DOI: 10.1111/jabr.

12117

SPECIAL ISSUE

Burnout in ER nurses: Review of the literature and

interview themes

Adrian Abellanoza  | Nicolette Provenzano-Hass | Robert J. Gatchel

Department of Psychology, The University of

Texas at Arlington, Arlington, TX, USA Burnout is especially disruptive among emergency room
(ER) nurses. This report covers the influencing factors and
Correspondence
Adrian Abellanoza, Department of Psychology, outcomes related to burnout in ER nursing populations,
The University of Texas at Arlington, Arlington, with the goal of providing helpful information to a profes-
TX, USA.
Email: [Link]@[Link] sional audience. The present article includes a literature
review on burnout as it occurs in the ER. Interviews from a
small sample of ER nurses (n = 5) are analyzed through a
combination of deductive thematic analysis and computer-
ized text analysis. Research from various related fields have
been pooled together and briefly described. Experiences,
comments, and recommendations concerning burnout col-
lected from interviews seem to align with findings from em-
pirical research, and recommendations given by interview
nurses closely resemble the recommendations given by re-
searchers. Sentiment analysis revealed a pattern of positive
word use when the nurses discussed resources, and a pat-
tern of negative word use when workload was discussed. A
better understanding of burnout, both anecdotal and em-
pirical, is valuable information for any professional who
works in the ER. Many options exist for reducing or mitigat-
ing burnout, including interventions at the individual, team,
and organizational levels. More involvement of ER nurses in
burnout reduction strategies should be made a priority.

1 |  OVERVIEW

With medical care expanding in industrialized and developing countries, new generations of healthcare profession-
als are entering the job market. As newly-­trained workers enter hospitals, clinics, and other care facilities, they will
encounter a myriad of issues pertaining to the health and well-­being of the patients who seek treatment. Nursing

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J Appl Behav Res. 2018;e12117. [Link]/journal/jabr
[Link]
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holds a place of importance among these professions; nurses are often considered to be the backbone of hospitals
and other health facilities, being responsible for a large amount of direct patient care. The total workforce of reg-
istered nurses in the U.S., as estimated by the Bureau of Labor Statistics in 2014, was 2.75 million. This number is
expected to increase to 3.19 million by 2024, with an extremely fast growth rate of 16% compared to most occupa-
tions (Bureau of Labor Statistics, 2014). Additionally, the average age of nurses and the level of education required
to work as a nurse are simultaneously increasing, presenting problems in replacing experienced nurses in the near
future (Brunetto & Teo, 2013). These skilled workers are forced to solve complex problems and provide services
to patients in literal life-­or-­death situations. In this context, ensuring that the emergent workforce is equipped to
handle the challenges presented to them not only affects their own well-­being, but also the quality of care that their
patients experience.
Many aspects of nursing, including working under time constraints, exposure to human injury and disease,
and communicating with emotionally distressed family members, are inherently stressful (Matziari, Montgomery,
Georganta, & Doulougeri, 2017). Likely because of these stressful situations, the prevalence of burnout among
nurses is higher than the general population, which ranges from 13% to 27% (Adriaenssens, De Gucht, & Maes,
2015). A recent study of five countries suggests that up to 40% of all nurses experience burnout, and that the
majority of nurses who quit do so because of burnout (Crawford & Daniels, 2014). While research in this area
usually addresses nursing in general, some investigators have hypothesized that different specialties within
medicine may have differences in the influence factors on mental health outcomes. For those who work in the
emergency room (ER), various workplace stressors are thought to be amplified due to the increased urgency
and trauma of emergency situations. Factors, including time demands, exposure to psychologically-­traumatic
events, and being forced to make critical decisions in time-­sensitive situations, may be more characteristic
of emergency departments than other environments. While this idea seems intuitive, evidence of differences
between departments and roles is mixed. For example, a recent study involving Suez Canal University hospital
doctors showed emergency doctors having a lower prevalence of burnout, compared to surgeons and internal
medicine doctors (Kotb, Mohamed, Kamel, Ismail, & Abdulmjeed, 2014). On the other hand, a study of Spanish
emergency departments showed doctors as having a higher rate of burnout than nurses (Escribà-­Agüir & Pérez-­
Hoyos, 2007).
Delineating the specific experiences of ER nurses is important for guiding staffing and talent-­management deci-
sions for many healthcare organizations. This article hopes to provide a general audience with important information
regarding burnout as it pertains to ER nurses. This includes a summary of current research that cuts across the
fields of nursing, organizational behavior, and management. Implications for practice, including possible individual,
team-­based, and organizational-­level interventions, will also be discussed. Finally, real-­world examples collected from
interviews with ER nurses will be examined and related to findings from published research. It is the goal of this
paper to provide readers will a full yet concise picture of what ER nursing burnout is, and how to prevent its negative
outcomes.

