A systematic review of psychological distress reduction programs among nurses in emergency departments

Abstract

Background

Emergency department (ED) nurses experience high levels of psychological distress. Practical programs that alleviate psychological distress are essential for enhancing the mental well-being of nurses, which in turn can mitigate the potential adverse effects on the quality of emergency care. However, no systematic review has been conducted.

Aim

This study aims to systematically summarize the evidence-based psychological distress reduction programs for ED nurses.

Methods

A systematic search of Web of Science, Scopus, PubMed, and China National Knowledge Infrastructure (CNKI) was conducted for randomized controlled trials published until April 10, 2023. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, and the quality of the qualified studies was assessed using the Cochrane RoB 2 tool.

Results

A total of 29 studies were eligible with 2058 participants. Three primary kinds of interventions have been identified: psychological interventions targeting the reduction of psychological distress symptoms, educational programs designed to enhance the coping skills of ED nurses, and organization-directed interventions aimed at alleviating stressors. Collectively, these interventions have contributed significantly to the reduction of stress, depression, anxiety, burnout, and post-traumatic stress disorder while also improving life satisfaction and overall quality of life.

Conclusion

Three types of interventions have provided pathways to alleviate the psychological stress of ED nurses at various levels. Future efforts should refine interventions for ED nurses’ psychological distress, evaluate their long-term benefits, and explore organizational strategies to promote healthier workplaces. Policymakers and administrators must support these initiatives, focusing on prevention and empowerment.

Introduction

Healthcare workers are entrusted with high-stress responsibilities, often leading to challenging work conditions and psychological issues [1]. According to the National Institute for Health Care Management [2], 35–54% of healthcare workers in the U.S. experience significant burnout. In China, 27.7% of healthcare workers report symptoms of depression, anxiety, and burnout [3], often attributed to factors such as workload, shift schedule and service demands [4]. Organizational and societal issues, such as strained nurse-patient relationships, lack of support or respect, and job insecurity, can exacerbate stress [5]. Moreover, events such as public health emergencies can further intensify the mental health risks faced by healthcare workers. Compared to other professions, healthcare workers, particularly nurses who have sustained patient contact, are more prone to psychological distress. The combination of high job demands, complex tasks, and long working hours increases their vulnerability to mental health challenges [6, 7].

In China, emergency medical services are responsible for providing first aid to the public and responding to large-scale emergencies. The core of these services is in-hospital emergency care, centered around the emergency room. This department handles patients with acute, severe conditions and takes on the most critical and demanding rescue tasks in the hospital. Emergency department (ED) nurses play a vital role in these operations, performing rapid health assessments, injury detection, triage, emergency care, psychological support, and coordination with patients and their families [8]. However, unlike the pre-hospital care personnel and ED nurses in many European countries and the United States, who are required to complete relevant courses and internships, possess qualifications, and undergo annual training [9, 10], pre-hospital emergency care personnel in China lack unified qualifications. Specifically, ED nurses in China are progressively trained in emergency procedures only after they start working in the emergency department, which contrasts with the formal pre-training systems in many other countries [9].

In summary, ED nurses manage a high volume of unpredictable and complex cases, often moving from one emergency to another in a short period [11, 12]. The combination of a wide range of responsibilities, heavy workloads, and insufficient pre-training contributes to the significant physical and mental stress for ED nurses in China.

ED nurses experience higher levels of distress from physical, psychological, and social factors compared to other healthcare workers. They frequently face acute care challenges and traumatic events, including severe injuries, critical illnesses, resuscitations, deaths, abuse, and suicides. Prolonged exposure to these high-stress situations often leads to physical and emotional exhaustion, negatively impacting their mental health [13]. A survey conducted by Yang et al. among 120 ED nurses in northwestern China revealed that these nurses experience moderate-to-high levels of stress, surpassing the stress levels of clinical medical and surgical nurses [14]. Similarly, Zhu et al. found that the incidence of post-traumatic stress disorder (PTSD) among ED nurses ranges from 19 to 33%, significantly higher than the 14% rate found among medical and surgical nurses [15]. A study by Butera et al. also reported that before the COVID-19 pandemic, burnout rates among ED nurses were significantly higher than those among ICU nurses, with rates of 70% and 51%, respectively [16]. Work overload, shift work, and long hours of mental stress can also contribute to the physical and psychological distress of ED nurses. In Shandong Province, China, a survey of 98 ED nurses showed that 71.4% reported fatigue and lethargy, 53.1% experienced muscle tension and lower back pain, and 48.9% suffered from sleep disturbances [17]. Additionally, ED nurses often work in poor environments where workplace violence (WPV, including physical and verbal assault and intimidation) from patients and family members affects up to 90% of nurses, which can increase nurses’ insecurity and occupational risks [13]. Such negative effects can be conceptualized as psychological distress. According to Ridner, psychological distress occurs when a person encounters a stressor viewed as threatening or experiences ineffective coping and a sense of loss of control and thus falls into a discomforting emotional state [18]. Psychological distress can cause temporary damage, for which recovery is possible, as well as permanent damage, such as suicide, hypertension, and heart attacks [18].

Although emergency departments in China differ from those in Europe and the United States, the mental health status of nurses with the same responsibilities is reflected in relevant studies conducted in different countries. For example, Cook et al. conducted a survey at the University of Texas (UT) Health Tyler, a 502-bed tertiary Level 1 trauma center, involving 98 nurses from the emergency department, ICU, and trauma ward [19]. The findings revealed that burnout rates were higher among ED nurses compared to those in the ICU and trauma wards [19]. Similarly, a web-based survey by Butera et al. in Belgium, with 2,058 participants, found that ED nurses had a higher risk of burnout than ICU nurses [16]. The psychological distress experienced by ED nurses has broader implications for the quality of care and socioeconomic factors. A cross-national study showed that burnout among ED nurses is associated with lower quality of patient care [20]. Furthermore, are strongly linked to higher turnover rates, resulting in the loss of experienced staff, understaffing, and increased costs for recruitment and training of new employees [21, 22].

In order to effectively address the aforementioned multifaceted psychological distress, researchers have developed and implemented a series of reduction programs. Previous studies focused on either specific interventions or the general nurse population. Ghawadra et al. conducted a systematic review of nine mindfulness-based stress reduction (MBSR) interventions for nurses, finding that MBSR helped reduce stress, anxiety, depression, burnout, and increased job satisfaction [23]. Karo et al. similarly reviewed randomized controlled trials (RCTs) on MBSR, concluding that MBSR significantly reduces stress and depression among nurses [24]. In another systematic review, Joseph and Jose found that mindfulness-centered interventions could effectively reduce distress and burnout while enhancing resilience and compassion in healthcare professionals working in emergency and critical care departments [25]. However, the interventions specifically targeting ED nurses remain limited. Sun et al. conducted an 8-week mindfulness decompression training for 100 ED nurses in a Chinese hospital, using both online and offline methods [26]. Their pre- and post-tests revealed improvements in mindfulness, quality of life, and reduced burnout [26]. Similarly, Caponnetto et al. implemented a stress management program involving autogenic training for 28 physicians and nurses in an Italian emergency room, finding that stress management improved quality of life, work motivation, and stress perception [27]. Although these studies showed positive effects on psychological distress, they were limited by small sample sizes and lacked RCT designs, making it difficult to assess the effectiveness of the interventions and to generalize.

