Factors that cause stress in physicians and nurses working in a pediatric and neonatal intensive care unit: bibliographic review

Fogaça, Monalisa de Cássia; Carvalho, Werther Brunow de; Cítero, Vanessa de Albuquerque; Nogueira-Martins, Luiz Antonio

doi:10.1590/S0103-507X2008000300009

Abstracts

OBJECTIVES: Bibliographic review on occupational stress and burnout presence in physicians and nurses that work in pediatric and neonatal intensive care units. METHODS: The articles were selected from the MedLine, LILACS and SciElo data base using the key words: stress, burnout, physicians, nursing, intensive care unit, pediatric intensive care unit and neonatal intensive care unit. The studied period ranged from 1990 to 2007. RESULTS: Health professionals who work in pediatric and neonatal intensive care units are strong candidates for developing stress, psychological alterations and burnout syndrome. Researches on this subject identified important alterations suffered by these physicians and nurses, such as: work overload, burnout, desires of giving up their jobs, high levels of cortisol, among other alterations. CONCLUSIONS: Professionals, who work in pediatric and neonatal intensive care units, due to the specificity of their job, are liable to develop occupational stress, and consequently burnout. These results suggest the need for further research with the objective of developing preventive measures and intervention models.

Burnout, professional; Intensive care units, neonatal; Nursing; Stress; Physicians

OBJETIVOS: Revisão de literatura sobre estresse ocupacional e síndrome de burnout em médicos e enfermeiros que trabalham em unidade de terapia intensiva pediátrica e neonatal. MÉTODOS: Os artigos foram identificados a partir das bases de dados MedLine, LILACS e SciElo, usando as palavras-chave estresse, burnout, médicos, enfermagem, unidade de terapia intensiva, unidade de cuidados intensivos pediátricos e unidades de cuidados intensivos neonatais. O período pesquisado foi de 1990 a 2007. RESULTADOS: Médicos e enfermeiros que trabalham em unidade de terapia intensiva pediátrica e neonatal são candidatos a apresentarem estresse, alterações psicológicas e síndrome de Burnout. Pesquisas sobre o tema identificaram alterações importantes que acometem médicos e enfermeiros intensivistas: sobrecarga de trabalho, burnout, desejo de abandonar o trabalho e níveis elevados de cortisol entre outros fatores. CONCLUSÕES: Os profissionais que trabalham em unidade de terapia intensiva pediátrica e neonatal , pela especificidade do seu trabalho, estão expostos ao risco do estresse ocupacional e, conseqüentemente ao Burnout. Estes dados sugerem a necessidade de serem feitas pesquisas, com o objetivo de desenvolver medidas preventivas e modelos de intervenção.

Esgotamento profissional; Unidades de terapia intensiva neonatal; Enfermagem; Estresse; Médicos

ORIGINAL ARTICLE

Factors that cause stress for physicians and nurses working in a pediatric and neonatal intensive care unit: bibliographic review

Monalisa de Cássia Fogaça^I; Werther Brunow de Carvalho^II; Vanessa de Albuquerque Cítero^III; Luiz Antonio Nogueira-Martins^IV

^IMaster, Psychologist and PhD student in Psychiatry from the Discipline of Medical Psychology, Department of Psychiatry of the Universidade Federal de São Paulo - UNIFESP, São Paulo (SP), Brazil

^IIPhD, Professor from the Department of Pediatrics of the Universidade Federal de São Paulo - UNIFESP, São Paulo (SP), Brazil

^IIIPost-Doutorate Degree, Physician from the Discipline of Medical Psychology, Department of Psychiatry of the Universidade Federal de São Paulo - UNIFESP, São Paulo (SP), Brazil

^IVPhD, Physician from the Discipline of Medical Psychology, Department of Psychiatry of the Universidade Federal de São Paulo - UNIFESP, São Paulo (SP), Brazil

Address for correspondence

ABSTRACT

OBJECTIVES: Bibliographic review on occupational stress and burnout presence in physicians and nurses that work in pediatric and neonatal intensive care units.

