Toward a Unified Framework of Burnout and Workload in Emergency Care Nursing: A Systematic Review and Conceptual Integration

Hery Wibowo1*, Iwan Aflanie2, Agianto1, Musafaah3, Islamiyah4

1School of Nursing, Medical Faculty, Lambung Mangkurat University, Banjarbaru, 70714, Indonesia

2Forensic Department, Medical Faculty, Lambung Mangkurat University, Banjarbaru, 70714, Indonesia

3Public Health Department, Medical Faculty, Lambung Mangkurat University, Banjarbaru, 70714, Indonesia

4Psychiatric Department, DKH Hospital, Balangan, 71615, Indonesia

*Corresponding Author’s Email id: hery.wibowo@ulm.ac.id

ABSTRACT

Background: Due to the urgent and unpredictable nature of their clinical settings, emergency care nurses are frequently exposed to high work demands. These persistent pressures can contribute to emotional exhaustion, reduced job satisfaction, and, ultimately, burnout, which significantly impacts their mental health and overall performance. Objectives: This study aims to synthesize the existing theory of burnout and workload in emergency nursing and integrate it into a framework model, addressing gaps in the existing literature. Methods: A systematic literature review was conducted using PRISMA guidelines. A total of 900 relevant articles published between 2022 and 2024 from the Scopus and Science Direct databases were analyzed. This review includes studies on burnout and workload models relevant to emergency nursing. Results: This review identified 11 relevant articles highlighting the link between burnout and workload. It deliberately prioritized studies that concurrently address validated theoretical models of burnout, operational definitions or measurements of workload, and empirical data from emergency department nurses. This tripartite criterion ensured conceptual coherence and contextual relevance, aligning with our aim to develop an integrated framework. Conclusions: This review underscores that burnout among emergency nurses is inextricably linked to multidimensional workload drivers ranging from shift intensity and patient acuity to environmental stressors and cannot be effectively mitigated through isolated interventions. By synthesizing empirical evidence into a unified theoretical framework, this study provides a foundation for context- sensitive, system-level strategies that simultaneously address structural demands and enhance psychological resilience, ultimately safeguarding both workforce well-being and patient care quality in high-acuity settings.

Keywords: Burnout Professional; Emergency Nursing; Healthcare Workforce; Workload

INTRODUCTION

Emergency Departments (EDs) represent high-acuity clinical environments characterized by unpredictable patient inflows, time-critical interventions, and complex decision-making under pressure. These inherent demands are further intensified by staffing shortages, resource constraints, and the emotional toll of managing life-threatening conditions (Galanis et al., 2021; Li et al., 2024). Effective management of such demands requires robust organizational support, clear role delineation, and evidence-based workflow protocols to sustain both staff well-being and patient safety. Prolonged exposure to these elevated job demands, without adequate buffering resources, significantly increases the risk of burnout among emergency nurses. Burnout, manifested through emotional exhaustion, depersonalization, and reduced personal accomplishment, compromises not only individual mental health but also the quality and continuity of patient care (Caulfield et al., 2023; Huang et al., 2024). Health workers face dire consequences, have their dignity degraded, experience significant fatigue, and consume psychological resources when their work and professional environment are not properly organized (Nagel et al., 2025; Soola et al., 2022). On a global level, in high-risk work environments such as emergency units, physical and mental fatigue often occurs due to the high workload experienced by nurses (Galanis et al., 2021; Li et al., 2024; Wu et al., 2025). Understanding the interplay between workload dynamics and burnout mechanisms is therefore critical for developing context- sensitive interventions in emergency nursing.

Numerous studies have found that emergency nurses have a higher risk of burnout than nurses in other units. Emergency nurses have developmental potential from work stress, including acute stress disorder, physical exhaustion, emotional exhaustion, and post-traumatic stress, as well as secondary trauma stress (Caulfield et al., 2023; Jachmann et al., 2025). However, high resilience or adequate employee preparation for future attacks has been shown to reduce the risk of burnout and perceived stress (Edú‐valsania et al., 2022). Management is important in preventing violence and its consequences on emergency nurses (Pien et al., 2025; Schablon et al., 2022).

