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Revista Gaúcha de Enfermagem

On-line version ISSN 1983-1447

Rev. Gaúcha Enferm. vol.37 no.1 Porto Alegre  2016  Epub Apr 12, 2016

http://dx.doi.org/10.1590/1983-1447.2016.01.53485 

Original Article

Absenteeism due to mental disorders in health professionals at a hospital in southern Brazil

Leni de Lima Santanaa 

Leila Maria Mansano Sarquisb 

Christiane Breya 

Fernanda Moura D’Almeida Mirandaa 

Vanda Elisa Andres Fellic 

a Universidade Federal do Paraná (UFPR), Programa de Pós-graduação em Enfermagem. Curitiba, Paraná, Brasil.

b Universidade Federal do Paraná (UFPR), Departamento de Enfermagem. Curitiba, Paraná, Brasil.

c Universidade de São Paulo (USP), Escola de Enfermagem, Programa de Pós-graduação em Enfermagem. São Paulo, São Paulo, Brasil.

ABSTRACT

Objective

To describe the health profile of mental and behavioral disorders in health professionals at a teaching hospital in southern Brazil.

Methods

This was a quantitative, retrospective cross-sectional epidemiological study whose data were collected through institutional documents used to feed the Health Monitoring System for Nursing Professionals and involved all absenteeism occurred in 2011.

Results

We found 55 records of absenteeism due to mental and behavioral disorders, a total of 317 days absent. Nursing technicians were the most absentee, with 29.09% of the records. The intensive care unit represented the sector with the highest number of days absent, 81%, and depressive episodes were the most frequent, representing 52.72% of mental disorders.

Conclusion

The results showed that mental disorders in health professionals are a cause for concern and urgently need intervention.

Key words: Occupational health; Mental disorders; Health personnel; Surveillance of the work environment

INTRODUCTION

The process of work-related illnesses has been studied by academics from different areas of knowledge. Among these, there is a consensus regarding the relationship between unfavorable work environments and the morbidity profile of this population(1-3).

In the professional practice of nursing, such conditions are observed in the intense work pace, shortage of human resources and materials, pressure exerted by managers, low wages, double or triple work shifts, the exhaustion caused by shift work, and interaction with sick people, often terminal, among other factors(3).

Despite the associative evidence(1) that has been shown throughout history, the significant increase of work-related diseases has drawn the attention of professionals and researchers who study health promotion at work. Although the list of work-related diseases is extensive, there has been a significant increase in the rate of illness attributed to mental and behavioral disorders (MBD).

According to the World Health Organization (WHO), MBD represent 13% of the total of all diseases and affect approximately 700 million people worldwide. This group comprises a set of disorders that share some common points, and whose etiology depends on the social, cultural, economic and legal context of different societies. They include illnesses, mental retardation, personality disorders and substance abuse(4).

Depression, anxiety and stress are at the top of the list of most common MBDs among the population(4-6). Currently, approximately 350 million people, or 5% of the world population, suffer from depression and it is estimated that in 2020, it will be the second greatest cause of disability on the planet. In Brazil, depression affects 10% of the population(4).

Anxiety affects approximately 10 million people in the world, and stress is already considered a global epidemic, present in the life of most of the population. Stress is strongly related to the high global rate of suicide, with an alarming association rate of 90%(4).

Mental and behavioral disorders are also among the most common work-related illnesses, ranking in third place of diseases responsible for long periods of absenteeism among Brazilian workers. Studies have demonstrated that the occurrence or worsening of these disorders is related to work environments with little social support, excessive work, inadequate compensation in relation to workers’ effort levels, excessive individual commitment(2), not abiding by basic worker safety regulations, and poor work environments and work processes(7).

Among health professionals, in addition to the unquestionable damage/harm on the personal, family, social and institutional level, MBD account for large part of absenteeism in a hospital environment(8), generate additional costs to the institution and reflect on the country’s economy. According to data from the Brazilian Ministry of Social Security, in 2011 alone, disorders of this nature cost the Brazilian government more than BRL 211 million in the form of payments of new social security benefits(9). It is estimated that in 20 years, the global economic impact due to this type of illness will be approximately USD 16 trillion(4).

In light of the alarming scenario of mental disorders among health professionals, positive coping strategies need to be developed that contribute to transforming the work process and the health-illness process of workers(2) in order to reduce the negative impacts at the individual, collective, institutional and social security levels.

