ABSTRACT
Objective:
to analyze the factors associated with Burnout Syndrome among nursing workers according to work shift.
Method:
cross-sectional study addressing a representative sample of 502 nursing workers from a philanthropic hospital facility. Data were collected using a characterization instrument, the Maslach Burnout Inventory - Human Service Survey and the Demand-Control-Support Questionnaire. Data were analyzed using descriptive statistics and multiple binary logistic regression.
Results:
levels of Burnout Syndrome were significantly higher among those working the day shift and associated factors included: high demand; low control; low social support; dissatisfaction with sleep and financial resources; being a nurse; and sedentariness. Professionals working the night shift, having low social support, being dissatisfied with sleep, having children, not having a religion, having worked for a short period in the institution, and being a nursing technician or aid were significantly more likely to experience high levels of the syndrome.
Conclusion:
psychosocial factors and factors from the work context, mainly low social support, were associated with the syndrome dimensions among nursing workers of both shifts.
Descriptors: Nursing; Shift Work; Workplace; Burnout, Professional; Stress Psychological; Occupational Health
Introduction
Shift work is necessary and indispensable in hospitals to ensure the continuity of care delivered to patients. In this sense, nursing workers are among the professionals who need to conform to this form of labor organization because nurses are required to provide care 24 hours every weekday 1 . Shift work, however, has been associated with changes in biological functions that lead to physical and mental disorders 2 - 3 .
In addition to shift work, nursing workers also experience a fragmented work process, interpersonal relationships that are often conflictive, low wages, a highly demanding environment, insufficient human and technological resources, emotional stress, and they witness suffering and death daily. Thus, they are often faced with factors that generate occupational stress with the potential to affect their mental health 4 - 5 .
Therefore, Burnout Syndrome is a psychosocial phenomenon emerging among nursing workers in response to their complex work environments 6 . This syndrome is composed of three dimensions: emotional exhaustion, understood as a lack of energy and a sense that emotional resources have been exhausted; depersonalization, characterized by emotional detachment; and low professional realization, a tendency of individuals to self-assess their work performance negatively and a dissatisfaction with their careers 7 . Hence, it is characterized by a loss of meaning at work, lack of motivation, negative attitudes, and detachment from others, which harm the work process in the health field 8 - 9 .
Despite the prevalence of Burnout Syndrome and the fact that nursing work in hospitals is performed as shift work, Brazilian studies investigating this relationship have only addressed nurses and specific sectors, with divergent results 10 - 11 . International studies only report that work shifts of more than 12 hours increase the levels of Burnout Syndrome 12 - 13 . Thus, it is important to broaden the settings where studies take place to address the entire nursing staff and verify factors associated with the syndrome according to the day and night shifts 3 , 14 . These studies are important to supporting managers and nursing workers in order to devise measures intended to improve the working conditions for the different work shifts and enable greater quality of life at work.
In accordance with the preceding discussion, this study’s objective was to analyze the factors associated with Burnout Syndrome among nursing workers according to work shift.
Method
Cross-sectional study conducted in a general hospital in a city in the state of Paraná, Brazil. This philanthropic hospital provides care of medium and high complexity and has 347 beds distributed among the hospitalization ward, intensive care unit, intermediate care unit, maternity ward, pediatrics, emergency room, and surgical center.
The study population was composed of 698 nursing professionals working in this facility. Inclusion criteria were providing direct care to patients and having worked in this facility for at least one year. Exclusion criteria were working exclusively in head positions or being on leave.
Based on this number of workers, the sample size was calculated adopting a 95% confidence interval and maximum error of 5%, which resulted in a minimum of 219 workers. A total of 510 workers met the inclusion criteria, 8(1.57%) of whom refused to participate. Of the 502 participants remaining, 193(38.44%) were nurses, 273(54.38%) were nursing technicians and 36(7.18%) were nursing aids; 271(53.98%) worked on the day shift (7am-13pm or from 13pm-19pm), while 231(46.02%) worked on the night shift (7pm-7am). Note that 86 workers had a second job, but the work shift of this second job was the same as that in which they worked in this facility; that is, all those working on the day shift, exclusively worked in the day shift in all their jobs. The same was true for those working on the night shift.