The strong relationship between high job demands and decreased nurse well-being has been underscored by workload theories such as the Demand-Control Model and JD-R. In nursing, controlling a high workload has been shown to increase job satisfaction and reduce negative emotions (Junaković & Macuka, 2021). Data indicate that high workload demands and work time pressures are strongly associated with increased burnout and decreased job satisfaction among health workers (Khamisa et al., 2025; Romero-Carazas et al., 2024). Likewise, mastery of work control and social support in the workplace can improve the welfare of emergency nurses (Liao et al., 2025; Yuan et al., 2021).

However, despite extensive literature on nurse burnout, existing models often treat workload and burnout as distinct constructs, overlooking their dynamic, bidirectional interactions within the unique context of emergency care. Emergency departments present distinct stressors, including patient acuity variability, shift irregularity, and exposure to trauma, that necessitate a context- specific theoretical integration (Parizad et al., 2026; Wang et al., 2026). This study addresses this gap by synthesizing empirical evidence to develop a unified framework that explicitly links multidimensional workload drivers with burnout pathways among emergency nurses (Arnold et al., 2026), thereby enabling more precise, system-level interventions (LaFontaine, 2025; Nantsupawat et al., 2024). Compared to a holistic view combining workload and fatigue studies, it can lead to more effective interventions and resilience-building strategies (Habeger et al., 2022). However, some literature suggests that addressing burnout through individual coping strategies and resilience training can be beneficial, even if the workload factor is not explicitly examined (Ghiya & Wilson, 2022).

This research is very important because it can address existing gaps and contribute to the development of a strong conceptual framework for understanding the relationship between burnout and emergency nurse workload (Provost et al., 2026). By formulating an integrated framework grounded in existing theories, this research is expected to guide the development of more targeted, context-specific interventions to improve nurses’ welfare and service quality. Therefore, this study aims to systematically synthesize burnout and workload models and indicators in emergency nursing.

METHODOLOGY

Article Selection

PRISMA has been widely recognized as a well-suited methodology for conducting systematic reviews of articles. This approach incorporates up-to-date elements that can avoid changes to real data. Various studies have widely applied the PRISMA methodology (Page et al., 2021). The PRISMA process in literature review is carried out in the following stages (Paul et al., 2021): (1) determining the research question, (2) collecting the articles to be processed, (3) conducting a selection process based on the research question, and finally (4) analyzing the selected articles in their entirety. The literature review will identify critical questions to obtain specific, detailed data on burnout and workload models and their indicators among emergency nurses.

Research Questions

The research questions in this systematic review (Riedel et al., 2021) were structured using the PICO framework (Hagen et al., 2026; Somma et al., 2026) as follows:

P (Population) means nurses who work in the emergency department of a hospital.

I (Intervention/Exposure) theworkloadandburnoutmodelappliedinemergencynursing.

C (Comparison) means not applicable (studies with or without specific theoretical models were considered).

O (Outcome) means identified models/theories and their indicators used to measure workload and burnout.

The questions are mainly focused on:

(RQ1): A burnout model to be applied in the context of emergency nursing (RQ2): A workload model to be applied in the context of emergency nursing (RQ3): Burnout and workload indicators in the context of emergency nurses

Table 1: Inclusion and exclusion criteria.

Inclusion Criteria

Obtained from the Scopus and ScienceDirect databases, appropriate articles and reviews were sourced from publications in the last three years, from 2022 to 2024. The search process used relevant keywords related to burnout models, workloads, and indicators applicable to the emergency nursing context. Only articles written in English were considered, while articles that did not meet the search criteria were excluded from the selection.

