Prevalence and impact of burnout in Emergency Department nurses; a multi-center study in Riyadh, Saudi Arabia

Background: Burnout among healthcare professionals, particularly nurses, is a significant concern globally. Emergency department (ED) nurses, operating in high-stress environments, may be particularly vulnerable to burnout. This study aimed to investigate the prevalence of burnout and its association with various sociodemographic factors among ED nurses in Saudi Arabia. Study Aim: To determine the prevalence of burnout and identify sociodemographic factors associated with burnout among ED nurses. Methodology: A cross-sectional study was conducted involving 179 ED nurses in Saudi Arabia, to evaluate burnout, the Maslach Burnout Inventory was utilized. Categorizing scores into high and low burnout. Sociodemographic factors including age, gender, marital status, nationality, current housing status, and years of experience were analyzed for their association with burnout using chi-square tests. When a p-value was less than 0.05, statistical significance was reached. Results: The overall prevalence of burnout among ED nurses was 65.4%. Personal burnout was reported by 60.2% of participants, work-related burnout by 64.4%, and patient-related burnout by 49.8%. Younger nurses (25-29 years) demonstrated significantly higher burnout scores compared to other age groups (χ² = 10.843, p = 0.028). Saudi nationality was associated with higher burnout prevalence (χ² = 10.505, p = 0.033). Significant correlations were found between personal, work-related, and patient-related burnout domains (p < 0.001). Conclusion: The interconnected nature of burnout domains emphasizes the need for comprehensive interventions. These findings provide insights for healthcare organizations to develop targeted strategies to mitigate burnout among ED nurses and enhance overall workforce well-being.


INTRODUCTION
The demanding nature of healthcare professions, particularly those within emergency departments (EDs), places a substantial burden on the well-being of healthcare professionals (Popa et al., 2010).Among these, nurses, as frontline providers, often encounter high levels of emotional tiredness and stress, which are contributing to a phenomenon widely recognized as burnout (Li et al., 2018;Gómez-Urquiza et al., 2017).Burnout is a complex and multifaceted psychological syndrome characterized by chronic workplace stress that has not been effectively managed (Kristensen et al., 2005).It encompasses emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment, ultimately impacting both the individual and the quality of patient care (Dall'Ora et al., 2020).Concern over the occurrence of burnout among healthcare workers has grown on a worldwide scale (Popa et al., 2010).
Numerous studies have demonstrated alarmingly high rates of burnout across various healthcare settings, with emergency healthcare workers particularly susceptible (Stehman et al., 2019).The unique challenges posed by the fast-paced, unpredictable, and often traumatic nature of emergency care contribute to elevated stress levels and burnout risk among emergency department staff (Li et al., 2018;Tarcan et al., 2017).Burnout not only detrimentally affects the well-being of healthcare professionals but also has profound implications for patient care and the overall healthcare system (Gómez-Urquiza et al., 2017).The emotional exhaustion component of burnout can lead to reduced empathy and compassion, potentially compromising the quality of patient-provider interactions (Salyers et al., 2017).Depersonalization, another key dimension of burnout, may result in a sense of detachment and cynicism towards patients, further eroding the humanistic aspects of care (Dall'Ora et al., 2020; West et al., 2018).
The diminished personal accomplishment associated with burnout may contribute to feelings of inefficacy and a reduced sense of professional achievement (Dall'Ora et al., 2020; West et al., 2018).Within the healthcare workforce, emergency department nurses represent a critical group, often serving as the first point of contact for patients in crisis (Li et al., 2018;Harkin and Melby, 2014).The unique stressors in the ED, including high patient acuity, time pressures, and exposure to trauma, intensify the challenges faced by these nurses (Lee et al., 2021).Despite their crucial role in healthcare delivery, ED nurses are susceptible to burnout, potentially leading to workforce shortages, decreased job satisfaction, and compromised patient safety (Hooper et al., 2010).Internationally, research on burnout among healthcare professionals, including nurses, has gained prominence.
Research from a number of nations has demonstrated how common burnout is and how badly it affects healthcare systems (Lee et al., 2021;Abellanoza et al., 2018).Cross-cultural investigations have identified common themes in burnout experiences, such as long working hours, inadequate staffing, and insufficient organizational support (Li et al., 2018).However, the unique sociodemographic and cultural context of each healthcare system introduces variability in the prevalence and manifestation of burnout (Lee et al., 2021;Hooper et al., 2010).In the context of Saudi Arabia, different studies have explored burnout among healthcare professionals, particularly among emergency department nurses (Alqahtani et al., 2019;Siam and Alrasheedi, 2022).The cultural nuances, organizational structures, and unique stressors in the Saudi healthcare system warrant specific attention (Li et al., 2018).Understanding the factors contributing to burnout in this context is crucial for developing targeted interventions and support systems (Popa et al., 2010).

