Prevalence of burnout and predictive factors among oncology nursing professionals: a cross-sectional study

ABSTRACT BACKGROUND: Burnout is a syndrome that mostly affects professionals working in contact with patients and their caregivers. In oncology care, nursing professionals are constantly required to provide emotional support for patients and their caregivers, throughout the process of becoming ill, suffering and dying. OBJECTIVE: To evaluate the prevalence and factors associated with burnout in a sample of nursing professionals at a cancer hospital. DESIGN AND SETTING: Cross-sectional study conducted at Hospital de Câncer de Barretos. METHODS: The study population comprised 655 nursing professionals. Burnout syndrome was assessed using the Maslach Burnout Inventory Human Service Survey. Univariate analysis and binary logistic regression models were used to identify independent predictors associated with burnout. RESULTS: Among 304 nursing professionals included in the study, 27 (8.9%) were classified as presenting burnout according to the two-dimensional criteria, and four (1.3%) were classified based on the three-dimensional criteria. Workplace characteristics were not associated with burnout, while single marital status (odds ratio, OR = 2.695; P = 0.037), perceived workplace stressors, such as impatience with colleagues (OR = 3.996; P = 0.007) and melancholy (OR = 2.840; P = 0.021) were considered to be predictors of burnout. Nursing professionals who would choose the profession again (OR = 0.214; P = 0.001) were least likely to present burnout. CONCLUSION: Perceived workplace stressors are strongly associated with burnout. Strategies focusing on restructuring of daily work processes and on activities that stimulate positive relationships are important for professionals’ health because motivation to continue working in oncology nursing has a protective effect against burnout.


INTRODUCTION
Oncological nursing is a specialty that can be characterized by constant exhaustion, especially emotional, due to the serious nature of cancer and the patient care profile. Nursing professionals within this specialty address patient suffering and death and perform the functions of encouraging and supporting family caregivers. 1,2 In addition, these professionals' practice can entail work overload, while maintaining institutional norms aimed at humanization and quality work. These factors require a high level of commitment from professionals and can lead to unsatisfactory interpersonal relationships in the work environment. All of these factors may cause professionals to develop burnout syndrome. [1][2][3] Burnout syndrome is multifactorial and presents three distinct dimensions, defined as (1) emotional exhaustion (the basic dimension of individual stress, which causes professionals to feel overloaded and exhausted); (2) depersonalization (insensitivity or cynicism toward coworkers and patients); and (3) reduction of personal accomplishment (characterized by a sense of unproductiveness, lack of professional accomplishment and feelings of incompetence). [4][5][6][7] Studies have shown that professionals and students in the field of healthcare have burnout levels that can be considered high in relation to those of other professions. [8][9][10][11] A previous study by our research group found that 58.1% of physicians who work in oncology had two-dimensional burnout. 10 In another study, we found that 44.9% of medical students also had levels compatible with two-dimensional burnout. 9 Specifically, in nursing, a study conducted among nurses at six cancer centers showed that emotional exhaustion from burnout was present in more than 60%, while depersonalization was present in 28.2%. The study also found that the difficulty that these professionals had in helping patients cope with their illnesses was correlated with the burnout dimensions. 12 Several studies have suggested that many oncology nurses present burnout or are at risk of this. [13][14][15][16][17][18] These professionals are part of a specialty that has been recognized as the main clinical area that is exposed to emotional labor. 18 Thus, it can be said that burnout is a matter of worldwide concern, which indicates that there is a need to improve the working conditions of professionals so that they can perform their functions with satisfaction, have good interpersonal relationships and consequently increase their productivity.
In addition, oncology nursing assists cancer patients and their families at all stages starting from diagnosis, including treatment, rehabilitation, dying, death and post-death. These professionals' overburden of work is generated through the complexity and subtypes of the disease and the extension of care to the psychosocial environment. Therefore, understanding the factors associated with high levels of burnout among these professionals forms an essential component of healthcare practice in a philanthropic humanized hospital in a middle-income country.

OBJECTIVE
The objective of this study was to evaluate the burnout levels of oncological nursing professionals and identify the factors that are related to burnout syndrome.

Place of study
The Hospital de Câncer de Barretos (HCB), located in the city of Barretos, São Paulo, Brazil, is a public institution that is recognized as a national reference center for cancer treatment. Its hospital attends approximately 6,000 cancer patients daily, from all 27 Brazilian states, through the Brazilian National Health System, which guarantees full, universal and free access for the country's population. 19 It is a care, teaching and research institution and has three oncological units, for provision of various specialties for children, adults and elderly patients (Unit I), for children and adolescents (Children's Unit) and for palliative care (Unit II).
These three units have a total of 226 hospital beds, a multiprofessional team and both inpatient and outpatient services.

