Preliminary Study About Occupational Stress of Physicians and Nurses in Pediatric and Neonatal Intensive Care Units: the Balance Between Effort and Reward

Endereço para correspondência: Monalisa de Cássia Fogaça Rua Dr. Clemente Ferreira, 126 Apto 24 Santo Antonio CEP: 09530-440 São Caetano do Sul, São Paulo, Brasil E-mail: monalisa.cassia@uol.com.br Universidade Federal de São Paulo, Brasil: 1 Psicóloga, Doutoranda, e-mail: monalisa.cassia@uol.com.br. 2 Livre Docente, Professor, e-mail: wertherbru.dped@unifesp.br. 3 Médica, Doutor, Professor, e-mail: vcitero@uol.com.br. 4 Médico, Livre Docente, Professor Associado, e-mail: nogmart2004@yahoo.com.br. O objetivo do estudo foi comparar o equilíbrio entre esforço (E) e recompensa (R) entre


Introduction
Occupational stress is an important, current problem because the rates of temporary incapacitation, absenteeism and early retirement, among others, in the workforce are alarming.It is worth noting in this context that the changes experienced by most workers are mainly due to technical progress, transformation originating in world economic development, the migration of workers and changing demographic structures of the active population (1) .
Health professionals seem to suffer tension specifically related to occupational stress.They face high levels of stress at work, which increases in pediatric and neonatal intensive care units (2)(3)(4)(5)(6)(7) .Professionals who work in these units might experience burnout syndrome (2)(3)(4)(5) , excessive workload, diminished satisfaction at work, in addition to psychological disorders (3) .Hence, stress and health problem risks appear when work demands do not Fogaça MC, Carvalho WB, Cítero VA, Nogueira-Martins LA.
adjust with workers' needs, expectations or skills.
Reactions to stressful work-related situations or situations that are characterized by high required effort to perform a task and low financial or emotional reward for performing the task can be evaluated by the balance between effort and reward through the Effort-Reward Imbalance (ERI) (8) .For researchers (1,8) , the term reward originates from the following statement contained in the model's theoretical construction: work in adulthood sets a crucial link between self-regulatory functions such as self-esteem and self-efficacy, and the social opportunity structure.Thus, work has the role of emotional and motivational self-regulation and these aspects are essential to enable changes in social life.The concept of effort is used as part of a search process of socially organized exchange at work, to which society contributes in terms of reward.The balance between effort and reward is achieved when the worker is able to actively or passively overcome problems.The model assumes that situations in which there is no reciprocity between effort and reward continually cause emotional and physiological reactions in workers.In general, discrepancies between effort exerted and rewards received at work are considered detrimental in terms of tension reactions and their harmful effects on health (8)(9)(10)(11) .
From this perspective, three recent Brazilian studies that evaluated intensive care nurses and physicians (12- 14) are worth highlighting.These studies show that the presence of stress in this occupational environment produces dissatisfaction at work, affects physical health, leads to feelings of suffering arising from relationships with patients and their family members, teamwork, rotation of employees, absenteeism and the complex technology present in these areas in addition to the high prevalence of burnout syndrome in physicians.
In agreement with these studies and using the ERI model, which describes situations in which there is no reciprocity between effort and reward at work, this study aimed to compare physicians and nurses working in pediatric and neonatal ICUs regarding effort and reward balance.The study also evaluates whether there are any differences between effort and reward in the same professional category but in different contexts of providing intensive care.

Method
This descriptive cross-sectional study was carried out using a non-randomized sample that included  The study was approved by the Research Ethics Committee at the UNIFESP/EPM and all participants signed free and informed consent forms.

Participants answered the Brazilian version of the
Effort-Reward Imbalance (ERI) (1) .The ERI describes situations in which there is no reciprocity between effort and reward at work.There are two sources of effort: extrinsic (work demands) and intrinsic (workers' individual motivation in the face of demands).The latter refers to the concept of "need of control" defined as standard to deal with work demands and contains two variables: vigor and immersion.Vigor is defined as active effort, with high probability of return (positive feedback) and immersion as a state of exhaustive competition (8) .
Nurses from the pediatric ICU displayed a higher average of effort (8.70±2.45) in relation to nurses in the neonatal ICU (7±1.33), with no significant differences (p=0.12).In the analysis of the variable reward, the average value among nurses who work in the pediatric ICU was higher (14.30±2.83)when compared to the neonatal ICU (13.20±3.05)with no statistically significant differences (p=0.23).Unlike physicians, three nurses from the pediatric ICU (30%) and one from the neonatal ICU (10%) revealed characteristics of over-commitment, though with no statically significant differences (p=0.28).
The computation for balance between effort and reward revealed that nurses in the pediatric ICU displayed a slight increase in effort in relation to reward (1.10) while nurses from the neonatal ICU were the only group with balance between measurements (0.95) (Table 2).
No statistically significant differences in any of the studied variables were found when physicians from the pediatric ICU were compared to nurses from the same unit.Statistically significant differences were found in the comparison between physicians and nurses from the neonatal unit (p<0.05),revealing that physicians reported a higher over-commitment to work than nurses, specifically due to a higher irritability with work and difficulty disengaging from work (Table 2).

