The environment of professional practice and Burnout in nurses in primary healthcare

OBJECTIVES: to assess how nurses perceive autonomy, control over the environment, the professional relationship between nurses and physicians and the organizational support and correlate them with burnout, satisfaction at work, quality of work and the intention to quit work in primary healthcare. METHOD: cross-sectional and correlation study, using a sample of 198 nurses. The tools used were the Nursing Work Index Revised, Maslach Burnout Inventory and a form to characterize the nurses. To analyze the data, descriptive statistics were applied and Spearman's correlation coefficient was used. RESULTS: the nurses assessed that the environment is partially favorable for: autonomy, professional relationship and organizational support and that the control over this environment is limited. Significant correlations were evidenced between the Nursing Work Index Revised, Maslach Burnout Inventory and the variables: satisfaction at work, quality of care and the intent to quit the job. CONCLUSION: the nurses' perceptions regarding the environment of practice are correlated with burnout, satisfaction at work, quality of care and the intent to quit the job. This study provides support for the restructuring of work processes in the primary health care environment and for communication among the health service management, human resources and occupational health areas.


Introduction
Basic or primary health care is considered the primary level of contact between individuals, families and communities and the Unified Health System (SUS) and family health is the strategy to reorganize is, considered as an alternative health care model to achieve universalization, equity and integrality (1) .
On the other hand, as a set of individual and collective health actions (1) , primary health care is an important nursing activity area, where the nurses develop and articulate actions to promote, prevent and recover the population's health (2) .
In the practice sphere, the nurses work independently and interdependently in teams (1) , with actions centered on the organization and management of health work processes for individual care. At the same time, there is a need to organize work processes focused on care for family needs and the qualification of care for individuals in their family and community contexts (3) . That imposes challenges for the nurses in daily practices, as different work processes demand more cognitive efforts and increase the work loads (4) , making the workers' actual activities more complex.
Another important aspect that puts a strain on the nurses in primary health care is their role as team leaders, involving the coordination of community health agents and the nursing team's work, besides specific and shared care activities, such as: nursing consultations and procedures, educational activities, home visits and surveillance actions (5) .
Nursing practice is characterized by the dichotomy between care and management actions and by tensions deriving from the task division in collective work management, resulting in conflicts with the physicians and with central management, in which the nurses perceive the unequal accountability as a work burden (6) .
Nurses working in environments that are considered favorable to professional practice, with sufficient human and material resources, describe positive experiences at work and a better perceived quality of care (6) . In addition, there is evidence that autonomy, cordial professional relationships between nurses and physicians, control over the professional practice environment and organizational support are environmental attributes that, when perceived by the nurses, enhance professional practice, guarantee greater satisfaction and contribute to a better quality of care offered to patients in inpatient services (7)(8)(9) .
Nevertheless, there are no studies in Brazil that assess these favorable characteristics in the professional practice environment of nurses in primary healthcare, which justifies the development of this study.
In health, the restructuring of the care production produces different care models that imply different organizational dynamics (10) , which influence the work processes of the nurses who play an important role in the reorganization of the care model within the health surveillance logic, which requires new technical and interpersonal skills to exercise their actual work activities, enhancing the complexity of these professionals' attributions and responsibilities.
On the other hand, the work environment in primary health care is not always favorable to the professional practice of nurses and, often, the physical environment is inappropriate; human resources, equipment and inputs are insufficient (11) ; the professionals are exposed to different categories of risks to health and occupational safety problems in the work environment (12) and to different forms of violence (12)(13) ; the staff turnover levels are considerable (14) ; the remuneration is low; the professionals choose to have more than one job, compromising the quality of work and their own health.
In work situations in which the nurses and continuously exposed to mental burdens, the environmental factors that are perceived with displeasure and without effective coping mechanisms, burnout is evidenced (15) . This is a three-dimensional syndrome, characterized by emotional exhaustion, depersonalization and reduced professional accomplishment, whose dimensions are independent and mutually related (16) .
Burnout can be considered a work-related disease because it is associated with exposure to health and occupational safety risk factors present in the work environment. In that sense, in a Brazilian study of nurses working at a public hospital, it was evidenced that the increase of perceived stress is significantly correlated with burnout (15) , while it was identified in a Canadian study that emotional burnout is positively associated with the work demands (17) .
While health, wellbeing and quality of life at work have been identified as key issues in the recruitment and retention of nurses, absenteeism and the phenomenon of the lack of human resources in nursing have made the professionals eliminate days of leave, making them more prone to physical and mental health problems due to the workload they carry (18) , besides preventing them from offering high-quality care the whole time, weakening their performance and distancing them from specific work environments or from their profession (17) . To allow the nurses to contribute to the reorganization of primary healthcare according to the logical of the health surveillance model, without a continuing feeling of burnout, treating patients and coworks in a humanized manner the whole time, feeling accomplished and satisfied at work, perceiving the quality of the work as good and moving away from the intent to quit their job, it is important for them to perceive that they have: autonomy, control over the environment of practice, a cordial professional relationship between nurses and physicians and organizational support, for them to assess the environment as favorable to innovative professional practices, which the ideal healthcare model requires to be effective.
In that context, the objective in this study is to analyze how nurses in primary healthcare perceive the autonomy, control over the environment of practice, cordial professional relationship between nurses and physicians and organizational support and correlate these perceptions with the dimensions of the burnout syndrome, professional satisfaction, perceived quality of care and intention to quit the current job.

