STRESS AND SUFFERING IN HOSPITAL NURSES: RELATIONSHIP WITH PERSONAL AND WORK VARIABLES AND LIFE HABITS

ABSTRACT Objective: to identify the possible associations between stress and suffering with personal, work and lifestyle variables. Method: cross-sectional, quantitative, exploratory, correlational, conducted from June 2019 to February 2020. Data on personal characteristics, life habits and working conditions were obtained with the application of a questionnaire. To assess stress, the Nurses’ Stress Inventory (Inventário de Estresse em Enfermeiros) was used and, for suffering, the Pleasure and Suffering Indicators at Work Scale was applied, both in the Brazilian versions. Results: stress was associated with dissatisfaction with remuneration, indicators of suffering and interest in changing jobs and professions. The comparisons between the indicators of suffering and the domains of stress investigation were significant. Conclusion: the stress experienced in nurses' work activity is strongly influenced by low remuneration, leading them to wish to change jobs and professions. Professional burnout and lack of recognition are stressors that drive defense mechanisms, among them, the desire to change jobs.


3/15 INTRODUCTION
Pleasure and suffering are inherent to any work activity¹.In the work of nurses, positive experiences such as the contribution to healing, rehabilitation of the sick and the feeling of gratitude of those involved in the care process reinforce the sensations of pleasure.However, stress, work overload, and exhausting workloads and the high demands foronowledge, technical and managerial skills are challanging.
The comprehension of these antagonistic feelings was proposed by the French psychiatrist Christophe Dejours, through the theoretical framework of the Psychodynamics of Work¹.According to the author, suffering can operate as a mobilizing factor of investments for the transformation of reality and confer pleasure to the worker².In this context, creativity is used to re-signify suffering in a positive experience that, in turn, it will contribute to the construction of professional identity and enhance resistance to the risks of psychosomatic destabilization³.
Professional exhaustion and lack of recognition at work are considered as indicators of suffering.Experiencing situations that cause stress, emotional exhaustion and overload, in addition to feelings of frustration, insecurity, dissatisfaction and fear, contribute to professional burnout.Moreover, the lack of recognition comes from devaluation, lack of recognition of the efforts made, discrimination, disqualification, as well as feelings of injustice, indignation and worthlessness.
Of the factors involved in the work activity of nurses, stress has a prominent position.Research has identified symptoms of stress with risks to nurses' health 4,5 .Stressful nursing situations include the high work flow, patient transfer, exhausting workloads, night work, multiple relationships, overtime, emotional involvement with patients and their companions, care responsibilities, insufficient salaries and conflicting interpersonal relationships in the work environment 6,7 .Such stressors can be a source of suffering and cause professional exhaustion and lack of recognition.
Thus, investigating stress and suffering in nurses considering personal, work and lifestyle variables corresponds to an important investment in the health of this professional who plays an indispensable role in society.Although scientific evidence demonstrates stress levels with risks to the health of these professionals 4,5 , the present research is added to the others, in an attempt to reiterate, with more clarity, stressors, experiences of suffering and associated factors.
The importance of investigating these phenomena is supported by the ability to understand factors that compromise the performance of nurses' work activity and bring contributions to the nursing of the future.The fact that the study took place in teaching hospitals makes the results even more relevant due to the proximity between nurses and undergraduate students who perform practical activities, curricular internships or technical visits, in the perspective that this interpersonal relationship can be based on experiences of pleasure or cause stress and suffering to those who are still in the training process.
In addition, nursing has gained visibility in the global context due to the COVID-19 pandemic.Concerned about the impacts of this crisis, national and international studies 8,9,10 were developed in order to investigate the suffering and physical and psychological impairments in nurses.It is worth mentioning that the present research was conducted in a pre-pandemic context, which in turn becomes of great relevance, since it will serve as a support to analyze the impacts, attenuated or aggravated, to health.Thus, it is appropriate to identify the possible associations between stress and suffering with personal, work and lifestyle variables.

