705669
research-article2017
WHSXXX10.1177/2165079917705669Workplace health & safetyWorkplace health & safety
Workplace Health & Safety
Article
Situational Factors Associated With Burnout Among
Emergency Department Nurses
Jose Andres Rozo, BSN, RN, CCRN1, DaiWai M. Olson, PhD, RN2, Hlaing (Sue) Thu, BSN, RN2, and Sonja E. Stutzman, PhD2
Abstract: Emergency departments are high-stress
environments for patients and clinicians. As part of the
clinical team, nurses experience this stress daily and are
subject to high levels of burnout, which has been shown
to lead to hypertension, depression, and anxiety. Presence
of these diseases may also contribute to burnout, creating a
cycle of stress and illness. This prospective qualitative study
used a phenomenological approach to better understand
factors associated with burnout among emergency
department nurses. Burnout manifests itself in multiple
modes, can affect nurses’ decisions to leave the profession,
and must be addressed to mitigate the phenomenon.
Keywords: emergency response, occupational hazards,
occupational health and safety team, continuous quality
improvement, management
E
mergency departments (EDs) are high-stress environments
for patients and health care workers. Emergency
department nurses are at risk for developing burnout due
to the nature of their fast-paced and demanding field (Hooper,
Craig, Janvrin, Wetsel, & Reimels, 2010). According to García-
Izquierdo, ED nurses with burnout can develop hypertension,
depression, and anxiety. Lack of empathy and medication errors
are associated with burnout (García-Izquierdo & Ríos-Rísquez,
2012). A recent study reviewed factors identified to be associated
with burnout among ED staff for over 25 years (Adriaenssens,
De Gucht, & Maes, 2015). However, the encounters that
contribute to burnout have not been adequately described. The
aim of this study was to use a phenomenological approach to
better understand lived experiences and factors that may lead to
burnout among ED nurses.
Background
Caregiver burnout is one of the most prevalent problems in
health care today (Adriaenssens et al., 2015). Burnout is a
syndrome characterized by emotional exhaustion, lack of
DOI: 10.1177/2165079917705669. From 1Parkland Health and Hospital System, Dallas, TX, USA, and 2The University of Texas Southwestern Medical Center, Dallas, TX, USA. Address
correspondence to: DaiWai M. Olson, PhD, RN, The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-8897, USA; email: DaiWai.Olson@
UTSouthwestern.edu.
For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav.
Copyright © 2017 The Author(s)
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June 2017
empathy, and low self-esteem (Maslach & Jackson, 1982), which
can lead to a variety of physical, emotional, and social problems
including substance abuse, depression, medication errors, and
job-related shortages as these nurses either decide to explore
other areas in nursing or leave the profession altogether. Nurses
are particularly afflicted by this phenomenon as they experience
unpredictable work environments, heavy workloads, long shifts,
exposure to traumatic events, overcrowding, lack of support,
violence, and patients who have experienced acute trauma,
illnesses, or injuries.
A phenomenological approach to studying nursing can
improve understanding of the relationship among life
experiences; this study is focused on ED nurses who have
experienced burnout, and burnout has affected their health and
overall quality of life (Pratt & Gibbons, 2012). Although burnout
is an acknowledged phenomenon within health care
(Adriaenssens et al., 2015), additional research is needed to
understand the experiences of nurses who have actually
experienced burnout in the ED. Phenomenological research
allows the researchers to gain a rich, thick description of the
experience (i.e., allowing for a detailed description of the
setting, characteristics, and findings of a study that may not be
allowable in quantitative research), leading to a better
understanding of lived experience (Merriam, 2002).
Method
This prospective, qualitative study was designed to better
understand external factors associated with burnout in ED
nurses. A phenomenological approach with purposive sampling
was used to better understand emergency nurses’ experiences.
Five interviews were conducted, transcribed, coded, and
analyzed. During the fourth and fifth interviews, several
responses were repetitive, and no new information was gathered
which suggested saturation had been reached.
Participants
Participants were recruited using purposive sampling and the
snowball technique (Merriam, 2002). Purposeful sampling is useful
vol. 65 ■ no. 6
Applying Research to Practice
The emergency department is a demanding and dynamic
environment. Burnout is high across the nursing
profession, but factors contributing to burnout vary by
nursing specialty. This study identified work environment,
workplace violence, moral distress, and perceptions
(internal and external) as themes associated with
emergency nurse burnout. Understanding the
underpinnings of these themes will allow for nurses,
managers, and administrators to identify strategies aimed
at reducing burnout. Identifying and separating the
themes is vital to provide researchers a platform to test
targeted interventions aimed to treat one or more factors
rather than struggling to find a one-size-fits-all approach
to reducing burnout.
in qualitative research because the investigator identifies
participants who have experienced the phenomenon of interest
(Creswell, 2007). Participants were included in the study if they
had ED nursing experience, reported work-related stress, were
English speaking, and were above the age of 18 years. A waiver of
consent was approved by the Institutional Review Board (Record
Number: STU 022015-013); therefore, verbal consent was given by
each nurse, which further protected confidentiality and anonymity.
