Indicators of burnout in Primary Health Care workers

Objective: to analyze the indicators of burnout peculiar to health workers from units of Primary Health Care. Method: integrative review of the literature structured in the stages: guiding question; search; categorization of studies; assessment; discussion; and interpretation of results, and synthesis of knowledge. Search for original articles and reviews published from 2000 to 2016, in Portuguese, English and Spanish, in the main databases of the health area. Descriptors used: Nursing, Burnout and Primary Health Care. Results: 14 articles met the proposed inclusion criteria, six (42.85%) presented a sample of nurses and eight (57.15%) health professionals. Conclusion: Primary Health Care workers are exhausted due to inadequate working conditions characterized by the lack of human and physical resources that leads to work overload, workplace violence and diffi culty with teamwork, despite being satisfi ed with the work environment. Descriptors: Burnout, Professional; Stress, Psychological; Primary Health Care; Health Personnel; Nursing. RESUMO Objetivo: analisar os indicadores de esgotamento profi ssional peculiares aos trabalhadores de saúde de unidades da Atenção Primária à Saúde. Método: revisão integrativa da literatura estruturada nas etapas: questão norteadora; busca; categorização dos estudos; avaliação; discussão; e interpretação dos resultados e síntese do conhecimento. Busca a artigos originais e revisões publicadas de 2000 a 2016, em português, inglês e espanhol, nas principais bases da área da saúde. Descritores usados: Enfermagem, Esgotamento Profi ssional e Atenção Primária à Saúde. Resultados: 14 artigos atenderam aos critérios de inclusão propostos, seis (42,85%) apresentam amostra de enfermeiros e oito (57,15%) profi ssionais da saúde. Conclusão: os trabalhadores de saúde da Atenção Primária à Saúde apresentam-se esgotados, devido às inadequadas condições de trabalho caracterizadas por escassez de recursos humanos e físicos que leva a sobrecarga de trabalho, a violência no ambiente de trabalho e difi culdade no trabalho em equipe, apesar de apresentarem satisfeitos com o ambiente de trabalho. Descritores: Esgotamento Profi ssional; Estresse Psicológico; Atenção Primária à Saúde; Pessoal de Saúde; Enfermagem. RESUMEN Objetivo: analizar los indicadores de agotamiento profesional peculiares a los trabajadores de la salud de unidades de la Atención Primaria de Salud. Método: la revisión integrativa de la literatura fue estructurada en las etapas: cuestión orientadora; buscar; categorización de los estudios; evaluación; discusión; e interpretación de los resultados y síntesis del conocimiento. Busca artículos originales y revisiones publicadas desde 2000 hasta 2016, en portugués, Inglés y Español, las principales bases de la salud. Descriptores usados: Enfermería, Agotamiento Profesional y Atención Primaria de Salud. Resultados: 14 artículos atendieron a los criterios de inclusión propuestos, seis (42,85%) presentan muestra de enfermeros y ocho (57,15%) profesionales de la salud. Conclusión: los trabajadores de la salud de la Atención Primaria de Salud se encuentran agotados debido a las inadecuadas condiciones de trabajo caracterizadas por escasez de recursos humanos y físicos que llevan a la sobrecarga de trabajo, a la violencia en el ambiente de trabajo y difi cultad en el trabajo en equipo, presentarse satisfechos con el entorno de trabajo. Descriptores: Agotamiento Profesional; Estrés Psicológico; Atención Primaria de Salud; Personal de Salud; Enfermería. Gracielle Pereira Aires Garcia E-mail: gracielleaires@gmail.com CORRESPONDING AUTHOR


