Burnout has been a widely studied topic of interest over the last 40 years, with significant resources devoted toward investigating its causes, impacts, and strategies for mitigation [1]. Burnout is a work outcome, defined by prolonged occupational stress in an individual that presents as emotional exhaustion, depersonalization, and diminished personal accomplishment [2].

The study of burnout in healthcare professionals is important as it has impacts at the level of the individual provider [3,4,5], the patient [6,7,8,9], and the organization [5, 10,11,12]. As nurses make up the largest group of healthcare professionals, there have been a number of studies that have explored contributing factors [13] and interventions for their burnout [14]. Pediatric nurses are a lesser-studied population, perhaps due to the relatively small number of pediatric nurses compared to general service nurses and the broader population of healthcare professionals. Burnout in pediatric nurses may be unique from adult care nurses because of the specialized nature of providing care to children who are typically seen as a vulnerable population, the high potential for empathetic engagement, and the inherent complexities in the relationships with families [15, 16]. Only one literature review could be located on the topic of pediatric nurse burnout; it mainly focused on burnout prevalence, which was found to be moderate to high [17]. Further synthesis of the literature in other domains of the topic is needed to explore factors associated with pediatric nurse burnout, the associated outcomes, and interventions.

The purpose of this scoping review is to explore what is known about pediatric nurse burnout to guide future research on this highly specialized population and, ultimately, improve both pediatric nurse and patient well-being. More specifically, the aim of this scoping review was to investigate, among pediatric nurses, (i) the prevalence and/or degree of burnout, (ii) the factors related to burnout, (iii) the outcomes of burnout, and (iv) the interventions that have been applied to prevent and/or mitigate burnout.

Methods

Protocol registration

This scoping review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines scoping review extension [18]. The protocol was registered on Open Science Framework on 25 March 2019 and can be accessed at https://osf.io/5xrkg/.

Information sources and search strategy

In consultation with an experienced librarian, the following electronic databases were searched on 3 November 2018 without limitation to a publication date range in order to maximize inclusion: The Cochrane Library, CINAHL, EMBASE, MEDLINE, PsycINFO, and ASSIA. All electronic database search strategies used in this review can be found in Appendix A. The term “pediatrics” was not part of the electronic database search to avoid inadvertently excluding studies that contained pediatric nurses as a non-primary subject group. The selected articles from the electronic database search were screened for inclusion of the pediatric nurse population. For the purposes of this review, the pediatric patient population is defined as newborn to age 21 as defined by the American Academy of Pediatrics, acknowledging that this age range may be slightly extended based on the country and patient needs [19].

Eligibility criteria

All qualitative, quantitative, or mixed-methods studies published in English that examined the prevalence and/or degree of burnout in pediatric nurses using self-identification or self-report assessment tools were included. Commentaries, letters, and editorials were excluded as these are not peer-reviewed and often referred to colloquial definitions, not the clinical definition of burnout of interest in this scoping review. Dissertations were excluded, but their corresponding publications were screened for inclusion. Conference abstracts were excluded as they are often inconsistent with their corresponding full reports [20]. Systematic or scoping reviews and meta-synthesis were excluded, but references were hand-screened for suitable studies.

Selection of sources of evidence

All citations retrieved from the databases were uploaded into Endnote with duplicates removed as per protocol [21]. The remaining citations were uploaded into Covidence for review by the research team (LB, CM, KW). Titles and abstracts were independently reviewed against the selection criteria in a blinded process by two reviewers (LB and CM). The remaining citations were then reviewed as full-text articles for inclusion against the selection criteria in a blinded process by two reviewers (LB and CM). Disagreements were resolved by a third reviewer (KW).

Data charting process

Data were extracted from included articles and entered into a Microsoft Excel spreadsheet. Extraction was performed by one researcher (LB). The following data items were extracted: title, journal, authors, year of publication, country of publication, sample size, study aim, study design, tool used to measure burnout, burnout prevalence and scores, factors that contribute to the development of burnout in pediatric nurses, factors that prevent or mitigate burnout in pediatric nurses, the impact of burnout in pediatric nurses, and interventions for pediatric nurse burnout.