Study Aim
The primary aim of this research is to assess the prevalence and determinants of burnout among emergency department nurses in Saudi Arabia.

To quantify the prevalence of burnout among emergency department nurses
To explore the associations between burnout and key sociodemographic factors To investigate potential variations in burnout prevalence and its dimensions among emergency department nurses working in two different healthcare institutions, comparing findings between King Saud University Medical City (KSUMC) and the National Guard Health Affairs (NGHA).

Study Design
This study employed a cross-sectional design to investigate the prevalence of burnout among emergency department (ED) nurses in Saudi Arabia and explore its association with sociodemographic factors.Cross-sectional studies are valuable for capturing a snapshot of a population at a specific point in time, allowing for the examination of relationships between variables without implying causation.

Study Setting and Participants
The study was conducted in two major tertiary care hospitals in Saudi Arabia: King Saud University Medical City (KSUMC) and the National Guard Health Affairs Hospital (NGHA) among 179 emergency department nurses in the period from May 2023 to Nov 2023.These hospitals were chosen for their diverse patient populations and the high-stress nature of their EDs.Participants included registered nurses working in the EDs of these hospitals.The inclusion criteria comprised nurses with at least six months of ED experience, ensuring an adequate understanding of the work environment.

Data Collection
Data were collected using self-administered questionnaires distributed among ED nurses.The questionnaires consisted of sections on sociodemographic information, burnout assessment, and work-related characteristics.The primary instrument for measuring burnout was the Copenhagen Burnout Inventory (CBI), a validated tool widely used in healthcare research.The CBI encompasses three subscales: Personal burnout, work-related burnout, and patient-related burnout.

Statistical Analysis
Data analysis was performed using appropriate statistical methods.Descriptive statistics were used to characterize the sociodemographic profile of the participants.Burnout scores were reported as means ± standard deviations.We used a cut-off point (>50) to categorize respondents into high burnout (score: >50), or low burnout (score: ≤50).To assess the association between burnout and sociodemographic variables, analysis of variance (ANOVA) tests were employed for continuous variables, while t-tests were used for binary variables.Chi-square tests were utilized to examine the association between categorical variables and burnout prevalence.
Significance was set at p < 0.05.To explore potential variations in burnout across different subgroups, subgroup analyses were conducted based on age, gender, marital status, nationality, current housing status, hospital, and years of experience as an emergency nurse.These analyses aimed to identify specific demographic groups that might be particularly vulnerable to burnout, providing insights for targeted interventions.

