Burnout in emergency and paediatric emergency departments: a narrative review

Introduction

Burnout affects two in five doctors in training in the UK (1). An occupational phenomenon well described in the medical workforce, burnout includes emotional exhaustion, depersonalisation and a reduced sense of effectiveness and lack of accomplishment (2,3). Its potential ramifications are huge: reduced quality of care, increased risk of medical error and depression and suicidal ideation in healthcare staff (4-6). The rate of burnout is increasing in emergency department (ED) settings, especially in the post-coronavirus disease 2019 (COVID-19) era (7-9). Although burnout has been discussed several times in the literature, the topic remains current in view of this increasing prevalence.

Prior research showed that paediatric emergency medicine (PEM) and emergency medicine (EM) healthcare workers are particularly at risk (10-13). Considering the impact of severe overcrowding, staffing shortages, workplace violence and workflow inefficiencies, alongside the burden of high-intensity working environments, long working hours and the high moral injury facing EM clinicians daily, burnout may seem inevitable (10,11,14). Especially in the post-COVID-19 era, due to the substantially increased workload and psychological burden, there has been an increase in burnout symptoms among PEM/EM healthcare workers (9,15,16). A recent meta-analysis showed that burnout was evident in approximately 40% of EM doctors (10), whereas a scoping review showed a prevalence between 10–70% depending on country and definition of burnout used in each study (17). Although previous reviews have characterised burnout in the PEM and EM setting, discussions on strategies to support and prevent burnout have been limited.

The objective of this review was to synthesise available evidence on burnout in PEM and EM healthcare workers and provide evidence-based strategies on how to reduce burnout rates in PEM and EM settings. The review identifies potential risk factors, evaluates the effect burnout may have on clinicians and their patients. This review also has the advantage of discussing evidence-based potential solutions in reducing burnout in PEM and EM healthcare workers. We present this article in accordance with the Narrative Review reporting checklist (available at https://pm.amegroups.com/article/view/10.21037/pm-25-16/rc).

Methods

For this narrative review, we followed the Scale for the Assessment of Narrative Review Articles (18). A literature search was performed on MEDLINE, Google Scholar, and Science Direct for articles on burnout in emergency and paediatric EDs, and an example of the search strategy can be seen in Appendix 1. Search terms included burnout, EM, and PEM. A manual search for references was also performed in the included studies. The search strategy summary is shown in Table 1.

We finally included in our conceptual analysis studies published in English that followed the following criteria:

• Burnout definitions;
• Internal and external factors associated with burnout;
• How burnout affects healthcare workers;
• Strategies to potentially prevent burnout.

We excluded studies not performed in the ED or critical care setting.

What is burnout and how is it assessed?

The World Health Organization (WHO) defines burnout as an occupational syndrome stemming from chronic work-related stress that includes (19):

• Energy exhaustion;
• Mental distance from work, cynicism;
• Reduced professional efficacy.

There are, however, multiple definitions of healthcare worker burnout; a recent systematic review and Delphi consensus identified 88 different definitions in 248 articles (20). Assessing healthcare worker burnout is complex. Several scoring tools have been developed which incorporate many of the symptoms of burnout (Table 2) (21-24). Two validated tools are most frequently used: the Maslach Burnout Inventory (MBI) modified for Human Services Survey (MBI-HSS) (25,26) and the Copenhagen Burnout Inventory (27). Scores generated from these two tools, however, do not always align, with 21.1% disagreement in a study in EM doctors, particularly in junior trainees compared to consultants, and doctors under 35 years and those older than 55 years (27). There is a need for further studies comparing validity of these tools in these cohorts.

The causes of burnout in ED healthcare workers can be simplified into organisational/external factors arising from the work environment, and personal/internal factors (Figure 1). Some of these may be modifiable, such as workplace-related factors and lifestyle factors, while others are non-modifiable, such as demographics and mental health history.

Figure 1 Internal and external factors causing burnout in PEM/EM healthcare workers. EM, emergency medicine; PEM, paediatric emergency medicine.

Organisational/external factors

Work-related issues include an excessive workload, exacerbated by staff shortages and long shift hours, a sense of limited professional development, and the emotional stress associated with the types of patients and pathologies encountered in emergency services. A recent review underlined the importance of investigating the interplay between wellbeing and burnout. Findings showed that there is increasing pressure in the ED that has a negative impact on healthcare workers’ wellbeing (28).