1.1 | What is burnout?
Burnout is defined in the research literature as the psychosocial state of physical and mental exhaustion result-
ing from prolonged emotional stress (Maslach, Schaufeli, & Leiter, 2001; Stephan, Patterson, Kelly, & Mair, 2016).
Burnout, and its effects on staffing procedures and performance management, has been studied for several decades.
Few topics in the realm of organizational research are of more importance; burnout has been linked to decreased
job satisfaction and job performance, and is thought to be a driver of negative outcomes for employees, including
increased absences from work (Jourdain & Chênevert, 2015), intentions to quit (Shemueli, Dolan, Ceretti, & Prado,
2015) and both mental and physical health issues (Bakker & Costa, 2014; Glaser & Kiecolt-­Glaser, 2005; Ross-­Adjie,
Leslie, & Gillman, 2007).
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Decades ago, researchers Maslach, Jackson, and Leiter (1997) compiled the existing literature on burnout, and
created both a conceptual model of burnout and a psychological questionnaire—the Maslach Burnout Inventory, or
MBI. Burnout consists of three primary components: emotional exhaustion; depersonalization; and lack of personal
accomplishment. Emotional exhaustion refers to a loss of emotional energy and strength; depersonalization includes
feelings of cynicism and negative, reactionary behavior; and lack of personal achievement refers to a feeling of failure
and inadequacy at work (Maslach et al., 1997). Of these components, emotional exhaustion is considered the “core”
of burnout (Schaufeli, Bakker, & Salanova, 2006).
Although burnout has been studied for several decades, the exact nature of burnout continues to be studied and
revised. For example, a recent study published in the European Journal of Psychological Assessment has suggested that
the emotional exhaustion and depersonalization components may be a single, unified component (de Beer & Bianchi,
2017). More information will undoubtedly continue to be collected through academic research, as well as findings
that form organizational best practice. Just as the field of medicine requires doctors and nurses to keep up-­to-­date
with the latest techniques, treatments, and procedures, it is important for healthcare administrators and professionals
to stay current with the issues affecting the workforce.

1.2 | Why is burnout important to hospitals and emergency departments?

When it comes to burnout, organizations stand to lose much in the way of productivity and financial resources.
Chief among the organizational impacts of burnout is its relationship with employee turnover. Hiring and training
ER nurses is a costly endeavor: the average cost to replace nursing staff ranges from $37,500 to $58,400, with each
percent of turnover potentially costing the average hospital $373,200 (Colosi, 2016). Furthermore, the average time
to replace an RN can range from 54 to 109 days—plenty of time for hospitals to feel the burden of staffing short-
ages (Colosi, 2016). Additionally, liability of the organization may be at stake. As will be discussed later in this article,
patient care is negatively affected by burnout in the nurses who suffer from it. This may open potential litigation
against hospitals and clinics for malpractice and negligence.
Fortunately, nursing management may have the ability to prevent or reduce burnout by influencing its antecedent
factors. The relationship between stress, burnout, and turnover is outlined by the job demands-­resources model, or
JD-­R model (Shemueli et al., 2015). Shemueli and colleagues presented and tested this model, which links job de-
mands (e.g., workload, psychological strain, and other individual costs of working), and job resources (e.g., physical
and social assets, “tools,” and mechanisms that help individuals deal with job demands). Burnout was found to be a
moderator between both work overload and (a lack of) social support, and turnover intentions. While burnout can
be costly, some of the many factors that contribute to its development can be controlled by organizations to some
degree.

1.3 | Why is it important to understand burnout in ER nurses?

Burnout is linked to many negative outcomes for nurses themselves, including both mental and physical health is-
sues (Adriaenssens et al., 2015; Ross-­Adjie et al., 2007). The effects of burnout also extend past the individual nurse,
namely the patients who receive care. Understanding burnout is key to providing patients with the best quality-­of-­
care possible, and ensuring that the nursing workforce is healthy and effective. Healthcare workers who suffer from
the same stress that precedes burnout also face a wide variety of related psychosocial issues, including depression,
anxiety, and stress disorders (Westphal et al., 2015). Stress can also cause structural changes in the parts of the brain
that are associated with memory, executive functioning, and fear responses. For example, chronic stress has been
shown to increase atrophy of neurons in the hippocampus and prefrontal cortex, as well as increase neuronal growth
in the amygdala (Arnsten, 2009). Excessive stress also has significant physical effects on the body. Physical responses
to stress include effects on both the cardiovascular system and immune system. Chronic psychosocial distress, and
a lack of ability to cope with stressors, has been shown to regulate immune and endocrine function in the body,
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making individuals more susceptible to infection, cardiovascular disease, and aging effects (Glaser & Kiecolt-­Glaser,
2005; Miller, Chen, & Parker, 2011). Among ER nurses, the effects of prolonged stress include maladaptive coping
behaviors, such as increased smoking and alcohol use. This compounding effect may contribute directly to poor
health in the short-­term for nurses, which worsens over time due to the health effects from such unhealthy coping
behaviors (Ross-­Adjie et al., 2007).
Furthermore, an ER nurse experiencing the psychosocial distress and physical fatigue brought on by burnout is
unlikely to provide optimal care to his/her patients. Investigators have examined the relationship between burnout
and its anteceding factors, and found that workload, as well as verbal abuse from patients and their families, were
associated with depersonalization and emotional exhaustion which, in turn, predicted patient falls, nosocomial in-
fections, and medication errors (Van Bogaert et al., 2014). Organizational and team-­level factors, such as staffing,
management, and nurse-­doctor relationships, have also been shown to predict burnout, as well as job satisfaction
and patient quality-­of-­care (Gunnarsdóttir, Clarke, Rafferty, & Nutbeam, 2009). However, a limitation of much of the
research in this area is that quality-­of-­care outcomes are typically reported by nurses, and as such may include higher
measurement error than more objective measures of patient outcomes (Lindqvist, Alenius, Griffiths, Runesdotter, &
Tishelman, 2015; Van Bogaert et al., 2014; Westphal et al., 2015).

1.4 | What causes burnout in ER nurses?

