Factors associated with the quality of life of multi-professional health residentes

ABSTRACT Objectives: to analyze factors associated with the quality of life of multi-professional health residents. Methods: cross-sectional and analytical design, carried out with 94 residents who answered a questionnaire containing general data, the Maslach Burnout Inventory, the Self Reporting Questionnaire, and the World Health Quality of Life. Data was submitted to multiple linear regression, considering p < 0.05. Results: minor mental disorders increased, respectively, by 0.31, 0.64 and 0.35 in the Physical, Psychological and General domains of quality of life. Emotional exhaustion had an inverse influence of 0.28 on the Physical and Environment domains. Satisfaction with residence increased the overall quality of life outcome by 0.20; Living alone, at 0.02 the Psychological domain; and Race/color, at 0.19 the Environment domain. Conclusions: there is a relationship between emotional exhaustion of the burnout, minor psychic disorders and the quality of life of multi-professional residents.


INTRODUCTION
The creation of the Multi-professional Residency program was based on Law No. 11,129 of 2005, being governed by the principles and guidelines of the Unified Health System (1) . It is a lato sensu specialization where the main focus is practical activities. This type of service education aims to promote in-service education and favor a qualified insertion of new professionals in the labor market (2) . The resident needs to dedicate himself exclusively to the program that provides teaching-assistance supervision, in addition to the provision of a paid scholarship (1) . In the work routine, there is a great demand on the residents (3) ; and studies have pointed out that the long working hours together with the occurrence of daily tension, the inability of workers to respond to the daily challenges of the profession without organizational support and the lack of preparation of supervisors can culminate in psychological distress, fatigue, sleep difficulties and physical exhaustion of the resident. , affecting their quality of life (3)(4)(5) .
In order to respond to the needs of daily work, in addition to psychological conditions, some workers may resort to substance use to face the daily challenges of the profession. Studies (11)(12) have pointed out that work-related stress can drive individuals to consume psychoactive substances, which cause damage to health and interfere with quality of life.
The quality of life is influenced by positive and negative aspects related to the social, cultural, and environmental context. These aspects are physical (vitality, tiredness), psychological (emotions), level of independence, social relationships (support network), surroundings (accessibility to health care) and personal and spiritual beliefs (meaning of life) (13) . Given the above, the need for studies aimed at this group of professionals, which represents an important contribution to the Unified Health System, became evident; and the question was: What factors are associated with the quality of life of multi-professional health residents?

OBJECTIVES
To analyze factors associated with the quality of life of multiprofessional health residents.

Ethical aspects
This study was approved by the Research Ethics Committee of the institution where the study was carried out. All participants signed the Free and Informed Consent Form (ICF), in compliance with the provisions of the National Health Council Resolution No. 466/2012, which deals with research in human beings.

Population, sample, inclusion, and exclusion criteria
Multi-professional HCPA residents from all RIMS programs (total of 106 residents), enrolled in 2019 and with active employment during the data collection period, from the professions of nursing, pharmacy, physiotherapy, speech therapy, nutrition, psychology, social work, physical education, and occupational therapy. The exclusion criterion was being away during the data collection period due to vacation, medical certificate, leave or disconnection from the multi-professional health residency. The sample size calculation considered the lowest correlation (0.326) between one of the associated factors (burnout) and the quality of life outcome (14) , statistical power of 80%, for a confidence level of 95%. The minimum sample expected was 72 residents, and the final sample of this study consisted of 94 residents.

Study protocol
Data were collected by previously trained students from UFRGS, with the face-to-face application of a closed questionnaire, created by the researchers and composed of sociodemographic and employment data, including variables such as gender, date of birth, marital status, profession, education, who lives with and days away from work. Substance use and self-medication are questions that addressed the use of controlled psychoactive medication, use of controlled psychoactive medication before residency, addition of controlled psychoactive medication, use of over-the-counter medication, use of over-the-counter medication without professional indication, use and increased use of caffeine, in addition to the influence of caffeine consumption on sleep.
Also used were: Environment (physical security, home environment, financial resources, health and social care, opportunities to acquire information and skills, recreation/leisure, physical environment and transportation) (16) . • Self-Report Questionnaire (SRQ-20) -Enables tracking of minor psychiatric disorders; was developed by Harding in 1980, funded by the WHO, validated in Brazil (17) and has 20 "yes" and "no" choice questions. The instrument has 80% specificity and 83% sensitivity for detecting MPD cases compared to the standard psychiatric interview using the semi-structured Clinical Interview Schedule (17) . The cut-off point used for detecting MPD were values equal to or greater than seven positive responses. • Maslach Burnout Inventory -MBI (burnout) -It was developed in 1978 by Christina Maslach and Susan Jackson and validated in Brazil (18) . It is an instrument composed of a Likert-type scale ranging from 0 to 6, capable of detecting the burnout syndrome and the factors that compose it: emotional exhaustion, depersonalization, and professional fulfillment.

