Background:
This study’s main purpose is to evaluate the stress level among emergency nurses systematically.
Methods:
Adhering to the preferred reporting items for systematic reviews and meta-analyses guidelines, nine databases, including PubMed, Cochrane, web of science, Scopus, ScienceDirect, Embase, China National Knowledge Infrastructure, Wanfang, and China biomedical literature service system, were searched to collect cross-sectional studies on emergency nurses. Two researchers independently screened the literature, extracted the data, and evaluated the risk of bias in the included studies.
Results:
From 2655 studies, 21 cross-sectional studies were included, including 4293 subjects. Meta-analysis showed that the incidence of low-level stress was 0.21% (95% CI [0.18–0.24]), the incidence of middle-level stress was 0.46% (95% CI [0.33–0.58]), and the incidence of high-level stress was 0.32% (95% CI [0.22–0.41]), which is mainly at the medium level.
Conclusion:
This review identified the stress level of emergency nurses mainly at the medium level. This result makes nursing administrators pay more attention to the mental health problems of emergency nurses and actively take measures to promote the physical and mental health of emergency nurses and further promote the development of the nursing profession.
Keywords: emergency nurses, meta-analysis, pressure, stress, stressor
1. Introduction
Stress is mainly a psychological change subjectively or objectively under certain occupational conditions, primarily manifested as negative emotions and psychological imbalance, to produce corresponding functional changes in the body or mind.[1] Excessive occupational stress can cause coronary heart disease, cancers, and depression, affecting nurses’ longevity and quality of life.[2–5]
The emergency department is characterized by a concentration of severe patients, multiple diseases, and heavy rescue tasks. Therefore, emergency nurses often work in a high state of tension under great psychological stress.[6] If left unchecked, nurses’ deterioration of health status will affect the overall quality of patient care.[7]
However, the prevalence of stress among emergency nurses has shown international variation due to inconsistencies in collection tools and cultural differences. A study at Rutgers used the Expanded Nurse Work Stress Scale showed that 73% of emergency nurses have low-level stress.[8] A study conducted in Iran used The Hospital Stress Scale showed that 80.3% of emergency nurses have moderate-level pressure.[9] Literature conducted in China used the Chinese Perceived Stress Scales showed that 51.73% of emergency nurses have high-level stress.[10]
Most studies focused on nurse stress in the emergency department in one country, with no data from across cultures or countries. Therefore, it is necessary to identify emergency nurses’ stress in different countries. No pooled data is available to assess the stress level of emergency nurses. Hence, this meta-analysis was conducted. The results of this study can help nursing managers understand the stress levels of emergency nurses in different countries and take measures to minimize stress.
2. Materials and methods
2.1. Eligibility criteria
To collect data on emergency nurse stress, quantitative cross-sectional studies were included which met the following criteria: Published in the English or Chinese language; Analyzed the incidence of stress among emergency nurses with sufficient statistical information; Based on a sample of emergency nurses or on a mixed sample in which the results for emergency nurses are provided separately; Utilized standardized validated instruments for assessing the incidence; and Peer-reviewed studies were available in full text.
2.2. Exclusion criteria
Studies were excluded if they: Published in other than English or Chinese and could not be translated by any of the two researchers; Non-cross-sectional studies; Insufficient data were provided to calculate the overall prevalence of stress; The lack of access to the full text prevented a full review; and Published repeatedly by the same author or by the same research group.
2.3. Literature retrieval strategy
To ensure the comprehensiveness of the literature, nine databases, including PubMed, Cochrane, Web of Science, Scopus, ScienceDirect, EMBASE, CNKI, Wanfang, and China biomedical literature service system, were searched to collect cross-sectional studies on emergency nurses’ stress. The retrieval time was from the establishment of the database to February 2022. The retrieval methods are based on the combination of subject and free words and are adjusted according to the specific database. English keywords included emergency room nurse, emergency nurse, emergency nursing, stress, strain, and pressure. The foreign language retrieval strategy was (“emergency room nurse OR emergency nurse OR emergency nursing”) AND (stress OR strain OR pressure). Taking PubMed as an example, the specific search strategy is shown in Figure 1.
