Table 1.

Research evidence around ED nurses perceptions of their working environment

Author, year, country	Aim/s	Sample	Research design/tools/analysis type†, ‡	Rigour, reliability, validity	Findings	Strengths	Limitations§	Recommendations/implications	MMAT %
1. Hawley, 1992, Urban Canada	To identify and describe the intraorganisational sources of stress perceived by emergency nurses	ED nurses n = 68 from four EDs	– Descriptive cross‐sectional correlational design from a self‐reported, previously validated, modified Stress Diagnostic Survey with 41 items each with a Likert‐type scaling 1–7 – Survey coupled with open‐ended questions – Limited participant demographic data also collected – Mixed method/§§quantitative descriptive	– Guided by the model for organisational stress research of Ivancevich and Matteson – Stipulated inclusion criteria: RNs, >3 months ED experience	– Emergency nurses experience work‐related stress originating from a variety of sources including inadequate staffing and resources, too many non‐nursing tasks, changing trends in ED use, patient transfer problems and also continual confrontation with patients and families who exhibited crisis or problematic behaviours	– Study provides an interesting historical context – with limited identified impact of workload on staff stress – Informed by a strong theoretical model	– Limited information about participant selection, follow up procedures or participation/response rate – Limited reporting of demographic data including % women	– Required development of strategies dealing directly with stressors and the creation of a workplace that fosters more support and recognition of nurses and promotes professional growth may also help to reduce the stressors	25
2. Helps, 1997, UK	To assess psychological and physiological experiences of occupational stressors in ED staff	ED nurses n = 51/57 distributed across three grade levels – Single site	– §§Mixed method study including semi‐structured interview, cross‐sectional a self‐reported quantitative questionnaire – A 42 item ‘Hassles’ Questionnaire, a General Health Questionnaire – 28, a Responses to Stress Questionnaire (RSQ) and The Maslach Burnout inventory (2nd edn) – Descriptive analysis (mean, SD, range), statistical analysis reported but tests not cited	– 89% response rate	– Top 10 identified ‘hassles’ were ambient temperature and Lighting, Too much to do, Budget cuts, Doctors, Erratic workload, Other nurses, People in charge, Time and work pressures, Lack of staff and interpersonal relationships were cited as the greatest sources of occupational stress – Greatest satisfaction was derived from patients (and staff) saying thank you, Providing a good service, supporting/helping/calming people – 25–30% of nurses reported significant psychological compromise – The most commonly suggested solution to stress was to employ more staff, followed by a ‘time out room’ and effective debriefing	– Use of multiple tools enabled a broad view of these nurses states – Broad process for inclusion of staff	– ††Validity checks not cited – Face and construct validity for ‘hassles’ and ‘responses to stress’ questionnaires not cited – No analysis of data, no identification of themes within interviews provided – No follow up of non‐respondents to the survey	– In general, A&E nurses satisfied in their work, with overall levels of occupational stress akin to or lower than general nurses – Urgent need for debriefing for staff and high risk of PTSD – Strategies to promote successful coping and prevent the development of negative outcomes to occupational stress could then be implemented and evaluated	25
3. Adeb‐Saeedi, 2002, Iran	To identify sources of stress for nurses working in ED	ED nurses – 120/160 selected at random – Qualifications from school diploma (24%) to Masters trained (4%) with the majority baccala‐ureate trained (68%)	– Mixed methods/§§quantitative descriptive including descriptive cross‐sectional correlational design from a self‐reported validated quantitative questionnaire – Survey examining demographics and experience as well as 25 previously identified stressor items that participants were asked to rate using a 1–5 Likert scale – Analysed using spssx	– Random sampling of possible ED nurses 75% response rate – Cronbach's alpha 0.87	– No significant correlation between stress, age, shift work or qualification/s – Women reported higher levels of stress – The most stressful demand on nurses was dealing with pain, suffering and grief and patient/family responses – Heavy workloads coupled with staff shortages and lack of resources also rated as highly stressful	– Relatively good mixture of women (66%) and men (33%) staff with good distribution across working shifts	– ‡‡, ††Sample all drawn from one University teaching pool – Not previously validated survey, no possible comparison to other study findings – Unclear how many sites involved	– Requirement for improved support and working conditions for nurses including provision of counselling/debriefing and stress management training	25
