Professional nursing practice : environment and emotional exhaustion among intensive care nurses 1

Objective: to evaluate the characteristics of the professional nursing practice environment and its relationship with burnout, perception of quality of care, job satisfaction and the intention to leave the job in the next 12 months. Method: cross-sectional study with a quantitative approach to data. The sample was composed of 129 nurses working in adult Intensive Care Units from a region in the interior of São Paulo, Brazil. Results: The structural equation modeling, using path analysis, revealed that characteristics of the environment influence job satisfaction, perception of quality of care, and having an intention to leave their job, when mediated by emotional exhaustion. Nurses with limited autonomy, poor control over their practice, and poor relationships with physicians, experience a greater level of emotional exhaustion, which can negatively influence their perception of quality of care, job satisfaction and an intention to abandon their jobs. Conclusion: the mediating role of emotional exhaustion may negatively influence care delivery. Therefore, there is a need to adopt strategies to minimize this condition among nurses.


Introduction
Environments that favor the practice of nurses have been studied (1)(2)(3) since some hospitals were acknowledged as being able to more easily attract and retain professionals and, consequently, provide high quality healthcare.These facilities have been called "magnet hospitals" (1) .
The presence of certain characteristics in professional nursing practice environments can promote the development of professionals and favor safe practices, among them, the philosophy of quality-focused care, interdisciplinary cooperation, responsibility with professional authority, promotion of nursing leadership, support for the professional development of nurses, and the development of cooperative relationships among health workers (4) .
The facilities that possess such attributes encourage improved outcomes for patients, for the nursing staff, and for the institution itself (2,5) .In turn, professionals working in negative environments are dissatisfied with their jobs (6)(7) , more frequently report an intention to leave their jobs (7)(8) , and are more exposed to burnout (6)(7)9) , a condition that negatively affects professionals and impacts the characteristics of the environment and patient outcomes (9) .
Burnout is a syndrome characterized by emotional exhaustion, depersonalization, and low personal accomplishment.It mainly affects health workers due to their continuous exposure to patients afflicted by chronic diseases (10) .
In the hospital context, professionals working in Intensive Care Units (ICUs) are responsible to provide care to patients in an environment associated with complex care and the imminent risk of death, experiencing situations of death and mourning daily at the risk of becoming more susceptible to emotional repercussions and stress, leading to burnout (11) .
It is a challenge to identify and analyze the aspects involved in the professional nursing practice environment, but such an endeavor seeks to propose improved working conditions and promote changes in hospital environments.
In this context, this study's objective was to assess the characteristics of the professional nursing practice environment and its relationship with nurses' experience of burnout, job satisfaction, perception of quality care, and intention to leave the job in the next 12 months.

Method
This cross-sectional study with a quantitative approach was conducted in the adult ICUs of 17 public, The NWI-R is designed to measure the presence of certain characteristics in the working environment that contribute to the professional practice of nurses (2) .The instrument has already been translated and adapted for the Brazilian culture (12) and contains 57 items, 15 of which were selected and distributed conceptually into three subscales: autonomy, nurse-physician relationships, and control over work environment.Ten out of these 15 items were grouped and gave origin to a fourth subscale: organizational support.
A four-point Likert scale was used.The lower the score, the higher the presence of positive attributes, conducive to the practice of professionals.Scores below 2.5 indicate favorable professional practice environments while scores above 2.5 indicate unfavorable environments.
The reliability of NWI-R was assessed using Cronbach's alpha, which indicated a satisfactory internal consistency for all the subscales (13) .The following alpha values were obtained in this study: 0.78 for autonomy; 0.73 for control over work environment; 0.82 for nursephysician relationships; and 0.80 for organizational support.
The MBI, already validated for the Brazilian culture, is designed to measure the physical and emotional exhaustion of workers in relation to work (14) .It contains 22 statements, the scores of which are defined according to the frequency professionals experience certain situations: 1 -never; 2 -rarely; 3 -sometimes; Panunto MR, Guirardello EB.
results concerning the reliability of these constructs are satisfactory (14)(15) .In this study, the following internal consistency was obtained: 0.90 for emotional exhaustion; 0.54 for depersonalization; and 0.70 for low personal accomplishment.
Data were analyzed with the help of an expert.The Statistical Package for Social Sciences (SPSS) version 15.0 was used for the descriptive analysis (average, standard deviation, frequencies, and percentages) of the individuals' characteristics.The Linear Structure Relations (LISREL) software, version 8.7, was used for the multivariate analysis, through which Structural Equation Modeling (SEM) was performed.SEM was used because it is able to measure, explain and preview the degree of relationship among the statistical variables, through the establishment of causal relationships for each set of dependent variables (16) .
The model proposed in this study was composed of exogenous variables (autonomy, control over work environment, nurse-physician relationships) and of endogenous variables (emotional exhaustion, depersonalization, personal accomplishment, job satisfaction, perception of quality of care, and intention to leave their job) (Figure 1).The model was estimated using the unweighted least square (ULS) method.
The main indicators of fitness used were: a) Chi-square ratio (χ

