Burnout among nurses: a multicentric comparative study

Elisabete Maria das Neves Borges Cristina Maria Leite Queirós Margarida da Silva Neves de Abreu Maria Pilar Mosteiro-Diaz Maria Baldonedo-Mosteiro Patrícia Campos Pavan Baptista Vanda Elisa Andres Felli Miriam Cristina dos Santos Almeida Silmar Maria Silva About the authors

Abstracts

Objetivo:

to identify and compare burnout levels between Portuguese, Spanish and Brazilian nurses.

Method:

quantitative, descriptive, correlational, comparative and cross-sectional study conducted using a sample of 1,052 nurses working in hospitals and primary care centers. A sociodemographic questionnaire and the Maslach Burnout Inventory were applied to nurses in Porto, Portugal (n=306), Oviedo, Spain (n=269) and S. Paulo, Brazil (n=477). Data analysis was performed using descriptive, inferential and multivariate analysis.

Results:

approximately 42% of the nurses showed moderate/high levels of burnout, with no differences found between countries (Portugal and Brazil 42%, Spain 43%). Only depersonalization showed differences between countries, presenting Spain the highest level and Portugal the lowest one. Comparative analysis showed higher burnout levels in young nurses and those working by shifts. Considering job schedules, burnout was associated to shift work in Portugal, while in Spain and Brazil it was associated with fixed schedules.

Conclusion:

these results suggest that this syndrome among nurses is a global phenomenon. The daily stressors and higher demands of the nursing profession are crucial in the preparation of nurses to deal with complex situations, to avoid burnout, and to reduce the negative impact on nurses’ health and on the quality of care they provide.

Descriptors:
Brazil; Professional Burnout; Multicenter Study; Nursing; Portugal; Spain


Objetivo:

identificar e comparar os níveis de burnout entre enfermeiros portugueses, espanhóis e brasileiros.

Método:

estudo quantitativo, descritivo, correlacional, comparativo e transversal, realizado com 1.052 enfermeiros em hospitais e unidades básicas de saúde. Um questionário sociodemográfico e o Maslach Burnout Inventory foram aplicados com enfermeiros de Porto-Portugal (n=306), Oviedo-Espanha (n=269) e São Paulo-Brasil (n=477). Os dados foram analisados por meio de estatística descritiva, inferencial e multivariada.

Resultados:

aproximadamente 42% dos enfermeiros apresentaram níveis moderados/altos de burnout, não sendo encontradas diferenças entre os países (Portugal e Brasil com 42%, Espanha com 43%). Apenas a dimensão despersonalização apresentou diferenças entre os países, com um nível mais elevado na Espanha e mais baixo em Portugal. A análise comparativa mostrou níveis mais elevados de burnout em enfermeiros jovens e naqueles que trabalhavam em turnos. Em relação às escalas de trabalho, burnout foi associada ao trabalho por turnos em Portugal e aos horários fixos na Espanha e no Brasil.

Conclusão:

esses resultados sugerem que essa síndrome em enfermeiros é um fenômeno global. Estressores diários e maiores demandas da profissão de enfermagem são elementos cruciais para preparar os enfermeiros para lidar com situações complexas, evitar burnout e reduzir o impacto negativo na sua saúde e na qualidade dos cuidados que prestam.

Descritores:
Brasil; Esgotamento Profissional; Estudo Multicêntrico; Enfermagem; Portugal; Espanha


Objetivo:

identificar y comparar los niveles de burnout entre enfermeros portugueses, españoles y brasileños.

Método:

estudio cuantitativo, descriptivo, correlacional, comparativo y transversal, realizado con 1.052 enfermeros de hospitales y unidades básicas de salud. Se aplicó un cuestionario sociodemográfico y el Maslach Burnout Inventory a enfermeras de Porto, Portugal (n=306), Oviedo, España (n=269) y São Paulo, Brasil (n=477). Los datos se analizaron mediante estadística descriptiva, inferencial y multivariada.

Resultados:

aproximadamente el 42% de los enfermeros presentaban niveles moderados/altos de burnout y no se encontraron diferencias entre países (Portugal y Brasil 42%, España 43%). Solo la dimensión de despersonalización mostró diferencias entre países, con un nivel mayor en España y menor en Portugal. El análisis comparativo mostró mayores niveles de burnout en enfermeros jóvenes y en los que trabajaban por turnos. En cuanto a los horarios de trabajo, el burnout se asoció con el trabajo por turnos en Portugal y con horario fijo en España y Brasil.

Conclusión:

estos resultados sugieren que el síndrome de burnout en enfermeros es un fenómeno global. Los estresores cotidianos y las mayores exigencias de la profesión de Enfermería son elementos cruciales para preparar a los enfermeros para enfrentar situaciones complejas, evitar el burnout y reducir el impacto negativo en la salud de los enfermeros y la calidad de la atención que brindan.

Descriptores:
Brasil; Agotamiento Profesional; Estudio Multicéntrico; Enfermería; Portugal; España