Exclusion Criteria

The next step was to identify articles that fulfilled the criteria and then analyze them, adjusting them to the inclusion criteria in Table 1. After determining the keywords, 900 relevant articles were obtained from the Scopus and ScienceDirect databases. Then, articles from the time range (January 2022 - December 2024) were selected, leaving 256 articles. After being selected based on duplication, 167 articles were obtained. Subsequently, themes and abstracts were screened to ensure that all selected articles were in English. This process ultimately selected 14 relevant articles. The next step was to examine the research methodology adopted in the article; research unrelated to the established criteria and irrelevant to burnout and workload in emergency nurses was excluded. Ultimately, 11 articles were selected as the most suitable for review.

Screening Process

A comprehensive literature search was conducted to identify relevant studies for review. Four authors (HW, IA, MU, and AG) independently screened the titles and abstracts according to the predefined inclusion criteria. Any discrepancies during the screening process were discussed and resolved through consensus with a fifth reviewer (IS).

Analysis Method

Subsequently, full-text articles were independently assessed by four authors, and disagreements were resolved through discussion with the fifth reviewer.

Data Extraction

For the data extraction process, HW, IA, MU, and AG independently extracted eligible studies using a standardized data extraction form. The extracted data included authorship, year of publication, methodological characteristics (study design, participants, and data analysis), nursing-related interventions or theoretical models applied, and key research findings.

Figure 1: PRISMA Flowchart

Figure 1 shows three stages in the article selection process: Eliminating articles that do not meet the criteria and identifying more relevant articles. Finally, the eleven articles to be reviewed were selected. These eleven selected articles were published between 2022 and 2024 and are part of the scientific publications indexed in Scopus.

RESULTS

The research articles obtained were spread across various countries and analyzed, including:

Table 2: Analysis and Characteristic of The Article

The primary focus of the articles studied is burnout, workload, and psychosocial challenges faced by nurses in emergency departments (Wang et al., 2024). Among these studies, Power et al. (2022) in the UK explored novice nurses’ experiences with emergency department challenges; Chahbounia and Gantare (2023) in Morocco examined stress, burnout, and coaching-based management interventions; while Hetherington et al. (2024) in Australia used a narrative approach to investigate burnout related to changing roles and boundaries among emergency nurses.

The results show a consistent trend related to factors contributing to burnout among emergency nurses. In China. Wang et al. (2024) showed that the number of work schedules and marital circumstances are predictors of burnout, while Luo et al. (2024) found that caring for unidentified patients increases emergency nurses’ mental workload due to communication and safety challenges. This study emphasizes the importance of actions to manage and control workloads and improve support for work environments.

Table 3: Overview of the Examined Study

Three main domains were identified from the synthesis: job demands and resources, individual protective factors, and outcomes. Emergency nurses experience high workload, organizational challenges, and psychosocial stressors, which contribute to burnout. However, individual protective factors such as resilience and coping strategies play a key role in mitigating these effects. The interaction between these domains results in outcomes including burnout, well-being, and quality of care.

Figure 2: A Synthesis Framework

Figure 2 presents a synthesis of a framework that illustrates the relationship between job demands and resources, individual protective factors, and their outcomes in emergency nursing. The demands and resources of the job, including workload and organizational factors, affect the psychological state of nurses. Individual protective factors, such as resilience and coping, can offset and mitigate these effects. Their interactions lead to outcomes, including burnout, well- being, and quality of care. This framework highlights that burnout is not only shaped by workload but also by adaptive capacity, and this emphasizes the importance of workload management and strengthening individual resilience.

DISCUSSION

All the studies underscore the need for knowledge to develop models to reduce fatigue in emergency settings. This result will help predict burnout and design appropriate actions to support the mental well-being of emergency nurses. Studies in Morocco show that coaching can significantly improve stress management and burnout skills (Chahbounia & Gantare, 2023), while research in Spain suggests improving working environment conditions as a measure to reduce burnout (Soto-Castellón et al., 2023) or other contextual factors, such as resilience, that can protect emergency nurses from burnout events (Giostra & Maiorano, 2025). These findings are important for formulating health policies (Tang et al., 2024) that support the well-being of medical personnel, especially in high-pressure workplaces such as emergency units.

