Quality of life at work and Burnout in family health strategy workers

Calidad de vida em el trabajo y agotamiento em trabajadores de la estrategia de salud de la família

ABSTRACT

Objective:

To analyze the correlation between quality of life at work and Burnout in workers in the Family Health Strategy.

Methods:

Correlational, cross-sectional study carried out with 112 workers, in the pandemic period (October/2020 to June/2021), in Palmas/Tocantins. The Quality of Work Life Assessment Questionnaire (QWLQ-bref) and the Maslach Burnout Inventory - Human Services Survey (MBI-HSS) were used.

Results:

A strong negative correlation was identified between Emotional Exhaustion and the Physical/Health, Professional and Total Quality of Life Score at work; and moderate negative correlation between Depersonalization and all domains of Quality of Work Life. Professional Achievement showed a moderate positive correlation with the Psychological and Personal domains and with the Total Quality of Work Life Score.

Conclusion:

The best Quality of Work Life indices were correlated with lower Emotional Exhaustion and Depersonalization scores and higher scores of Professional Achievement.

Keywords:
Burnout; professional. Quality of life. Primary health care. National health strategies.

RESUMEN

Objetivo:

Analizar la correlación entre calidad de vida en el trabajo y Burnout en trabajadores de la Estrategia Salud de la Familia.

Métodos:

Estudio correlacional, transversal, realizado con 112 trabajadores, en el período de pandemia (octubre/2020 a junio/2021), en Palmas/Tocantins. Se utilizaron el Quality of Work Life Assessment Questionnaire (QWLQ-bref) y el Maslach Burnout Inventory - Human Services Survey (MBI-HSS).

Resultados:

Se identificó una fuerte correlación negativa entre el Agotamiento Emocional y el Score de Calidad de Vida Física/Salud, Profesional y Total en el trabajo; y correlación negativa moderada entre Despersonalización y todos los dominios de Calidad de Vida Laboral. El Logro Profesional mostró una correlación positiva moderada con los dominios Psicológico y Personal y con el Puntaje de Calidad de Vida Laboral Total.

Conclusión:

Los mejores índices de Calidad de Vida Laboral se correlacionaron con puntajes más bajos de Agotamiento Emocional y Despersonalización y puntajes más altos de Logro Profesional.

Palabras clave:
Agotamiento profesional; Calidad de vida; Atención primaria de salud; Estrategias de salud nacionales.

RESUMO

Objetivo:

Analisar a correlação entre qualidade de vida no trabalho e as dimensões do Burnout em trabalhadores da Estratégia Saúde da Família.

Métodos:

Estudo correlacional, transversal, executado com 112 trabalhadores, no período pandêmico (outubro/2020 a junho/2021), em Palmas/Tocantins. Utilizou-se o Questionário de avaliação da qualidade de vida no trabalho (QWLQ-bref) e o Maslach Burnout Inventory - Human Services Survey (MBI-HSS).

Resultados:

Identificou-se correlação negativa forte entre Exaustão Emocional e os domínios Físico/Saúde, Profissional e Escore Total da Qualidade de Vida no Trabalho; e correlação negativa moderada entre Despersonalização e todos os domínios da Qualidade de Vida no Trabalho. A Realização Profissional apresentou correlação positiva moderada com os domínios Psicológico, Pessoal e com o Escore Total da Qualidade de Vida no Trabalho.

Conclusão:

Os melhores índices de Qualidade de Vida no Trabalho estiveram correlacionados a menores escores de Exaustão Emocional e Despersonalização e a maiores escores de Realização Profissional.

Palavras-chave:
Esgotamento profissional; Qualidade de vida; Atenção primária à saúde; Estratégias de saúde nacionais.

INTRODUCTION

Workers of the Family Health Strategy (ESF) are key elements of Primary Health Care (PHC), as they provide care and assist the families in the assigned territory during and throughout the life cycle, contributing to the implementation of health policies1. From this perspective, it is understood that working conditions are directly related to health conditions and quality of life, impacting the other people involved in this process and consequently the quality of the health services offered2.

Quality of Work Life(QWL) can be understood as a set of actions and organizational practices aimed to implement and develop improvements and innovations at the managerial, structural and technological levels3. It can provide benefits both for workers by producing pleasure, achievement and well-being, and for the organization, for the results achieved, including increased quality of services provided and yield.