Nevertheless, discovering ways to minimize adverse effects and promote healthy work environments is a challenge for managers, as it requires actions that go beyond the individual scope, such as collective interventions and structural, behavioral and managerial changes. Thus, being familiar with the profile of worker illness is an essential step in this process, as it helps establish a situational diagnosis and contributes to identifying epidemiological data and risk factors. Furthermore, it helps in the planning of intervention strategies aimed to improve working conditions and quality of life, and reduce absenteeism.

In light of the above, the guiding issue behind this study was the concern for the illness process among health professionals in the hospital environment. Its objective, therefore, was to describe the profile of disease due to mental and behavioral disorders at a teaching hospital in the south of Brazil via the Health Monitoring System for Nursing Professionals (Simoste1(10)). The results of this study can indicate possibilities for further research on the theme and underpin preventive and intervention actions in the workplace.

METHOD

This was an epidemiological, retrospective cross-sectional study based on the systematic gathering and quantification of information on health-related events(11) at a worker’s health unit part of a workers’ hospital in the municipality of Curitiba, Paraná, Brazil

Epidemiological studies describe health situations that affect a given population, explain the occurrence, causes and determinants of the distribution of diseases and predict the frequency of these illnesses, thus allowing for the control of negative events via intervention strategies. In terms of workers’ health, they help in the investigation of work-related health damages, both at the individual and collective dimension, via descriptive and retrospective studies and the quantitative assessment of the workplace(11).

The population of this study consisted of 1,050 records of worker absenteeism (physicians, nursing professionals, psychologists, nutritionists, social workers, professionals in support areas such as laundry, cleaning, renovation, and maintenance) that were recorded in the Simoste program in 2011. The sample consisted of 55 absenteeism records under the International Classification of Diseases (ICD) F(12), corresponding to MBD. The records were relative to professionals working at the mentioned hospital, regardless of professional category and employment relationship. As the same worker could have been dismissed from work more than once throughout the studied period, the population does not correspond to the number of professionals, but of absentee records.

The data were acquired from managerial reports generated by the workers’ health unit based on medical certificates presented by hospital professionals. These reports were fed into the Simoste database and contained information related to workers’ identification, professional category, employment relationship, sector and work shift, date and causes for dismissal according to the International Classification of Diseases, and the number of absentee days as indicated by the certificates. Data collection took place at the workers’ health unit between March and June 2012, conducted by the researcher.

Hospital employees who presented work accident notifications, medical declarations, or medical certificates with an ICD F diagnosis between January 1 and December 31, 2011, were included. This period was chosen because during this year the Simoste database was fed by the researcher, thus granting greater reliability to the data.

The variables used for the research were established based on the information identified in the Simoste database. Thus, we considered data regarding the institution, the professionals, dismissal from work activities, workloads, and strain processes.

Workloads are element of the work environment that interact between themselves and with the workers’ bodies, generating strain processes(1). In the Simoste software, there are several tabs with different types of workloads (physical, chemical, biological, physiological and psychic). Each category contains specific fields to be filled in with the consequences generated by exposure to these workloads, such as strain and types of leave of absence granted.

Regarding professional identification data, we considered gender, age group, professional category, work sector, employment relationship, weekly workload, and salary range. In terms of dismissal from work activities, we took into account type of dismissal (work accident notification, medical certificate or absences), the reason for and number of days of absence. Furthermore, we used all of the data contained in the database that made reference to psychological workload and strain.

For data analysis, the managerial reports provided by the institution were fed into Microsoft Excel® 2010 and processed via descriptive statistics analysis procedures. The results were expressed in mean (M), relative (n ) and absolute frequency (%).

To assess the risk of psychological strain, we used the following indicator:

This paper is a subproject of a study called “Implementing and Assessing the Health Monitoring System for Nursing Professionals – Simoste”, approved by the University of São Paulo School of Nursing’s research ethics committee under protocol no. 718/2008/CEP-EEUSP and also authorized by the workers’ hospital research ethics committee. As the study consisted of document analysis, informed consent forms were not necessary and the individuals were kept in anonymity.

RESULTS

In 2011, we found 55 records of dismissal of workers’ hospital professionals due to MBD, generating 317 days of absence. Of this total, 18% were nursing professionals, with a prevalence of women (76.36%). The predominant age group consisted of professionals between 21 and 30 years old, corresponding to 34.54%, of whom men represented 53.84% (Table 1).

