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Enfermería Global

On-line version ISSN 1695-6141

Enferm. glob. vol.16 n.48 Murcia Oct. 2017  Epub Oct 01, 2017

http://dx.doi.org/10.6018/eglobal.16.4.249321 

Originales

Job strain and psychosocial aspects of intensive care nurses

Jorge Luiz Lima da Silva1  , Liliane Reis Teixeira2  , Rafael da Silva Soares3  , Felipe dos Santos Costa4  , Joélinton Dos Santos Aranha5  , Enéas Rangel Teixeira6 

1PhD. Adjunct Professor, Fluminense Federal University. Niterói, RJ, Brazil.

2Researcher at the Center for Studies on Workers' Health and Human Ecology, Oswaldo Cruz, Rio de Janeiro, Brazil.

3Nurse of the Souza Aguiar Municipal Hospital, Rio de Janeiro, RJ, Brazil.

4Nurse from the Municipal Health Secretariat, Bananal, SP, Brazil.

5Placi - Extensive Care -UFF.

6Main Professor at the Fluminense Federal University Niterói, RJ, Brasil.

ABSTRACT

The study has as object the psychosocial aspects and burnout. This study aimed to describe psychosocial factors of intensive care nursing workers, according to socio-demographic and labor variables. Sectional study with 134 professionals, applying self-administered questionnaire containing: a summary of the Job Stress Scale - to measure stress; Maslach Burnout Inventory - to assess burnout; and Self Reporting Questionnaire - to assess common mental disorders. Regarding the stress dimensions: 30.8% of the workers were in high demand; 24.6% in active job; 20.8% passive jobs and 23.8% in low demand. The burnout prevalence was 55.3% and 72.5% were at high strain (p = 0.006). The prevalence of common mental disorders was 27.7%. The organization of work in intensive care unit favors the high-demand stress and consequently demonstrates significant prevalence of common mental disorders and burnout. Mental health appears as a key element in the hospital work environment and needs greater attention by the teams and officials.

Keywords Stress; intensive care unit; burnout; nursing; occupational health

INTRODUCTION

In the contemporary scenario, the workers’ modes of getting sick and dying has been transforming and gaining greater complexity, which translates into an increase in diseases such as mental and physical fatigue and other work-related suffering expressions such as stress 1)(2. According to the International Labour Organization (ILO), the negative impacts may also include psychosomatic and psychosocial disorders. These can favour the increase of accidents, injury, poor performance and productivity 3.

Stress can be understood as the relation between the person and the environment that is perceived by the individual as overload or exhaustion of coping resources, putting the well-being at risk 4)(5.

The Brazilian workers’ healthcare policies are scarce and there is little information on illness resulting from work stress and/or psychic illness. The paucity and inconsistency of the information on the real situation of the health of this specific population hinder the definition of priorities for public policies 6)(8.

Models have been used to assess the degree of stress and organic responses, in order to understand their role in psychosocial scope. Environmental stressors have also been investigated, by establishing relationships with factors contained in the working environment that may influence the professional performance 9)(10)(11)(12)(13.

Researchers Robert Karasek and Theorell Töres presented theoretical two-dimensional model relating the psychosocial dimensions demand and control at work to the risk of physical and mental illness. Demands are psychological pressures, such as time and speed in carrying out the work, and the contradictory conflicts. The term control refers to the task, that is, the worker’s skill or dexterity to comply with them, and the opportunity to participate in decisions in the workplace to perform them 11. In addition to the model, there is the social support in the workplace, defined as the level of social interaction between colleagues and bosses at work 14. The demand-control model has been widely applied in researches in countries in the Americas, Europe and Asia 15)(16)(17.

The intensive care unit (ICU) seems to be one of the most aggressive, tense and traumatic hospital environments. These hostile factors reach patients, and the multidisciplinary team, especially nursing, which daily experience scenes of ready attendance, serious patients, isolation and death situations, which qualifies the hospital work as drudgery. Therefore, these professionals have great probability to be subjected to various stress-related factors, present at that location 18.

