WHITE PAPER: Organisational factors affecting staff wellbeing and operational efficiency in emergency departments

13/04/2026

When pressure in the emergency department is managed reactively, it has consequences – both for staff wellbeing and for costs. What happens if, instead, we begin to plan based on what we can actually anticipate?

Emergency departments operate under conditions where patient inflow varies considerably, while the requirement for immediate capacity remains constant. Traditionally, this variation has often been managed reactively: the department adjusts when pressure arises. This approach is understandable, but it comes at a cost.

The literature indicates that workload strain in emergency care is not determined solely by volume, but also by the degree of predictability, influence over work organisation, and the experience of organisational support. A lack of insight into upcoming demand can therefore affect not only operations, but also staff wellbeing, perceived quality of work, and the motivation to remain in the profession. [1–3]

Unpredictability as a source of strain

A consistent finding in occupational health literature is that strain increases when employees have limited control over how work is organised. In a multicentre study from Swiss psychiatric hospitals, Gehri et al. found that low perceived control over shift scheduling, limited managerial support in planning, and overtime were associated with emotional exhaustion and intentions to leave the workplace. Although the study was not conducted in emergency departments, the mechanism is likely relevant here as well: unpredictability and short-term changes in work organisation place a strain on staff. [1]

Similarly, Ghaseminejad et al. found in a qualitative study among emergency physicians and internists that heavy workloads, planning conditions, frequent interruptions, cross-disciplinary conflicts, and a lack of recognition from management were key organisational contributors to burnout. Among emergency physicians, workplace violence and the assessment of patients in waiting areas were also highlighted as particular stressors. [2]

Danish data point in the same direction. In the report “Why do nurses leave the public healthcare system?”, former nurses describe work pressure, inadequate working conditions, and a lack of opportunity to perform their work to a professionally acceptable standard as key reasons for leaving public healthcare. The report is not limited to emergency departments, but it supports the conclusion that organisational factors play a central role in staff retention. [3]

Consequences of reactive operations

When staffing and capacity are primarily adjusted after pressure has already emerged, this often leads to secondary effects. A recent study showed that low staffing levels, overtime on the previous shift, consecutive working days, and longer shifts were associated with higher perceived workload, measured using the NASA-TLX score. The study did find that quick returns (i.e. returning to work shortly after finishing a shift) were rare in the dataset, and this point should therefore not be overstated. [4]

Another study found that agency nurses were used in 12.2% of shifts, but that this measure only to a limited extent compensated for deviations from planned staffing levels. More than half of absence situations were not addressed with temporary staff. These findings suggest that acute and temporary increases in staffing are not, in themselves, a robust solution to mismatches between demand and capacity. [5]

The importance of better demand insight

If workload in the emergency department can to some extent be anticipated, this changes the nature of the management task. It creates an opportunity to shift planning from intuition to data-informed decision-making. Studies on staffing and workload collectively suggest that better alignment between demand and resources can reduce perceived strain, decrease overtime, and strengthen the sense of control. [1,4]

Operational and economic implications

From an operational perspective, the key issue is not only whether there should be more or fewer staff, but whether staffing is better aligned with expected activity. When staffing is systematically too low during peak periods, the risk of overtime, last-minute call-ins, use of temporary staff, and loss of experienced employees increases. When it is too high during low-activity periods, resources are tied up without corresponding value.

The literature thus supports a more sober conclusion: organisational predictability and a stronger planning foundation are not merely questions of efficiency, but also of working environment and staff retention. [1–5]

Conclusion

The central challenge in emergency departments is not only high activity, but that this activity is often experienced as insufficiently transparent and therefore managed reactively. Available literature indicates that low control over work organisation, overtime, interruptions, and insufficient organisational support are associated with exhaustion, increased strain, and reduced staff retention. [1–4]

This suggests that efforts to improve the prediction of patient inflow and to enable more precise capacity planning should be understood as an organisational intervention, not merely a technical management tool. The potential lies both in improved resource utilisation and in a more sustainable working environment for the staff who carry the burden of emergency care. [1–5]

References

Gehri B, Bachnick S, Schwendimann R, Simon M. Work-schedule management in psychiatric hospitals and its associations with nurses’ emotional exhaustion and intention to leave: a cross-sectional multicenter study. Int J Nurs Stud. 2023;146:104583. doi:10.1016/j.ijnurstu.2023.104583.
Ghaseminejad F, Rich K, Rosenbaum D, Rydz E, Chow L, Salmon A, et al. Organisational factors associated with burnout among emergency and internal medicine physicians: a qualitative study. BMJ Open. 2025;15(1):e085973.
Vaaben NK, Weinreich E, Dahlager LMC, Mouritzen SS, Manstrup S. Hvorfor stopper sygeplejersker i det offentlige sundhedsvæsen?: og hvad skal der til, for at de bliver? København: Københavns Professionshøjskole; 2023.
Martins T, Musy SN, Simon M. Nurse shift patterns, staffing and their association with perceived workload: sequence analysis of multicentre data. Int J Nurs Stud Adv. 2025;9:100420. doi:10.1016/j.ijnsa.2025.100420.
Ahmadi Shad M, Khorasanizadeh M, Musy SN, Zúñiga F, Atoof F, Simon M. Temporary nurse deployments: a time-series analysis of shift scheduling dynamics and staffing level alignment. Int J Nurs Stud Adv. 2025;9:100383. doi:10.1016/j.ijnsa.2025.100383.