As previously discussed, the high level of stress-­exposure that ER nurses experience is unique among nursing
areas. Traumatic events, including episodes of violence, are common and have profoundly negative outcomes
for those involved (Roche, Diers, Duffield, & Catling-­Paull, 2009). In addition to the medical care of patients,
nursing staff must perform similar tasks as a customer-­service representative would, including: face-­to-­face
interaction with patients and their families; and managing discrepancies between felt emotions and what is
displayed to the public at large (Andela, Truchot, & Van der Doef, 2016). This emotional dissonance, or the “fak-
ing” or “disguising” of one’s true emotional state, has been found to be consistently related to the emotional
exhaustion dimension of burnout across job domains, and especially among women (Kenworthy, Fay, Frame, &
Petree, 2014).
A meta-­analysis by Adriaenssens et al. (2015) compiled decades of research on the antecedents of burnout, both
from ER nurses and in general populations. A total of 17 studies were reviewed and the authors outlined individual
factors of interest, such as demographics, personality, and differences in coping strategies, as well as work-­related
factors: exposure to trauma; job characteristics; job demands; and organizational factors (Adriaenssens et al., 2015).
Regarding individual factors, the authors found mixed results regarding age and burnout—in one study, a younger age
was related to lower levels of personal accomplishment but, in another study, higher seniority was related to lower
personal accomplishment (Adali & Priami, 2002; Adriaenssens et al., 2015; Alexander & Klein, 2001). Some empirical
support was found for personality and individual differences buffering against burnout, including flexibility, adapt-
ability, and judgmental behavior (Walsh, Dolan, & Lewis, 1998). Increased avoidant behavior was also associated
with higher depersonalization and emotional exhaustion, as well as lower personal accomplishment (Van der Ploeg
& Kleber, 2001).
Several work-­related factors were found to be associated with burnout. Exposure to traumatic events increases
the likelihood of burnout (Adriaenssens et al., 2015; Alexander & Klein, 2001). Excessive workload was found to
increase emotional exhaustion and depersonalization, while lack of social support predicted higher depersonalization
and lower perceptions of personal accomplishment (García-­Izquierdo & Ríos-­Rísquez, 2012). Poor communication
and collaboration (O’Mahony, 2011) and staffing issues (Walsh et al., 1998) were also found to increase burnout.
Many of these factors are practically unavoidable in a fast-­paced, high-­stakes environment such as an ER. However,
measures can be taken to mitigate or prevent negative outcomes associated with burnout. Actions taken to limit
burnout vary in scope, focusing on an individual, a team, a department, or the whole organization. They may also vary
in goal, such as distributing workload efficiently, increasing access to resources and support, or improving nurses’
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ability to cope with stress. Ideally, an organization’s approach to mitigating burnout should be multi-­faceted and
target multiple potential causes of burnout.

1.5 | What can be done to manage burnout among ER nurses?

Organizations should use their resources and influence to promote interventions at multiple levels, from organization-­
wide change initiatives down to individual-­level trainings. Targeting each level within an organization has different
benefits. For example, individual-­level training may equip nurses with methods to deal with a wide variety of stress-
ors. While individual-­level training is important, focusing solely on managing burnout at the individual-­level ignores
the social and interpersonal factors of work teams in which most ER nurses work. Furthermore, interventions involv-
ing individual training do not alleviate workload or increase social support among coworkers. Ideally, a combination
of individual, team-­level, and organization interventions is recommended in order to best manage burnout among ER
nurses. The next section provides an overview of interventions and potential targets, with evidence from relevant
nursing populations.

1.5.1 | Individual-­level interventions
Interventions aimed at individual nurses focus on the specific coping strategies that are used to handle stressors.
Interventions at this level typically include educational, training, or coaching programs designed to teach individuals
these strategies in the hopes that they will apply them in the workplace.
Problem-­solving coping strategies have been found to be especially relevant to ER nurses (Chang & Chan, 2015;
Shinan-­Altman, Werner, & Cohen, 2016). Problem-­solving coping is characterized by resolving stress through action,
whether through solving the issue or seeking assistance (Baker & Berenbaum, 2011). This contrasts with emotion-­
focused coping, which is more passive and is concerned with managing one’s emotions versus the problem itself.
Implementing a program to teach ER nurses these skills may reduce levels of burnout. For example, ER nurses who
have trouble communicating with a patient’s family may request help from another, more experienced nurse. Proactive
coping, which anticipates future stress, is negatively associated with burnout (Chang & Chan, 2015). ER nurses may
benefit individually from identifying potential stress ahead of time, and attempt to deal with the stressor beforehand.
Mindfulness training has been found to temper some of the effects of workplace stress on burnout. Mindfulness
training has its roots in the positive psychology movement, and is defined as “awareness that emerges through
paying attention on purpose, in the present moment, and nonjudgmentally, to the unfolding of experience moment
by moment”; alternatively, it is defined more scientifically as the “self-­regulation of attention, involving the ability
to sustain and switch attention and inhibit processing of task-­irrelevant stimuli” (Westphal et al., 2015). Among ER
nurses, mindfulness has been demonstrated to be negatively related to burnout, depression and anxiety. Researchers
theorize that mindfulness helps buffer against sources of stress that originate from interpersonal interaction, such as
negative emotional contagion. A systematic review of meditation programs aimed at inducing mindfulness showed
a modest effect in reducing both clinical and sub-­clinical levels of anxiety and depression symptoms (Goyal et al.,
2014). Providing access to programs such as these may give ER nurses the ability to interact with distressed individ-
uals and maintain levels of empathy without experiencing anger or anxiety.

