Burnout, Depression, and Stress in Emergency Department Nurses and Physicians and the Impact on Private and Work Life: A Systematic Review

Abstract

Objectives

In today’s fast-paced world, work-related stress is a prevalent problem, particularly among health care professionals in high-pressure environments such as emergency departments (EDs). This stress can lead to mental health disorders, such as depression and burnout, affecting job performance, patient care, and the quality of professional and private life. This systematic review aimed to investigate the prevalence of burnout, depression, and stress among ED nurses and physicians and the impact of these conditions on personal and professional quality of life (QoL).

Methods

The systematic literature search covered PubMed, PsycINFO, Embase, and grey literature databases. Articles were included if they were published in English or German by 31 January 2020, focused on ED physicians or nurses, and examined burnout, depression, or stress and its impact on professional or personal QoL. Quality assessment of the included studies was performed using a modified version of the Newcastle-Ottawa Scale.

Results

The systematic search resulted in 893 articles, of which 11 met the inclusion criteria. All reviewed studies had a cross-sectional study design and were of low to moderate quality. Depression, burnout, and stress were prevalent among ED physicians, ranging from 15.5% to 19.3%, 18% to 71.4%, and 19.5% to 22.7%, respectively. These were associated with lower job satisfaction in ED physicians, while findings in ED nurses also showed a considerable rate of burnout with an inverse association with compassion satisfaction. Burnout and stress were significantly associated with intentions to quit emergency medicine in ED physicians, whereas no association was found for depression. In addition, burnout showed a negative relationship to work-life balance and QoL, while higher stress levels were associated with lower life satisfaction in ED physicians.

Conclusion

Our review underlines the high prevalence of stress, depression, and burnout among ED health care professionals and their potential negative impact on private and professional life, emphasizing the need for targeted support and interventions to enhance resilience, reduce stress, and prevent the onset or deterioration of mental health diseases. This, in turn, can contribute to maintaining and strengthening the already limited human resources in EDs, ensuring the quality of patient care, and strengthening health care systems.

1. Introduction

1.1. Background

In today’s fast-paced world, where work-related tasks are also dealt with in free time and unforeseen challenges occur, work-related stress has become a prevalent issue affecting professionals across various industries. Work-related stress is defined by the World Health Organization as a reaction that can occur in people when they are confronted with job demands that do not match their skills and knowledge and with strains that challenge their coping ability.¹ The amount of workload/pace, long/inflexible working hours, and poor work-life balance are cited as risk factors.¹

The accumulation of stress can potentially lead to the onset or aggravation of mental health (MH) illnesses, among which depression is highly frequent.2, 3, 4, 5, 6 The lifetime prevalence of depression in the general population was reported to range from 3.8% to 14.6%.^7,8 Another prevalent stress-related disorder is burnout, defined as a syndrome caused by prolonged stress at work, which failed to be manageable.⁹ Previous studies estimated burnout rates in the general working population between 4% and 18%.^10,11

1.2. Importance

Work-related stress is of special concern in health care workers.^12,13 Numerous studies reported more frequent occurrences of stress and MH disorders, such as depression and burnout, in health care professionals (HCPs) than in the general population.^11,14, 15, 16, 17 ED staff, in particular, are confronted with a stressful and demanding work environment, characterized by shift work, high patient loads, constantly changing settings, challenging and time-critical decision-making, and exposure to patient suffering and death, resulting in high levels of stress, burnout, and depression.18, 19, 20, 21 The highly heterogeneous and unpredictable patient spectrum in EDs, encompassing patients with critical illnesses, minor medical issues, aggressive behavior, and migration backgrounds, along with associated communication difficulties, makes emergency medicine diverse but also very challenging. Chernoff et al²² reported a burnout rate of 78% among ED nurses and 70% among ED physicians, surpassing those of other HCPs in non-ED settings and that of the general working population.

