Occupational Burnout Syndrome in the nursing context: an integrative literature review

El síndrome do agotamiento profesional en el marco de la enfermería: una revisión integrativa de la literatura

Abstract

OBJECTIVE

To characterize the scientific production on Burnout Syndrome in the Nursingcontext, systematizing the location where the studies were carried out, the related constructs, the employed methods and their main results.

METHOD

An integrative review of the literature with a bibliometric approach of articles published in Portuguese, Spanish and English between 2005 and 2016.

RESULTS

106 articles wereincluded. Mostinvolvedprevalence, and were descriptive, quantitative studies performed in hospitals.The Southeastern and Southern regions of Brazil had the largest number of publications, and stress was the construct most related to burnout.Most of the studies used the Maslach Burnout Inventory to investigate the presence of the syndrome.

CONCLUSION

New case-control and cohort studies should be carried out.Qualitative-exploratory studies are necessary to better understand Burnout Syndrome among nursing professionals usingfocus groups or interviews, as well as comparative causal studies, with the purpose of exploring the syndrome’smanifestations.

Descriptors
Nursing; Burnout, Professional; Occupational Health; Review

Resumen

OBJETIVO

Caracterizar la producción científica acerca del Síndrome del Agotamiento Profesionalen el marco de la enfermería, sistematizando los sitios en donde las investigaciones fueron realizadas, los constructos relacionados, los métodos empleados y sus principales resultados.

MÉTODO

Revisión integrativa de la literatura, con abordaje bibliométrico, en artículos en lengua portuguesa, española e inglesa publicados entre 2005 y 2016.

RESULTADOS

Fueron seleccionados 106 artículos. La mayoría se compuso de estudios de prevalencia, descriptivos, cuantitativos y realizados en hospitales. En las regiones Sureste y Sur de Brasil se halla el mayor número de publicaciones, siendo el estrés el constructo más relacionado con el agotamiento profesional. La mayor parte de los estudios utilizó el Maslach Burnout Inventorycomo medio de la averiguación de la presencia del síndrome.

CONCLUSIÓN

Nuevos estudios de caso control y cohorte deben llevarse a cabo. Investigaciones de cuño cualitativo-exploratorio son necesarias para poder comprender mejor el Síndrome del Agotamiento Profesionalentre los profesionales de enfermería con grupos focales o entrevistas, como también investigaciones causales comparativas, a fin de explorar las manifestaciones del síndrome.

Descriptores
Enfermería; Agotamiento Profesional; Salud Laboral; Revisión.

Resumo

OBJETIVO

Caracterizar a produção científica sobre a Síndrome do Esgotamento Profissionalno contexto da enfermagem, sistematizando os locais onde as pesquisas foram realizadas, os construtos relacionados, os métodos empregados e seus principais resultados.

MÉTODO

Revisão integrativa da literatura, com abordagem bibliométrica, em artigos na língua portuguesa, espanhola e inglesa publicados entre 2005 e 2016.

RESULTADOS

Foram selecionados 106 artigos.A maioria estudos de prevalência, descritivos, quantitativos e realizados em hospitais. Nas regiões Sudeste e Sul do Brasil encontram-se o maior número de publicações, sendo o estresse o construto mais relacionado com o esgotamento profissional. A maior parte dos estudos utilizou o Maslach Burnout Inventory como meio de averiguação da presença da síndrome.

CONCLUSÃO

Novos estudos de caso controle e coorte devem ser realizados. Pesquisas de cunho qualitativo-exploratório são necessárias para poder compreender melhor a Síndrome do Esgotamento Profissionalentre os profissionais de enfermagem com grupos focais ou entrevistas, como também pesquisas causais comparativas, com o intuito de explorar as manifestações da síndrome.

Descritores
Enfermagem;Esgotamento Profissional;Saúde do Trabalhador; Revisão

Introduction

For nearly four decades Occupational Burnout Syndrome (OBS) (or better known as Burnout Syndrome) has been investigated in the academic setting. The syndrome arises from chronic stress related towork¹.Although it is recognized as an occupational psychopathology (Group V of the ICD-10) included in Annex II of the 2^ndarticle of Decree 6.957/1999 governed by Social Security, its diagnosis is rarely used².

