Psychological support system against burnout syndrome in pre-hospital emergency nurses: a cross-sectional survey

Carletta I, Cannizzaro G, Cicchitti C, Andreoli E, Maccaroni R, Menditto VG

Vincenzo G Menditto, MD; Emergency Department Ospedali Riuniti di Ancona

Carletta Ilenia, Nurse; Università Politecnica delle Marche Facoltà di Medicina e Chirurgia, Ancona,

Cannizzaro Giorgia, Psychologist, Emergency Department Ospedali Riuniti di Ancona Cicchitti Chiara, Nurse, Emergency Department Ospedali Riuniti di Ancona

Andreoli Elisa, Nurse, Emergency Department Ospedali Riuniti di Ancona

Maccaroni, Roberto Nurse, Emergency Department Ospedali Riuniti di Ancona


Study objective
Very little is known about the burnout syndrome (BOS) in pre-hospital service nursing staff. The objective of the study is to compare the incidence of BOS and its three domains in two cohorts of critical care nurses: one with and another without an internal psychological support service.
A survey using a questionnaire, MBI-GS (the Maslach Burnout Inventory-General Survey), among nurses of four Italian pre-hospital emergency services (PHES) has been performed: one is located in a large hospital and has a dedicated psychologist who supports the nurses (PHES-Psy); the second cohort was a “pool” of 3 “classical” smaller pre-hospital emergency services (PHES).
All 68 nurses surveyed (51% female) filled the questionnaires: 52 in the PHES group and 16 in the PHES-Psy group. BOS-related symptoms have been identified in at least 85% of the nurses in the entire study population: 88% in the PHES respondents and 75% the PEHS-Psy respondents (p=0.2). Moreover, the frequency of severe BOS in the group of the PHES-Psy was lower than the same rate in our previous (2014) survey (75% vs 90%, p=0.2).
More than least two-thirds of critical care nursing staff had a severe BOS. Among PHES-nurses the use of a psychological support service seemed to limit the prevalence and the grade of BOS.


The burnout syndrome (BOS) has been described in the first Seventies of the last century and is defined as an inability to cope with emotional stress at work or as excessive use of energy and resources leading to feelings of failure and exhaustion (1). The most accepted definition of burnout is the one proposed by Maslach and Jackson (2), who described it comprising three dimensions: emotional exhaustion (EE), depersonalization (DP), and (reduced sense of) personal accomplishment (PA). The Maslach Burnout Inventory-General Survey (MBI-GS) assesses the 3 indicators independently from each other (3).
Critical health-care professionals have one of the highest rates of BOS (4), and development of this disorder may adversely affect the ability to care for patients properly. Potential adverse outcomes of BOS for Emergency Department (ED) nurses include illness and absenteeism, substance abuse and retention, as staff leave their profession at a higher rate than those in other specialties. Based upon multiple studies, up to 86% of critical service nurses have at least one of the three classic symptoms of BOS (4,5). We previously reported that more than least 60% of pre-hospital emergency services (PHES) nursesmanifested almost medium level in one of the symptoms of BOS, and up to 90% had a severe BOS, defined as at least one degree of high burnout or ≥ 2 degrees of medium burnout (6).
The aim of this study was to assess burnout differences using MBI-GSacross two cohorts of PHES nurses: one with an internal psychological support service (PHES-Psy) and a pool of “classic” PHES (without this additional service).

Materials and methods

Study Design, Setting, and Selection of Participants

We performed a cross-sectional survey of nurses who provided total direct care as professional nurses in PHES at one large PHES and three smaller PHES. The large PHES was in a Regional Hospital with a mean of 75770 interventions/year and has a dedicated psychologist who supports the nurses (PHES-Psy). The other 3 pre-hospital emergency services made a mean of 44562 interventions/year and didn’t have a psychological support service (PHES). The PHES’s nurse job consisted both in the telephone triage of emergency call and in the ambulance service.


The psychological support consisted in a dedicated psychologist who utilized team debriefings, structured personal communication and collaborated with team members on the analysis of critical decisions taken during their job shifts. The “one to one” meetings were performed twice a month and the team debriefings were performed on demand and in case of extraordinary events. Structured communications were held once a month in group in order to teach the nurses to have a more structured approach answering to the telephone calls.


The survey in paper format was 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. The local ethics committee exempted our observational study from formal review. A set of questionnaires was administered to obtain socio-demographic and occupational information, as age, gender, marital status (married/stable or single/casual) and seniority in the critical healthcare profession. The survey included the Maslach Burnout Inventory-General Survey (MBI-GS) adapted for the Italian population. Level of burnout is low, medium or high using the three subscales of EE, DP and PA. The EE subscale means feelings of having loss of enthusiasm for work; DP means an unfeeling and impersonal response towards patients care (reduced empathy and increased cynicism); and PA means feelings of a decreased sense that one’s work is meaningful, leading to inefficacy.

Outcome Measures

For EE, the cut-off point for a intermediate and high level was 18-29 and ³30 respectively; for DP, it was for a intermediate and high level 6-11 and ³12 respectively; and for PA, it was for a intermediate and high level 34-29 and £33 respectively. Therefore, high scores for EE and DP, and low scores for PA were regarded as indicative of BOS. We defined BOS as present if there was at least one score of medium or high level.