Results
The  Afterward, the level of burnout and the characteristics of the professional nursing practice environment, obtained through the NWI-R, were evaluated.The averages, standard deviations, medians, and variation of the scores obtained by the subjects in relation to burnout and characteristics of their professional nursing practice environment are presented in Table 3. Panunto MR, Guirardello EB.
A new specification of model was required due to the high number of residuals indicated by the RMSEA; the acceptable upper limit is 0.08.
In this context, we opted to use a new theoretical model considering only one of the burnout domains for path analysis: emotional exhaustion.The statistics obtained with this model were: χ 2 /DF =0.90, GFI=0.95,AGFI=0.94,RMSR=0.07,RMSEA=0.00,CFI= 1.0 and NNFI= 1.06.Estimation of the coefficients revealed the paths were significant, described in Figure 2.

Discussion
The sample was composed of nurses, most working in general ICUs of public institutions.Young adults and women predominate, corroborating results reported by other studies (7)(8)(9)13) , results that are explained by the historical trajectory of nursing (17) .
In regard to the participants' background, most were specialists, with an education level above that reported by studies addressing nurses in other units (13,(18)(19) ; time since graduation was also greater than that reported by nurses working in ICUs from other countries (7,20) .In turn, their time of experience is less than that reported by studies addressing adult ICUs (8,20) .This is a concern, since lack of experience is associated with higher levels of emotional exhaustion and job dissatisfaction, resulting in poor quality of care delivered to patients (6) .
Even though most professionals reported only one job, the average weekly workload reported was 51 hours, which is higher than the workload allowed by the Brazilian Consolidation of Labor Laws (21) .The high number of weekly worked hours may be attributed to need on the part of the health service, or on the part of the professionals themselves seeking a higher income.
The nurses reported an average of 5.5 professionals under their supervision and 9.1 patients under their responsibility.The last figure is close to what is recommended by Resolution RDC No. 7, at least one nurse for each eight patients (22) .The variation observed in this study, however, indicates there are units in which this resolution is not complied with, where nurses are responsible for up to 33 patients.
In regard to the nurses' intention to leave their job in the next 12 months, the average presented by this study's professionals was below that of nurses working in non-specialized units (13) .Even though most nurses Rev. Latino-Am.Enfermagem 2013 May-June;21(3):765-72.
reported satisfaction with their current jobs, almost 30% reported being dissatisfied or very dissatisfied.In relation to care, they perceive that the quality of the care provided is good.
The nurses presented a moderate level of burnout on all the subscales: emotional exhaustion, depersonalization, and low personal accomplishment.
These findings are similar to studies reporting this level of burnout for the emotional exhaustion domain (15,23) , but differ in relation to the depersonalization and personal accomplishment domains.We note that the depersonalization subscale also presented an average above that found in other studies (15,23) .
We verified that the scores concerning the participants' evaluation of the characteristics of professional nursing practice environment were below 2.5 points for all the NWI-R's subscales, that is, the professionals reported having autonomy, control over their practice, good physician-nurse relationships, and organizational support.
In regard to the correlations, according to the causal model of the professional nursing practice environment, the initial analyses revealed that, in some cases, goodness of fit was adequate.However, given the large RMSEA, we opted for a new specification of the model, since this is the main index for validation of the causal model.An explanation for its high value may be the number of paths proposed for the studied model.In this sense, we opted for a theoretical model considering the most important construct for burnout, which is emotional exhaustion (10) .
Therefore We highlight the mediating role played by emotional exhaustion.Similar to other studies, this domain mediated the characteristics of environment and depersonalization (9) .This study's results corroborate the findings reported by other studies (2,13) showing that nurses with greater autonomy experience lower levels of emotional exhaustion, which reflects a lower intention to leave their job, greater job satisfaction, and the perception of improved quality of care.Additionally, the presence of autonomy in the professional practice environment of nurses working in ICUs is an important factor in retaining specialized workers, both to promote safe care and to qualify new nurses (24) .As noted in a recent study (25) , the implementation of strategies designed to promote positive working environments is important to lower levels of burnout, of intentions to leave a job, and job dissatisfaction.