The burnout model among emergency nurses is often described through Maslach’s framework. The results showed that 27.4% of nurses experienced high levels of emotional exhaustion, while 48.5% experienced depersonalization, which is a significant psychological impact of a high- pressure work environment (Wang et al., 2024). This model provides a clear framework for understanding burnout among nurses (Huang et al., 2024). In addition, the data showed that factors such as marital status, the specificity of hospital services, and work schedules contributed to increased nurse burnout (Chahbounia & Gantare, 2023; Wang et al., 2024). As a significant component, emotional exhaustion reflects nurses’ physical and psychological stress in emergencies (Rantung et al., 2024). Meanwhile, depersonalization indicates a negative attitude towards the patient, often resulting from long-term stress (Hetherington et al., 2024). Declining personal achievement is also an important indicator, with 18.6% of nurses feeling no longer effective in their roles (Wang et al., 2024). Overall, existing burnout models strongly link high workloads and increased burnout rates (Luo et al., 2024; Power et al., 2022). Therefore, it is important to design evidence-based interventions to reduce burnout risk and support nurses’ mental well-being in emergency settings (Benjamin, 2024; Ranta et al., 2024).

The workload model in emergency nursing significantly affects mental health and operational effectiveness in these care units. Research shows that high workloads, rated by night shift frequency and the complexity of patient cases, contribute to increased stress levels (Hetherington et al., 2024; Wang et al., 2024). In addition, nurses in general hospitals tend to have higher levels of burnout than those in hospitals with specializations, suggesting that the field of placement has an important impact (Chahbounia & Gantare, 2023; Wang et al., 2024). The workload is defined not only by the number of tasks to be completed but also by the intensity and nature of the care provided, which is often affected by the severity of the patient (Luo et al., 2024; Soto-Castellón et al., 2023). Environmental factors such as noise and lighting also contribute to nurses’ fatigue and mental stress (Soto-Castellón et al., 2023). In addition, the coping strategies nurses use, such as seeking social support, are crucial in managing high workloads (Hetherington et al., 2024; Luo et al., 2024). In seeking to develop a basic theory of sustainability in nursing, covering aspects of motivation and workload management strategies (Rantung et al., 2024), this study underscores the need to develop policies that reduce workload and increase support for nurses to prevent negative consequences of stress (Benjamin, 2024; Power et al., 2022). Thus, a deeper understanding of workload models can serve as a basis for effective interventions to improve nurse well-being in emergency settings.

Indicators of burnout and workload among emergency nurses are critical factors that affect medical personnel’s quality of care and mental well-being. Given the high prevalence of burnout, nurses experience emotional exhaustion and depersonalization, indicating significant challenges that need to be overcome (Wang et al., 2024). Additionally, nurses reported decreased personal achievement, indicating dissatisfaction and ineffectiveness in their work (Luo et al., 2024; Wang et al., 2024). Contributing risk factors, such as the hospital’s room type and the number of scheduled night shifts, further exacerbate this condition (Chahbounia & Gantare, 2023). Workload indicators also include the intensity of care to be provided, which is influenced by the patient's severity and the work environment, including noise and lighting (Luo et al., 2024; Soto-Castellón et al., 2023). Research shows that nurses working in units with high patient volume experience greater frustration and dissatisfaction (Benjamin, 2024; Hetherington et al., 2024). Coping strategies, such as seeking social support, are important in managing workloads and reducing the negative impact of stress (Hetherington et al., 2024; Power et al., 2022). Thus, a deeper understanding of burnout and workload indicators can help formulate more effective interventions to improve the well-being of emergency nurses (Ranta et al., 2024). In addition to the various coping strategies nurses adopt to manage their burnout and workload in these challenges (Chen et al., 2026; Khan et al., 2026), skill development and involvement in the learning process are also important factors in increasing nurses’ resistance to stress (Rantung et al., 2024).

This study systematically synthesized evidence from 11 studies to develop an integrated framework addressing burnout and workload in emergency nursing. The findings reveal complex interrelationships between job demands-resources, individual protective factors, and outcomes, providing a comprehensive understanding of burnout mechanisms in emergency departments. The following discussion addresses each domain systematically and explicates the proposed integrated framework.

