Nurses ’ Burnout Level and Clinical Competence in Emergency Department: A Scoping Review

The condition of nurse fatigue includes emotional exhaustion, lack of respect for others, and decreased self-achievement (Burnout) results in the disruption of routine services in the Emergency Room. Routine services in the Emergency Room such as CPR procedures that require special nurse competence with zero tolerance will result in suboptimal results and delays in service. This literature study aimed to determine the relationship between nurse fatigue and nurse competence in the Emergency Room. The method used in writing this Scooping Review is PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). Searching for literature or references focuses on 2018 – 2022 and Original Research. The databases used in the search for references or literature are Pubmed, Proquest, Science Direct, and Google Scholar. The data was analyzed using the Joanna


INTRODUCTION
Burnout condition in the Emergency Room as a common situation for the nurse as response towards stressors that is prolong and not well managed (1).Nurse will always be taking care of the patients professionally within 24 hours every weekday in shift which can alter their biological functions that lead to physical and mental disturbance (2).The increasing demand of high quality of care will affect the needs of nurse's emotional control and their expression continuously (3).Several factors that worsen the burnout condition such as work in shift, teamwork, interpersonal communication, wages, environment, human resources, and stress management(2).Thus, they are often faced with factors that generate occupational stress with the potential to affect their mental health.
The highest burnout level is in emergency room due to the characteristic of the life-threatening patient condition, the zero respond time, emotional stressors and a low sense of personal accomplishment (1).The emergency nurse can prevent the burnout condition by doing the early assessment of the stressors, the change of behavior and psychological condition (2).The hospital should arrange the method for prevent the burnout condition in emergency nurse staff by improving nurses' stress management during interactions with patients and family.The development of nurses' emotional competence will be helpful for emergency nurses to cope with the emotional labor stress and burnout (3).The impact of burnout in emergency nurse staff can elevate the cost of nursing turnover as high as 150%, lowering the level of patient safety, increasing the patient's negative attitude towards the emergency nursing staff, decreasing patient satisfaction and lowering the quality of healthcare (4)However, the nurse's level of competence still needs to be well developed (5) There were several factors that influence the nurse's competence such as communication skills, interest, work experience and personal factors such as ethical and professional principles, knowledge, and skills.The expert level of nursing competence will improve the patient's quality of care (5) The high level of competence (for example the ability of nurses to write prescriptions) can maintain the maximum standards of patient care, add access to medical services, improve nursing skills, and keep their professional status (6)

Search Strategy
This literature review searching for high and mediumquality criteria from 4 databases: Google Scholar, ProQuest, Pubmed, and ScienceDirect.Keywords in this literature review consist of: ("nurses' burnout") OR ("nurse tiredness") AND ("nurses' emergency") AND ("nurses' competence").The results for article selection on November 29, 2022: Google Scholar for 3 journals, Proquest for 2 journals, Pubmed with 3 journals, and ScienceDirect 2. The search was conducted to analyze Nurses' Burnout Level and Clinical Competence in Emergency Department.

Inclusion Criteria
The inclusion criteria of this literature review are: 1) article published in the 2018-2022; 2) International reputable articles; 3) study design: cross sectional and prospective/cohort study.4) free access and full text journal; 5) No duplication article.

Study Selection and Data Extraction
In this investigation, screening was done using the titles and abstracts that the search strategy produced.While other freely accessible journals are checked using predetermined inclusion criteria, irrelevant journal papers are published.The collected journals are then extracted into tabular form to facilitate describing the research journal's contents.The author (author), the year the journal was released, the nation of the journal publisher, the journal's study design, the quality score, the research population/research sample, and the result are all listed in the data analysis table (the results of the journal research).

Quality Assessment
Researchers assessed each study's methodological quality using the Joanna Briggs Institute (JBI) tool.The JBI instrument was chosen to evaluate the trustworthiness, relevance, and results of this papers with the Cross-Sectional study design (8 items) and Prospective/Cohort study design (11 items).