In most cases OBS is understood as a three-dimensional theoretical model based on the psychosocial perspective. According to this model, OBS involves three dimensions: emotional exhaustion (EE), depersonalization (DS) and lack of personal accomplishment (PA). EE is a direct manifestation of individual stress, where feelings of being beyond their limits are externalized, along with a deterioration of the individual's physical resources.DS is related to the interpersonal conjuncture of the syndrome, where negative attitudes and cynicism are directed towards the people/persons for whom the work is intended.Depersonalization is characterized as a loss of compassion towards others.Finally, PA relates to negative evaluations of the individual regarding their performance at work and their future in that profession^1-15.

Although the three-dimensional model is the most accepted and used for measuring the syndrome, there are controversies regarding this three-dimensional structure.In some cases, OBS is evaluated as a one-dimensional disorder; others consider it a two-dimensional phenomenon, considering only DS and EE as disease factors, and considering PA as an interdependent factor resulting from emotional exhaustion (EE)^16-17.

On the other hand, the EE dimension is sometimes seen as the most important and central factor in OBS^18-19.However, this dimension has been described in other phenomena, such as in occupational stress or stress related to work, which are models that precede the OBS definitions.In the theoretical OBS models, its manifestation occurs after the onset of stress²⁰,which is considered an independent construct of the syndrome¹.Although OBS is in some way related to occupational stress²¹, it seems that what qualifies and differentiates it is the DS dimension, being key construct of the syndrome²².

Empirical studies on OBS show that health professionals seem to constitute one of the most susceptible professional categories to the syndrome^23-24.Among health professionals, nurses are the ones who experience the most stress and OBS^25-42. These workers have the constant care of patients as their responsibility,and in this context they often witness cases of death and mourning,thereby being exposed to emotional tensions of such events, which may lead to the appearance of OBS^43-44.

In view of the above and due to the high number of studies on OBS among nursing professionals²⁶, it is relevant to analyze studies on OBS in the Nursing context.Thus, this workis an integrative bibliometric review guided by the following question:How is scientific production on OBS characterized in the context of Nursing, between 2005 and 2016?

The present study aims to characterize the scientific production on OBS in theNursing context, focusing and systematizing the siteswhere the studies were carried out, their related constructs, implemented methods and the main results found.

Method

This is an integrative review studywith a bibliometric approach.This technique allows for synthesizing methods and results of multiple published studies regarding a given topic in a systematic way, and points out knowledge gaps that need to be filled, thereby collaborating to further deepen the phenomenon investigated. We sought to characterize the scientific production on OBS in the Nursing context - nursing professionals (nurses, technicians and nursing assistants) and professors and students of nursing courses.Scientific articles from the period between 2005 and 2016 were investigated.The review consisted of the following steps: searching for the articles in the databases; defining inclusion and exclusion criteria; collecting information to be extracted from selected articles;analysing and interpreting the selected studies.

The databases initially investigated from the start of the research were: the Virtual Health Library (Biblioteca Virtual emSaúde - BVS);the Brazilian Nursing Database (Base de Dados de Enfermagem-BDENF); the Spanish Bibliographic Index of the Health Sciences (IBECS); the Psychology Index - Technical-scientific journals (Index-Psi); the Latin American and Caribbean Health Sciences Literature (LILACS) and the Medical Literature Analysis and Retrieval System Online (MEDLINE).Next, the Scientific Electronic Library Online (SciELO) and the Electronic Psychological Journals portal (PePSIC)databaseswere also consulted.

The descriptors used were generated from the list of Descriptors in Health Sciences (DeCS), which were: Burnout, Professional; Nurses; and Nursing. The Boolean search was performed using the connector AND, which allowed access to articles that have intersections between the different descriptors.

Only articles focusing on nursing professionals, Nursing professors or Nursing students were selected for analysis, and studies in which OBS was discussed and/or investigated.The articles couldhave been published in Portuguese, English or Spanish and their complete texts should be freely available. The articles were collected at two moments.The first was carried out between May 2^ndand 6^th, 2015, while the second between February 5^thand 7^th, 2017.Articles that did not meet the characteristics described above were excluded.

After the initial search and exclusion process, a chartwas prepared for characterizing the remaining articleswith the following information: article identification (title, year, study site, journal, authors) and article characteristics.The script of a research project was followed in order to verify the characteristics of the article, classifying them by type of study, type of objective(s), approach(es),delineation, collection procedure and data source, as well as the main results, relationships with other constructs and the recommendations⁴⁵.

Results

Process of inclusion/exclusion of the articles found

Through the search conducted by two independent researchers, 18,683 articles were initially retrieved. Next, titles, abstracts and descriptors were readfrom these, and each researcher selected articles for analysis.A third reviewer was then invited to check the relevance of the selected studies, commenting on the differences between the two researchers and determining the group of studies to be analyzed. Finally, 170 recordswere selected from this initial analysisto go through a more rigorous selection process⁴⁶ (Figure 1).

