Chapter 10: Burnout and Stress, Violence and Aggression

Learning objectives for this chapter

By the end of this chapter, we would like you:

-To describe the variety of reasons for burnout and stress, and violence and aggression, in emergency care settings.

-To explain how to recognise burnout and stress, and violence and aggression, in emergency care settings.

-To implement strategies to effectively manage burnout and stress, and violence and aggression, in emergency care settings.

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Burnout and stress in the emergency care setting

Burnout and stress are significant problems for nurses working in all clinical settings. Research conducted by the Royal College of Nursing (2013) suggests that the majority of National Hospital Service (NHS) staff experience some degree of work-related stress. Because of the intensity of the emergency care setting, it is likely that nurses working in this setting experience a higher degree of stress than those working in other settings.

Research conducted by the Royal College of Nursing (2013) suggests that there are 10 key reasons why nurses in the UK experience work-related stress:

  1. Workload.
  2. Staff shortages.
  3. Lack of time to complete tasks.
  4. Lack of adequate rest breaks.
  5. Poor management.
  1. Requirement to work long hours.
  2. Lack of control over working environment.
  3. Worries about job security.
  4. Worries about finances / income.
  5. Poor organisational policies.

However, there may be a variety of other issues which underpin nurses' experience of work-related stress. The experience of aggression and violence, which you will study in greater detail in a later section of this chapter, is another significant source of stress for nurses generally, and particularly for those working in emergency care settings.

Where stress is significant, and where it occurs over long periods, stress may lead to burnout. Burnout is a feeling of acute exhaustion, which may result in both physical and / or psychological illness. The Royal College of Nursing (2013) suggests that 42% of nurses in the UK consider themselves to be 'burned out'. It is important to note that burnout usually occurs gradually and covertly; nurses may struggle to continue in their stressful role for some time, before something causes them to realise that they are simply unable to continue.

Stress and burnout can have a number of significant negative consequences, both for nurses and for the patients for whom they care. Importantly, it can lead to nurses disengaging from their work in an effort to cope with the stresses it brings, and subsequently depersonalising patients. This can result in a number of poor outcomes for patients, essentially because it increases the risk of poor-quality care delivery. Burnout leads to an increase in presenteeism, an increase in the need for sickness absence, and also plays a crucial role in nurses' decision to leave the nursing profession.

Managing burnout and stress

The first step for nurses in managing their stress and / or burnout is to identify that these are problems they may be experiencing. There are a number of different checklist-type tools which a nurse working in an emergency care setting can use to determine their risk and / or level of burnout. You are encouraged to explore the variety of assessment tools for stress and / or burnout available for nurses to access online. Generally, nurses who experience stress and / or burnout:

  • Are fatigued and / or frustrated most of the time.
  • Are often sick with minor illness.
  • Record a change in their appetite, weight and / or sleep patterns.
  • Are anxious and / or depressed, and may show signs of clinical mental illness.
  • Feel failure, self-doubt, detachment, loss of motivation, lack of satisfaction, etc.
  • Lack satisfaction and a sense of accomplishment in relation to their work.
  • May withdraw from their responsibilities, procrastinate and / or disengage from work.
  • Use food and / or alcohol or other drugs to cope with their stress.
  • Report a lack of control, lack of recognition, excessive demands, or extreme pressure.

As highlighted in the previous section of this chapter, burnout and stress are often underpinned by work-related issues at the organisational level, over which nurses may have little control. However, there are a number of self-care strategies that nurses working in emergency care settings may implement to enable them to respond in a more positive way to these challenges. Consider the following list:

  • Ensuring adequate rest, including breaks at work and a good night's sleep.
  • Eating a healthy, well-balanced diet, including when at work.
  • Engaging in adequate exercise.
  • Using relaxation strategies.
  • Talking with others, both at work and outside it, about work-related problems.
  • Ensuring that work does not interfere with personal time.
  • Being aware of personal scope and limits, and working within these.
  • Raising issues with managers as they occur, and actively contributing to solutions.

Violence and aggression in the emergency care setting

Each day, NHS staff in the UK experience more than 150 incidents of violence and aggression, with most occurring in 'high-pressure' areas such as Accident and Emergency (A&E) Departments. There are more than 55000 physical assaults reported against NHS staff in the UK each year, including 30200 physical assaults in emergency care settings specifically, and incidents of verbal assault are significantly more common. As stated by the Design Council (2011: p. 15), "the NHS Constitution pledges a safe working environment for the NHS workforce, but it is clear that solutions are needed to help make this a reality for frontline staff".

There are a number of common features of 'violent' and 'aggressive' acts perpetrated in emergency care settings in the UK:

  • They are interactions which occur between two or more people.
  • They involve the use of force against a person and / or property.
  • They involve verbal and / or physical aspects.
  • They result in both short- and long-term physical and / or emotional consequences.

It is important to understand that violence and aggression in emergency care settings in the UK occurs on a scale of severity. The scale presented following ranks violent and aggressive acts in order of increasing severity:

Moderate verbal hostility; inappropriate use of language, etc.

Significant verbal hostility; offensive use of language; profanity, etc.

Physical contact; damage to property, etc.

Physical violence resulting in minor injury.

Physical violence resulting in moderate or serious injury.