1.5.2 | Team-­level interventions
Most ER nurses do not work in isolation. For patients to be treated effectively, doctors, nurses, technicians, and
other ER personnel must coordinate their efforts and expertise. Assessing a phenomenon in the appropriate contex-
tual and social environment is a common consideration in psychology (Miller & Konopaske, 2014). Within organiza-
tional research and practice, this means that outcomes, such as job performance, are now assessed at the team level
(Cannon-­Bowers & Bowers, 2011). Consistent with this line of thinking, researchers have explored team-­focused
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interventions and their efficacy in preventing or reducing burnout. Work teams, like all groups, confer benefits to in-
dividuals by providing resources and support (Morgeson, Garza, & Campion, 2012; Shemueli et al., 2015). Enhancing
these properties in teams is one of the main goals of this type of intervention.
Le Blanc, Hox, Schaufeli, Taris, and Peeters (2007) tested a team-­based burnout intervention program among
the staff of an oncology unit, using an approach that had been found previously to reduce depressive symptoms
and absenteeism in other medical units. Dubbed “participatory action research,” the program consisted of support
group meetings outside of duty, which allowed staff to discuss work-­related issues and “brainstorm” problem-­solving
strategies. A unit implementing this program was then compared to a control group that had no such program.
Results revealed that having an opportunity to meet with management and discuss work-­related issues reduced the
depersonalization factor of burnout and perceptions of job demands, and increased perceptions of job control and
social support (Le Blanc et al., 2007). This research also corroborates with other empirical evidence showing that a
collaborative, participatory environment increases nursing retention. The relationship between ER nursing managers
and frontline ER nurses is important for retention. Leadership styles that allow for employee empowerment in terms
of resources, support, and growth opportunities have been linked to increased retention (Laschinger, Wong, & Grau,
2013).

1.5.3 | Organizational-­level interventions
Organizations may seek to prevent ER nursing burnout in part by bolstering aspects of their selection process.
For example, personality characteristics have been found to be related to several factors associated with burn-
out. In a study by Burgess, Irvine, and Wallymahmed (2010), questionnaires were used to examine how person-
ality traits were related to workplace stress and coping traits in ICU nurses. The authors found that openness,
agreeableness, and conscientiousness were associated with increased use of active planning and reframing,
which are two coping strategies that help deal with stress (Burgess et al., 2010). ICU nurses who were higher
in openness and extraversion were also found to experience less stress from interacting with patients and their
relatives, and those higher in conscientiousness were found to have less stress regarding workload and feelings
of incompetence.
An additional personality characteristic referred to as “hardiness” has been shown to be particularly relevant for
nurses. Research has explored psychological hardiness as partially explaining the relationship between stress and
perceptions of happiness in nurses. Hardiness has traditionally been defined as the possession of three personality
characteristics, including a sense of control, commitment ability, and challenge orientation; a person is considered
hardy when he/she possesses all three of these characteristics (McCranie, Lambert & Lambert, 1987; Skomorovsky
& Sudom, 2011). Researchers have found that low levels of stress were associated with higher hardiness and hap-
piness, and happiness and hardiness were found to be positively related (Abdollahi, Talib, Yaacob, & Ismail, 2014).
Hardiness as a selection measure has also been used successfully in military populations, specifically special-­forces
soldiers whose work has a slim margin of error, and who are likely to face high levels of job-­related stress (Bartone,
Roland, Picano, & Williams, 2008) Researchers have long theorized that hardiness can also be taught, suggesting that
a focus on hardiness as an individual difference versus a fixed personality trait can be extended to other stages of the
employee’s life cycle (Abdollahi et al., 2014; McCranie, Lambert & Lambert, 1987).
Dispositional factors may interact with coping strategies to produce a “magnified” buffering effect against burn-
out. In a study on 314 Taiwanese staff nurses, Chang and Chan (2015) explored the effect of optimism and proactive
coping on burnout. Participants were asked to complete three questionnaires: a version of the MBI; the LOT-­T life ori-
entation test; and the Proactive Coping Scale. The study found that optimism had a direct effect on all three aspects
of burnout, such that highly optimistic nurses tended to report lower emotional exhaustion, depersonalization, and
diminished personal achievement (Chang & Chan, 2015). Additionally, highly optimistic nurses tended to use more
proactive coping skills, which also indirectly diminishes burnout. This may mean that ER nurses who tend to be more
optimistic may also see increased benefits from coping-­strategy training.
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Employers of ER nurses should seek to add personality testing to their existing selection processes.
While more longitudinal research needs to be done in this area, selecting for nurses who are likely to be
resilient to stress may help mitigate absenteeism and errors in practice (Burgess et al., 2010). Recruiters
and managers must balance the immediate need to fill staffing shortages with the long-­term need for experi-
enced, committed nurses. Using contracted nurses, such as travel nurses, may be an interim solution to provide
enough staff to ER departments with more reliable long-­term replacements. Furthermore, nursing educators
should emphasize the importance of these characteristics and advise students to pursue specialties that match
their dispositions. Educators should also teach the value of critically assessing personal fit during shadowing/
rotations.
Organizations must engage in the difficult task of striking a balance between having enough nursing staff to cover
workload, selecting for competent and high-­potential nurses, and the amount of resources at their disposal. However,
if burnout and its related outcomes are to be taken seriously, the first of these three factors, workload, is of the ut-
most importance. High workload is often implicated to be the primary cause of stress and burnout within ER nurses
(Ross-­Adjie et al., 2007), and also within other nursing specialties (Haut et al., 2006; Le Blanc et al., 2007), as well as
the general population (Fisher, 2014). Organizations may need to get creative to solve this problem. For example,
having each hospital carefully determine optimal unit sizes to fit its needs has been suggested as a possible solution
(Lindqvist et al., 2015). Because of its critical role in producing burnout, administrators should consider effective
ways of handling workload issues, whether through more strategic scheduling and shift management, or by hiring
more nurses to offset the load from any one given individual.
Selecting future nurses may indeed play an important role in managing burnout, but what is to be done with
the existing workforce? As mentioned previously, replacing nurses is a difficult and costly procedure (Colosi,
2016). The answer might lie with interventions aimed at improving employee attitudes toward the organiza-
tion. While studies involving ER nurses have not explored the relationship between employee attitudes and
burnout (Adriaenssens et al., 2015), studies in other populations have demonstrated relationships between
these attitudes and negative organizational outcomes. In particular, workplace engagement is one of the main
attitudes of interest regarding burnout. Engagement is defined as “the psychological state in which an em-
ployee has feelings of energy, enthusiasm, and activation at work” (Macey & Schneider, 2008). Engagement
has been found to ­mediate the relationship between worker overload and turnover intentions; in other words,
increasing engagement may act as a buffering factor, keeping employees from quitting despite a high workload
(Shemueli et al., 2015). Engagement has also been found to be negatively related to burnout (Schaufeli et al.,
2006). Interventions to increase workplace engagement include organization-­wide engagement programs that
encourage employees to display kindness, gratitude, and optimism while at work (Schaufeli & Salanova, 2007).
These programs can take the form of online coaching or other resources. Leveraging transformational leadership
training and career development programs can also increase engagement within an organization (Schaufeli &
Salanova, 2007).