Elevated stress levels among HCPs, which can result in burnout or depression, have been associated with diminished job performance and subsequent negative patient outcomes.23, 24, 25, 26, 27, 28, 29, 30, 31 These consequences may manifest as a reduction in the quality of care, decreased patient safety, and increased medical errors.23, 24, 25^,27 For the entire health care system (HCS), burnout in physicians and nurses is associated with poor performance, increased rates of sick leave, elevated turnover rates, and a consequential rise in health care costs.28, 29, 30, 31

Considering the negative effects on their own health, HCSs, patient outcomes, and job performance by stressed, depressed, or burned-out physicians and nurses, the assumption can be made that the impact must be even more severe among the group of HCPs operating in high-pressure environments such as EDs with the highest rates of depression, burnout, and stress. Nevertheless, the specialty of emergency medicine is crucial and widely sought after. Yet, there remains a scarcity of evidence regarding the impacts of increased stress, burnout, or depression on the personal and professional well-being of ED physicians and nurses.

1.3. Goals of this Investigation

The objectives of this systematic review (SR) were as follows: (1) to explore the prevalence of classified burnout, depression, and stress among ED nurses and physicians and (2) to identify and elaborate on the impact of these conditions on private and professional life.

2. Methods

2.1. Search Strategy and Sources of Information

A systematic literature search of articles published until January 31, 2020, on the topic of work stress, burnout, depression, and quality of life (QoL) in ED nurses and physicians was performed in PubMed, PsycINFO, Embase, and grey literature databases MedNar and Google Scholar. Keywords were identified carrying out a profound research on the topic, and suitable search terms were sorted following the patient/population, intervention, comparison, and outcomes (PICO) model and a CoCoPop concept map (Supplementary Appendix 1).^32,33

2.2. Eligibility Criteria

All original research articles fulfilling the eligibility criteria listed in Table 1 were included.

Table 1.

Inclusion and exclusion criteria.

Inclusion criteria	Exclusion criteria
Articles examining ED physicians and nurses aged >18 y, fully trained or in training.	Articles about nurses or physicians working in other specialties or covering other occupational groups.
Articles about adult EDs with no geographical restrictions.	Articles dealing with other departments or children’s emergency departments.
Articles with separable data for nurses and physicians or, if more departments are included, separable data for ED physicians and nurses.	Articles did not show separable data.
Articles covering depression, depressive disorder, burnout, and or stress.	Articles dealing with other mental health problems other than depression, depressive disorder, burnout, or stress.
Articles with validated instruments to determine the prevalence (among the studied population) of burnout, depression, and stress.	Articles with nonvalidated instruments to determine the prevalence (among the studied population) of burnout, depression, and stress.
Articles about the effects on life, such as quality of life, work-life quality, work-life balance, job satisfaction/career satisfaction, life satisfaction, sick leave, personnel turnover, or missing days.	Articles covering no effects on private and or professional life.
Articles written in English or German.	Articles written in languages other than English or German.

2.3. Data Collection and Selection of Studies

The articles resulting from the search process were gathered and stored in EndNote 20 (EndNote 20 edition, Clarivate; 2013). Two independent reviewers (A.J. and A.L.) screened titles, abstracts, and full text according to the inclusion and exclusion criteria (Table 1). Decisions on the inclusion and exclusion of articles were based on consensus. In case of dissent, the reviewers resolved the divergence by consensus or, if necessary, by involving a third reviewer (K.K.).

2.4. Data Items

The data items described in Supplementary Appendix 1 were extracted from the included articles using a predefined form in Microsoft Office Professional Plus Excel 2016 for Windows 10 (Microsoft Corporation). To ensure high accuracy and completeness of the data extraction by A.J. and A.L., data extraction was checked by K.K.

2.5. Quality Assessment

Two authors (A.J. and K.K.) independently evaluated study quality using the modified Newcastle-Ottawa Scale,¹⁹ with final ratings determined by consensus. A system based on a maximum of 9 points assessed selection bias (5), comparability (2), and outcomes (2). Studies scoring 7 to 9 points were considered high quality, 4 to 6 moderate quality, and 0 to 3 low quality. This SR followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.³⁴

3. Results

Our literature search identified 893 articles, of which 11 articles were included in our study. A detailed overview of the search and screening process is presented in Figure 1 and of all included studies in Table 2.35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45

Figure 1.

PRISMA flow diagram of the search and screening process. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Table 2.

All included studies.