Figure 1.
Search strategy.
2.4. Literature screening and data extraction
Two researchers (JJR and ZYX) independently screened literature, extracted data, and cross-checked. In case of disagreement, it was settled through discussion or negotiation with the third party (HWN). When selecting the articles, the researchers first read the title. After excluding the unrelated articles, they read the abstract and full text to determine whether they should be included. Data extraction included: Basic information about the included studies: first author, year of publication, total sample size, survey period and stress rate, etc. Outcome indicators: incidence of stress levels among emergency nurses. The related elements of bias risk assessment.
2.5. Bias risk assessment of included studies
Two reviewers (JJR and ZYX) in the form of mutual blindness independently evaluated the included literature using the AHRQ tool (Agency for Healthcare Research and Quality,[11] which consists of 11 items. If the answer was “no” or “unclear,” the item score was “0”; If the answer was “yes,” the item score was “1.” A score of 8 to 11 was considered high quality, 4 to 7 moderate quality, and below 4 poor quality. After the independent evaluation, two researchers discussed and reached a consensus. If there was any disagreement, the third researcher arbitrated, or the research group discussed.
2.6. Statistical analysis
Endnote X9 was used to summarize the literature. Excel software was used for data extraction management, statistics, and descriptive analysis of outcome indicators. RevMan 5.4 software was used for all statistical analyses. The I2 value low (25%), moderate (50%), or high (75%) heterogeneity. The analysis results in this study were highly heterogeneous, so it was appropriate to consider the random effect model. The definitions of low, medium and high-stress levels were based on the stress assessment tools used in the articles. For example, the stress grading criteria of the Nurse Stressor Scale (LX) were 35 to 70 for low-level stress, 71 to 105 for moderate-level stress, and 106 to 140 for high-level stress[12]; each item of Expanded nursing work stress scale (ENSS) had a score of 0 to 1 indicating low-level stress, a score of 1 to 3 indicating moderate-level stress, and a score of 3 to 4 indicating high-level stress.[13]
2.7. Ethical consideration
Ethical approval was not required based on the use of already published secondary data and the meta-analysis nature.
3. Results
3.1. Summary of article selection and data extraction
A total of 21 studies[8–10,12,14–30] met the inclusion criteria, as shown in Figure 2. The 21 articles used cross-sectional studies, and all quantitative studies used validated scales for data collection. The included literature was published from 2004 to 2021. The sample size of the study subjects was 709 at most and 44 at least, and the findings of these studies are based on a total of 4293 participants. The primary characteristics of the included studies are shown in Table 1.
Figure 2.
Literature screening process and result.
Table 1.
Basic characteristics of included studies.