Method
A cross-sectional correlation study was undertaken in the primary healthcare services of the public network in a Brazilian city that is considered fully in charge of its The subjects who accepted to participate in the study received an individual enveloped with a characterization form, the research tools to be answered, a pen and a seal to guarantee the participants' anonymity and the free and informed consent form, which the researcher and participant signed in two copies.
To collect the data, the following tools were used: the Brazilian version of the Nursing Work Index Revised (NWI-R) (8)(9) ; the Brazilian version of the Maslach Burnout Inventory (MBI), adapted and validated by Tamayo (19) , which has been used to assess burnout in inpatient services (8)(9) , and a personal and professional characterization form, to which three questions were added to assess: professional satisfaction, perceived quality of care and intention to quit the current job (8)(9) .
The Brazilian version of the NWI-R contains 57 items and its objective is to measure the nurses' perception of favorable characteristics in the professional practice environment, as follows: autonomy, control over the professional practice environment, cordial professional relationship between nurses and physicians and organizational support (8)(9)20) . For analysis purposes, only 15 items have been considered sufficient (8)(9)20) , which are distributed among four subscales: autonomy (five items), cordial professional relationship between nurses and physicians (three items), control over the professional practice environment (seven items) and organizational support (ten items), which contain the same items as the previous subscales (8)(9)20) . The NWI-R measure is a Likert scale ranging from one (I completely agree) to four (I completely disagree) and, the lower the score, the greater the perceived: autonomy, control over the professional practice environment, cordial professional relationship between nurses and physicians and organizational support, indicating an environment that is favorable to practice (8)(9)20) .
The MBI assesses how the workers experience their work through the frequency of feelings related to the burnout syndrome (16)(17)(18)(19) . The inventory contains 22 items, distributed in three subscales: emotional exhaustion (nine items), depersonalization (five items) and personal accomplishment (eight items) (18,21) . The MBI measures is a Likert scale ranging from one (never) to five (always) (19) and, the higher the score, the more frequent are feelings of emotional exhaustion, depersonalization and personal accomplishment (16)(17)(18)(19) . High scores on the emotional exhaustion and depersonalization subscales and low scores on the personal accomplishment subscale indicate a high level of burnout (16)(17)(18)(19) .

Satisfaction at work was measured by means of a
Likert scale ranging from one (highly satisfied) to four (highly dissatisfied) (8)(9) . The perceived quality of care was measured on a Likert scale from one (very bad) to four (very good) (8)(9) . The intent to quit the current job was measured using a visual analogue scale from zero (none) to 100 (a lot) millimeters. For the data analysis, the software Statistical Analysis System (SAS) version 9.2 was used. For the descriptive analysis, means, standard deviations (SD), medians, minimum, maximum and percentages were used. The reliability was assessed using Cronbach's alpha coefficient and values superior to 0.60 were considered satisfactory (21) .
To analyze the existence of correlations, Spearman's correlation coefficient was used and significance was set  (Table 2).  In the evaluation of the existence of correlations between the subscales of the NWI-R and the MBI, the data showed that the subscales autonomy, control over the practice environment and organizational support of the NWI-R showed eight significant correlations with the MBI subscales emotional exhaustion, depersonalization and personal accomplishment (Table 3).
In addition, the existence of correlations was assessed between the NWI-R subscales and the variables: satisfaction at work, perceived quality of care and intention to quite the current job, showing seven significant correlations (Table 4).  decision not to participate in this research, whose job contracts of limited length were about to expire or had expired, causing a possible selection bias.
The weekly hour load in this city is 36 hours and the corresponding mean was two hours longer, which can derive from the need for more nursing hours at the service and the professionals' option to work overtime, generating additional salary. Overtime means fewer hours for rest, family life and other activities needed to achieve quality of life.
The majority declares they are satisfied with their work and considers the quality of care offered to the users good. On the other hand, the intention to leave their current job was identified among the nurses, which can culminate in the intention to leave the profession in function of the work conditions (14)(15)(16)(17) .
The nurses assessed the work environment as partially favorable to practice, ranging from 1.9 to 2.2 for the NWI-R subscales: cordial professional relationship between nurses and physicians, autonomy and organizational support, on a scale ranging from one (favorable environment) to four (unfavorable environment) ( over the practice environment, the mean score of 2.7 points demonstrates that the nurses have little control over the environment they work in (Table 1).
Little autonomy, little control over the environment and little organizational support may reflect two existing care models, in which the nurses develop activities related to traditional primary care, focused on the user's disease and guided by medical-curative interventions (traditional technology); at the same time as their activities related to the expansion and consolidation of the family health strategy (10) , focused on the family and its social relations, guided by the SUS principles (technological innovation). These imply different work processes, demand more cognitive efforts and increase the workloads the nurses have to carry, causing dissatisfaction and stress (4) .
The increased workloads for the nurses who continue working, associated with the reduced perceived control over the environment, autonomy and organizational support, represent one of the consequences of the underfinancing of the SUS at the state and federal levels.
Associated with the fiscal responsibility law, this compels the cities to limit their spending on health staff, resulting in precarious work relations, health work management and work conditions (11) . For primary health care, this situation In the practice context, where the nurses work independently and interdependently in teams (1) , the work processes require additional efforts, such as strategy development, preview of future events and intellectual efforts to solve problems and overcome difficulties (22) .
Efforts are highlighted to overcome the psychological repercussions and mental suffering the exposure to different forms of work violence, violence at work and indirect violence (12)(13) .
As regards the reliability of the NWI-R, the

Conclusions
The study permitted assessing the nurses' This study contributes to support reflections on the nurses' environment of practice in primary healthcare and to restructure the work processes according to the health surveillance model, so as to turn work into a source of pleasure and accomplishment.

Study limitations
Among the study limitations, the sample size is highlighted, which represented 69.0% of the population of primary healthcare nurses, the possible selection bias and the impossibility to generalize the results, as the study was restricted to one city in the state of São Paulo. Therefore, further research is needed, involving nurses from different regions of the state and of Brazil.