Psychic and moral exhaustion in primary care workers^*

Desgaste psíquico moral en los trabajadores de la atención primaria

Abstract

OBJECTIVE

To report the experience of developing a workshop proposal to assist local managers with the identification, management and prevention of primary care workers' psychic and moral exhaustion.

METHOD

The workshop was developed through a literature review performed between November 2014 and June 2015. The temporal cut considered studies of the ten previous years. The selection included studies describing collective interventions for situations generating psychic and moral exhaustion, preferably in primary care services.

RESULTS

Thirty-five articles were analyzed. The workshop provides five meetings with an average duration of one hour. The themes are: awareness; recognizing personal stress; dealing with personal stress; recognizing team stress; and dealing with team stress. The workshop is based on five key principles: detection and coping; attention to interpersonal relationships; communication; self-knowledge and mindfulness.

CONCLUSION

Psychic and moral exhaustion may reflect negatively on workers' health, the care, and the organization. The proposal of measures to recognize, deal with and prevent psychic and moral exhaustion is relevant and strategic in the constant search for improvement of satisfaction and quality.

DESCRIPTORS
Health Personnel; Primary Care Nursing; Professional Exhaustion; Worker's Health; Moral Damage; Primary Health Care

Resumen

OBJETIVO

Relatar la experiencia de elaboración de una propuesta de taller para auxiliar a gestores locales a identificar, manejar y prevenir el desgaste psíquico moral de trabajadores de la atención primaria.

MÉTODO

El taller fue elaborado mediante revisión de la literatura, entre noviembre de 2014 y junio de 2015. El recorte temporal consideró trabajos de los últimos diez años. Fueron seleccionados estudios que describían intervenciones colectivas para situaciones generadoras de desgaste psíquico moral, preferentemente en la atención primaria.

RESULTADOS

Fueron analizados 35 artículos. El taller prevé cinco encuentros, con duración media de 1 hora. Los temas son: sensibilizarse; reconocer el estrés personal; manejar el estrés personal; reconocer el estrés del equipo; y manejar el estrés del equipo. El taller está fundado en cinco principios clave: detección y enfrentamiento; atención a las relaciones interpersonales; comunicación; autoconocimiento y mindfulness.

CONCLUSIÓN

El desgaste psíquico moral puede reflejarse negativamente en la salud del trabajador, el cuidado y la organización. La propuesta de medidas para reconocer, manejar y prevenir el desgaste psíquico moral se considera pertinente y estratégica, en la búsqueda constante por la mejoría de la satisfacción y la calidad.

DESCRIPTORES:
Personal de Salud; Enfermería de Atención Primaria; Agotamiento Profesional; Salud Laboral; Daño Moral; Atención Primaria de Salud

Resumo

OBJETIVO

Relatar a experiência de elaboração de uma proposta de oficina para auxiliar gestores locais a identificar, manejar e prevenir o desgaste psíquico-moral de trabalhadores da atenção primária.

MÉTODO

A oficina foi elaborada através de revisão da literatura, entre novembro de 2014 e junho de 2015. O recorte temporal considerou trabalhos dos últimos dez anos. Foram selecionados estudos que descreviam intervenções coletivas para situações geradoras de desgaste psíquico-moral, preferencialmente na atenção primária.

RESULTADOS

Foram analisados 35 artigos. A oficina prevê cinco encontros, com duração média de 1 hora. Os temas são: sensibilizar-se; reconhecer o estresse pessoal; lidar com o estresse pessoal; reconhecer o estresse da equipe; e lidar com o estresse da equipe. A oficina é fundamentada em cinco princípios-chave: detecção e enfrentamento; atenção às relações interpessoais; comunicação; autoconhecimento e mindfulness.

CONCLUSÃO

O desgaste psíquico-moral pode refletir negativamente na saúde do trabalhador, no cuidado e na organização. A proposta de medidas para reconhecer, lidar e prevenir o desgaste psíquico-moral é considerada pertinente e estratégica, na busca constante pela melhoria da satisfação e da qualidade.

DESCRITORES
Pessoal de Saúde; Enfermagem de Atenção Primária; Esgotamento Profissional; Saúde do Trabalhador; Dano Moral; Atenção Primária à Saúde

Introduction

The work environment can be an important means when discussing psychic and moral exhaustion, especially in primary care services, where the gap between professional moral commitment and workplace conditions can generate conflicts related to fundamental aspects of workers' health¹. Investing in the identification and analysis of causes of workers' health conditions is essential to elaborate initiatives with the aim to reduce illness rates and preserve the health of these professionals².