METHODS: The articles were selected from the MedLine, LILACS and Sci-Elo data base using the key words: stress, burnout, physicians, nursing, intensive care unit, pediatric intensive care unit and neonatal intensive care unit. The studied period was from 1990 to 2007.

RESULTS: Health professionals who work in pediatric and neonatal intensive care units are strong candidates for developing stress, psychological alterations and burnout syndrome. Researches on this subject identified important alterations suffered by these physicians and nurses, such as: work overload, burnout, desires of giving up their jobs, high levels of cortisol, among other alterations.

CONCLUSIONS: Professionals, who work in pediatric and neonatal intensive care units, due to the specificity of their job, are liable of developing occupational stress, and consequently burnout. These results suggest the need to research the matter further, with the objective of developing preventive measures and intervention models.

Keywords: Burnout, professional; Intensive care units, neonatal; Nursing; Stress/etiology; Physicians

INTRODUCTION

In the last years, the relationship between occupational stress and the workers' mental health has been the subject of many studies^1-3in our environment as well as in other countries, due to the alarming levels of temporary incapacitation, absenteeism, early retirements and health risks associated to professional activity.⁴

Several studies^5-9developed theoretical models in order to evaluate the prevalence of emotional problems and professional dysfunctions in the occupational setting and to identify the phenomena which are comparable in multiple working places and with different occupational groups. These models include the evaluation of the capacity of the professional to adapt to stress^10,the development of the burnout syndrome,^7-8,11the control over the job and the psychological demands that result from it^5-6and the balance between effort and reward in the job that continuously provokes emotional and physiological reactions.⁹

Nowadays, there is enough information affirming the need to dedicate more attention related to the physicians' and nurses' health,^3,12-13especially to their mental health.^1,13-18Candeias et al. point out that the hospital setting in itself generates stress in different levels. Death, an inherent fact in hospitals, demands a very strong emotional control of the health professionals in relation to the patients and their relatives¹⁹Physicians and nurses of high complexity specialties, who often work in the limit of life and death, such as emergency and intensive care units, are more exposed to psychological stress.^20-22

The effect of occupational stress in physicians and nurses from intensive care units, as well as the physical and mental overload is emphasized in literature.^20-32Stress can be of outmost importance in a pediatric and neonatal intensive care unit (PNICU), as the interpersonal relations between staff and relatives can create dysphoric and depressive reactions in the professionals.³¹

Burnout is present in these units, and it has been identified in considerable levels, due to working conditions and specific characteristics of the work that create physical and emotional demands in regard to critically ill patients.³²

In face of these results, it is valid to affirm that the studies in question agree to the fact that working in intensive care units creates occupational stress and burnout in physicians and nurses, but there is not a consensus as to which factors trigger these phenomena and how they express themselves. This review aims to identify the organizational and professional factors related to the presence of stress and burnout, and to verify if the literature presents evidence if occupational stress is a consequence in these factors (overload of work, turnover, overcrowding, inadequate physical space, high levels of noise, professional unprepared ness, professional dissatisfaction, among others).

METHODS

A bibliographic review on occupational stress and burnout in physicians and nurses who work in PNICU was done. The articles studied were researched in Med-Line, LILACS and SciElo data bases, using the key words: stress, Burnout, physicians, nursing staff, intensive care unit, pediatric intensive care unit and neonatal intensive care unit. The studied period was from 1990 to 2007. We included all articles that reported original investigations on the matter, excluding all systematic reviews and meta-analysis.

RESULTS

We identified 18 studies, of which 11 were descriptive investigations, 3 were longitudinal prospective studies and 4 were qualitative studies (Chart 1). Only three studies (two descriptive investigations and one prospective study) evaluated stress among physicians and 17 evaluated the nursing staff.

Five of the transversal descriptive studies^33-37measured the burnout levels of the professionals, pointing out the relationship between burnout due to professional exhaustion and lack of personal accomplishment, and therefore, greater stress.

