Supporting in grief and burnout of the nursing team from pediatric units in Chilean hospitals

www.ee.usp.br/reeusp Rev Esc Enferm USP · 2015;51:e03289 1 Pontifi cia Universidad Católica de Chile, Escuela de Enfermería, Santiago, Chile. 2 Hospital Clínico UC-Christus, Unidad de Oncología, Santiago, Chile. 3 Instituto Nacional de Estadística de Chile, Santiago, Chile. ABSTRACT Objective: To know the levels of Burnout Syndrome and perception of grief support in nursing teams of oncology and pediatric intensive care in public hospitals in Chile. Method: A study of descriptive cross-sectional design. Th e Maslach Burnout Inventory and the Grief Support Health Care Scale were applied to university-level and technical nursing professionals between March and November 2015. An analysis to compare the means was performed with use of the Student’s t-test, and the level of signifi cance was set at 5%. Results: Th e study included 153 professionals. Results show 4% of professionals have Burnout Syndrome (BS) and 89% are at risk of having it. Oncology professionals are at higher risk as they present higher levels of emotional exhaustion and lower levels of personal fulfi llment. Half of professionals have a high level of perception of grief support, which is greater in the oncology team. Conclusion: Professionals working in pediatric oncology units are at increased risk of Burnout Syndrome and grief support may be a mediating factor in this process.


INTRODUCTION
The phenomenon of death has become relevant within health teams in the last decades, particularly in units providing care for children with chronic diseases.Given the 'unnatural' and incomprehensible character of death in childhood, this is a complex issue to approach (1) .For nursing teams, death is conceived as a loss determined by the affective bonds generated by the long time of direct contact with patients (2)(3) .This feeling of loss coupled with a perception of providing less effective care cause more emotional exhaustion on staff (4) that is manifested both in physical and mental health problems (5) .
Nursing professionals dedicated to the care of children with cancer particularly present higher levels of stress associated with the severity of patients, the inherent suffering of this health problem and, above all, the fact of caring for pediatric patients in critical or terminal state (5)(6) .In addition, there is the long contact time usually maintained with patients and relatives that can reach a workload of 60 hours a week (7) .All these situations facilitate the establishment of strong emotional bonds leading to feelings of loss that could be perceived as a grieving process (1,8) .These experiences propitiate deterioration of the mood status and are related to emotional exhaustion, perception of frustration and feelings of vulnerability in the inevitable confrontation of death and suffering of the other.As an expected consequence, these professionals face their own suffering and conscience of finitude (6,9) .When such experiences are sustained over time, psycho-emotional malaise results in decreased work performance, increase of work leave for mental health problems, and increased unintentional errors and/or omissions, which can lead to professional exhaustion, especially in those with low training in coping with the grieving process (10)(11) .
Added to problems of those working in a context close to the experiences of loss, there are specific characteristics of complex units such as cancer services and intensive care.In these places, the surveyed rates of stress and exhaustion are higher than those found in professionals acting in units of other specialties (7,11) .The fact of cancer being a highly complex health problem requiring management of prolonged treatments with high toxicity for patients is an influence, as well as the growing demand for care (9)(10) .There are other organizational factors independent of the unit, such as fatigue due to lack of staff, communication deficit, substitute decision-making, role conflicts and insufficient vacation time.The area of oncology in particular is not included in Law 14.264 of compensatory rest that covers other high complexity Chilean public health units (12)(13) .Additionally, there are elements such as repetitive activities, lack of autonomy or undervaluation of the position, especially within nursing teams (12,14) .
The aforementioned facts result in greater professional exhaustion, which would favor the Burnout Syndrome (BS) onset.This syndrome is associated with depression and anxiety that in turn result in symptoms such as headaches, deconcentration, cognitive slowing, nervousness, sleep disturbances, gastrointestinal disturbances, hypertension, allergic reactions, low self-esteem, tendency to isolation and demotivation (9,12) .
It is important to consider the direct impact of these situations on institutions, especially in their quality of care and the care provided to users (2,7) .Specifically for nursing technicians, this could be more important because of the lower training and scarce tools to face this type of situation (7)(8) .
On the other hand, many studies have shown the importance of social support within the health team itself as a mediator in the grieving process.It helps to relieve stress and allows a better coping with losses and daily work in high complexity services (7,10) .According to the evidence, it is important to prevent the onset of BS within teams, since some of its behaviors and manifestations can be acquired by other health team members who were previously healthy (14) .Studies related to the level of Burnout in university professionals and technicians working with children with cancer in Chile, have not been found.However, in a study conducted in a pediatric public hospital in Santiago, 81% of nurses and 68% of nursing technicians presented Burnout-associated symptoms (15) .In addition, results of regional studies showed a deficiency in the health teams' process of coping with patients' deaths (16)(17) .
The aim of the present study was to know the levels of Burnout and perception of grief support within nursing teams working in oncology and pediatric intensive care units of public hospitals in Santiago, Chile.