1.5.4 | Summary
Burnout in ER nurses remains a heavily investigated topic because of the physical and mental health outcomes at
the individual level, as well as cost in terms of lost productivity and drains on financial resources at the organiza-
tional level. The distressing psychosocial and emotional phenomena are prevalent among ER nurses for several
reasons: the workload; exposure to injury and death of patients; and stressful interpersonal interactions. However,
there are many approaches to potentially mitigate these problems, and combinations of these suggested inter-
ventions can be employed to ensure a healthier workforce, better patient care, and a more efficient emergency
department. The topic will continue to be studied by researchers, but breakthroughs in the prevention of ER nurs-
ing burnout require the participation of all related professionals: administrators, nursing managers, and ER nurses
themselves.
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T A B L E   1   Descriptive statistics of interview words

Word category Frequency Percent

Negative words 193 49.60

Positive words 196 50.40
Coping question words 95 24.42
Environment question words 45 11.57
Management question words 25 6.43
Personality question words 45 11.57
Pride question words 34 8.74
Resources question words 28 7.20
Support question words 40 10.28
Typicality question words 17 4.37
Workload question words 52 13.37
Miscellaneous question wordsa 8 2.06
Total 389 100
a
Miscellaneous question words did not meet criteria for chi-­square test of association (<5 cases per cell); variable was ex-
cluded from analysis. Question percentages may not equate to 100% due to rounding.

2 |  DATA ANALYSIS OF ER NURSE INTERVIEWS

While the research literature describes burnout in scientific terms, the information presented in the previous
sections may not have as much impact as statements from actual ER nurses who claim to experience this phe-
nomenon. To highlight the problem on a more personal level, five current and former ER nurses agreed to par-
ticipate in semi-­structured interviews, which included prompts developed using the literature (see Appendix A).
Partial transcriptions and interviewer notes were obtained from these sessions. While these individuals were not
administered the MBI or another burnout inventory, their anecdotes about dealing with stress are important to
understand when describing the experience. To accomplish this, two types of analyses were used. First, a type of
text analysis was performed—known as a “sentiment analysis”—to determine the proportion of negative versus
positive words in each question category. Second, a theory-­driven deductive thematic analysis was performed,
highlighting several key themes found across the five interviewees. Both methods help to illuminate workplace
stress and burnout as they pertain to the present sample. Interestingly, although unaware of the research litera-
ture surrounding burnout in their field, the participants addressed several concepts covered by researchers, in-
cluding social support, staffing issues, attitudes toward management, organizational resources, and other facets
of ER work contributing to their personal experiences of burnout.

2.1 | Sentiment analysis methods

Notes from the interviews were formatted and analyzed using the “tidytext” package for R (Silge & Robinson, 2016).
To prepare the words for analysis, interview notes relating to each question were sorted into question categories
(see Appendix A for each category and the corresponding question). Using “tidytext,” notes were sorted into one
row per word, and matched against the “bing” lexicon. This lexicon contains 6,788 words that have previously been
sorted into “negative” and “positive” categories. Words not contained in the lexicon were automatically dropped by
the program and removed from further analysis. The remaining words were categorized into negative and positive
groups, per the “bing” lexicon. The results from each sentiment analysis were then loaded into IBM SPSS to assess
differences in sentiment per question category (see Table 1).
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2.1.1 | Sentiment analysis results and discussion

To assess whether each category had a significantly higher proportion of negative and/or positive words, a chi-­square
test of association was performed. A significant association was found between question category and positive/negative
sentiment, χ2(9, n = 389) = 20.11, p = .02, w = .23. Column proportions for each question category were then compared
using z-­tests to determine which question categories had significant differences between positive and negative words.
Responses to the Workload question were found to have a significantly higher proportion of negative words (67.31%)
than positive words (32.69%), z = −2.97, p < .01. Additionally, responses to the Resources question were found to have a
significantly higher proportion of positive words (75.00%) than negative words (25.00%), z = 2.25, p < .05.
Adjusted standardized residuals were then compared to assess which questions had significantly different neg-
ative or positive words than expected by chance (Sharpe, 2015). Results indicated that participant responses to the
Workload question had more negative (z = 2.7, p < .01) and less positive words (z = −2.7, p < .01) than expected
by chance, indicating the language used to describe workload was more negative than positive among the present
sample. This finding is in line with the research that considers workload to be a primary cause of stress and burnout
(García-­Izquierdo & Ríos-­Rísquez, 2012; Ross-­Adjie et al., 2007; Van Bogaert et al., 2014). This result also appears to
match the specific statements made by the participants regarding workload (noted in a later section).
Additionally, participant responses to the Resources question had less negative (z = −2.7, p < .01) and more posi-
tive words (z = 2.7, p < .01) than expected by chance. This was a surprising finding, and was not in line with the state-
ments given by the participants who reported an overall lack of resources. Based on the responses from the nurse
participants, this finding can be interpreted as expressed optimism about how additional resources could improve
their work experience. Job resources have been identified as a key buffer against burnout (Shemueli et al., 2015), and
the finding that the Resource question was associated with more positive words highlights their importance. All other
question categories did not differ significantly between positive/negative word proportions, or in amounts of words.
The above analyses help to provide a quantifiable measure of sentiment for the present interview data; however,
it should be noted that this method has some limitations. First is the reliance on self-­report data and the interpre-
tation of the researcher during interviews, as well as a limited sample size (n = 5). Additionally, this method did not
include syntax and sentence structure; thus, the absence of contextual information may have led to incorrect cat-
egorizations. Lastly, the “bing” lexicon was chosen to support nonparametric analyses, as the researchers felt that
parametric analyses were unsuitable for the present data. There exist various other lexicons which vary in size, cate-
gories, and scoring systems (Silge & Robinson, 2016). Future research should include a bigger, more inclusive sample
size and alternative lexicon(s) to allow for parametric techniques (e.g., ANOVA) using continuous sentiment scores.

