Indicators of burnout in Primary Health Care workers

integrative review of the literature structured in the stages: guiding question; search; categorization of studies; assessment; discussion; and interpretation of results, and synthesis of knowledge. Search for original articles and reviews published from 2000 to 2016, in Portuguese, English and Spanish, in the main databases of the health area. Descriptors used: Nursing, Burnout and Primary Health Care.

Results:

14 articles met the proposed inclusion criteria, six (42.85%) presented a sample of nurses and eight (57.15%) health professionals.

Conclusion:

Primary Health Care workers are exhausted due to inadequate working conditions characterized by the lack of human and physical resources that leads to work overload, workplace violence and difficulty with teamwork, despite being satisfied with the work environment.

Descriptors:
Burnout, Professional; Stress, Psychological; Primary Health Care; Health Personnel; Nursing

Level and Evidence Quality	Evidence Source
Level I	When evidence comes from a systematic review and/or meta-analysis, randomized controlled trials or systematic reviews of randomized controlled trials;
Level II	Evidence from at least one well-outlined randomized controlled trial;
Level III	Research with well-outlined clinical trials with no randomization;
Level IV	Well-outlined cohort and case-control study evidence;
Level V	Systematic reviews of descriptive and qualitative studies;
Level VI	Evidence from a single descriptive or qualitative study;
Level VII	Opinions of experts in the area studied.

