Introduction Ineffective coping may lead to impaired job performance and burnout, with adverse consequences to staff well-being and patient outcomes. We examined the relationship between coping styles and burnout in emergency physicians, nurses and support staff at seven small, medium and large emergency departments (ED) in a Canadian health region (population 500 000).
Methods Linear regression with the Coping Inventory for Stressful Situations (CISS) and Maslach Burnout Inventory (MBI) was used to evaluate the effect of coping style on levels of burnout in a cross-sectional survey of 616 ED staff members. CISS measures coping style in three categories: task-oriented, emotion-oriented and avoidance-oriented coping; MBI, in use for 30 years, assesses the level of burnout in healthcare workers.
Results Task-oriented coping was associated with decreased risk of burnout, while emotion-oriented coping was associated with increased risk of burnout.
Discussion Specific coping styles are associated with varied risk of burnout in ED staff across several different types of hospitals in a regional network. Coping style intervention may reduce burnout, while leading to improvement in staff well-being and patient outcomes. Further studies should focus on building and sustaining task-oriented coping, along with alternatives to emotion-oriented coping.
- emergency department
- psychology, staff support
- research, operational
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What is already known on this subject
Burnout is common among emergency department staff and is associated with decreased staff well-being and increased adverse events.
Interventions are needed to enable emergency department staff to acquire adaptive skills to deal with workplace burnout and its consequences.
What this study adds
Specific coping styles are associated with varied risk of burnout in emergency department staff across different types and sizes of facilities in a health region.
Task-oriented coping (action response) is associated with decreased burnout, whereas emotion-oriented coping (emotional response) is associated with increased burnout.
Interventions to increase the use of more effective task-oriented coping style may, therefore, be protective against burnout and improve staff well-being along with patient outcomes.
High levels of burnout exist among emergency department (ED) physicians, nurses and support staff.1–3 Waiting times, a demanding public, hospital crowding and inadequate human resources are common stressors in this setting.4 Over the long term, workers in intense patient-centred environments can find their interest and energy eroded by the demands; their engagement is gradually replaced by cynicism, emotional depletion, loss of motivation and reduced commitment, leading to a crisis in professional competence.5 This is the syndrome of burnout as described by Maslach et al.6 The three classic symptoms for burnout are loss of enthusiasm for work (emotional exhaustion); reduced empathy and increased cynicism (depersonalisation); and a decreased sense that one's work is meaningful, leading to inefficacy (personal accomplishment).6
Several studies have reported high levels of burnout in ED staff. An American source reported a 32.1% rate for emotional exhaustion,7 while a Canadian study reported 46% of ED physicians scored medium-to-high burnout in all burnout scales.1 A large 2011 survey of 7288 US physicians found that emergency physicians suffered the highest reported rates of burnout when compared to all specialties.8Leiter and Laschinger9 noted that nurses reporting unpleasant contacts with supervisors scored higher for burnout. Burnout is also associated with job stress, a known factor in higher suicide rates in physicians.10 Jourdain and Chênevert11 found job demands to be a strong determinant of burnout, with a lack of resources also being predictive.
In team environments, situations of increased job stress and burnout can lead to impaired cognitive functioning, increasing the potential for patient harm.12 A large body of literature outlines the potential adverse outcomes of burnout for staff, which include illness and absenteeism, staff conflict, distrust of management, poor coping and substance abuse.2 ,7 ,8 ,9 ,11 ,13–18 Clinical consequences of burnout include medical errors and adverse events, poor prescribing habits, low patient satisfaction and low adherence to physician recommendations.19 Another major problem for hospitals is retention of highly trained critical care staff, as ED staff leave their profession at a higher rate than those in other specialties.20
Although burnout is common among ED staff and is associated with a number of adverse outcomes,21 not all ED staff demonstrate burnout. Some members will thrive in the same seemingly stressful environment. One important factor that may influence the likelihood of burnout is an individual's coping style.22 Poor coping may lead to impairment in job performance, and staff at greatest risk of burnout may be those whose coping strategies are ineffective. Associations between emotion-oriented coping styles and higher levels of burnout have been documented in nurses and nursing students.23 ,24 Coping styles may thus affect staff well-being and retention through an effect on burnout, therefore being potentially amenable to intervention at an organisational level.25 If this relationship is confirmed, interventions targeting coping styles could reduce burnout and its consequences.2
This study was undertaken to determine if there was any association between burnout and coping styles within multidisciplinary ED staff teams in several types of ED facilities. The results from this study may lead to the identification of coping styles as an area for burnout intervention with a potential improvement in staff health and patient outcomes.