INTRODUCTION
The emergence of the development of mental disorders related to psychosocial risks in health and nursing workers working in Primary Health Care (PHC) services is concerning due to an increase in work overload, excess demand, problems in the physical structure of the units and problems in the organization and in the Health Care Network (RAS) (1)(2) . The reorganization of the primary level of the health care system in Brazil, according to Fontana and Lautert (3) , shows that the most susceptible risks to PHC workers, which lead to both suffering and physical and mental disorder, are psychosocial. Suffering is related to the precariousness of the service and its interfaces that lead the worker to perform a poor quality service, added to the accumulation of work overload due to the difficulty of implementing the prescribed Brazilian Unified Health System (SUS), due to problems in the different realities of PHC units, leaving them with occupational stress (4) .
The hospital environment is more conducive to the existence of occupational risk in the development of mental disorders. However, the gaps in the scientific knowledge of these risks are still identified in the work of nurses and other PHC workers who face different challenges to meet SUS demands. There is presence of work stressors that can favor the appearance of burnout, since these workers are directly exposed to the reality of communities where they work (5) .
Thus, understanding the processes involved in the constitution of the burnout may be relevant for the adoption of measures that help in the development of quality of life and well-being of worker's health. The vision of this disease as a disease with several causes brings reflection on the magnitude of occupational stress and the impact on the health workers, whether physical or mental (6) .
Historically, in the United States in the 1970s, Herbert Freudenberger first defined the burnout syndrome as a set of nonspecific biological, psychological, and social symptoms that develop in work activity as a result of excessive energy demand due to disproportion of efforts made and results obtained, which finally do not compensate worker's expectation (7) .
The burnout syndrome was later characterized by Maslach and Jackson (8) as a set of physical and psychological symptomatology, consisting of three related dimensions (three-dimensional): emotional exhaustion, depersonalization and lack of personal accomplishment. The definitions are: emotional exhaustion is the loss of emotional resources to deal with work; depersonalization is the development of negative attitudes, insensitivity and cynicism with those who receive the service provided; and the lack of personal accomplishment is the tendency to assess one's work in a negative way, associated with feelings and assessments of low professional self-esteem (8) .
The risk of PHC workers having burnout was studied by Albuquerque, Melo and Araújo Neto (9) and the results of the study identified the need for the development of other studies in this area, with the purpose of elaborating preventive strategies aiming at the promotion of health workers.
There are recent publications in China proving that burnout is present among community health nurses being prevalent and severe, consequently culminating in decreased job satisfaction and increased psychological symptoms. These employees have heavy workloads and extensive responsibilities, in addition to their official duties, they also need to undertake actions for disease prevention and health education, psychological counseling, administrative work and provide services in the homes (10) .
Therefore, the consequences of this syndrome are associated with a decrease in production, in quality of work performed, increased absenteeism, increased turnover and even occupational accidents. Finally, it can cause considerable financial losses for organizations and damage to workers' own health (11)(12) .

OBJECTIVE
To analyze the indicators of burnout of health workers working in Primary Health Care.

METHOD
This is an integrative review of the literature, carried out through the following methodological procedures: description of the question or guiding questions of the study; selection of sample studies (sample inclusion criteria: period, language, type of publication, database, descriptors); election of the characteristics of the reviewed researches (theme, theoretical framework, methodological outlining, tools used); analysis of the findings according to established inclusion criteria; interpretation of the results obtained; and finally, the elaboration of an article to spread the results obtained (13) .
The guiding questions in this study were: Do health workers working in PHC units present burnout? Are health workers working in PHC units satisfied with the work performed? What are the tools used in the studies to verify burnout? What is the evidence from the studies carried out on this subject? What are the gaps in knowledge about this topic?
The search in the database was carried out in March and April of the year 2016. Original articles and review articles published in the period 2006 to 2016 were included in the Portuguese, English or Spanish languages, with full texts available in the databases: Web of Science (WOS/ISI), SCOPUS, Medical Literature Analysis and Retrieval Online (MEDLINE/PuBMed), The Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Latin American and Caribbean Literature in Health Sciences (LILACS).
Articles repeated in more than one database were counted only once, these were maintained on the basis of the largest number of articles. Publications were excluded in the form of apostilles, letters, editorials, dissertations, theses and articles unavailable in their full and those that did not respond to the research question.
The article search was performed by means of descriptors of the databases "Descriptors in Health Sciences" (DeCS) and "Medical Subject Head Medical Subject Headings" (MESH). The selected descriptors were: "Enfermagem" OR "Nursing"; "Esgotamento Profissional" OR "Burnout, professional"; and "Atenção Primária à Saúde" OR "Primary Health Care". We defined the search strategy in which these English or Portuguese language descriptors were used according to the database and the combination of the Boolean "AND". The information search and recording of the information were performed twice to ensure the reliability of the data collection. The data collected through the full reading of the selected articles were recorded in an adapted form of the tool of the Occupational Health Nursing Network Form (REDENSO) (14) . Also, the articles selected were classified following the categorization proposed by Melnyk and Fineout-Overholt (15) , according to Chart 1.

