Health services across Europe face overlapping pressures that strain staff and jeopardise system resilience. Shortages in key professions, ageing workforces and rising demand coincide with mounting work intensity. Many healthcare workers (HCWs) report psychological distress, with burnout a recurring concern linked to workload and organisational conditions.
Evidence consolidated from reviews across European settings indicates that risk is not evenly distributed: nurses and staff in high-pressure environments such as emergency and intensive care report heightened distress, and ethnic minority and migrant personnel face additional hazards. Beyond immediate wellbeing, these patterns correspond with absenteeism, presenteeism, dissatisfaction and turnover intention, threatening retention and patient safety. The evidence base shows uneven measurement and limited focus on diagnosable mental disorders, yet it consistently highlights organisational drivers of distress. Addressing modifiable workplace factors and implementing multi-level, system-level interventions emerge as central to safeguarding staff and stabilising services.
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What Is Measured and Where the Burden Falls
Across the literature, psychological distress spans self-reported outcomes such as stress, burnout, fatigue, low morale and dissatisfaction, alongside symptom clusters associated with anxiety, depression and trauma. Most included evidence relies on screening scales rather than diagnostic assessments, making prevalence estimates sensitive to thresholds and tools. Burnout dominates reporting yet remains a psychological phenomenon rather than a formal disorder. Common measures include the Maslach Burnout Inventory and the Professional Quality of Life scale, but variable cut-offs and differing definitions of overall burnout hinder comparability. Where estimates are available, rates vary widely within and across professions and settings, reflecting methodological differences as well as contextual influences.
Nurses frequently report higher work-related distress than many other groups, particularly in palliative care, obstetrics, paediatrics, emergency and intensive care. Physicians, dentists, physiotherapists and oncologists are also represented, with specialty-specific pressures shaping risk profiles. Emergency clinicians, ambulance staff, forensic professionals and paediatric teams navigate ethically charged decisions, repeated exposure to death or distress and heavy emotional demands. Moral distress features in accounts where staff feel unable to act in line with professional judgement due to institutional constraints. Reports link moral distress with depressive and anxiety symptoms, anger and sadness, and with adverse occupational outcomes including intention to leave. Although some meta-analytic findings suggest low average moral distress, conflicting evidence and conceptual inconsistencies indicate the need for clearer definitions and stronger methods.
Evidence on diagnosable mental disorders is sparse. Reviews more often aggregate symptoms than apply gold-standard diagnostic interviews, and few offer reliable prevalence estimates for disorders. This limits inference about the scale of diagnosable conditions and about causal pathways from workplace stressors to clinical outcomes. Further challenges include the predominance of cross-sectional designs and uneven coverage across Europe, with under-representation of Eastern European countries and limited data on non-clinical staff.
Workplace Drivers and Unequal Risks
Workload and staffing repeatedly emerge as central drivers. Staff shortages contribute to long hours, rigid shift patterns and enforced overtime, while rising service demand increases intensity and cognitive load. These pressures are associated with stress, burnout, moral distress and erosion of job satisfaction, and they shape turnover intention. Mismatch between demands and control aligns with well-established job stress theory: lower autonomy and limited involvement in decision-making correlate with lower satisfaction and higher distress, whereas greater control relates to improved wellbeing and retention. Value conflicts can amplify distress when time pressure and resource constraints impede delivery of care aligned with professional standards.
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Leadership, management and organisational culture are pivotal. Supportive supervision, clear team goals, mutual trust and recognition are associated with reduced burnout and improved satisfaction, while unresponsive or inexperienced management and punitive or risk-averse cultures correspond with stress, low morale and attrition. High-quality teamwork is linked with care quality and safety, underscoring the interdependence between staff experience and patient outcomes. Conversely, bullying and workplace violence are reported in multiple contexts, particularly affecting nurses and those in emergency, psychiatric and geriatric settings. Such exposures are associated with anxiety and depressive symptoms, sleep disturbance, post-traumatic stress, reduced satisfaction and heightened turnover intention.
Inequalities intersect with occupational risks. Younger workers, women, those who are single or childless and those with lower socioeconomic status appear more vulnerable to distress and turnover intention. Ethnic minority and migrant HCWs report discrimination, harassment and barriers to career progression, with experiences of devaluation of skills and assignment to higher-risk roles. These patterns intensified during the COVID-19 pandemic, including reports of inadequate access to protective equipment and greater exposure to infected patients. For migrant staff, visa conditions, recognition of qualifications and social isolation shape workplace experiences and retention. Given the scale of nursing within Europe’s workforce and the proportion of internationally trained personnel in some systems, these inequities carry system-level significance.
What Helps: From Individual Skills to Organisational Change
Interventions aimed at individuals, including mindfulness, resilience training and technology-enabled psychological support, show short-term improvements in stress, resilience or distress in some analyses. Effects on burnout are inconsistent and often modest, and overall certainty of evidence is limited by risks of bias and small samples. Art and music therapy and grief-focused programmes demonstrate benefits in specific contexts such as palliative care. While these approaches can be part of a support package, they do not address upstream drivers embedded in work design, staffing and culture.
Evidence indicates that organisational-level interventions offer greater and more durable potential by targeting workload, autonomy, staffing and leadership. Changes to how work is organised, such as self-rostering and adjustments to hours or task allocation, are associated with reduced burnout and improved work-life balance and job satisfaction. Staff-led, context-specific and sustainable programmes appear more effective than generic offerings, and multi-level designs addressing both demands and resources show stronger effects. Broader organisational measures include strengthening leadership capability, improving managerial support and establishing clear processes for recognition, whistleblowing and conflict resolution. Violence prevention requires more robust evaluation, yet remains a critical priority given links to distress and turnover.
At policy level, recommendations emphasise long-term investment in safe and supportive workplaces, fair pay, adequate staffing and legal protections against overwork. Reducing stigma, improving access to timely psychological resources and embedding mental health education within training are also identified. Systematic monitoring of staff wellbeing and occupational outcomes can inform iterative reforms, while co-production with HCWs can improve relevance and uptake. Evidence gaps persist, including limited evaluation of policy impacts on mental health and retention, under-representation of non-clinical roles and marginalised groups, and a need for longitudinal designs with standardised outcome measures.
Psychological distress among Europe’s HCWs is widespread, with burnout and moral distress closely tied to structural factors such as workload, staffing and leadership. These pressures undermine satisfaction and retention and ultimately threaten service delivery and patient safety. While individual skills programmes can provide immediate support, the balance of evidence favours organisational and system-level interventions that realign demands, control and resources, strengthen managerial capability and foster supportive cultures. Progress depends on sustained investment, rigorous evaluation and inclusion of under-represented groups and regions. By addressing modifiable workplace risks and embedding co-produced, multi-level mental health initiatives, healthcare leaders can bolster workforce wellbeing and help secure the sustainability of European health systems.
Source: The Lancet
Image Credit: iStock
