Burnout syndrome in healthcare professionals: an integrative reviewAbstract
The incidence of burnout syndrome or professional exhaustion is significant among healthcare professionals, with negative impact on the personal, institutional, governmental, and patient care spheres. Aiming to investigate Brazilian research on the topic, we conducted an integrative literature review and selected 35 articles published from 2014 to 2019. We identified a high rate of burnout syndrome in healthcare professionals, a high risk of developing this condition and other mental disorders. Most studies were conducted in hospitals and public health centers, involved health professionals and had a greater number of female professionals. We emphasize the need to conduct further studies in the field, especially regarding other professional categories and other work environments, also analyzing the impact of the predominance of female healthcare professionals.
Burnout, Professional; Health personnel; Occupational health
Resumo
A incidência de síndrome de burnout ou síndrome do esgotamento profissional é significativa entre trabalhadores da saúde, com impacto negativo no âmbito pessoal, institucional, governamental e no cuidado com os pacientes. Com o objetivo de investigar o campo de pesquisas brasileiras sobre o tema, foi realizada revisão integrativa da literatura selecionando 35 artigos publicados entre 2014 e 2019. Identificou-se alto índice de síndrome de burnout em profissionais da saúde, assim como alto risco de desenvolver essa síndrome e incidência de outros transtornos mentais. A maior parte das pesquisas envolve profissionais de medicina e enfermagem, apresenta a maioria dos profissionais de saúde como do sexo feminino e é desenvolvida em hospitais e unidades básicas de saúde. Ressalta-se a necessidade de desenvolver mais pesquisas na área, principalmente envolvendo outras categorias profissionais e abrangendo outros ambientes de trabalho, analisando ainda o impacto da predominância de profissionais mulheres na saúde.
Esgotamento profissional; Pessoal de saúde; Saúde do trabalhador
Resumen
La incidencia del síndrome de burnout, o síndrome de desgaste profesional, es significativa entre los trabajadores de la salud, con un impacto negativo en el ámbito personal, institucional, gubernamental y en la atención al paciente. Para investigar los estudios brasileños sobre el tema, se realizó una revisión integradora de la literatura, con 35 artículos publicados entre 2014 y 2019. Se pudo identificar una alta tasa de síndrome de burnout en los profesionales de la salud, así como un alto riesgo de desarrollar este síndrome y la presencia de otros trastornos mentales. La mayor parte de las investigaciones involucran a profesionales médicos y de enfermería, presentan la mayoría de los profesionales de la salud como mujeres y se llevan a cabo en hospitales y unidades básicas de salud. Se destaca la necesidad de más investigaciones en el área, con otras categorías profesionales y otros entornos laborales, analizando también el impacto del predominio de las mujeres entre los profesionales en salud.
Agotamiento profesional; Personal de salud; Salud laboral
Mental disorders are characterized by anxiety symptoms, memory and concentration difficulties, fatigue, irritability, insomnia, and somatic complaints 1. Their development is related to psychological suffering and are usually diagnosed as anxiety and depression 1,2. The incidence rate of these conditions is significant: 28.8% lifetime risk of anxiety disorders 3 and 15 to 18% lifetime of major depression 4. Studies point to a correlation between psychic symptoms and work-related suffering, based on three main conceptual models: the stress-adaptation model, the demand-control model, and burnout 5.
Stress is defined as the individual’s response to pressures that trigger the fight-or-flight response in an attempt to return to a state of equilibrium. Stressors interfere in the organism’s homeostatic balance and can be physical (originating from the environment), cognitive (evaluated as threats to the individual’s integrity) or emotional (feelings or events with a prominent affective component). The consequences of this trigger are physical and psychological: accelerated thinking, increased cardiorespiratory function and muscle tone, and altered attention 6. The concept of stress is used in medicine to name the set of reactions to situations that require adaptive effort 5.
The stress-adaptation model indicates that nowadays stress and adaptive responses are much higher than before, as there are increasingly more external pressures at work, rapid technological changes, competitiveness, pressure for results, recession, fear of unemployment, etc. 5 The demand-control model, in turn, associates the psychological demand of working with the degree of autonomy and control over the work activity 7, where activities with greater psychological demand and less autonomy would have greater potential to cause illness. The burnout model is defined as a response to interpersonal stressors that occurs in work situations 8, with the burnout syndrome being the intensification of occupational stress.