All participant names were changed to protect their identities.
Data Collection
Data were collected from current and former ED nurses via a
demographic self-report form and one-on-one interviews. Prior
to each interview, a short description of the study, procedures,
interview protocol, and concept of burnout were discussed with
each participant. Interviews lasted approximately 1 hour and
were audio recorded. Interview questions addressed nurses’
experiences with work-related traumatic events within the ED
(Figure 1); additional probing questions were used as necessary.
Rigor
Validation strategies included triangulation, peer review, and
rich, thick descriptions via interviewer journaling. In triangulation,
different outside sources were used to corroborate the information
collected (Creswell, 2007). Peer review process included
presenting the information to other nurses in other areas including
current and former ED nurses and nurse managers (Creswell,
2007). Finally, rich and thick descriptions were composed after
each interview, detailing a summary of the interview as well as
generating new ideas and meanings (Creswell, 2007).
Data Analysis
This qualitative design used a hermeneutic approach.
Creswell (2007) refers to hermeneutical phenomenology as
“research oriented toward lived experience” (Creswell, 2007)
p. 59). Data analysis was conducted at the completion of each
Workplace Health & Safety
Figure 1. Participant interview questions.
Figure 2. Themes and subthemes.
interview. Field notes were written by the interviewer throughout
the interview. Immediately after each interview, the interviewer
journaled about the interview. The audiotape was transcribed
verbatim by a member of the research team after each interview.
For coding, the researcher read over the transcript without
taking notes or coding. Then reread the transcript and highlighted
important quotes that could potentially be identified as codes. The
researcher read through the codes and chunked the codes into
groups to form three or four themes. The data analysis was
completed by composing a table using the identified codes and
themes. Field notes were matched with themes and added to the
data analysis table. As a final step in individual interview analysis,
the researcher identified three to four remarkable quotes that could
potentially be used to support themes in the final presentation of
the data. After the completion of data analysis for all individual
interviews, the researcher began cross analysis of interview codes
by compiling codes and themes across all interviews, creating a
combined data analysis table and determining overall themes that
emerged in the data analysis process.
Results
Study results illuminated the development of burnout among
ED nurses. Transcription and coding uncovered four main
themes: (a) work environment, (b) perception, which was
supported by the subthemes of internal and external
perceptions, (c) workplace violence, and (d) moral distress
(Figure 2). Work environment was the most supported theme;
13 codes supported this theme.
Work Environment
The environment of the ED is fated to be somewhat chaotic.
Several codes in this study supported that overcrowding was the
main stressor in EDs. Overcrowding, due to the constant flow of
patients into and out of the department was one significant source
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of burnout. In addition, inadequate staffing was reported to be an
issue as it led to extra shifts, longer shifts and assuming extra
responsibilities that added to workload. Participants also identified
alarm fatigue, lack of supplies, and physical demands (e.g.,
walking demanded by larger EDs). Of the five nurses interviewed,
three nurses had left the ED due to high levels of burnout.
Scott, who worked as an emergency room nurse for 2 years
recalled, “At the end of the day, you are driving home and your
mind doesn’t stop. You hear the bells, the whistles as you’re driving
home.” Diane reported that there were times she had to shift
between being a bedside nurse and a charge nurse within a shift,
which caused her additional stress. Tina, who currently works as an
ED nurse, recounted the impact of understaffed shifts, “I think it
(burnout) happens more often when we’re short staffed and then
we end up picking up overtime and not really having time off.” She
also verbalized her frustration at the lack of help she encounters
when she has a heavy workload, “A lot of times, we have our 4
(patients) and no extra help.” Thomas described long shifts,
constantly standing and walking, and lack of proximity of services
(e.g., x-ray, CT scanners) and supplies as barriers to patient service
coordination and major contributors to stress in the workplace.
Perceptions
Nurses’ perceptions of their work environment (internal) as well
as others’ perceptions of emergency nurses (external) were also
reported to affect burnout. Internal perceptions, those experienced
by ED nurses, included feeling unappreciated, depersonalizing
patients due to excessive work flow, being unable to meet job
expectations, and lacking the time to properly perform their duties.
Eve often felt unappreciated and noticed nurses becoming “mean
and bitter” over time. Laura verbalized her frustration when patient
acuity levels were low, which made her feel like a “refreshment
administrator.” Thomas reported how stress was “part of the job.”
He also reported not being able to fully interact with patients, but
instead felt he was “just doing tasks.”
External perceptions included negative patient attitudes
toward nurses. Nurses reported that patients wanted tasks
completed on their time schedules, which was not always
possible. In addition, patients did not always understand the
triage process leading to patient dissatisfaction, which patients
projected onto their nurses. Eve articulated,
Because everybody had a complaint, we didn’t take care
of everybody fast enough. We didn’t do everything that
everybody wanted at the same time and it didn’t seem to
matter whether we saved somebody’s life or didn’t save
somebody’s life. Nobody was ever happy with us.
