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

Abstract

BACKGROUND:

Work-related stress is a significant health and safety concern.

OBJECTIVES:

To assess the prevalence of burnout and occupational stress among emergency department (ED) professionals and to identify associated factors.

METHODS:

A cross-sectional study included all ED professionals of a French university hospital. Data were collected using the French versions of the Maslach Burnout Inventory and the Karasek Job Content Questionnaire.

RESULTS:

Of the 166 respondents (75.8%), 19.3% reported burnout and 27.1% job strain. Factors associated with burnout were work-related dissatisfaction, fear of making mistakes, lack of time to perform tasks, and being younger. Those factors associated with job strain were having at least one sick leave in the past year, being affected by hard work, interpersonal conflicts at workplace, and sleep disorders.

CONCLUSIONS:

Compared to the literature, our results showed a lower prevalence of burnout among physicians but similar among paramedics. The proportion of professionals with job strain was higher than that of the whole French working population. Organizational factors and the work environment were the primary causes of burnout and job strain, while being younger was the only associated sociodemographic factor. The identification of professionals experiencing difficulty is essential to ensure patient safety, particularly in the high-risk field of emergency medicine.

Keywords

Job strain occupational characteristics workplace healthcare professionals

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);

to identify specific factors that can lead to the development of burnout and occupational stress, including various individual and work-related factors.

2 Methods

2.1 Study design

We conducted a cross-sectional study in the ED of La Timone Hospital in Marseille, France, a university hospital with 1,069 beds. It is the largest hospital in the Provence-Alpes-Côte d’Azur region. There are approximately 85,000 adult visits per year to this ED, a full range of emergency medical services are provided.

The study was conducted over two months, from October through November 2015.

2.2 Study population

The study population included all permanent professionals working in the ED for at least one year:

health-care professionals who provide clinical services to patients: physicians and paramedics (nurses, nurse managers, and nursing assistants),

administrative and support staff (Admin/support): secretaries, administrative officers, social worker, and security staff.

Those who had an experience of less than one year in the ED and trainees or students were excluded.

All professionals were informed of the objectives and interests of the study, and their right to refuse or agree to participate in the study. Verbal consent was obtained. Participation was voluntary and anonymous, by the law of 6 August 2004 [49]. Each respondent could reflect and answer the questionnaire in privacy for reflecting and selecting the answers for the questions.

2.3 Study instrument

Data were collected using a self-administered questionnaire divided into five parts:

Part 1. included sociodemographic characteristics (gender, age, and marital status),

Part 2. included occupational characteristics with professional status, contractual situation (government employee or not), length of employment at the institution (years), and daily work hours. For work-related data, the variable professional category was grouped into ED physicians, paramedics, and administrative/support staff.

Part 3. consisted of experiences in the workplace. Questions concerned work and health (sleep disturbances and sick leave during the last year), work-time pressures (workload, and its collateral effects), difficulties to balance work and private life, manage time pressure, feelings in workplace, hard work and the reasons, and exposure to violence (including verbal abuse, threatening behavior, or/and physical violence) from patients or patient accompanier, and from other professional working in the ED or other hospital professional.

Part 4. consisted of the French version of the Maslach Burnout Inventory (MBI) [51] to measure symptoms of burnout. It has 22 items divided into three dimensions: emotional exhaustion (9 items), depersonalization (5 items), and personal accomplishment (8 items). Each item consists of a 6-point rating scale from 0 (never) to 6 (every day). The score of each dimension is calculated by summing up the scores of its items. Burnout was defined for at least 1 dimension with a high score for emotional exhaustion and depersonalization and a low score for personal accomplishment. A high level of burnout was the sum both of participants in burnout and of those with a high risk of burnout (two dimensions reached) [51].

Part 5. consisted of the French version of the Karasek Job Content Questionnaire [52, 53] to measure occupational stress. It had 26 items scored from 1 (strongly disagree) to 4 (strongly agree) and assessed three dimensions: job demands (9 items), decision latitude (9 items), and social support (8 items). We constructed the scores according to Karasek’s recommendations [54] and dichotomized at the median of the total sample. Scores for the three dimensions were differentiated into two classes: low score (any score below the median score) and high score (any score above the median score). In total, we obtain four categories:

The “job strain” or tense work by the combination of high job demands and low decision latitude,

The “active work” category by the combination of high job demands and high decision latitude,

The “passive work” category by the combination of low job demands and low decision latitude,

The “relaxed work” category by the combination of low job demands and high decision latitude.