Introduction

Since the 1970s, mostly from the studies developed in 1974 and 1976(11 Freudenberger HJ. Staff Burn-Out. J Soc Issues. [Internet]. 1974 Jan [cited Jul 12, 2019];30(1):159-65. Available from: http://dx.doi.org/10.1111/j.1540-4560.1974.tb00706.x
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-22 Maslach C. Burned-out. Hum Behav. [Internet]. 1976 Jun [cited Jul 12, 2019];5:16-22. Available from: https://psycnet.apa.org/record/2016-26280-043
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), burnout syndrome is recognized as a serious professional hazard. Over the last decade, this syndrome has become more prevalent(33 White EM, Aiken LH, McHugh MD. Registered Nurse Burnout, Job dissatisfaction, and missed care in nursing homes. J Am Geriatr Soc. [Internet]. 2019 Jul [cited Jul 7, 2020];23;67(10):2065-71. Available from: http://dx.doi.org/10.1111/jgs.16051
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4 Laker C, Cella M, Callard F, Wykes T. Why is change a challenge in acute mental health wards? A cross-sectional investigation of the relationships between burnout, occupational status and nurses’ perceptions of barriers to change. Int J Ment Health Nurs. [Internet]. 2018 Jul 11 [cited Jul 12, 2019];28(1):190-8. Available from: http://dx.doi.org/10.1111/inm.12517
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-55 Paiva L, Canário A, China E, Gonçalves A. Burnout syndrome in health-care professionals in a university hospital. Clinics. [Internet]. 2017 May 5 [cited Jul 12, 2019];72(5):305-9. Available from: http://dx.doi.org/10.6061/clinics/2017(05)08
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) and in May 2019 was recognized it as an occupational phenomenon(66 World Health Organization. Burn-out an “occupational phenomenon”: international classification of diseases. [Internet]. Geneva: WHO; 2019 [cited Jul 12, 2019]. Available from: https://www.who.int/mental_health/evidence/burn-out/en/
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). Thus, it is now considered a public health problem due its related consequences and has triggered considerable interest and concern in the scientific community and organizations(33 White EM, Aiken LH, McHugh MD. Registered Nurse Burnout, Job dissatisfaction, and missed care in nursing homes. J Am Geriatr Soc. [Internet]. 2019 Jul [cited Jul 7, 2020];23;67(10):2065-71. Available from: http://dx.doi.org/10.1111/jgs.16051
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,77 Carlotto MS, Queirós C, Dias S, Kaiseler M. Hardiness and burnout syndrome: a cross-cultural study among Portuguese and Brazilian nurses. Temas Psicol. [Internet]. 2014 Abr [cited Sep 24, 2019];22(1):121-32. Available from: http://dx.doi.org/10.9788/tp2014.1-10
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8 Marques MM, Alves E, Queirós C, Norton P, Henriques A. The effect of profession on burnout in hospital staff. Occup Med. [Internet]. 2018 Mar 13 [cited Sep 24, 2019];68(3):207-10. Available from: http://dx.doi.org/10.1093/occmed/kqy039
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9 De Looff P, Didden R, Embregts P, Nijman H. Burnout symptoms in forensic mental health nurses: results from a longitudinal study. Int J Ment Health Nurs. [Internet]. 2018 Aug 28 [cited Sep 24, 2019];28(1):306-17. Available from: http://dx.doi.org/10.1111/inm.12536
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-1010 Faria S, Queirós C, Borges E, Abreu M. Nurses’ mental health: contributions of burnout and job engagement. Rev Port Enferm Saúde Mental. [Internet]. 2019 Dec [cited Jul 7, 2020];22:09-18. Available from: http://dx.doi.org/10.19131/rpesm.0258
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). Nurses’ burnout can negatively affect the quality of care provided to patients(1111 Liu X, Zheng J, Liu K, Baggs JG, Liu J, Wu Y, et al. Hospital nursing organizational factors, nursing care left undone, and nurse burnout as predictors of patient safety: a structural equation modeling analysis. IJNS. [Internet]. 2018 Oct [cited Jul 12, 2019];86:82-9. Available from: http://dx.doi.org/10.1016/j.ijnurstu.2018.05.005
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-1212 Batalha SEM, Melleiro MM, Borges EM. Burnout and its interface with patient safety. Rev Enferm UFPE On Line. [Internet]. 2019 Jun [cited Jul 7, 2020]:4;13. Available from: http://dx.doi.org/10.5205/1981-8963.2019.239641
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). In line with recommendations in 2018(1313 Agency for Occupational Safety and Health. Healthy workers, thriving companies - a practical guide to wellbeing at work. [Internet]. Luxembourg: Publications Office of the European Union; 2018 [cited Sep 24, 2019]. Available from: https://osha.europa.eu/en/publications/healthy-workers-thriving-companies-practical-guide-wellbeing-work/view
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) report stresses that mental health at the workplace and healthy workplaces are an increasing concern and burnout syndrome, in particular, seems to gain epidemic proportions(144 1. Bakhamis L, Paul DP, Smith H, Coustasse A. Still an epidemic: the burnout syndrome in hospital registered nurses. Health Care Manag. 2019 Jan/Mar;38(1):3-10. doi:10.1097/hcm.0000000000000243
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).

This syndrome is a psychological disorder triggered by chronic exposure to work stress. In 1981(1515 Maslach C, Jackson SE. The measurement of experienced burnout. J Organ Behav. 1981 Apr;2(2):99-113. Available from: http://dx.doi.org/10.1002/job.4030020205
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) it was presented a consensual definition of this condition by identifying it as a three-dimensional syndrome in which the worker shows signs of emotional exhaustion (feeling powerless to provide more support to others), depersonalization (cynical and unsympathetic attitude towards patients) and low personal fulfilment (feeling of personal and professional inadequacy). Authors(1616 Maslach C. Finding solutions to the problem of burnout. J Consult Psychol Pract Res. [Internet]. 2017 Jun [cited Jul 12, 2019];69(2):143-52. Available from: http://dx.doi.org/10.1037/cpb0000090
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-1717 Leite ES, Uva AS, Ferreira S, Costa PL, Passos AM. Working conditions and high emotional exhaustion among hospital nurses. Rev Bras Med Trab. [Internet]. 2019 [cited Jul 7, 2020];17(1):69-75. Available from: http://dx.doi.org/10.5327/z1679443520190339
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) demonstrated that it occurs among professionals working with other persons, especially as care providers and over the years these professionals are more likely to be affected by persons’ demands.

