Examining the determinants of resilience and mental stress in emergency department nurses

The emergency department (ED) is a vital hospital unit providing immediate care to acutely ill patients, with approximately 28% of hospital admissions occurring through the ED [1]. ED nurses, responsible for direct patient care, work in a dynamic environment characterized by high workload and rapid changes in patient conditions, leading to increased stress, burnout, and potential turnover [2, 3].

Nursing is generally recognized as a high-stress profession, with nurses exposed to various physical and psychological pressures [4]. The specific department and work environment in which nurses work play a critical role in determining their stress levels [5]. The ED presents unique challenges, such as patients’ critical conditions, exposure to the public, public scrutiny of nursing skills, fear of treatment failures, and time constraints [6, 7].

Factors such as globalization, increasing competition, rising migration, and changes in employment patterns have contributed to heightened psychological stress in workplaces [8, 9]. Stress, as a global phenomenon, affects all segments of society regardless of age, gender, race, socioeconomic status, or education level [10]. While some stress is normal and even essential for life, chronic or excessive stress, particularly in the absence of adequate coping mechanisms or sufficient support, can negatively impact individuals’ health [11].

The workplace is one of the primary sources of psychological stress [12]. Occupational stress has become a pervasive and costly issue, affecting both individual health and organizational performance [13]. Unmanaged occupational stress can compromise the quality of work and jeopardize employees’ mental health [14]. Healthcare workers, especially nurses working in hospitals, are exposed to high levels of occupational stress due to the nature of their work. Nursing is considered a high-risk profession for fatigue and illness [14‐16].

Nursing in the ED is associated with high levels of occupational stress [17]. In addition to the general stressors associated with the nursing profession, ED nurses face unique challenges such as fluctuations in patient volume, rapid changes in patients’ conditions, and the management of traumatic events and conflicts [18, 19]. High workload, exposure to patient mortality, unpredictable work patterns, shift work, inadequate psychological support, ambiguity in authority, and increasing bureaucratic burdens are among the factors that exacerbate occupational stress among nurses [20, 21].

Resilience is a critical factor for ED nurses facing high levels of occupational stress. It empowers them to cope with stressors such as critically ill patients, exposure to trauma, and time constraints, ultimately reducing burnout and promoting well-being. Resilience, defined as the ability to adapt to adverse conditions, equips nurses with positive coping strategies. Fostering resilience is essential for creating positive work environments and enhancing patient care [22‐27].

Considering the inherently stressful nature of nursing and individual variations in resilience and psychological pressure, this study examines the relationship between demographic factors, resilience, and psychological stress among ED nurses at Kermanshah University Hospitals in 2023. These hospitals serve as major referral centers for a large population in western Iran, managing a wide range of emergency cases, including trauma, cardiovascular diseases, and infectious diseases. The dynamic and high-pressure nature of the EDs in these hospitals, along with the diverse patient conditions, create a unique and challenging environment for nurses. This setting may influence the resilience and mental stress levels of nurses working in this environment and provide valuable insights into the factors affecting their well-being. Moreover, understanding how demographic factors interact with resilience and stress in this specific context can help develop targeted strategies to support nurses’ mental health and enhance the quality of patient care.

A total of 316 emergency room nurses participated in this study. The participants had a mean age of 34.5 years (SD = 6.6), ranging from 22 to 56 years. Their mean years of experience were 4 years (SD = 3.8). Of the participants, 55.5% were female, 55.9% were married, and 74.4% held a bachelor’s degree. Additional demographic information is presented in Table 1.

The mean mental stress score was 26.9 (SD = 8.3), ranging from 2 to 46, indicating a moderate level of mental stress. The mean resilience score was 64 (SD = 14.4), with a minimum of 13 and a maximum of 96. No significant differences were found in resilience scores based on gender, home ownership status, workplace emergency preparedness, place of residence, or type of hospital (p > 0.05). Analysis of variance revealed significant differences in resilience scores based on employment status, responsibility in the emergency room, and economic situation (p < 0.05) (Table 2).

