Table 3.

Research evidence around ED doctors' 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. Heyworth, Whitley, Allison and Revicki, 1993, UK	To describe occupational stress, depression, task and role clarity, work group functioning and overall satisfaction in senior ED medical staff	n = 201 respondents – n = 154 consultants (71%) and n = 47 senior registrars (77%) drawn from a register of all ED consultants and registrars	– §§Quantitative descriptive cross‐sectional correlational design from a self‐reported validated questionnaire, including the work‐related stress, depressive symptomatology and respondent evaluations of three aspects of the WE: task and role clarity, work group functioning, and overall satisfaction with work – General demographic information including hospital/ED size and average capacity, years of service and shift patterns – Descriptive statistics, and Pearson's correlations to relate factors – ANOVA to compare respondent subgroups	– 72% overall response rate, response rate from consultants 71% and 77% from senior registrars – Survey tools previously validated in other groups of medical staff – No ethics approval listed	– Overall levels of occupational stress and depression were low WEs were evaluated favourably – Levels of occupational stress were proportional to ED size, but not on‐call work, patient or staffing and was similar to those reported by other groups of health care providers – Respondents generally considered tasks and roles to be clearly defined, work groups to be supportive, efficient units and work satisfying – Senior staff with >10 years ED experience and consultants over 45 years old reported more satisfaction with work and work group functioning, and perceived their tasks and roles to be significantly clearer	– Captured a large proportion of this clinical group and thus multi‐site information – Quantitative analysis of a number of key variables cited in literature	– ††, ‡‡Highly skewed population – with a high proportion of married (86%), men (88%) respondents – Limited analysis (no factor analysis/regression attempted) – Limited follow up of non‐respondents to the survey	– Staff stress‐management probably reflects the personality of physicians – Continue to identify character traits of successful ED practitioners to provide a proven personality profile for junior doctors considering a career in ED – Provide and encourage use of counselling	75
2. Williams, Dale, Glucksman and Wellesley, 1997, UK	To investigate the relationship between accident and emergency senior house officers' psychological distress and confidence in performing clinical tasks and to describe work‐related stressors	n = 171 newly appointed ED SHOs from 27 hospitals	– §§Quantitative descriptive cross‐sectional design using two self‐reported and open‐ended qualitative questionnaires that included, demographic questions, modified mental health – Inventory, four from the 28 item general health questionnaire, 2× case report descriptors of recent ‘stressful’ scenarios and a list of recent personal stressors	– No ethics approval listed – Questionnaire piloted in a similar group of users prior to distribution response rates to the questionnaires were 82% (140/171) at the start, 77% (132/171) at the end of the first month, 64% (110/171) at the end of the fourth month, and 67% (115/171) at the end of the sixth month – Questionnaire component response reported varied – n = 97 to 116 (57–68%)	– Participants with lower confidence at the end of the first and fourth months showed significantly higher distress scores than those with higher confidence levels – Work stressors centred around three areas; the type of problem presented by the patient, communication difficulties and department organisational issues – Key stressors identified included intensity of workload, coping with diagnostic uncertainty, working alone, working unsocial hours and experiencing fatigue	– Repeated surveying explored changes in work stressors across time – Use of 100 mm visual analogue scales for participants to score responses (0 = not at all confident, 100 = very confident)	– ††Researchers cite that the distress questionnaire and confidence rating scale had not been tested for reliability and validity, and there was no control for the potential problem of reactivity in terms of biassed response sets – Relatively small population to sample	– Training in communication skills may be beneficial and provide the opportunity for case review – Need for further focused research on each identified domain of concern (communication, patient problem and department organisation)	75
3. McPherson, Hale, Richardson and Obholzer, 2003, UK	To identify levels of psychological distress in accident and emergency (ED) senior house officers so as to plan interventions that will help ED staff cope better in an intrinsically challenging environment	n = 37/64 SHOs from six EDs at district general hospitals in north London	– §§Quantitative descriptive cross‐sectional design using two self‐reported, extensively validated questionnaires that included, demographic questions – General Health Questionnaire (GHQ; 28 items each with four response options, subdivided into anxiety, depression, health and social functioning and Brief COPE has 28 items with four response options covering nine scales: substance misuse, religion, humour, behavioural disengagement, use of support, active coping/planning, venting/self‐distraction, denial/self‐blame and acceptance – Correlational analyses using Pearson's r	– 58% response rate	– 51% respondents scored over the threshold for psychological distress, higher than for other groups of doctors and for other professional groups – The coping style ‘Venting’ was significantly related to greater anxiety (r = 0.34; P < 0.05) and depression (r = 0.33; P < 0.05), while the coping style ‘Active’ was significantly related to lower anxiety (r = −0.38; P < 0.05), somatic complaints (r = −0.46; P < 0.001) and years since qualification (r = 0.40; P < 0.05)	– 100% completion rate for this select group of staff drawn from six district general hospitals	– ††, ‡‡Non‐probabilistic and intentional sampling based on participant availability	– An intervention to improve coping strategies may be useful for this group of doctors – Attention to aspects of psychological working conditions in ED may be essential to meet staff recruitment and retention targets – Requirement for managers and consultants to generate a culture that supports training and development of evidence‐based coping skills	50