According to the literature, health professionals are the most affected by the burnout syndrome with a higher prevalence in nurses(33 White EM, Aiken LH, McHugh MD. Registered Nurse Burnout, Job dissatisfaction, and missed care in nursing homes. J Am Geriatr Soc. [Internet]. 2019 Jul [cited Jul 7, 2020];23;67(10):2065-71. Available from: http://dx.doi.org/10.1111/jgs.16051
http://dx.doi.org/10.1111/jgs.16051...
,88 Marques MM, Alves E, Queirós C, Norton P, Henriques A. The effect of profession on burnout in hospital staff. Occup Med. [Internet]. 2018 Mar 13 [cited Sep 24, 2019];68(3):207-10. Available from: http://dx.doi.org/10.1093/occmed/kqy039
http://dx.doi.org/10.1093/occmed/kqy039...
,1010 Faria S, Queirós C, Borges E, Abreu M. Nurses’ mental health: contributions of burnout and job engagement. Rev Port Enferm Saúde Mental. [Internet]. 2019 Dec [cited Jul 7, 2020];22:09-18. Available from: http://dx.doi.org/10.19131/rpesm.0258
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,1818 Samaei SE, Khosravi Y, Heravizadeh O, Ahangar HG, Pourshariati F, Amrollahi M. The effect of emotional intelligence and job stress on burnout: a structural equation model among hospital nurses. Int J Occup Hyg. [Internet]. 2017 Jun [cited Sep 24, 2019];9(2):52-9. Available from: http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=124306166⟨=pt-pt&site=eds-live
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). Multiple factors contribute to this phenomenon, regardless of workplace environments, and may include sociodemographic, occupational, personal characteristics, as well as established interrelationship. Numerous studies have been developed on nurses’ burnout, especially over the last years. Meta-analysis and systematic reviews(1919 Friganović A, Selič P, Ilić B, Sedić B. Stress and burnout syndrome and their associations with coping and job satisfaction in critical care nurses: a literature review. Psychiatr Danub. [Internet]. 2019 [cited Sep 24, 2019];31(Suppl 1):21-31. Available from: http://www.psychiatria-danubina.com/UserDocsImages/pdf/dnb_vol31_noSuppl%201/dnb_vol31_noSuppl%201_21.pdf
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-2020 Molina-Praena J, Ramirez-Baena L, Gómez-Urquiza J, Cañadas G, De la Fuente E, Cañadas-De la Fuente G. Levels of burnout and risk factors in medical area nurses: a meta-analytic study. Int J Environ Res Public Health. [Internet]. 2018 Dec 10 [cited Jul 24, 2019];15(12):2800. Available from: http://dx.doi.org/10.3390/ijerph15122800
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) highlighted the influence of job tasks, age, gender, marital status, personality traits, among others. In addition, they identified higher risk factors for professionals working in emergency or paediatric services(2121 Salvarani V, Rampoldi G, Ardenghi S, et al. Protecting emergency room nurses from burnout: the role of dispositional mindfulness, emotion regulation and empathy. J Nurs Manag. 2019;27(4):765-74. doi:10.1111/jonm.12771
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22 Li H, Cheng B, Zhu XP. Quantification of burnout in emergency nurses: a systematic review and meta-analysis. Int Emerg Nurs. [Internet]. 2018 Jul [cited Feb 12, 2020];39:46-54. Available from: http://dx.doi.org/10.1016/j.ienj.2017.12.005
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-2323 Pradas-Hernández L, Ariza T, Gómez-Urquiza JL, Albendín-García L, De la Fuente EI, Cañadas-De la Fuente GA. Prevalence of burnout in paediatric nurses: a systematic review and meta-analysis. PLoS ONE. [Internet]. 2018 Apr 25 [cited Jul 24, 2019];13(4):e0195039. Available from: http://dx.doi.org/10.1371/journal.pone.0195039
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) and in primary care(2424 Monsalve-Reyes CS, San Luis-Costas C, Gómez-Urquiza JL, Albendín-García L, Aguayo R, Cañadas-De la Fuente GA. Burnout syndrome and its prevalence in primary care nursing: a systematic review and meta-analysis. BMC Fam Pract. [Internet]. 2018 May 10 [cited Jul 24, 2019];19(1). Available from: http://dx.doi.org/10.1186/s12875-018-0748-z
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) and nurses’ empathy-related features(2525 Hunt PA, Denieffe S, Gooney M. Burnout and its relationship to empathy in nursing: a review of the literature. J Res Nurs. [Internet]. 2017 Mar 22 [cited Jul 24, 2019];(1-2):7-22. Available from: http://dx.doi.org/10.1177/1744987116678902
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). In addition, some studies associate burnout with turnover, ageing among nurses, nursing as a stressful occupation(2626 Gnerre P, Rivetti C, Rossi AP, Tesei L, Montemurro D, Nardi R. Work stress and burnout among physicians and nurses in internal and emergency departments. Ital J Med. [Internet]. 2017 Jun 14 [cited Jul 24, 2019];11(2):151. Available from: http://dx.doi.org/10.4081/itjm.2017.740
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27 Hoff T, Carabetta S, Collinson GE. Satisfaction, burnout, and turnover among nurse practitioners and physician assistants: a review of the empirical literature. Med Care Res Rev. [Internet]. 2017 Sep 13 [cited Jul 24, 2019];76(1):3-31. Available from: http://dx.doi.org/10.1177/1077558717730157
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28 Mc Carthy VJC, Wills T, Crowley S. Nurses, age, job demands and physical activity at work and at leisure: a cross-sectional study. APPL Nurs Res. [Internet]. 2018 Apr [cited Jul 24, 2019];40:116-21. Available from: http://dx.doi.org/10.1016/j.apnr.2018.01.010
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29 Molero M de lM, Pérez-Fuentes M del C, Gázquez JJ. Analysis of the mediating role of self-efficacy and self-esteem on the effect of workload on burnout’s influence on nurses’ plans to work longer. Front Psychol. [Internet]. 2018 Dec [cited Jul 24, 2019];18:9. Available from: http://dx.doi.org/10.3389/fpsyg.2018.02605
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-3030 Ramirez-Baena L, Ortega-Campos E, Gomez-Urquiza J, Cañadas-De la Fuente G, De la Fuente-Solana E, Cañadas-De la Fuente G. A multicentre study of burnout prevalence and related psychological variables in medical area hospital nurses. J Clin Med. [Internet]. 2019 Jan 15 [cited Jul 24, 2019];8(1):92. Available from: http://dx.doi.org/10.3390/jcm801009
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) and, even, suicide risk among nurses(3131 Zeng HJ, Zhou GY, Yan HH, Yang XH, Jin HM. Chinese nurses are at high risk for suicide: A review of nurses suicide in China 2007-2016. Arch Psychiatr Nurs. [Internet]. 2018 Dec [cited Sep 24, 2019];32(6):896-900. Available from: http://dx.doi.org/10.1016/j.apnu.2018.07.005
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).