Figure 1
Flowchart for identification, selection and inclusion of the investigated articles -Fortaleza, Ceará, Brazil, 2017.

According to the process shown in Figure 1, only 106 articles qualified for the analysis^{2-20,22-44,47-110}. The main publication language of these manuscripts was English (64 articles), followed by articles in Portuguese and Spanish (25 and 17, respectively). The analyzed productions were published in 63 periodicals, and the most frequent was the Revista Latino-Americana de Enfermagemwith 10 articles.

Characterization of the studies

Of the106studies found in the studied period, the greatest number of publications occurred in 2015 (16.98%), followed by 2012 (16.04%) and 2014 (13.21%).Studies on OBS were concentrated in South America(51.89%) and Europe (24.53%).From the empirical investigations carried out in the Brazilian scenario, the highest concentrations of publications was found in the Southeast (48.78%) and South (36.59%) regions, while the Central-West (2.44%) and Northeast (12.20%) did not have significant production.

As shown in Table 1, excluding theoreticalstudies and reviews (n=95), the hospital environment was the place where the largest number of investigations occurred, comprising 74.73% of the total. This is followed by studies performed in institutions of nursing education (6.32%).

Table 1
Sites where studies on Burnout Syndrome were carried out - Fortaleza, Ceará, Brazil, 2017.

Study Site	F	%
Not specified Hospital	29	30.53%
University Hospital	16	16.84%
Private Hospitals	01	1.05%
Public Hospitals	13	13.68%
Military Hospital	01	1.05%
Philanthropic Hospital	01	1.05%
General Hospital	07	7.37%
Public and Private Hospital	02	2.11%
Community Hospital	01	1.05%
Private University	01	1.05%
Public University	02	2.11%
Unspecified educational institution	03	3.16%
Psychiatric Ward	01	1.05%
Emergency Mobile Care Service	02	2.11%
Basic Health Units	04	4.21%
Primary Care and Public Hospitals	02	2.11%
Several places	02	2.11%
Unspecified location	06	6.32%
Family Health Strategy	01	1.05%
Total	95	100%

By only analyzing the studies that contained some kind of correlation with other constructs (f=97), it can be noticed that the construct most related to OBS is stress (17.53%).However, there are a significant number of studies that relate OBS to job satisfaction and the perception of the work environment in Nursing, with 12.37% and 10.31%, respectively (Table 2).

Table 2
Constructs related to Burnout Syndrome in the Nursing context - Fortaleza, Ceará, Brazil, 2017

Constructs related to burnout	Related Frequency(f)	%
Occupational Stress	17	17.53%
Job Satisfaction	12	12.37%
Perception of the Work Environment	10	10.31%
Personality	06	6.19%
Quality of life	03	3.09%
Commitment to Work	03	3.09%
Compassion Fatigue	03	3.09%
Self-efficacy	02	2.06%
Post Traumatic Stress Disorders	02	2.06%
Quality in Attending and Care	03	3.09%
Leadership	02	2.06%
Somatic Complaints	02	2.06%
Work-Family Conflict	02	2.06%
Depression	03	3.09%
Organizational Support	02	2.06%
Sleep quality	01	1.03%
Team work	01	1.03%
Work organization	01	1.03%
Emotional intelligence	01	1.03%
Work conditions	02	2.06%
Psychological Capital	01	1.03%
Workaholic	01	1.03%
Autonomy	01	1.03%
Self-assessment	01	1.03%
Team Satisfaction	01	1.03%
Anxiety	02	2.06%
Moral Suffering	02	2.06%
Social capital	01	1.03%
Engagement	01	1.03%
Resilience	02	2.06%
Coping Strategies	02	2.06%
Common Mental Disorders	01	1.03%
Verbal Violence	01	1.03%
Cognitive Evaluation	01	1.03%
Violence caused by patients	01	1.03%
Total	97	100%

Table 3 presents an overview of the type of methodology used in the investigations⁴⁵.Most of the articles are prevalence studies (81.13%), followed by literature review articles (10.38%).Survey studies (5.66%) and intervention studies (1.89%) appear next. Only one study is characterized as a case-control study (0.94%).