To date of research, no systematic review of psychological distress reduction programs for ED nurses has been conducted. This study aims to fill the gap. In addition, both the primary outcomes (e.g., depression, anxiety, PTSD, and stress) and secondary outcomes (e.g., burnout, quality of life, and satisfaction) of psychological distress [23, 28] were examined. This study proposed the following research questions: (1) What interventions are currently available? (2) What types of interventions are worthy of further development? (3) What elements of psychological distress are interventions focusing on and how effective are they? (4) What are the shortcomings of existing interventions?

Methods

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement for the literature search and screening, the data coding and analysis, and the results reporting [29].

Information sources and search strategy

A comprehensive literature search was conducted on April 10, 2023 in the following databases: Web of Science, Scopus, PubMed, and China National Knowledge Infrastructure (CNKI). The PubMed database contains the literature on MEDLINE, which is an important database in the field of biomedicine and health. Meanwhile, Web of Science and Scopus are comprehensive interdisciplinary databases in English, and CNKI is a comprehensive database in Chinese. The databases can assist in effectively reducing the risk of reporting bias and identifying the relevant studies [30].

The specific search strategy is summarized in Table 1.

Table 1.

Search strategies

S1	emergency nurs*
S2	interven* or interference or train* or educat* or manag* or therap* or reduc* or treatment*
S3	randomized controlled trial or controlled clinical trial or RCT or placebo
S4	compassion fatigue
S5	depress* or dysthymic disorder
S6	anxiety
S7	insomnia* or sleepiness or parasomnias or dyssomnias or anhedonia
S8	burnout
S9	stress*
S10	trauma*
S11	emotional disturbanc*
S12	mood disorder*
S13	affective symptom*
S14	mental health
S15	mental disorder*
S16	mental fatigue
S17	psychological well-being
S18	psychological distress
S19	fear
S20	sadness
S21	急诊科护士
S22	干预 or 介入 or 治疗 or 疗法 or 训练
S23	压力 or 减压
S24	职业倦怠
S25	心理困扰
S26	焦虑
S27	抑郁
S28	失眠
S29	应激障碍
S30	恐惧
S31	S4 or S5 or S6 or S7 or S8 or S9 or S10 or S11 or S12 or S13 or S14 or S15 or S16 or S17 or S18 or S19 or S20
S32	S1 And S2 And S3 And S31
S33	S23 or S24 or S25 or S26 or S27 or S28 or S29 or S30
S34	S21 And S22 And S33

Inclusion and exclusion criteria

The inclusion criteria were set based on the PICOS principle, as follows: (a) population: emergency department nurses, (b) intervention: intervention programs for psychological distress, (c) comparison: a blank control group with no measures or a control group under usual care (routine counseling of nurses by managers), (d) outcome: psychological distress measured through psychometric assessment and complete data results, and (e) study design: RCT.

The following exclusion criteria were applied: (a) published articles not written in English or Chinese; (b) literature reviews, systematic reviews, and meta-analysis; (c) conference abstracts, letters, and guidelines; (d) works with no available full text; and (e) pharmacological interventions.

Selection process and data extraction

After the duplicate articles were eliminated, two authors (YWJ & XYY) independently screened the titles, abstracts, and full texts and excluded the articles that did not meet the inclusion and exclusion criteria. If a study included both a sample of ED nurses and a sample of nurses from other departments, check the results section to determine if the data of ED nurses was reported separately. If not, it should be excluded to maintain data fidelity. The references of the included articles were also screened to identify those that met the inclusion criteria. When the two authors encountered differences, a third author (PJ) was called to resolve disagreements. The following information was extracted: author, year of publication, country, intervention, intervention duration and frequency, sample size, measures, outcomes, and follow-up investigations.

Quality assessment

In this study, two independent authors (YWJ & XYY) used the Cochrane Risk of Bias 2 (RoB 2) assessment tool for the literature risk assessment and quality evaluation [31], which is widely used for risk- of-bias assessments for RCTs and considered to be the best tool for evaluating RCTs with authority. RoB 2 can test all bias types understood to affect the results of RCTs, including bias from the randomization process, bias owing to deviations from the intended interventions, bias owing to missing outcome data, bias in the measurement of the outcomes, and bias in the selection of the reported results. RoB 2 consists of seven items, each judged as “low, high, or unclear risk of bias.” Once the seven items are answered, the overall risk of bias in the literature can be categorized as “low risk of bias, some concerns, or high risk of bias,” based on the following criteria: (a) if the study is judged to be at low risk of bias in all domains, then the overall risk of bias is “low”; (b) if the study is judged to raise some concerns in at least one domain but not at high risk of bias in any domain, then the overall risk of bias is “some concerns”; (c) if the study is judged to be at high risk of bias in at least one domain, then the overall risk of bias is “high” [31].

Data synthesis

This study used a systematic review approach to narratively analyze and summarize the included studies on psychological distress reduction programs for ED nurses. Cochrane Collaboration RevMan 5.3 was used to evaluate the quality of the studies.

Results

Study selection

A total of 1,620 articles were initially identified from the four databases. After 261 duplicate articles were removed, the titles and abstracts of 1,359 studies were screened for eligibility. A total of 1,261 articles were further eliminated based on the inclusion and exclusion criteria. The full text of the remaining 98 articles was screened, and 69 papers were excluded for the following reasons: (a) the study was about other topics or subjects (n = 19), (b) the work was a noninterventional study (n = 11), (c) the study was not an RCT (n = 9), and (d) the article presented incomplete data (n = 30), including no prespecified outcomes, no information on sample size or group allocation, a lack of standardized or scientifically valid measurement tools, and results reported only in narrative form without specific numerical data or tables. A total of 29 articles were reviewed, and the flowchart is shown in Fig. 1.

Fig. 1.

PRISMA flow chart of the selection of articles

Quality of the included studies

Figures 2 and 3 show the results of the risk-of-bias assessment. Among the 29 studies reviewed in this work, two were considered to be high risk, one was low risk, and the remaining 26 raised some concerns. Randomization is an important step in an RCT, and the main risks stem from lack of description of the allocation sequence concealment process and the incomplete reporting of the random sequence generation methods. Researchers’ selective enrollment of participants or unscientific random grouping may also create bias. Another risk stems from lack of information on the participants’ reasons for dropping out of the study, which may affect the veracity of the results.

Fig. 2.

Deviation risk chart

Fig. 3.

Summary of the risk of bias

Study characteristics

The characteristics of the 29 studies are summarized in Tables 2, 3 and 4, and 5. Among the included studies, one was from Turkey [32], one was from Korea [33], two were from Iran [34, 35], one was from Jordan [36], one was from China’s Taiwan region [37], and the rest were from Chinese mainland.