OBJECTIVE

To analyze the stress-related aspects to characteristics of the intensivists’ work.

Justification

The WHO highlights a prevalence of 30% of common mental disorders and of 5 to 10% of serious disorders among the occupied working population 19. The worsening situation of stress caused by the continuous wear can lead to consequences of greatest impact for the workers’ health, as professional exhaustion syndrome, or burnout syndrome (BS) 6)(20)(21.

In the current scenario, there are cost cuts, fewer workers, precarious employment links and remarkable general wear of the worker. Thus, studying stress under various perspectives, such as the epidemiological investigation, becomes important. Mental illness just loses to heart disease, bring losses to the worker's health and lead to failure, especially in metropolitan regions 22.

In this way, health authorities and researchers give the stress and psychosocial factors a featured role, which refers to the thought of the glimpse of this phenomenon as public health problem that should be studied under the multidisciplinary approach.

MATERIAL AND METHOD

Observational study, sectional-type descriptive. The study population was the nursing team from the Coronary Unit (COU) and ICU of two large hospitals in the metropolitan region of Rio de Janeiro (RJ). The researchers searched actively for those who were at leave, transferred and absent in the ICU sector, as well as the reasons for the leaves, including, therefore, those who have been away from the sector for up to six months, after telephone contact and schedule for completing the questionnaire at the hospital. These measures were taken in order to avoid the bias of the healthy worker. The data collection occurred during the year 2011. The hospitals were named as university hospital (A) and general hospital (B).

The instrument used was a self-applied structured questionnaire with open and closed questions. The study used the scale adapted for Portuguese of the short version of the Job Stress Scale (JSS), originally drafted in English 15. Töres Theorell created the reduced version in 1988. This version has 17 issues, likert-type, with five items to assess the psychological demand at work, six to assess the degree of control at work and six for the social support 14)(15.

For the definition of the quadrants of exposure to stress at work, based on demand and control dimensions, the study used the median found in the two-dimensional scores 11. Regarding the composition of the groups demand-control model, demand and control variables and their respective dichotomized degrees (low and high), they were combined in order to build the quadrants of the two-dimensional model, where: high requirement (HR) = combination of high demand and low control; active work (AW) = combination of high demand and high control; low requirement (LR) = combination of low demand and high control; and passive work (PW) = combination of low demand and low control. The social assistance followed the same pattern of the previous score and the median was used as a cutting point.

The Maslach Burnout Inventory (MBI) was used for the evaluation of the BS, in its version adapted and validated for the Portuguese, with nursing professionals, consisting of 22 questions in likert-type scale, with values of 1 (never) to five (always) which assesses three dimensions: emotional exhaustion (EE) 9 statements; depersonification (DE) 5 statements; and personal fulfillment (PF) 8 affirmative 23.

Self Reporting Questionnaire (SRQ-20) was used to measure common mental disorders (CMD). It involves 20 questions, with validation in 1986, when recommending the cutting point in five positive responses to suspicion among men and seven, for women 24. This study used the cutting point = 7, value considered in other studies with nursing professionals 25)(27.

The descriptive analysis included measures of central tendency, dispersion and frequency analysis. The score of each subscale was performed in accordance with the standards previously mentioned, in addition to standard deviation. Bivariate analysis was performed between the exposure variables (stress at work) and sociodemographic and employment variables. The assessment of statistical significance considered the value p ≤ 0.05. The used tests were: the Pearson Chi-square and Fisher's exact test. Each step in the analysis process used the program Statistical Package for the Social Sciences version 21(SPSS®).

The Ethics Committee of the institutions approved the study, taking into account the provisions of resolution 466/2012 of the National Health Council for researches involving human beings.

RESULTS

Description of sociodemographic and labor variables

There was participation of 130 nursing professionals from two large-sized federal hospitals in the metropolitan region of Rio de Janeiro. Among the workers, 58 declared pardos, indigenous or asiatics, classified as mestizo (44.6%); regarding gender, the distribution was equal, 65 men and 65 women (50%); the average age was 35 years (s.d. = 8.6), with 68 above (52.3%); in terms of schooling, 81 attended high school (62.3%); as for the marital status, 71 lived with partner (54.6%); 68 did not have children (52.3%); the average per capita income was 7 minimum wages with 53.8% below this range.