Studies demonstrate a correlation between the incidence of burnout with the type of workload, particularly excessive administrative tasks including prior authorisations, electronic medical record (EMR) documentation and mandatory training requirements (12,13,29). A study performed in an academic medical centre found a lower prevalence of burnout among personnel who spent more time involved in activities they considered meaningful, even though this definition is subjective and varies from person to person (30). Small adjustments can make a meaningful impact; a randomised control trial and a systematic review and meta-analysis highlight the positive effect on reducing burnout by introducing medical scribes to reduce doctors’ electronic health record workload in non-EM settings (31,32). This was not confirmed in a quasi-experimental study in an academic paediatric ED where there was a marginal increase in clinical documentation when scribes were used (33). On the other, hand a prospective pre-post scribe intervention study in a paediatric ED showed that medical scribes increased ED efficiency without decreasing patient satisfaction (34). Reduction in burnout scores was also reported in a cluster-randomised trial that assessed reallocation of tasks from doctors to medical assistants, nurse practitioners, nurses and physician assistants (35).

Interpersonal conflicts include low-quality teamwork and potential conflicts with supervisors. A lack of effective communication and prompt support from leaders is commonly described (9,36). In contrast, recognition from colleagues and supervisors is considered to be protective against burnout (9,36).

Personal/internal factors

Personal factors encompass both demographic characteristics and components related to personality and adaptability. Younger age has been associated with a higher risk of burnout (37-40). Suggested explanations for this include a potentially lower capacity for adaptation in younger trainees, and an increased tolerance for adversity with increasing age (37-40). Imposter syndrome has also been observed to be common among emergency physicians, especially in younger doctors and women, and this has been associated with higher rates of burnout.

A recent meta-analysis found a higher level of burnout in female trainees (40), a finding also demonstrated in PEM trainees (41). However, sex has not been consistently associated with burnout among physicians (42).

A recent study found a higher prevalence of burnout among individuals with type D personalities, who tend to be more anxious than other personality types (11). These individuals tend to be more introverted and less likely to express their feelings, and less likely to seek help. Individuals who find it difficult to adapt to change, and lack flexibility, are also more susceptible. The ability to actively resolve problems is considered to be protective (11). Individuals with no family network or close friends are at increased risk of burnout (43). The role of hobbies, physical activity, and healthy lifestyles is unclear, but a lack of work/life balance has been shown to influence the presence of burnout (14,37,40).

Compassion fatigue is also a potentially significant contributor to burnout. Compassion fatigue is defined as a state of exhaustion and dysfunction biologically, psychologically, and socially as a result of prolonged exposure to compassion stress and all it entails invokes. With the unpredictable nature of EM placing physicians under substantial psychological, physical, and cognitive pressure and exposing them to significant traumatic events which can lead to compassion fatigue. This has implications for physicians and patients and is strongly linked as both a cause and a consequence of burnout. Moreover, compassion fatigue has also been described in both paediatric intensive care unit (PICU) and neonatal intensive care unit (NICU) settings (44,45).

From a deontological perspective another important factor is moral distress which is defined as ‘a negative emotional response that occurs when physicians know the morally correct action but are prevented from taking it because of internal or external constraints’. Although related to compassion fatigue, it differs in that sufferers may also feel they have lost personal and professional integrity, been compromised as moral agents, or abandoned their ethical principles. Unfortunately, this is a concept that over half of the 1,900 doctors surveyed by the British Medical Association (BMA) felt reflected their experiences at work.

Moral distress has been was shown to be associated with increased risk of burnout in both critical care physicians and NICU healthcare workers (46,47). In a Swedish qualitative study performed during COVID-19 pandemic, doctors working in the ED showed increased levels of moral distress which was contributed to inability to provide equal and sufficient care to their patients while also having an increasing workload (48).

What are the factors that increase burnout amongst PEM/EM healthcare workers?