Table 2.

Characteristics of the included psychological intervention studies

Author(s), year, and country	Sample size	Measures and Scales	Interventions	Duration and frequency	Follow-up	Dropout	Outcomes	Results
Li et al., 2014 China	Total(n = 68): Treatment(n = 34); Control(n = 34)	MBI-GS NJSS SAS	TG: Cluster cognitive-behavioral therapy (emotional experience, cognitive construction, behavioral training, feedback adjustment); CG: Unclustered and unthemed group discussion	Duration: 2 ~ 3 h at a time, biweekly for 4 months	No	No	Burnout↓ Stressor↓ Anxiety↓	Compared to the control group, in the treatment group: two dimensions of burnout were decreased significantly(p < 0.05) four dimensions of stressors were decreased significantly (p < 0.05) the anxiety level was decreased significantly (p < 0.01)
Zhu & Rui, 2009 China	Total(n = 115): Treatment(n = 60); Control(n = 55)	SAS SDS	TG: Cognitive behavior therapy (psychodiagnosis, insight, working through, and reeducation); Relaxation Therapy (head, limbs, chest and abdomen relaxation); CG: No treatment	Duration: 1 h Frequency: once a day for 6 weeks	No	4.1%	Anxiety↓ Depression↓	Anxiety and depression scores decreased after the intervention in the TG and did not change much in the CG
Li et al., 2021 China	Total(n = 70): Treatment(n = 35); Control(n = 35)	SAS SDS MBI-GS	TG: Cognitive behavior therapy: (psychodiagnosis, insight, working through, and reeducation); Emotional Release (relaxation, acupoints tapping, deep breathing and relaxation, feedback); CG: No treatment	Cognitive behavior therapy: 30 ~ 60 min once a day for 6 weeks Emotional release: 10 ~ 15 min, 3 times a day for 6 weeks	No	No	Anxiety↓ Depression↓ Burnout↓	Compared to the control group, in the treatment group: (a) the anxiety level was decreased significantly (p < 0.05) (b) the depression level was decreased significantly (p < 0.05) (c) all dimensions of burnout were decreased significantly (p < 0.05)
Li, 2012 China	Total(n = 46): Treatment(n = 23); Control(n = 23)	SAS	TG: Rational-emotive therapy (psychodiagnosis, insight, working through, and reeducation); CG: Routine care	Duration: 1 h Frequency: once a week for 1 month	No	No	Anxiety↓	Compared to the control group, the anxiety level was decreased significantly (p < 0.05) in the treatment group
Liu, 2012 China	Total(n = 60): Treatment(n = 30); Control(n = 30)	SCL-90 CSQ	TG: Rational-emotive therapy (psychodiagnosis, insight, working through, and reeducation); CG: Routine psychological counseling	Duration: 30 min Frequency: biweekly for 3 months	No	No	Mental health↑ Coping styles↑	Compared to the control group, in the treatment group: (a) five dimensions of SCL-90 were decreased significantly (p < 0.05) (b) the coping styles improved significantly (p < 0.05)
Yuan,2022 China	Total(n = 39): Treatment(n = 19); Control(n = 20)	MAAS IES-R SCSQ EE	TG: 8 weeks of MBSR (mindful breathing, body scanning, mindful yoga, mindful eating, mindful walking, meditation); CG: Routine psychological counseling	Duration: 1.5 ~ 2 h Frequency: once a week for 8 weeks	1 month	5%	Mindfulness↑ PTSD↓ Coping styles (ineffective) Burnout↓	Compared to the control group, in the treatment group: (a) the level of mindfulness was improved but not significant (b) post-traumatic stress symptom was significantly improved and kept valid at one-month follow-up (c) no change in the coping styles (d) the level of emotional exhaustion was significantly decreased and kept valid at one-month follow-up
Cao & Zhang, 2020 China	Total(n = 99): Treatment(n = 50); Control(n = 49)	SAS SDS	TG: MBSR (mindful breathing, meditation, body scanning, mindful walking); CG: Routine care	Duration: 2 h Frequency: once a week for 4 weeks	No	1%	Anxiety↓ Depression↓	Compared to the control group, in the treatment group: (a) the anxiety level was decreased significantly (p < 0.05) (b) the depression level was decreased significantly (p < 0.05)
Lin & Chen, 2022 China	Total(n = 80): Treatment(n = 40); Control(n = 40)	FFMQ SAS SDS MBI-HSS	TG: MBSR (mindful breathing, meditation, body scanning); CG: Routine psychological counseling	Duration: 45 min Frequency: once a week for 8 weeks	No	No	Mindfulness↑ Anxiety↓ Depression↓ Burnout↓	Compared to the control group, in the treatment group: (a) four dimensions of FFMQ were improved significantly (p < 0.05) (b) the anxiety and depression levels were decreased significantly (p < 0.05) (e) the scores of burnout were decreased significantly (p < 0.05)
Zhang et al., 2020 China	Total(n = 46): Treatment(n = 23); Control(n = 23)	SAS SDS PSS-10 NBS CSQ	TG: Music therapy (deep breathing and relaxation with soft music); MBSR (mindful breathing, meditation, body scanning, mindful walking, mindful introspection); CG: Routine psychological counseling	Music therapy: 30 min per day MBSR: Duration: 1 h Frequency: once a week for 6 months	No	No	Anxiety↓ Depression↓ Stress↓ Burnout↓ Coping styles↑	Compared to the control group, in the treatment group: (a) the anxiety and depression levels were decreased significantly (p < 0.05) (b) the perceived stress scores were decreased significantly (p < 0.05) (c) the scores of burnout were decreased significantly (p < 0.05) (d) the coping styles improved significantly (p < 0.05)
Liu et al., 2022 China	Total(n = 80): Treatment(n = 40); Control(n = 40)	SAS SDS SCL-90	TG: Group psychological training (team building, team communication of psychological problems, self-awareness construction, behavioral training, summary); CG: Routine psychological counseling	Duration: 1 ~ 2 h Frequency: 2 ~ 3 times a week for 5 weeks	No	No	Anxiety↓ Depression↓ Mental health↑	Compared to the control group, in the treatment group: (a) the anxiety level was decreased significantly (p < 0.05) (b) the depression level was decreased significantly (p < 0.05) (c) the scores of SCL-90 were decreased significantly (p < 0.05)
Xiao et al., 2014 China	Total(n = 48): Treatment(n = 24); Control(n = 24)	MBI	TG: Cognitive-behavioral interactive group therapy (interpersonal coordination, problem solving, cognitive and emotional response, and self-management); CG: No treatment	Duration: 2 h Frequency: once a week for 8 weeks	No	No	Burnout↓	Compared to the control group, all dimensions of burnout were decreased significantly (p < 0.05) in the treatment group
Chen & Huang, 2016 China	Total(n = 97): Treatment(n = 50); Control(n = 47)	SCL-90 SCCS	TG: Group psychological training (team building, theme activities, analysis of practical issues, summary); CG: Routine care	Duration: 2 h Frequency: 3 times a month for 10 times	No	No	Mental health↑ Self-consistency and congruence↑	Compared to the control group, in the treatment group: (a) seven dimensions of SCL-90 were decreased significantly (p < 0.05) (b) the self-consistency and congruence level was improved significantly (p < 0.01)
Yang & Jin, 2018 China	Total(n = 62): Treatment(n = 31); Control(n = 31)	SAS SDS SCCS SSRS	TG: Group psychological training (team building, theme activities, analysis of practical issues, summary); CG: Routine psychological counseling	Duration: 2 h Frequency: once a week for 10 weeks	No	No	Anxiety↓ Depression↓ Self-consistency and congruence↑ Social support↑	Compared to the control group, in the treatment group: (a) the anxiety level was decreased significantly (p < 0.05) (b) the depression level was decreased significantly (p < 0.05) (c) the self-consistency and congruence level was improved significantly (p < 0.05) (d) the social support rate was improved significantly (p < 0.05)
Yang & Feng, 2012 China	Total(n = 40): Treatment(n = 20); Control(n = 20)	PTSD-SS WCQ	TG: Group psychological training (team support, stress normalization); Individual counselling (traumatic experiences, cognitive emotions, positive coping styles and mental defense mechanisms); CG: No treatment	Duration: 2 h at least Frequency: once a week for 3 months	No	No	PTSD↓ Coping styles↑	Compared to the control group, in the treatment group: (a) four dimensions of PTSD-SS were decreased significantly (p < 0.05) (b) the active scores of coping were improved and the negative ones were decreased significantly (p < 0.05)
Zhai et al., 2016 China	Total(n = 60): Treatment(n = 30); Control(n = 30)	PTSD-SS	TG: Group psychological training (team support, stress normalization); Individual counselling (traumatic experiences, cognitive emotions, positive coping styles and mental defense mechanisms); CG: No treatment	Duration: 2 h Frequency: once a week for 3 months	No	No	PTSD↓	Compared to the control group, all dimensions of PTSD-SS were decreased significantly (p < 0.05) in the treatment group
Li et al., 2018 China	Total(n = 82): Treatment(n = 40); Control(n = 42)	SAS UWES	TG: Solution-focused approach (describing the problem, constructing goals, exploring exceptions, implementing feedback, and evaluating progress); CG: Routine psychological counseling	Duration: 40 min ~ 1 h Frequency: 2 ~ 3 times per week for 4 weeks	No	No	Anxiety↓ Burnout↓	Compared to the control group, in the treatment group: (a) the anxiety level was decreased significantly (p < 0.05) (b) the scores of UWES were improved significantly (p < 0.05)
Shao et al., 2019 China	Total(n = 20): Treatment(n = 10); Control(n = 10)	SAS UWES	TG: Solution-focused approach (describing the problem, constructing goals, exploring exceptions, implementing feedback, and evaluating progress); CG: Routine psychological counseling	Duration: 0.6 ~ 1 h Frequency: 2 ~ 3 times per week for 1 month	No	No	Anxiety↓ Burnout↓	Compared to the control group, in the treatment group: (a) the anxiety level was decreased significantly (p = 0.05) (b) the scores of UWES were improved significantly (p < 0.05)
Li et al., 2008 China	Total(n = 40): Treatment(n = 20); Control(n = 20)	SAS SDS	TG: Psychological crisis intervention (listening, providing opportunities to vent, explaining and guiding, boosting confidence, social support); CG: Routine care	Duration: 1week	No	No	Anxiety↓ Depression↓	Compared to the control group, in the treatment group: (a) the anxiety level was decreased significantly (p < 0.001) (b) the depression level was decreased significantly (p < 0.001)