METHOD
This is a cross-sectional descriptive study.It was a convenience sample including 153 university and technical nursing professionals working in oncology and pediatric intensive care units (Spanish acronym: UCIP) of the public sector of five hospitals in Santiago.The sample size estimation considered an expected variance of nine (9) in order to find statistically significant differences.The significance level was set at 0.05 and a power of 80% (18) .The inclusion criteria were the following: hired employee of the oncology or UCIP of the hospital, working more than three months in one of the units, not experiencing a recent personal grieving process and voluntarily accepting to participate.
The study considered the following variables: Level of Burnout Syndrome (BS) and Perception of Grief Support (GS).The first variable was measured using the Maslach Burnout Inventory (MBI) (19) , spanish version.The dimensions of emotional exhaustion (EE), despersonalitation (DP) and personal accomplishment (PA) were evaluated through 22 items assessed using a Likert scale with 0-6 scores.A high BS level corresponds to a score of the EE sub-scale above 26 points, of DP above 9 points and PA under 34 points.The Grief Support Health Care Scale (GSHCS), Spanish version, was used to evaluate the GS (20)(21) .The GSHCS scale measures three dimensions, namely recognition of the relationship (RR) acknowledgment of the loss (AL) and inclusion in the funeral rituals (IFR).It has 15 items measured through a 5-point Likert scale.Scores lower than 25 points indicate low level of perception of social support in grief.This project was developed between March and November of 2015, authorized by the directors of each hospital, and was approved by the Scientific Committee on Ethics under number CEC MEDUC (Number 14-236).
The nursing team was invited to participate through posters and contact from field assistants in the different hospitals.After they agreed to participate, was signed the informed consent form, and instruments were self-applied.The principal investigator contacted the professionals who obtained a high level of Burnout by phone, and advised them to arrange an appointment with the psychologist of their hospital.They were also invited to participate in a psychoeducational support intervention developed by psycho-oncologists of the research team.
Data analysis was performed using the R statistical software, version 3.3.1 (22) .The significance level was set at 5%.In the comparison of means, the student's t-test was used for independent samples after verification of assumptions of normality and homogeneity of variances.

CharaCteristiCs of the sample
The study included 153 professionals, of which 147 were women (96%) and six were men (4%).The mean age was 37.6 years, ranging from 21 to 60 years, 31% of the study professionals were married or living together, and 56% of the total had children.Regarding the labor market, 63% of participants worked in oncology and the rest in intensive care units.Of the total number of professionals, 46.4% had university studies and 53.5% had technical qualifications.In relation to time of employment, 40.5% had less than five years in the unit.In terms of training in the area of grief, 69% of participants had not had a previous training course and/or workshop.
As for significant deaths, 39.8% of participants reported having had them.

mBi sCores of nursing professionals
After analysis of the sociodemographic variables, there were no significant differences regarding gender, age, professional level, years of service and training.However, there is a difference in relation to the work unit; oncology professionals showed higher EE compared to UCIP professionals, although it was not significant (Figure 1).After analyzing the total data, 4% (n=6) of professionals presented BS at the time of the study, of which five out of the six staff members of the oncology unit.Eighty-nine percent of participants had some level of risk for BS and of these, 61% were from the oncology unit.When analyzed by dimension, 48.4% (n=74) of participants had medium or high level of EE, 16% (n=11) had high level of DP, and 79.7% (n=122) showed medium to low level of PA, and it was more evident in oncology professionals, as 41% of them showed low professional accomplishment.

gshCs sCores of nursing professionals
Of the total number of participants, 50.3% (n=77) had a high level of perception of grief support.In relation to work unit, 55.6% of oncology professionals feel supported in their grief, and the percentage is lower in UCIP, reaching 44.6% of professionals.This difference is mainly because oncology professionals have the possibility to participate in funeral rituals.They obtained higher IFR scores compared to professionals in critical units, which was statistically significant with a p-value <0.05 (Figure 2).
The highest score was reached for RR, with 81.6% (n=125) of participants showing high levels, and with no significant differences regarding work unit or gender.In relation to AL, 66.7% of participants showed high levels, with a higher perception of support among women, although not statistically significant.In this respect, there were no significant differences according to the work unit.