Conclusion
The professional nursing practice environment, assessed through the NWI-R's variables, was considered to be conducive to professional practice.The multivariate analysis, however, enabled the identification of correlations among the environment characteristics with a direct impact on levels of emotional exhaustion and an indirect impact on the perception of quality of care, job satisfaction, and the intention to leave their job in the next 12 months.We note that emotional exhaustion was the burnout domain that showed the greatest impact on the correlation of the model presented, therefore, indicating a need to adopt strategies that minimize this condition among nurses.
We highlight the importance of further studies

Study's limitations
One of the limitations of this study is the fact it was restricted to the ICUs of a single region in the state of São Paulo, Brazil that represents a small sample of the interior of the state.Hence, larger samples and also samples from other regions of the country are required.
In relation to the discussion of results, comparison with other studies was hindered since authors do not always private and philanthropic hospitals in the interior of São Paulo, Brazil.The population included 144 nurses, 129 of which composed the sample according to the inclusion criteria: exclusively performing care activities and having three months or more of experience in the current hospital.Those on vacation or on leave were not included.The study project was approved by the Institutional Board Review (Process No. 362/2011) and the individuals who agreed to participate signed free and informed consent forms.Data were collected through three self-reported instruments: a form addressing personal and professional characterization and a characterization of the working environment; the Brazilian short version of the Nursing Work Index -Revised (NWI-R); and the Malash Burnout Inventory (MBI).Data were collected from November 24 th 2011 to January 31 st 2012.

Figure 1 -
Figure 1 -Causal model of the professional nursing practice environment and outcome variables

Figure 2 -Figure 2
Figure 2 -Final model of correlation of professional nursing practice environment , a new model correlating professional nursing practice environment was specified.This model suggests that the outcome variables may be influenced by the environmental characteristics when mediated by emotional exhaustion.It means that having autonomy, control over their practice, and good physician-nurse relationships may indirectly influence the nurses' perception of quality of care, job satisfaction, and intention to leave their job.Nurses with limited autonomy, poor control over their practice, and with poor relationships with physicians, experience a greater level of emotional exhaustion, which may negatively influence their perception of quality of care, job satisfaction and intention to leave their jobs.
proposing other theoretical models to explain the characteristics of professional nursing practice environments and that assess these variables from the perspectives of nurses working in ICUs.The purpose is for nurses to have more support in the literature to devise strategies and propose changes in the professional nursing practice environment.Such changes may result in lower costs for institutions, costs that accrue from errors in care delivery and work leave due to workers' emotional issues.

Table 1 -
Personal and professional characterization and characterization of professional nursing practice environment in adult ICUs (n=129).Campinas, SP, Brazil, 2012 care, 8.5% in cardiac ICUs, 7% in transplantation ICUs, and 3.9% in ICUs specializing in neurology.The individuals' personal and professional characteristics and the characterization of their work environment are presented in Table 1.www.eerp.usp.br/rlaeRev.Latino-Am.Enfermagem 2013 May-June;21(3):765-72.Job satisfaction and perception of quality of care, both assessed using a Likert scale, are presented in Table2.Scores concerning poor and very poor assessments were grouped because these were less frequently reported.

Table 2 -
Frequency and percentage of job satisfaction and quality of care (n=129).Campinas, SP, Brazil, 2012