The model also includes the “iso-strain” category combining a job strain and low social support [54].

2.4 Data analysis

All analyses were performed with SPSS version 20.0 software. For data analysis, ED professionals were grouped into three job categories: ED physicians, paramedic staff, and administrative or support staff.

Descriptive analysis stratified by job categories was carried out for all the study variables. Bivariate analysis using an independent samples t-test or ANOVA for ordinal/continuous variables, and χ2 test for categorical variables were used to test for association between job categories and participant characteristics, MBI dimensions, and Karasek dimensions.

Also the prevalence of high level of burnout and prevalence of job strain was calculated. A second bivariate analysis was used to test for association between all participant characteristics and both job strain and high level of burnout.

We performed a multivariate analysis to assess the independent relationship between experiencing job strain and high level of burnout, and all participant characteristics. The independent variables were selected based on a previous univariate analysis.

Adjusted odds ratio and their 95% confidence interval (CI) were used to assess these associations. Significance was considered at the p-value<0.05 level for all analyses.

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.

3.1 Sociodemographic and occupational characteristics

Table 1 summarizes sociodemographic and occupational characteristics of the participants. Respondents were predominately clinicians (92.8% were physicians and paramedics), and women (80.1%), with no significant difference between job categories. The mean age was 37.7 years±10.1 (22 to 65 years). Administrative and support staff were older than the health workers group (p = 0.007). Of the respondents, 35.4% were single. ED physicians were more likely to have a partner (married or in couple; 85.7%) (p = 0,037).

Table 1
Sociodemographic and occupational characteristics by job category (%)

Total (n = 166) Physicians (n = 28) Paramedics (n = 126) Admin/support (n = 12) p-values

Age, mean±SD 37.7±10.1 36.9±8.5 37.1±10.1 46.5±11.1 0.007

Female 80.1 71.4 81.0 91.7 0.303

Having a partner 64.6 85.7 60.5 58.3 0.037

Government employee 85.5 50.0 92.1 100.0 <0.001

<5 years in the hospital 41.2 40.7 43.1 20.0 0.361

Daily hours of work <0.001

7-h48 7.3 4.0 58.3

10-h 3.6 11.1 1.6 8.3

12-h 76.4 11.1 94.4 33.3

24-h 12.7 77.8

	Total (n = 166)	Physicians (n = 28)	Paramedics (n = 126)	Admin/support (n = 12)	p-values
Age, mean±SD	37.7±10.1	36.9±8.5	37.1±10.1	46.5±11.1	0.007
Female	80.1	71.4	81.0	91.7	0.303
Having a partner	64.6	85.7	60.5	58.3	0.037
Government employee	85.5	50.0	92.1	100.0	<0.001
<5 years in the hospital	41.2	40.7	43.1	20.0	0.361
Daily hours of work					<0.001
7-h48	7.3		4.0	58.3
10-h	3.6	11.1	1.6	8.3
12-h	76.4	11.1	94.4	33.3
24-h	12.7	77.8

SD: Standard deviation.

About occupational characteristics, the majority (85.5%) had an open-ended contract and most were government employees. Work hours varied significantly across professional categories (p < 0.001). The majority of ED physicians worked continuously over a 24-hour period (77.8%), paramedical staff worked a regular 12-hour period, and administrative and support staff worked on a 7-hour and 48-minute period.

3.2 Work-related constraints in the ED

The constraints associated with work in the ED are shown in Table 2. ED physicians had more constraints than other categories. They often worked more than normal working hours and shortened their lunch breaks (p < 0.001). They were more likely to consider work as hard (66.3%). Unlike other categories, ED physicians were less likely to have at least one sick leave in the past year (p = 0.004).