Oehler et al., evaluating nurses intensive care units in both studies, found in the first a percentage of 24% for emotional exhaustion, 7% for depersonalization and 32% for lack of personal accomplishment in the work, in other words, suggestive scores for burnout, in moderate level in the subscales emotional exhaustion and depersonalization, and high in subscales personal accomplishment.³⁴The percentage for burnout in the second study was of 66%, including the total of the three subscales.³⁵

In the studies of Fields et al³⁶and Arriortua et al.,³⁷that evaluated pediatric doctors from intensive care units, it was found 36% and 41%, respectively, with risks to develop burnout; while the study of Jofré and Valenzuela informs that 65% of the studied population (nurses, paramedic and nursing assistants) had not presented propensity for burnout in the subscales emotional exhaustion and depersonalization, 53.8% had presented one high score for personal accomplishment and 7.7% only showed lack of personal accomplishment in the work.³³

Psychological alterations were prevalent in 32% of the nurses and 27% of physicians in neonatal intensive care units^38-39and these levels were associated to the presence of professional stress. With the objective of identifying the factors associated to stress, the studies agree in stating that the main factors were lack of professional formation, as well as an inappropriate intensive care setting.^40-43The same results were found in a qualitative approach.⁴⁴

In an attempt to evaluate objectively the levels of stress in a difficult situation, 2 prospective studies were performed by Fischer et al.^45,47and one by Morrison et al.⁴⁶showing the rise in salivary cortisol and amylase salivary levels in a neonatal intensive care setting, due to the excess of noise.

Out of the four qualitative studies found^44,48-50three showed^48-50an association between professional stress of the nursing staff of a neonatal intensive care unit, and these issues go beyond the working place, such as: having to deal with the patient's unpredictability, the professional's relationship with the patient's relatives and with the team itself, as well as the death of newborn patients.

DISCUSSION

The results found in the studies about stress and burnout in PNICU were consistent, confirming the presence of stress in these units.

Regarding the methods of study, by a bibliographic review, we had an overall view of the types of outlines used in the investigations, in the area of occupational stress and burnout in pediatric and neonatal intensive care units. The studies thus presented, which used both a qualitative and quantitative approach, showed the need to pursue the matter further, stressing the necessity of developing a greater number of cohort longitudinal prospective studies, in order to establish the incidence of occupational stress and burnout in pediatric and neonatal intensive care units, enabling the evaluation of the relationship of stressing factors with certain diseases.

Regarding the burnout syndrome, it seems adequate to consider differentiated patterns to analyze the answers, that is, to discriminate the answers according to gender, adaptability to the organizational space, environmental and occupational factors. These characteristics should be taken into consideration for future studies that aim to investigate the professional wear out found in health professionals, as a great number of the samples studied in pediatric and neonatal intensive care units, mostly in the nursing area, are formed by female subjects, which could compromise the study regarding male professionals included in the same organizational environment.

It is a known fact that PNICU are places that generate tensions and stress, motivated by interpersonal relationship, intense emotions caused by the constant exposure to risks of dying, by the frequent oscillation between success and failure and by the demands imposed on the team. With all these stimuli, feelings such as inadequacy, insecurity and impotence arise, which can influence negatively in the interpersonal relationships and the professional ability, thus creating a vicious circle, marked for the difficulties in the interpersonal relation with patients´ family , difficult relationships with some members of the multiprofissional team³⁹, desire to abandon the work, the emotional exhaustion, the lack of professional accomplishment^33-37, the overload of work (overcrowding, unprepared ness of the team technique, inappropriate physical space) among others factors, will influence negatively in the quality of life in the work. Inasmuch, these sectors have their own characteristics, with the need of restraining personal contact outside the boundaries of the working place, they become environments with a high health liability. Then, the attention given to patients in these units is differentiated, requiring agility and ability, as they are situations of extreme urgency, where the patient's life is in risk. Also, it is an environment with very advanced technology, demanding constant updating of the team.