Analysis of results and statistics
Data were entered into a Microsoft Excel spreadsheet, analyzed using the Statistical Package for the Social Sciences, version 20 (SPSS ® Statistics); and submitted to descriptive and inferential statistics. Qualitative variables were described using relative and absolute frequencies. Numerical variables were presented through measures of central tendency (mean or median) and dispersion (standard deviation or interquartile ranges), according to the Shapiro-Wilk test result, asymmetry, and kurtosis values. The analysis of association between the factors under study (MPD and burnout syndrome) and the outcome (quality of life) were performed using Tukey's test, Student's t test and Pearson's correlation. In the association with medication use, Student's t tests (variables with symmetrical distribution) and Mann-Whitney (variables with asymmetric distribution) were used. Values of p < 0.05 were considered significant. Multiple linear regression using the Stepwise method was performed to select the regression model for variables that were associated with the outcome (quality of life) with a confidence level of 95% (p ≤ 0.05). The variables with univariate analyzes of p < 0.20 were included in the model; and data with a two-tailed p lower than 0.05, or with a confidence interval of 95%, were considered as statistically significant differences. The quality-of-life domains presented means above 55, with 59.57 (± 13.14) being the mean of the Physical domain; 55.50 (± 13.97) in the Psychological domain, 60.10 (± 17.70) in the Social relationships, 56.74 (± 13.66) in the environment, and the average of the General domain of quality of life was 55.45 (± 19.18). Table 1 describes the association of psychological factors (burnout and minor mental disorders) with the residents' quality of life.   Table 2 shows the correlation of variables on the consumption of medication, psychoactive substances, and self-medication with quality of life. Table 3 shows the results of the linear regression analysis according to the variables associated with the domains of quality of life; and these variables compose the final analysis model for this outcome.

Most
It is identified that Emotional exhaustion (EE) of the burnout and Minor Psychiatric Disorders (MPD) are the variables with the greatest inverse influence on the Physical domain (PD) of quality of life. Being exposed to EE and Minor Psychic Disorders increased the outcome by 0. 28