Discussion
Data from this study initially reveal that each professional category present different responses in the face of organizational demands.
The variable immersion is present in the group of physicians from the neonatal ICU where vulnerability to occupational stress is more evident, that is, when physicians from the neonatal unit are compared to physicians in the pediatric ICU, the first present higher over-commitment due to their competitiveness and need for approval.Based on this information, physicians from the neonatal ICU have a higher level of need to control their workplace, which leads to an environment with high effort and low reward.These situations can be perceived as insufficient reward and return in the face of expended effort.This feeling might generate instability at work, sudden occupational changes, lack of opportunity for promotion, determining low control over occupational position (1) .
In the comparison between the teams of the neonatal ICU and the pediatric ICU, the latter present higher values of effort and reward, hence higher overcommitment to work.The demands from work are high but the rewards that result from these demands are high as well, which might lead to competitiveness and irritability within the work team.However, the nursing team from the neonatal ICU was the only group, among the four studied groups, that reported balance between effort and reward in relation to work, which constitutes a standard of response compatible with the definitions of the concept of rigor (8) , in which workers have a greater chance of having a positive return for their work.
When different categories are compared within their own work units, physicians and nurses who compose the neonatal ICU display statistically significant values for the variables irritability and difficulty disengaging from work, which constitutes an organizational environment of great professional demand and work overload.
The intense workload in the environment of neonatal intensive care has been addressed in previous studies (16- 17) .A possibility to be considered in this study is the larger number of beds in the neonatal ICU (20) compared to the pediatric ICU (9) .
In relation to the nursing team, we can say that the results presented here are in agreement with studies that used the ERI model as a resource to analyze organizational environments (18)(19) .
Another study using the ERI (20) revealed that female physicians show high scores in the over-commitment variable when compared to male physicians.A study (21) concomitantly using the ERI and Demand-Control instruments found that the over-commitment and control over work variables affect the physicians' physical health.
When female physicians were evaluated by the same instruments, the effort variable had a strong impact on physical health, while the reward variable improved the score in mental health.
Even though in this study we do not evaluate differences of gender in the occupational environment associated with tension at work, the results suggest interpersonal conflicts in the workplace among the studied population.
This study utilizes a descriptive design with frequencies and was carried out in a single facility with a small sample.Half the sample did not return the instrument, which might have compromised the results.
Despite these limitations, this (preliminary) study contributes to scientific understanding of the subject and provides information that can lead to potential outcomes, i.e. because unbalance between effort and reward is present in the medical work of both units, a longitudinal evaluation exploring the factors that lead to this unbalance should be carried out in the future, discriminating between intensive care physicians and resident physicians attending supervising training at the ICU.The rationale is that the latter might have exerted greater effort to perform tasks while having less experience.The task of the nursing team in both units, on the other hand, should be studied in a more descriptive way so that differences in the actions of these professionals in both units can be defined to investigate those that demand more effort and/or less reward among professionals in the neonatal ICU.

Final Considerations
Despite the limited number of participants, this study has important implications for future research carried out with the ERI instrument in intensive care units seeking to verify occupational factors and compare sociodemographic data with data on expended effort and reward from work with a view to provide tools for professionals of related fields so occupational risk factors are detected and reduced and also to orient workers to find appropriate ways to deal with demands from work.
physicians and nurses working in the pediatric (35) and neonatal (22) ICUs in the Federal University of São Paulo/Paulista School of Medicine (UNIFESP/EPM).Twenty-five physicians and 10 nurses from the pediatric ICU and 12 physicians and 10 nurses from the neonatal ICU, totaling 57 professionals agreed to participate in the study.The inclusion criterion consisted of being a physician or a nurse hired to work in the ICU or being a resident physician, and attending the ICU's supervised training.Distribution of sample loss is presented in

Table 1 -
Number of professionals in ICUs invited to participate in the study

Table 2 -
Results of comparisons between the pediatric and neonatal ICUs in the same professional category (physicians and nurses) and among different professional categories (physicians and nurses) PICU = pediatric intensive care unit NICU = neonatal intensive care unit