Synthesis of results

A quantitative synthesis specific to the prevalence and degree of burnout was completed based on the included articles that reported raw scores for any of the Maslach Burnout Inventory (MBI) subscales. A mean score was calculated by hand across studies for each subscale, by totaling the raw scores and dividing by the total number of studies that included a raw score for that subscale. The resulting mean was also categorized as low, moderate, or high burnout based on published cutoff scores [22]. Other data were synthesized qualitatively to map current evidence available to address the remaining study aims. Aims ii and iii were analyzed using directed content analysis [23] following the themes outlined by Berta et al. [24], work environment, work attitudes, and work outcomes. Aim iv data was synthesized by grouping together similar interventions and descriptively summarizing the interventions that were effective in reducing burnout. Given that the overall purpose of the review was to explore the breadth of what is currently known about burnout in pediatric nurses, a quality assessment of individual studies was not conducted [18].

Results

Description of the search and demographics of studies included

Through the initial database search, 16 909 possible papers were identified. After deduplication, 8629 titles/abstracts were screened and 1206 articles were assessed for eligibility at the level of full-text screening. After applying the inclusion and exclusion criteria, a total of 78 studies [16, 25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85,86,87,88,89,90,91,92,93,94,95,96,97,98,99,100,101] were deemed relevant and retained for analysis (Fig. 1). The characteristics of included studies are provided in Table 1. Publication dates ranged from 1981 to 2018, with the majority published between 2009 and 2017. The number of pediatric nurses who participated as either a primary or sub-sample ranged from five to 3710. The most common study design was cross-sectional (n = 60), with 10 studies using multi- or mixed methods, seven using an interventional design, and one each using case-control, exploratory prospective, and longitudinal designs. Only 45 of the 78 studies reviewed used exclusive samples of pediatric nurses; the remaining studies only included pediatric nurses as a subpopulation of a larger sample. The results in this review are reported for pediatric nurse samples and sub-samples only. Almost half (46%) of the included studies were conducted in the USA, followed by Canada (n = 7), China (n = 5), Turkey (n = 3), Brazil (n = 3), Taiwan (n = 2), Australia (n = 2), and Switzerland (n = 2), plus 18 other countries where only a study was conducted. Out of the 78 studies included, 53 (68%) used some form (either complete or abbreviated) of the MBI to measure burnout (see Table 1).

Fig. 1
figure 1

PRISMA diagram of study screening and selection

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Table 1 Characteristics of 78 studies exploring pediatric nurse burnout included in the scoping review
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Burnout prevalence and scores

Although all of the included studies measured burnout using a self-report assessment tool or binary self-identification, only 65 reported burnout scores for a sample of pediatric nurses (Table 2). In total, 53 studies used the MBI, 34 reported on the Emotional Exhaustion subscale with 24 reporting raw scores [25, 27, 29, 39, 42, 45, 48, 53, 61, 62, 72, 75, 77, 78, 84,85,86, 89, 90, 94, 97, 99, 100], and 16 reporting proportions and/or severity of those with scores indicating emotional exhaustion (e.g., low, moderate, high). The mean of the reported raw Emotional Exhaustion scores was 22.45 (SD = 6.54) which indicates moderate burnout [22]. Out of the 14 studies reporting the proportion of respondents with scores indicating high emotional exhaustion, the mean proportion was 38.7%. The mean of the reported raw Depersonalization scores [25, 29, 42, 45, 47, 48, 53, 61, 62, 72, 75, 77, 78, 84,85,86, 89, 90, 94, 97, 99, 100] was 6.95 (SD = 3.38) which indicates moderate burnout [22]. The mean of the reported raw Personal Accomplishment scores [25, 29, 42, 45, 47, 48, 53, 61, 62, 72, 75, 77, 78, 86, 89, 90, 94, 97, 99, 100] was 29.15 (SD = 11.48) which indicates high personal accomplishment [22]. The individual scores from the MBI and other measurement tools are reported for each study in Table 2.

