BURNOUT SYNDROME IN NURSING PROFESSIONALS IN PUNTA ARENAS, CHILE

SÍNDROME DE BURNOUT EM PROFISSIONAIS DE ENFERMAGEM DA CIDADE DE PUNTA ARENAS, CHILE

ABSTRACT

Objective:

to identify the prevalence of burnout syndrome in nursing professionals in Punta Arenas, Chile.

Method:

quantitative, descriptive, cross-sectional research in a sample of nursing professionals from Punta Arenas, Chile. Data were collected between January and March 2019, using the Maslach Burnout Inventory and a sociodemographic questionnaire. Descriptive statistics were applied in the data analysis.

Results:

163 individuals participated in the study. 18% of the sample suffered from burnout syndrome, who were female young adults, i.e. between 20 and 40 years of age, and who worked in direct user care.

Conclusion:

the prevalence of burnout in the as-yet-unexplored place of study and in different work scenarios, such as education, management, and hospital-based and primary health care, confirms the implications of this study for occupational health in this population. This knowledge offers recent evidence to ground the implementation of occupational health promotion policies and strategies in Chilean nursing professionals.

DESCRIPTORES:
Burnout, professional; Nursing; Occupational health; Nursing staff; Stress, psychological

RESUMO

Objetivo:

identificar a prevalência da síndrome de burnout entre os profissionais de enfermagem da cidade de Punta Arenas, Chile.

Método:

investigaçāo quantitativa, descritiva, de corte transversal, com uma amostra de profissionais de enfermagem da cidade de Punta Arenas, Chile. Para a coleta dos dados, realizada entre janeiro e março de 2019, utilizou-se a escala Maslach Burnout Inventory e o questionário sociodemográfico. Para a análise dos dados aplicou-se a estatística descritiva.

Resultados:

163 indivíduos participaram do estudo. 18% da amostra sofría da síndrome de burnout, correspondendo a mulheres no grupo etário de jovens adultos, isto é, entre 20 e 40 anos de idade e trabalhando na área assistencial ou de atençāo direta aos usuários.

Conclusāo:

a prevalência do burnout no local ainda nāo investigado e em diferentes cenários ocupacionais, tais como a educaçāo, a gestāo e a atençāo, hospitalária e primária de saúde, confirma as implicações deste trabalho para a saúde ocupacional desta populaçāo. Este conhecimento proporciona evidências atualizadas para fundamentar a implementaçāo de políticas e estratégias de promoçāo da saúde ocupacional em profissionais de enfermagem chilenos.

DESCRITORES:
Esgotamento profissional; Enfermagem; Saúde do trabalhador; Recursos humanos de enfermagem; Estresse psicológico

RESUMEN

Objetivo:

identificar la prevalencia de síndrome de burnout en los profesionales de enfermería de la ciudad de Punta Arenas, Chile.

Método:

investigación de enfoque cuantitativo, descriptivo, de corte transversal, con una muestra de profesionales de enfermería de la ciudad de Punta Arenas, Chile. Para la recolección de datos, realizada entre enero y marzo de 2019, se utilizó la escala Maslach Burnout Inventory y el cuestionario sociodemográfico. Se aplicó estadística descriptiva para el análisis de datos.

Resultados:

participaron 163 individuos en el estudo. El 18% de la muestra tenía síndrome de burnout, correspondiente a personas de sexo femenino, del grupo etario adulto joven, es decir entre 20 y 40 años de edad y que se desempeña en el área asistencial o de atención directa de usuarios.

Conclusión:

la prevalencia del burnout en el local aún no explorado y en diferentes escenarios de trabajo, como educación, gestión y atención, hospitalaria y primaria de salud, confirma las implicaciones de este trabajo em la salud ocupacional en esta población. Este conocimiento proporciona evidencia actualizada para fundamentar la implementación de políticas y estrategias de promoción de la salud laboral en profesionales de enfermería chilenos.