Healthcare workers suffering from burnout are three times more likely to leave the medical profession (9,36,49). In 2023, one in seven National Health Service (NHS) healthcare workers actively considered leaving healthcare (50). In 2024, the UK General Medical Council (GMC) reported a negative cycle driving burnout (Figure 2) (51). The report described a correlation between higher levels of burnout with increasing numbers of doctors seeking alternative careers, different working patterns and change of locations. Failure to retain staff due to poor working conditions further exacerbates the problem. The effect of doctors leaving healthcare leads to increasing workloads for the remaining doctors, in turn leading to burnout in other staff. The emphasis is on unmanageable workloads, a recurring theme seen in many studies focusing on burnout in the ED, leading to increased dissatisfaction within the workplace, a major pillar of burnout (41,42,52,53). A feeling of lack of control over one’s responsibilities and lack of empowerment in one’s role increases burnout rates. This cycle has been reported since 2019 and continues to be challenging to break. A recent ethnographic study from UK EDs, showed the importance of prioritising education and the effect the community has on retention of ED staff (49).

Figure 2 Cycle of burnout.

A cross-sectional study assessing the prevalence of burnout amongst EM healthcare workers, demonstrated higher rates of burnout amongst doctors (58%) and nurses (50%) compared to non-clinical staff (26%) (12). This suggests that job-specific roles such as being a leader, making clinical decisions under constant pressure and having responsibility for patients’ health may contribute to burnout (12). These high rates of burnout were associated with high rates of emotional exhaustion (44% for non-clinical staff, 68% of doctors and 61% of nurses) (12). Environmental factors within the ED contribute to an overall emotional exhaustion across all roles.

Sadly, it has been demonstrated consistently over the years that PEM/EM trainees are at the highest risk of burnout compared to other specialty doctors. Approximately 70% of PEM/EM trainees admitted that their work was emotionally exhausting and almost half described their work frustrating them to a high or very high degree (8). A recent meta-analysis and systematic review looked specifically at burnout within EM doctors (10). Data from a cohort including 1,943 EM clinicians showed that 40% experience high levels of emotional exhaustion and depersonalisation, higher than any other specialty. These findings were echoed in a survey study that found higher rates of emotional exhaustion and depersonalisation specifically in EM clinicians compared to other specialties (50).

The COVID-19 pandemic also augmented the emotional burden and moral injury in ED staff. a single-centre study conducted between 2015 and 2023 in Ireland found that COVID-19 and infection control measures specifically, were the least reported cause of stress amongst clinical and non-clinical staff (52). These findings echo the GMC survey findings, that it was the sheer workload itself, as well as staffing levels that appeared to contribute the most to staff stress levels (7). These increased rates of stress amongst staff contributed to increased rates of burnout (7,52).

What are the long-term consequences of burnout on healthcare workers?

There is growing discussion regarding the overall impact that high stress and burnout may have on PEM/EM trainees in the long run in their career. An overstretched workforce working relentlessly with little respite, in a high-pressured, crowded environment would be acknowledged by most as being neither healthy nor sustainable. A prospective cohort study examined the impact of early exposure to emotional distress on internal medicine trainees (54). They found that emotional distress, experienced specifically during training posts, persists in future practice and is associated with depersonalisation after ten years. This finding was also reported in a survey study that found a positive correlation between length of time in practice and levels of emotional exhaustion (50). This may imply that with more experience comes increased exposure to traumatic events, increasing the overall risk of burnout. This comes in contrast to results of prior studies that showed higher burnout rates in trainees (37-40) and underlines the difficulty of assessing potential risk factors for burnout.

Higher burnout rates in PEM/EM trainees also increase the potential risk for development of physical and mental health issues. For example, the UK National Training Survey by the GMC consistently reports that PEM/EM trainees face the highest risk of burnout among specialities, with the 2024 survey indicating a 34% risk of burnout among PEM/EM trainees. Although depression and anxiety are probably the most familiar of these, headaches, fatigue, sleep disturbances and substance misuse are common, along with cardiovascular disease and relationship breakdowns (8,53-56). A 2017 Accreditation Council for Graduate Medical Education report analysing causes of death in trainees in the United States (US) and a review on burnout, showed that approximately 10% of healthcare workers and trainees admitted considering suicide; suicide was the second most common cause of death in US trainees (57,58).

Poor mental health and wellbeing is estimated to cost the NHS an estimated £12.1 billion per year in employee absence (8). This further impacts the high-pressure workload that negatively affects staff morale and wellbeing (7,58).

What is the impact on patients?

