Stress and burnout among professionals working in the emergency department in a French university hospital: Prevalence and associated factors

1 Introduction

In the 1980s and 1990s, several major international organizations drew attention to the development of occupational stress and its consequences on the health of workers [1–4]. In 1993, the International Labor Office estimated that work-related stress had become one of the most serious health problems of our time [1, 4].

In France, awareness of work-related stress and the lack of resources to deal with it are a recent concern. Until the end of the 1990s, there were very few reports or studies on the subject, and they were under-exploited, particularly due to a lack of systematization and centralization [5–16]. The emergence of an initial stage with signs of harassment, followed by a second stage of the proliferation of suicides at France Telecom and Renault’s technocentre [16, 17], focused the public and the media on the reality of the major risks linked to mental suffering at work [16, 17].

In March 2016, the French government began to address the problem and created an information mission on burnout syndrome in order to understand the definitions better, take stock of the current French situation in all the concerned fields, know the actors and their actions, and describe and understand the different modes of care. A report was adopted in 2017 [16].

In the field of health, la Haute Autorité de Santé has been working since 2010 on the notion of quality of life at work as part of the certification of healthcare facilities and has shown the impact of poor quality of life at work on patient safety [18]. Indeed, the health sector is particularly affected by work conditions [17–21]. Health care workers are among the occupational groups most at risk of occupational accidents [21].

In emergency departments (EDs), workers regularly report difficulties in working conditions. The emergency department is a stressful workplace with excessive workloads or high demands on patient care (including exposure to violence), time pressures, and the intensive use of sophisticated technologies. Also, EDs suffer from overcrowding, from increased patient inflow and reduced capacity for patient care, the difficulty of caring for the elderly, lack of staff in all categories, high patient demand standards, and high managerial skill demands on the medical and paramedical staff [22–26].

Some studies have investigated burnout and occupational stress among emergency professionals [23–49]. The results most often target only one professional category, such as only ED physicians [28, 48] or only nurses [27, 49] and sometimes both physicians and nurses, but rarely all ED staff [29, 41]. Moreover, few studies have been published on French ED professionals [25, 30].

The specific objectives of our study are:

to assess the prevalence of burnout syndrome and occupational stress within an ED and among all the professional categories working in an ED namely physicians, paramedics (as well as nurses, nurse managers, nursing assistants), and administrative and support staff (secretaries, administrative officers, social worker, and security staff);

2 Methods

3 Results

The total number of participants was 166 professionals among the 219 working in the ED during the study period, with a response rate of 75.8%. Of this total, 16.9% were physicians, 75.9% were paramedics, and 7.2% were administrative and support professionals.

This is the first French study to include all of the professional categories working in an emergency department inclusive of physicians, paramedics, and administrative and support staff (response rate 76%). We used two tools validated in French: the Karasek’s Job Content Questionnaire [51, 52] and the MBI [50]; and we performed comprehensive multivariate analyses.

Overall, 19.3% of ED professionals reported a high level of burnout, and 27.1% reported job strain.

Before discussing our results of burnout, job strain, and the factors associated with both, we would like to highlight some methodological remarks. First, in previous studies of burnout, the prevalence of burnout is not always specified. The authors often described the results for each dimension without combining them to obtain prevalence [31, 47]. Second, the method to identify burnout stages is not always the same. The authors often present compiled results without detailing the different dimensions of MBI, which prevents comparison of some of studies for the level of burnout [31, 38].

Third, most studies in our field of research included not only ED professionals but also professionals of intensive care units [30, 47]. Moreover, in most studies, burnout was examined in only one professional category: nurses or physicians [31, 40]. Fourth, most other studies had a low response rate and resulted in selection bias [21, 46].

Contrary to the literature, our results showed a lower prevalence of burnout among ED physicians (21.4%) similar to that of ED paramedics (20.6% versus 25% [27, 38], 38]). In the literature, the percentage of ED physicians suffering from burnout ranges from about 11% [41, 45] to more than 60% [21, 48,]. The lowest rate was identified by the only French study found in the literature review [45]. To explain our lower burnout rate, we analyzed each of the three dimensions of the MBI. Very few ED physicians had a high level of emotional exhaustion: only 10.7% compared to 30% in the other studies. This can be the result from the gradual loss of the health worker’s ability to feel emotionally involved in their work. We hypothesize that the practice of emergency medicine leaves little space for emotions. It is necessary to act quickly and effectively in response to the patient’s condition. In this context, physicians do not allow themselves to be overwhelmed by emotions. This translates into distance from the patient: work on one side and feelings on the other, as also shown by Lloyd and Laurent [25, 26].