Table 2 Pediatric nurse burnout scores by tool
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Factors related to burnout

Of the included studies, 47 (60%) addressed factors associated with pediatric nurse burnout (Table 3). Factors related to pediatric nurse burnout were classified into the following categories: nurse demographics, work environment, work attitudes, work outcomes, and burnout interventions.

Table 3 Factors associated with pediatric nurse burnout
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Nurse personal factors

Burnout was found to be inversely associated with age; higher burnout was also associated with low/moderate level of experience (5–10 years) [26, 32, 46, 47, 58, 71, 85, 88]. A lack of university-level education or lower self-reported levels of clinical competency were also associated with higher levels of burnout [57, 90]. Being in a nursing supervisory position had ambiguous results on impact on burnout; in some studies, holding supervisory positions correlated with higher reports of burnout while in others, the opposite effects were found [29, 33]. Nurses identifying as not being White or Asian/Pacific Islander ethnicity/race scored significantly lower on the MBI subscale of Personal Accomplishment than respondents identifying as White and Asian/Pacific Islander, and Asian/Pacific Islanders scored lower on Emotional Exhaustion than those identifying as White [36]. High neuroticism and low agreeableness [31] were both associated with higher burnout. Finally, being married had mixed results on impact on burnout, whereas in some studies, being married correlated negatively with burnout, and in others, it correlated positively [26, 36, 101].

Work environment

The work environment is defined by the conditions in which nurses work; it influences work attitudes and, in turn, work outcomes [103]. Burnout was found to be high in certain high-acuity pediatric units including emergency, medical/surgical, surgery, pediatric intensive care unit (PICU), and neonatal intensive care unit (NICU) [26, 32, 35, 36, 76, 88]. Davis et al. [38] found that adult oncology nurses had higher personal accomplishment than pediatric oncology nurses while Neumann et al. [74] found nurses who care for both pediatric and adult patients had lower emotional exhaustion than those who cared for adult patents only. Conversely, Sun et al. [94] found that nurses who worked in adult obstetrics and gynecology units had more burnout than nurses who worked in pediatric units; however, Ohue et al. [78] reported the inverse. Working in hematology/oncology [88] and unit-level factors such as workload [65, 85], number of assigned patients [26], increased number of admissions, understaffing, and shifts > 8 h were associated with increased burnout [51, 92, 95, 96]. Aytekin et al. [29] found working longer years in the NICU was associated with lower levels of personal accomplishment. Brusch et al. [36] found that nurses working exclusively day shifts had higher levels of depersonalization than those working night shifts or a mix of days and nights. Favrod et al. [45] found NICU nurses reported more traumatic stressors in their working environment.

Pediatric nursing workplaces with a strict structure of rules and regulations [33] or nurse leaders who valued structure over staff considerations [41] were found to have nurses with higher burnout. Nurses who had higher perceived organizational support had lower burnout [39]. Higher burnout was generally associated with systems issues such as unreasonable policies, staffing shortages, insurance frustrations, high volumes of paperwork [65], lack of nursing supplies [36], and lack of regular staff meetings [56]. The relationship between resources and facets of burnout was mixed: Rochefort and Clarke [83] found a negative relationship between nurses’ emotional exhaustion and their rating of the adequacy of the resources available to them, while Gallagher and Gormley [46] found that even nurses who reported that support systems were in place and felt supported still were emotionally exhausted. The lack of access to work information and research information was consistently associated with higher levels of burnout [71, 91], and lower burnout was associated with increased communication [33, 36] and better work relationships [39].

Factors impacting increased pediatric nurse burnout were related to the role of the nurse in patient care activities such as decision-making/uncertainty around treatment [33, 39, 56, 76], lack of role clarity, and unclear plan of care [65]. Other factors associated with the development of burnout were related to exposure to suffering, pain, sadness, and death [65]; hopelessness [85]; providing futile care [56]; and overall moral distress [85].