Research on burnout has been carried out in different countries. In Portugal, predictors were identified in nurses working in hospitals(1010 Faria S, Queirós C, Borges E, Abreu M. Nurses’ mental health: contributions of burnout and job engagement. Rev Port Enferm Saúde Mental. [Internet]. 2019 Dec [cited Jul 7, 2020];22:09-18. Available from: http://dx.doi.org/10.19131/rpesm.0258
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), while authors(3232 Marôco J, Marôco AL, Leite E, Bastos C, Vazão MJ, Campos J. Burnout among Portuguese health professionals: an analysis at national level. Acta Medica Port. [Internet]. 2016 Jan [cited Feb 12, 2020];29(1):24-30. Available from: https://actamedicaportuguesa.com/revista/index.php/amp/article/view/6460/0
https://actamedicaportuguesa.com/revista...
) analysed burnout among health professionals at national level and assessed its prevalence in different professional groups in hospital environments, as well as the relation between professional category and burnout levels(88 Marques MM, Alves E, Queirós C, Norton P, Henriques A. The effect of profession on burnout in hospital staff. Occup Med. [Internet]. 2018 Mar 13 [cited Sep 24, 2019];68(3):207-10. Available from: http://dx.doi.org/10.1093/occmed/kqy039
http://dx.doi.org/10.1093/occmed/kqy039...
). In Spain, in a hospital, analysed the prevalence and typology of burnout syndrome in nursing professionals(3333 Salillas R. Burnout Syndrome in nursing professionals in the hospital setting: a descriptive study. Enferm Trab. [Internet]. 2017 May 12 [cited Feb 12, 2020];7(3):65-9. Available from: https://dialnet.unirioja.es/servlet/articulo?codigo=6112224
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), while other study(33 White EM, Aiken LH, McHugh MD. Registered Nurse Burnout, Job dissatisfaction, and missed care in nursing homes. J Am Geriatr Soc. [Internet]. 2019 Jul [cited Jul 7, 2020];23;67(10):2065-71. Available from: http://dx.doi.org/10.1111/jgs.16051
http://dx.doi.org/10.1111/jgs.16051...
) conducted a systematic review to identify the prevalence of Emotional Exhaustion, Depersonalization and Personal Achievement of primary health care nurses. Also authors(3434 Ballester Arnal R, Gómez Martínez S, Gil Juliá B, Ferrándiz-Sellés MD, Collado-Boira EJ. Burnout y factores estresantes en profesionales sanitarios de las unidades de cuidados intensivos. RPPC. [Internet]. 2016 Jul 26 [Acceso 24 sep 2019];21(2):129. Disponible en: http://dx.doi.org/10.5944/rppc.vol.21.num.2.2016.16146
http://dx.doi.org/10.5944/rppc.vol.21.nu...
) investigated burnout and stress causes among professionals working in intensive care units (physicians, nurses and assistants, showing respectively 28%, 49% and 22%). In Brazil, different studies have been developed particularly assessing the professional performance and factors associated with burnout among health professionals(55 Paiva L, Canário A, China E, Gonçalves A. Burnout syndrome in health-care professionals in a university hospital. Clinics. [Internet]. 2017 May 5 [cited Jul 12, 2019];72(5):305-9. Available from: http://dx.doi.org/10.6061/clinics/2017(05)08
http://dx.doi.org/10.6061/clinics/2017(0...
), the prevalence of burnout predictors in nurses of an intensive care unit(3535 Vasconcelos E, Martino M, França S. Predictors of burnout syndrome in intensive care nurses. Rev Gaúcha Enferm. [Internet]. 2017 Jun [cited Sep 24, 2019];38(4):e65354. Available from: https://doi.org/10.1590/1983-1447.2017.04.65354
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), the relationship between burnout and depressive symptoms in nurses of an intensive care unit(3636 Vasconcelos E, Martino M, França S. Burnout and depressive symptoms in intensive care nurses: relationship analysis. Rev Bras Enferm. [Internet]. 2018 Jan/Feb;71(1):147-53. doi: 10.1590/0034-7167-2016-0019
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), the association between burnout and job shifts of the nursing staff of a hospital(3737 Vidotti V, Ribeiro R, Galdino M, Martins J. Burnout Syndrome and shift work among the nursing staff. Rev. Latino-Am. Enfermagem. [Internet]. 2018 [cited Feb 12, 2020];26:e3022. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-11692018000100337&lng=en
http://www.scielo.br/scielo.php?script=s...
), and burnout and working environments among nurses working in public health institutions(3838 Nogueira LS, Sousa RMC, Guedes ES, Santos MA, Turrini RNT, Cruz DALM. Burnout and nursing work environment in public health institutions. Rev Bras Enferm. [Internet]. 2018 Apr [cited Feb 12, 2020];71(2):336-42. Available from: http://dx.doi.org/10.1590/0034-7167-2016-0524
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).

Over the past decades there has been an increase of cross-cultural methods in research addressing workplaces and organizations, since it allows understanding and dealing with both differences and common patterns in different cultural contexts(77 Carlotto MS, Queirós C, Dias S, Kaiseler M. Hardiness and burnout syndrome: a cross-cultural study among Portuguese and Brazilian nurses. Temas Psicol. [Internet]. 2014 Abr [cited Sep 24, 2019];22(1):121-32. Available from: http://dx.doi.org/10.9788/tp2014.1-10
http://dx.doi.org/10.9788/tp2014.1-10...
,3939 Alexandrova-Karamanova A, Todorova I, Montgomery A, Panagopoulou E, Costa P, Baban A, et al. Burnout and health behaviors in health professionals from seven European countries. Int Arch Occup Environ Health. [Internet]. 2016 Jun 1 [cited Feb 12, 2020];89(7):1059-75. Available from: http://dx.doi.org/10.1007/s00420-016-1143-5
http://dx.doi.org/10.1007/s00420-016-114...
-4040 Suñer-Soler R, Grau-Martín A, Flichtentrei D, Prats M, Braga F, Font-Mayolas S, et al. The consequences of burnout syndrome among healthcare professionals in Spain and Spanish speaking Latin American countries. Burn Res. [Internet]. 2014 Sep [cited Feb 12, 2020];1(2):82-9. Available from: http://dx.doi.org/10.1016/j.burn.2014.07.004
http://dx.doi.org/10.1016/j.burn.2014.07...
). Due to the historical background, geographical, cultural or language proximity, Portugal, Brazil and Spain share many characteristics that facilitate the regular movement of professionals between these countries. Therefore, it is important to develop comparative studies and an European report published by the Agency for the Improvement of Living and Working Conditions(4141 European Foundation for the Improvement of Living and Working Conditions. Burnout in the workplace: a review of data and policy responses in the EU. [Internet]. Luxembourg: Publications Office of the European Union; 2018 [cited Feb 12, 2020]. Available from: https://www.eurofound.europa.eu/sites/default/files/ef_publication/field_ef_document/ef18047en.pdf
https://www.eurofound.europa.eu/sites/de...
) emphasized that despite “burnout has been the subject of research and policy responses across Europe”, it is important that we gain “an EU (European Union) wide perspective on the issue”.