In this regard, national4^,5 and international6^,7⁾ researchers have investigated the presence of mental disorders, including Burnout in health workers, as it impacts not only the quality of life of workers, but also the quality of the work performed and hence patient safety.

The Burnout Syndrome, the result of prolonged exposure to chronic emotional and interpersonal stressors resulting from work, leads to the disruption of commitment to work, making it unsatisfactory and meaningless8. It triggers then negative emotional states that generate emotional exhaustion, depersonalization or cynicism (a negative interpersonal response that occurs when people are treated with cynicism or coldness, as if they were objects) and low professional achievement8.

Thus, Burnout is characterized by the chronic stress present in the work environment9 added to intense functional and psychological exhaustion10⁾ that reduces the quality of services provided by professionals, who in turn begin to perform their duties with decreased satisfaction, personal motivation and pleasure9.

Furthermore, during the COVID-19 pandemic, ESF workers were exposed to a sudden change in the work process: in the first year of coping with the disease these workers mostly cared for patients who had symptoms suggestive of COVID-19 and received spontaneous demand assistance, and followed up mild and moderate cases. However, these health professionals were exposed to the risk of illness and death, in addition to the fear of contaminating friends and family, facing adverse working conditions, with lack of personal protective equipment, which led to psychological distress and a strong psychosocial impact11.

A study carried out before the pandemic in a city in the northeast region of Brazil found a high level of Burnout in ESF, with 38.3% of professionals affected13. As for quality of life, another study reported that about 22% of ESF nursing professionals were classified as having a quality of life ranging from regular to very poor, with better scores in the social relations and psychological domains14.

In this context, it is essential that a situational diagnosis be made to support proactive organizational policies, with a view to preventing mental illnesses among workers and improving health outcomes in pandemic or non-pandemic periods.

Considering that QWL can be a protective factor against Burnout Syndrome, it is believed that investigating this construct is relevant to understanding this relationship. It could then be used as a tool by managers of health institutions to support the development and adoption of strategies for building a work environment that promotes the health of ESF workers, in addition to contributing to a better quality of care and greater yield.

In addition, there is still little research in the scientific literature on the health of ESF workers, more specifically in the pandemic period and in the northern region of Brazil. Deeper knowledge about QWL and Burnout Syndrome is necessary, so that strategies are sought to improve the health conditions of ESF workers, in order to ensure satisfactory performance of their functions and the effective use of PHC health policies15.

In view of the aforementioned, this study aimed to analyze the correlation between quality work life and the dimensions of Burnout in ESF workers.

METHODS

Correlational, cross-sectional study with a quantitative approach, carried out through non-probabilistic convenience sampling.

The study was carried out in the pandemic period (COVID-19) from October 2020 to June 2021. All ESF workers who performed their duties in the 34 Basic Health Units (UBS) in the city of Palmas (TO) distributed among eight territories of health were invited.

The UBS house the ESF teams, which provide assistance to the population in predetermined areas. Data from the Ministry of Health on Primary Health Care (ABS) coverage reveal that Palmas (TO) has 67 Family Health Strategy (ESF) teams, with 461 community health agents and endemic disease agents, 134 nursing assistants/technicians, 67 assistants/technicians in oral health, 67 dentists, 67 nurses and 67 doctors, totaling 863 workers. ABS coverage in the municipality is 100%16.

The workers who met the following inclusion criteria participated in the study: ESF professionals who were working in person during the data collection period. Three participants who failed to answer more than 20% of the questions on the data collection instruments were excluded, to avoid interference in data analysis.

After ESF workers were invited to participate in the study, data collection was performed, and all information relevant to the study was provided. The workers who verbally agreed to participate in the study received an envelope containing the data collection instrument along with two copies of the Free and Informed Consent Form (TCLE). Subsequently, the researchers returned to collect the completed questionnaires up to three times.

For data collection, the Participants' Profile Questionnaire, the Quality of Work Life Assessment Questionnaire - QWLQ-bref and the Maslach Burnout Inventory - Human Services Survey (MBI-HSS) were used.

The Quality of Work Life Questionnaire - QWLQ-bref, an abbreviated model of the QWLQ-78 questionnaire, was developed using the WHOQOL-100 parameters of the World Health Organization. It was designed by four researchers17,consisting of 20 questions subdivided into four domains: Physical/Health, Psychological, Personal and Professional, with answers based on the Likert scale (1-5 scores), and higher scores in these domains indicate a higher level of QWL.

