Impact of the Clinical Management of Pain : Evaluation of Stress and Coping Among Health Professionals

The specialist literature highlights that the clinical management of pain involves psychological difficulties associated with the pursuit of the alleviation of the suffering of patients. Therefore, an investigation was conducted into the perception of stress and coping strategies of 31 professionals of different categories from a severe burns care center (acute pain) and a pain control and palliative care unit (chronic pain). For this, a sociodemographic questionnaire, the Job Stress Scale (short version) and the Coping Strategies Inventory were applied. Compared to other categories, the nursing technicians indicated more stress factors. In compensation, they reported a greater diversity of coping strategies with significant differences between the services. These results corroborate previous studies, which warn of the adverse conditions that interfere in nursing practice. However, they also reveal the availability of protective factors, indicating perspectives of preventive intervention for the nursing team.


Introduction
Patients who suffer from chronic pain, and severe burn patients that experience acute pain, are usually assisted by a multidisciplinary team composed of physicians, nurses, physical medicine professionals, and psychologists, among others (1)(2) .Treating these patients constitutes a challenging and often frustrating task for the agents involved.It is noteworthy that the stress levels of caregivers are influenced by the reactions of the patients, who may present depression or anxiety (3) before treatments that induce many collateral effects with little immediate relief of suffering (2,4) .Added to this is the overload of work and the difficulties caused by their participation in a team composed of professionals of heterogeneous training (5)(6) .In fact, the specialized literature reveals increasing interest in the care of those who perform the role of caregivers (7)(8) .This trend is due, in part, to the verification of pathological reactions triggered by the act of caring.It is worth insisting that besides affecting the patient, the experiences provoked by pain contaminate their family and the rest of their socio-emotional context, including the professionals with whom they interact in the service (9) .The change Rev. Latino-Am.Enfermagem 2011 Mar-Apr;19(2):238-44.
in attitude of the health professionals themselves, who have started to admit their need for care in some circumstances (8) , also contributes to the development of studies on the subject.
According to the transactional model (10) , it is not possible to comprehend the stress by examining the environmental events and the responses of the individual separately.Both should be comprehended as a transaction, in which each individual seeks to adjust to the quotidian challenges (11) .Thus, the exchanges between people and the environment occur through a cognitive evaluation, in which the following are analyzed: whether the situation threatens the well-being; whether the resources are sufficient to cope; and, during the cycle, whether the chosen strategy is effective (12) .In the 1970s, Robert Karasec and other pioneering researchers showed that working relationships represent a generator source of stress with health repercussions.They proposed a bidimensional model that relates psychological demand and the control of the risks of becoming ill.
According to its supporters, the psychological demand refers to quantitative factors such as time and speed in performing the work, and qualitative factors, such as conflicts arising from contradictory requests.The control corresponds to making possible the use of intellectual abilities and decision making regarding how to conduct the work activity (13) .Therefore, the coexistence of high psychological demands with low control generates professional distress and may have a negative impact on the health of the worker (14) .These conditions typically characterize the practice of the health professionals, who are subjected to constant tension due to the nature of their actions with people whose physical, mental and social integrity is affected, as well as due to the need to manage complex institutional issues associated with public policies and the exchange between different professional categories (7) .
Coping is commonly defined as cognitive and behavioral efforts to deal with (reduce, dominate or tolerate) the external demands of the individualenvironment relationship, which are evaluated as overloading or exceeding the personal resources (15) .This definition comes from the model proposed by Lazarus and Folkman (10) , which advocates coping as a process resulting from reciprocal responses between individuals and their context over a period of time (16) .This is a moderator of the events evaluated as stressful, which can reduce the severity of the symptoms (17) .The coping strategy would be considered effective when the behavior alleviated the uncomfortable feelings raised by threats or losses.It would be considered ineffective, when it was not possible to deal with the stressful situation in a successful manner, which could trigger psychological and physiological imbalances (18) .In summary, in view of the scientific and professional interest in the area of health, an investigation was carried out into the perception of stress and coping strategies adopted by the professionals of specialized teams in the monitoring of patients with acute and chronic pain.

Method Participants
The purposive sample was constituted by professionals of different categories from a severe burns monitoring service (SBMS) and a chronic pain and palliative care service (CPPCS).Table 1 presents the main characteristics of these participants.

Instruments
Sociodemographic questionnaire for characterization of the sample Coping Strategies Inventory of Folkman and Lazarus (adapted into Portuguese) (19) , comprising 66 items that classify the coping strategies into eight factors Portuguese (14) , encompassing 17 items for the evaluation of demand, control and social support perceived by the worker, which are measured on a Likert scale of four points (ranging between often and never/almost never or between strongly agree and strongly disagree).