| Reference | Study design | Date collection | Country | Instruments | Subjects | Stress level (incidence rate) | ||
|---|---|---|---|---|---|---|---|---|
| Low | Medium | High | ||||||
| Cai H (2019) | Cross-sectional | January 2019 | China | Occupational stress source. | 58 | 18.9% | 62% | 15.5% |
| Questionnaire (Li Xiaomei) | ||||||||
| Tan CQ (2015) | Cross-sectional | October to December 2014 | China | Stress questionnaire | 59 | 8.47% | 37.28% | 54.23% |
| Self-designed | ||||||||
| Liang TY (2015) | Cross-sectional | Not reported | China | Emergency nurses stress questionnaire | 514 | 6.8% | 39.5% | 45.9% |
| Self-designed | ||||||||
| Su TT (2016) | Cross-sectional | March to May 2016 | China | Occupational stress source | 127 | Medium-high: 61.42% | ||
| Questionnaire (Li Xiaomei) | ||||||||
| Jin J (2019) | Cross-sectional | Not reported | China | Stress questionnaire self-designed | 44 | 43.18% | 22.7% | 27.27% |
| Yan HM (2015) | Cross-sectional | Not reported | China | Stressors questionnaire self-designed | 137 | 38.69% | 29.23% | 20.44% |
| Liu Y (2016) | Cross-sectional | October 2013 to December 2015 | China | Stress Questionnaire self-designed | 98 | 31.63% | 48.98% | 12.24% |
| Ma LJ (2012) | Cross-sectional | Not reported | China | Occupational stress source | 136 | 36.03% | 47.79% | 16.17% |
| Questionnaire (Li Xiaomei) | ||||||||
| Yang Q (2008) | Cross-sectional | Not reported | China | Occupational stress source | 120 | 36.7% | ||
| Questionnaire (Li Xiaomei) | ||||||||
| Wang JL (2008) | Cross-sectional | January, 2007 | China | Occupational stress source | 116 | 15.52% | ||
| Questionnaire (Li Xiaomei) | ||||||||
| He LY (2004) | Cross-sectional | Not reported | China | Stress questionnaire self-designed | 134 | 35% | ||
| Zhang XY (2006) | Cross-sectional | July,2005 | China | Stress questionnaire self-designed | 68 | 3.4% | 6.5% | 46.5% |
| Cao XX (2007) | Cross-sectional | December 2006 to February 2007 | China | Stress questionnaire self-designed | 124 | 16.1% | 71% | 13% |
| Yang J (2015) | Cross-sectional | November to December 2014 | China | Occupational stress source | 140 | 31% | 69% | |
| Questionnaire (Li Xiaomei) | ||||||||
| Zhang YR (2021) | Cross-sectional | January 2018 to June 2019 | China | Chinese nurses work | 262 | 15.27% | 48.85% | 35.88% |
| Stressors Scale (Wang Shu) | ||||||||
| Xu YJ (2020) | Cross-sectional | March to April 2019 | China | Occupational stress source | 453 | 3.31% | 52.1% | 44.59% |
| Questionnaire (Li Xiaomei) | ||||||||
| Johansen ML (2016) | Cross-sectional study | 2009 to 2010 | USA | Expanded nursing work stress scale (ENSS) | 222 | 73% | ||
| Tavakoli N (2018) | Cross-sectional study | 2017 | Tehran, Iran | The hospital stress scale (HSS-35) | 709 | 10.5% | 80.3% | 9.2% |
| Singh GP (2013) | Cross-sectional study | Not reported | India | Self-estimation scale | 52 | 12.8% | 65.11% | 20.93% |
| Perceived stress scale | 68.2% | 19% | ||||||
| Hendy A (2020) | Cross-sectional investigation | Not reported | Egypt | Nursing Stress Scale (NSS) | 374 | 13.4% | 52.1% | 26.2% |
| Chao Wu (2020) | Cross-sectional | Between March and May 2019 | China | Chinese Perceived Stress Scales | 346 | 3.47% | 44.8% | 51.73% |
3.2. Basic risk assessment results of included studies
The bias risk assessment results of the included studies are shown in Table 2. Among the 21 articles, the quality assessment grade of 4 literature was high, and that of 17 was medium.
Table 2.
Bias risk assessment results of included studies.