Note. MBI-GS = Maslach Burnout Inventory-General Survey; NJSS = Nurse Job Stressors Scale; SAS = Self-Rating Anxiety Scale; TG = Treatment group; CG = Control group; SDS = Self-rating Depression Scale; SCL-90 = Symptom Checklist 90; CSQ = Coping Style Questionnaire; MAAS = Mindfulness Attention Awareness Scale; IES-R = The Impact of Event Scale-Revised; SCSQ = Simple Coping Style Questionnaire; EE = Emotional Exhaustion; MBSR = Mindfulness-based Stress Reduction; FFMQ = Five Facet Mindfulness Questionnaire; MBI-HSS = Maslach Burnout Inventory-Human Services Survey; PSS-10 = Perceived Stress Scale 10; NBS = Nursing burnout Scale; MBI = Maslach Burnout Inventory; SCCS = Self-Consistency and Congruence Scale; SSRS = Social Support Rate Scale; PTSD-SS = Post-Traumatic Stress Disorder SeIf-rating Scale; WCQ = Ways of Coping Questionnaire; UWES = Utrecht Work Engagement Scale

Table 3.

Characteristics of the included educational program studies

Author(s), year, and country	Sample size	Measures and Scales	Interventions	Duration and frequency	Follow-up	Dropout	Outcomes	Results
Zhang et al., 2022 China	Total(n = 58): Treatment(n = 29); Control(n = 29)	T-DAS	TG: Death education (lecture, role-play, group discussion, summary); CG: Routine care	Duration: 2 days, 40 min per lesson	No	No	Anxiety↓	Compared to the control group, the scores of the T-DAS were decreased significantly (p < 0.05) in the treatment group
Chang et al., 2022 China, Taiwan	Total(n = 75): Treatment(n = 39); Control(n = 36)	OCSE-N	TG: 12-session workplace violence class + 1-hour in-service class (improving awareness of WPV, focusing on interaction, management, prevention, and post-incident action, developing assertiveness techniques and engaging in proactive violence management); CG: 1-hour in-service class	Duration: 13 h	No	No	Self-Efficacy↑	Compared to the control group, the scores of OCSE-N were improved significantly (p < 0.001) in the treatment group
Karbakhsh Ravari et al., 2020 Iran	Total(n = 80): Treatment(n = 40); Control(n = 40)	OSI-R	TG: A time management workshop (introduction, benefits, mechanisms, etc. about time management, group exercise, application in nursing, summary) CG: No treatment	Duration: 8 h	No	No	Stress (ineffective)	There was no statistically significant difference between the intervention and control group in job stress scores after the intervention
Al- Kalalden et al., 2019 Jordan	Total(n = 222): Treatment(n = 115); Control(n = 107)	CNLSES	TG: An educational program about ‘MEWS’ CG: No treatment	Duration: 12 h	Yes (time not given)	4.3%	Self-Efficacy↑	Compared to the control group, the scores of CNLSES were improved significantly (p < 0.001) in the treatment group in both post-test and follow-up phases
Wei et al., 2017 China	Total(n = 102): Treatment(n = 51); Control(n = 51)	MBI-GS	TG: Active intervention (classes about communication skills, approaches to conflict, efficacy elevation, and emotion control, working skills); CG: Regular management	Duration: 30 min Frequency: twice a week for 6 months	No	No	Burnout↓	Compared to the control group, two dimensions of burnout were decreased significantly (p < 0.05) in the treatment group

Note. T-DAS = the Chinese version of the Death Anxiety Scale; TG = Treatment group; CG = Control group; OCSE-N = Occupational Coping Self-Efficacy Questionnaire for Nurses; OSI-R = Occupational Stress Inventory revised edition; CNLSES = Clinical Nurse Leader Self-Efficacy Scale; MBI-GS = Maslach Burnout Inventory-General Survey

Table 4.