This type of stress, unlike common stress, have work as an essential factor for its development, occurring when it is impossible for the professional to act on the stress agents. The adaptation mechanism is thus disrupted, stress symptoms persist, and the organism is deteriorated or exhausted. Burnout syndrome affects people who perform activities with a lot of interpersonal contact, although this particularity is controversial 5. However, this definition generates different terms for this condition, such as “work,” “professional,” “assistance,” or “occupational” stress, linked to perceptions of illness induced by direct service to the public. “Professional” or “excellence” neurosis, “professional burnout syndrome” and “nervous exhaustion” are other terms used. Such variety of nomenclatures complicates surveying the bibliography in the field 9,10.
The first studies on the topic appeared in the 1960s, becoming more present and recognized in Brazil – where it is identified as a work-related disease 11 – in the 1970s 8. According to Fabichak, Silva-Junior and Morrone 12, international studies show a 50 to 74% incidence of burnout syndrome in medical professors, nurses, and residents. In Brazil, the same authors pointed out that this illness affects 78.4% of medical residents from several areas 12.
The Maslach Burnout Inventory (MBI) is the most widely used instrument to measure burnout 13 and aims to detect the syndrome or its risk by identifying consequences. It consists of 15 questions subdivided into three subgroups: emotional exhaustion, considered as energy loss and feeling of emotional exhaustion; depersonalization, characterized as a lack of sensitivity and rudeness when treating the public; and professional accomplishment, defined as a negative self-assessment of one’s own work or reduced feelings of competence regarding personal gains achieved at work 14. Answers range from “never” to “every day,” and their frequency is quantified. High mean scores for emotional exhaustion and depersonalization and low for professional accomplishment indicate burnout syndrome.
We have no precise data on the incidence of burnout syndrome, but it is estimated to vary from 4 to 85.7%, depending on the population studied 15. Brazil has few publications on the topic 15, which highlights the importance of this research, considering the impact of the health professionals’ illness on the well-being of patients, with social, personal and institutional consequences. Thus, this study conducted an integrative review of the Brazilian production on psychological suffering related to burnout syndrome in healthcare professionals between 2014 and 2019.
Method
This is an integrative literature review structured in the following steps: definition of the research question; database search; data collection; categorization and critical analysis of the studies included; discussion; and conclusion 16. We posed the following research question: what was the knowledge produced in the Brazilian literature between 2014 and 2019 about burnout and healthcare professionals?
We searched two databases. In PubMed, the search involved the descriptors “burnout” and “health personnel,” pulled from the Medical Subject Headings. In the Virtual Health Library, we used the keywords “burnout” and “health personnel,” draw from the Health Sciences Descriptors. In both cases the keywords were used in association with the Boolean operator “and.” Inclusion criteria included original articles, dissertations, and literature reviews published in Portuguese and English (English versions of Brazilian articles) between 2014 and 2019, having Brazil as the study setting, and whose sample involved healthcare professionals. We excluded papers that did not meet the inclusion criteria, as well as duplicates and artciles in other formats (Figure 1).
Both authors collected the data separately and compared the results for greater reliability, without using tools to select and extract data. After this step, we classified the corpus according to: type of study, instruments used, sample size, research location, and authors’ background (Chart 1).
Results and discussion
Results show that several studies used no instruments that measure burnout syndrome, preferring tools aimed at other aspects of the worker’s health 17-19,22-24,27,31-33,37-39,44,45,51. However, such articles were included in this research because they refer to the psychological suffering of healthcare professionals, relating it to burnout. We also observed that most studies pointed out the predominance of female healthcare professionals 18,19-22,25,27-29,31,32,34,36,39,42,43,45-47,50,51, mainly in nursing 18,20-22,25,28,29,39,45,47,51.
Of the 35 articles included, 27 (77%) used a quantitative approach, 2 (6%), qualitative, 5 (14%) were literature reviews and 1 (3%) was an editorial. Among the quantitative studies, 18 (67% of this subgroup) applied the MBI 14 instrument, indicating it as the most used to measure burnout, which corroborates the statements of Tamayo and Troccoli 13. These authors argue that, on one hand, the wide use of MBI is interesting to compare results, but on the other, it limits the understanding of the syndrome to what is asked in the instrument 13.