The group distributed into 80 (61.5%) workers from hospital A and 50 (38.5%) from hospital B; as for the professional category, 37 (28.5%) were nurses, 62 were nursing technicians (47.7%) and 31 (23.8%) were nursing assistants; 78 (60.0%) performed their activities in ICU and 52 (40.0%) in the coronary unit (COU); most possessed an employment relationship (60.8%), were part of the permanent staff of the institution (71.5%) , worked in mixed shifts (55.4%) (professionals who worked in night and day shifts, without fixed schedule); the average time in the sector was 5 years (s.d. = 5.5), with 92 (70.8%) professionals below that average; regarding the profession time, the average was 12 years (s.d. = 8.4), with 70 (53.8%) employees with less time than this range; the average weekly workload was 51 hours (s.d.= 19.3), and the subjects were allocated equally above and below this value.

Analysis of psychosocial aspects related to sociodemographic and labor variables

The majority of workers, 106 (81.5%), referred not to think at work during the holidays. About the self-reported stress, 93 (71.5%) reported the average layer of stress. The dimension demand presented median size 10 (s.d. = 2.28), in which 71 (54.6%) professionals were in the lower stratum. The dimension control with median of 12 (s.d. = 1.92), presented 72 individuals above this level (55.4%). The social support with median 11 (s.d. = 3.52), 69 (53.1%) was concentrated under this measure. As for the demand-control model quadrants: 40 employees (30.8%) were in HR; 32 in AW (24.6%); 27 in PW (20.8%); and 31 in LR (23.8%) (Figure 1).

Figura 1 Percentages of stress categories of intensive care workers, RJ-2014 / N = 130 

It was observed that, among those with up to 35 years, 25 (78.1%) were in AW, while above average population of age, 18 (66.7%) were in PW (p = 0.001). Those who have studied up to high school, 30 (75%) were in HR, while 19 (61.3%) with higher education were in LR (p = 0.010). As for the family income, it was realized that those with the lowest salaries, 24 (75%) presented AW, and between those who held the higher wages, 23 (57.5%) allocated in HR (p = 0.032) (Table 1).

Table 1 Psychosocial factors, according to Karasek's quadrants, according to sociodemographic and labor variables of intensive care workers, RJ-2014 / N = 130. 