No prospective study was found, be it clinical trial or longitudinal cohort study, which analyzed more deeply stress and burnout, and their relation with psychological symptoms and its impact on the attention. We found studies which show the impact of the intensive care unit environment on the health professionals, suggesting that stress and burnout are caused by working conditions. More efficient personal management models need to be adopted in order to solve the conflicts for the health professionals working in this environment.

Another aspect to be considered is the need to adequate the use of technology with scientific knowledge, and the relationship between the staff and patients' relatives.

The current study presents some limitations, as a systematic review and meta-analysis of the subject in focus were not performed, because defining a single measurement to evaluate stress and burnout is very complex.

CONCLUSION

Professionals, who work in pediatric and neonatal intensive care units, due to the specificity of their job, are liable of developing occupational stress, and consequently burnout. These results suggest the need to research the matter further, with the objective of developing preventive measures and intervention models.

REFERENCES

01. Nogueira-Martins LA, Jorge MR. Natureza e magnitude do estresse na residência médica. Rev Assoc Med Bras (1992). 1998;44(1):28-34.
02. Alvarez CJ, Torres JL, Martínez CM. Estudio del síndrome de "burnout" em cirujanos pediatras españoles. Cir Pediatr. 2002;15(1):73-8.
03. Thomas NK. Resident burnout. JAMA. 2004;292(23):2880-9. Comment in: JAMA. 2004;292(23):2913-5.
04. Vieira LC, Guimarães LAM, Martins DA. O estresse ocupacional em enfermeiros. In: Guimarães LAM, Grubits S. Saúde mental e trabalho. 3a Ed. São Paulo: Casa do Psicólogo; 2003. p.169-85.
05. Karasek Jr RA. Job demand, job decision latitude, and mental strain: implication for job redesign. Adm Sci Q. 1979;24(2):285-308.
06. Karasek R, Brisson C, Kawakami N, Houtman I, Bongers P, Amick B. The Job Content Questionnaire (JCQ): an instrument for internationally comparative assessments of psychosocial job characteristics. J Occup Health Psychol. 1998;3(4):322-55.
07. Maslach C, Jackson SE. The measurement of experienced burnout. J Occup Behavior. 1981;2:99-113.
08. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol. 2001;52:397-422.
09. Guimarães LAM, Grubits S. Alguns modelos teóricos sobre o estresse ocupacional. In: Guimarães LAM, Freire GS. Série Saúde Mental e Trabalho. São Paulo: Casa do Psicólogo; 2004. p.27-99.
10. Selye H. Stress and the general adaptation syndrome. Br Med J. 1950;1(4667):1383-92.
11. Freundenberg HJ. Staff burn-out. J Social Issues. 1974;30(1):159-65.
12. Alves HN, Surjan JC, Nogueira-Martins LA, Marques AC, Ramos SP, Laranjeiras RR. Perfil clinico e demográfico de medicos com dependência química. Rev Assoc Med Bras (1992). 2005;51(3):139-43.
13. Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Acad Med. 2006;81(4):354-73.
14. McAuliffe WE, Rohman M, Santangelo S, Feldman B, Magnuson E, Sobol A, et al. Psychoactive drug use among practicing physician and medical students. N Engl J Med. 1986;315(13):805-10.
15. Richings JC, Khara GS, McDowell M. Suicide in young doctors. Br J Psychiatry. 1986;149:475-8.
16. Smith JW, Denny WF, Witzke DB. Emotional impairment in internal medicine house staff: Results of a national survey. JAMA. 1986;255(9):1155-8.
17. Firth-Cozens J. Emotional distress in junior house officers. Br Med J (Clin Res Ed). 1987;295(6597):533-6.
18. Miranda PSC, Queiroz EA. Pensamento suicida e tentativa de suicídio entre estudantes de medicina. Rev ABP-APAL. 1991;13(4):157-60.
19. Candeias NM, Abujamra AM, Sabbag SN. Stress em atendentes de enfermagem. Rev Bras Saude Ocup. 1992;20(75):38-44.
20. Sluiter JK, van der Beek AJ, Frings-Dresen MH. Medical staff in emergency situations: severity of patient status predicts stress hormone reactivity and recovery. Occup Environ Med. 2003;60(5):373-4; discussion 375.
21. Lützen K, Nyström M. Nurses' lived experiences of moral stress support in the intensive care context. Aust Emerg Nurs J. 2006;9(2):57-64.
22. Hays MA, All AC, Mannahan C, Cuaderes E, Wallace D. Reported stressors and ways of coping utilized by intensive care unit nurses. Dimens Crit Care Nurs. 2006;25(4):185-93.