DESCRIPTORES:
Agotamiento profesional; Enfermería; Salud laboral; Personal de enfermería; Estrés psicológico

INTRODUCTION

Burnout syndrome has been defined as a response to chronic work-related stress that often occurs in service organization professionals working in direct contact with the users of those organizations. This three-dimensional syndrome is characterized by emotional exhaustion, depersonalization, and reduced personal accomplishment.1^-2

Emotional exhaustion refers to feelings of physical overexertion that occur as a result of contact with the people who need to be attended to. Depersonalization refers to the professionals' lack of feelings and insensitivity. Low personal accomplishment at work refers to a decline in the sense of competence and success at work.2

Therefore, burnout can be considered a reaction process to stress that starts with the emotional exhaustion dimension, generating occupational tension that is confronted through depersonalization. This gives rise to feelings of lack of personal competence.

In countless studies, nursing professors and staff have been considered a group vulnerable to burnout,3^-5especially in primary health care and in high-complexity hospital services.4^,6^-7The work environment at these services, the continuing physical and emotional demands the nursing professionals receive from the patients and their biased role are characteristics predisposing to burnout syndrome. Nevertheless, the presence of this syndrome is observed in work places that do not necessarily involve critical care or great contact with users. Therefore, the presence of this condition needs to be studied in any service where factors related to the worsening of the work climate and reduced efficiency of activities co-occur.8

Burnout is considered a causal factor of job dissatisfaction, absenteeism, mood disorders, increased consumption of alcohol and other drugs, besides a wide range of emotional disorders affecting the workers.9 Therefore, a diagnosis of burnout in nursing professionals is necessary to avoid its consequences for the quality of care and patient services.

As observed from personal and academic experience, in recent years, nursing professionals working in different areas of practice and responsibility centers have presented interpersonal relationship difficulties towards employees at distinct hierarchical levels, as well as verbal expressions of physical and mental fatigue. This observation was exclusively empirical but, in accordance with the search for scientific evidence in databases and virtual libraries such as Scielo, Cuiden, and Virtual Health Library, burnout has been studied in nursing professionals around the world, but no studies were found in the region of Punta Arenas, demanding further research in Chile.

Therefore, the objective was to identify the prevalence of burnout syndrome in nursing professionals in Punta Arenas, Chile.

METHOD

A quantitative, descriptive, and cross-sectional study was undertaken.

The universe consisted of nursing professionals working in different institutions in Punta Arenas, covering the area of care (primary health care and hospital-based care), education and management and research, from which a probabilistic sample was selected per cluster. To calculate the minimum sample size for finite populations, a 95% confidence interval (95%CI) was considered, a 5% sampling error margin, and a standard deviation of 3.10 for the depersonalization dimension in the assessment of burnout in nursing professionals,10 and population size of 305 individuals.

The stratification of the sample was as presented in Chart 1.

Chart 1 -
Distribution of the minimum sample in the burnout study in nursing professionals in Punta Arenas, Chile.

Area	Place of work	Total population	Minimum sample
Care	Primary care	60	20
	In-hospital care	186	61
Educational	Higher education institutions	30	10
Management and Research	Magallanes Health Service, Regional Ministerial Health Secretariat	29	9
Total		305	100

To select the participants, cluster sampling was used, as the sample units were enrolled together in the same physical spaces, that is, in the health services where they were enrolled. The observation units were selected in accordance with the following inclusion criteria: Nursing professionals working in care, education and management and research, in services located in Punta Arenas. The exclusion criteria were: professionals on leave or holiday during the data collection period.

One of the authors collected the data between January and March 2019. For the data collection, two self-applied tools were used: 1. General data survey, consisting of a structured questionnaire elaborated by the authors, including biopsychosocial and occupational variables, to collect the sociodemographic characteristics of the study population. No further validation was required for this survey. 2. Maslach Burnout Inventory (MBI).3

The Maslach Burnout Inventory (MBI) serves to identify Emotional Exhaustion, low Personal Accomplishment and Depersonalization, that is, the three dimensions of the syndrome. This version scores the frequency and consists of 22 Likert-type items in the form of assertions related to the professional's attitudes, emotions and personal feelings at work and towards the people (s)he needs to provide care to. The tool assesses the extent to which the content of each item is applicable to the professional's work. The items are scored from 0 to 6, according to how frequently the professional experiences a range of feelings. The 22 items are grouped into three dimensions or scales, deriving from their factorization, and each evaluates the three characteristic traits or symptoms that define burnout syndrome.