2.2 | Thematic analysis results

To provide a more detailed account of stress and burnout in the present ER nurse sample, partial transcriptions and
notes from the interviews were read and analyzed for common themes found in the research literature. Emergent
themes from the interviews are presented in the following paragraphs. It should be noted that the limitations men-
tioned previously (small sample size, researcher subjectivity) restricts the generalizability across all ER nurse popula-
tions. Nevertheless, it is valuable for healthcare professionals to start developing an understanding of how ER nurses
describe and communicate their experiences. When reading the results, consider the scientific findings presented
previously, and also compare these with personal observations and interactions with ER nurses on the job, perhaps
in the role of mentor or manager. All names have been changed to protect the individuals and their identities.

2.2.1 | Social support
As previously mentioned, lack of social support is a key antecedent to burnout under the JD-­R model (Shemueli
et al., 2015). Relationships with other nurses, and with doctors, patients, patient families, and hospital management,
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were discussed by each of the five participants. Participants provided the most detail about the relationship between
nurses, as well as attitudes toward hospital management. Unfortunately, several of the participants had negative per-
ceptions of both their leaders and their patients. For example, Participant #4 stated that he felt as if he was “always
being beat up by someone: doctors, the charge nurse, patients.”
The participants described teamwork and social support within the ER environment as one of the biggest factors
in the amount of effort and emotional stress experienced during a shift. Interdependence among nurses was de-
scribed as essential to a positive work environment. Participant #3 noted that she gets irritated if a nurse does not
“pull her load”; similarly, Participant #1 encountered both “team players who could pick up when [she] needed help,”
as well as “fat fannies who didn’t do a thing.” Participant #5 stated that “a team of great nurses who work collabora-
tively” makes a stressful shift more tolerable “even if unpredictable things happen.” Virtually all of five participants
mentioned the relationship between nurses as the deciding factor between a successful night and a difficult one.
Participants described the amount of teamwork and coordination required for a given shift; tasks that may be as-
signed to a specific nurse may be passed to another individual because of time constraints or random lulls/spikes in
patient activity. They also noted some aspects of what they consider to be a dependable nurse, which included not
only comments about medical competency but also traits such as trustworthiness and service orientation. Along with
other job-­relevant personality characteristics (Adriaenssens, De Gucht, & Maes, 2015; Burgess et al., 2010), emer-
gency departments may consider these traits when selecting nurses for positions and/or teams and units.

2.2.2 | Leadership
Some of the most critical opinions were reserved for hospital leadership, including doctors, charge nurses, and administra-
tion. The participants often described leadership as out of touch or in opposition to the interest of nurses. Participant #3
felt that “some doctors have a God complex”; Participant #1 recalled that in her hospital “doctors bark orders real rough.”
Leadership was described as being overly fixated on meeting quotas. For example, Participant #2 stated that management
was “always doing numbers…sometimes we think, ‘maybe we should have given them more treatment’. Everyone wants
to push for discharge, discharge, discharge.” Participant #5 described leadership as being resistant to change, “stay[ing]
in the same rut until something major happens with a patient.” The importance of having feedback heard was mentioned
by several participants. In Participant #4’s department, a suggestion box was available to employees. For leadership, the
suggestion box provided ideas on what can be improved in the work environment, as well as visibility on the well-­being
of nurses. Participant #1, who was a charge nurse in an ER environment, promoted the involvement of her subordinate
nurses in decision-­making. The charge nurse stated that, whenever she asked for ideas from her nurses, “there was never
a bad suggestion; we would work on [brainstorming] all the time, do little things, play games, problem solve.” She also
praised the president of the hospital where she worked, stating that “he would take what [she] said, and actually imple-
ment changes” and that “he was approachable, and would listen to you” although he “wasn’t always easy to get to.” She
went on to speculate that “knowing that managers were there for them, and not ‘against’ them would really cut burnout
down.” These statements highlight the importance of leaders within the ER department having leadership styles that dis-
play genuine consideration and support for subordinates, such as transformational leadership (Arnold, Connelly, Walsh, &
Martin Ginis, 2015). A potential solution to both relational issues between management and frontline ER nurses, as well
as issues surrounding individual coping skills and job demand (to be discussed later in this section), is mentoring programs.
For example, Participant #4 described a system in his hospital in which late-­career nurses, often in leadership positions,
are matched with early career new hires for up to 2 years. According to him, “it helped to talk to someone” and gave him
“more clout” when it came to suggesting changes to the workplace.