A cross-sectional survey of all 616 full-time and part-time physicians, certified nurses and support staff was performed at two small, two medium and three large hospitals in the Horizon Health Network (HHN). The HHN covers two-thirds of the province of New Brunswick, a catchment population of 500 000. Participation was voluntary and confidential. The study was approved by the HHN Research Ethics Board.
The survey included the Maslach Burnout Inventory for Human Services Survey (MBI), the Coping Inventory for Stressful Situations (CISS) and a section on demographic details.
The MBI is a validated 22-item tool that is the leading measure of burnout in the workplace.6 ,22 ,25 Level of burnout is low, medium or high using the three subscales of emotional exhaustion, depersonalisation and personal accomplishment.2 The Emotional Exhaustion subscale means feelings of being emotionally overextended and exhausted by one's work with people (loss of enthusiasm for work); depersonalisation means an unfeeling and impersonal response towards patients care (reduced empathy and increased cynicism); and personal accomplishment means feelings of competence and successful achievement (a sense that one's work is meaningful).
The CISS is a 48-item self-report survey22 that measures the different ways workers cope when faced with a stressful situation. Three major styles of coping response are identified: task oriented, emotion oriented and avoidance oriented. Task-oriented coping is dealing with the issue at hand; examples include outlining priorities or learning from mistakes. Emotion-oriented coping is experiencing emotional distress; examples include becoming tense or blaming oneself. Avoidance-oriented coping uses distractions, such as socialising away from work or doing a hobby.26
A demographic survey captured age; gender; profession (physician, nurse, nurse support worker); years worked in the ED; relational status and social support; type of ED facility; wanting to leave healthcare for a new career and patient visit data (see online supplementary appendix A; tables 1 and 2).
The study was modelled after a pilot project performed at a single hospital ED in Nova Scotia.3 The MBI,6 CISS22 and a demographic survey in paper format were offered by a site coordinator to each staff as an anonymous package during a dedicated 15 min break at work. It was privately completed, sealed and returned to the site coordinator. Participation was voluntary and confidential. Investigators were blinded to study participants, profession and facility.
Basic descriptive statistics were calculated for all baseline participant characteristics, as well as all outcome variables. Means and SDs were calculated for continuous variables, while frequencies and percentages were produced for categorical variables.
Scatter plots and correlations were examined to assess the form and strength of relationships between coping skills and the outcome MBI burnout scores. Multivariate linear regression models were constructed to examine the adjusted relationships between the MBI scale scores on baseline covariates and the CISS subscale scores.
Initially, all covariates of interest were fit independently to a simple linear regression model on each of the three MBI subscales. Variables with p values less than 0.20 were retained for the multivariate model fitting stage. For each outcome, a final model was selected using a stepwise procedure with the Aikake Information Criterion (AIC). Residual plots were used to examine model assumptions.26 ,27 All analyses were conducted using R, V.3.0.2.
A total of 322 surveys were submitted. Seven surveys had insufficient data for the first analysis and were removed. This resulted in completed questionnaires from 315 of 616 ED clinical staff at seven sites, a response rate of 51%. Table 1 provides participant baseline characteristics, along with the CISS and MBI scale results. Working conditions, location and place of origin are summarised in table 2.
Results from linear regression on MBI subscales
All effect sizes and SDs from the univariate and multivariate linear regression on the three MBI scales can be seen in table 3.
Coping style as a predictor of burnout
Task or problem-focused coping was a significant univariate predictor of lower emotional exhaustion (effect=−0.25, p<0.001), lower depersonalisation (effect=−0.25, p<0.001) and higher personal accomplishment (effect=0.25, p<0.001). In the final multivariate models, task-oriented coping was only associated with higher personal accomplishment and thus lower levels of burnout (effect=0.21, p<0.001).