Author, year of publication, and origin of the study	Title	Study population	Instruments (with cut-offs given by the author of the performed study)	Mental health problem	Measure of QoL	Findings	Quality rating
Ben-Itzhak et al,35 2015, Israel	Sense of meaning as a predictor of burnout in emergency physicians in Israel: a national survey	70 physicians	MBI (22-item): BO = high EE and/or DP. QoL survey: To what degree are you satisfied with your work (5-point Likert scale)? My work schedule leaves me enough time for my personal/family life (5-point Likert scale).	Burnout	Work satisfaction and work-life balance	BO: high EE 61.4%, high DP 51.4%, low PA 17.1%, overall BO prevalence (high on EE and/or DP): 71.4%. Mann-Whitney tests to determine the differences between burnout groups (burned out and not burned out) for which scores differed significantly between groups: − satisfaction with work (P < .001), − work-life balance (P < .05), + lack of interest in daily activities (P < .05), + stress (P < .001)	Low (3/9)
Gallery et al,45 1992, United States	A study of occupational stress and depression among emergency physicians	763 emergency physicians (members of the American College of Emergency Physicians)	CES-D: ≥16 = depression (cutoff for depressive symptomatology). Work-related strain inventory: ≥38 indicating high levels of work-related stress. Questionnaire regarding future plans relative to the practice of emergency medicine.	Stress and depression	Intention to leave emergency medicine	Depression: mean 9.16 (SD 8.23), 19.3% depressive symptoms (CES-D score > 16). Stress: mean 32.03 (SD 8.96), 22.7% high levels of stress. Work-related stress was positively associated with plans to leave emergency medicine in 1 year (B = 0.05, P < .01) or 5 years (B = 0.06, P < .0001) and negatively associated with intention to remain in clinical practice ≥7 years (B = −0.05, P < .0001). Depression was not significantly associated with the intention to leave emergency medicine or to stay in clinical practice.	Moderate (5/9)
Goldberg et al,36 1996, United States	Burnout and its correlates in emergency physicians: four years experience with a wellness booth	1272 physicians	MBI (23-item): divide the burnout process into 8 phases, with phases I-III representing low degrees and IV-V and phases VI-VIII representing moderate and high degrees (raw data scores were converted to phases). An additional 79-item questionnaire with questions regarding demographic characteristics, health habits, and career satisfaction (satisfaction scale from 1 to 7, with 1 representing very dissatisfied and 7 representing very satisfied: categorized 1-3 being low; 4 and 5 being medium; and 6 and 7 being high)	Burnout	Career satisfaction and intention to leave specialty	BO: EE mean 25.31 (SD 8.55), DP mean 20.70 (SD 8.49), PA mean 24.72 (SD 9.17), 60% moderate to high degree of BO. Chi-square tests to determine the differences between BO groups (low BO and moderate/high BO). Career satisfaction: low 236 total (62.3% moderate/high BO), medium 467 total (63.8% moderate/high BO), high 532 total (58.5% moderate/high BO). Negative correlation of career satisfaction and BO (P = 0.02). Higher levels of BO were significantly associated with dissatisfaction with career/subspecialty, intent to leave the specialty in 10 years, lower job involvement, and unwillingness to advise a friend to pursue the specialty.	Moderate (4/9)
Hooper et al37, 2010, United States	Compassion satisfaction, burnout, and compassion fatigue among emergency nurses compared with nurses in other selected inpatient specialties	49 nurses	Professional quality of life: CS low < 33, medium 34-41, high > 41; BO low < 18, medium 19-26, high > 26	Burnout	Compassion satisfaction	CS: low 24.5%, medium 49%, high 26.5%; BO: 82% reported moderate to high levels of BO, of which 22.4% were at risk for BO: low 18.4%, medium 59.2%, high 22.4%. Significant inverse relationship between CS and BO (the relationship is stronger when only emergency nurses are considered).	Moderate (5/9)