| ① | ② | ③ | ④ | ⑤ | ⑥ | ⑦ | ⑧ | ⑨ | ⑩ | ⑪ | Score | level | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Cai H (2019) | Y | Y | Y | Y | Y | N | N | Y | N | Y | N | 7 | Medium |
| Tan CQ (2015) | Y | N | Y | Y | Y | N | N | Y | N | Y | UN | 6 | Medium |
| Liang TY (2015) | Y | Y | N | N | Y | N | Y | Y | Y | Y | N | 7 | Medium |
| Su TT (2016) | Y | Y | N | Y | Y | N | Y | Y | N | Y | UN | 7 | Medium |
| Jin J (2019) | Y | N | N | Y | Y | N | N | Y | N | Y | N | 5 | Medium |
| Yan HM (2015) | Y | N | N | Y | Y | N | N | Y | N | Y | N | 5 | Medium |
| Liu Y (2016) | Y | N | Y | Y | Y | N | N | Y | N | Y | N | 6 | Medium |
| Ma LJ (2012) | Y | N | N | Y | Y | N | N | Y | UN | Y | UN | 5 | Medium |
| Yang Q (2008) | Y | N | N | N | Y | N | N | Y | Y | Y | N | 5 | Medium |
| Wang JL (2008) | Y | N | Y | Y | Y | N | N | Y | N | Y | UN | 6 | Medium |
| He LY (2004) | Y | N | N | N | Y | N | N | Y | Y | Y | N | 5 | Medium |
| Zhang XY (2006) | Y | N | Y | Y | Y | N | N | Y | Y | Y | N | 7 | Medium |
| Cao XX (2007) | Y | N | Y | N | Y | N | N | Y | Y | Y | N | 6 | Medium |
| Yang J (2015) | Y | Y | Y | Y | Y | N | Y | Y | N | Y | UN | 8 | High |
| Zhang YR (2021) | Y | Y | Y | N | Y | N | Y | Y | Y | Y | N | 8 | High |
| Xu YJ (2020) | Y | Y | Y | N | Y | N | Y | Y | Y | Y | N | 8 | High |
| Johansen ML (2016) | Y | Y | Y | N | Y | N | Y | Y | Y | Y | N | 8 | High |
| Tavakoli N (2018) | Y | N | Y | N | Y | N | N | Y | Y | Y | UN | 6 | Medium |
| Singh GP (2013) | Y | N | N | Y | Y | N | N | Y | N | Y | N | 5 | Medium |
| Hendy A (2020) | Y | Y | N | Y | Y | N | N | Y | N | Y | N | 6 | Medium |
| Chao W (2020) | Y | N | Y | N | Y | N | N | Y | Y | Y | N | 6 | Medium |
① Whether the source of the data is clear (investigation, literature review); ② Are the inclusion and exclusion criteria for exposure and no exposure groups (cases and controls) listed or referred to previous publications? ③ Is a time period given for identifying patients? ④If not from the population, are the subjects continuous? ⑤Does the subjective factor of the evaluator cover up other aspects of the research object? ⑥ Describe any assessment for quality assurance (e.g. testing/ retesting of primary outcome indicators); ⑦The reasons for excluding any patients from the analysis were explained; ⑧It describes how to evaluate and/ or control the confounding factors; ⑨ If possible, the explanation is that how to deal with the loss of data; ⑩ The response rate and data collection were summarized the integrity of the system; ⑪ If there is a follow-up, identify the percentage of expected incomplete data or follow-up results.
3.3. Meta-analysis results
A total of 20 studies[8–10,12,14–16,18–30] were included, including 4166 patients. The results of meta-analysis showed that the incidence of low-level stress was 0.21% (95% CI [0.18–0.24]), the incidence of medium-level stress was 0.46% (95% CI [0.33–0.58]), and the incidence of high-level stress was 0.32% (95% CI [0.22–0.41]). As shown in Figures 3–5.
Figure 3.
A meta-analysis of low-level stress incidence.
Figure 5.
A Meta-analysis of high-level stress incidence.
Figure 4.
A meta-analysis of medium-level stress incidence.
4. Discussion
As the first systematic review and meta-analysis to investigate the stress level of emergency nurses across countries, this paper reports that the incidence rate of the low, medium and high-stress levels was 0.21%, 0.46%, and 0.32%, respectively. This implies that the overall stress level of emergency nurses is mainly at the medium level, which is consistent with the research results of Park.[31] Due to the limitation of this study, only 5 countries were included in 21 studies: China, the USA, Iran, India, and Egypt. India and China are developing countries with many emergency patients and a shortage of emergency nurses.[32] Throughout Egypt’s COVID-19 pandemic, nurses are experiencing fear, pressure, tiredness, ongoing emotional trauma, and isolation.[33] This study was published during this period.[30] According to a census, Iran (with a population of 75 million) requires about 240,000 nursing staff; however, the number of nursing staff in Iran now is about 100,000.[34] The shortage of nursing staff resulted in increased stress on emergency nurses in Iran.