SOCIODEMOGRAPHIC AND LABOR VARIABLES HIGH REQUIREMENT PASSIVE WORK ACTIVE WORK LOW REQUIREMENT
N % N % N % N %
Mean age = 35 years (s.d.= 9,7) p=0.001
Up to 35 years 15 37.5 09 33.3 25 78.1 13 41.9
More than 35 years 25 62.5 18 66.7 07 21.9 18 59.1
Gender p=0.156
Female 20 50.0 17 63.0 11 34.4 17 54.8
Male 20 50.0 10 37.0 21 65.6 14 45.2
Recoded skin color/race p=0.412
Black 10 25.0 09 29.6 09 28.1 07 22.6
White 21 52.5 07 25.9 15 46.9 15 48.4
Mestizo 09 22.5 12 44.4 08 25.0 09 29.0
Recoded marital status p=0.160
With partner 25 62.5 16 59.3 12 37.5 18 58.1
Without partner 15 37.5 11 40.7 20 62.5 13 41.9
Presence of children P=0.533
Yes 22 55.0 13 48.1 12 37.5 15 48.4
No 18 45.0 14 51.9 20 62.5 16 51.6
Schooling by mean P=0.010
Up to high school 30 75.0 16 59.3 23 71.9 12 38.7
College or more 10 25.0 11 40.7 09 28.1 19 61.3
Mean Family income of 7 MW p=0.032
Up to 7 MW 17 42.5 15 55.6 24 75.0 14 45.2
More than 7 MW 23 57.5 12 44.4 08 25.0 17 54.8
Hospital p=0.0001
Hospital A (university) 28 70.0 16 59.3 26 81.3 10 32.3
Hospital B (general) 12 30.0 11 40.7 06 18.8 21 67.7
Professional category p = 0.259
Nurse 12 30.0 09 33.3 05 15.6 11 35.5
Nursing technician 18 45.0 09 33.3 21 65.6 14 45.2
Nursing assistant 10 25.0 09 33.3 06 18.8 06 19.4
Number of jobs p=0.159
Up to 2 jobs 32 80.0 25 92.6 29 90.6 23 74.2
More than 2 jobs 08 20.0 02 07.4 03 09.4 08 25.8
Work shift p=0.230
Diurnal 13 32.5 10 37.0 16 50.0 12 38.7
Nocturnal 01 02.5 01 03.7 04 12.5 01 03.2
Mixed 26 65.0 16 59.3 12 37.5 18 58.1
Weekly workload p=0.785
Up to 51 h 21 52.5 14 51.9 17 53.1 13 41.9
51h or more 19 47.5 13 48.1 15 46.9 18 58.1
Sectors P=0.138
ICU 30 75.0 15 55.6 17 53.1 16 51.6
COU 10 25.0 12 44.4 15 46.9 15 48.4
Time in the sector p=0.017
Up to 5 years 28 70.0 18 66.7 29 90.6 17 54.8
5 years or more 12 30.0 09 33.3 03 09.4 14 45.2
Professional time p=0.033
Up to 10 years 18 45.0 12 44.4 24 75.0 14 46.2
10 years or more 22 55.0 15 55.6 08 25.0 17 54.8
Type of job p=0.533
Temporary 08 20.0 08 29.6 11 34.4 10 32.3
Permanent 32 80.0 19 70.4 21 65.6 21 67.7
Suspicion of CMD p=0.120
Normal 24 60.0 23 85.2 25 78.1 22 71.1
Sick 16 40.0 04 14.8 07 21.9 09 29.0
Suspicion of burnout p=0.006
Normal 11 27.5 17 63.0 19 59.4 11 35.5
Sick 29 72.5 10 37.0 13 40.6 20 64.5
Thinking of work during holidays p=0.029
Yes 12 32.5 02 07.4 06 18.8 03 09.7
No 27 67.5 25 92.6 26 81.2 28 90.3
Social Support p=0.027
Below median (low) 18 45.0 17 63.0 12 37.5 22 71.0
Higher than the median (high) 22 55.0 10 37.0 20 62.5 09 29.0

Subtitle: N= total of elements in the stratum; % = relative frequency; s.d. = standard deviation; MW = minimum wage.

A total of 26 (81.3%) professionals presented HR work at the University hospital, and LR in general hospital 21 (67.7%) (p = 0.0001). As for the weather, one can see AW 29 (90.6%) among those who worked until the average of 5 years, and 14 (45.2%) in LR work among those above the average (p = 0.017). With respect to the time in the profession, were found 24 (75%) with AW among those in the top ten years, and among the group with more career was observed PW 14 (55.6%) (p = 0.033) (Table 1).

The prevalence of BS was 55.3% (72), with 29 cases (72.5%) in HR, followed by 20 (64.5%) in LR (p = 0.006). Was checked high support in AW with 20 workers (62.5%), and low support in LR with 22 (71%) (p = 0.027). As to the suspicion of CMD, was observed the prevalence of 27.7% (36 suspects), without statistical difference as to the categories of stress (Table 1).

DISCUSSION

This study describes the psychosocial aspects and factors associated with the sociodemographic aspects and how to behave among the population of workers, highlighting outcomes as mental disorders, burnout syndrome and high demand at work. These factors are related to harmful consequences for workers' health and, consequently, quality of care provided.

Sociodemographic and labor variables

The group of workers presented equal proportions related to gender, although studies point greater female population in intensive care nursing 28)(29. The sector in question of the University Hospital (HU in Portuguese) showed a higher frequency of masculine gender with Coronary Unit (UCO), while in the General Hospital (HG) the female gender became more frequent. The typically feminine concentration comes giving way to growing presence of men in this sector 30)(31.