Emotion-oriented coping responses were significant univariate and multivariate linear predictors of higher emotional exhaustion (effect=0.22, p<0.001), higher depersonalisation (effect=0.18, p<0.001) and lower personal accomplishment (effect=−0.13, p<0.001).
There were no independent associations between burnout and avoidance-based coping strategies.
Demographic predictors of burnout
Emotional exhaustion was significantly associated with profession, length of employment in the same department and having experienced professional stress. Depersonalisation was also associated with length of employment in the same department, while personal accomplishment was associated with gender.
After correcting for other important factors, nurses had higher emotional exhaustion scores than support staff (effect=4.72, p=0.009), while nurses and physicians scores were comparable. Employees working 6–10 years had higher emotional exhaustion scores (effect=3.56, p=0.029) and higher depersonalisation scores (effect=4.55, p<0.001) than those working in the same department for less than 5 years. Similarly, those working 11–20 years in the same department had higher emotional exhaustion scores (effect=5.20, p<0.001) and depersonalisation scores (effect=2.52, p=0.01) than those working less than 5 years. Finally, males had higher personal accomplishment scores than females (effect=2.17, p=0.029).
There was no association between age, years of practice, relationship status, having close relationships, experiencing a personal stress, hospital environment (large vs small) or patient volume per year on any of the burnout scales.
Burnout and coping style in the ED
In our study population, different coping styles are associated with different rates of burnout markers: task oriented coping is associated with a decreased risk of burnout, while emotion oriented coping style is a strong positive predictor of burnout. This association between coping styles and burnout is consistent with previous findings in various settings in the literature.23–25 ,28–30 Training ED staff to adopt a more task-oriented and less emotion-oriented coping style could improve staff well-being and patient care. Organisations thus need further research on interventions such as coping style to decrease the risk of burnout and its negative outcomes.25
Avoidance and social diversion
Avoidance-oriented coping in the CISS includes a measure of social diversion, but did not influence burnout in our study. The lack of an association is interesting because it means that staff social diversion and distraction (eg, better social networking, hobbies, distraction from stressful conditions) seemed to have neither protective effect nor adverse consequence. We also found a distinction between the influences of work stress versus personal stress on burnout. One logical conclusion is that task-oriented skills are necessary to combat burnout25; in the context of long-term system dysfunction, socialisation and distraction may not be sufficient to address burnout in the workplace.
Staff working 6–10 and 11–20 years in their current department had higher burnout compared with those working 5 years or less, reflecting the effect of prolonged exposure to this high stress environment. Curiously, participants who had worked longer than 20 years, having neither relocated nor left the specialty, had less burnout. Nowakowska31 reported increased age and length of time in the job as being associated with increased use of task-oriented coping. Some individuals may adapt, maintain an effective coping style and become ‘survivors’.
Support workers had lower burnout levels but there were no differences between nurses and physicians. Yates et al2 found increased emotional stress in physicians but not in nurses, suggesting a tendency for higher burnout in those with more responsibility and accountability. Males were found to have a higher personal accomplishment level; this may reflect the tendency for males to use more assertiveness, a task-oriented coping skill in the workplace.32 Consistent with other studies, professional stress was a predictor of higher burnout; some demographic factors were not associated with burnout: age; size and increasing complexity of facility; or personal stress.13 ,23 ,30 ,33
The demands of one's job, particularly in front-line health workers, are a major source of stress and have been shown in longitudinal studies to predict burnout.25 ,30 ,34–36 Burnout in turn predicts a higher likelihood of negative outcomes such as decreased job satisfaction, increased absenteeism and increased intention to leave, as reflected in current findings.34 Jenkins and Maslaach35 demonstrated that workers with better psychological health are more likely to move into and remain in demanding service-oriented jobs. A prospective Danish study showed increased absenteeism in staff with high burnout over a 3-year period.36
To invoke individual and cultural change in the workplace however is challenging. Burnout remains relatively stable over many years; it is the exception rather than the rule that this syndrome will naturally heal over time.25 Since coping style may reflect personality characteristics, environmental influence or both, and can, as we have shown, affect the risk of burnout, managers should be aware that coping style assessment and training may provide an effective form of intervention.
