Impact of critical care environment on burnout, perceived quality of care and safety attitude of the nursing team 1

ABSTRACT Objective: assess the perception of the nursing team about the environment of practice in critical care services and its relation with the safety attitude, perceived quality of care and burnout level. Method: cross-sectional study involving 114 nursing professionals from the intensive care unit of a teaching hospital. The following instruments were used: Nursing Work Index-Revised, Maslach Burnout Inventory and the Safety Attitude Questionnaire. Results: the professionals who perceived greater autonomy, good relationships with the medical team and better control over the work environment presented lower levels of burnout, assessed the quality of care as good and reported a positive perception on the safety attitude for the domain job satisfaction. Conclusion: the findings evidenced that environments favorable to these professionals' practice result in lower levels of burnout, a better perceived quality of care and attitudes favorable to patient safety.


Introduction
In the past three decades, considerable knowledge has been produced on the relevance of the environment of nursing practice for the nurse, patient and institution. The healthcare environment is complex, demands technological and human resources to respond to the patients and families' care demands and the paramount activity of nursing, representing the main contingent of health professionals, is patient surveillance 24 hours per day (1) .
The environment of practice is defined as the organizational characteristics of a work environment that make the nursing practice easier or more difficult (2) .
The American Association of Critical Care Nurses acknowledges the inseparable link between the quality of the work environment, the excellence of nursing practice and the patient and family care outcomes, highlighting six main standards to establish and sustain a healthy work environment, as follows: communication skills, cooperation among team members, effective decision making by the nurses, appropriate number of professionals, acknowledgement of the nurse for his/her contribution and authentic leadership by nurse leaders (3) .
The Institute of Medicine in the United States identified many risks to patient safety, originating in each component and level of the care system, including: work process, burden and work hours and work environment of the nursing team. It was equally highlighted that the changes in the care provision system in the past decades have affected the way nursing delivers care and preserves the patient safety (1) .
In this context, various studies focus on the impact of the environment of practice and the results for the patient and nursing, showing that environments in which the nurse possesses autonomy, control over the environment and good relationships with the medical team result in lower levels of burnout (4)(5)(6) , greater job satisfaction (5,7) , lesser intent to abandon the job (5,8) and better outcomes for the patients in terms of care quality (5,9) and patient safety (5,8,10) .
It is highlighted that, in Brazil, research on this theme is recent. Evidences appoint that environments favorable to nursing practice entail lower levels of emotional exhaustion for the professionals, greater job satisfaction and lesser intent to abandon the job (11)(12) .
Nevertheless, no studies are available that assess the impact of the environment of practice on the burnout level, job satisfaction and safety attitude of the nursing team at critical care services.  To collect the data, the following instruments were used: Nursing Work Index -Revised (NWI-R) -Brazilian version (13)(14) , Brazilian version of the Safety Attitudes www.eerp.usp.br/rlae 3 Guirardello EB.
The Nursing Work Index -Revised (NWI-R), validated for the Brazilian culture, assesses the nursing professionals' perception of their work environment (11) .
It consists of 15 items, distributed in four subscales: autonomy (five items), organizational support (ten items), control over the environment (seven items) and relations between physicians and nursing team (three items). It is highlighted that the items in the organizational support subscale were taken from the first three subscales and therefore are not added to the total number of items in the instrument. For the sake of this study, two versions of the NWI-R were considered, one for nurses (13) and the other for nursing technicians (14) . Answers are provided on a four-point Likert scale, with the following alternatives: 1 (I strongly agree); 2 (I partially agree); 3 (I partially disagree) and 4 (I strongly disagree) and, the lower the score, the greater the presence of attributes favorable to these professionals' practice.
The Safety Attitudes Questionnaire Short Form

-(SAQ) intends to assess the health professionals'
perception of the safety attitudes permeating their work environment (15) .   In another analysis, we looked for correlations among the NWI-R subscales, SAQ domains, MBI subscales and the variable perceived quality of care (Table 2).
When evaluating the existence of correlations among the SAQ subscales, the length of experience at the unit and the intention to abandon the profession, a weak correlation was found between the length of experience at the unit and the safety climate (r= -0.24; p= < 0.0112), job satisfaction (r= -0.24; p= < 0.0108), perception of unit management (r= -0.26; p= < 0.0054) and perception of hospital management (r= -0.26; p= < 0.0067) domains.

Discussion
In this study, the impact of the environment of professional practice, the burnout level, the perceived quality of care and the safety attitudes of nursing professionals at intensive care units was investigated.
The participants were young adult professionals, mostly female with a single job. Most nurses held some specialization degree, but few degrees were related with their activity area, appointing that no culture exists at the institution to encourage the professionals to seek qualification/specialization related to their own work.
As regards the nursing technicians, 27 (37.0%) held an undergraduate degree in nursing, demonstrating the concern with or search for qualified education. reflects the team's experience (17) . It is important to highlight that, in this research, the burnout level did not differ between the nurses and nursing technicians.
With regard to the perceived safety attitude, it could be identified that only the job satisfaction domain was considered favorable, as observed earlier (15) . The stress recognition and teamwork climate domains, on the other hand, obtained averages superior to 68 points and should be valued by the unit manager, as they can influence the perceived safety attitude at the institution.
Significant differences were verified between the professional categories in terms of stress recognition, as most nurses, corresponding to more than ¾ of this group, presented averages of 93.75 points or higher, signaling that the perceived stress was an important variable that interferes in these professionals' perceived safety attitude.
As appointed in other international studies, a significant correlation was found between the NWI-R (autonomy, relations with physicians and control over the environment), emotional exhaustion and job satisfaction (4)(5)(7)(8)17) . Another important aspect similar to the international studies (8,18) was the moderate correlation between emotional exhaustion and the subscales autonomy and control over the environment. This means that, in environments in which the professionals report having autonomy and control over the environment, they present lower levels of emotional exhaustion. In addition, a moderate and weak correlation was evidenced between the subscales: autonomy, control over the environment, good relationships between physician and nursing team and all SAQ domains, except for the stress recognition domain, which showed no correlation with any of the variables.
And finally, but not less important, a weak correlation was found between the length of experience at the unit and the safety climate, job satisfaction, perception of unit and hospital management domains, indicating that, the shorted the length of experience at the unit, the worse these professionals' perception of the safety attitude.

Study limitations
This study comes with several limitations. The

Conclusion
The findings evidence that environments favorable to the nursing team's professional practice can result in lower levels of emotional exhaustion, a higher quality of care and a positive perception of the safety attitudes.