Burnout and Stress Among Nurses in a University Tertiary Hospital 1

This cross-sectional, analytical and correlational study investigated the existence of Burnout based on a sample of 149 nurses of a university tertiary hospital from October to December 2008 and correlate Burnout with stressors in the hospital work environment. The Maslach Burnout Inventory, the Nurses’ Stress Inventory and a questionnaire to characterize the subjects were applied. The results indicated the presence of Burnout in 7.3% of nurses (quartile) and 10.22% (tercile), and also a correlation among the inventories’ domains. Vulnerability to this type of illness among nurses was increased by stress experienced in the work environment.


Introduction
The focus of this study emerges from the context of relations between psychological load and work, acknowledged by the Psychodynamics of Work (1) .Lack of adaptation between the needs that accrue from the mental structure and the tasks' ergonomic content in the workers' experience lead to dissatisfaction, suffering or anxiety, feelings rarely expressed in words or clearly manifested by workers (2) .That is why this study assumes that nurses are especially vulnerable to mental disorders related to work such as Burnout, since their objects of work such as care, education, management, research and political participation are actions that depend on intense interpersonal relationships that occur in dynamic and overloaded work contexts.
In terms of profession, it is acknowledged that an expressive number of nurses with Burnout not characterized as a consequence of their occupation, can contribute to belittling their activity as these workers may be seen by clients and colleagues as bad and cold professionals, indifferent to human suffering, disease and death.Burnout in nursing workers is harmful in the individual and professional spheres because it can negatively affect the quality of nursing care delivered to patients and family members in health services in a time when humanization in health care is a priority.Professional Incompetence (PI) (Reduced Professional Accomplishment), which can be independent or associated (3) .
Emotional exhaustion is the first response to chronic occupational stress, accompanied by physical exhaustion and depleted emotional resources to deal with the stressing situation (4) .Depersonalization, in the sense of dehumanization, refers to the perception of deteriorated problem-solving capacity and diminished satisfaction with work accomplishments, leading to emotional insensitivity, at which point the professional starts to treat the recipients of health care, colleagues and the organization in a dehumanized manner (4) .
Manifestations such as anxiety, increased irritability, lack of motivation, reduced work goals and commitment to results, reduced idealism, alienation and egoistic attitudes (5)  The literature discusses the limits between stress and Burnout: the exposure to work factors perceived as dissatisfaction by workers leads to physical and emotional exhaustion, which initially appears under the form of stress accompanied by efficient coping mechanisms (6) .
If exposure to stress factors is perceived by the worker as dissatisfaction without efficient and sufficient coping strategies, Burnout sets in.While stress can present both positive and negative aspects, Burnout always has a negative character (3) .
In terms of recognition of workers' health protection and promotion arising in the Constitution of the Federative Republic of Brazil (7) and the Organic Health Law (8) , the Regulation of Social Security (9) was approved, which acknowledges Burnout as a disease related to the special condition of work, associating it with risk factors of an occupational nature such as "laborious work pace" and "other physical and mental difficulties related to work".The Social Security Protocol on Medical-Expert Procedures on Burnout states that in the face of the syndrome's epidemiological evidence in certain occupational groups, its occurrence in these groups can be classified as "occupational disease" (10) .
It is important to stress that for a condition to be characterized as Burnout Syndrome, a relationship with occupation must exist (10) .
The levels of Burnout differ according to culture, professional category and occupational characteristics, evidencing the importance of specific studies for each population (3) .Despite the academic and legal acknowledgement of Burnout, its diagnosis and report as an occupational-related disease is still a challenge for Worker Health.Hence, this study investigates the existence of Burnout in a group of nurses in a tertiary university hospital and its relation with occupational stress.
From this perspective, this study can support the understanding of this condition and provide suggestions to cope with occupational problems such as professional dissatisfaction, absenteeism, job turnover, occupational accidents, occupation-related diseases and abandonment of profession, and also allow the comparison of results among studies, demonstrating its social relevance.Burnout Inventory (MBI) (11) , and the Nurses' Stress Inventory (NSI) (12) .

Method
Lorenz VR, Benatti MCC, Sabino MO. scores are summed into a global score; the higher the Emotional Exhaustion and Depersonalization, the higher the final score.In the case of Incompetence, the higher the score the lower is for Competence, generating Incompetence (11) .
There is no consensus in studies investigating the prevalence of Burnout in specific groups of workers regarding the cutoff point to classify subscales in low, moderate and high according to the original version of the Maslach Burnout Inventory (13)(14) .Therefore, this study established cutoff points by quartiles (25% and 75%) (11) and terciles (33.3% and 66.6%) (15) to classify the studied sample in low, moderate or high levels of Burnout.
The Nurses' Stress Inventory (NSI) was developed to measure the frequency with which the strongest stressors in the workplace are perceived by nurses (12) .
It  (12,16) ., the obtained values were accepted and allowed the study to proceed.
To identify and ordinate the magnitude of correlations between stress (NSI) and Burnout (MBI), correlation values below 0.30 were considered weak, between 0.30 and 0.50 moderate and above 0.50 strong (18) .Level of significance was set at 5.0%.