Table 1 – Records of dismissal due to ICD F diagnoses among health professionals at a workers’ hospital in 2011 by gender and age group. Curitiba, Paraná, Brazil, 2014 

Male Female Total

Age group n % n % n %
21 to 30 7 12.72 12 21.81 19 34.54
31 to 40 2 3.63 12 21.81 15 27.27
41 to 50 2 3.63 11 20 13 23.63
51 to 60 2 3.63 6 10.90 6 10.90
Not identified 2 3.63 0 0 2 3.63

Total 13 23.63 42 76.36 55 100

Source: Research data, 2014.

On assessing the number of dismissals by professional category, we found a prevalence of nursing technicians, with 29.09%. Nursing technicians represented 21.81% of the records, administrative assistants 10.90%, and nurses and administrative technicians 7.27%.

Regarding salary range, the greatest number of dismissals was found among those with a monthly income between BRL 1,501 and R$ 2,000, corresponding to 90.90%. Workers with salaries lower than BRL 1,000 and higher than 2,000 represented the minority of dismissals, equal to 1.81% during the assessed period.

Considering employment relationship, the results revealed that 40% of those absent due to work accident notifications recorded in the Simoste in 2011 were professionals hired under regular Brazilian labor laws (as per the Consolidation of Labor Laws) and 60% were hired under statutory regime.

The work sectors that presented the highest levels of absenteeism were intensive care units (ICUs) and emergency services (21.81% and 10.90% respectively), followed by surgical units and nutrition and dietetic services, with 9.09% each. However, in terms of the number of working days lost by sector, the ICU represented 32.17%, post I (adult inpatient) 11.67%, surgical units 10.72%, and the maternity ward 9.46%, as illustrated in table 2.

Table 2 – Records of dismissals and number of days absent by ICD F among health professionals at a workers’ hospital in 2011 by work sector. Curitiba, Paraná, Brazil, 2014 

Sector Dismissals due to ICD F

Number of records Days absent

n % n %
Rooming in 1 1.81 10 3.15
Outpatient care 1 1.81 2 0.63
Study center 1 1.81 10 3.15
Surgical units 5 9.09 34 10.72
Materials and Sterilization Center 2 3.63 15 4.73
Technical Care Management 1 1.81 2 0.63
Sanitation 1 1.81 1 0.31
Day hospital 3 5.45 17 5.36
Laboratory 3 5.45 5 1.57
Maternity 2 3.63 30 9.46
Pediatrics 2 3.63 5 1.57
Post I 3 5.45 37 11.67
Emergency 6 10.90 25 7.88
Laundry 1 1.81 1 0.31
Nutrition and Dietetic Services 5 9.09 9 2.83
Telephony 2 3.63 4 1.26
Transportation 1 1.81 2 0.63
Neonatal Intermediary Care Unit 3 5.45 6 1.89
General Intensive Care Unit 3 5.45 30 9.46
Intensive Care Unit II 5 9.09 63 19.87
Neonatal Intensive Care Unit 4 7.27 9 2.83

Total 55 100 317 100

Source: Research data, 2014.

Regarding causes for dismissal, the results revealed a significant frequency of depressive episodes (F32, F32.1 and F32.2), corresponding to 52.72% of mental disorders. Anxiety disorders represented the second most frequent occurrence (F41, F41.1, F41.2 and F41.9) with 18.18% of the sample. Reactions to stress (F42, F43.0, F43.1) were the third most common cause, with 16.36%.

Chart 1 shows the main causes of absenteeism in the workers’ hospital due to ICD F by gender.

Source: Research data, 2014

Chart 1 – Causes of absenteeism among health workers at a workers’ hospital in 2011 by MBD, by gender. Curitiba, Paraná, Brazil, 2014 

The main cause of dismissal among both men and women was related to ICD F32 (depressive episodes). Among women, these disorders represented 50% of the records and 66.5% of days absent, and among the men, 53.84% of the records and 70.68% of days absent.

Anxiety disorders (ICD F41, F41.1, F41.2 and F41.9) represented the second greatest cause of records among women, with 21.42%. However, stress reactions (ICD F43, F43.0, and F43.1) were the second most frequent cause for days absent, representing 14% of working days lost by the female population. Stress reactions were also the second main cause of records and dismissals among the male population, with 30.76% and 19.82%, respectively.

Next, we assessed the Coefficient of Risk (CR) for illness due to mental disorders, according to the ICD, in relation to the total number of notifications attributed to ICD F. The results showed that depression obtained CR: 52.72; anxiety CR: 18.18, stress CR: 16.36, mood disorders CR: 5.45, and bipolar affective disorder, hyperkinetic disorder, manic episodes and nonorganic insomnia CR: 1.81 each.