METHOD
This is a cross-sectional study with a quantitative, exploratory, correlational approach, carried out at the Hospital Complex of the University of Pernambuco (UPE), located in Recife -Pernambuco, Brazil.The Hospital Complex is composed of three units, named A, B and C, in order to respect confidentiality and anonymity.The hospitals offer hospital care of medium and high complexity in several medical specialties and are the setting of academic practices of teaching, research and extension for the health courses of the UPE.
Among the professionals who make up the nursing categories, we chose to conduct the research with nurses.The lists with the number of professionals by sector were made available by the nursing managements.The study population consisted of 500 nurses, 110 of whom were linked to hospital A, 172 to hospital B and 218 to unit C.
The study included 221 nurses from a stratified sampling by sector, in which the number of research participants was defined based on the number of nurses assigned to each hospital area.Data collection was planned to prevent any sectors from being prioritized.
Data collection was performed by the first author of this study, from June 2019 to February 2020, when the COVID-19 pandemic outbreak in Brazil began.Data were collected in person and individually during working hours, taking about 10 minutes to complete the questions contained in the interview form.
To avoid bias in the research results, it was decided to interrupt data collection when the first case of COVID in Brazil was registered, considering the possibility of increasing the levels of stress and suffering in nurses due to the pandemic.Nurses working in management and direct patient care, in any type of shift were included in the study, excluding those with less than one year of professional activity and those on leave due to vacations, sick leave or maternity leave.
The data that characterized the workers were obtained from an instrument, developed by the authors, addressing personal, labor and life habit issues, such as: sex, race/color, marital status, title, number of employment contracts, remuneration in minimum wages, weekly workload, extra hours, overtime, satisfaction with remuneration, double shift, interest in changing jobs and professions, days off and rest time during the shift, consumption/frequency of alcoholic beverages and smoking, hours of sleep per day and quality of sleep.
The Nurses' Stress Inventory (IEE -Inventário de Estresse em Enfermeiros) was used to measure stress¹¹.This is a 5-point scale of intensity, consisting of 44 items considered as sources of stress and tension in nurses' work.The inventory investigates three specific factors, namely: interpersonal relationships, stressful career roles and factors intrinsic to work.Furthermore, factor 4 was titled as such because it did not present commonalities, being kept in the scale because it indicates reliability¹¹.
The results can be described by mean and standard deviation, raw score and z-score.The minimum score is 44 points and the maximum is 220.Scores higher than 145 are strong indicators that nurses consider work activities stressful¹¹.
Suffering was investigated by the Pleasure and Suffering Indicators at Work Scale (EIPST -Escala de Indicadores de Prazer e Sofrimento no Trabalho).The EIPST is composed of 47 experiences that investigate four indicators, two positive or referring to pleasure (professional achievement and freedom of expression) and two negative or suffering (professional burnout and lack of recognition).Although the scale evaluates pleasure and suffering, only the experiences of suffering will be considered in this study.The evaluation of the indicators of suffering was classified as: severe ≥ 4; moderate or critical, between 3.9 and 2.1; and satisfactory ≤ 2.0¹².
To eliminate typing errors, the data was double entered in Microsoft Excel, version 2010.The conference was conducted using the Epi-Info software, version 3.5.4.The data were checked

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in their entirety and only went to the analysis phase after complete parity.After this stage, the data were exported and analyzed by version 12 of the Software for Statistics and Data Science -STATA.Descriptive analyses were developed from absolute (n) and relative (%) frequencies.The Kolmogorov-Smirnov normality test was applied to evaluate data distribution.The associations between categorical variables were verified using the Chi-Square test or Fisher's exact test.One-way ANOVA was used to compare continuous variables between groups.For the statistical analyses, the significance level of p<0.05 was adopted.In case of missing, the analyses were performed only with the participants with complete information.
The research project was approved by the Research Ethics Committee.The nurses' participation was voluntary and formalized with the signing of the Free and Informed Consent Form.
Data concerning rest during the shift revealed that 45.3% rest, 16.7% for up to two hours.Extra shifts are performed by 27.6%, with 21.3% to supplement income.In addition, 18.9% work overtime due to neccessity, due to waiting for the next shift, and 33.9% do double shifts due to absences and lack of professionals at the institution.
The IEE evaluation found that 19.9% of the nurses are stressed.The main sources of stress and tension in the interpersonal relationships domain were attending a large number of people (μ=3.17;SD=1.51) and solving unforeseen events that happen in the workplace (μ=3.13;SD=1.27).In stressful roles in the career, working in inadequate physical facilities (μ=3.35

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According to Table 1, stress was associated with satisfaction with remuneration (p=0.019),interest in changing jobs (p=0.000) and profession (p=0.002),but there was no significant association with gender (p=0.055),degree (p=0.189),number of employment contracts (p=0.271),sleep quality (p=0.173),alcohol consumption (p=0.393) and frequency of alcohol consumption (p=0.871).The associations with the indicators of suffering are shown in Tables 2 and 3.

