Resilience and the reduction of occupational stress in Nursing

Abstract Objective: to analyze the association between resilience and occupational stress of Nursing professionals from a general hospital. Method: an observational, cross-sectional study involving 321 Nursing professionals. The data collected were: socio-demographic and labour variables, stress and resilience, analyzed with descriptive and inferential statistics. Results: 54.5% of the participants presented moderate resilience and 36.4%, high; 73.5% were at risk of exposure to occupational stress; the relationship between psychological demands and professional category (p=0.009), between control over work and age (p=0.04), professional category (p<0.001), having a management position (p=0.009), being a specialist (p=0.006) and between social support and professional category (p<0.001), having a management position (p=0.03), daily working hours (p=0.03), being a specialist (p<0.001) were verified. There was an association between resilience Factor I - resolutions of actions and values and control over work (p=0.04) and social support (p=0.002). Conclusion: the Nursing professionals of a general hospital have moderate to high resilience which, associated with high control over their work and high social support, may contribute to the reduction of exposure to occupational stress.


Introduction
Stress has become a common health problem, with significant repercussions in the worker's life. Psychosocial factors arising from the interaction of the individual with the work environment, its work demands, conditions and organizational structure can influence health and job satisfaction (1) .
Occupational stress, besides causing impacts on the daily work of nursing, in view of the physical, psychological, social and cultural damage resulting from it, is reflected in the family, in the institution and in society (2) .
Characteristics of the nursing work in the hospital context, such as constant exposure to biological, chemical and ergonomic loads, as well as to psychological demands and unfavorable working conditions and the working environment itself, contribute to the worker's physical and psychological illness (3) .
Factors such as organizational structure, nature and work environment predispose the nursing professional to occupational stress (4) . In addition, the intense pace, the high cognitive and emotional demands, shift work, physical and psychological aggravations (5) , stressful situations, conflicting relationships, pressing risk of errors and losses permeate the day-to-day work and have repercussions on the worker's mental health, with repercussions on the assistance (6) .
A study of nurses in Spain affirmed the negative relationship between Nursing occupational stress, the work environment and coping with death (7) . In this sense, a Brazilian investigation evidenced occupational stress, at medium or high level, in 57.4% of the Nursing professionals investigated and explained that the highest levels of stress were associated with the professional category of being a nurse, the shortest time of training, facing the death of the patient and attending to the emergencies and needs of the family members (8) .
Exposure to stress is influenced by personal and professional characteristics, such as gender, marital status, parenthood, work regime, dual employment status, shift and weekly working hours (2) . A study with Nursing professionals from a university hospital pointed out night work, the simultaneous performance of different tasks combined with frequent interruptions, work overload and the lack of sufficient time to provide care and emotional support to the patient among the main stressors in the profession (4) .
As for the symptoms resulting from stress, besides physical alterations, psychological alterations can be perceived, such as emotional lability, anxiety, fatigue, among others, which interfere with patient care and professional satisfaction (9) . In this sense, the early identification of the main stressors in the work of nursing enables the development of strategies for the promotion and protection of health and prevention of occupational illness in the context of work organization (10) . The ability to cope with stressors depends on the support offered to the professional and the demands of the context and requires the implementation of intervention programs aimed at promoting coping strategies focused on overcoming vulnerabilities (9) .
Among the strategies to overcome the difficulties of everyday work in Nursing, studies have focused on resilience (11) , considered a defense mechanism against the threats of suffering or illness, which enables the individual to recover, learn and become stronger to face challenges (12) , constituting an internal reconfiguration that favours positive and creative attitudes and perceptions of the human being when facing difficulties (13) . A study with Nursing professionals, which scored the risk of physical and psychological illness of the category, made explicit the correlation between psychosocial stress and resilience and the need to reorganize work processes and encourage programs that promote resilience in Nursing (14) .
Identifying factors that contribute to reducing work stress among nursing professionals in the hospital environment and coping strategies can directly impact working conditions and, indirectly, the quality and safety of care provided to patients. Given the above, this study aimed to analyze the association between resilience and occupational stress of Nursing professionals from a general hospital.

Type of study
This is an observational, exploratory, crosssectional study.

Data collection site
The study was developed in a philanthropic hospital with 225 beds, a macro-regional reference in health, located in a city in the North-western Region of the State of Rio Grande do Sul (RS), Brazil.

Period
Data collection took place from December 2019 to March 2020.

Population
The target population of the study comprised 527 Nursing professionals, of whom 90 were nurses and 437 Nursing technicians.

Selection criteria
The inclusion criteria established were: being a Nursing professional and working in the Nursing service of the institution, regardless of how long they had worked.
Five nurses and 59 Nursing technicians who, during data collection, were on vacation, on sick leave, or on maternity leave were excluded; two nurses and ten technicians who did not agree to participate in the study and 130 Nursing technicians who did not respond to the instrument after the third Google Forms ® link was sent via WhatsApp ® , provided by the professional himself. The sample was composed of 321 Nursing professionals, of whom 83 were nurses and 238 Nursing technicians.

Participants
There was no sample size calculation, since all Nursing professionals of the institution were eligible and were invited to participate in the study. However, from a total of 527 eligible professionals, 321 (60.9%) participated in the study. This quantitative allows us to infer that these data have a confidence level of 99% and sampling error of 3%, which demonstrates the reproducibility of the data collected.