Discussion
The MBI analysis compared this study's averages to those of the original (6,11) , and increased Emotional www.eerp.usp.br/rlaeservice management and the Worker Health service to investigate epidemiological evidence (10) .The obtained results reinforce the assertion that psychosocial stressors are as potent as microorganisms and insalubrities in the onset of diseases.Hence, a tense and unsatisfactory work atmosphere coupled with long work hours result in stress factors (19) , which reinforce the view that nursing is a very stressful profession, given the results obtained in this study (16) .
Strong and positive MBI intra-domains correlations were verified between Emotional Exhaustion and Depersonalization, suggesting that nurses who obtain high scores in one of these domains will likely obtain high scores in the other (6) .Testing the NSI intradomain correlations revealed positive correlations in all the factors, which confirm the existence of a global factor (12) .
Suffering experienced by nurses in intensive care units is related to the care these professionals provide to critical patients, problems they take home, the need to deal with patients' family members, teamwork, lack of acknowledgment and work-related technology (20) ,  (21) .It highlights the importance of deeply investigating nursing work organization in the context of hospitals to diminish Burnout levels.
Qualities in the environment of health facilities such as autonomy, control over the environment, and work relationships among physicians and nurses favor good nursing practices (22) .In this context, the strong to improve the workers' quality of life (23) .
Emotional Exhaustion displayed a moderate correlation with Interpersonal Relations in this study.A recent study carried out with workers from the Family Health Strategy revealed that interpersonal relationships were determining factors for non-exhausted workers to cope with occupational stress, develop motivation at work, and deal with problems.For the exhausted workers, on the other hand, interpersonal relationships were a source of suffering and exhaustion at work (24) .
As verified in this study, hospital nurses experience high levels of stress and as perceived stress increased, the MBI dimensions also increased.When the stressing event is of a long duration, the consequences on the body can also be more intense and lead to progressive weariness and exhaustion (25) .While stress can present positive and negative aspects, Burnout always has a negative character (3) , which harms the worker, manager and citizen, hence the importance of acknowledging, preventing, treating and reporting Burnout.

Conclusion
The collective approach, within the limits of the Maslach Burnout Inventory and the Nurses' Stress or Burnout Syndrome, is a process in which the work context and interpersonal aspects contribute to the development of burnout and a condition of psychological suffering related to work organization characterized by three dimensions: Emotional Exhaustion (EE), Depersonalization (D) and feelings of Rev. Latino-Am.Enfermagem 2010 Nov-Dec;18(6):1084-91.
This is a cross-sectional, exploratory, analytical and correlational study.Data collection was carried out between October and December 2008 in clinical, medical and surgical inpatient units, intensive therapy units, Emergency Department, Pediatric Nursing Service, Nephrology Integrated Center, and Day Hospital for AIDS treatment, all linked to the Nursing Department of a large tertiary university hospital, that solely cares for patients within the Brazilian Single Health System (SUS).The simple random sample was composed of 149 nurses (care, support, supervision and management) of the morning, afternoon, and night shifts and administrative office hours, proportionally drawn according to the workplace, obtained from a population of 267 nurses.The following inclusion criteria were used: being a nurse, working in the places previously defined in the study, and returning appropriately completed instruments.The exclusion criterion was being on leave or vacation during data collection.In order to meet the study's objectives the following instruments were used: a form developed by the researchers to collect characterization data of participants, the Maslach Exhaustion and Depersonalization as well as diminishedCompetence were observed in the studied sample.The MBI application evidenced three dimensions that suggested Burnout in 7.3% (quartile) and 10.2% (tercile) of the sample.The application of the NSI revealed high levels of stress in the three domains 8.03% (quartile) and 13.14% (tercile), indicating the need for the health Rev. Latino-Am.Enfermagem 2010 Nov-Dec;18(6):1084-91.
may explain the strong correlations found in this study among the MBI (EE, D and I) and NSI (RSC and IWF) domains.These correlations refer us to the psychodynamics and Psychopathology of labor, analytical aspects of which encompass the dynamics of psychological processes mobilized by the confrontation of the individual with the reality of work based on the categories of the analysis of work organization and mental suffering correlations found in this study between the MBI (EE, D, I) and NSI (RSC and IWF) domains demonstrate the importance of managing issues related to Role Stressors in Career and Intrinsic Factors to Work to minimize suffering that accrues from Burnout in nurses.Nursing management can, through knowledge concerning its team, promote organizational and educational actions Inventory, indicated Burnout (work related) in 7.30% (quartile) and 10.22% (tercile) of the nurses, whose scores were high in all the BMI domains.High levels of stress were also seen in 8.03% (quartile) and 13.14% (tercile) of nurses, whose scores were high in all the NSI domains.The conclusion is that nurses are vulnerable to being affected by Burnout due to stress experienced in the hospital environment.In this study, Emotional Exhaustion showed a strong correlation with Intrinsic Factors to Work (0.65), as with the Role Stressors in Career (0.57); and a moderate correlation with Interpersonal Relations (0.50).Depersonalization showed a moderate correlation with the Stressor Role in Career (0.46) and with Intrinsic Factors to Work (0.38) and a weak correlation with Interpersonal Relations (0.27).Incompetence presented an inverse weak correlation with Stressor Role in Career (-0.29),Intrinsic Factors to work (-0.27) and Interpersonal Relations (-0.17).Finally, psychological and cognitive overload should be taken into account in the evaluation of workload in the work environment of health facilities, which would represent a leap forward in the investigation of risk in nursing practice, especially in highly complex university hospitals.

Table 4 -
Intra domains of the NSI, Brazil, 2008 n: nurses p: p-value r: Spearman or Pearson correlation coefficient The NSI application evidenced that the correlation between the Role Stressors in Career and Intrinsic Factors to Work was strong (0.72); between the Role Stressors in Career and Interpersonal Relations was also strong (0.58); and the correlation between Interpersonal Relations and Intrinsic Factors to Work was moderate (0.50).The correlations between total NSI and each of the domains were strong.

Table 5 -
Correlations between the inventories NSI and the MBI applied in nurses,Brazil, 2008 Moderate correlations were found between EmotionalExhaustion and Interpersonal Relations (0.50); between Depersonalization and the Role Stressors in Career (0.46); between Depersonalization and Intrinsic Factors to Work (0.38); and between Depersonalization and total NSI (0.40).