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According to Table 2, professional burnout was associated with interest in changing jobs (p=0.001),interest in changing professions (p=0.006) and IEE (p=0.000).Table 3 shows a significant association between lack of recognition and the IEE (p=0.000).

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Lack of recognition was not associated with gender (p=0.630),qualification (p=0.307),number of employment contracts (p=0.791),satisfaction with remuneration (p=0.290),interest in changing jobs (p=0.026),interest in changing professions (p=0.143),sleep quality (p=0.282),alcohol consumption (p=0.793) or frequency of consumption (p=0.442).The comparisons were significant in their entirety between the stress domains and the classification of the indicators of suffering, as shown in Table 4.

DISCUSSION
The research showed a prominent position for females with regard to stress.In this context, it is considered that the stress of nursing professionals is linked to the accumulation of tasks and professional and/or personal functions, since the woman does not detach herself from the role of mother and head of the home 13 , being more prone to stress and an impaired quality of life 14 .Furthermore, although there is an increasing trend of men in nursing, female predominance is sustained in the profession 15 .
With regard to qualifications, the largest number of stressed nurses had a Lato Sensu postgraduate degree, but the number of stressed nurses with a master's and doctor's degree was considerable, which suggests that Strictu Sensu training does not play a buffering role for stress.By engaging in these qualifications, professionals create different expectations that, when not met, can generate frustration and eventually stress even more in the face of the profession.A study carried out with master and doctor nurses who graduated from the Stricto Sensu graduate program, showed the relevance of this qualification for greater recognition and appreciation at work.However, emphasis was placed on the increase in responsibilities and workload, the decrease in time for leisure and rest, which resulted in exhaustion and psychological distress 16 .
Sleep quality was considered by most stressed nurses as "poor" or "very poor".Sleep is an essential process for the establishment of the body's functions and its deprivation or irregularity results in hormonal changes and weight gain 17 , and stress can bring various consequences such as anxiety and changes in sleep pattern and food intake 18 .