Most of the workers studied until high school, which entailed elated income per captures below average and the number of nursing technicians, followed by top-level professionals. There are peculiarities and unique demands by intensive nursing care, the number of top-level professionals (nurses) is more expressive, as there are more assistance needs of greater complexity. The lack of intensive workers have excelled in the U.S. health system, this shows that the increase of the demands have not been accompanied by increased physical, technological and human resources 32. The same cannot be said about the Brazilian system, for lack of records on working conditions in Icus by responsible authorities, however studies point out that deficit33)(34.

The population proved to be dedicated to the institution, once they presented only an employment relationship, and are permanent staff. The higher frequency of mixed shift workers can be explained by extra shifts, strikes and absenteeism. In this dynamic, the group is formed by young, recent in the profession and in the industry, with over 51h hours per week. It should be emphasized that this load time is possibly related to extra shifts, and schedules coverage of professionals who are absent.

Analysis of psychosocial aspects

The perception of stress had relationship with the dimension control at work, which measured as high among the group. This fact was reflected in the categories where stress and AW were the second and third, respectively. Leadership and planning activity is common in the team process work in the ICU, since those with higher education were LR when compared to those of lower educational level in HR, aspects related to the control at work. In addition, the perception of manual activities in addition to the leadership and planning is striking in this environment.

The professionals presented HR work at the University hospital, and LR in general hospital. Due to HU having to deal with activities of teaching, research and extension, the team ends up getting involved in a dynamic that, somehow, can increase the demand for work, in serving the students at ICU. Can be stress factor activities that require a high degree of responsibility and qualifications, in addition to the physical, emotional, and voltages, overloading the most experienced professionals in the ICU 35. The majority of the population above the average age was in PW, which is the second stage of higher risk for mental illness. Demand and low control situations combined create a scenario little motivator, and may lead to gradual loss of skills 11)(36. These data and facts, added up to high load in the environment described, besides the psychic emotional demand before the impending process of death make the environment a source of strenuous activity for the nursing professional.

The growth of hard running and invasive procedures in medicine requires constant training of the staff for the field of new technologies, increasingly complex and more active. The updates require the effort of professionals for its improvement, constituting itself as another charge in the process of work. In this context, there is a risk of technological human professional stand out so necessary in this environment. This technological dynamics can wear the links required for the patient care and critical attention to their families, as well as open space for the despersonificação, one of the main features of the BS 37. However, the worker, even under constant psychosocial risks, should remember the human relationship, a great challenge 35.

The youngsters were in AW, as well as those who worked until the average of 5 years. The LR work focused on those above that average. Thus, young people are the most demanded in their jobs under the supervision of experienced old officials. That reflects the data about the time in the profession, in which there were AW among those in the top ten-year career, when compared to those with more time in PW. So, the older professionals are in LR or PW, and the youngest in AW or HR. Learning and growth are provided for when are high psychological demand and control, but not excessively11)(36.

Regarding suspicion of BS, most employees were in HR and LR. This shows that the risk for mental illnesses is corroborated by the demand-control model, confirmed in research with intensive physicians, in which was found the association between BS, observed in high requirement situation of demand-control model 38.

There was high support among AW workers and low support among group of employees. Similar results were found in survey of the nursing staff of public hospital in Salvador, Bahia, to AW workers, with social support (68.5%) 25. Studies with similar population show statistical association between low social support and the quadrant HR, different from this study 25)(39.

Social support is an important element in health maintenance. Built through social relations in the workplace, is a factor of great importance in the workers’ health-disease process, either from the institutions or from the relationship among employees. Low levels of support can join harmful manifestations and negative effects to health 11)(36. Some studies showed that the lack of support in the workplace makes workers more prone to cardiovascular disorders, stress, physical and emotional exhaustion 40)(41.