Study measures
The outcome variable evaluated in this study was exposure to occupational stress. The explanatory variables were resilience and socio-demographic and labour characteristics: gender; age; marital status; category; position held; shift; daily and weekly work hours; time of graduation (years); how long he has worked in Nursing; graduate courses; work unit and presence of employment in another institution. The exposure to occupational stress was evaluated according to the Demand-Control Model (DCM), using the JSS translated and adapted to Portuguese (15) , which evaluates psychosocial factors and exposure to stress in work activities. It is a self-administered scale, with 17 questions on a Likert scale, distributed into three dimensions:1) psychological demand (questions one to five) -assesses the time and speed to perform tasks and the existence of conflict between different demands;

Instruments used to collect the information
2) control (questions six to 11) -assesses the use and development of skills and authority to make decisions at work and 3) social support (questions 12 to 17) -assesses the worker's perception of support from managers and colleagues in their work environment (15) .
For the demand and control questions, the score ranges from one (never or almost never) to four (often); for the social support questions, the score ranges from four (strongly agree) to one (strongly disagree). Questions four ("Do you have enough time to do all the tasks of your job?") and nine ("In your job, do you have to repeat the same task many times?") were reversed to calculate the final score according to the rules of the original instrument. For each dimension of the scale, the higher the score, the greater the psychological demand, the control over work, or the social support perceived by the worker (15) .
In the bivariate statistical analysis of the JSS, for the dichotomization, due to the lack of data symmetry, the median of the total score of each dimension was used as cut-off point (15) . Values below the median were allocated to the low demand, low control, or low social support groups and values equal to or greater than the median were allocated to the high demand, high control, or high social support groups (15) . The score of the domain "psychological demand" varies from five to 20 points and was dichotomized into low demand (five to 14 points) and high demand (15 to 20 points). The score of the "control over work" dimension ranges from six to 24 points and was dichotomized by the median into low control (nine to 17 points) and high control (18 to 24 points). The score for the "social support" domain ranges from six to 24 points and was dichotomized into low social support (six to ten points) and high social support (11 to 24 points).
Finally, the distribution in the quadrants of the DCM (16) was stratified into low-demand work (high control and low demand), passive work (low control and low demand), active work (high control and high demand) and highdemand work (low control and high demand). According to the theory on which this psychometric instrument is based, the "social support" dimension works as a moderator of work stress (15) .
The RS, developed in 1993 (17) and translated and validated into Portuguese (18) , evaluates the level of positive with response options on a Likert scale ranging from one (strongly disagree) to seven (strongly agree). The sum of the value assigned to each item, at the end, varies between 25 points (less resilience) and 175 points (high resilience) (18) . In this study, we chose to adopt as a classification criterion a score below 121 as low resilience, from 121 to 146 as moderate resilience, and above 147 as high resilience (19) . RS comprises three factors: Factor I represents the sum of the questions characterized by resolutions of actions and values that give meaning to life (1,2,6,8,10,12,14,16,18,19,21,23,24, and 25); Factor II encompasses questions that convey the idea of independence and determination (5, 7, 9, 11, 13, and 22) and Factor III represents the sum of the questions characterized by self-confidence and the ability to adapt to situations (3, 4, 15, 17, and 20) (18) .

Data analysis
The data collected on printed forms were typed into Excel ® by two independent typists, being compared later, and the returns obtained online were also checked.
Data was transferred to the Statistical Package for the Social Sciences (SPSS) software, version 22.0, and analyzed with descriptive and inferential statistics. In Table 1, for the significant analyses, variables with p < 0.05 when associated with the outcome, the odds ratio (OR) was calculated and simple linear regression was performed, considering the Durbin-Watson and the graph of the relationship for the certification of the adequacy to the model.

Discussion
The fact that 73.5% of the Nursing professionals participating in this study presented some degree of exposure to stress and that 27.7% of them were in the quadrant of highly demanding work is worthy of attention, since this situation can have negative repercussions on the work environment. There was the perception, by the worker, that the high social support and the control over the work performed are protective factors against stress exposure (2) . Support from colleagues and supervisors in performing tasks, social integration and a trusting relationship in the group contribute to the prevention of the harmful effects of work-related stress on the worker's health (21) .
Another result indicating an alert exposure to stress is the sum of the percentage of workers who performed passive work (19.0%) to the percentage of those who were in highly demanding work (27.7%), which shows  A systematic review that aimed to identify the main psychosocial factors in Nursing work indicated that the perception of justice, respect, support from supervisors and social inclusion favour the preservation of the mental health of Nursing workers (5) . The subjective and individual character in the perception of factors that contribute to stress and the need for health-promoting interventions focused on psychosocial characteristics, which enable the active participation of professionals, are highlighted (28) .  (29) . Problemcentered problem solving is considered a cognitive strategy in which the individual recognizes adversity and seeks alternative solutions focusing on the positive aspects involved (3) .
The sum of the percentage of professionals in active work (26.8%) to those who were in a low demand job (26.5%) showed that a little more than half of the participants were in a range considered to be at a lower risk of getting sick. Increased control over work is associated with better health assessment and lower levels of stress (25) . Active work is when high demands and high control of work coexist, which enables the worker to learn, to grow personally and to plan strategies to better cope with stress.
Finally, despite a not worrisome figure in terms of occupational health, it is noteworthy that 9% of the participants in this study showed low resilience.
Resilience is a competence that can be developed (17) . force for overcoming adversity (29) .