Burnout syndrome among nurses working in mobile emergency services is a relevant issue, as it influences the well-being of health professionals and the quality of care provided. Understanding the factors related to Burnout in this population is crucial for developing effective prevention and intervention strategies. This review aimed to critically analyze the Burnout syndrome in nurses working in mobile emergency services. After carefully selecting studies in relevant databases, a high workload, exposure to critical incidents, lack of organizational support, and inadequate coping mechanisms were identified. These factors promote emotional exhaustion, depersonalization, and a reduction in personal fulfillment, central components of the Burnout Syndrome. The need for interventions to face the challenges and risk factors involved in the illness process is highlighted. The importance of organizational support, workload management, and implementation of coping strategies to mitigate Burnout and improve the general well-being of nurses in this environment was emphasized. Additional research is needed to develop evidence- based interventions that effectively prevent and alleviate Burnout in this population.

 Keywords: prehospital emergency, prehospital emergency care, occupational burnout, professional burnout, nurses, nursing personnel

Burnout syndrome is a multi-causal pathology characterized by continuous exposure to work-related stress and poor working conditions, resulting in decreased pleasure and work performance ^1,2. It is associated with excessive and prolonged anxiety and manifests through depersonalization, emotional exhaustion, and reduced professional achievement. Nursing, as a profession in the healthcare sector, is particularly prone to burnout due to the demanding nature of the work, including patient care in a highly stressful environment with limited resources and excessive workload.^3,4 Nursing is recognized as one of the most exhausting occupations, and burnout is commonly found among healthcare professionals, especially nurses. While some professionals can cope with the symptoms, those who struggle with long-term working conditions, a lack of staff, and poor communication tend to experience physical and emotional exhaustion.^5,6

Burnout impairs nurses' ability to provide care effectively, as they face the daily challenge of being empathetic in a work environment filled with numerous responsibilities. Difficult situations encountered in patient care, such as cost recovery or non-recovery, and the inability to effectively cope with challenging situations like death can lead to feelings of powerlessness and professional dissatisfaction.^7–9 The World Health Organization emphasizes the importance of investing in prevention and improving the work environment's quality to protect workers' well-being and health. Recognizing other mental pathologies that may influence the development of burnout is also essential.^8–10 Factors such as distress symptoms, coping mechanisms, work limitations, job satisfaction, substance use for stress relief, alcohol consumption, and understanding of depression and anxiety should be considered when addressing burnout.¹¹ Prehospital emergency care is crucial in the health area, as it requires nurses to provide urgent and immediate care to individuals in emergencies outside the hospital context since SAMU ambulances are not always triggered by the presence of doctors in helping the victims.^12–14 In this sense, the role of nurses is fundamental both in accessing the accident scene and in assisting victims, consisting of patients affected by various types of trauma mechanisms and different clinical states of severity. Therefore, nurses are essential in the prehospital care provided by Mobile Emergency Care Services – SAMU.^15,16 High-stress levels, long hours, exposure to traumatic incidents, and intense emotional demands characterize prehospital care. As a result, nurses are at greater risk of developing Burnout Syndrome, emotional, physical, and mental exhaustion, depersonalization, and reduced personal fulfillment.¹⁷ Burnout syndrome among nurses in prehospital emergency care is a significant concern due to its potential impact on the well-being of professionals, the quality of care provided to patients, and the high rates of absenteeism associated with it. Notably, whether public or private, absenteeism in health services is a real fact and has become a problem for managers, raising costs and compromising the quality of health service provision in all its stages and levels of care. Understanding the specific factors related to burnout in this nursing population is crucial for developing effective prevention and intervention strategies. Therefore, this narrative review aims to gather and critically analyze the available literature on Burnout Syndrome in nurses who work in prehospital emergency care.

The review included studies focusing on nurses' experiences and challenges in prehospital emergency care. The main themes and findings related to burnout in this population of professionals were identified. The prevalence of Burnout among nurses in prehospital emergency care is a growing concern. Several studies have reported high rates of burnout in this population, highlighting the need for targeted interventions. Factors include increased workload, exposure to traumatic incidents, lack of organizational support, and inadequate coping mechanisms. It is essential to understand the consequences of burnout to emphasize the importance of this issue and to develop strategies to promote the well-being of nurses and thus provide quality care. In this sense, this review addresses interventions and preventive measures to mitigate burnout in nurses who work in prehospital emergency care. It included organizational support strategies, workload management, promoting self-care practices, and building resilience. The findings will help identify gaps in the literature and provide information for future research and the development of evidence-based interventions. By addressing burnout in nurses, healthcare organizations can provide a healthier work environment, improve nurse satisfaction and retention, and ultimately improve patient care in prehospital emergency settings.^15–18 This narrative review seeks to examine the phenomenon of burnout among nurses in prehospital emergency care. By exploring the factors involved, it is possible to plan actions to improve the well-being of nurses and patient care and interventions to be implemented concretely.