The MBI-HSS developed by Maslach and Jackson18 and translated and validated into Portuguese by Lautert19 was used for the assessment of the presence of Burnout Syndrome. It consists of 22 items distributed on a 5-point scale, ranging from “never” (0) to “daily” (4). The instrument assesses how the professionals experience their work in three dimensions: Emotional Exhaustion (EE), Depersonalization (DE) and Professional Achievement (PA). High scores in the Emotional Exhaustion and Depersonalization dimensions, associated with low scores in the Professional Achievement dimension indicate Burnout19.

Data were entered into the Software Statistical Package for the Social Sciences for Windows (SPSS®) version 22.0, with independent double entry. After correction of errors and inconsistencies, descriptive and inferential analyzes relevant to the study were carried out. In the analysis of associations between the dimensions of the QWL and Burnout Syndrome constructs, Pearson's correlation was used. Correlation values between 0.30 and 0.50 were considered moderate and values above 0.50 were considered strong20.

Data were collected after authorization by the Commission for the Evaluation of Research Projects of the Municipal Health Department of Palmas, Tocantins, and approval by the Research Ethics Committee of Universidade Federal do Tocantins (UFT), approved by Protocol No. 3,677,932 under CAAE No. 21331419.3.0000.5519.

After consent, participants received a copy of the TCLE, prepared according to the guidelines of Resolution 466/12.

RESULTS

Table 1 shows the categorization of the research participants' profile. The total number of participants was 112 health workers, with a mean age of 39.71 years (SD 9.34, ranging from 23 to 58 years). Most are female (82.10%), half are married or in a stable relationship (50.00%), 90.18% declared to be fully or partially responsible for supporting the family and more than half had completed higher education or graduate studies (56.25%).

Regarding the professional occupation, most participants were community health agents (CHA) (32.15%), followed by nursing assistants or technicians (25.89%). The largest proportion (46.40%) of workers have an employment contract. Of the total number of participants, 82.14% do not have another job. Regarding the frequency of practice of physical or leisure activities, a little more than half (53.57%) of the participants reported practicing physical or leisure activities.

As for monthly personal income, the mean was BRL 3,671.34 (equivalent to three minimum wages), with wages ranging from BRL 1,100.00 to BRL 10,000.00 (SD BRL 2,221.79).

Table 1 -
Categorization of the profile of ESF workers. Palmas, Tocantins, Brazil, 2020/2021

Variables	n=112	%
Gender
Female	92	82.11
Male	19	17.00
Did not answer	1	0.89
Marital status
Single	42	37.50
Married or in a stable relationship	56	50.00
Divorced, separated or widowed	14	12.50
Participation in the family’s economic life
Is responsible for supporting the family or contributes partially for the support	101	90.18
Contributes sporadically/ Does not contribute	9	8.03
Did not answer	2	1.79
Education
Complete high school	48	42.86
Higher education	46	41.07
Postgraduate studies	17	15.18
Did not answer	01	0.89
Position
Community health agent	36	32.15
Endemic disease control agent	1	0.89
Nursing assistant or technician	29	25.89
Oral health assistant or technician	4	3.57
Dental surgeon	10	8.93
Nurse	17	15.18
Physician	10	8.93
Did not answer	5	4.46
Type of employment contract
Effective	52	46.40
Not effective	27	24.10
Did not answer	33	29.50
Has another job
Yes	19	16.96
No	92	82.14
Did not answer	1	0.89
Often performs physical or leisure activities
Yes	60	53.57
No	49	43.75
Did not answer	3	2.68

• Source: Research data.

The mean working time in the ESF was nine years (SD 7.66 years; minimum 2 months; maximum 22 years), with a mean of hours worked per week of 44.48 hours (SD 9.9; minimum 24 hours; maximum 64 hours).

As shown in Table 2, the lowest mean in the assessment of QWL were assigned to the Physical/Health (3.73) and Professional (3.75) domains, considering scores from 1 to 5 on the Likert scale.

Table 2 -
Assessment of Quality of Work Life by workers in the Family Health Strategy. Palmas, Tocantins, Brazil, 2020/2021

Domains/ Total Score	n	Mean	Standard deviation	Minimum	Maximum
Physical/Health	112	3.73	0.61	2.50	5.00
Psychological	112	4.05	0.71	1.67	5.00
Personal	112	4.17	0.70	1.50	5.00
Professional	112	3.75	0.63	2.22	5.00
Total score	112	3.87	0.57	2.35	4.95

• Source: Research data.