4. Ross‐Adjie, Leslie and Gillman, 2007, Australia	To determine which stress‐evoking incidents ED nurses perceive as the most significant, and whether demographic characteristics affect these perceptions To discuss current debriefing practices in EDs	ED nurses n = 156/300	– Mixed methods/§§cross‐sectional quantitative descriptive study was undertaken – Non‐parametric testing (Kruskal–Wallis) to identify and rank 15 listed workplace stressors and determine whether demographic sub‐groups ranked the identified stressors differently – Three‐part questionnaire – SPSSx was used to manage data	– 52% response rate	– In order of significance, stressors were the following: violence against staff, workload, skill‐mix, dealing with a mass casualty incident, the death/sexual abuse of a child, dealing with high acuity patients – There was a relationship between the paediatric death/sexual assault stressor and number of years ED experience, as well as the acuity stressor and number of years ED experience – 40% of respondents reported having personally sought debriefing while almost 60% reported that workplace debriefing is not routinely offered after a stress‐evoking incident in their workplace – Free text listing of stressors included lack of, or outdated equipment’ and ‘shift work’	– Quant data was enriched by free comment to contextualise findings	– 10% respondents were men (twice the proportion employed in these EDs) – No information about survey follow up – Non‐validated, unpiloted, author developed survey may compromise survey validity and results	– Debriefing after stress‐evoking incidents in the workplace should be mandatory not optional, and should be conducted by professionals with specific debriefing and counselling skills – Nurses perceived debriefing to be a useful part of maintaining a healthy WE – A consistent and objective system of staff allocation to manage workload and patient acuity should be implemented, matching resources with workloads	50
5. Kilcoyne and Dowling, 2007, Ireland	To identify themes from nurses narratives around ED crowding	ED nurses – Purposive sample n = 11 – Wide range of time in ED, 2–20 years – Single site	– §§Qualitative study using unstructured interviews from which data were extracted using an interpretive phenomenological approach – Colaizzis 7 procedural steps for data analysis was used	– Study participants were asked to confirm interpreted findings together with a peer validation process. Interviewer journaled their experiences to limit bias	– The primary themes that emerged around WE were lack of space, powerlessness including not feeling valued, feeling stressed, lack of respect and dignity and poor service delivery	– Enables a free flow of lived experiences to be recorded – enriching the published record around areas of stress	– Data maybe biassed by volunteer self‐selection – Small sample from one site limits generalisability of findings – Non‐probabilistic and intentional sampling based on participant availability	– Managers must work to listen to and act on stressors experienced by nurses in ED to improve patient care and nurses perceptions of WE	100
6. Stathopoulou, Karanikola, Panagiotopoulou and Papathanassoglou, 2011, Greece	To document anxiety and stress levels in ED nurses	ED nurses and assistant nurses –n = 213 – Eight adult general hospital sites	– §§Quantitative descriptive design using cross‐sectional correlational from a self‐reported, validated quantitative questionnaire – Hamilton anxiety scale, Maslach burnout inventory and demographics + demographics – Statistical analysis using multiple regression and correlations	– Validated scales providing quantitative parametric data – Power analysis response rate 80%	– ~75% of ED nurses tested showed a mild (affective) degree of anxiety that was higher in women than men and weakly positively correlated with duration of WE in ED – Anxiety was marginally greater in public sector hospitals	– Multisite – First such study in Greek EDs	– ‡‡, ††Participants had widely varying levels of clinical education (2 year vocational training – 4 year tertiary training) – No assessment of ‘baseline’ anxiety or personal history	– Counselling to support development and implementation of relaxation techniques, coping and problem‐solving strategies – Need for management and supervisory support	100
7. Gholamzadeh, Sharif and Rad, 2011, Iran	To establish the sources of job stress and the adopted coping strategies of nurses working in the ED	ED nurse volunteers – n = 90 – From three large teaching hospitals	– §§Quantitative descriptive cross‐sectional study using a self‐reported questionnaire to identify the sources of job stress and nurse's profile, and Lazarus standard questionnaires to determine the types of coping strategies – Simple descriptive statistics applied (mean ± SEM)	– Total possible population not reported – Survey well validated in previous studies – Cronbach's alpha 0.88 calculated	– Frequent high levels of stress noted with major stressors related to physical environment and lack of equipment, work load, managing patients and family, exposure to H&S hazards, lack of admin support and lack of physician attendance – Gender difference in coping strategy: women tending to use emotion‐focussed strategies (self‐controlling and positive reappraisal) and men used a more problem‐focussed approach – Most nurses (~75%) indicated satisfaction with their job	– Study focused on problems and potential solutions/ areas for intervention – Multisite in a geographical region where there is relatively little published literature	– ‡‡Heavy skewed population, 87% women aged between 23 and 50 – More than half (57%) had less than 5 years ED experience – Participants volunteered, no randomisation so potential population bias – χ2 values not reported	– Limited recommendations – Nurses tended to use a conscious effort to reduce stress centred around attempting to regulate emotional responses to stress (rather than address the stressor)	0‐25