23. Goodfellow A, Varnam R, Rees D, Shelly MP. Staff stress on the intensive care unit: a comparison of doctor and nurses. Anaesthesia. 1997;52(11):1037-41.
24. Coomber S, Todd C, Park G, Baxter P, Firth-Cozens J, Shore S. Stress in UK intensive care unit doctors. Br J Anaesth. 2002;89(6):873-81. Comment in: Br J Anaesth. 2004;92(1):151-2.
25. Bühler KE, Land T. Burnout and personality in intensive care: an empirical study. Hosp Top. 2003;81(4):5-12.
26. Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med. 2004;351(18):1838-48. Comment in: CMAJ. 2005;172(4):474; N Engl J Med. 2004;351(18):1884; N Engl J Med. 2005;352(7):726-8; author reply 726-8.
27. De Martino MM, Misko MD. Emotional states of nurses in professional performance at intensive care units. Rev Esc Enferm USP. 2004;38(2):161-7.
28. Bakker AB, Le Blanc PM, Schaufeli WB. Burnout contagion among intensive care nurses. J Adv Nurs. 2005;51(3):276-87.
29. Carvalho WB. Erros médicos associados com a deprivação do sono em UCI. Rev Assoc Med Bras (1992). 2005;51(1):4.
30. Ozyurt A, Hayran O, Sur H. Predictors of burnout and job satisfaction among Turkish physicians. QJM. 2006;99(3):161-9.
31. Faria DG, Junior MM. Humanização na UTI pediátrica. In: Associação de Medicina Intensiva Brasileira (AMIB). Humanização em cuidados intensivos. Rio de Janeiro: Revinter; 2004. p.83-90.
32. Raggio B, Malacarne P. Burnout in intensive care unit. Minerva Anestesiol. 2007;73(4):195-200.
33. Jofré AV, Valenzuela SS. Burnout em personal de enfermaria de la unidad de cuidados intensivos pediátricos. Aquichan. 2005;5(1):56-63.
34. Oehler JM, Davidson MG, Starr LE, Lee DA. Burnout, job stress, anxiety, and perceived social support in neonatal nurses. Hearth Lung. 1991;20(5 Pt 1):500-5.
35. Oehler JM, Davidson MG. Job stress and burnout in acute and nonacute pediatric nurses. Am J Crit Care. 1992;1(2):81-90.
36. Fields AI, Cuerdon TT, Brasseux CO, Getson PR, Thompson AE, Orlowski JP, et al. Physician burnout in pediatric care medicine. Crit Care Med. 1995;23(8):1425-9.
37. Bustinza Arriortua A, López-Herce Cid J, Carrillo Álvarez A, Vigil Escribano MD, de Lucas García N, Panadero Carlavilla E. [Burnout hmong Spanish pediatricians specialized in intensive care] .An Esp Pediatr. 2000;52(5):418-23. Spanish.
38. Oates RK, Oates P. Stress and mental health in neonatal intensive care units. Arch Dis Child Fetal Neonatal Ed. 1995;72(2):F107-F110.
39. Oates PR, Oates RK. Stress and work relationships in the neonatal intensive care unit: are they worse than in the wards? J Paediatr Child Health. 1996;32(1):57-9.
40. Benica SW, Longo CB, Barnsteiner JH. Perceptions and significance of patient deaths for pediatric critical care nurses. Crit Care Nurse. 1992;12(3):72-5.
41. Heuer L, Bengiamin M, Downey VW, Imler NJ. Neonatal intensive care nurse stressors: an American study. Br J Nurs. 1996;5(18):1126-30.
42. Bratt MM, Broome M, Kelber S, Lostocco L. Influence of stress and nursing leadership on job satisfaction of pediatric intensive care unit nurses. Am J Crit Care. 2000;9(5):307-17.
43. Downey V, Bengiamin M, Heuer L, Juhl N. Dying babies and associated stress in NICU nurses. Neonatal Netw. 1995;14(1):41-6.
44. Gibbons C, Geller S, Glatz E. Biomedical equipment in the neonatal intensive care unit: is it a stressor? J Perinat Neonatal Nurs. 1998;12(3):67-73.
45. Fischer JE, Calame A, Dettling AC, Zeier H, Fanconi S. Experience and endocrine stress responses in neonatal and pediatric critical care nurses and physicians. Crit Care Med. 2000;28(9):3281-8. Comment in: Crit Care Med. 2000;28(9):3362-3.
46. Morrison WE, Haas EC, Shaffner DH, Garret ES, Fackler JC. Noise, stress, and annoyance in pediatric intensive care unit. Crit Care Med. 2003;31(1):113-9.
47. Fischer JE, Calame A, Detting AC, Zeier H, Fanconi S. Objectifying psychomental stress in the workplace--an example. Int Arch Occup Environ Health. 2000;73 Suppl:S46-52.
48. Hoga LAK. Causas de estresse e mecanismos de promoção do bem-estar dos profissionais de enfermagem de unidade neonatal. Acta Paul Enferm. 2002;15(2):19-25.
49. Gomes GC, Lunardi Filho WD, Erdmann AL. O sofrimento psíquico em trabalhadores de UTI interferindo no seu modo de viver a enfermagem. Rev Enferm UERJ. 2006;14(1):93-9.
50. Cronqvist A, Lützen K, Nyström M. Nurses' lived experiences of moral stress support in the intensive care context. J Nurs Manag. 2006;14(5):405-13.