Ethical aspects
This study was performed in accordance with the regulations of the Brazilian National Health Council (Conselho Nacional

Study design
A descriptive cross-sectional study was conducted between June 2017 and September 2018.

Study population and sample size
Nursing assistants, nurses and nursing coordinators working in Units I and II were included. Professionals who had been hired less than three months prior to the study were excluded.
In accordance with practices in Brazil and at the study site, nursing assistants are professionals with a technical level of education who are responsible for maintaining the patient's hygiene, checking vital signs and administering medications. While nurses provide care directly to patients, plan the assistance and perform medium and high-complexity procedures, nursing coordinators do not have direct contact with patients. The latter are responsible for the bureaucratic and organizational functions of the staff and department.
The study population was composed of nursing assistants, nurses and nursing coordinators from among the total of 655 nursing professionals working in the oncology units (Unit I and Unit II).

Procedures
Initially, informational posters about the research project were posted at strategic points in the oncology units to alert nursing professionals to the research event. Subsequently, the researchers invited all nursing assistants, nurses and nursing coordinators to participate in the study and attend meetings that were scheduled during work shifts in the outpatient, radiology, hospitalization, research and palliative care departments. At these meetings, the study was presented, questions were answered and all nursing professionals who were present were invited to participate in the study. At that time, those who agreed to participate in the study provided written consent and received the study questionnaires to answer. The evaluation questionnaires for this study were completed individually and confidentially by each person who had agreed to participate.

Data collection
The following types of data were collected through the evaluation questionnaire: • Sociodemographic data -age, gender, marital status, children, school education and other professional activity; • Data on the professionals' state of health -health problems and the professionals' views of their own health, their own personality and whether they were a happy or unhappy person; • Data on workplace characteristics -function, time of work, department, time dedicated to direct patient care and whether the work routine was exhausting; • Data on activities outside of work -family meetings, leisure activities, physical activity, religion and influence of spirituality on work; • Data on perceived workplace stressors -lack of recognition by the hospital, patients or relatives, difficulties in relationships among the nursing team or with multidisciplinary team members, excessive work, lack of time to perform other work activities, lack of resources for appropriate treatment of patients, institutional rules, lack of knowledge about the strategic planning of the hospital, lack of autonomy at work, constantly dealing with incurable and/or severe diseases, and feelings and symptoms in the work environment;  20,21 The bidimensional criterion (high EE and DP scores) and the three-dimensional criterion (high EE and DP scores and low PA score) were used to identify burnout. 22 The version of the MBI-HSS used in this study had previously been validated and adapted for use in the Portuguese language. 20 The right to use this instrument was purchased from and authorized by Mind Garden, as described on the website http://www. mindgarden.com/.
The instruments used in the study were self-administered in paper format and were completed by the participants in an average of 20 minutes.

Data analysis
The study population was characterized using frequency tables for qualitative variables and means and standard deviations for quantitative variables. Comparisons were made using the nonparametric Mann-Whitney test for continuous variables and the Pearson chi-square test or Fisher's exact test for categorical variables. To identify independent predictors associated with burnout, variables with a P-value < 0.2 obtained in the univariate analysis were included in the binary logistic regression model.
To compose the final model, we selected variables with a P-value < 0.05 (stepwise regression, Wald test). The IBM-SPSS software, version 21.0 (IBM Corp., Armonk, New York, United States) was used for statistical analysis, and the significance level was taken to be 0.05.
Missing values in the MBI-HSS were imputed by calculating the average of the responses for each item. Out of the total number of participants, 24 (7.9%) had at least one missing item in the MBI-HSS, and data allocation was used in these situations.

Sample description
Among the 655 nursing professionals potentially eligible to be invited to participate in the study , 11  and high scores (Figure 1). The mean (with SD) burnout scores were 23.8 (12.1) for EE, 5.8 (5.5) for DP and 39.3 (7.2) for PA. along with the majority of the professional consideration variables, were associated with low burnout.

Factors associated with bidimensional burnout
Regarding workplace characteristics, no statistically significant association with burnout was observed. In evaluating the presence of perceived workplace stressors, there was higher prevalence of burnout related to lack of recognition by the hospital (P = 0.006), difficulties in relationships among the nursing team (P = 0.001) and lack of recognition by patients or their relatives (P = 0.004).

Multivariate analyses
The adjusted multivariate model showed that the nursing professionals who would choose to enter the nursing profession again  Table 3).