Among the qualitative and quantitative research, 18 (62% of this subgroup) were conducted in hospitals or addressed this environment, and 11 (38%) focused or were conducted within primary care. The results reflect the tradition of addressing the well-being of healthcare professionals, especially in nursing and medicine, mostly in hospital settings, places with the highest occupational risk of causing mental illness in this population 17.
The significant number of studies conducted in primary care is probably due to the protagonism of this sector, whose professionals are often overloaded, playing roles that go beyond the tasks defined for their position, with emphasis on nursing 52. Further research on burnout in others workplaces is needed, as outpatient clinics, emergency care units, psychosocial care centers and other units of the Brazilian Unified Health System were not investigated in the articles found in this research.
Most authors in the sample had a bachelor in nursing, which is also the main profession surveyed, accounting for 24 (69%) articles 17,18,20-25,27-29,31-33,36,37,39,41,45-48,50,51 with at least one author from this field. Ten (29%) articles 19,26,28,38,42-44,46,49,50 included at least one medical researcher, and 13 (37%) 18,19,27,30,31,33-35, 38,40,41,46,51 had authors from other professional categories. This is probably due to the tradition of research in hospital settings 17 and the fact that the professionals working there are mostly nurses and physicians, professions exposed to additional stress factors 52. In health care, the physician’s work is traditionally the most studied regarding psychological impact 5, but other studies report a special risk of nursing professionals developing disorders resulting from stress experienced at work 53.
Burnout syndrome is a work-related illness 54, thus, most of the research included in this study points to the importance of managers promoting interventional and preventive actions. They also conclude that we must diagnose the syndrome early, as many professionals are at high risk of developing it, associated with high risk of depression. Additionally, difficulties in hierarchical relationships and insufficient human and physical resources are stressful factors also related to psychosocial factors and young age. They also recommend further studies in the area.
Among the 35 articles in the sample, 29 (83%) concluded that working conditions are related to burnout and, of these, 13 (45%) suggest the need for management intervention in the work environment as a health measure. The literature points out that burnout treatment must consider the origin of problem, covering work itself, and personal and work organization aspects 55. Treating only one of its symptoms, such as depression or anxiety, would be palliative, since burnout is a collective and organizational phenomenon 6.
Lack of autonomy at work can be related to burnout or other type of mental illness, being associated with task organization. Autonomy, understood as the possibility to express desire and subjectivity at work 56, would allow professionals to interfere in what causes them suffering. In this situation, illness occurs when the worker is forced to systematically go beyond their subjective limit 57. High work demand related to low autonomy elicits a higher risk of burnout 58. Unable to express the feelings mobilized by suffering at work, the subject must suppress them, which generates a process that Seligmann-Silva 59 calls “distress.” This indicates that intervention strategies may include increasing the professional’s autonomy 25.
Finally, most studies 18,20-22,25,28,29,39,45,47,51 revealed a predominance of women in nursing. However, this finding was not analyzed in any of the selected studies, showing that the impact of gender on illness and work dynamics has been neglected by researchers. The association between the predominance of women in nursing and care is historical 60 and has cultural marks, also impacting the choices of researchers. It has also been described in the literature how much women’s double shift, the cultural tendency of devaluing female labor, and the hegemony of the medical discourse impact the mental health of these professionals 5, being also stress factors.
Final considerations
The literature on burnout in healthcare professionals is still scarce, possibly because the International Statistical Classification of Diseases and Health-Related Problems, both in its 10 61 and 11 54versions, includes burnout not as a health condition, but as an occupational phenomenon, which can result in underdiagnosis. Given the lack of research on the topic and the prevalence of small samples with low power of generalization, the numbers are uncertain; but the conclusions of many articles in this research point to a significant rate of burnout in health professionals.
The decline in quality of work and the increase in absenteeism, turnover, and number of occupational accidents harm companies financially and in terms of their image. Additionally, they cause social damage by reducing the number of adults in productive age due to illness and healthcare expenses. The impacts as a whole are wide-ranging, and may be personal, social, business, governmental, and on the public served.
Additional research concerning the prevalence of women and its impact is needed, as well as studies that cover professions other than nursing and medicine, since we need to know whether these areas are the most affected by burnout or if their rates seem higher because they are the most researched. We must also investigate environments other than hospitals and primary care, so that findings can be more consistent and generate more effective interventions to combat and prevent burnout in healthcare institutions.
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