This study aims to identify and compare burnout levels of Portuguese, Spanish and Brazilian nurses.

Method

A quantitative, descriptive, correlational, comparative and cross-sectional study was conducted using a sample of 1,052 nurses, being 306 from Porto, Portugal, 269 from Oviedo, Spain and 477 from S. Paulo, Brazil, through an intentional sampling and the snowball technique. Participants were all working in public hospitals and public health centres and the inclusion criteria were: to be actively employed and with a job experience of more than 6 months. Data collection was conducted between 2016 and 2017. Considering the whole sample, 83% were female, with an average age of 37 years, 58% had a marital partner, 60% worked in hospital settings, 56% worked fixed shifts and 58% had less than 13 years of job experience (Table 1).

Table 1
Social demographic characteristics of nurses (1,052). Portugal, Spain and Brazil, 2016-2017

A sociodemographic and professional questionnaire (gender, age, marital status, country, workplace, professional category, shift work and professional experience), was used to collect data. To assess burnout it was used the Maslach Burnout Inventory-Human Services Survey (MBI-HSS) translated and adapted for the Portuguese, Spanish and Brazilian population(1515 Maslach C, Jackson SE. The measurement of experienced burnout. J Organ Behav. 1981 Apr;2(2):99-113. Available from: http://dx.doi.org/10.1002/job.4030020205
http://dx.doi.org/10.1002/job.4030020205...
,4242 Maslach C, Jackson S, Leiter M. Maslach burnout inventory manual. [Internet]. Palo Alto: Consulting Psychologists Press; 1996 [cited Jul 12, 2019]. Available from: https://www.researchgate.net/publication/277816643_The_Maslach_Burnout_Inventory_Manual
https://www.researchgate.net/publication...

43 Maslach C, Jackson SE. MBI. Inventário burnout de Maslach, síndrome del “quemado” por estrés laboral asistencial. Madrid: TEA Publicaciones de Psicologia Aplicada; 1997.

44 Marques Pinto A, Picado L. Adaptation and well-being at Portuguese schools: from students to teachers (Portuguese). Lisboa: Coisas de Ler; 2011.
-4545 Lautert L. O desgaste profissional do enfermeiro. [Internet]. [Tese] Salamanca: Universidade Pontificia de Salamanca; 1995 [Acesso 12 jul 2019]. Disponível em: https://lume.ufrgs.br/handle/10183/11028
https://lume.ufrgs.br/handle/10183/11028...
). This instrument includes 22 items, recorded on a Likert scale ranging from 0 (never) to 6 (every day) and organized in three dimensions: Emotional Exhaustion (9 items), Depersonalization (5 items) and Personal Achievement (8 items). The total score of the instrument was used to calculate burnout levels considering the inverted items of Personal Achievement and all scores were calculated considering the average of all related items. It was also possible to classify individuals according to the level of burnout, based on the following cut-off points(3232 Marôco J, Marôco AL, Leite E, Bastos C, Vazão MJ, Campos J. Burnout among Portuguese health professionals: an analysis at national level. Acta Medica Port. [Internet]. 2016 Jan [cited Feb 12, 2020];29(1):24-30. Available from: https://actamedicaportuguesa.com/revista/index.php/amp/article/view/6460/0
https://actamedicaportuguesa.com/revista...
): <2, no burnout; [2,3[, moderate burnout; ≥3, high burnout.

No direct contact was established between researchers and participants and the questionnaires were sealed and delivered by one of the researchers at the previously set locations and date and after anonymously completed by the participants (whenever possible the questionnaires were filled in at the time of delivery to the workplace, considering the participant’s availability, and the period of a month was extended for an equal period to complete the questionnaires) they were collected for analysis. To allow comparative studies, the same procedures were adopted in all countries involved in this study and standard surveys, namely no individual results disclosure to the institutions.

The study was approved by the Ethics Committees of Nursing School of Porto (8/2016), and University Hospital of the University of São Paulo, Brazil and Regional Clinical Research Ethics Committee of the Principality of Asturias, Oviedo, Spain. Formal consents were granted by the institutions involving nurses’ participation and all participants were asked to sign an informed consent.

Data analysis was performed using the SPSS 24 software with a significance level of 0.05 in all analyses. Descriptive analysis of the data was performed, considering absolute and relative frequencies, median or median and standard deviation and interquartile range.

Normality was tested through the Kolmogorov-Smirnov test. The Chi-square of Pearson test and Analysis of variance ANOVA were applied to compare the participants’ characteristics according to country. Kruskall-Wallis test was used when the assumption of normality was not verified. The Scheffe test or the Dunn’s test were used for multiple comparisons of the ANOVA or Kruskall-Wallis, respectively.

To identify potential predictors of the quantitative dependent variables under analysis and with normal distribution, mixed linear models were used, considering the country as a random effect (based on the multi-level nature of the study). In a first step, univariate models were used (considering one factor at a time), in order to identify potential predictive factors of each dependent variable. Based on these results, a multivariate model for each dependent variable was developed, with all independent related variables obtained from the univariable models (except for “workplace” and “professional category”, because data were not available for the three countries). Finally, the country’s interactions with the independent variables were tested. Only the significant results were presented.