Literature Search
The 25.410 journals found by the literature search on November 29, 2022, were then narrowed down to 5604 by a set of criteria that included only those that had been published between 2018 -2022, had Cross Sectional research study designs, Prospective or Cohort research design, and completely accessible journal (full text).Ten (10) journals passed the inclusion requirements after the second screening of journals, which involved examining titles and abstracts in accordance with PICOTS (Problem, Intervention, Compare, Outcome, Time, and Study Design).Based on 10 articles that meet the inclusion criteria and have been analyzed, the results are shown below: 1. Nurses who work in Emergency Department were easier to become frustrated, depressed and have high burnout level as compared to nurses who work in another unit, due to the high pressure of critical condition, crowded settings, workload and high expectation from the patient and family to get the highest standard of care.2. The high level of burnout condition will lower the quality of care in emergency units, decrease the patient level of satisfaction, reduce the level of professional competence of emergency nurse, lead the nurse to quit this job, elevate the self-depersonalization and cause the severe crises situation of emergency unit.3. Several approaches are needed to lower the burnout level and increasing the professional level of emergency nurse competence.Build the trust among the team member and establish more support system can help the emergency nurse to stay longer and convenient in emergency unit.Shortened the shift time, manage the emergency nursing procedure based on evidence-based practice, enhance the opportunity for the staff and all team member to express their needs and provide the positive feedback, reward, and appraisal to help them lessen the overload duty in emergency units.

Nurse Burnout Level
Emergency nurses are at the greatest risk to become burnout than nurse in another unit.Several personal factors that result the high burnout level are the age, gender, type of personality, self-control, and self-management ability.Several professional factor that includes cause burnout are the type of service in the unit (like emergency room that very crowded and high-pressured condition), characteristics of the work environment, overload duty, overtime shift work, less support, lack of resources, low decision-making autonomy, bad management system (7).Some study had shown that estimated 26% of emergency nurses got high burnout level due to their daily work shift (8).The burnout phenomena should be well solved due to the increasing rate of nursing quit.
Prolong burnout condition can lower patient safety and the quality of health care in emergency unit.The estimated of financial loss can reach from $10,000 to $88,000 depending on the nurse position (9).The high emotional exhaustion, self-depersonalization, and low personal accomplishment among emergency nurse will decrease the satisfaction of patient and their family so the hospital can loss the patient loyalty and will seriously impact to hospital reputation.However, the better arrangement of emergency unit, such as proportional remuneration, regular supervision, rewards mechanism, safe operating conditions, cooperative team, balance nature of work, regular work promotion, effective communication, could reduce the burnout level of emergency nurse (10).

Clinical Competence in Emergency Department
Emergency nurses must improve their knowledge level for caring the patient to meet their optimum health care needs (11).They need to be skilled not only in technical areas but also in decision-making, prioritizing, and teamwork.Nurses working in emergency rooms offer special patient care in a variety of quickly changing circumstances.To guarantee safe and effective patient care in this specialized context, it is critical to establish the clinical competences needed of emergency nurses (12).Stress in nurses, especially emergency nurses, is influenced by situational factors like patient violence, holidays, or healthrelated events like the seasonal flu in addition to organizational culture factors like work overload, inappropriate treatment by the organization, and environmental factors like system and noises.Personal factors like education, burnout, and compassion fatigue, as well as environmental factors like understaffing and time constraints, were the main causes of distress (13).Effective communication, cooperation, and understanding between parties are all professional practices that are compatible with the primary traits of clinical leadership can enhance level of emergency nurse competence (14).

CONCLUSION AND RECOMMENDATIONS
After conducting a number of research procedures, based on the findings of research published in national and international journals regarding the study of nurses' burnout level and clinical competency in emergency departments, it can be concluded that nurses working in emergency departments were more likely to experience frustration, depression, and high levels of burnout than nurses working in other units, likely because of the high pressure of critical conditions, crowded settings, and long hours.Building teamwork and support networks can enable the emergency nurse to work more conveniently and for longer in the emergency unit.reduced the shift duration and managed the emergency nursing protocol appraisals based on evidencebased practice to assist them reduce overworked emergency unit employees.

ACKNOWLEDGEMENT
The author appreciates Universitas Brawijaya for making the databases accessible.

ETHICAL CONSIDERATION Funding Statement
There was no specific grant provided for this project from supporting organizations in the public, private, or nonprofit sectors sectors

Conflict of Interest statement
There is no conflict of interest, according to the author.