As shown in Table 3, articles that for the most partaddressed OBS in Nursing are descriptive (66.04%), and there are descriptive-exploratory studies at a lower frequency (29.25%). Exploratory and prospective investigations are not so frequent, with 2.83% and 1.89%, respectively. Regarding the approaches, quantitative studies comprise a total of 87.74% of the analyzed production, and there are those that combine qualitative-quantitative approaches on a significantly smaller scale (1.89%).

Table 3
Overview of employedmethods in studies on Burnout Syndrome in the Nursing context - Fortaleza, Ceará, Brazil, 2017.

Type of study	F	%
Case Control	01	0.94%
Prevalence	86	81.13%
Review	11	10.38%
Intervention	02	1.89%
Survey	06	5.66%
Total	106	100%
Objectives	F	%
Exploratory	03	2.83%
Descriptive	70	66.04%
Descriptive-Exploratory	31	29.25%
Prospective studies	02	1.89%
Total	106	100%
Approach	F	%
Quantitative	93	87.74%
Mixed	02	1.89%
Bibliographic searches	11	10.38%
Total	106	100%
Delineation	F	%
Experimental	01	0.94%
Non-experimental	11	10.38%
Quasi-Experimental approach	94	88.68%
Total	106	100%
Data collection procedure	F	%
Case study	43	40.57%
Study in two or more places	50	47.17%
Action Research	02	1.89%
Library and database (books, articles, dissertations and theses)	11	10.38%
Total	106	100%
Data source	F	%
Interview and questionnaire	02	1.89%
Questionnaire	89	83.96%
Pre-and post-test	03	2.83%
Bibliographic research	11	10.38%
Observation and questionnaire	01	0.94%
Total	106	100%

Still regarding the data presented in Table 3, it is verified that the investigations were for the most part quasi-experimental (88.68%), while only one was experimental and performed in the laboratory (0.94%).Regarding data collection procedures, studies performed in two or more places were the most frequent, corresponding to 47.17% of the total.Action research was not carried out frequently, equivalent to 1.89% of the analyzed studies.The application of questionnaires was the technique most used for data collection (83.96%); Pre-tests and post-tests were performed in 2.83% of the studies;1.89% used interviews and questionnaires;while observations and questionnaires were used in 0.94% of the studies analyzed.

Discussion

The first publications on OBS occurred between 2005 and 2007 among nursing students^26,47. The scientific production distributed by geographic region of Brazil revealed that no articles were found on the subject in the North region and few studies were carried out in the Central-West region^13,32,54. In contrast, the state of São Paulo had the most studies on OBS in Nursing^{2,10,19,22,41,44,47,64-65,78,87,92}. With regard to production in other parts of the world, Africa has the lowest number of publications^35,52-53, as the studies are mostlyconcentrated in Latin America and Europe.

The articles were mostly published in nursing journals^{2,4-7,11,13-16,18-20,22,24-25,29,31-32,37-38,40-41,48-53,56-59,61-72,76-78,80,82-84,87,91-92,95-98,100-101,103-105,107,110}, thehealth area^{3,8-9,12,17,30,33,35,39,42,44,47,60,79,81,85-86,88-89,93,99,102,106}and psychology^{10,23,26-28,34,36,43,54-55,73-75,90,94,108-109}. After reading and critical analysisof the 106 analyzedarticles, the content was organized into five thematic categories to facilitate understanding, as presented below.

OBS among nursing professionals in health facilities

The large number of studies performed in hospitals is justifiable, since this work context is prone to OBS manifestation⁷².These establishments have a diversity of sectors in which nursing professionals can work^30,111. Thus, hospitals are the ideal place to approach nursing staff and obtain a relatively large number of interviews, considering that the majority of studies are quantitative in nature, requiring relatively large samples for statistical analysis^{12,15,33-34,36-37,42-44,52,55,57,59-60,62-63,75,79,83-87,91-92,95-96,98-99,103-106}. This seems to be a characteristic of studies on OBS, to the detriment of qualitative research that could provide a deeper understanding of the mechanisms underlying the syndrome⁵⁴.

Overall, studies propose generalizations without giving due attention to the specificities of hospital sectors, assuming that the different work contexts present similar risks for the onset of OBS^71,94, which is not always proven.Furthermore, emergency rooms and palliative care units are the least investigated sitesprobably due to difficulties in researchoperationalization^14,41,57,102, although a small concentration of studies on OBS in intensive care nurses can be found^{19,22,39-40,92-93}. Still, the need for further investigations on OBS in professionals from acute care^59,62and psychiatric ward units^57,86 is clear,given that these are places whichin theory present greater risks in relation to the syndromedue to the type of work performed and the attended patients.