The reduction in staff wellbeing directly impacts the standards and safety of care for patients and reduces patient satisfaction. This can be quantified by waiting times, “left without being seen” numbers and direct patient feedback, as used in a recent survey (8). Burnt-out staff are more likely to make mistakes, have conflicts with co-workers and show hostility towards patients (6,55). This could be explained by the depersonalisation experienced when staff becomes increasingly exhausted and emotionally withdrawn from practice. There is also a potential crossover with the phenomenon of compassion fatigue, which occurs due to chronic exposure to traumatic events rather than exclusively due to chronic exposure to workload stress (55,58).

Time constraints and high workload mean clinicians spend less time with patients, which impairs the patient-centred approach to our care. This leads to a reduction in patient satisfaction, where patients feel less involved in their care in circumstances when they are already feeling overwhelmed and vulnerable (56,59). Reduced patient satisfaction, in turn, is linked to decreased compliance with their medical treatment (56,59,60). To further compound this, burnt-out staff are less likely to be cognitively sharp, which can lead to additional errors and consequently, complaints (61,62).

What are the strategies and interventions to adopt against burnout?

In 2016, a systematic review and meta-analysis explored interventions to prevent and reduce doctors’ burnout (62). The study included 15 randomised controlled trials (RCTs) including 716 doctors and 37 cohort studies of 2,914 doctors. The MBI was used in all but one of the RCTs and all but three of the cohort studies (62).

Individual-focused interventions consisted of small group curricula, stress management and self-care training, communication skills training, and mindfulness-based approaches, whilst organisational interventions included adaptations of the work environment through shift pattern changes and modifications to the clinical work processes. Effects were consistent between RCTs and cohort studies, which allowed for the pooling of results. There was a significant reduction in emotional exhaustion, depersonalisation, and absolute burnout scores following these interventions (62). Results were similar for individual-focused and organisational interventions. However, the practical application of these results is limited as few studies included any long-term follow-up (58). These studies may also suffer from the Hawthorne effect in which participants alter their responses knowing that a burnout scale is being used (58,63). Furthermore, the MBI does not distinguish between work-related or non-work-related stress symptoms and none of the studies explored the combination of individual-focused and organisational interventions (42,62). Overall, the review demonstrated evidence of the utility of both intervention strategies but also highlighted the challenges with conducting quantitative research on clinician burnout. Another potential strategy to reduce burnout could involve training of PEM/EM healthcare workers on topics that could cause moral distress. This could be done via ethics discussion and reflection groups and education of healthcare workers on difficult decisions’ making process (64,65).

Individual-focused strategies to combat burnout are based upon the theory that burnout occurs due to a lack of sufficient coping resources, which leads to increased psychological injury from stressful and challenging situations (66). These strategies consider how individuals may improve their internal coping resources (66,67). A number of individual strategies are available which, in addition to those abovementioned, may also include a focus on relationships, work attitudes, and greater attentiveness to self (67). In addition to demonstrating utility, studies have also shown that these strategies may be more effective when tailored to the individual’s circumstances, personality traits, and wider contextual factors (66). The potential risk of focusing on individual strategies is that this may de-emphasise the broader organisational and environmental factors contributing to burnout, with no emphasis on putting fixes into the system (58).

The need for rest and organisational changes to the EM working environment are paramount (68-70). Organisational strategies aim to modify structural factors and implement policy and procedure changes to reduce the sources of stress (69). Further interventions may include organisational responses to violence and incivility, flexible scheduling adapted to childcare, and realistic workload and expectations (69,71). However, there are challenges with implementing organisational interventions which should be acknowledged. For example, large-scale changes may be difficult to achieve in already stretched departments that have limited resources and budget constraints (69). Despite potential challenges, all organisations should strive towards a culture of greater openness that embraces wellness and supports the growth of individuals (Figure 3).

Figure 3 Individual and organisational strategies to manage burnout.

More broadly, evidence suggests that emergency medicine clinicians with an academic, clinical education, or leadership component to their careers are less prone to burnout (72). Several studies have explored what qualities among academic doctors and clinical educators may be protective against burnout (30,72-74). A study involving 268 Canadian emergency medicine clinicians found that a successful research publication in the preceding two years was associated with lower emotional exhaustion and higher personal accomplishment scores (73). Similarly, a longitudinal study by the American Board of Emergency Medicine (ABEM) found that doctors involved in teaching, academia, or leadership roles were twice as likely to report high career satisfaction (74). The mentorship that often comes together with these roles was also associated with high career satisfaction (72,74). Mentorship may help guard against burnout due to peer support and career advancement (72). Although not all doctors desire a career in academia, clinical education, or leadership, there are still factors within this that may be transferable on both individual and organisational levels, for example, allowing clinicians to engage in complimentary meaningful work allied to medicine, providing peer support and mentorship, and ensuring career goals are supported.