No statistically significant differences in mean mental stress scores were found among ED nurses based on gender, home ownership status, or type of hospital (p > 0.05). However, significant differences were observed in mental stress scores according to workplace emergency status (p < 0.05), with nurses in outpatient departments reporting higher levels of stress compared to those in inpatient departments. Additionally, nurses residing in urban areas exhibited significantly higher mean mental stress scores than those living in suburban areas (p < 0.05). Marital status was not associated with mental stress levels among ED nurses (p > 0.05).

Analysis of variance revealed significant differences in mean mental stress scores based on number of children, education level, shift work, social network participation, employment status, emergency room responsibilities, and economic status (p < 0.05) (Table 3).

Pearson correlation analysis revealed a significant negative correlation between mental stress and resilience (r = -0.123, p < 0.05), indicating that as resilience increased, mental stress decreased. Additionally, a significant negative correlation was found between age and mental stress (r = -0.408, p < 0.001), suggesting that older nurses experienced lower levels of mental stress. Overtime hours per month were positively correlated with resilience (r = 0.135, p = 0.016) and negatively correlated with mental stress (r = -0.482, p < 0.001), indicating that nurses who worked more overtime hours had higher levels of resilience but also experienced higher levels of mental stress. No significant correlations were found between work experience, resilience, and mental stress (p > 0.05). Similarly, no significant relationships were observed between years of experience in the emergency room and resilience or mental stress (p > 0.05). These findings are summarized in Table 4.

Results indicated significant associations between resilience and employment status, emergency responsibilities, and economic status among ED nurses. Specifically, officially employed nurses exhibited higher mean resilience scores compared to other employment categories, while nurses undergoing mandatory service (mandatory service nurses) reported lower resilience levels. These findings align with previous research by Garrosa et al. and Graminejad et al., who also reported lower resilience among plan and corporate nurses [35, 36].

Potential explanations for these findings include the greater job security and benefits associated with official employment, which may contribute to increased job satisfaction and lower stress levels. Conversely, contractual employees often face job insecurity, lower wages, and fewer benefits, potentially leading to heightened psychological distress and reduced resilience [37, 38].

Furthermore, resilience levels varied significantly based on job responsibility within the emergency department. ED supervisors exhibited the highest levels of resilience, while bedside nurses reported the lowest. Paradoxically, despite greater responsibilities, supervisors demonstrated higher resilience, suggesting potential factors contributing to their role selection [39‐41].

Emergency and intensive care environments are characterized by demanding workloads and increased risk of burnout, job dissatisfaction, and turnover intentions [42, 43]. High resilience is crucial for nurses in these settings, enabling them to effectively cope with stress and maintain professional well-being. Our findings align with those of [30, 44] who emphasized the importance of resilience in high-pressure environments.

However, these results contradict the findings of Sotoodeh et al. (2021), who reported no significant differences in resilience between head nurses and staff nurses in a special care unit [45]. This discrepancy might be attributed to the distinct nature of emergency departments, which pose unique challenges compared to other units.

While our findings suggest that resilience levels vary significantly based on job responsibility within the emergency department, these results contradict those of Sotoodeh et al. (2021) who reported no significant differences in resilience between head nurses and staff nurses in a special care unit [45]. This discrepancy might be attributed to several factors, including differences in methodology (e.g., study design, measurement tools, variables examined), cultural contexts (e.g., healthcare system), and sample characteristics (e.g., sample size, demographic profiles, and the specific department studied). EDs and special care units differ significantly in terms of patient acuity, workload, and other factors that could influence nurses’ resilience levels. Further research is needed to explore these potential contributing factors in greater depth.

Our findings revealed a significant association between economic status and resilience among ED nurses. Specifically, nurses with higher economic status exhibited greater resilience compared to those with lower economic status. This finding aligns with the notion that economic factors can significantly influence individual well-being, particularly in challenging professions such as nursing.