Country, Language	Authors, Title, Year	Method, Sample and Tools	Outcomes
Brazil, Portuguese	Lorenz VR, Guirardello EB⁽¹⁶16 Lorenz VR, Guirardello EB. The environment of professional practice and Burnout in nurses in primary healthcare. Rev Latino-Am Enfermagem[Internet]. 2014[cited 2016 Jun 11];22(6):926-33. Available from: http://www.scielo.br/pdf/rlae/v22n6/0104-1169-rlae-0011-2497.pdf http://www.scielo.br/pdf/rlae/v22n6/0104... ⁾ O ambiente da prática profissional e Burnout em enfermeiros na atenção básica (2014)	Cross-sectional and correlational study; Nurses;Brazilian version of the Nursing Work Index Revised (NWI-R); the Brazilian version of the Maslach Burnout Inventory (MBI); and a personal and professional characterization form, added by three questions with the purpose of assessing professional satisfaction, perception of care quality and intention to leave the current work.	Increased workloads for nurses associated with reduced perceptions of control over theenvironment, autonomy, and organizational support are one of the consequences of SUS state and federal underfunding, as these perceptions correlate with burnout and the quality of care itself.
Sweden, English	Sundin L, Hochwälder J, Lisspers J⁽¹⁷17 Sundin L, Hochwälder J, Lisspers J. A longitudinal examination of generic and occupational specific job demands, and work-related social support associated with burnout among nurses in Sweden. Work[Internet]. 2011[cited 2016 Jun 11];38:389-400. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21508528 https://www.ncbi.nlm.nih.gov/pubmed/2150... ⁾A longitudinal examination of generic and occupational specific job demands, and work-related social support associated with burnout among nurses in Sweden (2011)	Exploratory longitudinal study;Nurses;Maslach Burnout Inventory (MBI);Swedish Work Environment Survey (SWES); besides socio-demographic data.	Changes were recognized over time in job demand as well as social support as a coping strategy for burnout. The fatigue professional experienced by the nurses was identified because of work demands and the lack of support associated with depersonalization.
Spain, Spanish	Tomás-Sábado J et al.⁽¹⁸18 Tomás-Sábado J, Maynegre-Santaulària M, Pérez-Bartolomé M, Alsina-Rodríguez M, Quinta-Barbero R, Granell-Navas S. Sindrome de Burnout y riesgo suicida em enfermeiras de atención primaria. Enferm Clín[Internet]. 2010[cited 2016 Jun 11];20(3):173-78. Available from: http://www.sciencedirect.com/science/article/pii/S1130862110000707 http://www.sciencedirect.com/science/art... ⁾ Sindrome de Burnout y riesgo suicida em enfermeiras de atención primaria (2010)	Observational, transverse and correlational study;Nurses;Maslach Burnout Inventory (MBI); Suicide Risk Scale (SR); Self-rating Depression Scale (SDS); Kuwait University Anxiety Scale (KUAS); Rosenberg Self-esteem Scale (RSES).	The scores obtained for burnout and suicide risk were, in general, lower than those observed in other studies, and emphasized the high level of personal accomplishment, which reflects professional satisfaction. The results show the importance of early recognition of mental disorders and suicide risk prevention at work.
South Africa,English	Mohale MP, Mulaudzi FM⁽¹⁹19 Mohale MPF, Mulaudzi, FM. Experiences of nurses working in a rural primary health-care setting in Mopani district, Limpopo Province. Curationis[Internet]. 2008[cited 2016 Jun 11];31(2):60-6. Available from: https://pdfs.semanticscholar.org/b41f/0f7763a6099a0e86bff951f169a3a4cae3a4.pdf https://pdfs.semanticscholar.org/b41f/0f... ⁾Experiences of nurses working in a rural primary health-care setting in Mopani district, Limpopo Province (2008)	Qualitative, descriptive and exploratory research;Nurses.	The study revealed that nurses working in primary care settings have experienced emotional and physical stress, characteristic of burnout and their own dissatisfaction with work, despite autonomy, as a result of human resource shortages and work overload.
South Africa,English	Engelbrecht MC et al.⁽²⁰20 Engelbrecht MC, Bester CL, Van Den Berg H, Van Rensburg HCJ. A study of predictors and levels of burnout: the case of professional nurses in primary health care facilities in the free state. South Afr J Econ[Internet]. 2008[cited 2016 Jun 11];76(S1):S15-S27. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1813-6982.2008.00164.x/pdf http://onlinelibrary.wiley.com/doi/10.11... ⁾A study of predictors and levels of Burnout: the case of professional nurses in primary health care facilities in the Free State (2008)	Cohort study.Nurses;Maslash Burnout Inventory (MBI); Interpersonal Conflict at Work Scale (ICAWS); Organizational Constraints Scala (OCS); Quantitative Workload Scale (QWS); Rotter locus of Control Scale (1996), as well as a biographical questionnaire.	High levels of burnout and unavailability of resources and infrastructure, conflict at work have been identified. The results indicate that well-being of nursing workers is significantly affected by work overload and severe occupational stress.
United Kingdom,English	Blake H, Lee S⁽²¹21 Blake H, Lee, S. Health of community nurses: a case for workplace wellness schemes. Br J Community Nurs[Internet] 2007[cited 2016 Jun 11];12(6):263-7. Available from: http://www.magonlinelibrary.com/doi/pdf/10.12968/bjcn.2007.12.6.23774 http://www.magonlinelibrary.com/doi/pdf/... ⁾Health of community nurses: a case for workplace wellness schemes (2007)	Descriptive Study;Nurses;Without tools.	Lessons from a well-being program employed in a hospital environment demonstrate that such systems can positively change health and individual attitudes to the employer. There is room for developing such systems to improve health and well-being in primary care nurses.