The mechanisms by which social support in working environment can affect health, well-being and quality of life are diverse, mitigating the deleterious effects is of psychosocial work stressors and also catalyzing the development of new skills or behaviors 41. In addition, social support can moderate the tension and other adverse health effects, reducing your power or increase coping strategies 36.

When existing, social support softens negative stress labour demands and may contribute to the employee to establish efficient mechanisms of resilience in the face of common difficulties of daily life of work.

Concerning the suspicion of CMD, was observed a prevalence among nearly a third of the professionals of insituition. In research with nursing staff in the intensive care unit, the work of Silva et al. presented 21.3% prevalence 26. There is some compatibility of results with the study in question. Study with nursing workers of University hospital showed 18.7% suspicion 42 and confirmed the disclosure of the existence of the health problem in question among these workers. HR group presented higher prevalence among workers, as well as in this study (40.0%). Most adverse reactions to stress occur when psychological demands of work are high and the decision-making is low 11)(36.

For the HR, the suspicion to burnout in most workers and nearly half to CMD. There is a higher prevalence of BS between intensive workers, when compared to public health professionals. The high frequency of health problems arising from high levels of stress, and its association with CMD and BS, among health professionals from various fields, denote the need for intervention strategies in the everyday life of these workers, and further investigation into the dimensions and their determining factors 43.

Therefore, there is a sum of psychosocial factors that related to stress at work, synergistically, contribute to mental illness among intensive workers36)(44, among other factors. However, the existence of association between these factors and the disease development is clear.

It's worth adding that mental health problems in a general aspect cannot be observed in isolation, since it overlaps and constitute as a public health matter, therefore, of great importance to the collectivities.

Mental disorders, as well as depressive symptoms, no longer appear as isolated problems and intra-psychic, but as collective dramas 2)(45. An example that could be cited and that proves this fact is the creation of the national network of Integral attention to health of the worker (Renast), which aims to articulate actions of promotion, prevention and recovery of the health of workers, observed as actions still fall short of the desired in the area of mental health worker 1.

The institution of Renast, in 2002, assumes an integrated intervention model and articulation of devices, network equipment and services of the SUS, even in the face of these features, there is the deficiency in the role of the network in the identification and prevention of stress and mental illnesses, through the reference regional and state centres in occupational health (Cerest). The aggravating factor is that the distress appears in a secondary form, sometimes underreported, in addition to the difficulty of establishing causal work with mental disorder, whether on the part of trade unions by the workers themselves, or on the part of health professionals 2)(22.

This is a present reality, however little analyzed and often neglected by employers, organizations and services and the worker still remains oblivious to the problem at hand, not knowing for sure what the real consequences of stressful work can bring to your mental health. This is a complex issue, and yet little investigated.

CONCLUSION

The study found that most of the workers were in HR, with low social support, and those in higher scores that showed AW dimension. The prevalence of BS was expressive, and most of the cases concentrated in HR-category of major risk. As to the suspicion of CMD, measured prevalence was average.

The organization of work in the ICU promotes the harmful stress to health and, consequently, the occurrence of mental disorders and BS, problems of great magnitude for professionals and their families, the families of the patients, health service users and hospital institutions themselves. Such harmful dynamics involves broad issues as political aspects, institutional issues and economic.

Workers operating in Icus are exposed to environments with tension, conflicting feelings and deaths. Therefore, it is of the utmost relevance the discussion of quality of life at work, as well as in-depth analysis of the factors involved in the work stress and its possible consequences as the CMD and BS.

The initial path is to listen to the worker’s needs to minimize the causative agents of stress and promote resilience. From this, must be fetched interdisciplinary joint decisions, in order to provide greater social support and decrease the wear caused by known factors in the working environment as malevolent, so strengthening the principles of workers' health. An approach to the theme of multidisciplinary form meets the requirements of Renast, promotes workers' health surveillance, the Cerests, and provides subsidies for the network services to the worker. Mental health shows up as a key element in the hospital work environment and requires more attention by the teams and authorities.

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Received: January 29, 2016; Accepted: August 08, 2016

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