Professionals presenting burnout syndrome will obtain high MBI scores on emotional exhaustion (the subject is bearing tension beyond his/her possibilities and limits) and Depersonalization (the worker tends to take distance from other people and think of them as objects), and low scores on Personal Accomplishment (for the professional, his/her work is not worth it). As for the result, both the presence of burnout syndrome and each of its dimensions are considered continuous variables, and the professionals' scores are classified using a system of percentiles for each scale. To determine the dimensions, the participants above the 75th percentile are classified as "high", between the 75th and the 25th percentile as "medium" and below the 25th percentile as "low".

Concerning the psychometric properties of the MBI,3 the internal consistency estimated by the authors amounts to 0.90 for Emotional exhaustion, 0.79 for Depersonalization, and 0.71 for Personal accomplishment. This multiple-choice tool with Likert-type answers has been validated in Chile,11 guaranteeing the quality of the collected data.

The collected data were included in a database, using the calculation application Microsoft Excel, version 15.0, which is part of Microsoft Office. For the statistical treatment of the collected data, Statistical Package for the Social Sciences (SPSS) version 22 was used. Descriptive statistical analysis was applied to the data. The numerical variables were expressed as central trend and dispersion measures. For the categorical variables, the frequencies and percentages of each class were used, in accordance with the nature of the variables.

The variables defined for the study were the presence of burnout syndrome, age, sex, marital status, head of household, number of children, age of children, institution, service, length of employment, type of contract, job title, hours of work, income, remuneration, autonomy at work, job stability, amount of work, resources of the institution, professional growth, conflict with users, conflicts with colleagues, conflicts with head, institutional support, personal time, family support and personal/family issues.

The professionals selected for the sample received information about the study design and objectives, respecting the principles of anonymity and no influence on their work performance. All participants agreed to participate in a document elaborated for this end, called informed consent form.

The research involves human beings, complies with and respects the premises of the Helsinki Declaration (1964), reworded in 1975, 1983, 1989, 1996, and 2001.

RESULTS

In total, 163 nursing professionals participated in the study, distributed according to their work area in 97 (59.6%) in-hospital care professionals, 33 (20.2%) primary health care professionals, 17 (10.4%) professionals in the education area and 16 (9.8%) in the management area.

In the study sample, 147 individuals were women, which corresponds to 90% of the total, and 72% were classified as young adults, that is, between 20 and 40 years of age, corresponding to 117 people. The distribution of the age variable was not normal and ranged between 24 and 67 years, with a median of 37 years.

The presence of burnout syndrome was analyzed in accordance with the high scores found on the Emotional exhaustion and Depersonalization subscales, and low scores on the Personal accomplishment subscale. Medium and high Emotional exhaustion were present in almost 50% of the sample, with 20.9% scoring high levels of Emotional exhaustion. High Depersonalization was observed in 10.4% and low Personal accomplishment in 8% of the nursing professionals (Table 1).

Table 1 -
Numerical and percentage distribution of nursing professionals according to classification by subscales of burnout syndrome. Punta Arenas, Chile, 2019. (n=163)

Subscale	Classification	n	%
Emotional exhaustion	High	34	20.9
	Medium	46	28.2
	Low	83	50.9
Depersonalization	High	17	10.4
	Medium	41	25.2
	Low	105	64.4
Personal accomplishment	High	115	70.6
	Medium	35	21.5
	Low	13	8.0

Thirty participants presented burnout syndrome, corresponding to 18% of the sample, as shown in Table 2.

Table 2 -
Numerical and percentage distribution of nursing professionals according to the presence of burnout syndrome. Punta Arenas, Chile, 2019. (n=163)

Variable	n	%
Presence of burnout syndrome	30	18
Absence of burnout syndrome	133	82
Total	163	100

The distribution of burnout syndrome according to the work area was: 23 professionals from the care area, four from the education area and three from the management area. When individually comparing the distribution of professionals with burnout syndrome by area with the total number of professionals per corresponding area according to the sample, the group with the highest frequency of burnout syndrome was the Education group with 23.5%, while the group with the lowest frequency was the Primary Care group with 15.6% (Table 3).