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With regard to stress, Brazilian studies carried out in a private service 18 and with nursing professionals in a university hospital 19 identified the stressful roles in the career as the main factors influencing stress.The investigation of stress in nurses at the Intensive Care Unit showed that the highest scores on the IEE items were: "managing or supervising the work of other people", "restriction of professional autonomy" and "interference of institutional policy at work" 20 .
For Reis et al. (2020) 18 , the main stressful situations were "having a short deadline to carry out orders", "performing different tasks simultaneously" and "working with unprepared people".Contrary to the aforementioned studies, interpersonal relationships were the main sources of stress, mainly represented by "resolving unforeseen events that occur in the workplace" and "serving a large number of people", which proves the weaknesses of public health services regarding overcrowding and lack of resources of various natures, requiring nurses to improvise.
In addition, the research revealed that nurses are dealing with several risks inherent to their work, they work in inadequate physical facilities and work with unprepared professionals, they do not have the necessary materials or human resources to do their job, they feel emotionally exhausted when carrying out their work and when managing and supervising staff and receive low wages.
With regard to remuneration, nurses are linked to two or more jobs in order to receive a living wage.Such dissatisfaction reflects the desire to change jobs and professions.Thus, it is believed that with the approval of Law 14,434,21 which establishes the minimum salary for nursing professionals, there will be a reduction in the number of nurses who are stressed and dissatisfied with their jobs and profession.
Contrary to the present study, in Cartagena, Colombia, stress was associated with those under 30 years of age, having a partner, having more than one child, working in an outpatient clinic, being hired, being linked to the company for more than two years and having more than five years of experience in the position 22 .In Taiwam, China, the predictors of burnout syndrome were age, physical/ psychological symptoms, job satisfaction, and work involvement 23 .
The nurse's work activity has nuances that can provide pleasure and/or suffering.The nurse fights against death and illness on a daily basis, manages teams, controls equipment and materials, commands a team and offers health care to patients.In this scenario, pleasure emerges as a result of the contribution to the cure and/or recovery of patients and suffering arises when working conditions are unsatisfactory to offer quality care or when investments in health care are in vain.
Work is fundamental for structuring the health of individuals, because it encourages subjectivity and self-realization 24 .Suffering begins when the worker does not reach the goal of completing tasks at work, despite zeal.Nevertheless, sensations of pleasure arise when, through zeal, appropriate solutions are met.Zeal is understood as the affective involvement of subjectivity, in friction with experienced teachings, when performing customary activities 25 .
Contrary to the presented results, similar studies classified the lack of recognition satisfactorily 26,27 and critical professional burnout 27,28,29 .In the oncopediatric inpatient unit, suffering was experienced when providing palliative care, performing invasive procedures and work organization, as well as dealing with the death of patients 30 .In the surgical clinic, inappropriate working conditions, clinics difficult to deal with, the death of patients, lack of distraction and the need to choose between working and taking care of the family 31 .
Although the focus of the investigation is stress and suffering, satisfaction was considered to be multifactorial in the work of intensive care nurses, relating to autonomy, decent wages, results achieved in groups and excessive workload 32 .Furthermore, when experienced in the workplace work, 11/15 pleasure improves interpersonal communication 33 .In sectors such as the pediatric intensive care unit, pleasure was experienced in the success of the child's recovery 34 , despite the oncological palliative care in the feeling of motivation and recognition of the work performed 35 .
In this research, professional burnout was shown to be serious, being strongly influenced by stress, emotional exhaustion, dissatisfaction, overload, frustration, insecurity and fear.These feelings of suffering, combined with the lack of recognition of the effort and performance employed, devaluation, indignation and injustice, put the nurse in a position of vulnerability.Professional exhaustion and lack of recognition are stressors that motivate nurses to change jobs and professions.
Nursing is a profession whose mission is to "care", however, it is unfair to demand so much from a profession that is not "cared for".The feeling of those who care is one of "ingratitude", for giving so much and receiving little in return.In view of the above, it can be inferred that the dissatisfaction in nursing work is multifactorial and requires constant investigation, considering that the work contexts are in constant transformation.
When considering the important social role played by nurses, dignified working conditions that allow these professionals to experience constant feelings of pleasure in exercising their profession become imperative.Although the presented results serve as triggers for health protection strategies to be traced, the research is limited because it does not establish a cause and effect relationship, nor laboratory measurements of stress dimensioning.Furthermore, questions such as the number of patients under the nurses' responsibility per shift and the number of hours dedicated to family and activities of daily living were not addressed.
In this context, it is suggested that future studies engage in unaddressed questions, as well as investigate the foundations and consequences of stress and suffering, so that their confrontation is outlined considering the individuality of nurses.It is believed that the reality of the research is specific, as it represents the scenario of three hospitals in the capital of Pernambuco.However, in view of the economic, social and cultural diversity of the country, studies of this nature deserve to be carried out, problematized and discussed in other locations, so that similarities and differences are highlighted.
Given the above, it is considered relevant that professionals of the area become aware of the results presented here, so that measures are taken in accordance with their competences.In addition, it is necessary for hospitals to prioritize worker health, through actions that minimize stressors, reduce occupational risks, operate changes in working conditions and nurses are active in building and monitoring conditions of health.

CONCLUSION
Stress, overload, emotional burnout, dissatisfaction, frustration, devaluation, lack of recognition of effort and performance, indignation and injustice were highlighted as the feelings associated with suffering.The stress experienced in the nurse's work activity is strongly influenced by low pay, leading them to want to change jobs and professions.Professional burnout and lack of recognition are stressors that drive defense mechanisms, among them, the desire to change profession.
The fact that this study was developed in teaching hospitals further aggravates the results of this research, because the students imagine an ideal scenario of the internship fields, however, in many cases, the reality is a different context, causing discouragement, insecurity and dissatisfaction at the beginning of professional training.
The results of the research serve as a warning to recognize that nursing is falling ill as a result of inadequate working conditions, physical, mental and emotional overloads, occupational stress and lack of recognition.

Table 1 .
Data on the associations between stress and personal, work and lifestyle variables are shown in

Table 1 -
Association between stress and personal, work and lifestyle variables in nurses of the Hospital Complex of the University of Pernambuco, Recife, Pernambuco, Brazil, 2019-2020.

Table 2 -
Association of professional burnout with the IEE, personal and work variables and life habits in nurses of the Hospital Complex of the University of Pernambuco, Recife, Pernambuco, Brazil, 2019-2020.

Table 3 -
Association of lack of recognition with the IEE, personal and work variables and life habits in nurses of the Hospital Complex of the University of Pernambuco (UPE), Recife -Pernambuco, Brazil, 2019-2020.

Table 4 -
Comparison of stress domains according to the classification of distress indicators in nurses of the Hospital Complex of the University of Pernambuco, Recife, Pernambuco, Brazil, 2019-2020.