In terms of the mean number of days absent due to ICD F, bipolar disorder (F31.5) and manic episodes (F30) resulted in more days absent per worker, with M: 10 days. Depressive episodes (F32, F 32.1, and F32.2) obtained M: 7.44, stress reactions (F43, F43.0, and F43.1) M: 5.66 and anxiety disorders (F 41, F41.1, F41.2 and F41.9) M: 2.57 days. This analysis shows that even though depressive episodes, stress reactions and anxiety disorders obtained the highest frequency of records, these diagnoses were not related to the longest periods of absenteeism. Among professionals with tertiary education, the greatest number of records was associated with anxiety disorders, with a mean of 2.5 days absent (M: 2.5). Among the other professionals, with secondary and technical education degrees, depression was the main cause of dismissals, with an average of 7.44 days absent (M: 7.44).

In terms of rate of days absent by ICD F according to professional category, among nurses, anxiety disorders accounted for the most days absent (F41, F41.1), or 5 days. Among nursing technicians and aides, there was a predominance of depressive episodes (F32), with 129 and 53 days absent, respectively. Administrative assistants were absent more often due to depressive episodes, 16 days, and anxiety disorders, 13 days.

Dismissals given to administrative technicians totaled eight days, of which six were due to depressive episodes, and there was only one record in the advisor category (due to ICD F31.5) with ten days absent. The other professional categories presented one to two dismissals due to ICD F, with a maximum of four days absent from work.

DISCUSSION

In the delimited one-year period, dismissals due to MBD at the workers’ hospital resulted in 317 days absent, almost a year of lost work, considering objective data alone. Regarding the profile of dismissals, there was a predominance of female professionals, corroborating other studies on the theme(3,13), between the ages of 21 and 30, and with a salary range corresponding to workers with a secondary education level.

The predominance of dismissals among women can be associated with the great number of absences among nursing professionals. Studies have shown that nursing professionals represent the greatest contingent of health workers in Brazil and, historically, most are women. Thus, this reality corroborates the result presented for dismissals in the nursing category(14-15). In addition, the greatest prevalence of absenteeism among women in general is also due to family circumstances that interfere with work(14).

According to a study developed in Ireland, younger and less experienced professionals find it more stressful to work with patients in critical care with risk of death than older and more experienced professionals(3). The latter are more confident in their decisions, find it easier to control emotions and present higher organizational capacity when dealing with work demands.

In terms of professional category, there was a prevalence of dismissals among nursing professionals, especially those with technical positions, and professionals who worked in intensive care units and emergency services. This result can be explained by the high number of such professionals in the hospital environment and the difficulty of controlling the strain caused by the work demand in these sectors(2,5).

Another possible relevant factor was education level, as workers with lower education levels presented more chances of being absent from work due to work-related accidents and diseases(6). This scenario can be explained by their positions and possible limitations when understanding orientation and instructions.

In order to establish a relationship between education levels, professional category and absenteeism, we highlight a study that related these factors and presented the variations among absenteeism rates according to education level. In this study, the highest rates of absenteeism were concentrated at the elementary education level (8.45%±1.02) followed by secondary (5.60%±0.41) and tertiary education (3.45%±0.38)(16). The results of another study conducted with 994 nursing professionals at a teaching hospital, showed that nursing aides presented a higher mean number of absences due to medical certificates than nursing technicians, which in turn presented higher rates than nurses. The authors of these studies stated that absenteeism due to disease is due to complex and multifactorial factors. Among such factors, there was a greater statistical significance associated with education level, in addition to age group, function, shift, time at institution, and work environment(17).

Therefore, as indicated by a Chilean study, when psychophysiological symptomatology is associated with working conditions, nursing professionals present greater levels of discomfort and statistically more significant results of emotional distress(13).

The location of the present study was a public teaching hospital, a reference center for trauma victims in Curitiba and its metropolitan region. Thus, the complexity of care provided represents a stressful factor, as demonstrated in this study, especially among ICU, emergency and surgical center workers. Work in these units is characterized by high patient turnover and a high concentration of professionals with different training backgrounds, conditions that require more dynamic activities, quick thinking, and high interaction and teamwork skills.

Regarding salary range, our results confirmed the higher number of dismissals among workers with lower education levels. This contributes to the development of illnesses, given that in order to meet financial needs, these professionals hold more than one job. This reality results in high levels of physical and psychological strain, in addition to interfering with their leisure time and social life.