4. Burbeck, Coomber, Robinson and Todd, 2002, UK	To assess occupational stress levels in ED consultants	UK practicing ED consultants complete lists provided by British Association of Emergency Medicine (BAEM) and the Faculty of Accident and Emergency Medicine (FAEM) – n = 371/479 responses – 350/479 survey completion	– Mixed methods including §§quantitative descriptive cross‐sectional correlational design from a self‐reported validated questionnaire – Demographic and work‐related information and included the general health questionnaire‐12 (GHQ‐12) to assess psychological distress, 15 and the symptom checklist‐depression scale (SCL‐D) to measure depression – Non‐parametric statistics for GHQ‐12 and SCL‐D scores. Qualitative data, including aspects of the job respondents enjoyed, analysed using the constant comparative method to develop coding frames – Logistic regression was used to build a predictive model of GHQ‐12‐ and SCL‐D – Demographic and stressor variables were correlated individually with both GHQ‐12 and SCL‐D scores. The six most highly correlated stressors were entered as independent variables in multivariate logistic regressions with GHQ‐12 and SCL‐D scores as dependent variables	– Validated scales providing scaled data (non‐parametric‡) – Response rate = 78% – Completion rate 73%	– High levels of psychological distress amongst doctors working in ED compared with other groups of doctors – Respondents were highly satisfied with ED as a specialty – The number of hours reportedly worked during previous week significantly correlated with stress outcome measures – Factors including ‘being overstretched’, ‘effect of hours’, ‘stress on family life’, ‘lack of recognition’, ‘low prestige of specialty’ and ‘dealing with management’ were all shown to be important	– Large pool of specialist clinicians – Commonly used tools and thus comparison with other doctors was possible – Free text options enabled key themes to be identified – Open‐ended text questions and stressful scenario description for qualitative comment – Also explored the effects of ‘protective’ factors identified in other studies (minimal input)	– ††, ‡‡Sample all drawn from one professional society – Limited follow up of non‐respondents to the survey	– Assessment of characteristics, or combination of characteristics, within ED that are particularly problematic – Requirement for NHS provision of employment environments, in which doctors can practice effectively without compromising health	100
5. Taylor, Pallant, Crook and Cameron, 2004, Australasia	To evaluate psychological health of ED physicians and identify factors that impact on their health	– n = 323 – ACEM fellows	– §§Quantitative descriptive cross‐sectional correlational design from a self‐reported validated questionnaire – Perceived stress scale, Zung depression scale, Zung anxiety scale, Revised life orientation test, Mastery scale, Physical symptoms checklist, Perceived control of internal states scale, Satisfaction with life scale + demographics – Pearson's correlations, ANOVA and t‐tests	– Validated scales providing quantitative ordinal (parametric‡) data on scale of 1–4 to 1–10 – Response rate 64%	– Significant positive correlation between work and life satisfaction and perception of control over hours worked and professional activity mix – Significant negative correlation between work and life satisfaction and work stress – Maladaptive strategies (alcohol/drugs/disengagement) positively associated with anxiety, depression and stress – Very weak relationship between work stress/satisfaction and demographic, workplace factors or hours worked aside from gender	– Comparison to community population data – Conservative statistical significance set at 0.01 – Good follow up of non‐responders to limit possible bias by responder characteristics	– ††, ‡‡Skewed FACEM population limiting validity of comparison with community data – Response rate may have introduced a selection bias	– FACEMs had as good or better psychological health than the comparison population with moderate work stress and work satisfaction scores – Important to provide some level of working autonomy/flexibility around hours worked and activity mix – Stress identification and management (coping) should be included in ACEM training and workforce subjected to regular review	100
6. Wrenn, Lorenzen, Jones, Zhou and Aronsky, 2010, USA	To identify factors other than work hours in the ED WE contributing to resident stress	n = 18 postgraduate year (PGY)‐2 and PGY‐3 EM residents – Twelve surveys and questionaires were collected from each participant, four each from the day, evening and night shifts – Single site	– Prospective cohort evaluation of stress levels – Self‐reported quantitative survey consisted of a modified version of the previously validated Perceived Stress Questionnaire normalised to a possible range of 0 to 100 and, because of the modifications, a rating of self‐perceived stress where subjects placed a mark on a 100‐mm visual analogue scale labelled ‘none’ at one end and ‘extreme’ at the other was also included – Data collected also included the shift number of a given consecutive sequence of shifts, number of procedures performed, number of adverse events, average age of the patients seen by the resident, triage nurse–assigned acuities of the patients seen by the resident during the shift, the number of patients seen during a shift, the number of patients admitted by the resident during the shift, anticipated overtime after a shift and shift‐specific metrics related to overcrowding, including average waiting room time both for the individual residents and for all patients, average waiting room count for all patients and average occupancy of the ED for all patients – Descriptive statistics and