Primary Data Analysis

We analyzed our data descriptively with SPSS (version 13; SPSS Inc, Chicago, IL).


A total of 68 nursing professionals comprised the study sample: 16 in the PEHS-Psy group and 52 in the PHES. The overall response rate was 100%. None participants were excluded from the study because of missing data. The median age of the participants was between 40 and 49 years, and the percentage of women was 51% (table 1). The were no significant differences in the two groups on the participant baseline characteristics, nor the organization of the two PHES, except the psychological support service and the shifts in emergency helicopter (table 1). 









Age – n (%)

20-39 years

40-49 years

50-59 years

23 (34)

34 (50)

11 (16)

6 (38)

9 (56)

1 (6)

17 (33)

25 (48)

10 (19)

Male n (%)

33 (49)

8 (50)

25 (48)

Years in practice in critical area – n (%)

< 5


> 10

10 (15)

10 (15)

48 (70)

0 (0)

2 (12)

14 (88)

10 (20)

8 (15)

34 (65)

Relationship – n (%)



34 (50)

34 (50)

9 (56)

7 (44)

25 (48)

27 (52)

Day/night job shift duration – hours




Night shifts in a month – n




Table 1. Demographic characteristics of the study population
BOS-related symptoms have been identified in at least 85% of the nurses in the entire study population (table 2): 75% the PEHS-Psy group and 88% in the PHES group (p=0.2). In the indicator EE a BOS was found in the 57% of the respondents in the PHES group and 75% in the PEHS-Psy (p=0.7). In the indicator DP 76% among the PEHS nurses and 75% among PHE-Psy nurses suffered a BOS (p=0.6). In the indicator PA, 63% and 50% respondents had a BOS respectively in the PEHS and the PEHS-Psy populations (p=0.03).

Indicator of BOS



Total (n=68)

PHES-Psy (n=16)

PHES (n=52)



% (CI 95%)


% (95% CI)


% (95%CI)


Emotional exhaustion 



50 (38-61)


38 (35-64)


54 (40-66)




24 (15-35)


18 (7-43)


25 (15-38)




26 (17-38)


44 (23-67)


21 (12-34)





36 (26-48)


25 (10-49)


40 (28-54)




34 (23-46)


37.5 (18-61)


33 (21-46)




30 (19-41)


37.5 (18-61)


27 (17-40)


Personal accomplishment



40 (28-51)


50 (28-72)


37 (25-50)




24 (15-35)


32 (14-56)


21 (12-34)




36 (26-48)


18 (7-43)


42 (77-95)





85 (75-92)


75 (50-90)


88 (77-97)


Table 2. Prevalence of burnout syndrome in the study population  
BOS: burnout syndrome. CI: Confidence Interval


This study is a cross-sectional study that represents a snapshot in time limited to participants at 4 public hospitals in Italy. Thus, the results may not be generalizable to all hospitals, based on different country of origin, cultural or educational background. Since the survey response was 100%, our study didn’t suffer of selection bias. Temporal confounds (eg, vacations or relocation during the data collection phase) were minimized by conducting the study rapidly in a 2-month time frame. While the MBI-GS is one of the most widely used instrument for measuring BOS, its relevancy as a diagnostic tool was debated, with some believing that EE alone should define BOS (7).


Very little is known of the prevalence of BOS in pre-hospital emergency nurses (8). Our study showed a high estimated prevalence of BOS among PHE nurses. These results are similar to those obtained by other researchers on hospital emergency departments, which described that up to 86% nurses have at least one of the three classic symptoms (4,5). In a more recent study (9) 86% of emergency department nurses showed moderate and high levels of exhaustion scores, 100% of them showed moderate and high levels of depersonalization scores and 97% showed moderate and high levels of low professional accomplishment.
In literature, the most common described symptom of BOS among critical care nurses was emotional exhaustion (4), while in our cohort it was not so frequent, in particular among PHE responders (high EE 21% vs 44% among PHE-Psy nurses, p=0.07). We found the depersonalization as the most recurrent domain of BOS in both group of pre-hospital nurses (respectively 76% and 75% among the PEHS and PHE-Psy nurses).
Currently, there are no large randomized controlled trials that have examined strategies to prevent BOS in critical care health-care professionals. Potentially beneficial strategies that have been effectively used against BOS include team debriefings, structured communication, assertiveness training and cognitive behavioural (4,5,7). Since 2 years the described PHES-Psy has adopted a psychological support to prevent BOS among pre-hospital nurses and we found that the frequency of severe BOS (6) was lower than the same rate in the previous survey (75% vs 90%, p=0.2).
Moreover, Garcia-Izquierdo (10) found excessive workload to be related to higher level of BOS. Nonetheless, taking into account that in the Psy-PHES there were 75770 interventions/year vs a mean of 44562 in the other services, we found less levels of BOS in the Psy-HES group.
In conclusion, our data confirmed that more than least two-thirds of critical care nursing staff had a severe BOS. The use of a psychological support service seemed to limit the prevalence and the grade of BOS among PHES-nurses. Further interventional studies are needed to better investigate this potentially preventive strategy.


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