Domain 1: Job Demands and Resources – Workload and Organizational Factors

Emergency nurses operate within high-demand environments characterized by elevated psychological workload, emotional labor, and systemic organizational constraints, wherein concurrent stressors – including high patient acuity, unpredictable caseloads, time pressure, and repeated trauma exposure – consistently elevate burnout risk when job resources are insufficient to buffer these demands (Barnard et al., 2023; Wang et al., 2024). Grounded in the Job Demands- Resources (JD-R) model and Conservation of Resources theory, evidence indicates that organizational deficits (inadequate staffing, equipment shortages, limited supervisory support, and constrained career pathways) and adverse psychosocial conditions (workplace violence, interpersonal conflict, and lack of recognition) precipitate resource loss spirals that exacerbate emotional exhaustion and depersonalization (Hetherington et al., 2024; Soto-Castellón et al., 2023; Zhang et al., 2024). Critically, protective social resources – particularly collegiality, workplace connectedness, and collective coping strategies—function as adaptive "armories" that mitigate psychosocial strain, underscoring the imperative for multilevel interventions targeting both structural resource enhancement and psychosocial support systems to sustain emergency nursing workforce resilience (Rantung et al., 2024). This finding underscores the importance of social support as a protective resource within the JD-R framework.

Domain 2: Individual Protective Factors – Resilience and Coping Mechanisms

Resilience functions as a critical dynamic protective factor that partially mediates the burnout– well-being relationship among emergency nurses, accounting for 16.91% of variance in large-scale multicenter evidence (Zhang et al., 2024). and operates through multifaceted coping "armories" including clinical skill development, spiritual integration, linguistic adaptation, health maintenance, and collegial support that encompass both problem-focused and emotion-focused strategies (Boulton et al., 2025; Rantung et al., 2024). While structured individual-level interventions, such as transtheoretical coaching, significantly enhance stress management competencies (Chahbounia & Gantare, 2023), their limited impact on reducing moderate-to-high burnout prevalence (71.4%) underscores the insufficiency of person-centered approaches lacking concurrent organizational reform. Critically, resilience is not an isolated trait but is reciprocally enabled by contextual resources such as supervisory support, job autonomy, and equipment adequacy, demonstrating that sustainable burnout mitigation requires synergistic interventions targeting both individual adaptive capacities and systemic workplace determinants (Barnard et al., 2023). This finding suggests that organizational resources enable the development and deployment of individual resilience, supporting a reciprocal relationship between individual and organizational factors.

Domain 3: Outcomes – Burnout, Well-being, and Quality of Care

Emergency nurses exhibit disproportionately high burnout prevalence, with 27.4% reporting elevated emotional exhaustion, 48.5% high depersonalization, and 31.1% experiencing multidimensional burnout, significantly exceeding rates in general nursing populations and confirming emergency care as a high-risk specialty (Wang et al., 2024). Burnout emerges as the strongest predictor of diminished well-being, explaining 46.5% of its variance among 15 identified determinants (Zhang et al., 2024) and exerts cascading adverse effects on patient safety, with burned-out nurses demonstrating 26%–71% higher odds of medical errors and compromised safety indicators, including falls, pressure injuries, and infection rates. Beyond clinical outcomes, burnout permeates personal domains, fostering hypervigilance and work-life boundary erosion that impair family functioning and psychological recovery (Hetherington et al., 2024). Critically, modifiable organizational and individual factors, including night-shift frequency, hospital type, marital status, and Post-Traumatic Stress Disorder (PTSD) severity (risk amplifiers) versus participation in psychological support groups, leadership development, and adequate remuneration (protective factors), offer actionable targets for multilevel interventions aimed at mitigating burnout and preserving both workforce sustainability and quality of care (Wang et al., 2024; Zhang et al., 2024). These findings suggest that targeted interventions addressing specific risk factors could reduce burnout prevalence.