Characteristics of the included organization-directed intervention studies

Author(s), year, and country	Sample size	Measures and Scales	Interventions	Duration and frequency	Follow-up	Dropout	Outcomes	Results
Hosseinabadi et al., 2013 Iran	Total(n = 40): Treatment(n = 24); Control(n = 16)	Job satisfaction questionnaire QWL	TG: Quality circles (quality circle training and implementation); CG: No treatment	Duration: 3 months	No	28.6%	Satisfaction↑ Quality of life↑	Compared to the control group, in the treatment group: (a) the total scores of job satisfaction were improved significantly (p < 0.05) (b) the total scores of QWL were improved significantly (p < 0.05)
Cui, 2017 China	Total(n = 45): Treatment(n = 23); Control(n = 22)	SAS SDS	TG: Flexible management (lecture of flexible management, building a harmonious, fair and encouraging working atmosphere, democratic management, performance management ); CG: Traditional management	Duration: 3 months	No	No	Anxiety↓ Depression↓	Compared to the control group, in the treatment group: (a) the anxiety level was decreased significantly (p < 0.05) (b) the depression level was decreased significantly (p < 0.05)
Nie, 2017 China	Total(n = 78): Treatment(n = 39); Control(n = 39)	OSI-R SAS SDS TCSQ	TG: Comprehensive Interventions (improvement of working environment, management, training, psychological intervention and patient education); CG: No treatment	Duration: 6 months	No	No	Stress↓ Anxiety↓ Depression↓ Coping styles↑	Compared to the control group, in the treatment group: (a) the scores of OSI-R were decreased significantly (p < 0.05) (b) the anxiety and depression levels were decreased significantly (p < 0.05) (c) the active coping scores were improved and the negative coping scores decreased significantly (p < 0.05)
Wang et al., 2022 China	Total(n = 96): Treatment(n = 48); Control(n = 48)	SAS SDS SCL-90 GSES CD-RISC	TG: Comprehensive psychological intervention (verbal encouragement, physical and emotional support, safety and security, environmental improvement, psychological intervention); CG: Routine psychological counseling	/	No	No	Anxiety↓ Depression↓ Mental health↑ Self-Efficacy↑ Resilience↑	Compared to the control group, in the treatment group: (a) the anxiety level was decreased significantly (p < 0.05) (b) the depression level was decreased significantly (p < 0.05) (c) five dimensions of SCL-90 were decreased significantly (p < 0.05) (d) the scores of the GSES were improved significantly (p < 0.05) (e) the scores of the CD-RISC were improved significantly (p < 0.05)

Note. QWL = Walton’s work-life quality questionnaire; TG = Treatment group; CG = Control group; SAS = Self-Rating Anxiety Scale; SDS = Self-rating Depression Scale; OSI-R = Occupational Stress Inventory revised edition; TCSQ = Trait Coping Style Questionnaire; SCL-90 = Symptom Checklist 90; GSES = General self-efficacy Scale; CD-RISC = Connor-Davidson resilience Scale

Table 5.

Characteristics of the included studies on other interventions

Author(s), year, and country	Sample size	Measures and Scales	Interventions	Duration and frequency	Follow-up	Dropout	Outcomes	Results
Shin et al., 2020 Korea	Total(n = 50): Treatment(n = 25); Control(n = 25)	ProQOL VAS	Aromatherapy TG: Inhaling 5% patchouli oil in sweet almond oil CG: Pure sweet almond oil	Frequency: twice, 24-h interval	No	16.6%	Quality of life↑ Stress↓	Compared to the control group, in the treatment group: (a) one dimension of ProQOL was improved significantly (p < 0.001) but there were no significant changes in the other two dimensions (b) the scores of VAS were decreased significantly (p < 0.001)
Goktas et al., 2022 Turkey	Total(n = 60): Treatment(n = 30); Control(n = 30)	Job Satisfaction Scale Compassion Fatigue Scale	Online motivational messages TG: motivational messages CG: No treatment	Frequency: 3 times a day for 3 weeks	No	4.7%	Satisfaction↑ Burnout↓	Compared to the control group, in the treatment group: (a) the levels of job satisfaction were improved significantly (p < 0.05) (a) the levels of compassion fatigue were decreased significantly (p < 0.05)

Note. ProQOL = Professional Quality of Life; VAS = Visual Analog Scale; TG = Treatment group; CG = Control group

The average sample size was 70 individuals, which ranged from 10 to 115 individuals in the intervention group and from 10 to 107 individuals in the control group. Only two studies conducted a follow-up investigation [36, 38], and seven studies reported dropouts. The dropout rate was low, that is, generally less than 5% [32, 36, 38–40]; however, two studies reported a high dropout rate of 16.6% [33] and 28.6% [35].

The duration of the interventions was typically 1–4 months, 1–3 times per week or once every 2 weeks, with one intervention session lasting around 0.5–3 h. For educational interventions, a workshop format was typically used, which lasted 1–2 days [34, 36]. Meanwhile, the organization-directed interventions lasted over several months [41, 42].

Types of intervention

Among the studies, 27 were divided based on three types of interventions, namely, psychological interventions (18 studies; 62.0%), educational programs (5 studies; 17.2%), and organization-directed interventions (4 studies; 13.8%), and two were analyzed separately.

Psychological interventions

A psychological intervention is a systematic and planned intervention guided by theories to change the participants’ emotional, cognitive, and behavioral functioning [43]. Various psychological interventions were used in the 18 studies, including cognitive behavioral therapy (CBT), rational-emotive therapy (RET), MBSR, group psychological training, the solution-focused approach, and psychological crisis intervention. Among the studies, 10 involved psychologists and counselors as therapists or trained nurses, and eight did not report information on the professionals involved. The studies had small sample sizes, and only one psychological intervention reported a follow-up investigation [38].

CBT uses multiple techniques to replace negative thoughts, cognitive distortion, and maladaptive behaviors with positive and adaptive ones [44]. For example, Li et al. used cluster CBT and divided the participants into four subgroups based on their stressors [45]. The study conducted cognitive construction and behavior training and found that four dimensions of stressors and two dimensions of burnout improved significantly after the intervention, but the environmental stressors did not change [45]. Moreover, two studies combined CBT with relaxation techniques and showed the intervention’s effectiveness in relieving anxiety, depression, and burnout [39, 46]. However, though the studies claimed to use CBT, behavioral therapy was not used in the intervention program. In addition, two studies used RET, which is a type of cognitive therapy to address the participants’ irrational beliefs and anxiety and improve their coping style through a four-step intervention process: psychodiagnosis, insight, working through, and reeducation [47, 48].