DISCUSSION
This study evaluated the prevalence of burnout among active oncology nurses at a Brazilian hospital and the potential factors related to the syndrome. Approximately 9% and 1.3% of the participants presented two-dimensional and three-dimensional burnout, respectively. Impatience with colleagues, melancholy and being single were the factors related to greater risk of burnout syndrome. Furthermore, we found that the participants who reported that they would choose to enter the nursing profession again presented lower risk of burnout.   The results shown in the present study have been identified in the worldwide literature. 6,[12][13][14][15][16][17][18] The high level of burnout among oncology nurses and a growing lack of job satisfaction might negatively affect their quality of life and have an impact on the quality of nursing care and the services to be provided in general. 17,23 A study conducted in hematology and oncology clinics and palliative care units in three different public hospitals in Turkey demonstrated high emotional exhaustion scores among nurses who perceived that their interpersonal relationships were bad and who were not satisfied with workplace. Their emotional exhaustion was higher than that of nurses who were satisfied. In addition, a positive correlation between job satisfaction scores and personal accomplishment scores was identified. 17 The results from that study in Turkey by Yıldırım  Oncology is a specialty that requires much from professionals, especially emotionally. This has been identified as the largest clinical field in which nurses are exposed to emotional labor.
Nurses in this field are in greater contact with suffering and death than are colleagues in other areas. 18 Constantly coping with serious life-threatening illness generates feelings associated with burnout, such as discouragement (P = 0.006), lack of empathy with patients (P = 0.010), lack of patience with coworkers (P = 0.001), lack of motivation (P < 0.001) and impotence (P = 0.019). Oncology nurses are faced with diseases that generate suffering and that often have an outcome of death. This causes frailty and a feeling of impotence in professionals, because there is no possibility of reversing the situation. 1 Education and training for dealing with death, and discussion of attitudes towards death, can be a way to decrease the levels of burnout among oncology nurses. 15 In the binary logistic regression analysis, it could be seen that separated, divorced and widowed individuals (OR = 2.483) and single individuals (OR = 2.695) were more likely to develop burnout than were married individuals. This finding corroborates other studies conducted in Australia and China. 14,27 The emotional support and stability that a family or partner can offer are important protective factors that support mental health and prevent burnout. In addition, it is understood that social support in its different forms is considered predictive of and protective against burnout syndrome. 28 Another important result from the present study was that relationship difficulties among the nursing team were associated with burnout. In Brazil, nursing is further subdivided into categories.
It is a hierarchy, with different positions, functions and salaries.
This scenario may not be healthy for relationships among professionals and may cause difficulty and imbalance in the relationships between team members.
The professionals who reported feeling a lack of patience with coworkers (OR = 3.996; P = 0.007) were approximately four times more likely to experience burnout than those who did not report this feeling. One dimension of burnout, i.e. depersonalization, corroborates this finding. The main characteristics of this domain are cynicism and insensitivity toward coworkers, patients and family members, thus indicating that burnout itself leads to a lack of patience with colleagues, which further increases the probability of developing burnout. 5 The feeling of melancholy at work (OR = 2.840) increases the risk of burnout, compared with professionals who do not feel melancholy. It is evident that depression is related to burnout: melancholy is a common feeling among depressive individuals, since it is characterized by mental fatigue. 29 The professionals were asked whether they would choose to enter the nursing profession again (OR = 0.214), and those who said yes had a lower probability of burnout than those who said no. This finding demonstrates that achievement and job satisfaction are protective factors against burnout.
This study had some limitations. The first was that it was a cross-sectional study, and it was therefore impossible to determine cause-and-effect relationships. The second was that we evaluated work stressors based on the opinions of nursing professionals and did not objectively measure their numbers of appointments or actual working time. However, we believe that perceptions of one's work, and not necessarily the work itself, are more important with regard to the genesis of burnout. Thirdly, the data were based on nursing professionals who were working in a single oncology center, and this may limit the generalizability of our results to other care settings or may not reflect the overall reality of Brazil. Fourthly, the sample consisted mostly of women. Thus, this reflected the demographics of this field, which can be explained by the historical context within which the profession emerged. Although an increasing number of men are entering the profession, women still comprise the majority of nurses in this country. Additionally, the questionnaire that was developed to obtain sociodemographic data relating to nursing professionals' health, perceived stressors in daily work and activities outside of work had not been validated.

CONCLUSIONS
An important number of nursing professionals working in oncology were identified as having possible burnout. The association between perceived workplace stressors and burnout suggested that organizational dynamics had contributed to creation of a stressful work environment that affected these professionals' emotional wellbeing and commitment to the field. In this context, strategies for reorganizing work processes and practices that promote professional interaction, involvement in decision-making and sharing of emotions are relevant for self-management, health promotion and maintenance of care quality.