Workplace Violence
Workplace violence is a top priority for ED nurses and
administration (American Organization of Nurse Executives and
Emergency Nurses Association, 2015). Violent experiences, the
constant fear of the unknown, and lack of administrative
support in maintaining safe EDs were all reported contributors
to burnout. Diane said she had experienced “verbal violence”
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almost once a shift. “I’ve been spit on, grabbed and kicked, you
name it.” She recalled a particular experience of physical
violence committed by a patient that left her with physical and
emotional scars “I still have nerve damage. I do carry that
experience with me.” Laura described being the target of
violence from both patients and coworkers, stating that she was
hazed by coworkers when she began working in the ED.
Moral Distress
Nurses in this study described experiencing moral distress as
part of the burnout process. Some described sadness over the
death of a patient, dealing with patients who return to the ED
due to suicide attempts, and not having “official” ways to
decompress when stressful situations occur. Often these nurses
wondered if they would like to continue in their roles as ED
nurses, switch specialties, or leave the profession altogether.
Eve reported “experiencing sadness due to seeing people
dying from accidents or experiencing pain.” She mentioned that
seeing the same people return to the ED was draining and
eventually she left the profession altogether. Scott recalled
dealing with the death of an infant.
One of the first deaths that I experienced was a child, an
infant . . . It impacted me . . . I felt saddened for the child
who obviously would not grow up, for the family
members who had lost their loved one.
Thomas stated, “If a patient dies, and you are a part of that,
you don’t get to talk about it . . . and you carry that with you.”
Thomas, Diane, and Eve had all considered, or had actually left
the ED due to moral distress.
Discussion
Burnout is prevalent in the nursing profession. Previous
literature has found that burnout is the outcome of contributory
factors such as excessive workload, lack of support, and
workplace violence (García-Izquierdo & Ríos-Rísquez, 2012).
This study supported these previous responses. Studies dating
back to the early 1980s have looked at factors associated with
burnout (Adriaenssens et al., 2015). This study found that
burnout continues to occur and nurses continue to leave the ED
because of factors such as workplace violence, workload and
staffing, and perceptions of administrative support.
In this sample, communication and interaction with physicians
were not associated with burnout. This finding is congruent with
recent literature suggesting that physician-nurse communication is
often positive (Van Bogaert et al., 2017). Similarly, although an ED
study found that nurses had moral distress from following
physician orders, this finding appears to be driven by orders
nurses consider to be unnecessary (Zavotsky & Chan, 2016).
This study adds to the literature as it uncovered the
importance of moral distress and nurses’ perceptions. This
study also found a relationship between moral distress and
burnout that was enhanced by lack of administrative support
(MacKusick & Minick, 2010). According to Kirwan, Matthews,
vol. 65 ■ no. 6
and Scott (2013), “Nurses perceive their work environment to be
supportive of patient safety outcomes.”
Limitations
Although this study adequately describes the experiences of
some nurses who developed burnout in the ED, it is not
without limitations. As with all qualitative research, the purpose
was to generate hypotheses and therefore lacks generalizability
to all nurses’ experiences in the ED. The researchers
acknowledge that questions were formulated specifically about
burnout and that not all ED nurses experience burnout or have
had the same experiences as the participants in this study. The
coding of this study was conducted by one researcher, which
presents both benefits and potential bias. Future studies could
employ multiple coders to analyze interview content.
Implications for Practice
It is well established that nursing practice can be taxing.
Burnout can be described as a product of stress, workplace
violence, and lack of support. This study demonstrated that these
factors also resonated with nurses working in the ED. The
findings of this particular qualitative study indicate that work
environment, violence, and moral distress play a significant role
in burnout. Strategies to assist ED nurses in coping with these
factors include support groups where nurses are allowed to share
their experiences and listen to others with the same experiences
(Braunschneider, 2013). Another study highlighted the benefits of
mindfulness training as a tool to decrease burnout and promote
well-being among ER nurses (Westphal et al., 2015). Additional
studies may be needed to improve support among bedside
nurses as well as from nurse administrators. The themes also
indicated that nurses need rest breaks, unit based support groups,
time away from the unit and patients, and reprieve from the ED.
Conclusion
The findings of this qualitative study revealed that
emergency nurses experience burnout due to unhealthy,
stressful, and sometimes violent environments. Therefore,
quantitative research is needed to explore strategies to eliminate
burnout among ED nurses as well as nurse administrators. This
study raises awareness of burnout risk and can proactively
generate ideas to mitigate burnout and improve quality of care
to ED patients and their families.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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Author Biographies
Jose Andres Rozo is currently a bedside nurse in the critical care
unit at Parkland Hospital.
DaiWai M. Olson is an associate faculty at the University of
Texas Southwestern Medical Center and a bedside nurse in the
neuroscience intensive care unit.
Hlaing (Sue) Thu is a bedside nurse in the imaging department at
the University of Texas Southwestern Medical Center.
Sonja E. Stutzman is the Clinical Research Manager at the
University of Texas Southwestern Medical Center.
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