Endereço para correspondência:

Werther Brunow de Carvalho

Departamento de Pediatria

Rua Botucatu, 598 - Vila Clementino

04023-062 São Paulo (SP), Brasil

Fone/Fax: (55-11) 3081-9877

Email:

monalisa.cassia@uol.com.br;

wertherbru.dped@epm.br

Publication Dates

Publication in this collection
04 Nov 2008
Date of issue
Sept 2008

History

Accepted
13 Aug 2008
Received
19 May 2008

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 01. Nogueira-Martins LA, Jorge MR. Natureza e magnitude do estresse na residência médica. Rev Assoc Med Bras (1992). 1998;44(1):28-34.

[2] 02. Alvarez CJ, Torres JL, Martínez CM. Estudio del síndrome de "burnout" em cirujanos pediatras españoles. Cir Pediatr. 2002;15(1):73-8.

[3] 03. Thomas NK. Resident burnout. JAMA. 2004;292(23):2880-9. Comment in: JAMA. 2004;292(23):2913-5.

[4] 04. Vieira LC, Guimarães LAM, Martins DA. O estresse ocupacional em enfermeiros. In: Guimarães LAM, Grubits S. Saúde mental e trabalho. 3a Ed. São Paulo: Casa do Psicólogo; 2003. p.169-85.

[5] 05. Karasek Jr RA. Job demand, job decision latitude, and mental strain: implication for job redesign. Adm Sci Q. 1979;24(2):285-308.

[6] 06. Karasek R, Brisson C, Kawakami N, Houtman I, Bongers P, Amick B. The Job Content Questionnaire (JCQ): an instrument for internationally comparative assessments of psychosocial job characteristics. J Occup Health Psychol. 1998;3(4):322-55.

[7] 07. Maslach C, Jackson SE. The measurement of experienced burnout. J Occup Behavior. 1981;2:99-113.

[8] 08. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol. 2001;52:397-422.

[9] 09. Guimarães LAM, Grubits S. Alguns modelos teóricos sobre o estresse ocupacional. In: Guimarães LAM, Freire GS. Série Saúde Mental e Trabalho. São Paulo: Casa do Psicólogo; 2004. p.27-99.