In the assessment of Burnout dimensions, considering the 0-4 scale, Depersonalization had the lowest mean (0.80) and Professional Achievement the highest mean (2.91) (Table 3). Burnout is characterized by high scores in the Depersonalization and Emotional Exhaustion dimensions and low scores in the Professional Achievement dimension19.

Table 3 -
Assessment of Burnout dimensions by Family Health Strategy workers. Palmas, Tocantins, Brazil, 2020/2021

Dimensions	n	Mean	Standard deviation	Minimum	Maximum
Emotional exhaustion	108	1.35	0.94	0.00	4.00
Depersonalization	106	0.80	0.89	0.00	4.00
Professional Achievement	106	2.91	0.84	0.00	4.88

• Source: Research data.

As seen in Table 4, in the correlation of the Burnout dimensions with QWL domains, there was a strong negative correlation between Emotional and Physical Exhaustion/Health, Professional and Total Score of QWL. All QWL domains had a strong positive correlation with the Total QWL Score.

Table 4 also shows a moderate negative correlation between Depersonalization and all QWL domains. Professional Achievement showed a moderate positive correlation with the Psychological and Personal domains and with Total Score of QWL.

Table 4 -
Correlation between Quality of Work Life domains and Burnout dimensions in ESF workers. Palmas, Tocantins, Brazil, 2020/2021

Domains/ dimensions		Quality of Work Life					Burnout
		Physical/ Health	Psychological	Personal	Professional	Total Score	EE	DE	PA
Quality of life at Work	Physical/ Health	1	0.479	0.467	0.573	0.703	-0.531	-0.408	0.159
	Psychological		1	0.785	0.749	0.855	-0.478	-0.395	0.411
	Personal			1	0.780	0.880	-0.459	-0.326	0.325
	Professional				1	0.952	-0.593	-0.362	0.223
	Total Score					1	-0.609	-0.422	0.300
Burnout	EE						1	0.707	-0.124
	DE							1	-0.089
	PA								1

• Source: Research data.
• EE= Emotional exhaustion; DE= Depersonalization; PA=Professional achievement.

DISCUSSION

Regarding the demographic categorization of the population that participated in this study, most ESF workers are women and a considerable portion of them are married and responsible for supporting the family, a profile confirmed in other Brazilian surveys carried out in the states of Mato Grosso do Sul, Paraná, São Paulo21 and Minas Gerais22. This factor can have a positive impact on QWL, since relatives can be a motivation for work. Moreover, a pleasant family environment can provide well-being and rest, improving performance at work23.

Another study24 demonstrated that married workers had a lower prevalence of Burnout compared to single workers. On the other hand, the excess of tasks and the difficulty in reconciling professional and family demands can be a triggering factor of stress, physical and emotional exhaustion25. There is evidence that women who work excessive hours (in PHC and at home) are more subject to deterioration in mental and physical health26.

More than 40% of the participants in the study have an effective employment contract, which gives them greater financial stability. Also, most participants do not have another employment contract, unlike findings in other settings24, which contributes to the reduction of physical and psychological exhaustion that lead to Burnout25.

The average workload was consistent with findings of another study. There is evidence that an excessive workload contributes to a higher level of stress, physical and psychological exhaustion, in addition to low professional achievement, contributing to the development of Burnout27.

Although the average income of the participants was relatively low and varied significantly due to the discrepancy in the remuneration paid to the professional occupations in the ESF, a study showed that a high average income is associated with a higher prevalence of Burnout24, as many workers resort to other jobs to increase their earnings28, and consequently have to work excessive hours without enjoying the proper rest and leisure.

Most professionals said that they performed physical and leisure activities, which is a protective characteristic of Burnout, as there is evidence of a high prevalence of Burnout in sedentary workers29.

The strong negative correlation between the Emotional Exhaustion dimension of Burnout and the Physical/Health, Professional domains and the total score of QWL indicate that the greater the emotional exhaustion, the lower the scores attributed to QWL.

In the QWL assessment, the lowest means were assigned to the same domains, that is, Physical/Health, Professional and total Score. In the pandemic period, ESF professionals had to face challenges inherent to the atypical scenario, both in the family and professional fields, which led to emotional and psychological problems11, often caused by poor quality of sleep and rest, by physical and psychological overload during the referred period. They also did not feel comfortable in the work environment with the abrupt change in life habits, because they had to move away from their families due to the greater risk of infection, the lack of adequate and quick training to deal with this situation and also because they felt impotent facing an as yet unknown disease 21. These factors contribute to greater emotional exhaustion in health professionals, as highlighted by other studies6^,7.