Lloyd et al,43 1994, Canada	Burnout, depression, life and job satisfaction among Canadian emergency physicians	223 physicians	MBI: poor scores = EE ≥ 40, DP ≥ 15, and PA ≤ 36; Centre for Epidemiologic Research Self-Report Depression Scale (CES-D): >16 = depression (the cut-off for depressive symptomatology). Satisfaction with Life Scale and emergency physician job satisfaction.	Depression	Job satisfaction	BO: EE mean 26.1 (SD 11.3), 46% medium to high EE; DP mean 16.5 (SD 6.9), 93% medium to high DP; PA mean 37.2 (SD 7.6), 79% medium to low PA. Depression: mean 8.3 (SD 7.8), 15.5% depressive symptomatology (>16). Life satisfaction: mean 20.9 (SD 6.4), 61% satisfied. 35.1% dissatisfied. Job satisfaction: mean 2.32 (SD 3.77), 75.5% satisfied, 24.5% dissatisfied. Negative correlation of depression and JS (for CES-D > 16 correlation = −0.53 vs 2.83 for <17, P = .0001).	Moderate (5/9)
Lu et al,39 2015, United States	Impact of burnout on self-reported patient care among emergency physicians	77 physicians (attendings and residents)	BO: MBI (22-item): BO = high DP / EE (BO was dichotomized yes/no). Depression: Primary Care Evaluation of Mental Disorder Instruments (first 2 questions: A “yes” response to either question = positive screen for depression. QoL: single-item QoL (“How would you rate your overall QoL over the past week?”); single-item career satisfaction (“If given the opportunity to revisit your career choice, would you choose to become a physician again?”): Responses of “likely” and “very likely” on a 5-point Likert scale were categorized as positive for career satisfaction. Patient care practices: suboptimal care was measured with 6 statements adapted from prior work that investigated self-reported patient care.	Burnout (depression)	Career satisfaction, (patient care practices)	BO rate: 57.1%, EE high 20.8%, DP high 49.4%, PA low 7.8%; overall depression (positive screen): 27.3% (18.5% of attendings, 47.8% of residents); career satisfaction: 85.7%; QoL: median 7.2 (IQR, 6.1-8); BO associated with depression: 38.6% vs 12.1%, P = 0.01; BO associated with lower career satisfaction (BO yes/no, P = .02). Burned-out EPs were significantly more likely to report performing on a more frequent basis all 6 suboptimal patient care practices (admitting/discharging patients early (P < .001); not discussing options/answering questions (P = .012); ordering more tests (P < .001); not treating patients’ pain timely (P = .019); not communicating important information at handoffs (P < .001); and not discussing plans with staff (P =.009). No significant associations between rates of suboptimal care and depression.	Low (3/9)
Moukarzel et al,40 2019, France	Burnout syndrome among emergency department staff: Prevalence and associated factors	69 physicians (= medical category)	Karasek’s Job Content Questionnaire (French version, 26 items, results grouped into 4 categories (job strain, low strain, passive, and active); QoL by the Medical Outcome Study Short Form (SF-12, 12 items): physical and mental component score; MBI (French version, 22-item): EE high ≥ 30; DP high ≥ 12. BO = high EE/DP, and high BO = high EE/DP + low PA	Burnout (Job strain = work stress)	Quality of life (intention to quit)	≥1 sick leave last year: 19.1%; intention to quit: 15.9%; Job strain: 17.2%; QoL: physical component score mean 49.7 (SD 4.9); mental component score mean 36.6 (SD 10.4); BO prevalence: 50.7%. BO associated with lower mental component score (QoL) and job strain (P < .05 and more pronounced for the medical category); intention to quit associated with BO (P < .001) for all ED staff (physician, paramedic, and administrative)	Moderate (5/9)