What can be done now?

As evident, addressing burnout requires a multifaceted approach to supporting individuals, improving the work environment, and creating a culture of openness and well-being (presented on Figure 4). Based on current evidence, organisational and personal interventions should focus on:

• Reducing the exhausting workload of PEM/EM healthcare workers;
• Reducing administrative workload;
• Improving PEM/EM healthcare worker retention;
• Creating a community where healthcare workers wellbeing is supported and respected;
• Providing educational and leadership opportunities;
• Ensuring that long-term career goals are supported in multiple ways (e.g., providing mentorship).

Figure 4 Summary infographic with colleague’s tips for burnout recovery.

Further research should consider better capturing longitudinal assessments for concurrent confounders (e.g., psychiatric co-morbidity) and following up on the effects of interventions over a more significant period.

Limitations

As a narrative review of the literature, this study has methodological limitations due to the lack of quantitative synthesis. However, conducting a quantitative synthesis in this field is challenging because of the numerous confounders related to burnout and the wide variety of burnout measures used, which may minimise some points covered in this review. Therefore, the authors believe that a literature review provides a more comprehensive representation of the broader landscape of burnout literature, including ethical and deontological perspectives considerations such as moral distress that may not be captured in formal systematic review and meta-analyses, and offers insights into the relationships and outcomes in the emergency medicine field in the United Kingdom.

Conclusions

This review assessed the current landscape of burnout in the ED. Findings of this review highlight that burnout is not a new problem in the ED and that a career in PEM/EM compared to other subspecialties may put healthcare workers at higher risk of burnout. Based on available evidence, organisational and individual interventions focusing on reducing workload and optimizing wellbeing are needed. Future studies should focus on how to improve the well-being of ED healthcare workers, reducing burnout rates and improving retention rates.

Acknowledgments

The authors would like to acknowledge the ‘Don’t Forget The Bubbles’ team, in particular Andy Tagg, Dani Hall, Becky Platt, and Tessa Davis for their ongoing support of collaborative paediatric emergency medicine research and reviews.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://pm.amegroups.com/article/view/10.21037/pm-25-16/rc