univariate analysis of data	– The RA had no other connection to the ED, administered the survey and was the only one who knew the tracking number – RA was not involved in any sort of evaluation of residents – All investigators except the RA were blinded to the particular resident data – All 18 residents completed 100% of the surveys for a total of 216 shifts (100% response)	– Only anticipated overtime and process failures were correlated with stress – Factors related to ED overcrowding had no significant effect on reported resident stress – EM resident shift‐specific stress was associated primarily with the perception of excessive time required to finalise or hand over patient care after the shift and with adverse events – Night shifts correlated inversely with stress – Environmental factors that reflect ED overcrowding such as high average occupancy, long LOS, long WR times and high WR counts did not seem to impact resident stress to any great degree in multivariate analysis – When overcrowding is a chronic problem, it is possible that crowding has less impact on stress because it is the norm	– Explicit control for many workload factors – Multiple controls for bias – The survey took less than 5 min to complete	– ‡‡Non‐probabilistic and intentional sampling based on participant availability – Timing of administration of the surveys at the end of a shift may have led some variables, such as anticipated overtime, to influence the results more than they would have if the instrument had been administered mid‐shift – An end‐of‐shift survey may also underestimate the immediate impact of stressors occurring during a shift – The findings from this small cohort of participants at a single institution providing care for a high‐acuity patient population may not generalise to other settings – Environmental stressors will vary across EDs	– It is unlikely that solving the ED overcrowding issue will necessarily translate into less stress for the residents – In fact ‘solving’ overcrowding might increase resident stress as throughput pressure increases – Need for further research to establish generalisability of findings	100
7. Estryn‐Behar, Doppia, Guetarni et al., 2011, France	To examine ED physicians' perceptions of working conditions, satisfaction and health – Based around the Nurses Early eXit sTudy (NEXT project)	Physicians – 3196 of the 4799 physicians who visited the website completed the survey; 538/3196 were ED physicians – Control sample chosen at random from database of French physicians	– §§Quantitative online questionnaire including descriptive cross‐sectional correlational design from a self‐reported validated 260 questions exploring occupational/demographic content, private life, social WE, work organisation, work demands, individual resources and future occupational plans drawn from various previously validated surveys – Descriptive and multivariate analyses	– Reported overall response rate: 66%	– ¶Intention to leave was highest amongst ED physicians, particularly female physicians – Fewer meal breaks taken, fewer opportunities to teach and less frequently part of administrative hierarchy, but attended more ongoing education and worked more hours and more nights than other speciality physicians	– Well‐matched large sample – Captured a large volume of information enabling some contextualisation of responses and good factor analysis	– ††, ‡‡Difficult to segregate the number of ED physicians included in the final analysis – Significant questionnaire burden may reduce response rate and response accuracy – No follow up of non‐respondents to the survey	– Many factors around ED physician retention focused around WE – These included the need to improve multidisciplinary teamwork, work processes, team training and clinical area design	75
8. Xiao, Wang, Chen et al., 2014, China	To measure psychological distress and job satisfaction amongst Chinese emergency physicians	n = 205 ED physicians from three general hospitals	– §§Quantitative descriptive cross‐sectional design using three self‐reported surveys including the Hospital Anxiety and Depression Scale (HADS), Maslach Burnout Inventory‐General Survey and Minnesota Satisfaction Questionnaire – Descriptive statistics and Pearson correlation was used to explore data relationships	– All the physicians from the EDs of three large general hospitals across a month were invited to participate – Response rate = 82%	– Psychological distress is prevalent in Chinese EM physicians and they are at risk of having their mental health undermined gradually – Job satisfaction is moderate – ED physicians experienced higher levels of anxiety and depression as measured by the HADS, compared with the general population – Worsening psychological distress might partly be related to the worsening physician/patient relationship and the mistrust for doctors	– Used well validated instruments to capture a good sample of senior ED doctors, providing a unique view of responsibilities in Chinese EDs	– ‡‡, ††Non‐probabilistic and intentional sampling based on participant availability – Participants in the present study may fairly represent the ED physicians in city hospitals but might not be representative of those working in township health centres or private clinics	– National healthcare administrators need to legislate regulations to forbid attacking healthcare staff, guarantee physicians resting time and increase their income – Need for further research across clinical levels and geographical regions	75

^† 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), 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.

^†† Cross‐sectional, study and thus no causal inferences can be drawn.

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

^§§ MMAT classification system

ACEM, Australian College of Emergency Medicine; EM, Emergency Medicine; FACEMs, fellows of the Australasian college of emergency medicine; MD, medical doctor; MMAT, mixed methods appraisal tool; PGY, post graduate year; 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; SSEM, Spanish Society of Emergency Medicine; SHOs, senior house officers; USA, United States; WE, work environment.