MBSR was developed by Kabat-Zinn and found to be effective in the reducing psychological distress among nurses [23]. With its principle of “paying attention to the present moment nonjudgmentally,” MBSR can help individuals connect their body and mind and enhance their awareness of and attention to the present moment and thus help them effectively manage their emotions and cope with stress. A total of four studies used MBSR, one of which adopted the traditional 8-week MBSR process [38], and the remaining three involved self-paced courses that included activities such as mindful breathing, meditation, body scanning, and mindful walking [40, 49, 50]. Kabat-Zinn suggested that MBSR requires focused and daily practice [51], but only two studies assigned the participants homework [38, 40]. The two studies investigated the impact of MBSR on the participants’ negative emotions, burnout, mindfulness, PTSD, and stress coping. Meanwhile, two studies obtained conflicting results on stress coping [38, 50]. Specifically, Yuan argued that stress coping styles cannot be changed by short-term intervention, and long-term practice is necessary [38], whereas Zhang et al. combined MBSR with music therapy and observed a significant improvement in the participants’ stress coping [50]. All the other indicators improved. Furthermore, in a follow-up investigation, one study found that the intervention remained effective for PTSD and burnout one month after the completion of the program [38].

A total of six studies examined group psychological training, which mainly involves the creation of a group of several individuals with common problems and the implementation of psychological training to achieve a common objective [52]. Group psychological training consists of several sessions, with each session centered around a specific theme, such as teamwork, interpersonal communication, stress management, emotion management, cognitive regulation, self-exploration, and responsibility awareness [52–55]. Two studies combined such training with individual psychological interventions, because they targeted severe cases of PTSD [56, 57]. Specifically, the studies reviewed, analyzed, and desensitized the participants’ traumatic experiences in individual counseling sessions, explained the appropriate coping styles and psychological defense mechanisms in group psychological training sessions, and provided mutual support and encouragement to the group to address and resolve the participants’ problems. The studies focused on anxiety, depression, self-consistency, social support, burnout, coping styles, and PTSD and showed satisfactory intervention effects. Various methods, such as brainstorming, group games, scenarios, and theoretical explanations, were used in the reported group psychological training [55].

Among the reviewed studies, two used the solution-focused approach, which views participants as healthy and capable individuals who can use their resources and potential to solve problems and live satisfactory lives [58]. The service process of this approach consists of a problem description phase, a concrete and feasible goal construction phase, an exception detection phase, an implementation feedback phase, and a progress evaluation phase [59, 60]. Nurses certified as counselors were selected as therapists for the intervention, and solution-focused approach experts were asked to provide them with intensive training. The intervention consisted of 8 to 12 one-on-one sessions, and the results showed that the intervention reduced the nurses’ anxiety and enhanced their work engagement. Instead of examining an individual’s past or the roots of their problems, researchers can use the approach to actively find positive and useful exceptions to their problems.

Psychological crisis intervention refers to the timely provision of appropriate psychological assistance to individuals in a state of psychological crisis to enable them to overcome their difficulties. It is characterized by a short intervention time, clear intervention goals, and the ability to effectively restore psychological balance and stability among nurses in a crisis state [61]. Li et al. conducted a psychological crisis intervention with 20 ED nurses that involved providing the nurses with a channel for emotional catharsis, explaining the crisis process to enhance the nurses’ positive coping skills, boosting the nurses’ confidence, and providing social support from family members, coworkers, and friends [61]. After a week-long intervention, the nurses’ anxiety and depression levels dropped significantly.

Educational programs

A total of five studies introduced educational programs to alleviate nurses’ psychological distress by improving their work-related skills and knowledge and coping abilities in work situations they may encounter. Zhang et al. implemented a death education program for ED nurses to discuss their understanding of death, the meaning of life, previous experiences and problems in dealing with death, and how to cope with death properly and reported that the educational program significantly decreased the nurses’ anxiety about death [62]. WPV is common in the emergency department, which may cause physical injuries, psychological distress, and occupational stress in nurses [37]. Chang et al. integrated WPV education into in-service classes to teach nurses to recognize, prevent, understand, and cope with WPV, which improved their occupational coping self-efficacy level [37]. By contrast, Karbakhsh Ravari et al. conducted an 8-hour time management workshop but observed that the intervention did not decrease the nurses’ stress levels [34]. Al-Kalaldeh introduced the modified early warning score to help ED nurses detect and manage deteriorating patients, which improved their self-efficacy in coping with work [36]. Meanwhile, Wei et al. conducted a series of classes to improve nurses’ work-related abilities to decrease their burnout [63]. The sample size of the aforementioned studies was relatively large, and the interventions were typically conducted in the form of lectures or workshops that lasted 1 to 2 days. However, the long-term effects of the educational programs remain unknown, because only one educational program conducted a follow-up investigation and demonstrated long-term effects, though they did not report the time of follow-up [36].

Organization-directed interventions

Among the included studies, four implemented an intervention for organizational management systems, including quality circles, flexible management, and comprehensive interventions. Quality circles are a participatory management technique involving the voluntary training of employees and team leaders to identify, evaluate, and solve work-related problems [64]. This approach can help managers address nurses’ concerns and enhance their work–life quality and job satisfaction [35]. Meanwhile, flexible management prioritizes a “people-oriented” approach to mobilize staff motivation through noncoercive methods for improved work completion [41], and comprehensive interventions consider all aspects of the work of ED nurses, such as providing verbal encouragement and psychological, safety, and environmental support and raising patient–family awareness [42, 65]. The studies had a relatively large sample size, but none conducted a follow-up investigation, and one study reported a 28.6% dropout rate [35].

In addition to the three types of interventions described above, two types of interventions can be further investigated in future studies. A study used aromatherapy to reduce stress and promote the professional quality of life of ED nurses, because previous studies revealed that patchouli oil can have a calming effect and reduce stress [33]. Another noteworthy study was conducted during the COVID-19 pandemic [32], when centralized and offline interventions were impossible; thus, the study used motivational messages to provide social support to the nurses. The messages helped strengthen the nurses’ interpersonal communication and promote their personal well-being by focusing on gratitude and appreciation. The intervention was easy to implement and low cost and highlighted the importance of supporting and motivating ED nurses.

Outcomes

The included studies focused on various outcomes of psychological distress, and most of the interventions helped reduce the participants’ psychological distress.