From August to November 2016, these workers were invited to a private room on the facility’s premises to receive clarification about the study. Those who consented and signed free and informed consent forms received an envelop containing an instrument intended to characterize the participants, the Maslach Burnout Inventory - Human Service Survey (MBI-HSS) and the Demand-Control-Support Questionnaire (DCSQ). After completing the instruments, they were asked to drop the envelop inside an urn located in the same room to ensure confidentiality.
A questionnaire was developed to address sociodemographic and occupational characterization, identify life habits, age, sex, marital status, children, religion, education, work shift, profession, weekly workload, years working in the facility, number of jobs, monthly income, physical activity (frequency and duration), smoking, satisfaction with sleep patterns, leisure and financial resources.
The MBI-HSS is a self-reported questionnaire with 22 items assessing Burnout Syndrome by considering three dimensions: emotional exhaustion (nine items), depersonalization (five items) and personal fulfillment (eight items). The frequency with which the respondents experience certain situations in their workplaces was determined on a six-point Likert scale. Predisposition to Burnout Syndrome is seen as a combination of high emotional exhaustion, high depersonalization and low professional fulfillment. The instrument was developed in 1981 and the Brazilian version was translated in 2001, presenting a Cronbach’s alpha coefficient from 0.65 to 0.94 15 . The Maslach Burnout Inventory is the instrument most frequently adopted worldwide because it was the first one developed and is considered the gold standard for the assessment of Burnout Syndrome in various professions, including nursing 16 - 17 . For these reasons, this theoretical methodological framework was chosen for this study.
The DCSQ was developed in 1988 and translated and validated for Brazil in 2004 18 , presenting appropriate psychometric properties and a Cronbach’s alpha between 0.63 and 0.86. This questionnaire has 17 items with a four-point Likert scale assessing three dimensions: psychological demands (five items); work control (six items); and social support received at work (six items).
Data were analyzed using the Statistical Package for the Social Sciences (SPSS), version 20.0. There were no missing data. The Cronbach’s alpha coefficient was used to assess the internal consistency of the MBI-HSS and DCSQ, considering α>0.70 as appropriate. Data were described using absolute and relative frequencies. Pearson’s chi-square test and Fisher’s exact test were used to determine differences between the participants of each shift.
The dependent variables were the dimensions of Burnout Syndrome: emotional exhaustion, depersonalization, and professional fulfillment, which were dichotomized into high and low, considering the median as the cutoff point 19 . Univariate binary logistic regressions were performed according to work shift to investigate the relationships among dependent and independent variables (sociodemographic and occupational characteristics, life habits and the DCSQ dimensions).
The independent variables that presented p<0.20 (recommended to identify potential associated factors) were organized in decreasing order according to significance and likelihood ratio. Multiple models using logistic regression according to the stepwise forward method were developed. That is, the models began with the independent variable having the highest significance and then each of the remaining variables were added according to a predetermined order. Variables with statistical significance (p<0.05) and adjustment variables remained in the model. All analyzed data were adjusted by the variables: number of jobs, according to statistical criterion of adjusting values of β, in at least10%; and sex, because the literature suggests it is an aspect to be controlled for 7 , 20 . The results were expressed according to odds ratio (OR) with confidence intervals. Goodness-of-fit of the final model was verified using the Hosmer-Lemeshow test, in which the greater the p-value, the better the fit.
This study was approved by the Institutional Review Board (CAAE No. 57591816.3.0000.5231) and complied with ethical recommendations according to National and International norms, including permission for using the MBI-HSS with 502 individuals. The study was financed by the researchers themselves.