Higher levels of burnout were found in nurses who cared for specific pediatric patient populations such as caring for children with cerebral palsy [97], children with cystic fibrosis [59], and babies with neonatal abstinence syndrome [73]. Another patient factor related to higher burnout involved behavioral issues from patients/families [65, 79].

Work attitudes

Work attitudes are factors that impact the positive or negative perceptions of one’s work environment [104]. Low self-compassion and low mindfulness [47] were associated with higher burnout. Co-occurring conditions with burnout such as depression [37, 63, 97], anxiety [97], and somatic work-related health problems [101] were correlated with greater burnout whereas positive psychosocial factors and coping strategies such as positive affect [30], acting with awareness [70], self-care, humor, reflection, non-work relationships, and a personal philosophy related to work were found to be associated with lower burnout [65].

Nurses’ perceived work stress was positively associated with burnout in several studies [16, 28, 63, 76, 77]. Meyer et al. [16] found that current stress exposure significantly predicted higher levels of burnout after controlling for pre-existing stress exposure, and Holden et al. [51] found that burnout was positively associated with mental workload. Oehler and Davidson [76] found perceived workload made a significant contribution to feelings of burnout. Job satisfaction was also found to be negatively associated with burnout [26, 29, 39, 43, 47, 51, 67].

Work outcomes

Work outcomes refer to occupational performance factors that are influenced by work attitudes and the work environment [24]. Nine studies examined work outcomes associated with burnout including nurse retention, nurse well-being, patient safety, and patient-family satisfaction (Table 4). An increase in burnout was associated with nurses considering a career change [37], decreased quality of life [29], tiredness [89], and feeling negatively toward their teammates and the impact of their work [37]. Work-associated compassion fatigue [16, 66], secondary traumatic stress [48, 58], and post-traumatic stress disorder (PTSD) [37, 60, 70] were all found to be associated with pediatric nurse burnout. However, Li et al. [60] report that high group cohesion may prevent pediatric nurses from developing burnout from PTSD by protecting nurses from the impacts of negative outcomes. Nurse burnout was found to be negatively associated with the safety climate of the hospital in which they work [27, 39] and positively associated with higher infection rates when nurses were feeling overworked [96]. Moussa and Mahmood [71] found that as nurses’ personal accomplishment increased, so did patients’ mothers’ satisfaction with meeting their child’s care needs in the hospital.

Table 4 Burnout’s relationship with other work outcomes in pediatric nurses
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Burnout interventions

Seven of the 78 studies included interventions to mitigate burnout (Table 5). Interventions included coping workshops [42], mindfulness activities [47, 68, 70], workshops to improve knowledge/understanding of their patient population [81, 85], and clinical supervision [50]. Only three of the seven interventions studied provided varying positive impacts on burnout scores [42, 70, 85]. An in-person day-long retreat resulted in a significant improvement in emotional exhaustion for pediatric nurses. The intervention involved didactic and hands-on trauma, adaptive grief, and coping strategies; half of the subjects were also randomized to a booster session 6 months later [42]. Another intervention involved a 90-min interactive module on clinical skills surrounding the management of pediatric pain and resulted in a significant decrease in emotional exhaustion and depersonalization [85]. Finally, the third study of smartphone-delivered mindfulness interventions showed a marginal decrease in burnout compared to nurses receiving traditional mindfulness interventions [70].