Table 2
Work-related constraints by job category (%)

Total (n = 166) Physicians (n = 28) Paramedics (n = 126) Admin/support (n = 12) p-values

Sleep disturbances 44.0 39.3 46.8 25.0 0.298

≥1 sick leave during the last year 46.4 17.9 51.6 58.3 0.004

Exceeded work schedules 33.1 89.3 23.0 8.3 <0.001

Meals shortened 78.9 100.0 77.8 41.7 <0.001

Tasks/Work processed too quickly 62.7 85.7 59.5 41.7 0.010

Difficulties to

Balance work and private life 31.9 50.0 29.4 16.7 0.053

Manage time pressure 48.8 67.9 44.4 50.0 0.081

Fear of making mistakes 51.2 67.9 50.8 16.7 0.012

Interpersonal conflicts 18.1 7.1 20.6 16.7 0.242

Lack of compassion 83.1 89.3 81.7 83.3 0.628

Work-related dissatisfaction 13.3 17.9 11.9 16.7 0.658

Hard work 66.3 89.3 64.3 33.3 0.002

Suffering at work 19.3 10.7 21.4 16.7 0.418

Intention to withdraw from ED to other service in future 21.1 7.1 24.6 17.7 0.114

	Total (n = 166)	Physicians (n = 28)	Paramedics (n = 126)	Admin/support (n = 12)	p-values
Sleep disturbances	44.0	39.3	46.8	25.0	0.298
≥1 sick leave during the last year	46.4	17.9	51.6	58.3	0.004
Exceeded work schedules	33.1	89.3	23.0	8.3	<0.001
Meals shortened	78.9	100.0	77.8	41.7	<0.001
Tasks/Work processed too quickly	62.7	85.7	59.5	41.7	0.010
Difficulties to
Balance work and private life	31.9	50.0	29.4	16.7	0.053
Manage time pressure	48.8	67.9	44.4	50.0	0.081
Fear of making mistakes	51.2	67.9	50.8	16.7	0.012
Interpersonal conflicts	18.1	7.1	20.6	16.7	0.242
Lack of compassion	83.1	89.3	81.7	83.3	0.628
Work-related dissatisfaction	13.3	17.9	11.9	16.7	0.658
Hard work	66.3	89.3	64.3	33.3	0.002
Suffering at work	19.3	10.7	21.4	16.7	0.418
Intention to withdraw from ED to other service in future	21.1	7.1	24.6	17.7	0.114

All ED clinicians (physicians and paramedics) felt that they were performing the tasks too quickly and that they were not compassionate and caring. Almost 50% of ED professionals were afraid of making mistakes, especially physicians and paramedics (p = 0.012).

Paradoxically, despite these constraints, the majority of ED professionals were satisfied with their current job (86.7%), and only 19.3% reported suffering at work.

Table 3 presents the reasons cited by ED professionals to explain why their work was hard (n = 110). The two most frequently cited reasons were the great difficulty in finding hospital beds and the problems related to the lack of availability of mobile stretchers used to transport patients from the ED to another care service. Other reasons were an excessive workload and too large premises.

Table 3

Reasons for hard work (%)

	Total (n = 110)
Organizational factors
Great difficulty in finding hospital beds	97.3
Lack of availability of mobile stretchers to transport patients from the ED to another care service	89.1
Excessive workload	86.4
Lack of personnel resources	72.7
Lack of job design in workstations	57.3
Lack of material resources	53.6
Frequent changes in work organization	50.0
Lack of communication with ED professionals	50.0
Bureaucracy, administrative workload and nonclinical tasks	48.2
Relationship with the patient
Unreasonable patient demands	74.5
Aggressive patient behaviour	69.1
Physical environment of the ED
Too large premises: lots of walking	86.4
Lack of privacy for patients	84.5
Feeling of insecurity (ED open access)	82.7
Inadequate workplace: storage room too far away	74.5
Management and hierarchy
Lack of respect from other hospital services	74.5
Decreased feeling of competence	64.5
No interpersonal relationships with colleagues	28.2
Lack of recognition of own contribution by supervisor	14.5

The great majority of ED professionals were exposed regularly to violence, including insults, threats, and physical violence (87.3%), especially clinicians (Physicians 92.9% and Paramedics 88.9% versus 58.3% of administrative/support staff, p = 0.006). They were more exposed to violence because of patients and their accompaniers (87.7% versus 66.7 of administrative/support staff, p = 0.043). More than a third of physicians felt assaulted by other hospital professionals (39.3%) due to the searches for hospital beds as compared with paramedics (13.5%) or administrative and support staff (8.3%, p = 0.003).