In terms of the coefficient of risk for illness, there was a greater risk due to depressive episodes (CR: 52.72), anxiety (CR: 18.18) and stress (CR: 16.36), results similar to those found in the literature. Brazilian and international studies have pointed to mental disorders, especially depression, stress, and anxiety disorders, as the leading causes of absenteeism due to ICD F among health professionals(4,6).

These results are corroborated by the WHO(4) and by several studies on the theme that focus on the relationship between mental disorders and work, given their high prevalence. The WHO has estimated that conditions known as minor mental disorders affect approximately 30% of employed people, and major mental disorders, between 5% and 10%.

Irish researchers found stress to be the main complaint of MBD among physicians and nurses in emergency services, with a frequency of 51%(3). Sleep disorders, depressive episodes and anxiety disorders were the main psychological symptoms reported by nurses in Greek emergency services, with 24.8%, 23.8% and 10.7% of the results, respectively(18).

In Saudi Arabia, anxiety and depression corresponded to 47% and 25%, respectively, of disorders reported by the nurses interviewed(7). In Brazil, a study developed among health professionals in the city of João Pessoa, Paraíba, showed that 30% of those interviewed reported some type of work-related psychological distress. Stress was the main symptom declared, with 64.6% of the records(19).

Mental disorders in the workplace are generally associated with the exposure of workers to psychological workload, characterized by work overload. They are also associated with characteristics of work dynamics and other organizational factors(1,2).

Special mention also goes to the mean number of days absent due to mental disorders (M: 10 days for bipolar disorder and manic episode, M: 7.44 for depressive episodes and M: 5.66 days for anxiety disorders). These results are cause for concern, for in addition to representing a burden for the institution, they portray the process psychological illness among these workers, whose causal link with working conditions is hardly ever established.

In Brazil, a study developed in the city of Montes Claros, Minas Gerais, assessed the profile of social security benefits due to MBD and its relationship with work. The results showed that the benefits granted due to these diseases represented, on average, 6.3% of the total benefits between 2008 and 2011. Regarding accident benefits, mood disorders represented the main group of diagnoses, with a yearly mean frequency of 47.7%, followed by neurotic disorders, stress-related disorders, and somatoform disorders, with a yearly mean of 43.7%(20).

Regarding the rate of dismissals by professional category, by ICD F, the results showed that workers with secondary and technical levels of education presented more dismissals due to depressive episodes. The mean average of days absent among these workers was practically three times greater than that presented by professionals with tertiary degrees. Among these, the main cause for dismissals was anxiety disorders.

In general, studies have demonstrated that workers with lower levels of education, especially in the field of nursing, are more exposed to workload, present higher rates and greater probability of presenting absenteeism due to avoidable causes than the rest of the team(14).

FINAL CONSIDERATIONS

In addition to displaying the profile of illness among workers due to mental disorders in a hospital environment, the present study also showed the relationship between working conditions and the occurrence of such disorders. The prevalence of records among technical-level workers, allocated mainly to units that are known for demanding more attention, a differentiated work dynamic, and providing more constant and closer contact with death and severe diseases confirm this relationship.

Furthermore, the problems shown here, for the most part common mental disorders, could be prevented in the workplace, in so far as their origin is recognized both by workers and managers. The necessary interventions to prevent or reduce such illnesses can only be conducted based on the recognition of the relationship between working conditions and the occurrence of disorders.

Interventions must include the review of work organization, managerial and organizational structures and models. Also, investments must be made in programs that promote workers’ health, healthy work environments, sufficient number of human resources per workload, and, above all, valuing workers with fair and dignified work days and remuneration.

Regarding the limitations of this study, the database was not complete, as there were flaws due to lack of information regarding the number or workers per professional category and/or gender and difficulty investigating different work regimes, such as the Consolidation of Labor Laws and statutory regime. These limitations hindered a more in-depth analysis of the data. In addition, the study represents a reality of a hospital institution during a specific delimitated period.

Further studies are needed to improve our understanding of the influence of the workplace on mental illness. These studies should include larger populations and different institutions so as to conduct a multiprofessional investigation of dismissals due to mental disorders, thus establishing a better relationship among work-related mental illnesses.

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1 The Simoste consists of an important technological tool for gathering data on and monitoring determinants that generate wear among health professionals, developed by the Nursing Professional Health study group of the University of São Paulo School of Nursing (EEUSP), in partnership with seven national hospitals and the financial support of the São Paulo Research Foundation – FAPESP.

Received: February 14, 2015; Accepted: December 16, 2015

Corresponding author: Leni de Lima Santana. E-mail: lenisantana@hotmail.com

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