Country, Language	Authors, Title, Year	Method, Sample and Tools	Outcomes
Spain,Spanish	Garcia-Rodriguez A et al.⁽²²22 Garcia-Rodriguez A, Gutiérrez-Bedmara M, Bellón-Saameño JÁ, Muñoz-Bravo C, Navajas JFC. Entorno psicosocial y estrés en trabajadores sanitarios de la sanidad pública: diferencias entre atención primaria y hospitalaria. Aten Prim[Internet]. 2015[cited 2016 Jun 11];47(6):359-66. Available from: http://www.sciencedirect.com/science/article/pii/S021265671400287X http://www.sciencedirect.com/science/art... ⁾ Entorno psicosocial y estrés en trabajadores sanitarios de la sanidad pública: diferencias entre atención primaria y hospitalaria (2015)	Observational and cross-sectional study;Health workers;Copenhagen Psychosocial Questionnaire (CopSoQ)	Primary health care workers have a more unfavorable psychosocial environment with high levels of stress symptoms. In this context, it encompasses psychological, cognitive, emotional and sensorial demands with greater demands, in addition to job insecurity.
Spain, Spanish	Leal-Costa C et al.⁽²³23 Leal-Costa C, Díaz-Agea JL, Tirado-González S, Rodríguez-Marín J, van-der Hofstadt CJ. Las habilidades de comunicación como factor preventivo del síndrome de Burnout en los profesionales de la salud. Anales Sis San Navarra[Internet]. 2015[cited 2016 Jun 22];38(2):213-23. Available from: http://scielo.isciii.es/pdf/asisna/v38n2/original4.pdf http://scielo.isciii.es/pdf/asisna/v38n2... ⁾ Las habilidades de comunicación como factor preventive del síndrome de Burnout en los profesionales de la salud (2015)	Observational, analytical and cross-sectional study;Health workers;Scale on Habilidades de Comunicación en Profesionales de la Salud (EHC-PS) and Maslach Burnout Inventory Human Services Survey (MBI-HSS)	Communication skills are related to less emotional exhaustion and depersonalization, consequently causing greater satisfaction in the work environment. In conclusion, knowing how to communicate and having emotional intelligence is related to the lower level of burnout.
Brazil,Portuguese	Silva SCPS et al.⁽²⁴24 Silva SCPS, Nunes MAP, Santana VR, Reis FP, Machado NJ, Lima SO. Burnout syndrome in professionals of the primary healthcare network in Aracaju, Brazil. Ciênc Saúde Colet[Internet]. 2015 [cited 2016 Jun 22];20(10):3011-20. Available from: http://www.scielo.br/pdf/csc/v20n10/en_1413-8123-csc-20-10-3011.pdf http://www.scielo.br/pdf/csc/v20n10/en_1... ⁾ Síndrome de Burnout em profissionais da rede de Atenção Primária à Saúde Aracaju, Brazil (2015)	Cross-sectional study;Health workers;Adapted sociodemographic questionnaire; Maslach Burnout Inventory (MBI)	Most of the participating workers presented from moderate to high risk for burnout, threatening their well-being. There were no significant changes between professions, and emphasized that burnout occurs more often in young people who are dissatisfied with work. In this way, taking preventive measures are necessary.
Spain,Spanish	Falgueiras MV et al.⁽²⁵25 Falgueiras MV, Muñoza CC, Pernas FO, Sureda JC, López MPG, Miralles JD. Burnout y trabajo en equipo en los profesionales de Atención Primaria. Aten Prim[Internet]. 2015[cited 2016 Jun 23];47(1):25-31. Available from: http://www.sciencedirect.com/science/article/pii/S0212656714001498 http://www.sciencedirect.com/science/art... ⁾ Burnout y trabajo en equipo en los profesionales de Atención Primaria (2015)	Multicentric cross-sectional study;Health workers;Maslach Burnout Inventory (MBI) Questionnaire on teamwork; Socio-demographic and team variables.	Workers who don’t have the feeling of teamwork are more emotionally exhausted, with greater depersonalization and less personal accomplishment. As for teamwork, this is shown as a preventive factor against burnout. However, the response rate was less than 40%.