3.3 Prevalence of burnout syndrome in ED professionals

Table 4 presents the distribution of MBI dimensions. Analysis of the MBI scores showed the prevalence of high emotional exhaustion, high depersonalization, and low personal accomplishment among the study group were 12.7%, 30.1%, and 32.5%, respectively; with no significant difference between the three professional categories. No administrative or support staff had a high level of burnout.

Table 4
Levels of burnout (MBI) by job category, (%)

Total (n = 166) Physicians (n = 28) Paramedics (n = 126) Admin/support (n = 12) p-values

Emotional exhaustion

Low 61.4 60.7 61.1 66.7 0.975

Average 25.9 28.6 25.4 25.0

High 12.7 10.7 13.5 8.3

Depersonalization

Low 38.0 28.6 38.9 50.0 0.106

Average 31.9 28.6 31.0 50.0

High 30.1 42.9 30.2

Personal accomplishment

Low 32.5 28.6 32.5 41.7 0.921

Average 34.9 35.7 35.7 25.0

High 32.5 35.7 31.7 33.3

Burnout

Low risk 48.8 46.4 49.2 50.0 0.650

Average risk 31.9 32.1 30.2 50.0

High risk 14.5 14.3 15.9

In burnout 4.8 7.1 4.8

High level of burnout (High risk/In burnout) 19.3 21.4 20.6 0.212

A high level of burnout was identified among 19.3% of participants. Of the remaining participants, 48.8% had a low risk of burnout and 31.9% had a medium risk.

3.4 Prevalence of occupational stress according to Karasek’s model

About the level of stress by the Karasek’s model (Table 5), 27.1% of ED professionals presented with job strain, and 21.1% experienced iso strain which is the combination of job strain and low social support, with no significant relationship between job categories. Ed physicians presented a high decision latitude as opposed to the other categories.

Table 5
Occupational stress according to Karasek’s model by job category (%)

Total n = 166 Physicians n = 28 Paramedics n = 126 Admin/support n = 12 p-values

Decision latitude 0.001

High 39.2 75.0 33.3 16.7

Job demand 0.086

High 52.4 71.4 48.4 50.0

Social support 0.256

Low 53.0 39.3 56.3 50.0

Categories 0.001

Passive work 33.7 0.7 38.1 41.7

Relaxed work 13.9 7.9 13.5 8.3

Active work 25.3 57.1 19.8 8.3

Job strain 27.1 4.3 28.6 41.7

Iso strain 21.1 14.3 21.4 33.3 0.393

	Total n = 166	Physicians n = 28	Paramedics n = 126	Admin/support n = 12	p-values
Decision latitude					0.001
High	39.2	75.0	33.3	16.7
Job demand					0.086
High	52.4	71.4	48.4	50.0
Social support					0.256
Low	53.0	39.3	56.3	50.0
Categories					0.001
Passive work	33.7	0.7	38.1	41.7
Relaxed work	13.9	7.9	13.5	8.3
Active work	25.3	57.1	19.8	8.3
Job strain	27.1	4.3	28.6	41.7
Iso strain	21.1	14.3	21.4	33.3	0.393

3.5 Risk factors with high level of burnout and job strain: Univariate analysis

All factors significantly associated with a high level of burnout and job strain are presented in Table 6 (p < 0.05).

Table 6
Risk factors with prevalence of burnout and job strain

Job strain High level of burnout

Professional characteristics, n (%) No (n = 121) Yes (n = 45) p-values No (n = 134) Yes (n = 32) p-values

Age, mean±SD 37.7±10.1 37.7±10.4 0.987 39.3±10.3 31.1±6.3 <0.001

<5 years of professional practice in the current institution 48 (40.3) 18 (43.9) 0.689 47 (36.7) 19 (59.4) 0.020

At least one sick leave during the last year 46 (38.0) 31 (68.9) <0.001 – – –

Sleep disturbances 30 (24.8) 24 (53.3) <0.001 34 (25.4) 20 (62.5) <0.001

Short meals, starggered or not taken 90 (74.4) 41 (91.1) 0.019 100 (74.6) 31 (96.9) 0.006

Task/Work processed too quickly 73 (60.3) 31 (68.9) 0.311 76 (56.7) 28 (87.5) 0.001

Difficulties balancing work and private life 36 (29.8) 17 (37.8) 0.324 35 (26.1) 18 (56.2) 0.001

