The unprecedented COVID-19 pandemic introduced substantial challenges for nurses to meet the high demand for patient care, altered clinical work environments and team compositions, and threatened personal safety risk during care delivery.^1,2 A substantial body of evidence has been formed surrounding exacerbated nursing burnout rates during the pandemic.³ Nurses have been found to have significantly higher burnout rates than other healthcare worker disciplines and some suggest that pre-pandemic system-level factors contributed to this phenomenon.⁴ Prior to the pandemic, there were limited literature that isolates burnout factors in emergency nurses, a healthcare worker population that were thrust onto the frontlines of the COVID-19 response. More and more organizations and policymakers have called for the investigation of factors that precipitate burnout risk. The US Surgeon General recently released an advisory report highlighting the importance of identifying and addressing factors that contribute to burnout.⁵ Yet, this knowledge remained largely unknown prior to the onset of COVID-19 and inhibits our ability to inform interventions during the aftermath of the pandemic outbreak. In this present study, we seek to advance the work on national estimates of emergency nurses to examine reasons for burnout and workforce turnover. The aims of our study were to: 1) test pre-pandemic differences in reasons for turnover or not currently working between emergency nurses and other registered nurses (RN); and 2) ascertain factors associated with burnout as a reason for turnover or not currently working among emergency nurses. This knowledge may inform practice and policy changes for present day pandemic recovery by addressing pre-pandemic burnout factors that specifically impacted emergency nurses.

Clinician burnout, defined by emotional exhaustion, cynicism, and a low sense of accomplishment at work⁶ is a pervasive challenge affecting broad swaths of health care workforce. Recognized by the World Health Organization as an “occupational phenomenon,” burnout can primarily be attributed to the work environment and ongoing discrepancy between an employee’s resources and their workload.⁷ Acute care clinicians, such as nurses and physicians working in an emergency department (ED) setting (emergency nurses and physicians), may be particularly vulnerable to burnout. Pre-pandemic literature demonstrates that almost half of the 900,000 practicing physicians in the US report symptoms of burnout with emergency physicians endorsing the highest rates.⁸ Similarly, a systematic review conducted in 2017 found higher rates of emergency nurse burnout (31%) compared with nurses working in other specialties or units.⁹ Burnout in nurses has been associated with not only adverse individual health outcomes such as increased risk of depression, drug abuse, and suicidal ideation, but also suboptimal professional and patient care outcomes, including increased workforce turnover, decreased quality of care, increased hospital-acquired infections, and reduced patient satisfaction.^6–8

Compared to other nursing specialties, emergency nurses may face unique risk factors for burnout due to the emergency care work environment, such as experience with violence and traumatic incidents.^9–11 While past research has documented the prevalence of burnout amongst the emergency nursing workforce, such studies have been limited by small sample sizes and local sampling approaches, unable to capture the diversity of clinical, geographic and demographic environments that encompass the emergency nursing workforce in the US.^12–14 Additionally, potential key factors associated with the presence of burnout have been described, ranging from individual, environmental, and system level variables.¹⁵ Few studies have examined burnout in participants who have left their job position or are not currently working, resulting in the potential for a healthy worker or survivor bias in the current body of evidence. In previous work on a national level, over 17% of those licensed to practice as a RN were not working in nursing in 2017.¹⁶ An analysis of reasons for job turnover that includes those not currently working after recently leaving a nursing position, among a diverse and nationally representative sample of emergency nurses, is essential to identify the most salient, priority focus of both risk detection and as a needs assessment for future national level interdisciplinary policies and interventions.

This study aimed to 1) explore reasons for job turnover among a nationally representative sample of emergency nurses, 2) compare these reasons to the reasons of other RNs, and 3) analyze factors associated with burnout as a reason for job turnover or not currently working in nursing (limited by those that endorsed burnout as a reason for turnover). Our study contributes to the important growing body of evidence exploring burnout and emergency nurse turnover in the United States. In this nationally representative sample, 10.6% of all emergency nurses reported burnout prior to the pandemic as a reason they had left a job or were no longer working over a period of less than two years. This represents an estimated 23,000 RNs. Now, over two years into the COVID-19 pandemic, these numbers have likely increased.²⁰ Characteristics of the emergency nursing subsample differed from other nurses in terms of age, years since nursing license, educational attainment, and gender. These demographic factors were also associated with differences in burnout as a reason for turnover or not working in nursing. Thus, levels of burnout in emergency nursing may be indirectly explained by demographic differences of emergency nurses from RN working in other settings rather than explained solely by working in the specialty alone.

Our results are consistent with past work finding job absenteeism and turnover associated with nursing reports of burnout.^14,21 RNs experience high rates of burnout in general, with up to one-third of participants reporting burnout in previous smaller studies.⁹ Existing studies that sample the current workforce are limited by a healthy worker effect, or survivor bias in burnout estimates, and fail to capture respondents that already have left their position. Our results contribute uniquely to the body of literature by including those who left a job or are no longer working in the emergency nursing workforce analysis at the national level, and reveal a national crisis in emergency nursing retention. Given the essential nature of the emergency nursing occupation and high proportion of turnover due to burnout in the specialty, this study provides a timely and essential contribution to knowledge as a needs assessment for interdisciplinary preventative intervention to consider as we move beyond the COVID-19 pandemic.