Studies carried out in Primary Care show signs of the syndrome among nurses^{20,24,48-49,101}, although not at a very high level.Both investigations carried out with the nursing professionals of the Emergency Mobile Care Servicefound different results. One of them found low-moderate levelsfor the three dimensions of OBS⁵⁰; while DS and EE presented high levels and PA was lowin the other investigation⁵¹.

The studies are largely descriptive and/or exploratory, and only use the Maslach Burnout Inventory - Human Services Survey (MBI-HSS) to assess OBS^{2-3,6-7,9,11,13-15,17-20,22-23,27-28,30,32-34,36,38-40,42-44,48-53,57,59-60,62-63,73-79,81-84,86-95,101-106,108}. A version of theMaslach Burnout Inventory - General Survey (MBI-GS)was also used in two investigations^12,85,109.Two studies investigated OBS using the Burnout Characterization Scale^54-55 and one used the Compassion Satisfaction and Fatigue Test (CSF)³⁷.Another study used the Copenhagen Burnout Inventory⁹⁶.

The use of different instruments makes it difficult to compare the studies.Studies rely on samples ranging from 11 to 11,000 participants, and because there is no standard for measuring the syndrome, it is not possible to conduct a more categorical assessment of the results.However, by analyzingthe mean scores of some studies, in most casesit can be noticed that nursing professionals manifest low-moderate EE, low DS and moderate PA^{2-3,17,19,23,27-28,30,34,36,49-54,57,59-60,62-64,73-79,81-86,91,93-94,101,105}. Nursing technicians and assistants have higher levels of the syndrome compared to nurses, although this difference is small^10,13,50,91.

Burnout syndrome among teachers and nursing students

Investigations on OBS among students are more frequent than among professors^{4-5,8,26,47,65,80,107}, again, perhaps due to operational problems.These studies arise from the expansion of the OBS study field and the broadening of the Burnout concept, since the depersonalization factor has come to be denominateddisbelief¹¹². Studies on OBS in students have used theMaslach Burnout Inventory - Student Survey (MBI-SS) as the main data collectioninstrument^{4-5,26,80,107},and only one study made use of the MBI-HSS⁴⁷ in nursing students.With samples varying from 42 to 255 participants and similar results, students have shown low-moderate EE, low DS (disbelief) and high-moderate PA. When asked about the syndrome, most of the graduates reported not knowing about it⁴⁷.It is possible that high-moderate PA, increased in relation to professionals, is due to the fact that students still have high expectations when it comes to the profession.

Studies carried out with professors have samples between 13 and 95 subjects, and are studies employing a quantitative-qualitative approach.Prevalence of OBS in nursing professors in one of the analyzed studies was 94.7%, characterizing them as a vulnerable group to the manifestation of health problems associated with the syndrome⁸.In the qualitative analysis, professors classified the relations between students and co-workers as sources of stress.However, in a second study, the professors did not associate the manifestations of tension with the syndrome⁶⁵.

Studies that focused on nursing students and professors show that both groupshave little knowledge regarding OBS^47,65.This result shows that although OBS is recognized as an occupational pathology by the Social Security Agency, it is unknown to those involved in the prevention and diagnosis of patients. People who have the syndrome are often diagnosed with depression or another mental disorder, withoutproper connection to the occupation¹¹³.

Reviews on OBS in Nursing

Still incipient, reviews on OBS in Nursing continue without in depth analysis ofthe theme and its origin or triggering mechanism¹⁰⁰.They are studies that investigated the "state of the art", analyzing between 4 and 70 manuscripts. For the most part, these studies only describe the syndrome and its impacts on the life of the nursing professional^29,68,71-72. These investigations explore stress and OBS, and mainly their relationships and peculiarities^{29,35,67,70,97}. However, little is said about the methods or intervention cases on preventing and reducing the syndrome in the nursingcontext²⁹.

The review articles analyzed here are only focused on national scientific production^{67-68,70-72,97,100}. However, a bibliographic investigation selected 70 articles, of which 26 were European, 25 American, 12 Asian, 4 Australian and 3 African, but no South American studies were included³⁵. Of the bibliographic studies, four are narrative reviews^25,29,67-68, followed by integrative reviews^69-71,97,100, and one systematic review³⁵. One analytical bibliographic review was found based on secondary studies between 1996 and 2011⁷².