Peer Review File: Available at https://pm.amegroups.com/article/view/10.21037/pm-25-16/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://pm.amegroups.com/article/view/10.21037/pm-25-16/coif). D.R. serves as the unpaid Executive Committee member of the Don’t Forget the Bubbles. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. National Training Survey 2024 Results. [cited 2025 July 30]. Available online: https://www.gmc-uk.org/-/media/documents/national-training-survey-summary-report-2024_pdf-107834344.pdf
2. Maslach C, Leiter MP. Understanding the burnout experience: recent research and its implications for psychiatry. World Psychiatry 2016;15:103-11.
3. Burn-out an ‘occupational phenomenon’: International Classification of Diseases. [cited 2024 Nov 15]. Available online: https://www.who.int/news/item/28-05-2019-burn-out-an-occupational-phenomenon-international-classification-of-diseases
4. Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet 2009;374:1714-21.
5. Shanafelt TD, Balch CM, Dyrbye L, et al. Special report: suicidal ideation among American surgeons. Arch Surg 2011;146:54-62.
6. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg 2010;251:995-1000.
7. Doe L. GMC National Training Survey findings could exacerbate retention problems in EM. RCEM. 2024 [cited 2024 Nov 18]. Available online: https://rcem.ac.uk/gmc-national-training-survey-findings-could-exacerbate-retention-problems-in-em/
8. National training surveys. [cited 2024 Nov 18]. Available online: https://www.gmc-uk.org/education/how-we-quality-assure-medical-education-and-training/evidence-data-and-intelligence/national-training-surveys
9. Petrino R, Riesgo LG, Yilmaz B. Burnout in emergency medicine professionals after 2 years of the COVID-19 pandemic: a threat to the healthcare system? Eur J Emerg Med 2022;29:279-84.
10. Zhang Q, Mu MC, He Y, et al. Burnout in emergency medicine physicians: A meta-analysis and systematic review. Medicine (Baltimore) 2020;99:e21462.
11. Somville F, Van Bogaert P, Wellens B, et al. Work stress and burnout among emergency physicians: a systematic review of last 10 years of research. Acta Clin Belg 2024;79:52-61.
12. Naidoo R, Schoeman R. Burnout in emergency department staff: The prevalence and barriers to intervention. S Afr J Psychiatr 2023;29:2095.
13. Hamdan M, Hamra AA. Burnout among workers in emergency Departments in Palestinian hospitals: prevalence and associated factors. BMC Health Serv Res 2017;17:407.
14. Alanazy ARM, Alruwaili A. The Global Prevalence and Associated Factors of Burnout among Emergency Department Healthcare Workers and the Impact of the COVID-19 Pandemic: A Systematic Review and Meta-Analysis. Healthcare (Basel) 2023;11:2220.
15. Tan ML, Pek JH, Wong SH. Burnout in emergency department personnel—A continuing concern post pandemic. Hong Kong J Emerg Med 2024;31:13-21.
16. Kondrich JE, Han R, Clark S, et al. Burnout in Pediatric Emergency Medicine Physicians: A Predictive Model. Pediatr Emerg Care 2022;38:e1003-8.
17. Yang L, Lei Y, Zhang R, et al. Common antecedents and outcomes of burnout among healthcare workers in the Emergency Department: A scoping review. Am J Emerg Med 2025;96:140-50.
18. Baethge C, Goldbeck-Wood S, Mertens S. SANRA-a scale for the quality assessment of narrative review articles. Res Integr Peer Rev 2019;4:5.
19. Burn-out an occupational phenomenon. [cited 2024 Nov 21]. Available online: https://www.who.int/standards/classifications/frequently-asked-questions/burn-out-an-occupational-phenomenon
20. Guseva Canu I, Marca SC, Dell’Oro F, et al. Harmonized definition of occupational burnout: A systematic review, semantic analysis, and Delphi consensus in 29 countries. Scand J Work Environ Health 2021;47:95-107.
21. de Beer LT, Bianchi R. Confirmatory Factor Analysis of the Maslach Burnout Inventory: A Bayesian Structural Equation Modeling Approach. Eur J Psychol Assess 2019;35:217-24.
22. Wheeler DL, Vassar M, Worley JA, et al. A Reliability Generalization Meta-Analysis of Coefficient Alpha for the Maslach Burnout Inventory. Educational and Psychological Measurement 2011;71:231-44.
23. Schaufeli WB, Desart S, De Witte H. Burnout Assessment Tool (BAT)-Development, Validity, and Reliability. Int J Environ Res Public Health 2020;17:9495.
24. Dyrbye LN, Meyers D, Ripp J, et al. A Pragmatic Approach for Organizations to Measure Health Care Professional Well-Being. NAM Perspectives. 2018;8:
25. Maslach C, Jackson SE. The measurement of experienced burnout. J Organ Behavior 1981;2:99-113.
26. Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory: Third edition. In: Evaluating Stress: A Book of Resources. Lanham, MD, USA: Scarecrow Education; 1997:191-218.
27. Li H, Dance E, Poonja Z, et al. Agreement between the Maslach Burnout Inventory and the Copenhagen Burnout Inventory among emergency physicians and trainees. Acad Emerg Med 2024;31:1243-55.
28. Swancott L, Armstrong N, Roland D, et al. Emergency department workforces’ experiences and perceptions of well-being from an international perspective: a scoping review. BMJ Open 2024;14:e087485.
29. Rao SK, Kimball AB, Lehrhoff SR, et al. The Impact of Administrative Burden on Academic Physicians: Results of a Hospital-Wide Physician Survey. Acad Med 2017;92:237-43.
30. Shanafelt TD, West CP, Sloan JA, et al. Career fit and burnout among academic faculty. Arch Intern Med 2009;169:990-5.
31. Gidwani R, Nguyen C, Kofoed A, et al. Impact of Scribes on Physician Satisfaction, Patient Satisfaction, and Charting Efficiency: A Randomized Controlled Trial. Ann Fam Med 2017;15:427-33.
32. Gottlieb M, Palter J, Westrick J, et al. Effect of Medical Scribes on Throughput, Revenue, and Patient and Provider Satisfaction: A Systematic Review and Meta-analysis. Ann Emerg Med 2021;77:180-9.
33. Rizvi M, Friedman BW, Fein DM, et al. The impact of scribes in an academic pediatric emergency department. Acad Emerg Med 2023;30:874-6.
34. Addesso LC, Nimmer M, Visotcky A, et al. Impact of Medical Scribes on Provider Efficiency in the Pediatric Emergency Department. Acad Emerg Med 2019;26:174-82.
35. Linzer M, Poplau S, Grossman E, et al. A Cluster Randomized Trial of Interventions to Improve Work Conditions and Clinician Burnout in Primary Care: Results from the Healthy Work Place (HWP) Study. J Gen Intern Med 2015;30:1105-11.
36. Estryn-Behar M, Doppia MA, Guetarni K, et al. Emergency physicians accumulate more stress factors than other physicians-results from the French SESMAT study. Emerg Med J 2011;28:397-410.
37. Norful AA, Brewer KC, Cahir KM, et al. Individual and organizational factors influencing well-being and burnout amongst healthcare assistants: A systematic review. Int J Nurs Stud Adv 2024;6:100187.
38. Aronsson G, Theorell T, Grape T, et al. A systematic review including meta-analysis of work environment and burnout symptoms. BMC Public Health 2017;17:264.
39. Galaiya R, Kinross J, Arulampalam T. Factors associated with burnout syndrome in surgeons: a systematic review. Ann R Coll Surg Engl 2020;102:401-7.
40. Zhou AY, Panagioti M, Esmail A, et al. Factors Associated With Burnout and Stress in Trainee Physicians: A Systematic Review and Meta-analysis. JAMA Netw Open 2020;3:e2013761.
41. Feeks C, Chao J, Sinert R. Prevalence and Risk Factors for Burnout in Pediatric Emergency Medicine Fellows. Pediatr Emerg Care 2020;36:236-9.
42. Rotenstein LS, Torre M, Ramos MA, et al. Prevalence of Burnout Among Physicians: A Systematic Review. JAMA 2018;320:1131-50.
43. Koutsouri AK, Gkentzi D, Paraskevas T, et al. Burnout Among Healthcare Workers During Covid-19 Pandemic: Results from Seven Hospitals in Western Greece. Mater Sociomed 2023;35:285-9.
44. Richardson KS, Greenle MM. Impact of Exposure to Patient Death or Near Death on Compassion Fatigue in Pediatric Intensive Care Nurses. Am J Crit Care 2020;29:285-91. [Crossref] [PubMed]
45. Tawfik DS, Phibbs CS, Sexton JB, et al. Factors Associated With Provider Burnout in the NICU. Pediatrics 2017;139:e20164134.
46. Dodek PM, Cheung EO, Burns KEA, et al. Moral Distress and Other Wellness Measures in Canadian Critical Care Physicians. Ann Am Thorac Soc 2021;18:1343-51.
47. Carletto S, Ariotti MC, Garelli G, et al. Moral Distress and Burnout in Neonatal Intensive Care Unit Healthcare Providers: A Cross-Sectional Study in Italy. Int J Environ Res Public Health 2022;19:8526.
48. Brune C, Agerholm J, Burström B, et al. Experience of moral distress among doctors at emergency departments in Stockholm during the Covid-19 pandemic: a qualitative interview study. Int J Qual Stud Health Well-being 2024;19:2300151.
49. Darbyshire D, Brewster L, Isba R, et al. Retaining doctors in emergency medicine: an ethnographic study of emergency departments in England. BMJ Open 2024;14:e086733.