Results

To perform comparative analyses with models adjusted for the burnout results, the total and country sociodemographic and professional variables were identified. Statistically significant differences were found between countries for all studied variables (Table 1). Portugal showed the highest percentage of male participants, with no marital partner; the average age of participants was lower in Portugal and higher in Spain. No nurses were working in health centres in Spain. In Brazil, nursing assistants were included in the sample, since nurses perform tasks similar to Portugal and Spain. Almost all participants work rotating shifts in Spain and in Brazil, the most common is the fixed shift. Spanish participants had more professional experience. The Scheffe test revealed significant differences between all countries for mean age.

Concerning burnout, Table 2 presents the median scores and standard deviations for the total burnout scale and its dimensions, for the total sample and per country, as well as the distribution of participants according to the categories of the burnout level, for the total sample and per country. A large percentage of nurses showed moderate/high burnout levels (42%, 43% and 42%, respectively in Portugal, Spain and Brazil) and higher values of Emotional Exhaustion and Personal Achievement than of Depersonalization. Only the Depersonalization dimension showed differences between countries (p<0.001). No statistically differences were found between countries on the remaining dimensions and total score (p>0.05). Spain scored the highest for the Depersonalization dimension [median=1.60 (IQI-Interquartile interval=1.80)] and Portugal received the lowest score [median=0.60 (IQI=1.20)]. The multiple comparisons test revealed that all countries were distinct from each other (p<0.05 when comparing all pairs).

Table 2
Comparative analysis of burnout and dimensions in nurses (1,052). Portugal, Spain and Brazil, 2016-2017

Table 3 shows the coefficients and standard errors estimated for the independent variables under analysis, considering the univariate models and the multivariate model (adjusted model). From the data analysis, it is possible to verify that the variables age and shift are significant predictors of burnout, remaining significant in the adjusted model. Older participants with a fixed shift report lower burnout levels compared to younger participants with a rotating shift, controlling for the remaining variables.

Table 3
Univariate models and adjusted model of the nurses' burnout (1,052). Portugal, Spain and Brazil, 2016-2017

Considering the multivariable model presented at Table 3 and including a covariate composed by the interaction between country and shift variable, a statistically significant interaction between these variables was found (Figure 1), showing the shift effect on burnout to be different depending on the country. In Portugal, the rotating shift is associated with a higher level of burnout, contrary to Brazil and Spain, where the fixed shift is associated with a higher level of burnout. Results of the other main effects remain similar.

Figure 1
Interaction effect of country-shift work on nurses’ burnout (1,052). Portugal, Spain and Brazil, 2016-2017 (based on the multivariable model)

Regarding Emotional Exhaustion (Table 4), the coefficients and standard errors estimated for the independent variables under analysis, were calculated, considering the univariate models. The analysis showed that no tested variable was a predictive factor of emotional exhaustion, and, considering this result, it was decided not to develop the adjusted model.

Table 4
Emotional exhaustion, depersonalization and personal achievement: univariate models and adjusted model in nurses (1,052). Portugal, Spain and Brazil, 2016-2017

Despite the asymmetry found in the variable Depersonalization (through the analysis of the histogram by country), the index of asymmetry varied between 0.213 and 1.533 and the index of flattening varied between -0.218 and 2.367. According to these indices, the variable was considered symmetric and the model described above was used. In Table 4 it is possible to observe the variables gender, age workplace, professional category and shift as significant predictors of Depersonalization, with variables gender and shift remaining significant in the adjusted model. Male participants show higher Depersonalization levels compared to female participants, controlling for the remaining variables. In addition, participants with a fixed shift report lower Depersonalization levels compared to those with a rotating shift, controlling for the remaining variables. After testing the interactions between the country and the variables gender and shift, no statistically significant interaction were found between them.

Regarding Personal Achievement (Table 4), the coefficients and standard errors estimated for the independent variables under analysis were calculated, considering the univariate models and multivariate model (adjusted model), showing age and professional experience as significant predictors of Personal Achievement. However, only the variable age remains significant in the adjusted model and older participants show a higher level of Personal Achievement, controlling the remaining variables. The interaction between country and age is significant, since for Portuguese and Spanish participants, as they get older, lower scores in Personal Achievement are obtained, compared to Brazil.

Discussion

These study findings revealed a large percentage of nurses with moderate/high burnout levels (42%, 43% and 42%, respectively in Portugal, Spain and Brazil) and higher scores on Emotional Exhaustion and Personal Achievement than for Depersonalization. One study(3636 Vasconcelos E, Martino M, França S. Burnout and depressive symptoms in intensive care nurses: relationship analysis. Rev Bras Enferm. [Internet]. 2018 Jan/Feb;71(1):147-53. doi: 10.1590/0034-7167-2016-0019
https://doi.org/10.1590/0034-7167-2016-0...
) revealed that only 14% of Brazilian nurses reported burnout levels. However, the cross-cultural study among Portuguese and Brazilian nurses found that in the Emotional Exhaustion and Personal Achievement dimensions, nurses from both countries showed moderate and high values, respectively(77 Carlotto MS, Queirós C, Dias S, Kaiseler M. Hardiness and burnout syndrome: a cross-cultural study among Portuguese and Brazilian nurses. Temas Psicol. [Internet]. 2014 Abr [cited Sep 24, 2019];22(1):121-32. Available from: http://dx.doi.org/10.9788/tp2014.1-10
http://dx.doi.org/10.9788/tp2014.1-10...
). These findings are explained by the differences in the type and work contexts. It should be noticed that in Portugal nurses spend most of their time providing direct care to patients and it is expected that they establish a strong relationship with the patient and demonstrate high technical competence. Moreover, in Portugal, a study(88 Marques MM, Alves E, Queirós C, Norton P, Henriques A. The effect of profession on burnout in hospital staff. Occup Med. [Internet]. 2018 Mar 13 [cited Sep 24, 2019];68(3):207-10. Available from: http://dx.doi.org/10.1093/occmed/kqy039
http://dx.doi.org/10.1093/occmed/kqy039...
) found that the Emotional Exhaustion dimension scored the highest values in the majority of nurses (59%). Regarding Spain, in the systematic review with primary care nurses, the authors found that 50% of nurses had low/medium levels on Emotional Exhaustion and 50% had high levels(33 White EM, Aiken LH, McHugh MD. Registered Nurse Burnout, Job dissatisfaction, and missed care in nursing homes. J Am Geriatr Soc. [Internet]. 2019 Jul [cited Jul 7, 2020];23;67(10):2065-71. Available from: http://dx.doi.org/10.1111/jgs.16051
http://dx.doi.org/10.1111/jgs.16051...
).