Chart 1 -Strength of evidence assessed from individual surveys or from other sources
Level and Evidence Quality

Evidence Source
Level I When evidence comes from a systematic review and/ or meta-analysis, randomized controlled trials or systematic reviews of randomized controlled trials; Level II Evidence from at least one well-outlined randomized controlled trial; Level III Research with well-outlined clinical trials with no randomization; Level IV Well-outlined cohort and case-control study evidence; Level V Systematic reviews of descriptive and qualitative studies; Level VI Evidence from a single descriptive or qualitative study; Level VII Opinions of experts in the area studied. (15) .

RESULTS
From the criteria adopted, 112 articles were identified in the selected databases. Figure 01 shows the process of articles selection.
Of In relation to the evidence resulting from the studies, an article (7.15%) with evidence level II was identified that is a well-outlined, randomized controlled trial, an article (7.15%) with evidence level IV by be a well-outlined cohort and case control study and twelve (85.70%) articles present evidence level VI because they are descriptive studies.
Of the articles analyzed, six (42.85%) articles have as examples nurses who work in several PHC services, while eight (57.15%) articles were carried out with a sample of all the health workers who work at PHC. Chart 2 shows the characterization of the articles carried out with nurses.
Chart 3 shows the results regarding the characterization of articles in a sample of health workers.
The studies, in the majority, present nurses participating in the sample. It is noted that one (12.5%) article involves hospital health workers, four (50%) articles have participants from health centers and three (37.5%) articles compare the hospital network with the PHC. Cross-sectional and correlational study; Nurses; Brazilian version of the Nursing Work Index Revised (NWI-R); the Brazilian version of the Maslach Burnout Inventory (MBI); and a personal and professional characterization form, added by three questions with the purpose of assessing professional satisfaction, perception of care quality and intention to leave the current work.
Increased workloads for nurses associated with reduced perceptions of control over theenvironment, autonomy, and organizational support are one of the consequences of SUS state and federal underfunding, as these perceptions correlate with burnout and the quality of care itself.
To be continued Changes were recognized over time in job demand as well as social support as a coping strategy for burnout. The fatigue professional experienced by the nurses was identified because of work demands and the lack of support associated with depersonalization.
The scores obtained for burnout and suicide risk were, in general, lower than those observed in other studies, and emphasized the high level of personal accomplishment, which reflects professional satisfaction. The results show the importance of early recognition of mental disorders and suicide risk prevention at work. Most of the participating workers presented from moderate to high risk for burnout, threatening their well-being. There were no significant changes between professions, and emphasized that burnout occurs more often in young people who are dissatisfied with work. In this way, taking preventive measures are necessary.
Workers who don't have the feeling of teamwork are more emotionally exhausted, with greater depersonalization and less personal accomplishment. As for teamwork, this is shown as a preventive factor against burnout. However, the response rate was less than 40%.
Physicians and nurses had lower levels of mindfulness and higher levels of perceived stress compared to other professional categories, and these were also the most stressed among workers in family health teams. Service time greater than one year showed a clear influence on the levels of perceived stress and subjective well-being, regardless of the professional category.

China, English
Chou LP, Li CY, Hu, SC (27) Job stress and burnout in hospital employees: comparisons of different medical professions in a regional hospital in Taiwan (2014) Cross-sectional study; Health workers; Copenhagen Burnout Inventory (CBI), Job Content Questionnaire (C-JCQ) Physicians working in the emergency room are similar to nurses. However, nurses had characteristics with younger age prevalence, most of them being women, most of them worked on shifts, as well as having the highest percentage perceiving high tension in the work environment.