The emergency department is a department that integrates critically ill patients with multiple types of diseases, and the task of patient rescue and management is heavy. It is the first defensive line for the hospital to save the patient’s lives, and it is also a place prone to nurse-patient disputes, complaints, and other adverse events.[35,36] So, among high-dependency nursing specialties, emergency nursing is at the vanguard of being affected by negative psychosocial work stressors.[37] Adib-Hajbaghery et al[38] showed that emergency nurses’ primary sources of stress were low social status, the attitude of nurses’ managers, and constant vigilance. Yuwanich et al[39] provided that job variability, limited decision-making power, and insufficient social support were major stressors for emergency nurses. The treatment of special patients, stimulation of death, workplace violence, and other traumatic events are the direct causes of post-traumatic stress disorder in emergency nurses.[40] Park indicates that violence in the workplace Is a serious stressor for emergency nurses. Such stress may undermine nurses’ morale and affect the quality of care.[31] Abdul et al[41] showed that emergency nurses were four times more likely to experience violent incidents and 2.8 times more likely to experience chronic fatigue than intensive care nurses. Nursing managers should pay attention to the mental health of emergency nurses and take personalized decompression measures in time, such as organizing regular psychological counseling and job training and arranging rational shifts to relieve the fatigue caused by work stress. Nurses should take the initiative to increase resilience and self-adjust, such as practicing more to improve operational proficiency and enjoy recreation properly.
5. Limitations of this review
While this review adopts a systematic process and incorporates a global perspective on ongoing research, it has several limitations. First, only English and Chinese papers were included in the review, limiting the inclusion of other languages. Second, the review was based on seven English and three Chinese language databases and did not include gray literature sources. Finally, due to the limitations of the included studies, this review did not analyze factors affecting stress among emergency nurses.
6. Conclusion
This systematic review has reported that the stress level of emergency nurses was mainly at the medium level. Nursing managers should pay attention to the physical and mental condition of nurses and timely take effective measures to help nurses relieve stress, improve their physical and mental health levels and reduce the emergency department nurses’ turnover rate.
Future studies should analyze differences in the incidence of stress measured on different diagnostic criteria, regions, and genders. Also, future studies should adopt corresponding emergency department stress scales to investigate the stress levels of emergency nurses.
Acknowledgments
The corresponding author has full access to all data in the research and is ultimately responsible for the decision to submit for publication.
Author contributions
JJR: designed the meta-analysis, extracted the data, performed the meta-analysis, wrote the first draft and revise manuscript. ZYX: designed the meta-analysis, extracted the data, performed the meta-analysis. HWN: supervision, reviewed the articles. All authors have read and approved the final draft.
Investigation: Jiao Jiaru, Zheng Yanxue.
Methodology: Jiao Jiaru, Zheng Yanxue.
Supervision: Hao Wennv.
Writing – original draft: Jiao Jiaru, Zheng Yanxue.
Writing – review & editing: Jiao Jiaru, Zheng Yanxue.
Footnotes
JJ and ZY contributed equally to this work.
The authors have no conflicts of interest to disclose.
This study was provided by the Inner Mongolia Medical University "Trinity" college student innovation and entrepreneurship cultivation project, Inner Mongolia, China (SWYT2022032).
All data generated or analyzed during this study are included in this published article [and its supplementary information files].
How to cite this article: Jiaru J, Yanxue Z, Wennv H. Incidence of stress among emergency nurses: A systematic review and meta-analysis. Medicine 2023;102:4(e31963).
Contributor Information
Jiao Jiaru, Email: 1768358136@qq.com.
Zheng Yanxue, Email: 1085059152@qq.com.
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