Difficulties in managing time pressure 53 (43.8) 28 (62.2) 0.035 58 (43.3) 23 (71.9) 0.004

Exposure to violence (≥1 time / month) 105 (86.8) 40 (88.9) 0.716 113 (84.3) 32 (100.0) 0.017

Relationship problems with other ED professionals 16 (13.2) 14 (31.1) 0.008 20 (14.9) 10 (31.2) 0.031

Lack of compassion 16 (13.2) 12 (26.7) 0.040 17 (12.7) 11 (34.4) 0.003

Excessive workload 23 (19.0) 25 (55.6) <0.001 25 (18.7) 23 (71.9) <0.001

Work-related dissatisfaction 10 (8.3) 12 (26.7) 0.002 8 (6.0) 14 (43.8) <0.001

Suffering at work 18 (14.9) 14 (31.1) 0.018 15 (11.2) 17 (53.1) <0.001

Fear of making mistakes 60 (49.6) 25 (55.6) 0.494 63 (47.0) 22 (68.8) 0.027

Hard work 72 (59.5) 38 (84.4) 0.003 81 (60.4) 29 (90.6) 0.001

Intention to change service 17 (14.0) 18 (40.0) <0.001 19 (14.2) 16 (50.0) <0.001

Moderate to high burnout 18 (14.9) 14 (31.1) 0.048 – – –

Job strain – – – 31 (23.1) 14 (43.8) 0.018

Iso strain – – – 24 (17.9) 11 (34.4) 0.040

	Job strain	High level of burnout
Age, mean±SD	37.7±10.1	37.7±10.4	0.987	39.3±10.3	31.1±6.3	<0.001
<5 years of professional practice in the current institution	48 (40.3)	18 (43.9)	0.689	47 (36.7)	19 (59.4)	0.020
At least one sick leave during the last year	46 (38.0)	31 (68.9)	<0.001	–	–	–
Sleep disturbances	30 (24.8)	24 (53.3)	<0.001	34 (25.4)	20 (62.5)	<0.001
Short meals, starggered or not taken	90 (74.4)	41 (91.1)	0.019	100 (74.6)	31 (96.9)	0.006
Task/Work processed too quickly	73 (60.3)	31 (68.9)	0.311	76 (56.7)	28 (87.5)	0.001
Difficulties balancing work and private life	36 (29.8)	17 (37.8)	0.324	35 (26.1)	18 (56.2)	0.001
Difficulties in managing time pressure	53 (43.8)	28 (62.2)	0.035	58 (43.3)	23 (71.9)	0.004
Exposure to violence (≥1 time / month)	105 (86.8)	40 (88.9)	0.716	113 (84.3)	32 (100.0)	0.017
Relationship problems with other ED professionals	16 (13.2)	14 (31.1)	0.008	20 (14.9)	10 (31.2)	0.031
Lack of compassion	16 (13.2)	12 (26.7)	0.040	17 (12.7)	11 (34.4)	0.003
Excessive workload	23 (19.0)	25 (55.6)	<0.001	25 (18.7)	23 (71.9)	<0.001
Work-related dissatisfaction	10 (8.3)	12 (26.7)	0.002	8 (6.0)	14 (43.8)	<0.001
Suffering at work	18 (14.9)	14 (31.1)	0.018	15 (11.2)	17 (53.1)	<0.001
Fear of making mistakes	60 (49.6)	25 (55.6)	0.494	63 (47.0)	22 (68.8)	0.027
Hard work	72 (59.5)	38 (84.4)	0.003	81 (60.4)	29 (90.6)	0.001
Intention to change service	17 (14.0)	18 (40.0)	<0.001	19 (14.2)	16 (50.0)	<0.001
Moderate to high burnout	18 (14.9)	14 (31.1)	0.048	–	–	–
Job strain	–	–	–	31 (23.1)	14 (43.8)	0.018
Iso strain	–	–	–	24 (17.9)	11 (34.4)	0.040

3.6 Risk factors with high level of burnout and job strain: Multivariate analysis

In the multivariate analysis (Table 7), work-related dissatisfaction, fear of making mistakes, work processed too quickly, and being younger were the factors most associated with a high level of burnout. In particular, professionals who expressed a work-related dissatisfaction were nearly 14 times more likely to experience a high level of burnout (OR 14.47; 95% CI 3.48–60.99, p < 0.001). Moreover, having at least one sick leave during the last year, being affected by hard work, having problems relating to other ED professionals, and sleep disturbances were the factors most associated with the experience of job strain.