Takayesu et al,38 2014, United States	Factors associated with burnout during emergency medicine residency	218 physicians (EM residents)	MBI (22-item): BO dichotomized into yes/no, with BO defined as high EE, high DP, or low PA; Emergency Physician Job Satisfaction (administrative and clinical autonomy); Global Job Satisfaction	Burnout	Job satisfaction	BO: EE 33% high, DP 59% high, PA 59% low, overall BO prevalence 65% (meeting criteria); poor global JS correlates with BO (low BO mean −0.19 (SD 0.39), high BO mean −0.34 (SD 0.28), P < .0001). Significant correlations between BO and poor JS scores in administrative & clinical autonomy (P > .05).	Moderate (5/9)
Taylor et al,44 2004, Australasia (Australia and New Zealand)	The psychological health of emergency physicians in Australasia	323 physicians (ACEM Fellows)	Zung Depression Scale; Satisfaction with Life Scale; Perceived Stress Scale; work satisfaction rating scales (range, 1-10): low 1-3, high 8-10. Rating scale of work stress (range, 1-10): high 8-10	Depression and stress	Work satisfaction and life satisfaction	Depression: mean 31.1 (SD 6.7); overall classified mild-severe depression = 15.6% (48/308): 12.3% mild (38/308), 2.9% moderate (9/308), 0.3% severe depression (1/308). Perceived Stress Scale : mean 24.6 (SD 6.4); work stress: mean 5.6 (SD 2.1), 19.5% high levels; life satisfaction: mean 24.6 (SD 6.2); work satisfaction: mean 6.3 (SD 2.1), high 30.7%, very low 13.3%. Negative correlation between work stress and work satisfaction (r = −0.47, P < .001) and life satisfaction (r = −0.31, P < .001). Negative correlation of work satisfaction with perceived stress (r = −0.52, P < .001) and depression (r = −0.51, P < .001).	Moderate (6/9)
Williamson et al,41 2018, United States	Comparing the Maslach Burnout Inventory to other well-being instruments in emergency medicine residents	261 physicians (residents)	MBI (22-item): BO = high EE (> 26) and high DP (> 12); Visual Analog Scale for QoL: single item: ‘‘How would you rate your overall QoL during the past week?’’ For Depression: Primary Care Evaluation of Mental Disorders Patient Health Questionnaire 2-question screen: yes to either question = positive screen for depression; CAS (1 item: likely/very likely = positive for CAS); WLB (1 item: strongly agree/agree = positive for WLB)	Burnout (depression)	Quality of life, career satisfaction, and work-life-balance	QoL: median 75 (IQR 60-83.75); positive WLB: 52%; positive CAS: 84%; depression prevalence: 40%; BO prevalence: 18%; BO significantly correlated with lower scores for QoL and negative scores for CAS and WLB (eg, QoL correlations with BO: EE negative P = −.437 P < .0001, DP negative.P = −.18 P < .005, PA positive. P = .347 P < .001); depression positively correlated with BO.	Moderate (5/9)
Xiao et al,42 2014, China	Psychological distress, burnout level and job satisfaction in emergency medicine: A cross-sectional study of physicians in China	205 physicians	Hospital Anxiety and Depression Scale (Chinese version): 0-7 clinically normal, 8-10 mild, 11-14 moderate, and 15-21 severe, ≥ 8 = cut-off clinically significant; MBI-General Survey (Chinese version, 15-item): BO = high EE/high cynicism/low PA; Minnesota Satisfaction Questionnaire (20 items, range 20-100)	Burnout	Job Satisfaction	Psychol. Distress = anxiety/depression >8 = 37.1%, depression mean 7.9 (SD 3.6); high levels of BO: 25.4%; JS: mean 68.72 (SD 10.90), 9.3% dissatisfied (≤40), 6.8% satisfied (≥80); BO was significantly negatively correlated with JS (intrinsic and extrinsic).	Moderate (5/9)