2.2.3 | Interventions
The inclusion of supplementary programs (support groups, team meetings, etc.) may also influence the interaction
between nurses and their peers. The participants were asked if any outside-­of-­work programs, such as counseling
ABELLANOZA et al. |
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services or even unit/department meetings, were offered by their respective hospitals. Most of the participants
stated that they did not have such resources or gatherings, which meant that nurses had little opportunity to address
issues or provide feedback to leaders and hospital management. Some of the differences in resource availability may
be due to the nature of night-­shift work. For example, Participant #5, who works night shifts, stated: “In my first
year as a nurse, we had once-­a-­month meetings, but I didn’t go because it was early in the morning. I don’t feel like
it would change anything if we were to go to one. Nothing changes if we just talk about it.” There also seemed to be
a consistent view among participants that such interventions do not benefit nurses, or that they are unnecessary.
Recalling a series of emergency meetings held after the death of a young patient, Participant #2 commented, “we
didn’t feel like we needed it; we’re supposed to be above that…even though you think about that death for many
years.” Participant #5 noted that while she and her fellow nurses “hang out outside of work,” they “really don’t talk
about work” when they are not on duty. The idea that nurses may not have an outlet to speak about their workplace
experience is troubling. In fact, the emotional trauma associated with the death of patients, particularly young or
infantile patients, was noted by almost every participant. The idea that these resources are unnecessary contradicts
research showing that this type of intervention can be successful in either directly or indirectly reducing burnout
(Goyal et al., 2014; Le Blanc et al., 2007; Schaufeli et al., 2006). The disconnect may have to do with cultural norms
within hospitals. Organizational culture change initiatives, including targeted marketing and educational programs,
could be used to promote the potential benefits of such interventions and increase participation (Pignata, Boyd,
Gillespie, Provis, & Winefield, 2016).

2.2.4 | Job demands
Patients and their families were mentioned as a source of stress across all interviews. Participant #2 addressed the
issue at length, describing various times in which patients attempted to lie or manipulate her. The participant men-
tioned instances of patients stealing narcotics, with one patient of hers mentioning that she was “allergic to Demerol
if it’s under 100 mg.” After discussing these incidents, Participant #2 stated bitterly that “in the ER you see the best
of humanity and the worst of humanity,” and stated that due to her experiences she “[doesn’t] ever want to walk in
an ER again.”
As expected, staffing was mentioned frequently throughout the interviews. Almost every participant mentioned
that ER departments are often short-­staffed. Lacking sufficient personnel to handle operation of the emergency
department places additional burden on nurses and increases the potential of poor patient care (Adriaenssens et al.,
2015). As a result, Participant #2 reported that nurses “always ate on [their] feet” and that there did not seem to be
enough time to complete tasks. All participants more or less agreed that increasing staffing would decrease their
experiences related to burnout. To partially attenuate the effects of being short-­staffed, ER nurses describe using
their moderate level of job autonomy in order to fill gaps in patient care; if a certain task takes too long or if an
emergency occurs, participants stated that they generally would rely on other nurses to cover for them, with the
understanding that this would be reciprocated. However, this may increase role ambiguity, an antecedent factor
to burnout (Ambrose, Rutherford, Shepherd, & Tashchian, 2014; Olivares-­Faúndez, Gil-­Monte, Mena, Jélvez-­Wilke,
& Figueiredo-­Ferraz, 2014). Participant #2 described an instance in which time demands placed on other nurses
required her to provide a nebulizer treatment to a patient—something that she had not been properly trained to do.
Discussion surrounding staffing also highlighted organizational practices that are potentially unethical or harmful
to ER nurses. Participant #5 described her department’s reliance on convincing nurses to work overtime: “they’ll send
out a text if you’re not working and ask you to work, and if people aren’t responding that’s usually when they’ll offer
it. You’re going to know you’re getting your ass kicked that night.” As seemed to be the case with the other nurses,
Participant #3 stated that there were no limits to the amount of overtime shifts a nurse may work. Additionally,
Participant #5 stated she heard claims of a “blacklist” that area hospitals share in order to make hiring decisions. This
blacklist supposedly is created to deter turnover by reporting nurses who break an unofficial non-­compete clauses.
If a nurse quits working for any of the hospitals contributing to the blacklist, that nurse will be unable to find work
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with any of the other hospitals. Even if such rumors are untrue, negative perceptions of an organization’s fairness may
increase burnout (Ronen & Mikulincer, 2009; Simha, Elloy, & Huang, 2014).
In describing how their hospitals addressed staffing issues, two of the participants highlighted a growing
trend in healthcare: contract work (Pittman, Folsom, & Bass, 2010). Both Participant #2 and Participant #5 dis-
cussed the phenomenon of using agency nurses, or “travelers,” to supplement permanent staff. Participant #5
went into this in detail, explaining that, in her opinion, contract work “makes the job easier overall, but you never
know what you’re going to get.” According to her, travelers in her hospital rotate through a 13-­week contract;
however, she explained that orienting these nurses took a considerable amount of time. Participant #3 suggested
that in order to deal with the issue, emergency departments should increase staffing, tie raises to overall hospital
approval ratings, rotate acuity responsibility, and set maximum hours for nurses.

2.2.5 | Individual differences
The nurses described several individual difference variables that they felt had an impact on their and other ER
nurses’ experiences of burnout. These included coping behaviors, personality traits, and motivations for becoming
ER nurses.

Coping behaviors
Among coping behaviors, participants generally described going to social places and events, such as clubs, bars,
concerts, movies, etc., as a primary way to “de-­stress.” However, as mentioned earlier, participants noted that they
rarely discuss workplace issues outside of working hours, even if their off-­work time is spent with coworkers. Two
of the participants mentioned physical exercise as being beneficial to them in reducing stress.
Substance abuse was a recurrent topic throughout the five interviews. The use of alcohol in moderation was
described as common; participants described drinking alcohol during social gatherings on a consistent basis, and that
this lifestyle was usually attributed to younger nurses. However, two of the participants described instances in which
more harmful forms of alcohol and illicit drug use affected coworkers. Participant #4 described a coworker whose
alcoholism resulted in deviant workplace behaviors and instances of sexual harassment. This not only resulted in said
coworker being fired, but a potential suicide attempt that involved another coworker. Additionally, Participant #5
spoke of nurses who used stimulants, such as cocaine and Adderall, to handle their workload. As previously stated,
these behaviors may reduce stress for the individual in the short-­term, but over time result in long-­term negative
effects on physical and mental health (Ross-­Adjie et al., 2007). Organizational change initiatives, such as the imple-
mentation of wellness and educational programs, may help to address the concerning issue of substance abuse.