50. Popa F, Arafat R, Purcărea VL, et al. Occupational burnout levels in emergency medicine--a stage 2 nationwide study and analysis. J Med Life 2010;3:449-53.
51. The state of medical education and practice in the UK. Workplace experiences 2024. Available online: https://www.gmc-uk.org/about/what-we-do-and-why/data-and-research/the-state-of-medical-education-and-practice-in-the-uk
52. Sathyanarayanan V, Daunt R, O’Sullivan I, et al. #106 Staff stress at work in the emergency department – a cross-sectional comparative study at Cork University Hospital between 2015 and 2023. In: Oral Presentations. BMJ Publishing Group Ltd and the British Association for Accident & Emergency Medicine; 2024:A1.1-A1. Available online: https://emj.bmj.com/lookup/doi/10.1136/emermed-2024-IAEM.1
53. Wise J. Burnout among trainees is at all time high, GMC survey shows. BMJ 2022;378:o1796.
54. Raimo J, LaVine S, Spielmann K, et al. The Correlation of Stress in Residency With Future Stress and Burnout: A 10-Year Prospective Cohort Study. J Grad Med Educ 2018;10:524-31.
55. Kumar S. Burnout and Doctors: Prevalence, Prevention and Intervention. Healthcare (Basel) 2016;4:37.
56. Arora M, Asha S, Chinnappa J, et al. Review article: burnout in emergency medicine physicians. Emerg Med Australas 2013;25:491-5.
57. Yaghmour NA, Brigham TP, Richter T, et al. Causes of Death of Residents in ACGME-Accredited Programs 2000 Through 2014: Implications for the Learning Environment. Acad Med 2017;92:976-83.
58. Stehman CR, Testo Z, Gershaw RS, et al. Burnout, Drop Out, Suicide: Physician Loss in Emergency Medicine, Part I. West J Emerg Med 2019;20:485-94.
59. Boudreaux ED, O’Hea EL. Patient satisfaction in the Emergency Department: a review of the literature and implications for practice. J Emerg Med 2004;26:13-26.
60. Lu DW, Weygandt PL, Pinchbeck C, et al. Emergency Medicine Trainee Burnout Is Associated With Lower Patients’ Satisfaction With Their Emergency Department Care. AEM Educ Train 2018;2:86-90.
61. Garcia CL, Abreu LC, Ramos JLS, et al. Influence of Burnout on Patient Safety: Systematic Review and Meta-Analysis. Medicina (Kaunas) 2019;55:553.
62. West CP, Dyrbye LN, Erwin PJ, et al. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet 2016;388:2272-81.
63. Sedgwick P, Greenwood N. Understanding the Hawthorne effect. BMJ 2015;351:h4672.
64. Huniche L, Milling L, Wittrock D, et al. Preventing burnout from moral distress among prehospital emergency personnel through action research and targeted clinical ethics support. Sci Rep 2024;14:31956.
65. Rasoal D, Skovdahl K, Gifford M, et al. Clinical Ethics Support for Healthcare Personnel: An Integrative Literature Review. HEC Forum 2017;29:313-46.
66. Adnan NBB, Dafny HA, Baldwin C, et al. What are the solutions for well-being and burn-out for healthcare professionals? An umbrella realist review of learnings of individual-focused interventions for critical care. BMJ Open 2022;12:e060973.
67. De Hert S. Burnout in Healthcare Workers: Prevalence, Impact and Preventative Strategies. Local Reg Anesth 2020;13:171-83.
68. Cottey L, Roberts T, Graham B, et al. Need for recovery and physician well-being in emergency departments: national survey findings. Eur J Emerg Med 2021;28:386-93.
69. Xu HG, Kynoch K, Tuckett A, et al. Effectiveness of interventions to reduce emergency department staff occupational stress and/or burnout: a systematic review. JBI Evid Synth 2020;18:1156-88. [Crossref] [PubMed]
70. Guille C, Sen S. Burnout, Depression, and Diminished Well-Being among Physicians. N Engl J Med 2024;391:1519-27. [Crossref] [PubMed]
71. Anger WK, Dimoff JK, Alley L. Addressing Health Care Workers’ Mental Health: A Systematic Review of Evidence-Based Interventions and Current Resources. Am J Public Health 2024;114:213-26.
72. Norvell JG, Baker AM, Carlberg DJ, et al. Does academic practice protect emergency physicians against burnout? J Am Coll Emerg Physicians Open 2021;2:e12329.
73. Lloyd S, Streiner D, Shannon S. Burnout, depression, life and job satisfaction among Canadian emergency physicians. J Emerg Med 1994;12:559-65. [Crossref] [PubMed]
74. Cydulka RK, Korte R. Career satisfaction in emergency medicine: the ABEM Longitudinal Study of Emergency Physicians. Ann Emerg Med 2008;51:714-722.e1.