It was also found that older nurses in all countries and those working in shifts in Spain and Brazil showed lower burnout levels. Another study(3535 Vasconcelos E, Martino M, França S. Predictors of burnout syndrome in intensive care nurses. Rev Gaúcha Enferm. [Internet]. 2017 Jun [cited Sep 24, 2019];38(4):e65354. Available from: https://doi.org/10.1590/1983-1447.2017.04.65354
https://doi.org/10.1590/1983-1447.2017.0...
) corroborate these results, as they found that the burnout syndrome was higher for individuals aged between 22 and 29 years. These authors report that young professionals are considered inexperienced and more likely to feel anxiety when dealing with complex and unknown situations. Contrarily, in Spain, highlighted that longer professional experience may be related to the age of professionals and found that professionals with medium and high professional experience showed the highest percentage of burnout(3333 Salillas R. Burnout Syndrome in nursing professionals in the hospital setting: a descriptive study. Enferm Trab. [Internet]. 2017 May 12 [cited Feb 12, 2020];7(3):65-9. Available from: https://dialnet.unirioja.es/servlet/articulo?codigo=6112224
https://dialnet.unirioja.es/servlet/arti...
). In addition, the syndrome occurs in two periods: in the first two years of the professional career and following 10 years of experience(3333 Salillas R. Burnout Syndrome in nursing professionals in the hospital setting: a descriptive study. Enferm Trab. [Internet]. 2017 May 12 [cited Feb 12, 2020];7(3):65-9. Available from: https://dialnet.unirioja.es/servlet/articulo?codigo=6112224
https://dialnet.unirioja.es/servlet/arti...
). Moreover, in Spain, found that older nurses with longer working experience had higher levels of burnout(33 White EM, Aiken LH, McHugh MD. Registered Nurse Burnout, Job dissatisfaction, and missed care in nursing homes. J Am Geriatr Soc. [Internet]. 2019 Jul [cited Jul 7, 2020];23;67(10):2065-71. Available from: http://dx.doi.org/10.1111/jgs.16051
http://dx.doi.org/10.1111/jgs.16051...
). In the study addressing shift work in Brazil, found equal percentages of burnout in professionals with fixed and rotating work(3636 Vasconcelos E, Martino M, França S. Burnout and depressive symptoms in intensive care nurses: relationship analysis. Rev Bras Enferm. [Internet]. 2018 Jan/Feb;71(1):147-53. doi: 10.1590/0034-7167-2016-0019
https://doi.org/10.1590/0034-7167-2016-0...
).

Regarding the dimensions Emotional Exhaustion, Depersonalization and Personal Achievement, in this study, it was possible to observe that gender, age, workplace, professional category and shift predicted Depersonalization, while age and professional experience predicted Personal Achievement. There was an association between Depersonalization and gender, with Depersonalization scoring higher for women. Depersonalization in nurses also showed a significant association with schooling. In addition, higher levels of professional achievement were associated with professionals with post-graduate training(55 Paiva L, Canário A, China E, Gonçalves A. Burnout syndrome in health-care professionals in a university hospital. Clinics. [Internet]. 2017 May 5 [cited Jul 12, 2019];72(5):305-9. Available from: http://dx.doi.org/10.6061/clinics/2017(05)08
http://dx.doi.org/10.6061/clinics/2017(0...
). That Emotional Exhaustion was related to the institutions with more unfavourable working conditions regarding autonomy, organisational support and environmental control(3838 Nogueira LS, Sousa RMC, Guedes ES, Santos MA, Turrini RNT, Cruz DALM. Burnout and nursing work environment in public health institutions. Rev Bras Enferm. [Internet]. 2018 Apr [cited Feb 12, 2020];71(2):336-42. Available from: http://dx.doi.org/10.1590/0034-7167-2016-0524
http://dx.doi.org/10.1590/0034-7167-2016...
).

Study findings showed that Emotional Exhaustion and Low Professional Achievement levels were significantly higher among nurses with daytime shifts(3737 Vidotti V, Ribeiro R, Galdino M, Martins J. Burnout Syndrome and shift work among the nursing staff. Rev. Latino-Am. Enfermagem. [Internet]. 2018 [cited Feb 12, 2020];26:e3022. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-11692018000100337&lng=en
http://www.scielo.br/scielo.php?script=s...
). This could be explained by the workload of nursing care and procedures during this period. Also, the interpersonal relationship with the multiprofessional team is often more frequent, increasing occupational stress and the development of the burnout. The importance of the workplace in the development of burnout syndrome alerted for the differences between the working day of an emergency or intensive care nurse with that of primary health care nurses(33 White EM, Aiken LH, McHugh MD. Registered Nurse Burnout, Job dissatisfaction, and missed care in nursing homes. J Am Geriatr Soc. [Internet]. 2019 Jul [cited Jul 7, 2020];23;67(10):2065-71. Available from: http://dx.doi.org/10.1111/jgs.16051
http://dx.doi.org/10.1111/jgs.16051...
). In primary health care services, nurses work in prevention, education, follow-up and prolonged and continuous treatment of the population, mainly focused on chronic pathologies. Special attention is also given to the community and home-dwelling more prolonged interventions, compared to the short duration of acute diseases common to hospital services. This highly explains different levels of burnout across services.

A study(4646 Ballester Arnal R, Gómez Martínez S, Gil Juliá B, Ferrándiz-Sellés MD, Collado-Boira EJ. Burnout y factores estresantes en profesionales sanitarios de las unidades de cuidados intensivos. Rev Psicopatología Psicol Clín. [Internet]. 2016 Jul 26 [Acceso 12 Jul 2019];21(2):129. Disponible en: http://dx.doi.org/10.5944/rppc.vol.21.num.2.2016.1614bb
http://dx.doi.org/10.5944/rppc.vol.21.nu...
) found that women reported higher levels of burnout, although with no significant differences, while men experienced higher levels of Depersonalization, with Emotional Exhaustion predicted by professional experience and gender (higher in the most experienced participants and women). Regarding Depersonalization, the variance was only explained by gender and women were less likely to evidence symptoms of Depersonalization than men. These results can be due to the way that man and women deal with their own emotions and job emotional demands.