Brazil, English	Atanes ACM et al.⁽²⁶26 Atanes ACM, Andreoni S, Hirayama MS, Montero-Marin J, Barros VV, Ronzani TM, et al. Mindfulness, perceived stress, and subjective well-being: a correlational study in primary care health professional. BMC Complement Altern Med[Internet]. 2015[cited 2016 Jun 23];15(303):1-7. Available from: http://bmccomplementalternmed.biomedcentral.com/articles/10.1186/s12906-015-0823-0 http://bmccomplementalternmed.biomedcent... ⁾ Mindfulness, perceived stress, and subjective well-being: a correlational study in primary care health professionals(2015)	Correlation cross-correlation study;Health workers;Mindful Attention Awareness Scale (MAAS), Perceived Stress Scale (PSS), Subjective Well-being Scale (SWS).	Physicians and nurses had lower levels of mindfulness and higher levels of perceived stress compared to other professional categories, and these were also the most stressed among workers in family health teams. Service time greater than one year showed a clear influence on the levels of perceived stress and subjective well-being, regardless of the professional category.
China,English	Chou LP, Li CY, Hu, SC⁽²⁷27 Chou LP, Li CY, Hu SC. Job stress and burnout in hospital employees: comparisons of different medical professions in a regional hospital in Taiwan. BMJ Open[Internet]. 2014[cited 2016 jun 23];4:e004185. Available from: http://bmjopen.bmj.com/content/bmjopen/4/2/e004185.full.pdf http://bmjopen.bmj.com/content/bmjopen/4... ⁾Job stress and burnout in hospital employees: comparisons of different medical professions in a regional hospital in Taiwan (2014)	Cross-sectional study;Health workers;Copenhagen Burnout Inventory (CBI), JobContent Questionnaire (C-JCQ)	Physicians working in the emergency room are similar to nurses. However, nurses had characteristics with younger age prevalence, most of them being women, most of them worked on shifts, as well as having the highest percentage perceiving high tension in the work environment.
Spain,English	Gómez-Gascón T et al.⁽²⁸28 Gómez-Gascón T, Martín-Fernández J, Gálvez-Herrer M, Tapias-Merino E, Beamud-Lagos M, Mingote-Adán JC, et al. Effectiveness of an intervention for prevention and treatment of burnout in primary health care professionals. BMC Fam Pract[Internet]. 2013[cited 2016 jun 23];14(173):1-7. Available from: http://bmcfampract.biomedcentral.com/articles/10.1186/1471-2296-14-173 http://bmcfampract.biomedcentral.com/art... ⁾Effectiveness of an intervention for prevention and treatment of burnout in primary health care professional(2013)	Controlled, pragmatic, randomized clinical study in two parallel groups: intervention and control.Health workers.Maslach Burnout Inventory (MBI), Medical or Nurse Wearer Questionnaire, and Goldberg’s General Health Questionnaire (Golberg’s GHQ).	An intervention was performed on all health workers from a Primary Health Care team, acting at both the personal and interpersonal levels to know and recognize the risk and the process of burnout, and the specific characteristics for the definition of health, evidencing the importance as a preventive measure to combat this syndrome.
Spain,English	Gascon S et al.⁽²⁹29 Gascon S, Leiter MP, Andrés E, Santed MA, Pereira JP, Cunha MJ, et al. The role of aggressions suffered by healthcare workers as predictors of burnout. J Clin Nurs [Internet]. 2013[cited 2016 Jun 23];22(21-22):3120-9. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2702.2012.04255.x/full http://onlinelibrary.wiley.com/doi/10.11... ⁾The role of aggressions suffered by healthcare workers as predictors of burnout (2013)	Retrospective study;Health workers.Maslach Burnout Inventory (MBI), Areas of Work-Life Scale (AWS), Aggression Questionnaire and Socio-demographic Data.	Both forms of physical and verbal violence showed significant correlations with symptoms of burnout syndrome (emotional exhaustion, depersonalization and lack of personal accomplishment). Proving that work overload affects the process of burnout-cynicism-ineffectiveness.

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[1] CORRESPONDING AUTHOR: Gracielle Pereira Aires Garcia E-mail: gracielleaires@gmail.com