Regarding the moderate negative correlation between Depersonalization and all QWL domains, it was found that the higher the scores assigned to QWL, the lower the depersonalization. The literature shows that the more professionals remain dissatisfied with their work and do not feel well, the more indifference and distance from people in their work environment they may have to face, which even generates dehumanization of the care process and absenteeism11^,30.

Therefore, it is a disturbing condition, as ESF professionals provide direct care to patients. In order to ensure effective care, it is essential that health professionals establish bonds with the families assisted, so that they can properly welcome these people and establish a relationship of trust, tasks that require empathy and sensitivity from ESF professionals towards the others. The development of these characteristics is often more difficult in professionals who suffer from depersonalization31.

Furthermore, professionals affected by Burnout are more likely to have difficulties in their relationship with the work team, which negatively impacts their quality of life32.

Professional Achievement showed a moderate positive correlation with the Psychological, Personal domains and with the Total Score of QWL, indicating that the higher the score for these domains, the greater the professional achievement. Authors confirm that personal psychological well-being and happiness contribute to a better quality of life, greater engagement and self-motivation for work33.

It should be stressed that the Psychological domain showed a strong positive correlation with the personal, professional domain, in addition to QWL, and the Professional domain showed a strong positive correlation with Physical/Health, Psychological and Personal domain. By considering the difficulties faced by these professionals in the pandemic period, with the fears resulting from contamination by the virus and the large number of deaths, even of relatives and friends, these correlations demonstrate the relevance of psychological health to guarantee QWL. According to a study carried out in Indonesia34, the incidence of symptoms of depression, anxiety and stress among health professionals during the pandemic was also a factor that contributed to the incidence of Burnout signs.

Emotional Exhaustion showed a strong positive correlation with Depersonalization, collaborating with the strengthening of the assumption that Emotional Exhaustion leads to Depersonalization, as it is often a defense mechanism for professionals against emotional exhaustion and low personal achievement35. Thus, it is necessary to intervene in the aspects that lead to emotional exhaustion to prevent depersonalization and protect the health of workers and the quality of the care provided to the community.

Some limitations of this study include the difficulty of collecting data in person during the pandemic period, due to sanitary restrictions and the workload of health professionals, which resulted in a smaller number of participants. Another limitation is the research design that made it difficult to establish a causal relationship. A possible bias concerns the fact that only active workers participated in the study. Health professionals who were away for various reasons, including due to physical and mental health problems did not participate.

The findings of this study can contribute to professional practice by demonstrating the importance of carrying out a diagnosis on QWL and Burnout in ESF workers. This diagnosis seeks to identify critical nodes in an intervention aimed at preventing mental illness, supporting decisionmaking regarding working conditions both in the pandemic context and in everyday life.

CONCLUSION

Amidst the COVID-19 pandemic, the results of the present study point to a correlation between QWL and Burnout in ESF workers, where better QWL rates were related to lower scores in Emotional Exhaustion, Depersonalization and higher scores in Professional Achievement.

Moreover, the strong correlation between emotional exhaustion and depersonalization, both characteristics of Burnout, explain the importance of QWL for reducing the incidence of this syndrome. QWL is also important for the quality of care provided in the context of the ESF, with fewer professionals affected by emotional exhaustion and depersonalization.

Thus, based on the diagnosis identified, it has become evident that local managers must develop strategies and actions aimed to ensure better working conditions, in the search for a better quality of life at work for healthcare professionals, reducing therisk of Burnout.

Acknowledgments:

To the National Council for Scientific and Technological Development (CNPQ-Brasil) forscientific initiation scholarships for co-authorsViviane Reis Nunes and Bianca G. Lima.

To Universidade Federal do Tocantins (UFT) for the scholarship to co-author Mateus Portilho Pires through the Institutional Scholarship Program for Research Training (PIBIC-UFT).

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Edited by

Associate editor:

Rosana Maffacciolli

Editor-in-chief: João Lucas Campos de Oliveira

Publication Dates

• Publication in this collection
  10 July 2023
• Date of issue
  2023

History

• Received
  10 Sept 2022
• Accepted
  23 Dec 2022