RESULTS
The study's 179 emergency department nurses' sociodemographic details are displayed in (Table 1).The age distribution of the participants reflects a diverse range, with the majority falling between 25 and 34 years old, comprising 25.7% aged 25-29 and 28.5% aged 30-34.The age groups of 35-39, 40-44, and those over 45 years old represent 24.6%, 10.1%, and 11.2%, respectively.In terms of gender, the nursing staff in the study is predominantly female, constituting 83.2% of the participants, while male nurses make up 16.8%.The marital status of the participants is diverse, with half of the nurses being single (50.3%), while 43% are married.A smaller percentage comprises divorced (5%) and widowed (1.7%) individuals.The nationality distribution of the nurses indicates a mix of cultural backgrounds, with Saudi nationals representing 25.1%, GCC nationals at 2.8%, Filipinos comprising the highest percentage at 46.9%, Indians at 14%, and others accounting for 11.2%.
Regarding housing status, the nurses demonstrate diverse living arrangements, with 30.7% living alone, 29.1% with roommates, and 40.2% residing with their families.The participating nurses are evenly distributed between King Saud University Medical City (KSUMC) and the National Guard Hospital (NGHA), with 50.3% and 49.7%, respectively.The distribution of years of experience among the emergency nurses reveals that the majority have more than 3 years of experience (66.5%), while 20.1% have 1-3 years of experience, and 13.4% have less than 1 year of experience.Table 2 offers a thorough analysis of the emergency department nurses that were part in the study.It does this by classifying their experiences into the following categories: "Never", "Seldom", "Sometimes", "Often", and "Always".In the domain of personal burnout, a substantial proportion of nurses reported feeling tired (36.9% often, 23.5% always) and physically exhausted (38.5% often, 26.8% always), highlighting the prevalence of fatigue among this cohort.
Emotional exhaustion was also notable, with 35.2% reporting feeling emotionally exhausted sometimes and 33.5% often.Furthermore, a significant percentage expressed thoughts of not being able to endure their workload, with 41.3% sometimes and 25.1% often feeling this way.The work-related burnout items revealed that a considerable number of nurses found their work emotionally exhausting (36.3% sometimes, 21.2% always) and felt burnt out because of their work (35.2% sometimes, 24.6% always).Patient-related burnout was also evident, with 48% reporting finding it hard to work with clients sometimes and 14% always.Table 3 presents the average CBI scores and burnout prevalence among the participants.The overall CBI score reflects a mean of 57.4 ± 16, indicating a moderate level of burnout among the nurses.Personal burnout scores are notably higher, with a mean of 62.7 ± 18.9.Similarly, the work burnout score is elevated, with a mean of 61.3 ± 17.7, indicating a significant level of burnout related to job-related factors (Figure 1).
The patient-related burnout score has a mean of 47.7 ± 20.2, suggesting a comparatively lower impact of client interactions on burnout.The prevalence of high burnout across all dimensions is considerable.Overall, 65.4% of the nurses experience high burnout, with 34.6% reporting low burnout.In terms of personal burnout, 66.5% report high burnout, while 33.5% report low burnout.Similarly, work-related burnout is prevalent, with 68.2% experiencing high burnout and 31.8%reporting low burnout.For patient-related burnout, 36.3% report high burnout, and 63.7% report low burnout.Table 4 illustrates the association between average CBI scores and various sociodemographic factors among the emergency department nurses.In terms of age, the analysis reveals no statistically significant differences in overall burnout scores (p = 0.07).However, a trend is observed, where nurses aged 30-34 years tend to have higher overall burnout scores (59.9 ± 15.7) compared to other age groups.
Similar patterns are observed in personal and work-related burnout, suggesting a potential age-related influence on burnout that may warrant further investigation.For patient-related burnout, the difference across age groups is not statistically significant (p = 0.087), but a trend suggests higher burnout scores among younger age groups.The analysis of gender indicates no statistically significant differences in overall, personal, and work-related burnout scores (p > 0.05).However, male nurses tend to have higher patient-related burnout scores (52.5 ± 18) compared to their female counterparts (46.7 ± 20.6), although the difference is not statistically significant (p = 0.123).Marital status analysis shows no statistically significant differences in overall and work-related burnout scores (p > 0.05).However, there is a trend indicating that divorced nurses have lower personal burnout scores (52.8 ± 12.4), potentially suggesting a protective factor associated with this marital status.Patient-related burnout scores also show no significant differences across marital status categories.
Nationality emerges as a significant factor influencing burnout, with Saudi nurses demonstrating higher overall (p = 0.023), personal (p = 0.086), and work-related (p = 0.03) burnout scores compared to other nationalities.This finding raises questions about cultural and contextual factors contributing to burnout among Saudi nurses.Patient-related burnout scores, however, do not show significant differences across nationalities.Current housing status does not significantly affect overall, personal, or work-related burnout scores (p > 0.05).Similarly, patient-related burnout scores exhibit no significant differences among nurses with different housing arrangements.Hospital affiliation shows a notable difference in overall and work-related burnout scores between nurses at King Saud University Medical City (KSUMC) and the National Guard Hospital (NGHA).Nurses at KSUMC exhibit lower burnout scores overall (p = 0.067) and specifically in the work-related domain (p = 0.036).This suggests potential variations in work environments or organizational factors contributing to burnout among nurses from different hospitals.Years of experience as an emergency nurse do not significantly impact overall, personal, and work-related burnout scores (p > 0.05).However, a trend is observed in patient-related burnout scores, where nurses with less than 1 year of experience tend to have higher scores (55. 2 ± 15.8).This indicates that the duration of experience may influence the perception of patient-related burnout.Table 5 presents the prevalence of burnout among emergency department nurses, examining the association with various sociodemographic factors.For age groups, statistically significant differences in the prevalence of overall burnout are observed (χ^2 = 10.843,p = 0.028).Nurses aged 30-34 years exhibit the highest prevalence of overall burnout (76.5%), while those aged 40-44 years have a lower prevalence (50%).A similar pattern is noted in personal and work-related burnout, indicating potential age-related variations in burnout experiences.
Patient-related burnout, however, does not show significant differences across age groups.Regarding gender, the prevalence of overall burnout is not much different amongst nurses who are male and female.(χ^2 = 1.011, p = 0.315).However, male nurses demonstrate a higher prevalence of work-related burnout (80%) compared to their female counterparts (66.4%).This gender-based variation in the specific domain of work-related burnout is noteworthy.Marital status analysis reveals no significant differences in the prevalence of overall burnout (χ^2 = 4.135, p = 0.247).While the prevalence of burnout is higher among single nurses (68.9%), divorced and widowed nurses show relatively lower prevalence.Patient-related burnout does not significantly differ across marital status categories.Nationality emerges as a significant factor influencing burnout prevalence, with Saudi nurses exhibiting higher overall burnout (χ^2 = 10.505,p = 0.033).Filipino nurses also demonstrate a relatively higher prevalence of overall burnout (64.3%).Patientrelated burnout shows significant differences across nationalities (χ^2 = 10.839,p = 0.028), with Saudi and Filipino nurses having distinct prevalence rates.
Current housing status does not significantly impact the prevalence of overall burnout (χ^2 = 0.674, p = 0.714).Similar findings are observed for personal, work-related, and patient-related burnout, indicating that the living arrangement does not play a significant role in burnout prevalence among the studied nurses.Hospital affiliation reveals variations in burnout prevalence, with nurses from King Saud University Medical City (KSUMC) exhibiting a slightly lower overall burnout prevalence compared to those from the National Guard Hospital (NGHA) (χ^2 = 2.3, p = 0.129).Work-related burnout, however, shows significant differences (χ^2 = 3.411, p = 0.065), suggesting potential organizational factors contributing to variations in this specific domain.Years of experience as an emergency nurse do not significantly influence the overall burnout prevalence (χ^2 = 3.702, p = 0.157).However, nurses with less than 1 year of experience tend to have a higher prevalence of overall burnout (75%).Work-related burnout also shows variations across experience levels, but the differences are not statistically significant.
5. CONCLUSIONIn conclusion, our study sheds light on the prevalence and factors influencing burnout among emergency department nurses in Saudi Arabia.The high prevalence of burnout, particularly among younger nurses and those of Saudi nationality, emphasizes the need for targeted interventions.Recognizing the interconnected nature of burnout domains and addressing sociodemographic factors in interventions can contribute to the well-being of emergency department nurses and, by extension, the quality of patient care.This research contributes to the growing body of knowledge on burnout among healthcare professionals and provides a foundation for further investigations into tailored interventions and preventive strategies.By understanding the unique sociodemographic factors influencing burnout in specific healthcare settings, healthcare organizations can foster environments that promote nurse well-being and, consequently, enhance the overall resilience of the healthcare workforce.