Spain, English
Gómez-Gascón T et al. (28) Effectiveness of an intervention for prevention and treatment of burnout in primary health care professional (2013) Controlled, pragmatic, randomized clinical study in two parallel groups: intervention and control. Health workers. Maslach Burnout Inventory (MBI), Medical or Nurse Wearer Questionnaire, and Goldberg's General Health Questionnaire (Golberg's GHQ).
An intervention was performed on all health workers from a Primary Health Care team, acting at both the personal and interpersonal levels to know and recognize the risk and the process of burnout, and the specific characteristics for the definition of health, evidencing the importance as a preventive measure to combat this syndrome.

Spain, English
Gascon S et al. (29) The role of aggressions suffered by healthcare workers as predictors of burnout (2013) Retrospective study; Health workers. Maslach Burnout Inventory (MBI), Areas of Work-Life Scale (AWS), Aggression Questionnaire and Sociodemographic Data.
Both forms of physical and verbal violence showed significant correlations with symptoms of burnout syndrome (emotional exhaustion, depersonalization and lack of personal accomplishment). Proving that work overload affects the process of burnout-cynicismineffectiveness. Chart 3 (concluded) When we analyzed the keywords and/or descriptors used to describe the articles published, we had in common: ten (71.42%) using PHC or their synonyms, five (35.71%) with burnout and two (33.33%) outlining the research sample as exclusive of nurses.
In the quantitative studies, the Maslach Burnout Inventory (MBI) and the theoretical framework proposed by Maslach and Jackson (8) were used in nine (64.28%) articles with the presence of the three dimensions of burnout syndrome symptomatology: emotional exhaustion, depersonalization, and lack of personal accomplishment. In one (7.15%) study the tool of Copenhagen Burnout Inventory (CBI) was used.

DISCUSSION
With the exploration of the topic addressed in the selected articles, three categories of analysis can be abstracted: burnout variables and their measurement; job satisfaction; and interventions for the prevention of burnout.