There are several examples of comparative studies, such as the cross-cultural study about the influence of hardiness in burnout syndrome among Brazilian and Portuguese nurses(77 Carlotto MS, Queirós C, Dias S, Kaiseler M. Hardiness and burnout syndrome: a cross-cultural study among Portuguese and Brazilian nurses. Temas Psicol. [Internet]. 2014 Abr [cited Sep 24, 2019];22(1):121-32. Available from: http://dx.doi.org/10.9788/tp2014.1-10
http://dx.doi.org/10.9788/tp2014.1-10...
). Some authors(3939 Alexandrova-Karamanova A, Todorova I, Montgomery A, Panagopoulou E, Costa P, Baban A, et al. Burnout and health behaviors in health professionals from seven European countries. Int Arch Occup Environ Health. [Internet]. 2016 Jun 1 [cited Feb 12, 2020];89(7):1059-75. Available from: http://dx.doi.org/10.1007/s00420-016-1143-5
http://dx.doi.org/10.1007/s00420-016-114...
) studied the association between fast food and alcohol consumption, physical exercise and analgesic use in a multinational sample of 2,623 physicians and nurses living in Greece, Portugal, Bulgaria, Romania, Turkey, Croatia and Macedonia. Another study including health professionals from Spain and Spanish-speaking Latin American countries, identified the frequency and intensity of the perception of the adverse consequences of the profession and its association with burnout syndrome and professional variables(4040 Suñer-Soler R, Grau-Martín A, Flichtentrei D, Prats M, Braga F, Font-Mayolas S, et al. The consequences of burnout syndrome among healthcare professionals in Spain and Spanish speaking Latin American countries. Burn Res. [Internet]. 2014 Sep [cited Feb 12, 2020];1(2):82-9. Available from: http://dx.doi.org/10.1016/j.burn.2014.07.004
http://dx.doi.org/10.1016/j.burn.2014.07...
).

Comparative studies are still difficult to perform, despite the fact that we currently live in a globalization world where nurses are constantly facing the same challenge and threats worldwide(4747 Iro E. Nursing, UHC and people-centred care in the 21st century. Int Nurs Rev. [Internet]. 2018 Jun [cited Feb 12, 2020];65(2):148-9. Available from: http://dx.doi.org/10.1111/inr.12462
http://dx.doi.org/10.1111/inr.12462...
). In fact, these professionals need to work and decide under stressful and pressure environments, while interacting with patients and their families in situations often characterized by strong emotional distress. Additionally, nurses experience changes in the family relationship(4848 Fang YX. Burnout and work-family conflict among nurses during the preparation for reevaluation of a grade a tertiary hospital. Chin Nurs Res. 2017;4:51-55.), leading to less job satisfaction and more turnover and disengagement(33 White EM, Aiken LH, McHugh MD. Registered Nurse Burnout, Job dissatisfaction, and missed care in nursing homes. J Am Geriatr Soc. [Internet]. 2019 Jul [cited Jul 7, 2020];23;67(10):2065-71. Available from: http://dx.doi.org/10.1111/jgs.16051
http://dx.doi.org/10.1111/jgs.16051...
).

The World Health Organization(66 World Health Organization. Burn-out an “occupational phenomenon”: international classification of diseases. [Internet]. Geneva: WHO; 2019 [cited Jul 12, 2019]. Available from: https://www.who.int/mental_health/evidence/burn-out/en/
https://www.who.int/mental_health/eviden...
) has recently acknowledged burnout syndrome as a disease-related employment problem. In addition, the COVID-19 pandemic triggered new challenges, with profound impact on nurses well-being, namely increased stress levels, post-traumatic stress and burnout(4949 EU-OSHA. European Agency for Safety and health at Work. World day for safety and health at work in 2020 urges response to the COVID-19 pandemic. [Internet]. 2020 [cited Jun 13, 2020]. Available from: https://osha.europa.eu/pt/highlights/world-day-safety-and-health-work-2020-urges-response-covid-19-pandemic
https://osha.europa.eu/pt/highlights/wor...
-5050 Sinclair RR, Allen T, Barbeiro L, Bergman M, Britt T, Butler A, et al. Occupational health science in the time of COVID-19: now more than ever. Occup Health Sci. [Internet]. 2020 Jun [cited Jun 8, 2020];1-22. Available from: https://doi.org/10.1007/s41542-020-00064-3
https://doi.org/10.1007/s41542-020-00064...
).

Despite being a multicentre study, the generalisability of these results is not recommended, mainly because it is a cross-sectional study and based on voluntary participation though the application of a self-administered questionnaire with data collection being performed in specific regions of each country. Although these countries share many similarities, the differences found stress the importance of conducting longitudinal and randomized studies involving other nurses’ working environments. It is also suggested that the dimension emotional exhaustion is further investigated to test other variables that may explain this dimension.

As a result of research on burnout and due to the high percentage of Portuguese, Spanish and Brazilian nurses with moderate/high burnout levels and the significant financial burden for health institutions, nurses, family and society, it is imperative that policy makers continue to invest in the area of occupational health. Importantly, health services administrators must develop infrastructures that promote the occupational health and well-being of nurses. We strongly believe that investing on the academic curricula with special emphasis on burnout and other work-related risks may likely lead to improved well-being, safety, quality of care and overall health of populations. Also, the development of multicentric research provides a strong contribution to scientific nursing knowledge.

Conclusion

During the professional activity, nurses are exposed to numerous and multiple combining stressors, very likely to have a negative impact on the professional and the organization, with special highlight to burnout syndrome. Approximately 40% of nurses showing burnout levels were found in each country. Therefore, it is important to prepare nurses to identify the risks of developing burnout and help them to find resources within the family, the community and the organization in order to improve their well-being. Considering the impact of burnout, a future randomised controlled trial should be conducted to include a programme involving work contexts with potentially high levels of stress.

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Publication Dates

  • Publication in this collection
    28 June 2021
  • Date of issue
    2021

History

  • Received
    25 Mar 2020
  • Accepted
    12 Oct 2020
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