Procedures for collecting and analyzing data
The study was previously approved by a Research Ethics Committee and the agreement of the professionals was obtained by signing the Terms of Free Prior Informed Consent (TFPIC).Initially, the Sociodemographic Questionnaire was applied followed by the scale and the inventory, respectively.For data analysis, the statistical package SPSS version 17.0 was used.As the distribution of participants in the majority of groups based on the antecedent variables, was less than 15, the use of nonparametric tests was chosen to obtain descriptive, comparative statistics and, in a few cases, correlations.

Stress
Regarding the psychological demands, the scores obtained ranged from 12 to 22, with an associated mean These values indicate the existence of demands at higher levels than the expected median (15).Similarly, the factor control reached values between 16 and 29 and an associated mean of 22.9, also above the expected median (18).Regarding social support, considered to be a moderating factor of work stress, a mean value of 18.2 was verified, which is slightly higher than the expected median (between 12 and 18).Comparing the four groups identified in the professional categories (antecedent variable) with the factors proposed by the Job Stress Scale, statistically significant differences were found in the dimensions control and social support (Figure 1).

Coping
All factors relating to the Coping Inventory achieved means congruent with the median values expected.
The coping strategies used most often encompassed the following factors in ascending order: escapeavoidance, confrontation, self-control, problem solving, withdrawal, social support, accepting responsibility and positive reappraisal.
As illustrated in Figure 2, significant differences were found between the members of the SBMS (acute pain) and the CPPCS (chronic pain) in relation to the confrontation and resolution of problems (U=29, p=0.05 and U=22, p=0.02, respectively).It is important to highlight that the professionals of the CPPCS reported using more of the strategies grouped in these factors.

Discussion
The overall results obtained from the Job Stress Scale indicated high levels of psychological demands.
Conversely, they also highlighted higher levels of control in the work and social support received.Such a situation, in which high psychological demands are associated with high control, reveals that the participants experience their work actively.That is, although the psychological demands are excessive, they are less harmful, since the worker can develop strategies to cope with the difficulties (14) .Furthermore, the adverse conditions of the work context of the studied teams also seem to ease when high levels of positive social interaction are detected.However, when analyzing each of the professional categories separately, specificities emerged.
Thus, while the indexes related to the perception of psychological demands were presented as equally high for all categories, differences were verified between control and social support in the area of nursing.It is worth reflecting that the low mean scores achieved by the nursing technicians can be comprehended by considering the persistence of a strong hierarchy in the health services, despite the nefarious consequences of this mode of organization, already widely discussed in the literature (20) .In the case of the nurses who achieved higher values, it must be remembered that they assume It is worth mentioning that, in the SBMS, the burn remains as an acute pathological condition that demands, at least in the initial phases of care, actions geared primarily to maintaining the vital signs of the patient.In the CPPCS there are peculiarities inherent in the outpatient context in which complaints related to chronicity predominate, such as the terminality, which require a high complexity of care (2) .In these circumstances, the high levels of social support perceived by the professionals can be generated by feelings of intense frustration due to the recurrence of therapeutic weaknesses (9) , which ultimately favor an approach known as integrative metatheory.This is a perspective where the different dimensions interact in the health-disease process and enable effective multidisciplinary practice (20) .Similarly, it can be observed that the chronicity provokes changes that mainly affect the relationship of the physician with the other health professionals and with the patient (2) .

Conclusion
This study showed that the nursing technicians are subjected to more stress than the other categories, including nurses.In compensation, the nursing categories mobilize a greater diversity of coping strategies.These results warn of the adversities that interfere in nursing

(
confrontation, distancing, self-control, social support, accepting responsibility, escape-avoidance, problem solving and positive reappraisal) and according to the intensity (I did not use this strategy, I used it a little, I used it, and I used it very much).Job Stress Scale, the reduced version adapted to Negromonte MRO, Araujo TCCF.

Figure 1 -
Figure 1 -Distribution of the Job Stress Scale factors for the professional groups

Figure 2 -
Figure 2 -Distribution of the Coping Inventory factors by service the administrative coordination of the services and the leadership of the nursing staff.Due to this function, they concentrate much of the information regarding the operation of the service and the clinical condition of the patients, by increasing their interaction with the other members of the multidisciplinary team and ensuring greater autonomy in establishing their work routines.This peculiarity can clarify the data found in this category.
practice.Protective factors were also identified, which can support proposals for preventive intervention aimed at the nursing team.In other words, it is essential to strengthen the coping strategies already employed and to introduce other modalities indicated by the literature and acceptable in the context of each team, depending on their specialization in the care of patients with acute or chronic pain.It is equally crucial to organize and offer continuing education courses, aimed at the qualification and training of these teams, which are based on previously developed studies.Further studies are recommended to better elucidate the conditions that promote and hinder the effective and efficient multidisciplinary teamwork in the context of services that treat patients with pain.It is essential to evaluate more fully and accurately the impact of the clinical management of pain on the health of the professionals and consequently on the quality of life and well-being of the users.

Table 1 -
Characterization of the professionals