Mental health problems in brackets: there was only information on the prevalence of this problem in the study population, but no information on correlations with QoL measures.

ACEM, Australasian College for Emergency Medicine; BO, burnout; CAS, career satisfaction; CES-D, Center for Epidemiologic Studies Depression Scale; CS, compassion satisfaction; DP, depersonalization; EE, emotional exhaustion; EM, emergency medicine; EP, emergency physician; JS, job satisfaction; MBI, Maslach Burnout Inventory; PA, personal accomplishment; QoL, quality of life; WLB, Work-life balance.

Ten studies focused on ED physicians and one on ED nurses. The sample size of the studies ranged from 49 to 1272 participants. All studies were cross-sectional survey studies. Most of the studies were rated of moderate quality (9/11), with only 2 studies of low quality.

3.1. Burnout, Depression, and Stress

The reported prevalence of burnout, depression, and stress within the identified studies and their impact on professional and or private QoL are summarized in Figure 2. The results were not pooled due to the heterogeneity of the included studies.

Figure 2.

Reported prevalence of mental health problems with 95% CI and impact on professional and or private quality of life.

3.1.1. Burnout

In total, 72% of the studies focused on burnout in ED physicians or nurses. These studies demonstrated a wide variation in the prevalence of classified burnout between 18% and 71%.35, 36, 37, 38, 39, 40, 41, 42 Thereby, 7 out of 8 used the Maslach Burnout Inventory (MBI) to determine burnout, of which 5 used the general 22-item version MBI^35,38, 39, 40, 41; one used a 23-item MBI version³⁶ and another used the 15-item MBI-General Survey.⁴² The remaining study applied the professional QoL scale to measure burnout.³⁷

One study concentrated on nurses with burnout, where 22.4% of the 49 ED nurses were at risk of burnout, while 82% showed moderate to high levels of burnout.³⁷ They also compared ED nurses with nurses from other specialties (nephrology, intensive care, and oncology) and found no significant differences regarding burnout between them.³⁷

Only 2 of the 7 studies on ED physicians showed similar rates of burnout to those of ED nurses. One of these studies demonstrated high levels of burnout among 25.4% of the 205 ED physicians studied.⁴² The other study conducted among 261 ED residents revealed a burnout prevalence of 18%.⁴¹ The results of the remaining studies showed that burnout was even more prevalent in ED physicians throughout various countries. Compared with other ED staff (paramedics, administrative, and technical), ED physicians reached significantly higher burnout rates, with 1 out of 2 having burnout (50.7%).⁴⁰ In another study, 60% of 1272 ED physicians reported moderate to high degrees of burnout.³⁶ Lu et al³⁹ showed high burnout rates of 57.1% among ED physician attendings and residents, without any significant differences between these groups. Similar results were reported by Kimo et al³⁸ who also studied emergency medicine residents and detected a burnout prevalence of 65%. A study from Ben-Itzhak et al,³⁵ which defined significant burnout levels with high emotional exhaustion or high depersonalization, demonstrated the highest prevalence of burnout with 71.4% among the included studies.

3.1.2. Depression

Depression and its association with private and/or professional life were evaluated in a quarter of the studies reviewed, and all of them were conducted among physicians.43, 44, 45 Additionally, 2 studies that investigated the prevalence of burnout and its association with private or professional life also reported on the prevalence of depression among the studied ED physicians without analyzing its association with QoL.^39,41 Two studies^43,45 measured depression using the Center for Epidemiologic Studies Depression Scale, and another 2 studies^39,41 used the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire 2 question screen, and 1 study applied the Zung Depression Scale.⁴⁴ All these studies demonstrated a variation in the overall prevalence of classified depression between 15.5% and 40%, whereby this range differs between 15.5% and 19.3%^39,43, 44, 45 for emergency physicians, and between 40%⁴¹ and 47.8%³⁹ for emergency medicine residents.

Among ED physicians from Canada,⁴³ 15.5%, showed depressive symptoms, followed by 19.3% in a study from the United States.⁴⁵ In a study from Australia and New Zealand,⁴⁴ 15.6% of the participating ED physicians classified for mild to severe depression, which was significantly lower than compared with a community sample. A high prevalence of 27.3% for depression among emergency attendings and residents was presented by Lu et al,³⁹ whereby residents screened significantly more frequently positive for depression than attendings (47.8% vs 18.5%). Similar results for emergency medicine residents were presented by Williamson et al⁴¹ with a prevalence among the studied population of 40% for depression.

3.1.3. Stress

Two of the reviewed studies examined the prevalence of high levels of stress and their association with private or professional life, and both were limited to ED physicians. Gallery et al⁴⁵ reported high levels of work-related stress among 22.7% of the investigated emergency physicians, while using the Work-Related Strain Inventory (WRSI) to measure it. Similar results were demonstrated in a study among ED physicians from Australia and New Zealand, which showed 19.5% high levels of work stress using a rating scale of work stress and a mean of 24.6 for the whole sample on the Perceived Stress Scale, indicating a moderate work stress level, whereas these scores did not differ from a community sample.⁴⁴ Additionally, a study from France⁴⁰, which investigated burnout among ED staff, detected that 17.2% of the ED physicians were in job strain, feeling that their work was very stressful, whereby this was significantly lower compared with other ED staff (paramedics, administrative, and technical).