Table 3 -
Numerical and percentage distribution of the prevalence of burnout syndrome by work area. Punta Arenas, Chile, 2019. (n=163)

	Without burnout syndrome		With burnout syndrome		Total
Area	n	%	n	%	n	%
Management	13	81.2	3	18.8	16	100
Education	13	76.5	4	23.5	17	100
Care (Primary Care)	28	84.8	5	15.2	33	100
Care (In-Hospital Care)	79	81.4	18	18.6	97	100
Total	133	81.6	30	18.4	163	100

The professionals with burnout syndrome were female young adults (between 20 and 40 years old) who worked in the care area. Most of the participants with burnout syndrome are single household heads without children. If they have children, these are of school age.

As regards their employment situation, the majority has less than 10 years of work experience and works on a fixed-term contract, that is, which ends and is renewed each year; their function is care/clinical and they work in shifts or during the day.

The main income range is between $1,000,000 and $1,500,000 Chilean pesos (equivalent to USD 1,300 to 2,000) and they perceive their remuneration as "sufficient".

In this group, the low perceived autonomy at work and job insecurity stand out. Most report that the quantity of work they perform is excessive, they consider the resources at their employment institution as ”scarce", and they also perceive little institutional support.

Finally, 83% of the participants with burnout syndrome consider that the time they have for personal activities beyond work is scarce and report having abundant family support.

DISCUSSION

Based on the 18% prevalence of burnout among the nursing professionals in Punta Arenas, the implications of this work and the environment for their health should be taken into account, as this prevalence was distributed among different scenarios, such as education, management and hospital-based and primary health care. In view of this result, the managers of these institutions should consider burnout and the objective of policies and strategies more attentively, as this can interfere in the quality of care the workers provide, who may withdraw from work in this context.

One recently announced international measure in this respect is the inclusion of burnout syndrome in the 11^th Review of the International Classification of Diseases (ICD-11) as an occupational phenomenon, considered as the result of chronic stress in the workplace, and should not apply to experiences in other areas of life. The syndrome is characterized by feelings of exhaustion, mental distance from work or cynism, and impaired professional effectiveness,12 supporting the growing need for diagnoses in this respect in different areas of nursing practices, as this profession has demonstrated burnout levels among its professionals for a long time.

To investigate burnout levels, the studies developed in the context of the nursing profession between 2005 and 2016, published in English, Portuguese and Spanish, have mostly used the Maslach Burnout Inventory (MBI),1 similar to studies in the same period (2005-2016) undertaken in different employment scenarios in Brazil,3 supporting the choice of this research instrument.

Among the nursing professionals in Punta Arenas, the dimension levels ranged between 8% for low Professional accomplishment, 10.4% for Depersonalization, and 20.9% for Emotional exhaustion. Other studies, including a meta-analysis of 1,110 primary care nurses in Spain, Brazil, and England, showed a 28% prevalence for Emotional exhaustion, 15% for Depersonalization, and 31% for low Professional accomplishment.13 In a survey of 301 nurses working in different medical areas of a hospital in Southern Spain, such as the medical clinic, oncology, and mental health, 22.1% of Emotional exhaustion, 23.1% of Depersonalization, 45.5% of low Professional accomplishment and a general prevalence of 39.8% of burnout were found in that sample.14

In a survey among medical residents and surgeons in Chile, the global prevalence of burnout syndrome was 64.4%. According to the subscales, the prevalence of Emotional exhaustion was 76%, low Personal accomplishment at work 55%, and Depersonalization 62%.15 And based on an integrative review of 106 studies, studies showing medium levels of burnout mostly revealed low to moderate Emotional exhaustion, low Depersonalization and moderate Personal accomplishment.5

In the research context, the scores for Emotional exhaustion and Depersonalization were significantly high, and low for Personal accomplishment. This indicates that, despite the unfavorable scores on the first two subscales, the professionals do not perceive their Personal accomplishment as impaired yet. That is, in comparison with other studies around the world, the nursing professionals in Punta Arenas have lower but no less concerning burnout levels and dimensions, as these professionals are distributed across different services and, without proper management, these rates can be higher.