Table 5 Interventions for pediatric nurse burnout
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Discussion

To our knowledge, this is the first scoping review that focuses on what is known about pediatric nurse burnout. Burnout was measured with a variety of instruments and interpretations, thereby making score comparisons a challenge. Even in those studies that used the MBI, the most commonly used burnout measurement [105], variations of the tool were applied, as were diverse subscale cutoff scores. Similar challenges in synthesizing extremely heterogeneous burnout data were echoed in a 2018 JAMA review of the prevalence of burnout among different types of physicians [106]. Of the MBI Emotional Exhaustion and Depersonalization subscale results that were synthesized, the results showed moderate scores indicating a significant level of burnout in pediatric nurses. Personal Accomplishment subscale results were high, perhaps indicating a factor of pediatric nursing that increases resilience despite moderate burnout in other domains. In studies that compared nurses who work in pediatric units to other in-patient units, burnout results were mixed [26, 32, 35, 36, 38, 74, 78, 94]. The majority of the included studies identified correlational relationships using cross-sectional study designs, which limited causal inferences. Study designs, such as longitudinal approaches, would allow for causal inference and in-depth analysis of this phenomenon in this unique population.

Nurse personal factors

Pediatric nurse demographic factors that are associated with burnout, such as age, work experience, and level of education, have been a common area of studied burnout associations across other healthcare populations. Similar burnout associations were found in research studying healthcare providers caring for adults such as younger age (< 31 years) [107, 108] and years of experience (> 7 years) [109]. It is likely that nurses new to the profession are younger, are experiencing the challenges of the nursing profession for the first time, and are less likely to have well-developed skills for resiliency. Given that the start of nurses’ careers is a vulnerable stage for burnout, nursing schools and orientation programs may be well-positioned to highlight burnout prevention and mitigation strategies with students and new hires [107]. Personality traits such as high neuroticism and low agreeableness were found to be associated with pediatric nurse burnout [31]. These results have been supported in other nurse and physician populations, along with conscientiousness, extraversion, and openness contributing to lower levels of burnout [110,111,112,113]. Although personality traits appear to have significant correlations with healthcare provider burnout, targeting modulation of personality traits as a mitigation strategy for burnout may be a high-cost, low-yield strategy.

It has been suggested that healthcare provider burnout is not a failure on the part of the individual, rather it is a culmination of impacts stemming from the work environment and the healthcare system as a whole [114]. Responsibility, then, is thought to lie within the individual, the organization, and the profession in general.

Work environment

Job demands and resource variables in pediatric nursing lead to increased burnout, work-life interference, psychosomatic complaints, and intent to leave; these associations are also represented in adult nursing literature [102, 115], including associations with excessive workload, number of assigned patients, admissions, understaffing, and longer shifts [116,117,118,119]. Although Bursch et al. [36] found that pediatric nurses who worked straight day shifts had higher depersonalization than those who worked mixed shifts or just night shifts, Poncet et al. [108] found that working more night shifts was associated with higher burnout in adult critical care nurses. Day shift nurses have potentially more strenuous workloads as patients are more wakeful, have diagnostic tests, or consulting services visiting; however, night shifts could be perceived as more strenuous as it requires the provider to work against their natural circadian rhythm and less support staff are available [120]. These results may also be dependent on individuals’ preference and the specific unit on which they work.

Systems issues such as overwhelming clerical work, administrative, and resource issues have impacts on provider burnout in both the pediatric nurse and general physician populations [36, 56, 65, 121]. Poor leadership is associated with pediatric nurse burnout as identified by Bilial and Ahmed [33] and Druxbury et al. [41]; this relationship is echoed in research with physicians, nurses, and allied health [122]. In pediatric nurses [39], increased perception of organizational support is associated with lower burnout; this association is supported in general nursing populations [119, 123]. In all populations, the support a healthcare provider perceives they get from the organization is predictive of their level of organizational commitment. When healthcare providers perceive that they have high organizational support, they will exhibit greater organizational citizenship behavior, which are extra-role tasks that ultimately improve the organization [124]. Burnout itself results in reduced organizational commitment on the part of the healthcare provider [125].

The experience of witnessing patient suffering and death [65, 122], uncertainty around plan/utility of care [15, 56, 126], moral distress [15, 85], and behavioral issues with patient families (e.g., aggressive patients/families) [65, 79, 127] were found to be significant factors that contributed to burnout in both pediatric nurses and general population physicians and nurses.