Burnout variables and their measurement
When analyzing the chosen studies, it is noticed that they portrayed the burnout aimed at health workers or nurses working at PHC as the central theme of the research, being that among the Indicators of burnout in Primary Health Care workers Garcia GPA, Marziale MHP. indicators are the psychosocial risks, these related to occupational stress. One of the classes of psychosocial stressors cited was "stressors linked to interpersonal relationship at work" (17,23,25,28) , identifying that good work relationships are important for the health of workers (6,24) .
For Falgueiras et al. (25) , the importance of teamwork is emphasized, since workers who are not strengthened in teamwork are emotionally exhausted, depersonalization and have less personal accomplishment. Thus, having communication skills in social relationships is associated with less emotional exhaustion and depersonalization, besides having greater accomplishment in the profession (23) .
Atanes et al. (26) presented a cross-sectional study with a quantitative approach that investigated PHC workers working in the minimal team, making it clear that nurses and physicians are the most subject to perceived stress, consequently, a lower level of well-being. Up to the time of service, this being over one year, demonstrated influence in the levels of perceived stress and the subjective well-being, regardless of the professional category.
The variables evidenced as stress sources were: training and preparation of technical reports; make mistakes and deal with failures; overwork and professional involvement; professional and career instability; lack of recognition and power. Since, nurses experience all these attributes in their daily work at PHC (30) .
In almost all publications, Maslach and Jackson (8) refer to the three dimensions of this syndrome: emotional exhaustion, depersonalization and lack of professional accomplishment. The average scores of the dimensions of fatigue professional put the subscale of emotional exhaustion in a medium to high level, besides implying an increase in the level of depersonalization; it means a decrease in satisfaction and professional accomplishment. It is worth noting that emotional exhaustion is one of the first manifestations in the burnout process or the most obvious of this syndrome (20,25,(30)(31)(32)(33) .
However, in the study by Lorenz and Guirardello (16) , because it is a specific sample of PHC nurses, it shows the contrary, the average frequency of feelings related to burnout was 24.6% for emotional exhaustion, 9, 4% for depersonalization and 30.4% for reduced professional accomplishment. It may be due to the low autonomy, poor control over the work environment and poor organizational support, which may be related to the expansion and consolidation of the Family Health Strategy (FHS) focused on family and social relations, oriented SUS principles and technological innovation. Given that, in 2006, the Política Nacional de Atenção Básica (freely translated as National Basic Care Policy-PNAB) emerged to define strategies for operationalization and consolidation of PHC actions, since the discussions and tendencies in the health area were and are focused on improvements in the models management (34) . On the other hand, greater personal accomplishment is associated with a lower level of depersonalization and, therefore, higher satisfaction and professional accomplishment, which explains the high satisfaction rate in a study of 2014 (30) . However, Falgueiras et al. (25) demonstrated in the results that, in general, health workers present a high degree of burnout, a mean of depersonalization and high levels of personal accomplishment.
Still, even with few findings, when correlating age with burnout syndrome there is a negative association, that is, the younger the individual is, the more likely they are to develop burnout and/or be emotionally drained. Younger nurses have more problems related to career instability and wages, as well as a greater tendency for depersonalization (24,27,30,33,35) . For Gomes, Cruz and Cabanelas (30) , depersonalization may represent a strategy for managing the lack of experience of workers in the face of their patients.
Also, it was evidenced the presence of the Job Demands framework -Resource Model of Demerouti et al. (36) , which was used to predict employee burnout and organizational involvement and performance on the well-being of these workers (17,20) . There are two general interrelated categories that are job demands and work resources burnout develops when job demands are high and resources are low. For Demerouti et al. (37) , work demands and work resources have an indirect impact on life satisfaction through the experience of burnout.
Thus, Rickard et al. (38) presented an innovative proposal with pre and post-intervention assessments in the organization of the work environment, obtaining data of mental disorder and proposing strategies to improve system factors, reduce labor demand and increase the jobs, in order to meet individual needs and increase satisfaction with the organization's support.
Thus, it is concluded that improvements for nurses can be attributed to organizational intervention, and further research should be undertaken to explore long-term impacts. Therefore, it is necessary to periodically monitor the mental and physical health of workers (35,39) .
Although the JD-R model is present as a theoretical framework for the investigation of Sundin, Hochwälder and Lisspers (17) and Engelbrecht et al. (20) , the tool used for data collection that prevailed was the MBI, following the assessment of the three dimensions of burnout.
One tool that was built prior to the theorizing of this model is the Oldenburg Burnout Inventory (OLBI), which is two-dimensional in testing demands and resources of work, with burnout and disengagement as subscales for the development of this disease. There are seven items for burnout that refer to a feeling of emptiness, work overload, fatigue, whereas for disengagement, there are eighteen items assessed that refer to work distancing, negative and cynical attitudes and behaviors, among others (37) .

Job satisfaction
When discussing the subject, the indicator "job satisfaction" influences nurses' permanence and the successful implementation of health system reforms, although it is directly related to motivation and labor productivity (31,40) . Therefore, the study by Lorenz and Guirardello (16) shows the importance of job satisfaction, as the majority of the sample (62.6%) considered themselves satisfied, 34.9% dissatisfied, 1.0% very dissatisfied and 1.5% % very satisfied. In this way, most of them are satisfied with the work, which reflects in the good quality of care offered to the users of their health facilities.
However, as presented by Tomás-Sábado et al. (18) on the risk of suicide due to burnout, although the satisfaction in the work is relatively high, one must be aware of the predisposing factors for such a development of psychopathology and the higher correlation with depression. However, in the study by Silva et al. (24) , health workers presented professional dissatisfaction with a desire to leave the profession, reports of not having work as a source of accomplishment, feelings of discomfort, mental disorder diagnosed by a psychiatrist, and emotional tension.
Furthermore, the research of Mohale and Mulaudzi (19) has brought dissatisfaction among PHC nurses in rural South Africa, as there is work overload and few staff able to work, lacking materials and inadequate infrastructure, despite having autonomy. This article presents the results of a qualitative study and its potential implications for the implementation of health policies that need to be reviewed. Also, a cross-sectional study was conducted to determine satisfaction with the work of PHC health unit managers in two South African provinces. However, they included in this study qualitative comments made by nursing managers that contradict the highest scores on personal career satisfaction and career perspectives, because in their lines they show that they are affected by working conditions, which limit their ability to practice their skills. He even mentioned the lack of maintenance and infrastructure of the unit. Incidentally, there is the unavailability of basic equipment. Low levels of satisfaction were related to the workload, and when they answered the open-ended question about the problems that affect job satisfaction, many managers mentioned that they often worked with limited human resources, consequently they have increased responsibilities beyond their obligations with the job (40) .
In addition, in the same study by Munyewende, Rispel and Chirwa (40) , nurses have shown themselves exhausted to work because of existing conditions and are concerned about violence. The data show that 43% of nursing managers were concerned about workplace violence, 31% had experienced some type of violence and 39% had experienced verbal aggression from other colleagues and patients in the workplace. Although the average scores for the personal satisfaction subscales, professional support, prospects, and service patterns were relatively high.
There was another study that examined the prevalence of aggression against health workers and determined the possible impact of violent episodes on health workers in terms of loss of enthusiasm and involvement with work. With the results, all forms of violence, physical and non-physical aggressions showed significant correlations with burnout symptoms. Again, there is being overload and incompatibility of values or interpersonal conflicts, which contribute significantly to each of the dimensions of burnout (29) .
Although the Gomez-Gáscon et al. (28) study could not have established a cause-effect of the relationship between aggression and burnout, because of the variables studied, they could contribute to an ill-adapted cycle of violence that cooperates for burnout and cynicism. Also, these events may promote an aggressive behavior of a patient who does not feel properly served.