One positive aspect for the lower prevalence when compared to the other studies cited may be the economic aspect, that is, the fact that the professionals assess the remuneration they receive as sufficient, as this can be considered an aggravating factor for the development of job dissatisfaction. The reported income is equivalent to between 3.2 and 4.8 minimum wages in the country, while the average salary in Chile is $300.000 Chilean pesos, equivalent to USD550. The adjusted family income per year is around $17.000, half of the family income put forward by the Organization for Economic Cooperation and Development (OECD).16-17

In descriptive terms, most of the professionals with burnout were active in hospital-based care when compared to primary care, young adults, women, with less work experience, working on a fixed-term contract, with little institutional support and insufficient time for non-professional activities.

Other studies demonstrate a higher frequency of studies involving young adults,3^,18a characteristic that is also predominant in the study population. In this study, active nursing professionals were selected, but results exist that also indicate manifestations of burnout among nursing students.19

What the work area is concerned, in line with the findings of this study, professionals working in primary health care presented lower burnout levels that more complex services.5^,20^-21

In a study of burnout involving Chinese nurses, it was discovered that occupational stress positively affected the development of burnout and negatively affected social support and self-efficacy. Social support serves as a mediator between stress and burnout, with a slightly stronger effect on exhaustion than stress. Although the main stressful factors were the high workload, the interpersonal relationships with the physicians and patients, and the distance from their families due to the work time, it was the lack of social support, at work as well as in the family, that most affected burnout.22

In descriptive terms, the prevalence of burnout was higher among women, in line with the literature about different prevalences according to the dimensions of the syndrome between men and women, with women presenting greater Emotional exhaustion, while men present greater Depersonalization.23 Similarly, there is evidence that female nursing workers had 5.6 times more chance of dissatisfaction with their quality of life at work when compared to male workers.24 These aspects are gender characteristics and should indicate adaptations in the teams in order to maintain the emotional and interactional skills and competences necessary for nursing.3^,24

In Argentinean intensive care nurses, despite being a neighboring country, no significant associations were found between burnout and sex, education level, or the number of jobs. Nevertheless, it could be verified that a large number of patients per nurse affects burnout, with three or more patients per nurse representing a risk factor for emotional exhaustion and depersonalization. The same was true for age, with younger nurses showing greater exhaustion, and less educated nurses showing greater depersonalization.25

These results mainly contributed by identifying the burnout level and characteristics of nursing professionals from an as-yet-unexplored location, that is, Punta Arenas, Chile, so that these results could be discussed with the literature, verifying similarities and differences. This presents new support for the implementation of strategies in nursing work environments, which can permit bringing down the levels of emotional exhaustion and depersonalization, consequently increasing these professionals' accomplishment.

The limitations of this study did not permit a more in-depth analysis of the origin and impact of the burnout syndrome in nursing professionals' lives and coping and intervention alternatives, aiming to prevent it or to reduce its effects. These limitations are similar to those identified in many studies included in the literature review, thus confirming the need for further research on the theme, especially related to teamwork and organizational support.5

CONCLUSION

The burnout syndrome is present in 18% of the nursing professionals in Punta Arenas, Chile. The most affected professionals are young adult women working in care. Nevertheless, an analysis per specific area, considering the proportion per sample area, revealed that the group with the highest burnout rates were teachers, working in higher education institutions.

It should be highlighted that almost half of the professionals with burnout have low or medium levels of personal accomplishment, confirming that burnout is a reaction process to stress that starts with the Emotional exhaustion dimension, generating occupational tension, which is confronted through depersonalization. This entails feelings of lack of personal competence, which appear in later stages of the syndrome.

Knowledge on these characteristics offers updated scientific evidence to ground the implementation of occupational health promotion programs in nursing professionals. In the end, this will permit improvements in the quality of care these professionals provide to their clients.

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NOTES

• ORIGIN OF THE ARTICLE:

  Article extracted from the thesis - Factors associated with burnout syndrome in nursing professionals in Punta Arenas, Chile, presented to the Graduate Nursing Program, Universidade Federal de Santa Catarina, in 2019.

• FUNDING INFORMATION:

  This study was financed by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brazil (CAPES) - Finance Code 001.

• APPROVAL OF ETHICS COMMITTEE IN RESEARCH:

  Approved by the Research Ethics Committee of the Universidad de Magallanes Chile, opinion 004/2019

Publication Dates

• Publication in this collection
  13 Nov 2020
• Date of issue
  2020

History

• Received
  12 Sept 2019
• Accepted
  09 Mar 2020