3.2. Associations with Private and Professional Life

3.2.1. Job satisfaction

Nine of the 11 included studies investigated the relationship between job, work, career, or compassion satisfaction with burnout, depression, or stress among ED physicians and nurses.35, 36, 37, 38, 39^,41, 42, 43, 44 All of these studies found a negative correlation to burnout, depression, and stress in both physicians and nurses. Thus, higher burnout, depression, or stress scores were associated with lower job satisfaction levels.

Lu et al³⁹ demonstrated that in the group of emergency medicine attending physicians and residents with burnout, about 77% were satisfied with their careers, and in the group without burnout 97% were satisfied. They additionally explored the impact on patient care practices, where burned-out ED physicians were more inclined to perform suboptimal patient care practices (eg, not treating patients’ pain in a timely manner or not discussing treatment plans with other staff) than not burned-out ED physicians did. The study by Hooper et al³⁷ showed that the inverse relationship between burnout and compassion satisfaction was stronger among nurses working in EDs and that they were less satisfied with their jobs than staff from other specialties.

3.2.2. Intention to leave

Two of the reviewed studies examined the correlation between the intention to leave (ITL) the specialty of emergency medicine/the career, and burnout, depression, and stress among ED physicians.^36,45 One study³⁶ showed a significant correlation between burnout and the intention to quit, meaning higher levels of burnout were associated with the ITL the specialty, with lower degrees of job involvement and reluctance to advise a friend to pursue the specialty. A study that investigated the association between intention to quit, stress, and depression reported a positive correlation of stress with ITL emergency medicine and a negative relationship with the intention to stay in clinical practice.⁴⁵ In contrast, depression was not significantly associated with ITL emergency medicine or stay in clinical practice.⁴⁵

3.2.3. Work-life balance

Two studies reported on the relationship between burnout and work-life balance in emergency physicians.^35,41 They demonstrated a negative correlation between burnout and work-life balance, meaning higher burnout levels were associated with negative scores for work-life balance.

3.3. QoL

The association between burnout and QoL in ED physicians was reported in 2 studies, where lower QoL scores were associated with higher burnout rates.^40,41

3.4. Life Satisfaction

One study reported on life satisfaction, where they showed a negative correlation of work stress with life satisfaction, meaning higher stress scores were associated with lower life satisfaction.⁴⁴

4. Limitations

Our review has several limitations. It represents the first SR of stress, depression, and burnout, including their effects on both personal and professional life, among ED physicians and nurses. The heterogeneity across the study designs, including variations in sample sizes, populations, assessment scales, and MH screening thresholds, limits the comparability of mental illness rates and hinders the synthesis and generalizability of findings. For instance, definitions for burnout varied, with some studies requiring a minimum threshold on 2 of 3 MBI dimensions, whereas others only required 1, potentially overestimating prevalence. Additionally, the limited number of studies on the impact of MH on personal and professional life, combined with a lack of high-quality evidence, poses challenges. Cross-sectional studies prevent the determination of cause and effect, and self-reported assessments may introduce recall, selection, or reporting biases. Additionally, most screened studies lacked clear reporting of burnout prevalence, by missing consolidation of individual dimensions into a comprehensive estimate. Furthermore, by including studies that reported the prevalence of mental illnesses and their impact on both private and/or professional QoL, a relevant number of studies (only reporting on prevalence or not at all) were excluded to ensure at least a certain level of comparability. Lastly, the potential influence of the COVID-19 pandemic on ED staff’s MH should be considered, and further research is needed to explore long-term effects and establish causal links between MH conditions and QoL.

5. Discussion

EDs are renowned for their demanding work environment characterized by a fast pace, diverse patient cases, and continuous, year-round service. Consequently, studies have reported high levels of stress, burnout, and depression among staff. Despite these challenges, emergency medicine remains a popular and vital specialty, raising questions about the impact of these MH problems on personal and professional QoL.