The Integrated Framework: Synthesis and Theoretical Implications

This study proposes an integrated framework synthesizing Job Demands-Resources theory (Leep- Lazar et al., 2026), Conservation of Resources (Lei et al., 2026; Masih et al., 2026), the Capability Approach (Gawthorne et al., 2026), and positive psychology (Xia et al., 2026) to elucidate burnout mechanisms among emergency nurses. The model delineates dual pathways: excessive demands deplete resources, precipitating burnout, while organizational supports foster engagement through enhanced capabilities consistent with previous studies in high-acuity settings (Jimenez-Garcia & Flor-Martinez, 2026). This model will result in unforeseen load pressures from an unpredictable number of patients, as well as time pressures in the emergency room (Güngör & Sönmez, 2025). Resilience and coping function as dynamic mediators and allow a change of direction to be a reciprocal process from structural to psychological (Barnard et al., 2023; Hu et al., 2025), not just one-way, in contrast to previous studies about resilience (Grande & Berdida, 2026; Jimenez-Garcia et al., 2026). The study’s novelty lies in its emergency-specific contextualization, incorporating unpredictable patient flow, trauma exposure, and time-critical decision-making, while mapping three synergistic intervention tiers that address integrated workload burnout frameworks and underexplored protective factors as actionable leverage points.

Limitations

The framework yields measurable, contextually grounded indicators informing strategic, multi- level burnout prevention, advancing theoretical precision and translational applicability. It establishes a foundation for resilience-based protocols and institutional policies that concurrently mitigate demands and strengthen adaptive capacities, optimizing nurse well-being and patient safety. Limitations include database/language restrictions, methodological heterogeneity, and limited intervention testing, delineating clear avenues for longitudinal, cross-cultural, and randomized trials to establish causal pathways and refine ecological validity across diverse emergency healthcare systems.

Future Scope

Future research should prioritize longitudinal and multi-center designs to establish causal pathways and trace the pathways of burnout over time. Intervention trials that can evaluate the outcomes of resilience training in a structured manner, predictive staffing models that can optimally adjust and meet the well-being needs of nurses going forward, and technology-assisted workload optimization (e.g., AI-based scheduling or assignment and mapping of tasks based on ability, acuity, reliability and skills) are needed to translate knowledge theoretically into measurable practice, computed and scaled. In addition, integrating objective workload metrics with a mixed-method approach and conducting cross-cultural comparative studies will add to and strengthen the ecological validity and policy transferability of the proposed model across various emergency nursing settings.

CONCLUSION

Burnout among emergency nurses is a very complex, multifactorial phenomenon that significantly endangers nurse well-being, patient safety and renders the health system inefficient. The study shows that high workload intensity, emotional demands, and organizational constraints drive burnout, while resilience, social support, and structured skills development serve as important protection mechanisms. Integration of workload, resilience, and burnout models looks at and reminds us of how systemic stress can become emotional exhaustion and how targeted coping strategies can reduce it. By identifying key indicators such as shift loads, role ambiguities, and erosion of personal resources, stakeholders can design evidence-based workload management policies and institutional resilience programs.

CRediT Authorship Contribution Statement

H. W: Conceptualization, methodology, investigation, data curation, formal analysis, writing – original draft, writing – review and editing. I.A.: Methodology, Validation, writing – review and editing, supervision. AG.: Data curation, investigation, visualization, writing – review and editing, methodology, supervision. MU.: Supervision, project administration, writing – review and editing, methodology. IS.: Formal analysis, visualization, writing – review and editing, investigation.

AI Assistance Declaration

The authors declare that no artificial intelligence tools were used in the development of the scientific content of this manuscript. AI-based tools were only used for minor language editing to improve clarity and readability.

Conflict of Interest

The authors declare that they have no competing interests.

ACKNOWLEDGMENT

The authors would like to express their sincere gratitude to everyone who provided assistance and support for this research, especially the Dean of the Faculty of Medicine and Health, Lambung Mangkurat University, Indonesia.

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