A systematic review of psychological distress reduction programs among nurses in emergency departments

Healthcare workers are entrusted with high-stress responsibilities, often leading to challenging work conditions and psychological issues [1]. According to the National Institute for Health Care Management [2], 35–54% of healthcare workers in the U.S. experience significant burnout. In China, 27.7% of healthcare workers report symptoms of depression, anxiety, and burnout [3], often attributed to factors such as workload, shift schedule and service demands [4]. Organizational and societal issues, such as strained nurse-patient relationships, lack of support or respect, and job insecurity, can exacerbate stress [5]. Moreover, events such as public health emergencies can further intensify the mental health risks faced by healthcare workers. Compared to other professions, healthcare workers, particularly nurses who have sustained patient contact, are more prone to psychological distress. The combination of high job demands, complex tasks, and long working hours increases their vulnerability to mental health challenges [6, 7].

In China, emergency medical services are responsible for providing first aid to the public and responding to large-scale emergencies. The core of these services is in-hospital emergency care, centered around the emergency room. This department handles patients with acute, severe conditions and takes on the most critical and demanding rescue tasks in the hospital. Emergency department (ED) nurses play a vital role in these operations, performing rapid health assessments, injury detection, triage, emergency care, psychological support, and coordination with patients and their families [8]. However, unlike the pre-hospital care personnel and ED nurses in many European countries and the United States, who are required to complete relevant courses and internships, possess qualifications, and undergo annual training [9, 10], pre-hospital emergency care personnel in China lack unified qualifications. Specifically, ED nurses in China are progressively trained in emergency procedures only after they start working in the emergency department, which contrasts with the formal pre-training systems in many other countries [9].

In summary, ED nurses manage a high volume of unpredictable and complex cases, often moving from one emergency to another in a short period [11, 12]. The combination of a wide range of responsibilities, heavy workloads, and insufficient pre-training contributes to the significant physical and mental stress for ED nurses in China.

ED nurses experience higher levels of distress from physical, psychological, and social factors compared to other healthcare workers. They frequently face acute care challenges and traumatic events, including severe injuries, critical illnesses, resuscitations, deaths, abuse, and suicides. Prolonged exposure to these high-stress situations often leads to physical and emotional exhaustion, negatively impacting their mental health [13]. A survey conducted by Yang et al. among 120 ED nurses in northwestern China revealed that these nurses experience moderate-to-high levels of stress, surpassing the stress levels of clinical medical and surgical nurses [14]. Similarly, Zhu et al. found that the incidence of post-traumatic stress disorder (PTSD) among ED nurses ranges from 19 to 33%, significantly higher than the 14% rate found among medical and surgical nurses [15]. A study by Butera et al. also reported that before the COVID-19 pandemic, burnout rates among ED nurses were significantly higher than those among ICU nurses, with rates of 70% and 51%, respectively [16]. Work overload, shift work, and long hours of mental stress can also contribute to the physical and psychological distress of ED nurses. In Shandong Province, China, a survey of 98 ED nurses showed that 71.4% reported fatigue and lethargy, 53.1% experienced muscle tension and lower back pain, and 48.9% suffered from sleep disturbances [17]. Additionally, ED nurses often work in poor environments where workplace violence (WPV, including physical and verbal assault and intimidation) from patients and family members affects up to 90% of nurses, which can increase nurses’ insecurity and occupational risks [13]. Such negative effects can be conceptualized as psychological distress. According to Ridner, psychological distress occurs when a person encounters a stressor viewed as threatening or experiences ineffective coping and a sense of loss of control and thus falls into a discomforting emotional state [18]. Psychological distress can cause temporary damage, for which recovery is possible, as well as permanent damage, such as suicide, hypertension, and heart attacks [18].

Although emergency departments in China differ from those in Europe and the United States, the mental health status of nurses with the same responsibilities is reflected in relevant studies conducted in different countries. For example, Cook et al. conducted a survey at the University of Texas (UT) Health Tyler, a 502-bed tertiary Level 1 trauma center, involving 98 nurses from the emergency department, ICU, and trauma ward [19]. The findings revealed that burnout rates were higher among ED nurses compared to those in the ICU and trauma wards [19]. Similarly, a web-based survey by Butera et al. in Belgium, with 2,058 participants, found that ED nurses had a higher risk of burnout than ICU nurses [16]. The psychological distress experienced by ED nurses has broader implications for the quality of care and socioeconomic factors. A cross-national study showed that burnout among ED nurses is associated with lower quality of patient care [20]. Furthermore, are strongly linked to higher turnover rates, resulting in the loss of experienced staff, understaffing, and increased costs for recruitment and training of new employees [21, 22].