Among the 8 studies in our review focusing on burnout, 5 reported a high prevalence among ED physicians, ranging from 50.7% to 71.4%. The remaining studies indicated burnout rates of 18% to 25.4% among both ED physicians and nurses. Discrepancies in reported rates may result from variations in assessment tools and cut-off points employed across studies. Other SRs have similarly documented a wide range of burnout prevalence among ED physicians, spanning from 25% to 78%.⁴⁶ These rates align with previous findings, where ED physicians exhibited the highest rates of burnout at 65%, surpassing those in other medical specialties or the broader US working population.⁴⁷ Comparatively, ED nurses demonstrated lower burnout rates in previous investigations, consistent with the present findings.⁴⁸

Similar results emerged for depression, with prevalence ranging from 15.5% to 40% among ED physicians, aligning with the SR of residents in different specialties, which reported rates of 20.9% to 43.2%, depending on the assessment tool.⁴⁹ Depression rates varied by training level, ranging from 15.5% to 19.3% for ED physicians and 40% to 47.8% for ED residents. Other studies show an increase in depressive symptoms with the start of medical residency programs (by 15.8%⁴⁹), and a decline in later years.⁵⁰

High stress levels among ED physicians ranged from 19.3% to 22.7% in our review, consistent with studies reporting rates of 30% in the United States (physicians)⁵¹, and 28.3% in Pakistan (ED nurses and physicians)⁵². Some studies reported even higher rates (up to 65% in ED physicians based on WRSI-scores > 38)⁵³. Variability may stem from reporting bias, study design, measurement tools, and differing cut-off thresholds.

The findings of our review confirmed high levels of burnout, depression, and stress among ED nurses and physicians, underlining the relevance of examining their impact on both professional and personal QoL. In essence, 9 out of 11 reviewed studies revealed a consistent association between elevated levels of burnout, depression, or stress among ED physicians and nurses and decreased job/career satisfaction. This relationship was pronounced for ED nurses in comparison to nurses from other specialties. Furthermore, higher rates of burnout were linked to lower QoL scores and negative work-life balance, while increased stress scores in ED physicians were associated with reduced life satisfaction. Regarding the ITL the field of emergency medicine, heightened levels of burnout or stress were related to a desire to exit the specialty, whereas depression did not exhibit an association. Considering the limited number of studies investigating this relationship, further studies, incorporating alternative study designs with higher levels of evidence, are necessary to provide comprehensive information about this association.

In addition to the already-known negative impact of MH problems among HCPs on their health, patient outcomes, and the HCS, the results of this review highlight the profound impact of stress, depression, and burnout on the work and personal lives of ED nurses and physicians. These MH conditions contribute to increased turnover and absenteeism, further straining the ED workforce. The resultant shortage of experienced staff further exacerbates stress, burnout, and the quality of patient care, creating a damaging cycle. Addressing these MH challenges is therefore crucial not only for the well-being of ED staff but also for maintaining effective and sustainable emergency services. Implementing targeted support measures, resilience training, and MH resources is essential to stabilizing the workforce and improving overall emergency care quality.

To address work stress and prevent mental illness in EDs, efforts should combine adequate working conditions with resilience training and coping strategies for staff. A SR highlighted promising individual-focused interventions, including mindfulness and educational programs, for reducing stress and burnout among ED staff.⁵⁴ Another SR indicated that interventions grounded in cognitive and behavioral principles hold promise for reducing stress and burnout among physicians.⁵⁵ Nevertheless, both reviews demonstrate that despite the already known increased need for appropriate MH support interventions, the quality of research investigating the effectiveness of behavioral or psychosocial interventions for addressing occupational stress and burnout in HCPs remains scarce.

In conclusion, this SR highlights the high prevalence of stress, depression, and burnout among ED HCPs and their potential impacts on their lives. Further high-quality research is needed to clarify causal relationships. Still, these insights can guide preventive measures to enhance resilience, reduce stress, and support MH, ultimately preserving limited ED resources, ensuring patient care quality, and strengthening HCSs.

Author Contributions

A.J. conceived the study. A.J., A.L., and K.K. designed the study. A.J., A.L., and K.K. collected the data and reviewed the articles. All authors contributed to the critical review of analytic results. A.J. and A.L. drafted the paper. All authors contributed to the critical review and revision of the paper.

Funding and Support

By JACEP Open policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist.

Conflict of Interest

All authors have affirmed they have no conflicts of interest to declare.