A total of eight studies measured three aspects of stress: stressors, stress levels, and coping styles. Li et al. measured the impact of psychological interventions on stressors that may affect nurses by using the Nurse Job Stressors Scale, which decreased the stressors from patient care and interaction, interpersonal relationships and management issues, workload and time pressure, and professional and career issues but did not resolve resource and environmental problems [45]. Four studies measured stress levels [33, 34, 42, 50], commonly using the Occupational Stress Inventory (revised edition) owing to its measurements specific to the occupational setting [34, 42]. Five studies measured coping styles and reported that three psychological interventions [48, 50, 57] and one organization-directed intervention [42] were effective in improving coping styles but one psychological intervention was ineffective [38].

Among the included studies, 16 measured anxiety mainly by using the Self-rating Anxiety Scale, with one using the Chinese version of the Death Anxiety Scale to measure death anxiety. All the interventions in the studies showed improvements in the participants’ anxiety levels. Moreover, 11 studies measured depression by using the Self-rating Depression Scale and demonstrated improvements in the participants’ depression levels.

Meanwhile, three studies addressed PTSD with psychological interventions. Specifically, Yuan used the Impact of Event Scale-Revised to measure PTSD levels and found that MBSR is effective in reducing PTSD and remained effective one month after the completion of the program in the follow-up assessment [38]. The Post-traumatic Stress Disorder Self-rating Scale was used in two group psychological trainings, with one study reporting reductions in all the dimensions, and the other study observing reductions in four dimensions [56, 57].

A total of 10 studies included measurements of burnout and the Maslach Burnout Inventory (its modifications were the most commonly used), and two studies reported nonsignificant intervention effects on the personal achievement dimension of the Maslach Burnout Inventory but significant effects on two other dimensions [45, 63]. The other studies showed significant improvements in the participants’ burnout symptoms.

Two studies included measures of occupational quality of life. Specifically, Shin et al. used the Professional Quality of Life Scale and found that the inhalation of patchouli oil significantly increased the compassion and satisfaction of the ED nurses but did not provide significant relief from burnout and compassion fatigue [33]. Hosseinabadi et al. used Walton’s work–life quality questionnaire and observed that quality circles are effective in improving work-life quality [35]. Two studies measured job satisfaction, and their results showed significant validity [32, 35].

In addition to the psychological distress outcome indicators described above, the included studies focused on the effects of interventions on the self-consistency, perceived social support, self-efficacy, resilience, and mindfulness of ED nurses. The specific measurement tools and results are summarized in Tables 2, 3 and 4, and 5.

It is worth noting that the included studies reported several limitations and potential confounders that could impact the effectiveness of the interventions. First, the generalizability of these findings was limited due to small sample sizes, single-site settings, and the focus on specific populations, such as ED nurses during the COVID-19 pandemic [34, 37, 45]. Second, some studies lacked a rigorous randomization process, raising concerns about potential bias [34, 37]. Third, many studies relied on self-reported data, which may raise subjective bias and lacked long-term follow-up to assess the sustained effects of the interventions [32, 34]. Finally, several Chinese studies employed foreign scales, which could present issues related to cultural adaptation [53].

Discussion

This study systematically summarizes the main points of evidence-based psychological distress reduction programs for ED nurses. The review includes a total of 29 studies, which can be categorized as psychological interventions, educational programs, and organization-directed interventions, based on the different intervention objectives and characteristics. These interventions can help ED nurses reduce their stress, depression, anxiety, burnout, and PTSD and enhance their life satisfaction and quality.

Psychological interventions such as CBT, MBSR, and the solution-focused approach are theory driven and involve structured steps [49, 53, 60]. Such interventions are well established and vary in form and can be conducted in groups or in an individual basis [52, 56], such as brainstorming, group games, scenarios, and theoretical explanations [54, 55]. While these interventions have proven effective in reducing stress, depression, anxiety, burnout, and PTSD among ED nurses [38, 40, 50], their effectiveness in promoting stress coping strategies remains uncertain, with varying research outcomes [38, 50]. Moreover, the included studies focused on addressing existing psychological problems and provided no preventive measures or recommendations.

Educational programs are centered around the development of coping skills for emergency department work, such as death education, time management, coping with WPV, and early warning mechanisms [34, 36, 37, 62]. These interventions are essential as they align with the unique challenges of ED nursing, including exposure to violence and death, thereby enhancing nurses’ ability to navigate risks in their work environment. The long-term effects of educational programs are critical because they do not provide immediate relief from psychological distress. For example, the studies by Chang et al. and Zhang et al. indicate that these programs primarily improve nurses’ self-efficacy and understanding of specific issues [37, 62]. Future research is needed to assess whether educational programs can effectively reduce psychological distress among ED nurses. Among the studies, only one educational program conducted a follow-up investigation and they did not report the time of the follow-up [36], which should be improved in the future.

Organization-directed interventions aim to reduce the incidence of psychological distress by changing the stressors, management systems, and social environments. Existing interventions include quality circles, flexible management, and comprehensive management [35, 41, 65]. However, studies on such interventions are few. This scarcity may be due to challenges in implementation, such as organizational structure, personnel cooperation, and funding constraints [66]. In contrast, educational programs and psychological interventions are easier to implement sustainably, because they do not disrupt daily work [67]. It should be noted that psychological distress cannot be alleviated effectively without addressing the underlying issues within the healthcare system and relying solely on personal adaptation approaches [66]. Current interventions often lack clarity, with improvements primarily focused on management styles, such as providing verbal encouragement and psychological support [65]. However, studies have not adequately addressed workload reduction, emergency management optimization, or environmental stress relief, despite widespread advocacy for these methods [5, 68]. In the future, organization-directed interventions need to explore more structured intervention mechanisms and improve the working environment for ED nurses in multiple ways, such as policy advocacy and patient education. Another noteworthy point is that ED nurses should be equally involved in the change. Building their capacity for effective decision-making, collaboration, skilled communication, and meaningful recognition is vital, as these factors directly relate to their stressors and ability to manage stress-related situations [69].

The above analysis explores the advantages and disadvantages of the three types of interventions. The disadvantages of the interventions may affect their stability and credibility. In addition to the limitations of the interventions, their main drawbacks stem from the irregularities in their content design and intervention delivery. For example, Li et al. reported the use of CBT in the study design but did not draw on behavioral theory in the actual intervention [46]. Hosseinabadi et al. conducted a 3-month quality circle but reported a 28.6% dropout rate [35], though a dropout rate of 20% or less is generally accepted in psychological research [70]. Furthermore, only two studies conducted follow-up investigation [36, 38], and the long-term effects of most of the interventions remain unknown. Therefore, experts should be invited to guide the intervention design and implementation, and RCTs should be conducted by using the CONSORT checklist to ensure the effectiveness and scientific validity of the interventions [71].

The sample sizes of the included studies are too small to be generalizable, and only four studies reported the calculation of the sample size [32, 33, 37, 38]. According to the CONSORT checklist [71], sample size estimation is an important part of RCTs, and a reasonable sample size is a crucial safeguard for obtaining high-level clinical research results. Researchers should be rigorous in their sample size calculation and engage actively in inter-hospital collaboration to expand the sample size. Researchers can also conduct meta-analyses to assess the effectiveness of specific intervention methods.

