Burnout, Stress, and Moral Injury Among Emergency Medical Services Clinicians: A Systematic Review

As frontline health care workers, Emergency Medical Service (EMS) clinicians are subject to stressful conditions. These conditions contribute to burnout, stress, and moral injury.

The objectives of this systematic review were to 1) evaluate the incidence, prevalence, and severity of adverse occupationally related mental health conditions, including burnout, stress, and moral injury among EMS clinicians; and 2) to identify any modifying factors associated with those conditions.

We searched MEDLINE, Embase®, Cochrane Register of Clinical Trials, PsycINFO®, and Cumulative Index to the Nursing and Allied Health Literature from January 1, 2001 through June 30, 2024. We also searched websites, the ClinicalTrials.gov registry, and journals not indexed in Medline. To increase applicability to the U.S. decision-making context, we restricted to studies of EMS clinicians in high-income countries. We used standard methods to assess the risk of bias and evaluate the strength of evidence.

We included 92 studies (88 cross-sectional studies and 4 cohort studies). During routine practice, the mean levels of organizational job stress were mild to moderate, burnout and general stress were mild to severe, and secondary traumatic stress was mild (moderate strength of evidence for each). There was considerable heterogeneity in prevalence and severity by country, setting, population, context, and outcome measurement instruments and scoring methodology or threshold. No study reported on incidence. Some modifying factors (e.g., more trauma exposure, more hours per week, more burnout, higher call volumes) may be associated with poor outcomes.

Despite considerable variation, the stress issues in the EMS workforce are substantial enough to merit greater attention by health systems. Addressing these challenges will require evidence-based comprehensive strategies that consider the modifying factors associated with poor outcomes.