Table 7
Multivariate analysis: Factors associated with a high level of burnout and a job strain

Odds ratio 95% confidence interval p-values

High level of burnout

Age 0.87 0.80–0.94 0.001

Task/Work processed too quickly 4.45 0.10–18.13 0.037

Work-related dissatisfaction 14.47 3.48–60.99 <0.001

Fear of making mistakes 5.92 1.87–18.78 0.003

Job strain

Sleep disturbances 2.91 1.34–6.32 0.007

≥1 sick leave during the last year 3.52 1.60–7.75 0.002

Interpersonal conflicts 2.97 1.18–7.49 0.021

Hard work 3.49 1.35–9.04 <0.001

	Odds ratio	95% confidence interval	p-values
High level of burnout
Age	0.87	0.80–0.94	0.001
Task/Work processed too quickly	4.45	0.10–18.13	0.037
Work-related dissatisfaction	14.47	3.48–60.99	<0.001
Fear of making mistakes	5.92	1.87–18.78	0.003
Job strain
Sleep disturbances	2.91	1.34–6.32	0.007
≥1 sick leave during the last year	3.52	1.60–7.75	0.002
Interpersonal conflicts	2.97	1.18–7.49	0.021
Hard work	3.49	1.35–9.04	<0.001

4 Discussion

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].

Footnotes

Acknowledgments

The authors would like to thank all permanent ED professionals who participated in this study.

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	Job strain			High level of burnout
Professional characteristics, n (%)	No (n = 121)	Yes (n = 45)	p-values	No (n = 134)	Yes (n = 32)	p-values
Age, mean±SD	37.7±10.1	37.7±10.4	0.987	39.3±10.3	31.1±6.3	<0.001
<5 years of professional practice in the current institution	48 (40.3)	18 (43.9)	0.689	47 (36.7)	19 (59.4)	0.020
At least one sick leave during the last year	46 (38.0)	31 (68.9)	<0.001	–	–	–
Sleep disturbances	30 (24.8)	24 (53.3)	<0.001	34 (25.4)	20 (62.5)	<0.001
Short meals, starggered or not taken	90 (74.4)	41 (91.1)	0.019	100 (74.6)	31 (96.9)	0.006
Task/Work processed too quickly	73 (60.3)	31 (68.9)	0.311	76 (56.7)	28 (87.5)	0.001
Difficulties balancing work and private life	36 (29.8)	17 (37.8)	0.324	35 (26.1)	18 (56.2)	0.001
Difficulties in managing time pressure	53 (43.8)	28 (62.2)	0.035	58 (43.3)	23 (71.9)	0.004
Exposure to violence (≥1 time / month)	105 (86.8)	40 (88.9)	0.716	113 (84.3)	32 (100.0)	0.017
Relationship problems with other ED professionals	16 (13.2)	14 (31.1)	0.008	20 (14.9)	10 (31.2)	0.031
Lack of compassion	16 (13.2)	12 (26.7)	0.040	17 (12.7)	11 (34.4)	0.003
Excessive workload	23 (19.0)	25 (55.6)	<0.001	25 (18.7)	23 (71.9)	<0.001
Work-related dissatisfaction	10 (8.3)	12 (26.7)	0.002	8 (6.0)	14 (43.8)	<0.001
Suffering at work	18 (14.9)	14 (31.1)	0.018	15 (11.2)	17 (53.1)	<0.001
Fear of making mistakes	60 (49.6)	25 (55.6)	0.494	63 (47.0)	22 (68.8)	0.027
Hard work	72 (59.5)	38 (84.4)	0.003	81 (60.4)	29 (90.6)	0.001
Intention to change service	17 (14.0)	18 (40.0)	<0.001	19 (14.2)	16 (50.0)	<0.001
Moderate to high burnout	18 (14.9)	14 (31.1)	0.048	–	–	–
Job strain	–	–	–	31 (23.1)	14 (43.8)	0.018
Iso strain	–	–	–	24 (17.9)	11 (34.4)	0.040