8. Adriaenssens, De Gucht, Van Der Doef and Maes, 2011, Belgium	To establish if job and organisational factors reported by ED nurses differ from those of general hospital nurses and to describe to what extent these characteristics can predict job satisfaction, turnover intention, work engagement, fatigue and distress	ED nurses – n = 254/308 – Cross‐sectional study – carried out in 15 EDs of Belgian general hospitals in 2007–2008	– §§Comparative (non‐RCT) descriptive cross‐sectional correlational and comparative design using self‐reported validated quantitative questionnaires including the Leiden Quality of Work Questionnaire for Nurses, the Checklist Individual Strength, the Utrecht Work Engagement Scale and the Brief Symptom Inventory – each with a 4‐point Likert scale response – Descriptive statistics (chi squared) and hierarchical regression analyses for each measure, via SPSSx	– 82% response rate – Comparison against n = 669 general nurses from a previous study Gelsema, van der Doef, Maes and Akerboom, 2005 – Senior nurses and managers excluded – 0.93 >Cronbach's alpha >0.57 on all scales	– ED nurses reported more time pressure and physical demands, less decision authority and adequate work procedures, and fewer rewards than a general hospital nursing population – ED nurses also recorded more opportunity for skill discretion and better social support by colleagues – Work‐time was rated as an important contributor to fatigue in ED nurses – Apart from personal characteristics, decision authority, skill discretion, adequate work procedures, perceived reward and social support by supervisors proved to be strong determinants of job satisfaction, work engagement and lower turnover intention in emergency nurses	– Multiple sites and broad study population – Comparison with general nursing population enhanced understanding of the study findings (i.e. ED nurses are demographically different to general hospital nurses – with more experience, males, qualifications, shift work and number of shifts worked per week	– ‡‡, ††No follow‐up processes for non‐respondents	– Further investigation of job and workplace characteristics is required to curtail ED nurses stress‐health problems – Increasing skills, autonomy, effective working procedures and quality supervisors will positively impact on ED nurses	75
9. Wu, Sun and Wang, 2012, China	To describe factors linked to occupational stress in ED nurses	ED nurses – n = 510 – 16 hospital EDs – In Liaoning province	– §§Quantitative descriptive cross‐sectional correlational design from a self‐reported validated quantitative questionnaire – Chinese version of the Personal strain questionnaire + demographics + information about occupational roles (overload, insufficiency, ambiguity, boundaries, responsibilities) + personal resources (recreation, self‐care, social support and rational coping) – One‐way ANOVA Pearson correlation, general linear regression modelling	– Validated scales providing quantitative ordinal (parametric see ‡) data on scale of 1–5 – Data tested for normality – Response rate 78%	– Female ED nurses report greater work stress than reported in other occupational groups – Personal strain or ‘stress’ was correlated with role overload, role boundaries, role insufficiencies, lack of social support, chronic disease and inadequate self‐care	– Included EDs with varying patient loads – Comparison with equivalent data from a broader population	– ‡‡, ††Only 0.4% of potential population was men – EDs were all located in urban regions – No follow up of non‐respondents to the survey	– Improve work conditions, health education and occupational training to reduce stress in female ED nurses	100
10. Chiang and Chang, 2012, Taiwan	To compare the levels of stress, depression, and intention to leave amongst clinical nurses employed in different medical units in relation to their demographic characteristics	ED nurses – 29/314 – Recruited from regional hospitals in the Northern area Taiwan – Nurses >99% women	– §§Quantitative descriptive cross‐sectional correlational design from a self‐reported quantitative questionnaire, including the context‐specific adaptation of the Centre for Epidemiological Studies Depression Scale (CES‐D), the Perceived Stress Scale, Intention to Leave Scale and general demographic information including hospital area of work – Descriptive statistics, and Spearman's correlations for all study variables to identify possible factors for multiple regression modelling, ANOVA to identify clinical area differences	– Used validated scales	– Significant variations in reported stress levels in nurses, with ER nurses rating fairly low in the categories of nurses who were stressed, depressed and intending to leave – Demographic characteristics (i.e. tenure, marital status, education, and age) were not mainly influential factors in the level of stress, depression, and intention to leave amongst nurses in various medical unit and thus other factors need to be considered	– Good comparison of ER nurses compared with other speciality nurses and general nurses within the same hospital environments – Inexperienced nurses and nurses who were married were more likely to intend to leave and more likely to show signs of depression – Samples drawn from multiple sites	– ‡‡, ††Almost no male nurses – Relatively few (~9%) ER nurses – Limited information provided about recruitment strategies and response rates – Number of discrete data collection sites is unclear – Sample sizes from different clinical units varied; therefore, results need to be considered with caution and may lack generalisability – Limited follow up of non‐respondents to the survey	– ER is a relatively well supported WE for north Taiwanese district nurses compared with other clinical areas – Requirement broadly for policymakers and nursing managers to more clearly direct policies that correctly reflect effective nursing human resource management	50