[10] 10. Selye H. Stress and the general adaptation syndrome. Br Med J. 1950;1(4667):1383-92.

[11] 11. Freundenberg HJ. Staff burn-out. J Social Issues. 1974;30(1):159-65.

[12] 12. Alves HN, Surjan JC, Nogueira-Martins LA, Marques AC, Ramos SP, Laranjeiras RR. Perfil clinico e demográfico de medicos com dependência química. Rev Assoc Med Bras (1992). 2005;51(3):139-43.

[13] 13. Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Acad Med. 2006;81(4):354-73.

[14] 14. McAuliffe WE, Rohman M, Santangelo S, Feldman B, Magnuson E, Sobol A, et al. Psychoactive drug use among practicing physician and medical students. N Engl J Med. 1986;315(13):805-10.

[15] 15. Richings JC, Khara GS, McDowell M. Suicide in young doctors. Br J Psychiatry. 1986;149:475-8.

[16] 16. Smith JW, Denny WF, Witzke DB. Emotional impairment in internal medicine house staff: Results of a national survey. JAMA. 1986;255(9):1155-8.

[17] 17. Firth-Cozens J. Emotional distress in junior house officers. Br Med J (Clin Res Ed). 1987;295(6597):533-6.

[18] 18. Miranda PSC, Queiroz EA. Pensamento suicida e tentativa de suicídio entre estudantes de medicina. Rev ABP-APAL. 1991;13(4):157-60.

[19] 19. Candeias NM, Abujamra AM, Sabbag SN. Stress em atendentes de enfermagem. Rev Bras Saude Ocup. 1992;20(75):38-44.

[20] 20. Sluiter JK, van der Beek AJ, Frings-Dresen MH. Medical staff in emergency situations: severity of patient status predicts stress hormone reactivity and recovery. Occup Environ Med. 2003;60(5):373-4; discussion 375.

[21] 21. Lützen K, Nyström M. Nurses' lived experiences of moral stress support in the intensive care context. Aust Emerg Nurs J. 2006;9(2):57-64.

[22] 22. Hays MA, All AC, Mannahan C, Cuaderes E, Wallace D. Reported stressors and ways of coping utilized by intensive care unit nurses. Dimens Crit Care Nurs. 2006;25(4):185-93.

[23] 23. Goodfellow A, Varnam R, Rees D, Shelly MP. Staff stress on the intensive care unit: a comparison of doctor and nurses. Anaesthesia. 1997;52(11):1037-41.

[24] 24. Coomber S, Todd C, Park G, Baxter P, Firth-Cozens J, Shore S. Stress in UK intensive care unit doctors. Br J Anaesth. 2002;89(6):873-81. Comment in: Br J Anaesth. 2004;92(1):151-2.

[25] 25. Bühler KE, Land T. Burnout and personality in intensive care: an empirical study. Hosp Top. 2003;81(4):5-12.

[26] 26. Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med. 2004;351(18):1838-48. Comment in: CMAJ. 2005;172(4):474; N Engl J Med. 2004;351(18):1884; N Engl J Med. 2005;352(7):726-8; author reply 726-8.

[27] 27. De Martino MM, Misko MD. Emotional states of nurses in professional performance at intensive care units. Rev Esc Enferm USP. 2004;38(2):161-7.

[28] 28. Bakker AB, Le Blanc PM, Schaufeli WB. Burnout contagion among intensive care nurses. J Adv Nurs. 2005;51(3):276-87.

[29] 29. Carvalho WB. Erros médicos associados com a deprivação do sono em UCI. Rev Assoc Med Bras (1992). 2005;51(1):4.

[30] 30. Ozyurt A, Hayran O, Sur H. Predictors of burnout and job satisfaction among Turkish physicians. QJM. 2006;99(3):161-9.

[31] 31. Faria DG, Junior MM. Humanização na UTI pediátrica. In: Associação de Medicina Intensiva Brasileira (AMIB). Humanização em cuidados intensivos. Rio de Janeiro: Revinter; 2004. p.83-90.

