeed, the ED and SICU often involve the most critically injured and more intense work environment. In addition, the patient needs and the staffing in SICU setting may also be contributing factors to the emotional exhaustion (Seago & Spetz, 2008). This emphasizes the importance of the American College of Surgeons's requirement to assign one nurse to no more than two patients in the SICU (Committee on Trauma, 2014), as this criterion goes a long way in helping reduce workload while improving work satisfaction and indirectly quality of care.

The job satisfaction in terms of opportunities for promotion differed significantly by race and health status of the nurses. Our finding that Asian nurses expressed higher satisfaction with opportunities for promotion than White nurses is congruent with a finding by Seago and Spetz (2008), who reported that minority nurses are more likely than White nurses to agree that they have fair opportunities to advance in their workplace. This finding may also be a reflection of culture and needs to be confirmed by future studies. Furthermore, the noted high satisfaction with opportunities for promotion in nurses that self-reported health problems also requires further investigation.

It is critical for nursing administration to be aware of these factors impacting the job satisfaction of trauma nurses in order to be able to make better decisions that impact their job performance. Although it is agreeably hard to improve satisfaction in terms of limiting factors such as pay in a safety-net hospital setting with budgetary constraints, efforts should be focused on other impactful intrinsic motivators. For example, altering the level of responsibility by ensuring adequate support from ancillary unit staff, promoting positive organizational culture, and enhancing coworker relationships would enhance satisfaction and may reduce job turnover that is usually high in nursing (Harper et al., 2015 ; Li & Jones, 2013).

The finding of high emotional exhaustion and higher levels of depersonalization but higher satisfaction with coworkers suggests that in the safety-net setting, the employee-to-employee relationship does not weigh as much in creating burnout but rather another significant variable might be at play. Indeed, depersonalization positively correlated with satisfaction with coworkers in part due to the realization that they are all part of the same system or work environment. Likewise, we noted lower work satisfaction and higher level of depersonalization but higher satisfaction with the job, suggesting that although the staff may be experiencing burnout, they are not necessarily dissatisfied with their nursing profession or their job per se but again the work environment seems to be of prime importance. These study findings further point out the significant role of the work environment in generating nursing burnout. Indeed, they emphasize the importance of creating a sophisticated strategy with a focus on the work environment to block the spiral leading to burnout.

Poor interpersonal relationships at a workplace have been previously identified to be a risk factor for decreased job satisfaction (Zangaro & Soeken, 2007). Furthermore, cohesive and supportive coworkers are vital determinants of satisfaction in nurses (Tourangeau & Cranley, 2006). In our study, older nurses, males, and those with children had lower satisfaction with their coworkers. Although several factors may influence these findings, initiatives to minimize major source of stress such as intergenerational conflict with younger nurses and support groups can enhance coworker relationships (Letvak, 2003 ; Weston, 2006).

Perceived stress in trauma nurses negatively correlated with personal accomplishment, overall satisfaction with work in their present job, and the satisfaction with supervision. It was found to increase with depersonalization and emotional exhaustion. This reaffirms the finding that personal accomplishment is critical to improve job satisfaction and decrease depersonalization in nurses. These results further point out to a need for implementation of activities that can boost a sense of personal accomplishment and decrease emotional exhaustion levels in nurses. Indeed, nurses themselves can be aware of the risk of burnout and stress in their domain of responsibilities and promote wellness among their peers. They can also try to coalesce and form support groups to identify stressors and develop strategies to mitigate these stressors. Employee assistance programs are often another overlooked resource that can potentially be valuable in assisting the nurses with several personal issues.

In addition, recognition programs can be established to promote acknowledgement of the contributions made by nurses. Perhaps, this can then help enhance the work engagement and thus overall job satisfaction. Although resources are scarce in safety-net institutions, a significant effort should be made at the administrative level to provide adequate human and material resources to help encourage team building and foster a harmonious work environment in the various nursing units. Likewise, nursing supervisors should demonstrate availability and willingness to assist nursing staff in addressing work related or personal difficulties and encourage them to work in a pleasant work environment. A demonstrated synergistic effort by the nursing leadership, hospital administration, and the nurses themselves can immensely help alleviate burnout or stress at the work place.

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This study provides some empirical evidence confirming the relationships among perceived stress, burnout, job satisfaction, and sociodemographic characteristics of trauma nurses in the context of a safety-net trauma center. Examining these relationships and clearly delineating the influencing factors salient to the safety-net environment are critical to develop targeted strategies and intervention programs that can ameliorate stress and burnout and improve job satisfaction in trauma nurses.

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A number of limitations should be considered while interpreting the results of the present study. First, the cross-sectional design of the study prevents any causal associations. Second, despite the anonymous nature of the study, there may be a report bias as the measures studied were self-reported. In addition, the generalizability of the findings to a wider trauma nursing population is a limitation as the nurse participants in this study are specific to one Level I safety-net trauma center, and there may be other factors intrinsic to facilities making comparisons difficult.

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  • Burnout and perceived stress are prevalent in trauma nurses working at a Level I safety-net trauma center.
  • The levels of satisfaction with the opportunities for promotion differed significantly by race and the health status of the nurses.
  • Satisfaction with coworkers varied by age and was lowest in those between the ages of 60 and 69 years.
  • Female nurses were more satisfied with their coworkers than male nurses. Nurses working in the MICU were more satisfied with their coworkers than ED nurses and SICU nurses.
  • Nurses with higher satisfaction with their pay had lower satisfaction with the supervision they received.
  • The nurses with higher personal accomplishment scores had lower emotional exhaustion.
  • Work environment significantly impacts burnout, job satisfaction, and perceived stress experienced by trauma nurses in a safety-net trauma center.
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The authors thank all the nurses and nursing managers of the hospital who participated in this study. They also acknowledge the assistance received from Jordan Black, B.S., for data collection.

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Burnout; Job Satisfaction; Nurses; Perceived stress; Safety-net; Trauma

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