11. Adriaenssens, De Gucht and Maes, 2013, Belgium	To repeat a previous study: to establish if job and organisational factors reported by ED nurses differ across time (18 months) and to describe to what extent these characteristics continue to predict job satisfaction, turnover intention, work engagement, fatigue and distress in ED nurses.	ED nurses – n = 170/204 nurses still working from previous study, 2007–2008; where n = 254 was carried out in 15 EDs of Belgian general hospitals in 2009	– §§Comparative (non‐RCT) descriptive cross‐sectional correlational and comparative design using self‐reported validated quantitative questionnaires including the Leiden Quality of Work Questionnaire for Nurses, the Checklist Individual Strength, the Utrecht Work Engagement Scale and the Brief Symptom Inventory – each with a 4‐point Likert scale response – Descriptive statistics (chi squared) and hierarchical regression analyses using difference scores (T1 versus T2) for each measure, via SPSSx	– 83% response rate – Comparison against n = 254 ED nurses from a previous study Adriaenssens et al., 2011 – Senior nurses and managers excluded – 0.95 > Cronbach's alpha >0.56 on all scales	– One‐fifth of nurses (~20%) had left ED nursing positions over the 18‐month study period with large variance between sites (5–36%) – Gender differences included that female nurses reported higher job satisfaction, higher work engagement and lower emotional exhaustion – Reported job demands remained high but stable over time, while social support and intention to leave varied widely, as did control, predicted job satisfaction, work engagement and emotional exhaustion, reward, social harassment and work agreements. This suggests a rapid and significant flux in nurse perception of working conditions can occur	– High repeated response rate – Large sample size for comparison	– ‡‡No consideration of ED or hospital size or setting – High turnover may bias results, recording exclusively from ‘survivors’ – staff who remained	– Staff turnover rates can be very high and cause a significant loss of staff capital – Rapid (~18 months) changes in nurse reported work‐related factors influencing stress provides managers many opportunities to positively impact on WE and staff satisfaction – Frequent assessment of WE in ED is important, as it can change rapidly and impact staff retention	75
12. Kogien and Cedaro, 2014, Brazil	To determine factors that may increase nurse‐related work stress and decrease quality of life for ED nurses	ED nurses – n = 189 – Wide range of ages, experience and average workloads	– §§Quantitative descriptive cross‐sectional study using a correlational design from a1 self‐reported validated quantitative surveys including the Job stress scale, the WHOQOL‐brief and the job content questionnaire – Analysed using SPSSx and MS Excel – Pearson's χ2 test (or Fisher's exact test, when necessary) for the categorical variables, and Student's t test was used for the continuous variables, then, multivariate analysis using logistic regression was performed and the odds ratios (OR) were obtained and adjusted for socio‐demographic variables	– An estimated 50% proportion of staff totals drawn from a large ED (Rondonia) – Helps to support an international conceptualisation of the work stressors in EDs	– Low intellectual engagement, poor social support and high occupational demands or a passive work expectation were the main risk factors for concern in the physical domain of quality of life, altering rest/sleep quality – Psychological demands of ED environment are high – with staff exposed to pain, distress, helplessness, anxiety, fear, hopelessness, feelings of abandonment and loss – Working conditions can be poor because of overcrowding, scarcity of resources, work overload and the fast pace of the work required of the professionals providing care	– Little research undertaken in South America and published in English – Strong and comprehensive statistical analysis of quantitative and qualitative data	– ‡‡Non‐probabilistic and intentional – Biased population (76% women; 81% nursing technicians) – Sampling based on participant availability – No follow up of non‐participation – No information provided about response rate	– Increase social support for staff in EDs to reduce the negative consequences of stress on staff, promote wellness, provide a predisposition to good health and improve indicators of quality of life	50

^† Note: all survey completion was deidentified and voluntary, with appropriate accompanying ethical approval unless noted otherwise.

^‡ Data type (quantitative/qualitative) is identified in the study and/or on the basis of the analysis performed.

^§ Note: all survey and interview data are subject to potential prevarication bias and even response falsification. Additionally, the selections required in surveys are often ‘relative’ and so can be challenging ascertain consistently and reliably (‘soft’ responses). Additionally, there may be a response bias based on the psychological well‐being of participants (single point in time survey).

^¶ There were additional study findings not related to the focus of this review not reported here.

^†† Convenience (cross‐sectional) sampling and thus no causal inferences can be drawn.

^‡‡ No provision for open‐ended responses so participants' responses are constrained by study.

^§§ MMAT classification system.

EM, Emergency Medicine; ER, Emergency room; MMAT, mixed methods appraisal tool; NWI‐R, revised nurse work index; PTSD, posttraumatic stress disorder; RA, research assistant; RN, registered nurse; RPPE, Revised Professional Practice Environment; SAS, statistical analysis systems; SD, standard deviation; SEM, standard error of the mean; SPSSx, statistics package for the social sciences; USA, United States; WE, work environment; WHOQOL, World Health Organization Quality of Life.