This cross-sectional, observational, and integrative study consists of a review of Burnout syndrome among nurses working in mobile emergency services is a relevant issue, as it influences the well-being of health professionals and the quality of care provided. A search for studies was carried out in the PubMed/Medline, Scopus, Scielo, Embase, and Web of Science databases, in addition to Google Scholar, considered a source of gray literature, as it does not contain peer- reviewed articles. Studies related to the topic were selected using the following search strategy: (("Emergency Medical Services"[Mesh] OR (Emergency Services, Medical) OR (Emergency Service, Medical) OR (Medical Emergency Service) OR (Medical Emergency Services) OR (Service, Medical Emergency) OR (Services, Medical Emergency) OR (Medical Services, Emergency) OR (Emergency Medical Service) OR (Medical Service, Emergency) OR (Service, Emergency Medical) OR (Services, Emergency Medical) OR (Prehospital Emergency Care) OR (Emergency Care, Prehospital) OR (Emergicenters) OR (Emergicenter) OR (Emergency Care) OR (Emergency Health Services) OR (Emergency Health Service) OR (Health Service, Emergency) OR (Health Services, Emergency) OR (Service, Emergency Health) OR (Services, Emergency Health)) AND ("Nurses"[Mesh] OR (Nurse) OR (Personnel, Nursing) OR (Nursing Personnel) OR (Registered Nurses) OR (Nurse, Registered) OR ( Nurses, Registered) OR (Registered Nurse))) AND ("Burnout, Professional"[Mesh] OR (Professional Burnout) OR (Occupational Burnout) OR (Burnout, Occupational) OR (Career Burnout) OR (Burnout, Career)) AND and (Prehospital Emergency Care) in the last 5 years. Cohort studies, systematic reviews, case-control, cross-sectional studies, case series studies, and randomized clinical trials were included. Experimental studies were used as exclusion criteria. Duplicate reports were excluded using the Rayyan software - Reviewer. Analysis, review, and selection of the studies were made by peers unthinkingly, from reading the title and summary of the study, with a third reviewer in case of disagreement between the other two reviewers.

Burnout Syndrome is a challenging problem for nurses in emergency departments and pre-hospital services. Work overload and lack of organizational support are factors identified in several studies, such as those by Cañadas-de la Fuente et al & Adriaenssens et al.^10–13 High levels of stress and emotional exhaustion contribute to the involvement of Burnout Syndrome. Empathy, emotion regulation, and mindfulness are preventive skills against Burnout. Yuguero et al. & Salvarani et al.^18,19 demonstrated that high levels of empathy and mindfulness are beneficial against Burnout. Such potentials strengthen the prevention and management of Burnout in health professionals. Sánchez-Zaballos and Mosteiro-Díaz^20,21 found a positive association between resilience and job satisfaction; that is, more resilient professionals are protected against the syndrome.²² Other factors, such as the intention to leave the job and the experience of post-traumatic stress, according to Bales et al. are predisposing to the installation of Burnout in nurses, highlighting the need for psychological support.²³ Overall, there is consistent evidence that Burnout Syndrome is a common problem in emergency departments and pre-hospital settings.¹⁶ Work overload, lack of organizational support, exposure to stressful and traumatic situations, and lack of empathy and emotional balance skills contribute to the development of burnout. On the other hand, resilience, mindfulness, and empathy were identified as protective characteristics.

These results underscore the importance of training programs in emotional skills, organizational support, stress management, and promoting the well-being of professionals. These measures can help mitigate the impact of burnout and improve professionals' quality of life. Friganović et al.²⁴ investigated psychosocial, individual risk factors, and burnout in emergency physicians and nurses. He highlighted the influence of workload, interpersonal conflicts, and lack of support in the work environment in the development of burnout. These organizational factors reinforce the importance of policies and practices that promote a healthy work environment. Li et al.²⁵ highlighted that violence in the workplace is associated with higher levels of Burnout and a greater likelihood of dismissals. This highlights the need to address workplace violence as a risk factor and the need for adequate prevention and protection measures.

Córdova-Martínez et al.²⁶ revealed a positive association between mental strength and quality of life. Such findings highlight the strategic importance of personal empowerment to promote quality of life in the professional environment in preventing Burnout Syndrome. In Iran, Sahebi et al.²⁷ performed a meta-analysis involving Burnout in professionals of pre- hospital emergency services. There was a high prevalence of the syndrome in this population, an opportunity in which the authors inferred the importance of preventive interventions and psychosocial support. Even when dealing with a controversial topic, Witczak-Błoszyk et al.²⁸ explored suicide exposure, occupational burnout, and coping strategies in emergency medical service professionals in Poland. There was a direct relationship between suicide and high levels of Burnout, which reinforces the role of effective methods in reducing the impact of occupational stress on nurses.  Finally, the studies by Westphal et al& Power et al.^29,30 investigated the influence of mindfulness and positive experiences at work on emergency professionals' mental health and well-being. Both studies found a positive association with lower rates of depression and anxiety, highlighting the importance of these factors in promoting the mental health of emergency

Professionals.

In conclusion, Burnout Syndrome is a relevant and worrying issue among nurses working in emergency departments and pre-hospital services. These professionals face several challenges, including intense workloads, exposure to stressful and traumatic situations, lack of resources, and violence in the workplace. These factors contribute to high levels of occupational stress, emotional exhaustion, and decreased quality of professional life. The prevalence of Burnout is significant, and its negative effects extend not only to health and well-being but also to the quality of patient care. Burnout reduces empathy and engagement with patients, increasing error and dismissal rates, and impairs the quality and safety of care provided. However, studies highlight resilience, mindfulness, and positive work experiences, promoting well-being and prevention. Strengthening these factors and promoting a healthy work environment reduces the occurrence of Burnout and improves the quality of professional life of emergency nurses. Health institutions and managers must implement psychosocial support programs and organizational policies that prioritize the well-being of nurses, establish workload management, and promote a culture of care and mutual support. In addition, it is essential to invest in ongoing training and development of adequate coping skills, providing them with the necessary tools to deal with stress and protect their mental health.

The authors thank the Federal University of Rio Grande do Norte, Potiguar University, and Liga Contra o Cancer for supporting this study.

The authors declare that there is no conflicts of interest.

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