In our study, more than one-quarter of ED professionals reported job strain (27.1%). Our proportion is higher than that of the French general working population (23%). However, this proportion is lower than that observed in three previous studies conducted in EDs [46, 35] which fluctuated from 28% [46] to 60.7% [30, 35]. Chakroun’s study was conducted in the ED and pre-hospital emergency department [18], and Trousselard’s study [16], and Bellagamba’s study [30] were conducted in the ED, ICU, and anesthesiology units [15]. Also response rates were very low for two of the three studies, less than 40% [16, 18], resulting in selection bias. Finally, the inclusion criteria were different. Chakroun included medical students who appeared to be the most concerned with job strain [18]. In the study of Bellagamba, the factors associated with the job strain were primarily due to the organization of the ICU, and not relevant to the ED [15]. Trousselard, for his study, targeted only nurses and most of them worked for the ICU. We believe selection bias influences results [16]. We hypothesize that in these surveys, professionals working in ICU are certainly most concerned by the problem because the ICU is more stressful than the ED.

In our study, job strain differs among the three ED professional categories of physicians, paramedics, and administrative and support staff. Administrative and support staff are significantly more stressed (41.7%) than the ED physicians and paramedics due to the low level of decision latitude (80%). Contrary to the French national study describing French nurses as in the active job quadrant, our study showed paramedics were more numerous in the passive work quadrant (38.1%) [8]. This result can be explained by an excessive workload and repetitive tasks. Our hypothesis is that the professionals surveyed felt that they were working in a factory rather thana hospital.

Our study investigated specific factors associated with a high level of burnout and occupational stress. Organizational factors and the working environment were the primary causes of job strain and a high level of burnout. While being younger was the only associated sociodemographic factor, which is consistent with the previous studies [21, 41].

Our results highlight that the work overload is perceived by ED professionals as the main source of stress and burnout. This is related both to the workload with the need to perform a large number of tasks, and the perception of being under pressure with the requirement to perform tasks very quickly. These are constant and common conditions in all EDs. In addition, other factors related to the work environment contribute to the perception of hard work and the fear of making mistakes: unreasonable demands from patients, lack of personnel resources, and the great difficulty in finding a hospital bed for a patient. Hard work is related to the malfunctioning of the physical work environment (design and ergonomics) of the workplace. ED workers considered their working environment as inadequate with too large premises, an inadequate workspace (remote storage room), and a feeling of insecurity.

Conflicts with colleagues working in the same hospital were also associated with job strain. Biaggi P et al. (2003) described collegial conflicts as associated with high levels of job stress [55]. Conflicts with colleagues, in our study, were mainly due to the problem of finding hospital beds. Recently, a position of bed manager was created for the search for beds. This new administrative position cannot solve all the problems because this issue of a search for beds highlights the lack of institutional policy regarding the ED within the institution.

We also found that work-related dissatisfaction increases the risk of burnout. Despite signs of burnout and occupational stress among ED workers, 86.7% reported being satisfied with their work. Job satisfaction can be an important factor in enabling ED professionals to cope with the high-stress load that they encounter every day. Job satisfaction can have a positive effect that allows workers to relieve the high-stress load which they experience. Our study found the level of absenteeism among ED professionals experiencing stress at work was higher (at least one sick leave in the past year).

The main limitation of our study is the study design because the cross-sectional nature of the study imposes temporal limitations. It cannot prove a cause-effect relationship between the associated variables, particularly concerning the health of ED professionals, therefore, we are unable to assess whether, for example, a level of burnout is the result of a work-related dissatisfaction, or whether it is the cause. A cohort or panel study might allow a better opportunity to analyze risk factors and use correlations to determine absolute predictive factors. We conducted our study in the entire population of professionals working in an ED with a large volume of activity (85,000 adult visits per year), and we obtained a high response rate which contributed to the strengths of our study. Despite the limitations as noted, the results of our study can make a significant contribution towards improving the quality of life at this type of workplace.

5 Conclusion

Our study shows almost 20% of ED professionals had a high level of burnout and almost 30% had a job strain. These rates are lower than those of previous studies published in other countries but similar to the French conducted by Sendé et al in 2012. We believe our result is inherent in EDs because the professionals most attracted by fast work, quick decision making, and mental strength in critical situations will select this work, as demonstrated by the study conducted within the SMUR (French prehospital emergency and resuscitation service teams) [4,5, 4,5]. This study shows that, unlike most other professionals, ED professionals are more distant from emotional demands.

We also examined the main psychosocial risk factors of excessive workload and workplace relationships, especially interpersonal conflicts. Many ED professionals, especially those who are in burnout, stated that they are afraid of making medical errors. This has a very worrying implication for patient safety. Identification of professionals in the field of high-risk emergency medicine who experience difficulty is essential to protecting patient safety.

Conflict of interest

None to report.

Ethics approval and consent to participate

Informed consent for participation in the study was obtained from every participant. Participation was voluntary and anonymous, in accordance with the law of 6 August 2004 [50].