In order to effectively address the aforementioned multifaceted psychological distress, researchers have developed and implemented a series of reduction programs. Previous studies focused on either specific interventions or the general nurse population. Ghawadra et al. conducted a systematic review of nine mindfulness-based stress reduction (MBSR) interventions for nurses, finding that MBSR helped reduce stress, anxiety, depression, burnout, and increased job satisfaction [23]. Karo et al. similarly reviewed randomized controlled trials (RCTs) on MBSR, concluding that MBSR significantly reduces stress and depression among nurses [24]. In another systematic review, Joseph and Jose found that mindfulness-centered interventions could effectively reduce distress and burnout while enhancing resilience and compassion in healthcare professionals working in emergency and critical care departments [25]. However, the interventions specifically targeting ED nurses remain limited. Sun et al. conducted an 8-week mindfulness decompression training for 100 ED nurses in a Chinese hospital, using both online and offline methods [26]. Their pre- and post-tests revealed improvements in mindfulness, quality of life, and reduced burnout [26]. Similarly, Caponnetto et al. implemented a stress management program involving autogenic training for 28 physicians and nurses in an Italian emergency room, finding that stress management improved quality of life, work motivation, and stress perception [27]. Although these studies showed positive effects on psychological distress, they were limited by small sample sizes and lacked RCT designs, making it difficult to assess the effectiveness of the interventions and to generalize.

To date of research, no systematic review of psychological distress reduction programs for ED nurses has been conducted. This study aims to fill the gap. In addition, both the primary outcomes (e.g., depression, anxiety, PTSD, and stress) and secondary outcomes (e.g., burnout, quality of life, and satisfaction) of psychological distress [23, 28] were examined. This study proposed the following research questions: (1) What interventions are currently available? (2) What types of interventions are worthy of further development? (3) What elements of psychological distress are interventions focusing on and how effective are they? (4) What are the shortcomings of existing interventions?

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement for the literature search and screening, the data coding and analysis, and the results reporting [29].

This study systematically summarizes the main points of evidence-based psychological distress reduction programs for ED nurses. The review includes a total of 29 studies, which can be categorized as psychological interventions, educational programs, and organization-directed interventions, based on the different intervention objectives and characteristics. These interventions can help ED nurses reduce their stress, depression, anxiety, burnout, and PTSD and enhance their life satisfaction and quality.

Psychological interventions such as CBT, MBSR, and the solution-focused approach are theory driven and involve structured steps [49, 53, 60]. Such interventions are well established and vary in form and can be conducted in groups or in an individual basis [52, 56], such as brainstorming, group games, scenarios, and theoretical explanations [54, 55]. While these interventions have proven effective in reducing stress, depression, anxiety, burnout, and PTSD among ED nurses [38, 40, 50], their effectiveness in promoting stress coping strategies remains uncertain, with varying research outcomes [38, 50]. Moreover, the included studies focused on addressing existing psychological problems and provided no preventive measures or recommendations.

Educational programs are centered around the development of coping skills for emergency department work, such as death education, time management, coping with WPV, and early warning mechanisms [34, 36, 37, 62]. These interventions are essential as they align with the unique challenges of ED nursing, including exposure to violence and death, thereby enhancing nurses’ ability to navigate risks in their work environment. The long-term effects of educational programs are critical because they do not provide immediate relief from psychological distress. For example, the studies by Chang et al. and Zhang et al. indicate that these programs primarily improve nurses’ self-efficacy and understanding of specific issues [37, 62]. Future research is needed to assess whether educational programs can effectively reduce psychological distress among ED nurses. Among the studies, only one educational program conducted a follow-up investigation and they did not report the time of the follow-up [36], which should be improved in the future.

Organization-directed interventions aim to reduce the incidence of psychological distress by changing the stressors, management systems, and social environments. Existing interventions include quality circles, flexible management, and comprehensive management [35, 41, 65]. However, studies on such interventions are few. This scarcity may be due to challenges in implementation, such as organizational structure, personnel cooperation, and funding constraints [66]. In contrast, educational programs and psychological interventions are easier to implement sustainably, because they do not disrupt daily work [67]. It should be noted that psychological distress cannot be alleviated effectively without addressing the underlying issues within the healthcare system and relying solely on personal adaptation approaches [66]. Current interventions often lack clarity, with improvements primarily focused on management styles, such as providing verbal encouragement and psychological support [65]. However, studies have not adequately addressed workload reduction, emergency management optimization, or environmental stress relief, despite widespread advocacy for these methods [5, 68]. In the future, organization-directed interventions need to explore more structured intervention mechanisms and improve the working environment for ED nurses in multiple ways, such as policy advocacy and patient education. Another noteworthy point is that ED nurses should be equally involved in the change. Building their capacity for effective decision-making, collaboration, skilled communication, and meaningful recognition is vital, as these factors directly relate to their stressors and ability to manage stress-related situations [69].