There are reasons to be optimistic; two recent Cochrane reviews and a recent paper suggest assertiveness training and cognitive behavioural approaches may reduce burnout.33 ,37 ,38 One study of 10 forensic nurses found that a coping skills intervention reduced burnout at the end of 6-month training compared with a control group.39 Smith-Jentsch et al32 examined the determinants of assertiveness in the context of task-oriented team function. Based on a set of assertive behaviours that have been linked to effective team performance, they found effective use of team performance-related assertiveness involves a significant skill component. While both attitude-focused and skill-based training improved attitudes towards team member assertiveness, practice and feedback were essential to produce behavioural effects.32 ,40
Deliberate planning with implementation at an organisational level may be more successful.25 Leiter and Laschinger9 demonstrated that a training programme for ED staff, aimed at improving communication and reducing conflict, may reduce burnout and provide opportunities to improve staff well-being, while preserving the cognitive resource, improving absenteeism and staff retention, and optimising patient care and safety.25 ,40 Indeed, some studies have shown hospital staff civility training to increase positive communication, while improving social interactions and attitudes in a way that is maintained over time.21 ,25
While the survey response was good at 51%, a limitation of surveys is selection bias: those who are more stressed or burned out may be less likely to perform the survey. This was mitigated in part by allowing time during work, and by ensuring confidentiality to engage both positive and negative feedback. Temporal confounds (eg, vacations or relocation during the data collection phase) were minimised by conducting the study rapidly in a 2-month time frame.
Cross-sectional analysis can identify associations between predictor variables and outcomes, but it is insufficient for proving causality. The documented relationship between burnout reduction and the well-being of workers therefore warrants longitudinal studies of interventions such as coping style skills training, using more complex modelling like mediation analysis.
The majority of staff were nurses and female, and were of local regional (87%) or Canadian (9.3%) origin. This could limit the applicability of findings to other populations based on different country of origin, cultural or educational background. Some investigators have emphasised studies aimed at single professions, while others have used the pragmatic focus of the interdisciplinary team as the target group.25 The latter approach is favoured as a successful work environment is a function of the relationships and processes between all team members. Organisational interventions affect all members and their relationships, and are implemented in the hope of a shared outcome benefit.
Coping styles and burnout among ED professionals share a relationship that is consistent across different types and sizes of facilities. Task-oriented coping predicts decreased burnout, while emotion-oriented coping style predicts increased burnout. Professional stress, years of experience up to 20 years and gender influenced burnout. There was no difference between types or sizes of HHN facilities, age or personal stress. Further research should examine skills training in task-oriented coping for ED physicians, nurses and support staff, to reduce burnout and improve staff well-being and patient outcomes.
The authors would like to gratefully acknowledge the assistance of Dr Jo-Ann Talbot in reviewing the final manuscript, Mr Barry Strack from the Horizon Health Network Research Services Department for his extensive support and insight, the Health Promotion and Research Fund for providing study support through an unrestricted research grant and local facility staff and management for supporting the study.
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Files in this Data Supplement:
- Data supplement 1 - Online appendix
Contributors All are part of the Critical Dynamics Study Group and contribute as regular members at meetings and networking discussions. MH was involved in concept and initiation of Study Group; writing, review, discussion. KD was involved in design and discussion of all elements requiring psychology expertise; supervision of survey tools and data collection and interpretation; writing, review, discussion. PRA provided advisory on study progress and structure; writing, review, discussion. JM provided advisory on data analysis and tools; writing, review, discussion. Barry Strack and DL-D provided support; study design and structure advice; writing, review, discussion. JF provided advice on study implementation and data collection; writing, review, discussion; administering documents, submissions.
Funding Horizon Health Promotion Research Fund Local Grant.
Competing interests None.
Ethics approval Horizon Health Network Research Ethics Board REB#2011-1594.
Provenance and peer review Not commissioned; externally peer reviewed.
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