In the health area, conditions related to professionals' psychic and moral exhaustion are among the main reasons for illness and absence from work^3-4. Psychological disorders do require attention because they can interfere with biopsychosocial behavior and professional performance, and increase organizations costs⁵. The current scenario is worrisome: a recent study conducted with nursing workers from all over Brazil shows that 64% of professionals consider themselves to be in process of professional exhaustion⁶.

Burnout and moral distress (among others) are at the core of conditions leading to the psychological and moral exhaustion of health workers⁷. The Burnout syndrome reflects emotional exhaustion, depersonalization, and lack of achievement related to work⁸. It is a serious problem of psychosocial character⁹ often associated with heavy workload that can lead to symptoms of exhaustion, fatigue and irritation¹⁰. Moral distress, in turn, is the result of restriction to an intended moral action associated with symptoms of dissatisfaction, frustration, and distance from patients¹¹.

Even though nurses' training prioritizes the excellence of clinical care, these professionals are the main protagonists of management roles in primary care services. Among the main barriers generating work stress, are incomplete teams, lack of training of some professionals for work, lack of financial resources and lack of materials and equipment¹².

There are few studies proposing interventions to solve problems associated with the psychic and moral exhaustion of health workers, especially in primary care services¹³. The present study was designed to contribute with filling this gap through the search and development of technologies to improve work processes. Thus, workshops can be the systematization of an intervention because they presuppose an emancipatory and critical nature by using non-habitual or formal elements, and allow the recovery of participants' spontaneity¹³.

Considering the fundamental role of managers in reducing the psychic and moral exhaustion of workers, the objective of the study was to report the experience of developing a workshop proposal to help managers identify and manage the psychic and moral exhaustion of primary care workers.

Method

This is an experience report about the theoretical elaboration of a workshop proposal to train managers in the recognition and collective coping with psychic and moral exhaustion of health workers, especially in primary care.

For the preparation of the workshop, between November 2014 and June 2015 was conducted a literature review in the following databases: Virtual Health Library Portal - VHL, which integrates the IBECS databases - Spanish Bibliographic Index of Health Sciences, LILACS - Latin American and Caribbean Literature in Health Sciences, SCIELO - Scientific Electronic Library Online and COCHRANE Library. The descriptors used were: Professional Exhaustion; Moral damage; Workers Health; And Primary Health Care. The temporal cut of the survey (for convenience) were the ten previous years. The languages of articles were Portuguese, English or Spanish.

The selection criteria considered texts on interventions for the collective confrontation of situations of psychic and moral exhaustion. It were identified 337 articles related to professional exhaustion, moral damage and workers health, of which 11 were selected. Another 129 articles related to professional exhaustion, moral damage and primary health care were identified, of which 24 were selected. In total, 35 articles were analyzed in full (Figure 1).

Figure 1
Flowchart of the search and selection of studies included in the review.

The content included in the workshop proposal was based on the analysis of the literature, and its methodological development was based on specific bibliography^14-16. It included weekly meetings of average duration of one hour, and participation of between six and 15 people. The meetings are structured and include activities beyond the usual forms of communication, that is, oral and written. The suggestion is to start with a brief warm up, followed by a reflection on the issue through the manipulation of materials such as magazines, pictures, modeling clay, waste materials, colored threads, ink, paper. The communication between participants is mediated by the production of concrete material, which allows for greater detail and a deeper discussion.

The report of participants' concrete production triggers the discussion that is aimed at the sharing and problematization of the theme. The purpose is helping people overcome common sense by articulating the singular, particular and structural dimensions involved in the realities pertinent to the theme. This leads to wider possibilities of interpretation of problems and confrontations¹⁴.

Since the study does not involve research subjects, it was not necessary to request approval by the Research Ethics Committee.

Results

The review of the literature allowed the identification of theoretical references, health policies, strategies and practices for coping with the psychic and moral exhaustion and health promotion of workers, which supported the proposal of creating the workshop intended for managers of Basic Health Units. The purpose of the workshop is helping managers with the development of skills and competencies to recognize situations that generate psychic and moral exhaustion, and strategies to deal with and prevent the team distress.

From the analysis of studies, the main factors identified as responsible for the psychic and moral exhaustion were moral distress^7,13,17-19 and burnout syndrome^2,5,7,20-22. The analyzed studies were performed mainly with nurses, and describe moral distress and Burnout as frequent phenomena in the reality of different health work contexts.

Regarding coping strategies, the studies highlight the importance of a collective approach based on organizational intervention strategies²². The key to the success of this type of intervention is ensuring a multivariate and prolonged nature, and considering the relationships between organization, structure and individual¹³.

The process of workshop development took into account the literature findings to propose the following as key principles for reducing psychic and moral exhaustion: detection and coping^5,22-23, attention to interpersonal relationships^24-26, communication²⁷, self-knowledge and mindfulness²⁸.