Work attitudes

As might be expected, optimism, self-efficiency, resilience, and positive coping strategies are supported as inversely related to burnout in broader nursing populations [128,129,130]. The identification and treatment of burnout is particularly important to consider in light of the evidence that burnout is inversely related to job satisfaction and burnout is a contagious phenomenon between nurses; therefore, early intervention is essential to prevent transmission among staff [131,132,133].

Work outcomes

The association between burnout and patient satisfaction and intent to leave has been reported in non-pediatric nurse populations as well [5, 6, 115, 134,135,136]. It is likely that as nurses become increasingly burned out their satisfaction with their jobs decreases and their desire to leave their position increases. This linkage highlights the importance of addressing nurse burnout in the organization to retain staff and reduce the financial and tacit knowledge losses associated with high nurse turnover.

Higher work-related burnout is also associated with mental health conditions such as anxiety and depression in pediatric nurses; this is represented in several studies of other healthcare provider populations [113, 137,138,139,140]. However, the majority of these associations are correlational; thus, they are left open for further assessment if they impact the development of burnout or if burnout impacted their development. Further research is needed to confirm causal, directional effects.

The relationship of increased clinician burnout and decreased patient safety has been supported in additional studies of healthcare provider burnout [7, 141]. As clinician burnout increases, the detachment from patients and their work does too, which may contribute to negative attitudes toward patient safety, incomplete infection control practices, and decreased patient engagement [7, 141]. Reducing burnout has the potential to impact patient safety; the Quadruple Aim of Healthcare hopes to improve patient outcomes, such as safety, through the addition of clinician well-being as a primary aim in the model [142].

Interventions

Although only seven of the studies analyzed in this review included interventions, there is modest evidence on the efficacy of burnout interventions in the broader healthcare provider population. Similar to the results of Hallberg [50], a study of Swedish district nurses showed no impact of clinical supervision on burnout [143]. While Morrison Wylde et al. [70] found a marginal improvement in pediatric nurse burnout with smartphone-based intervention vs. traditional mindfulness interventions, studies investigating mindfulness interventions in other healthcare populations reported mixed results [144,145,146,147]. Similar to pediatric nurses [84], social workers showed a significant decrease in burnout after attending skills development courses [148] suggesting that improving clinical knowledge and skills may reduce burnout. This is supported by the finding that pediatric nurses with lower clinical competency and education level have increased burnout [57, 90]. Although Edmonds et al. [42] showed significant decreases in pediatric nurse burnout using in-person trauma, adaptive grief, and coping sessions with follow-up, similar sessions have shown mixed results in other healthcare provider populations [149,150,151]. More research is needed to identify reliable interventions for pediatric nurse burnout that can be pre-emptively and routinely implemented by nursing schools and healthcare organizations.

Study limitations

The search strategy was limited to publications in English; thus, potentially relevant studies in other languages were excluded. Gray literature was not included; thus, informal annual surveys conducted at various healthcare institutions may have been missed; however, this was outweighed by the desire to only include peer-reviewed literature to ensure the quality of data reviewed [152]. Third, the definition of “nurses” varies internationally as does their required education and scope of practice; however, the slight variations were outweighed by the need to include thorough, culturally diverse research. Finally, the extreme heterogeneity of the burnout measurement tools and their application and interpretation inhibited the comparison of results across studies.

Conclusion

Our scoping review showed inconsistent measurement and interpretation of pediatric nurse burnout scores. Factors associated with pediatric nurse burnout were similar to those found in other healthcare professional groups and can be separated into the domains of nurse personal factors, work environment, work attitudes, and work outcomes. Only 45 of the 78 studies reviewed studied exclusive populations of pediatric nurses, and most associations identified were correlational. Few interventions to prevent or mitigate pediatric nurse burnout have been undertaken, and the results were mixed, at best. Further studies using mixed methods are needed to expand on these results and incorporate the direct feedback of the nurses. Additional research is needed to develop and test interventions for pediatric nurse burnout. The improvement of pediatric nurse burnout has the potential to improve nurse well-being and, ultimately, patient care.