Interventions for the prevention of burnout
It is understood that all the studies describe the importance of changes to improve the worker's physical and mental well-being. However, only one article brought a potential action to prevent and combat stress. Blake and Lee (21) report that in the United Kingdom there are high rates of absenteeism and increased risk that health workers may have some mental disorder. Thus, taking care of the workforce has become a high priority of government. In this way, the promotion of physical activity can reduce stress, and increase competence and performance, as well as increase satisfaction in the work environment, improve mental concentration and agility, presenting better cooperation and relationships with colleagues, reducing absenteeism, lower rates of work-related accidents, all indirectly reflecting the quality of patient care.
Thus, there is an important gap in studies with strong scientific evidence that may allow the translation of knowledge through intervention actions in the work of health workers in PHC units. The importance of organizations/managers of the development and inclusion of policies of stress management to identify the identity and to eradicate practices of work that cause the dissatisfaction of the work is emphasized.
In addition to organizational changes, researchers also indicate individual interventions (21,33,38) . Cao et al. (10) suggests the creation of strategies for a favorable working environment and the formation of professional competence, that is, the qualification of the worker for the activity to be performed.

Study limitations
The limits of this study are the non-burnout of the search for original articles and reviews of the literature in a longer period. However, this criterion was used, considering the possibility of identifying the most current studies that aggregate knowledge in relation to older studies when discussing the data. The restriction of articles published in open access can also be considered as limiting factor.
Contributions to the sectors of nursing, health and public policy Special attention should be given to the manifestations of burnout in these workers, where specific demands, tasks and skills are imposed with the community, since this syndrome is a problem characteristic of modern man, who has less time to perform pleasurable activities because of the demands of the work, predominating the stress (5) . Thus, from the results presented in this study, it is expanded the scientific knowledge about the object analyzed in the context of the PHC, which still remains little explored by the researchers.

CONCLUSION
Most health workers working in PHC units are exhausted, although they are satisfied with their work environment.
The studies reveal indicators of burnout in PHC related to emotional exhaustion, depersonalization and lack of personal accomplishment, being: inadequate working conditions characterized by precarious human and physical resources and resulting in work overload, violence in the work environment, difficulty in teamwork, and conflicting interpersonal relationships.
The studies performed are mostly descriptive and impossible to generalize data and do not result in strong scientific evidence to support the translation of knowledge in practice and the planning and implementation of strategies to prevent new cases of burnout in health workers.
There are effective tools for previous identification of signs of burnout syndrome in health workers. However, there is no evidence on how to control the evolution of emotional exhaustion, depersonalization, and lack of personal accomplishment. Therefore, it is emphasized the importance for the prioritization of investigations that seek the prevention of burnout, as well as the search of new cases in the PHC and control of them.