Table 1
Sociodemographic characters of the included nurses (n=179).

Table 2
CBI items and responses among the included nurses (n=179).

Table 3
Average CBI scores and burnout prevalence among the included nurses (n=179).
Figure 1 Boxplot of average CBI scores among included nurses.

Table 4
Average CBI scores in association with sociodemographic characters (n=179).

Table 5
(Sabbah et al., 2012ez-Urquiza et al., 2017)ciodemographic characters (n=179).complexhealthcaresystems(Lietal., 2018;Gómez-Urquiza et al., 2017).The influence of nationality on burnout experiences has been explored in various cultural contexts.Cultural differences in work expectations, social support systems, and coping mechanisms may contribute to varying burnout experiences across nationalities, as observed in our study(Sabbah et al., 2012; Shams and El-Masry, 2013; Al-Dubai and Rampal, 2010).Our findings have practical implications for healthcare organizations aiming to address burnout among emergency department nurses.Interventions should be tailored to the specific needs of different age groups and consider the cultural nuances influencing burnout experiences.Implementing mentorship programs for younger nurses, promoting a supportive organizational culture, and providing resources for coping and resilience-building are potential strategies.Future research should delve deeper into the qualitative aspects of burnout experiences among emergency department nurses, exploring the contextual factors contributing to the observed patterns.Additionally, longitudinal studies can provide insights into the dynamic nature of burnout, tracking changes over time and identifying potential risk and protective factors.