OBS and its relationship with other constructs

In the three-dimensional OBS model, Burnout appears as a reaction to chronic stress¹. Thus, the large number of studies aimed at exploring this relationship is sustainable^{2,5,22,29-30,35,37,41,53,63,67,89,91-93,96,108}. Other studies investigate the mediating role of OBS and its relation with other mental changes^{15,33,35,37-38,41,52,54,82,84,93,108}.

Some studies have investigated the relationship between personality traits and OBS.Two studies in which multivariate analyzes were performed showed that personality traits can significantly explain OBS in nurses^34,36,95.However, a third study showed that the variable "personality" had a weak potential predictor for the syndrome³⁰.

Some studies have explored the relation between work environment perception and OBS.The first studies of this type werecarried out by researchers involved in the Registered Nurse Forecasting Project. These researchers conducted several survey studies in North American, European and Asian countries.The studies applied the MBI andthePractice Environment Scale of the Nursing Work Index (PES-NWI). The latter measures the presence of variables related to the nurses' work environment^56-63. The PES-NWI and the MBIhave already been revalidated into the Portuguese language and applied in Brazilian investigations^19,49,87.

Studies in recent years have explored the occurrence of OBS, measured their levels and correlated them with sociodemographic and occupationalvariables, psychosocial risks and other constructs in order to understand its genesis²⁹.However, further studies seem necessary to analyze the relationship between the occurrence of OBS and occupational conditions and work organization^{23,52,57,68,101}, and to investigate the mediation that teamwork and organizational support may play in the onset of the syndrome^37,49,83,86.

Intervention and prevention of OBS in Nursing

Interventional studies are scarce in the case of OBS in nursing and developing an action plan for its prevention seems to be a challenge.Studies of this type propose to carry out individual interventions focusing on the nursing professional, aiming at behavioral changes and not modifications in the work, which is the origin of the syndrome.Cognitive-behavioral approaches accompanied by relaxation techniques are one of the most applied in these cases.However, the major disadvantage of these interventions is in enabling participants to cope with stress, rather than fighting it^29,89.

Another way of describing interventions is through longitudinal, pre/post-test studies⁴¹. It is possible to analyze the levels and manifestation of the syndrome within the studied period through these methods⁶⁴.This is the case of a controlled study carried out in the laboratory.In this research, a Reiki session was performed in nurses diagnosed with OBS, and later reverberation of the session on salivary immunoglobulin A (IgAs), α-amylase activity and blood pressure was verified.A significant relationship was found between intervention and diastolic blood pressure and IgAs concentration. The authors point out that Reiki sessions can improve the response of IgAs and blood pressure in nursing professionals affected by OBS³². Another prospective case study was carried out with 16 nursing residents measuring the levels of the syndrome in different periods of time.It was verified that only one participant presented the syndrome outof the 16residents⁶⁴.

No interventions aimed at raising the awareness of professionals, students or nursing professors regarding OBSwere found.A study with nursing professors sought to ascertain social representations of the professionals about OBS and to later intervene by using texts as an educational proposal to raise awareness about OBS⁶⁵.

Despite the small number of intervention studies, a large part of the analyzed publications affirm the need to carry out in-depth studies that will allow for formulating and implementing policies to support prevention and intervention in the case of this syndrome in the nursing area^{5,8,14,20,22-23,26,28,30,33,36,47,50,52-53,56-57,63,65,71,73-75,79,81,84-85,93}.

Conclusion

We found that the majority of studies on OBS in the Nursing context were published in 2015,where most of the research took place inthe South America, and mainly in Brazil.However, this data should be noted with caution, since the choice for the consulted databases may have contributed to this result.

The largest number of publications are concentrated in Southeast and Southern regions of Brazil, and the majority of investigations were conducted in hospitals.As for the employed methods, the majority of the studies areprevalent, descriptive, quantitative, and usinga quasi-experimental design, withmultiple case studies in which MBI was applied.In addition, stress is the most closely related construct to OBS.

Thus, new case-control and cohort studies are suggested.Qualitative-exploratory and longitudinal studies are necessary to better understand OBS among nursing professionals, as well as comparative causal research and focus groups with the purpose of exploring OBS manifestations.

New instruments that measure OBS must be tested and revalidated, and different theoretical models than three-dimensional ones must be studied and verified.If OBS is indeed a lingering stress, interventions focused on conditions, organization and social relations at work are necessary.

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Publication Dates

• Publication in this collection
  2017

History

• Received
  17 June 2016
• Accepted
  21 Mar 2017