DISCUSSION
In this study, the average quality of life scores were low in all domains, being lower in the Psychological domain, followed by the Environment, Physical, and the least affected domain was Social Relations. A national study obtained similar results, indicating negative repercussions over the years of residency due to lesser commitment to social relationships (3) . The lowest scores in the domain of Social Relations of Quality of Life can be mitigated by the bonds that are built in the coexistence of residents, allowing for support, and understanding, since they are going through similar professional phases. A similar condition was observed in a study developed with multidisciplinary residents, in which the psychological domain seems to have been the least affected due to the routine sustained by a shared space with other residents (19)(20) .
Furthermore, other studies also pointed to a progressive worsening in the quality of life regarding physical aspects, pain, vitality and mental health of residents (3,21) . Thus, the results found in this study related to the reduction in quality of life can be explained by the intense working hours, increased responsibilities, number of theoretical-practical activities and lack of time for completing the residency work. The greater commitment in the Psychological domain may be associated with the lack of time to deal with their own problems and feelings, the high  demand for their own professional results, work relationships and expectations for the future. In the present study, an inversely proportional association was observed between emotional exhaustion of the burnout and all domains of quality of life. In this regard, it is worth reflecting on the dichotomous process of being a worker and an apprentice, linked to the adaptations and challenges that the resident needs to face in their daily practices, in addition to the uncertainties about the future: all this tends to cause the physical and emotional exhaustion of these professionals. Such data corroborate the study that found a negative correlation between the Vitality variable (quality of life) and the burnout domain of Emotional exhaustion (21) .
Regarding professional fulfillment, it was shown to be negatively associated with the Physical and Social domains of quality of life. A Brazilian study found a positive correlation for the Decreased Feeling of Professional and Personal Achievement at Work dimension in the first year of residency (21) .
The use of caffeine was positively related to the average score of quality of life in the Psychological domain and was able to interfere with sleep in the Physical, Social and Environmental domains in residents who used it. Residents probably have the habit and pleasure of using caffeine due to its stimulant properties and as an aid to increase concentration, which can help with studies and keep them awake for longer, in addition to the social practice of consuming it in the form of drink (coffee). On the other hand, when consuming it in excess or at night, it can cause insomnia, irritability, agitation, tachycardia and increased anxiety (22) . A literature review points out that most university students find pleasure and satisfaction with the use of caffeine, but consumption should be moderate, given its influence on sleep disorders and the quality of life of students (23) . As for the data on the consumption of psychoactive drugs, a significant difference can be seen between the Physical and Psychological domains; and the group that uses medication has worse scores for quality of life. In this regard, medications have been used as a faster method to cure anguish, sadness and psychological suffering, factors that contribute to the abusive increase in the use of psychotropic drugs (24)(25) . However, this reality is not exclusive to residents, as a study with university professors identified that most professors also use medication to help cope with work-related adversities (26) .
When analyzing the use of controlled psychoactive drugs before residency, the group that reported this practice had worse quality of life scores compared to the group that did not use them, with a significant difference in the Social Relations domain. Regarding the addition of another controlled psychoactive medication, there was a significant difference in the Psychological domain, with worse scores. Residents often end up resorting to drug therapies to relieve symptoms caused by work overload. In the work environment of a hospital, residents assume responsibility for patient care, have extensive working hours, essential search for knowledge, demands and challenges intrinsic to the profession, which are risk factors for psychosocial illness that culminate in physical and emotional fatigue. psychological (27) . Therefore, it is up to the institution to consider the social context in which the professional lives and how their mental health can be affected. Thus, they resort to self-medication for the treatment of health problems, masking the symptoms and, sometimes, worsening their clinical condition. However, it is worth mentioning that the option for self-medication aims to minimize the physical or psychological disorder presented, without ensuring cure (28) .
Furthermore, the variable Emotional exhaustion of the burnout resulted in lower levels of quality of life in the Physical and Environment domains. Studies with workers, such as dentists (29) , nursing professionals (30) , postgraduate nursing professors (31) , have also shown that burnout negatively interferes with quality of life, pointing out that this is a worrying problem that needs to be addressed. be reviewed in organizations globally. Regarding residents, this result can be explained by the extensive workload and many demands assigned. In this way, time for other activities is scarce, such as leisure and even rest itself, which can generate physical and emotional exhaustion. A study revealed the excess of activities, the long workday and the scarce time for individual tasks at home as factors of dissatisfaction, culminating in emotional exhaustion (32) .
Regarding minor psychiatric disorders, the Physical, Psychological and Environmental domains of quality of life increased, reinforcing the interference of mental health in the quality of life of individuals. The data confirm the literature, which highlights the characteristic symptoms of MPD as a threat to functionality at work, affecting the performance and income of professionals and culminating in damage to self-esteem and quality of life (33) . A similar study showed a lower quality of life among individuals with MPD, in the Environmental, Psychological, Physical and Social Relations domains (3) . The relationship between depressive symptoms and the domains of quality of life was also found in Nursing students (34) , highlighting that psychic changes are present since graduation and require early detection and interventions.
In addition to psychological distress, the fact of living alone has a direct impact on the residents' quality of life, in the Psychological domain. This fact is probably associated with the lack of emotional and financial support and also the accumulation of household chores, added to the inherent requirements of carrying out the residency. Added to this, living far from family members can influence the quality of life, due to the changes faced due to this new phase, in addition to the emergence of feelings of homesickness and sadness (3) . The data from this research confirm the findings of a study conducted with students in the health area, in which those who lived alone, compared to those who lived with other individuals, had lower quality of life scores in the Physical domain (35) .
An important factor that can directly contribute to the quality of life of residents is satisfaction with the residence. Professionals spend long hours in the work environment, where there is physical and mental exhaustion, since, in addition to working, they are learning. A study (20) showed that the most interfering facet in the quality of life of multi-professional residents was job satisfaction. They develop long journeys in health care, exposed to stressful and often unfamiliar environments, which can negatively affect their performance in addition to physical and mental health. Such data converge with the findings of this study, in which satisfaction with the residence positively impacted the General domain of quality of life.

Study limitations
A limiting factor in this study was the cross-sectional design, in which data collection takes place in a single moment, not allowing causal inference to be made.

Contributions to the area of Nursing, Health, or Public Policy
This study contributes to the feasibility of strategies focused on the residents' quality of life. The associated variables must be considered within the scope of the institution and public policies as important factors in the implementation of measures that promote quality of life and health of residents. In this way, it will be possible to impact patient care and reduce physical and mental illness.

CONCLUSIONS
This study contributes to the feasibility of strategies focused on the residents' quality of life. The associated variables must be considered within the scope of the institution and public policies as important factors in the implementation of measures that promote quality of life and health of residents. In this way, it will be possible to impact patient care and reduce physical and mental illness.
In view of the results found, it is important to point out that the residents are in the process of psychological distress, which was inversely correlated with quality of life. It is suggested to carry out studies that make it possible to intervene through strategies to minimize the effects of psychic demands on the quality of life of residents.