Personality traits
The present sample of ER nurses also described personality traits that they thought were important for ER nurses’ suc-
cess. The idea that some nurses are naturally suited to the role was expressed. According to Participant #1, “some nurses
are born to be nurses, and have a calling to help people” by possessing such qualities as “compassion, love for humanity,
patience, and the ability to listen.” Others, such as Participant #5, thought that ER nurses are a diverse group: “Emergency
department nurses are a strange breed. There are very diverse personalities, very laid back all the way to very Type-­A; it’s
funny to see how people deal with things differently.” However, the ability to empathize with patients, and the ability to
tolerate stress, were important. Per Participant #5, “the more high-­strung you are as a person, the more a shift will take
a toll on you. You have to let things roll off your back.” Participant #1 also claimed that an ER nurse “absolutely [has] to
have compassion, or [they] will not last. If you are not very much of a people person, you have to change that.”

Motivation
The participants also described the personal motivations that helped keep them in the ER. Overall, they seemed to
enjoy the challenge of work as an ER nurse, and the continued learning associated with it. Participant #1 stated that
ABELLANOZA et al. |
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she is “proud to be a nurse, but not so proud to think [she] knows it all,” adding that she enjoys “learn[ing] something
new every day”. This sentiment was shared by Participants #3 and #4, the latter of whom had chosen the profession
after becoming unsatisfied with his previous career as a marketing manager. For him, the environment of the ER was
similar in terms of pace and difficulty, while also offering him the chance to help people. Participant #2 stated that
when “[she] was an ER nurse, [she] would challenge myself and increase [her] goals. Seeing so many different things
was rewarding in [her] personal life as well.”

3 |  DISCUSSIO N

The issue of burnout remains a difficult problem to solve among academics, business professionals, and the employ-
ees who experience it. The negative outcomes associated with burnout—loss of productivity, decreased quality of
care, increased turnover, and the mental and physical health of nurses themselves—should make addressing burnout
a priority in ER nursing management. Preventing these outcomes will require action plans that must be both evi-
dence based and practical.
The current literature offers many possible solutions. Administrators may choose to implement any combination of
interventions to target burnout. These actions range from individual training and coaching programs, to team-­based dis-
cussions and participation, to organization-­wide interventions, including the implementation of new selection measures
and culture change initiatives. From the perspective of the interviewees, many existing programs are considered ineffec-
tive or unnecessary. The mismanagement of such programs may be due to a lack of ER nurse input, which also fosters
mistrust of administration in nurses. Allowing nurses to be part of decision-­making processes, and being transparent
about decisions made at the top level, should be included in any actions taken. While the focus of emergency depart-
ments can and should be to stabilize and process as many patients as possible, it is important to realize that too much of a
focus on speed and efficiency may create long-­term problems for both nurses and the organizations in which they work.
Targeted procedures that reduce the occurrence of burnout can begin with implementing a systematic selection
process focused specifically on the skills and characteristics that are required for successful performance as an ER
nurse. Additional interventions that address the particular needs of the nurse population, as well as changes to or-
ganizational culture, can reinforce the strategies aimed at reducing burnout. Staffing shortages constitute only part
of the problem—organizations could be overlooking deeper and more systematic issues in the working environment,
which may vary somewhat across emergency departments. Gathering feedback from ER nurses themselves should
not be an exclusive exercise to academic pursuits but instead will be important in uncovering the deeper issues.
While the general trends found in the research may prove useful in identifying and designing interventions and
change solutions, collaboration and transparency between executives, supervisors, and subordinates is essential for
the success of any intervention strategy. Indeed, the participation of ER nurses in efforts to improve their own work
environment may be a critical factor in combating burnout.

ACKNOWLE DG ME NT

We would like to thank Dr. Craig T. Nagoshi, Ph.D, for his guidance on how to conduct thematic analyses.

CO N FLI CT OF I NTE RE ST

No conflict of interest is declared by the authors of this manuscript.

O RC ID

Adrian Abellanoza  [Link]

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How to cite this article: Abellanoza A, Provenzano-Hass N, Gatchel RJ. Burnout in ER nurses: Review of the
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APPENDIX A

Interview questions

• [Coping] “Could you describe a time in which you felt any of the following regarding your job: emotionally ex-
hausted, negative or cynical attitudes towards work, feelings of failure? How did you cope with these experiences?”
• [Environment] “What are your feelings towards the emergency room environment? What aspects of your work
environment helped you or held you back?”
• [Resources] “Were/are there any resources available from your hospital to help with psychological symptoms? If
so, are they widely used?”
• [Management] “What are your perceptions regarding the relationship between management and the nursing
staff?”
• [Workload] “What are your thoughts on the workload you and your fellow ER nurses experience? How did they
affect your stress? Your quality of care?”
• [Typicality] “Were your experiences typical or atypical for someone in your role? What do you think caused this?”
• [Support] “What are your feelings regarding support from your fellow nurses?”
• [Personality] “Do you think your personality plays a role in how you deal with issues in the emergency room?”
• [Pride] “Do you take pride in your personal accomplishments at work? Why or why not?”
• [Miscellaneous] (Participants were asked for closing comments before the conclusion of the interview).