The duration of the psychological interventions and organization-directed interventions is typically 1–4 months [41, 60], whereas that of the educational programs is generally 1–2 days [34, 62]. The frequency of the interventions ranges from 3 times a day to once every 2 weeks, and the duration of each intervention ranges from 0.5 h to 3 h [45, 46]. The differences in the intervention methods can be explained. For example, relaxation or music therapy is associated with frequent but short interventions, whereas the opposite is true for CBT. However, some differences should be noted. For instance, the included studies conducted MBSR for 4, 6, and 8 weeks [38, 40, 50]. Specifically, Kabat-Zinn developed an 8-week MBSR program [51], and in their systematic review, Ghawadra et al. showed that a 4-week MBSR can reduce nurses’ psychological distress [23]. The dose-response relationship remains unknown; thus, the duration (e.g., 4 versus 6 versus 8 weeks) and frequency (e.g., once a week versus twice a week) of interventions should be varied.

Most current measures of the effectiveness of psychological distress reduction programs for ED nurses use self-rating scales, which may be influenced by subjective factors and thus affect the accuracy of the assessment results. In future studies, objective measures such as blood pressure, heart rate, and salivary amylase may be employed [33]. Once the psychological distress levels of ED nurses improve, the effectiveness of an intervention should be assessed further in terms of work tasks and efficiency, such as in changes in patient care, incidence of medical emergency team activations, unplanned intensive care admissions, and unexpected deaths [72]. The results of such assessments can provide evidence for the effectiveness of interventions in improving the mental health of ED nurses and thus the quality of emergency care.

The analysis of the characteristics of the three intervention types reveals their limitations and core differences in their objectives. Organization-directed interventions are designed to reduce stressors at the organizational or systemic level [73], and educational programs are designed to improve nurses’ competencies to cope with stressors. Meanwhile, psychological interventions directly target the outcomes of psychological distress to alleviate negative outcomes (e.g., stress, anxiety, depression, PTSD, and burnout) and enhance positive ones (e.g., life satisfaction and quality). The combination of the strengths of the three intervention types can effectively help ED nurses alleviate their psychological distress. First, psychological interventions should be categorized as preventive projects and therapeutic interventions. Preventive projects aim at improving nurses’ comprehensive capacity. For instance, a study showed that positive psychology interventions have a significant small-to-medium effect on well-being, strengths, depression, anxiety, and stress, which remains stable over a three-month period [74]. Therapeutic intervention programs can provide specialized psychological interventions for ED nurses with serious psychological problems, such as PTSD, anxiety, and depression. Second, educational programs can be combined with in-service classes [37], and follow-up appraisals should be conducted. Last, organization-directed interventions can be conducted through pilot programs and high-quality RCTs with a large sample size to assess their feasibility and effectiveness [66]. Policymakers and medical administrators should promote system optimization through policy advocacy and improved legislation to promote a positive working environment and atmosphere for ED nurses. ED nurses should be equally involved and empowered to improve their work environment.

Limitations of this study

This study has several limitations. First, this study reviewed only interventions using RCTs; thus, it may have overlooked some valuable quasi-experimental studies or qualitative research. Second, to ensure data fidelity, this study only included studies with ED nurses as subjects and excluded studies with a mix of ED nurses and other nurses, this may have overlooked some effective interventions worth exploring. Third, this study reviewed only publicly available papers and thus may have induced publication bias. Fourth, this study limited the articles to be included to those published in English or in Chinese and thus may have overlooked relevant studies published in other languages. Last, the majority of the included studies were of moderate quality owing to the weaknesses in their study design and intervention implementation or selection bias. Thus, the results of this study should be interpreted critically owing to the above limitations.

Conclusion

Three types of interventions have provided pathways to alleviate the psychological stress of ED nurses at various levels. In the future, efforts should focus on improving the standardization and scientific rigor of psychological interventions, while also assessing the long-term effects of both psychological interventions and educational programs. For organization-directed interventions, developing effective models through pilot programs and RCTs will be crucial to fostering a healthier work environment. Policymakers and medical administrators must support these initiatives, focusing on prevention and empowerment.

Abbreviations

CBT

Cognitive Behavioral Therapy

CD-RISC

Connor-Davidson Resilience Scale

CG

Control Group

CNKI

China National Knowledge Infrastructure

CNLSES

Clinical Nurse Leader Self-Efficacy Scale

CONSORT

Consolidated Standards of Reporting Trials

CSQ

Coping Style Questionnaire

EE

Emotional Exhaustion

ED

Emergency Department

FFMQ

Five Facet Mindfulness Questionnaire

GSES

General self-efficacy Scale

ICU

Intensive Care Unit

IES-R

The Impact of Event Scale-Revised

MAAS

Mindfulness Attention Awareness Scale

MBI

Maslach Burnout Inventory

MBI-GS

Maslach Burnout Inventory-General Survey

MBI-HSS

Maslach Burnout Inventory-Human Services Survey

MBSR

Mindfulness-Based Stress Reduction

MEWS

Modified Early Warning Score

NBS

Nursing burnout Scale

NJSS

Nurse Job Stressors Scale

OCSE-N

Occupational Coping Self-Efficacy Questionnaire for Nurses

OSI-R

Occupational Stress Inventory revised edition

PICOS

Population, Intervention, Comparison, Outcomes and Study design

PRISMA

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses

ProQOL

Professional Quality of Life

PSS-10

Perceived Stress Scale 10

PTSD

Post-Traumatic Stress Disorder

PTSD-SS

Post-Traumatic Stress Disorder SeIf-rating Scale

QWL

Walton’s work-life quality questionnaire

RCTs

Randomized Controlled Trials

RET

Rational-Emotive Therapy

ROB2

Risk of Bias 2

SAS

Self-Rating Anxiety Scale

SCCS

Self-Consistency and Congruence Scale

SCL-90

Symptom Checklist 90

SCSQ

Simple Coping Style Questionnaire

SDS

Self-rating Depression Scale

SSRS

Social Support Rate Scale

TCSQ

Trait Coping Style Questionnaire

T-DAS

The Chinese version of the Death Anxiety Scale

TG

Treatment Group

UWES

Utrecht Work Engagement Scale

VAS

Visual Analog Scale

WCQ

Post-Traumatic Stress Disorder SeIf-rating Scale

WPV

Workplace Violence

Author contributions

PJ managed the study design and final approval of the article. YWJ searched the database, screened the literature, and analyzed them. XYY searched the database and screened the literature, analyzing them, and preparing the draft of the article. WJD managed the study design, analyzed articles, and revised and approved the article. YPN searched the database. YZ and YHC revised the article. JPD, FQX & LWH analyzed and conceptualized the article.

Funding

This research was partially supported by the Medical Discipline Construction Program of Shanghai Pudong New Area Health Commission (the Key Weak Disciplines Program) (PWZbr 2022-10) and the Shanghai Natural Science Foundation (23ZR1415000).

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.