[32] 32. Raggio B, Malacarne P. Burnout in intensive care unit. Minerva Anestesiol. 2007;73(4):195-200.

[33] 33. Jofré AV, Valenzuela SS. Burnout em personal de enfermaria de la unidad de cuidados intensivos pediátricos. Aquichan. 2005;5(1):56-63.

[34] 34. Oehler JM, Davidson MG, Starr LE, Lee DA. Burnout, job stress, anxiety, and perceived social support in neonatal nurses. Hearth Lung. 1991;20(5 Pt 1):500-5.

[35] 35. Oehler JM, Davidson MG. Job stress and burnout in acute and nonacute pediatric nurses. Am J Crit Care. 1992;1(2):81-90.

[36] 36. Fields AI, Cuerdon TT, Brasseux CO, Getson PR, Thompson AE, Orlowski JP, et al. Physician burnout in pediatric care medicine. Crit Care Med. 1995;23(8):1425-9.

[37] 37. Bustinza Arriortua A, López-Herce Cid J, Carrillo Álvarez A, Vigil Escribano MD, de Lucas García N, Panadero Carlavilla E. [Burnout hmong Spanish pediatricians specialized in intensive care] .An Esp Pediatr. 2000;52(5):418-23. Spanish.

[38] 38. Oates RK, Oates P. Stress and mental health in neonatal intensive care units. Arch Dis Child Fetal Neonatal Ed. 1995;72(2):F107-F110.

[39] 39. Oates PR, Oates RK. Stress and work relationships in the neonatal intensive care unit: are they worse than in the wards? J Paediatr Child Health. 1996;32(1):57-9.

[40] 40. Benica SW, Longo CB, Barnsteiner JH. Perceptions and significance of patient deaths for pediatric critical care nurses. Crit Care Nurse. 1992;12(3):72-5.

[41] 41. Heuer L, Bengiamin M, Downey VW, Imler NJ. Neonatal intensive care nurse stressors: an American study. Br J Nurs. 1996;5(18):1126-30.

[42] 42. Bratt MM, Broome M, Kelber S, Lostocco L. Influence of stress and nursing leadership on job satisfaction of pediatric intensive care unit nurses. Am J Crit Care. 2000;9(5):307-17.

[43] 43. Downey V, Bengiamin M, Heuer L, Juhl N. Dying babies and associated stress in NICU nurses. Neonatal Netw. 1995;14(1):41-6.

[44] 44. Gibbons C, Geller S, Glatz E. Biomedical equipment in the neonatal intensive care unit: is it a stressor? J Perinat Neonatal Nurs. 1998;12(3):67-73.

[45] 45. Fischer JE, Calame A, Dettling AC, Zeier H, Fanconi S. Experience and endocrine stress responses in neonatal and pediatric critical care nurses and physicians. Crit Care Med. 2000;28(9):3281-8. Comment in: Crit Care Med. 2000;28(9):3362-3.

[46] 46. Morrison WE, Haas EC, Shaffner DH, Garret ES, Fackler JC. Noise, stress, and annoyance in pediatric intensive care unit. Crit Care Med. 2003;31(1):113-9.

[47] 47. Fischer JE, Calame A, Detting AC, Zeier H, Fanconi S. Objectifying psychomental stress in the workplace--an example. Int Arch Occup Environ Health. 2000;73 Suppl:S46-52.

[48] 48. Hoga LAK. Causas de estresse e mecanismos de promoção do bem-estar dos profissionais de enfermagem de unidade neonatal. Acta Paul Enferm. 2002;15(2):19-25.

[49] 49. Gomes GC, Lunardi Filho WD, Erdmann AL. O sofrimento psíquico em trabalhadores de UTI interferindo no seu modo de viver a enfermagem. Rev Enferm UERJ. 2006;14(1):93-9.

[50] 50. Cronqvist A, Lützen K, Nyström M. Nurses' lived experiences of moral stress support in the intensive care context. J Nurs Manag. 2006;14(5):405-13.