Mindfulness is a group intervention that allows self-regulation and has the objective to bring the mind or mental state into the present. There are several techniques to stimulate and develop mindfulness, and the most known are those derived from meditation. The central objective is to promote well-being and quality of life. The specific objectives are diverse, according to the nature of the actions and environments where programs are developed²⁹.

The workshop is planned for five meetings that should take place in the hour before managers' weekly meetings to avoid interference with the work organization and additional displacement of people. Meetings are described in chart 1.

Chart 1
Description of the five meetings proposed for the workshop on identification and management of psychic and moral exhaustion of primary care workers - São Paulo, SP, Brazil, 2015.

Throughout the workshop, the term 'stress' is used as a strategic concept to increase managers' interest and participation, and concepts of Burnout and moral distress are addressed throughout the meetings. This type of strategy can be applied and replicated in any primary care context and does not require investment on hard technology, only time and space in schedule for learning and developing a soft technology¹⁴.

Discussion

Difficulties of the health system, such as long queues, lack of beds, scarce resources, the demand and difficulty of access can directly affect professionals involved in care. This can generate dissatisfaction, especially in primary care services, which are users' gateway to the health system²¹. In addition, the work environment can be a determining factor for the quality of care and patients' outcomes³⁰. The critical point in this type of problem is that professionals may experience difficulties as part of work routine, often not realizing what is happening before feeling depleted².

The concern with this theme is confirmed in the 2012-2015 National Health Plan that describes the importance of personnel management for training, allocation, qualification, valorization and democratization of work relations³¹. To improve the quality of life at work, the literature suggests the adoption of intervention strategies of institutional nature, such as training, courses and workshops with the aim to minimize damages and prevent situations such as absenteeism and taking work leave³².

This type of intervention can represent a viable tool in reducing the negative effects of work-related psychic and moral exhaustion, as long as there is support from the institution in the process³³. The application of this type of strategy has an example with positive results, and reports of improved personal well-being, emotional exhaustion, depersonalization and personal fulfillment³⁴.

Besides personal aspects, the success of this type of strategy can generate impacts in reduction of work-associated costs. Costs of absenteeism and taking work leave for work-related mental illness far outweigh the costs associated with improving work conditions, such as reducing working hours and hiring the adequate numbers of professionals³⁵.

In this context, many professionals end up cultivating the desire to quit the job or even abandon the profession³⁶. Of these, despite their desire to leave, only a small portion effectively leaves their working position and most remain in their jobs for various contextual factors, such as shortage of other jobs³⁷. This reality requires that researchers, managers and nursing leaders work together to identify and implement strategies to deal with the psychic and moral exhaustion of health workers in order to improve retention and job satisfaction³⁸.

Nurses in leading positions, such as managers, would be more likely to experience psychic and moral exhaustion mainly because of the inherent complexity in the decision-making process that involves expectations of the organization, patients, and workers³⁹. Studies seeking to collaborate for the success of the managerial role of nurses - who are increasingly protagonists on the path to achieve institutional health and quality objectives - should be encouraged.

This study reports the proposal of a workshop theoretically designed with the intention of collaborating in improving working conditions and increasing the level of professional satisfaction. A limiting factor is the need for practical application of the proposal, a fundamental step to enable the evaluation of results and confirm their effectiveness.

Conclusion

The psychic and moral exhaustion phenomenon affects a large number of health professionals hence, it must be approached from prevention and coping measures in the organizational scope. Such initiatives can contribute to reduce absenteeism, work leave, organizational costs, and improve outcomes.

Workshops with the purpose of improving the organizational environment, stimulating teamwork, facilitating coexistence and communication, and teaching about tools for the recognition and management of situations that generate psychic and moral exhaustion have proven very effective, including with primary care service workers. The workshop proposed in this study intends to collaborate with the practice by stimulating the identification, understanding and coping with psychic and moral exhaustion in work routine.

The product resulting from this report is a material with great potential of applicability and reproduction for managers of primary care services, aiming at a return to society. It is necessary to continue this study with the development of research that follows the possibilities and evaluate the effects of using the workshop, considering the local health management routine.

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• Financial support

  Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES). Process number BEX 1050/13-3.
• *
  Extracted from the dissertation: "Desgaste Psíquico Moral na Atenção Primária à Saúde: uma proposta de enfrentamento para a gestão local do Município de Campinas - SP", Escola de Enfermagem, Universidade de São Paulo, 2015.

Publication Dates

• Publication in this collection
  2017

History

• Received
  15 Sept 2016
• Accepted
  05 May 2017