It is estimated that violence and aggression costs the NHS £69 million each year. Many hospitals in the UK now employ security personnel in emergency care settings, particularly on weekends, to protect staff. Violence and aggression in health care settings has significant effects on individual staff and service users, impacting them both physically and psychologically in a variety of complex, negative ways. The time taken for staff to recover from incidents of violence and aggression places a greater strain on already overstretched emergency care settings, and staff morale and productivity are also affected. Following an experience of violence and aggression, a significant number of NHS nurses choose to leave the emergency care setting - or even the nursing profession more broadly.

The Design Council (2011) suggests that people who perpetrate violence and aggression in health care settings in the UK are usually those who are:

  • Clinically confused. The violent / aggressive acts perpetrated by these patients are usually directed towards clinicians but generally lack intent, as the person is not in control of their behaviour.
  • Frustrated, often because they are required to wait to receive care. Frustration may build gradually over time, or it may occur with no obvious advanced warning.
  • Intoxicated. Alcohol and other drugs impair a person's cognitive function, judgement and ability to predict consequences, etc.
  • Anti-social / angry, with a history or pattern of violent and / or aggressive behaviour.
  • Distressed / frightened.
  • Socially isolated. Because many emergency care settings are open continuously 24 hours per day, 7 days per week, they can "become a strange gathering place for all sorts of people who are lonely or have nowhere else to go" (Design Council, 2011: p. 50). These people may be threatening and manipulative towards staff.

The Design Council (2011) also reports on a number of triggers for violence and aggression in health care settings in the UK:

  • Clash of people: emergency care settings are crowded with a variety of different people who are forced together in a high-pressure setting; each of these people are experiencing their own difficult circumstances and have their own needs.
  • Lack of progression: some people become frustrated when they are required to wait any length of time to receive care, particularly when they consider the experience uncomfortable and boring.
  • Inhospitable environment: hospitals generally, and high-pressure emergency care settings in particular, are not pleasant places in which to spend time.
  • Intense emotions: people in emergency care settings are often experiencing significant negative life events and suffering with pain and / or stress, all while observing those around them go through the same complex situations and emotions.
  • Unsafe environment: many people perceive emergency care settings to be unsafe environments - because they are crowded, because there are many people who are considerably unwell, because they often result in a loss of patient dignity, and because there is a large amount of equipment in use.
  • Inconsistent response: many patients may fail to understand the triage process, and wonder why they are left waiting for care when those arriving later are seen urgently.
  • Staff fatigue: emergency care settings are physically- and emotionally-demanding environments, and staff may struggle to manage the constant flow of patients.

Managing violence and aggression

There are a variety of strategies that nurses working in emergency care settings can use to manage violence and aggression:

  • For lower-level aggression, the aim is to prevent progression to violence. This involves responding early to the triggers of aggression and violence through interactions with patients and their family / carers at all stages of their visit to the emergency care setting.

Research suggests that it is important for staff working in emergency care settings to manage people's expectations and reduce their anxiety. This can be achieved by communicating to patients and their family / carers: (1) how the patient processing system in emergency care settings works, particularly in terms of triage, and (2) what will happen to the patient during their time in the emergency care setting. Nurses may provide patients and their families / carers with accurate information about:

  • How busy the emergency care setting currently is, including expected wait times.
  • Why they are waiting, what they are waiting for and what will happen next. 
  • Options and alternatives to emergency care service provision.
  • Where they should go and what they should do at different stages of their visit.
  • Who to seek assistance and information from, and how to do so.
  • Expected outcomes of their visit to the emergency care setting.

In dealing with violence and aggression in the emergency care setting, it is also important to make a note about the presence of family / carers during life-saving procedures, such as resuscitation. Occasionally, family / carers will witness somebody they care about enter cardiac and / or respiratory failure in an emergency care setting, and they may observe clinical staff administer aggressive interventions such as cardiopulmonary resuscitation (CPR). These situations are among the most stressful that people in emergency care settings will encounter - they are, therefore, likely to bring about aggressive and / or violent behaviour. In these situations, it is important that a dedicated nurse attends the family member/s or carer/s to explain what is happening and why. Regardless of the outcome of the resuscitation, it can be traumatic to witness; family member/s or carer/s should therefore be provided with appropriate support after resuscitation.

  • For higher-level aggression or violence, the aim is to contain and defend oneself.

There are a number of strategies that nurses working in emergency care settings may use to contain and / or defend themselves from aggression or violence. De-escalation techniques should be used, where appropriate; these techniques are used with the intention of calming an angry person, and they may include techniques such as:

  • Physical behaviours: allowing the person physical space, avoiding constant eye contact, standing at an angle to the person, keeping hands free for defence, etc.
  • Verbal behaviours: maintaining a calm tone, not responding to provocative questions / statements, explaining limits and rules, empathising, avoiding judgement, etc.

Containing and / or defending oneself from aggression or violence often involves liaising with security personnel and / or police officers present in the emergency care setting. It is important that nurses work closely with these professionals to: (1) identify patients who are, or who have the potential to become, violent and / or aggressive, and (2) effectively manage these patients. This may involve forms of seclusion and / or restraint of people within the emergency care setting. It may also involve the removal of a person from the emergency care setting if they continue to behave inappropriately. 

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This chapter has discussed burnout and stress, and violence and aggression, in emergency care settings, beginning with an overview of the reasons why these issues occur and how they can be recognised. The chapter also presents a variety of strategies and techniques that nurses working in emergency care settings can implement to effectively manage burnout and stress, and violence and aggression.

Reference list

Design Council. (2011). Reducing Violence and Aggression in A&E Through a Better Experience. Retrieved from:

Royal College of Nursing. (2013). Beyond Breaking Point. Retrieved from:

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