In this present study, we investigated factors associated with both burnout and job turnover, using burnout as the primary dependent variable (Table 4). Past research demonstrates that burnout is associated to a variety of patient, organizational, and provider outcomes. For example, burnout is significantly associated to increased medical errors, poor perceived patient communication and satisfaction.⁸ Further, there is evolving evidence that burnout yields suboptimal health risk in clinicians, including poor psychological outcomes, (e.g., depression, substance abuse, and suicidality risk).^22,23 Past studies have also found a mediating role between burnout and job turnover, hence our present focus on burnout.²⁴ Despite our results depicting no differences in burnout or turnover between emergency nurses and other RNs, we found significant difference in reasons for job turnover between groups. This finding suggests that factors contributing to burnout and turnover may vary by nursing discipline or setting. This result is aligned with emerging evidence that has depicted significant differences in unit culture.²⁵ It also supports the idea that there is no “one-sized-fits-all” approach to reducing burnout.

It is also important to acknowledge other factors outside of burnout may independently contribute to job turnover. This present study identified additional factors contributing to job turnover such as insufficient staffing, lack of good management, patient population, physical demands, and stressful work environment. This result is consistent with existing evidence about the substantial influence that nurse work environment factors have on nursing and patient outcomes. For example, safe staffing ratios has increasingly been at the forefront of recent policy discussions with mandated ratios disputed. Consistent with past evidence, insufficient staffing has been linked to job turnover, failure to rescue, and missed and delayed patient care.²⁶ Cross-sectional and longitudinal observational studies have demonstrated consistent associations between increased nurse-to-patient ratios, and higher education and training of nurses, with improved morbidity and mortality for hospital inpatients.²⁷ In this current study, stressful work environments, scheduling, and insufficient staffing appear to be associated with a gender difference between male and female nurses’ experience with burnout as a reason for not working or turnover. While staffing ratios have been found to significantly impact patient safety risk, length of stay, and quality of care²⁸, more research is needed to isolate which setting-specific (e.g., emergency department; medical/surgical unit) ratios optimize patient care outcomes and mitigate burnout and subsequent job turnover. Further, it remains unclear how unmet peri- and post-pandemic staffing needs precipitated higher risk for burnout and/or job turnover. Appropriate emergency nurse staffing may rely on having adequate overall budgetary and human resources in a hired pool of qualified full time equivalents, ensuring sufficient numbers and skills mix of nurses for shift-to-shift patient care, and maximizing efficient work processes to enhance productivity.²⁹ The Emergency Nurses Association (ENA) has developed staffing guidelines, and further health services research is needed to ascertain the effectiveness and efficacy of implementing these guidelines, the national proportion of EDs that meet or exceed recommended benchmark staffing levels, and the impact on both patient outcomes and emergency nurse burnout and turnover.^29,30 Physical demands were also found to be endorsed by emergency nurses significantly more than non-emergency nurses as a reason for job turnover. However, it remains unclear what causes increased physical demand and if physical demand is related to a particular patient population. More research that investigates the physical aspects of job performance is needed to inform policies and practice that promote a healthy and safe work environment for emergency nurses.

Evidence on promising interventions to reduce burnout and job turnover include enhancing the quality of work environments (including sufficient resources/staffing among other factors), implementing culture change, applying leadership strategies, and supporting individual coping.³¹ While clinician self-care practices can mitigate some risk factors for burnout, there is little supporting evidence individual-level intervention alone without also addressing multi-level workload and work environments in the emergency setting.^32–34 The National Academy of Medicine’s (NAM) Future of Nursing 2020–2030 report highlights the importance and necessity of addressing policies, structures and systems that create threats in the workplace that contribute to burnout and poor mental/physical health among the nursing workforce.³⁵ NAM recognizes that the health and well-being of nurses directly impacts the safety, quality and cost of the care they provide. Consistent with recommendations in past studies, future work aimed at the precursors of nursing burnout as modifiable targets of intervention to reduce turnover offer the promise of improving individual well-being, career longevity, improved patient care outcomes and enhancing the financial viability of health care organizations.^31,36–39 Emergency specialty-specific applications of the guidance provided in the framework for clinician well-being, also published by NAM, is needed, parallel to the collaborative models produced jointly by intensive care clinician specialty organizations.^40,41

Our study also indicates increasing age and years since nursing license appear to have a protective association with burnout. These findings warrant further exploration, but it may be reasonable to proactively tailor interventions to younger nursing cohorts and prioritize early career nurses. One cross-sectional study examined formal orientation programs on burnout and emergency nurses’ intent to leave.⁴² Authors found that participation in a formal orientation program may enhance a sense of personal accomplishment, decreasing intent to leave.

This paper aimed to identify factors prior to COVID-19 that precipitated burnout risk and job turnover in emergency nurses. This study contributes new evidence about emergency nurses after they have left their primary position and provides key insight to what drives nursing workforce turnover. While there were no significant differences in burnout between emergency nurses and other nurses, we did find significant difference of factors that precipitate job turnover when comparing groups. Factors such as staffing, physical job demands and better pay elsewhere were significantly associated with burnout and turnover. Age and increased experience appeared to be protective of burnout. Organizations should invest efforts in new graduate nurse retention interventions and continue to test the impact of unit-specific staffing ratios on burnout, among other organizational outcomes.

In summary, this study quantified burnout endorsement and reasons for national nursing estimates of job turnover or no longer working, in both emergency and non-emergency nurses prior to the pandemic at the national level. There was no significant difference in burnout when comparing emergency nurses to other nurse. However, we identified that insufficient staffing, physical demands, patient population, better pay elsewhere, career advancement, length of commute, and relocation were significantly endorsed more in emergency nurses compared to all other nurses for job turnover reasons. Our findings suggest the need to address job turnover factors at the unit-specific level as the needs and preferences of nurses across settings may vary, and subsequently yield job turnover differently.