DISCUSSION
Several authors have mentioned the type of work performed by nursing teams and the characteristics of patients under their care as determinants for including these professional in the group at high risk for development of Burnout Syndrome (23)(24)(25) .This can also be determined by personal aspects with direct influence on how they cope with stress situations (8,14) .Like other studies conducted with the nursing staff, participants' profile corresponds mostly to women from the technical staff at ages close to 40 years (16,26) .In the same context and after data analysis, there were no significant differences in the prevalence of BS within nursing teams in relation to gender, age, marital status, length of time working in the unit, participation in grief courses and number of children (27)(28) .However, there are differences in relation to the work unit, although not statistically significant, which is in line with findings of studies conducted with pediatric professionals (16,24,29) .Although in this study the number of professionals with Burnout Syndrome is low compared to other studies in the pediatric area, it stands out that the majority were staff from the oncology unit (8,15,27) .In the same sense, these are the professionals at greater risk of having Burnout Syndrome.
When considering values by BS dimension, data showed almost 50% with medium to high EE levels associated with medium to low PA levels, and oncology professionals had the lowest levels.These figures are important, since in several studies the EE and PA dimensions are considered relevant in the development of BS (27)(28) .
On the other hand, some studies relate the development of BS with variables such as social support and complicated grieving processes (28)(29) .Such studies mentioned cohesion and social support as factors negatively correlated with the occurrence of BS (27) .The present study showed differences in the perception of grief support according to gender; women feel more recognized in relation to the loss of a patient, which is a situation observed in studies in the area of adults (26) and pediatrics (8,27) .The data also showed a difference in perception of grief support between professionals of oncology and intensive care, with the first feeling more supported.This is explained by a significant difference in the recognition of loss and the possibility of participating in rituals and funerary ceremonies of patients.Some studies emphasize the importance of participation and development of funeral rituals by teams, which would generate cases of support that in turn would reduce the risk of prolonged grief in health professionals (20)(21) .After the results of this study, this type of interventions should be encouraged in pediatric intensive care teams in order that professionals feel more recognized in their losses and thus, have the possibility of participating in patients' funerary ceremonies according to their will (29) .
These results demonstrate the relevance of developing interventions and formal training for health teams with participation of all staff members of the unit.This would favor internal processes for the improvement of attitudes of enthusiasm, dedication, safety, enjoyment at work and emotional support between peers (15,20) , which would allow them to give meaning for the professional work (30) .
Despite the findings, one of the limitations of the present study was the lower participation of UCIP staff (compared to oncology staff ) and the low participation of professionals from some hospitals, which did not allow to perform a local analysis.

CONCLUSION
The findings of this study led to the conclusion that professionals working in high complexity children's units, especially in oncology services, may present a higher risk of Burnout Syndrome, mainly due to emotional exhaustion and less personal achievement.Note that oncology units do not have a law granting compensatory rest to their staff, as is the case of intensive care units, and this factor should be considered.
In relation to grief support, the results showed that professionals feel recognized both in their connection with patients, and with the possibility of feeling grief when caring for them until their death.However, the instance of participating in funeral rituals is still complex to perform because they perceive to be questioned by the environment around them.Therefore, interventions favoring the development of grief rituals within the unit would be appropriate, and professionals should be able to participate in children's funerals if they wish so.This element should be considered for favoring health professionals' perception of grief support, especially in professionals of intensive care units.
The present study showed that not only social support has relevance in the development of Burnout Syndrome, but also the perception of health professionals regarding recognition and support in the face of death of patients under their care.
Therefore, the development of new formal and ongoing coping strategies within health teams with a focus on teamwork, effective communication and strategies to cope with grief would allow the provision of more meaningful and healing care for professionals by acting as a protective element of Burnout Syndrome, thus achieving team cohesion, efficiency and above all, a humanized team.
These results are relevant for nursing, since they demonstrate the problem of grief in a Latin American country, which could be transferred to other realities in the region.However, it opens new paths to continue studying this phenomenon from a qualitative perspective.

Figure 1 -
Figure 1 -Burnout syndrome dimensions according to work unit.Oncology and Pediatric Intensive Care Units of Public Hospitals -Santiago, Chile, 2015.

Figure 2 -
Figure 2 -Dimensions of grief support according to work unit.Oncology and Pediatric Intensive Care Units of Public Hospitals -Santiago, Chile, 2015.