The above analysis explores the advantages and disadvantages of the three types of interventions. The disadvantages of the interventions may affect their stability and credibility. In addition to the limitations of the interventions, their main drawbacks stem from the irregularities in their content design and intervention delivery. For example, Li et al. reported the use of CBT in the study design but did not draw on behavioral theory in the actual intervention [46]. Hosseinabadi et al. conducted a 3-month quality circle but reported a 28.6% dropout rate [35], though a dropout rate of 20% or less is generally accepted in psychological research [70]. Furthermore, only two studies conducted follow-up investigation [36, 38], and the long-term effects of most of the interventions remain unknown. Therefore, experts should be invited to guide the intervention design and implementation, and RCTs should be conducted by using the CONSORT checklist to ensure the effectiveness and scientific validity of the interventions [71].

The sample sizes of the included studies are too small to be generalizable, and only four studies reported the calculation of the sample size [32, 33, 37, 38]. According to the CONSORT checklist [71], sample size estimation is an important part of RCTs, and a reasonable sample size is a crucial safeguard for obtaining high-level clinical research results. Researchers should be rigorous in their sample size calculation and engage actively in inter-hospital collaboration to expand the sample size. Researchers can also conduct meta-analyses to assess the effectiveness of specific intervention methods.

The duration of the psychological interventions and organization-directed interventions is typically 1–4 months [41, 60], whereas that of the educational programs is generally 1–2 days [34, 62]. The frequency of the interventions ranges from 3 times a day to once every 2 weeks, and the duration of each intervention ranges from 0.5 h to 3 h [45, 46]. The differences in the intervention methods can be explained. For example, relaxation or music therapy is associated with frequent but short interventions, whereas the opposite is true for CBT. However, some differences should be noted. For instance, the included studies conducted MBSR for 4, 6, and 8 weeks [38, 40, 50]. Specifically, Kabat-Zinn developed an 8-week MBSR program [51], and in their systematic review, Ghawadra et al. showed that a 4-week MBSR can reduce nurses’ psychological distress [23]. The dose-response relationship remains unknown; thus, the duration (e.g., 4 versus 6 versus 8 weeks) and frequency (e.g., once a week versus twice a week) of interventions should be varied.

Most current measures of the effectiveness of psychological distress reduction programs for ED nurses use self-rating scales, which may be influenced by subjective factors and thus affect the accuracy of the assessment results. In future studies, objective measures such as blood pressure, heart rate, and salivary amylase may be employed [33]. Once the psychological distress levels of ED nurses improve, the effectiveness of an intervention should be assessed further in terms of work tasks and efficiency, such as in changes in patient care, incidence of medical emergency team activations, unplanned intensive care admissions, and unexpected deaths [72]. The results of such assessments can provide evidence for the effectiveness of interventions in improving the mental health of ED nurses and thus the quality of emergency care.

The analysis of the characteristics of the three intervention types reveals their limitations and core differences in their objectives. Organization-directed interventions are designed to reduce stressors at the organizational or systemic level [73], and educational programs are designed to improve nurses’ competencies to cope with stressors. Meanwhile, psychological interventions directly target the outcomes of psychological distress to alleviate negative outcomes (e.g., stress, anxiety, depression, PTSD, and burnout) and enhance positive ones (e.g., life satisfaction and quality). The combination of the strengths of the three intervention types can effectively help ED nurses alleviate their psychological distress. First, psychological interventions should be categorized as preventive projects and therapeutic interventions. Preventive projects aim at improving nurses’ comprehensive capacity. For instance, a study showed that positive psychology interventions have a significant small-to-medium effect on well-being, strengths, depression, anxiety, and stress, which remains stable over a three-month period [74]. Therapeutic intervention programs can provide specialized psychological interventions for ED nurses with serious psychological problems, such as PTSD, anxiety, and depression. Second, educational programs can be combined with in-service classes [37], and follow-up appraisals should be conducted. Last, organization-directed interventions can be conducted through pilot programs and high-quality RCTs with a large sample size to assess their feasibility and effectiveness [66]. Policymakers and medical administrators should promote system optimization through policy advocacy and improved legislation to promote a positive working environment and atmosphere for ED nurses. ED nurses should be equally involved and empowered to improve their work environment.

Three types of interventions have provided pathways to alleviate the psychological stress of ED nurses at various levels. In the future, efforts should focus on improving the standardization and scientific rigor of psychological interventions, while also assessing the long-term effects of both psychological interventions and educational programs. For organization-directed interventions, developing effective models through pilot programs and RCTs will be crucial to fostering a healthier work environment. Policymakers and medical administrators must support these initiatives, focusing on prevention and empowerment.