Given the demanding nature of nursing, financial stress can exacerbate burnout and diminish resilience. Nurses facing economic hardship may experience increased anxiety and decreased job satisfaction, hindering their ability to provide optimal patient care. The current economic climate in Iran may exacerbate these challenges, as financial concerns can compound the stressors associated with the nursing profession [46‐48].

The identified associations between employment status, job responsibilities, and economic status with resilience levels suggest that contract nurses and nurses undergoing mandatory service (mandatory service nurses), particularly those with lower socioeconomic positions and inpatient roles, may exhibit reduced adaptive capacities. Individuals with low resilience often struggle to build strong social support networks, make sound decisions under pressure, and recover from adversity. They may experience difficulty setting and achieving goals, cope ineffectively with stress, and exhibit poor emotional regulation. Consequently, they may feel overwhelmed, helpless, and incapable of handling challenges, leading to impulsive decisions and a perceived lack of control over their lives [33].

However, significant differences in mental stress emerged based on the ED setting. Nurses in outpatient departments reported higher mean stress scores compared to those in inpatient units. This finding is consistent with the work of Falahat Pisheh et al. [49]. The increased stress experienced by outpatient nurses may be attributed to the often unpredictable and acute nature of patient conditions, leading to heightened anxiety and pressure. In contrast, inpatient settings typically involve more stable patient conditions, potentially contributing to a more controlled and less stressful work environment.

Our findings also revealed a significant difference in mean mental stress scores based on place of residence, with urban-dwelling nurses reporting higher levels of stress compared to suburban counterparts. This disparity may be attributed to the heightened psychological demands associated with urban living, including financial pressures, housing costs, and child-related concerns.

Additionally, the number of children was found to significantly influence mental stress levels. Nurses with two or three children reported higher mean stress scores compared to those with no or one child. The demands of childcare, coupled with the already stressful nature of nursing, may contribute to increased psychological burden among nurses with multiple children.

Our findings revealed significant differences in mental stress levels among different nurse categories. Project nurses experienced higher levels of stress compared to permanent staff due to job insecurity and career uncertainty. Additionally, nurses working rotating shifts (two or three shifts) reported higher stress levels than those on fixed shifts (one shift), aligning with the findings of Falahat Pisheh et al. but contradicting those of Abdi [49, 50]. Irregular work schedules associated with rotating shifts can disrupt sleep patterns and daily routines, contributing to increased stress.

Furthermore, nurses with lower educational qualifications exhibited higher levels of mental stress compared to those with higher degrees, contrary to the findings of Abdi [50]. A higher education level may equip nurses with better problem-solving skills, increased job satisfaction, and enhanced career prospects, potentially mitigating stress.

Additionally, we observed a positive correlation between social media use and mental stress levels. While this novel finding warrants further investigation, it is possible that the constant connectivity associated with social media may contribute to increased feelings of overwhelm and burnout among nurses. Future studies could explore the specific mechanisms underlying this relationship, such as the impact of social comparison or information overload.

Our findings indicate that nurses’ resilience is significantly correlated with their employment status, job responsibilities within the emergency department, and socioeconomic status. Moreover, factors such as place of residence, number of children, educational attainment, work shift patterns, social media use, and the aforementioned employment-related variables influence the level of mental stress experienced by ED nurses. A significant inverse relationship was observed between resilience and mental stress, suggesting that higher levels of resilience are associated with lower levels of stress. This study highlights the importance of considering demographic and occupational factors when examining the mental health and well-being of ED nurses. Our results underscore the need for healthcare organizations to prioritize the support and well-being of their nursing staff, particularly in terms of work-life balance, job security, and socioeconomic support. Given the significant findings regarding resilience and mental stress, we recommend implementing interventions and strategies to enhance resilience, reduce stress, and address job insecurity among ED nurses.