Results
The response rate was 98.43%, with 502 of the 510 eligible workers participating in the study: 271(53.98%) worked on the day shift and 231(46.02%) worked on the night shift; 488(97.21%) worked 42 hours/week. Most of the participants who did not have children were sedentary, and were satisfied with their sleep worked on the day shift. The professionals older than 41 years old, male, with higher salaries, who had worked for a longer period in the institution, and who were satisfied with their leisure worked on the night shift (Table 1).
Table 1. Sociodemographic and occupational characteristics and life habits of nursing workers, according to work shift (n=502). Londrina, PR, Brazil, 2016.
Variable | Work shift | p-value | |
Day n(%) | Night n(%) | ||
Age group | |||
20-40 years old | 224(57.00) | 169(43.00) | <0.01 |
≥41 years old | 47(43.12) | 62(56.88) | |
Sex | |||
Male | 20(41.67) | 28(58.33) | 0.05 |
Female | 251(55.29) | 203(44.71) | |
Marital status | |||
Single | 122(51.26) | 116(48.74) | 0.14 |
Married/stable union | 149(56.44) | 115(43.56) | |
Children | |||
No | 118(59.90) | 79(40.10) | 0.02 |
Yes | 153(50.16) | 152(49.84) | |
Religion | |||
No | 18(47.37) | 20(52.63) | 0.25 |
Yes | 253(54.53) | 211(45.47) | |
Physical activity | |||
Sedentary | 188(56.97) | 142(43.03) | 0.04 |
Physically active* | 83(48.29) | 89(51.74) | |
Smoking | |||
No | 260(54.74) | 215(45.26) | 0.11 |
Yes | 11(40.74) | 16(59.26) | |
Satisfied with sleep | |||
No | 124(46.79) | 141(53.21) | <0.01 |
Yes | 147(62.03) | 90(37.97) | |
Satisfied with leisure | |||
No | 213(59.66) | 144(40.34) | <0.01 |
Yes | 58(40.00) | 87(60.00) | |
Education | |||
High School | 164(55.03) | 134(44.97) | 0.57 |
Higher education | 107(52.45) | 97(47.55) | |
Profession | |||
Nurse | 100(51.81) | 93(48.19) | 0.25 |
Nursing technician/aid | 171(55.34) | 138(44.66) | |
Time working in the institution | |||
1-2 years | 167(61.62) | 104(38.38) | <0.01 |
≥3 years | 104(45.02) | 127(54.98) | |
Other job | |||
No | 228(54.81) | 188(45.19) | 0.24 |
Yes | 43(50.00) | 43(50.00) | |
Monthly wage† | |||
1-2 times the minimum wage | 203(56.70) | 155(43.30) | 0.03 |
3-5 times the minimum wage | 68(47.22) | 76(52.78) | |
Satisfied with financial resources | |||
No | 239(54.82) | 197(45.18) | 0.20 |
Yes | 32(48.48) | 34(51.52) |
Level of physical activity needed to obtain health benefits (≥3x and/or ≥150 minutes/week)(21-23); †Minimum wage in 2016: R$880.00
The levels of the Burnout dimensions and those of the DCSQ significantly differed between work shifts, with the exception of depersonalization and work control. Thus, the levels of Burnout and DCSQ were at the highest among nursing workers from the day shift (Table 2).
Table 2. Reliability and comparison between the dimensions of Burnout Syndrome and the Demand-Control-Support Questionnaire among nursing workers, according to work shift (n=502). Londrina, PR, Brazil, 2016.
Dimensions | Cronbach’s alpha | Work shift | p-value | |
Day n(%) | Night n(%) | |||
Emotional exhaustion | 0.90 | |||
Low | 132(51.16) | 126(48.84) | 0.04 | |
High | 139(56.97) | 105(43.03) | ||
Depersonalization | 0.71 | |||
Low | 156(54.17) | 132(45.83) | 0.92 | |
High | 115(53.74) | 99(46.26) | ||
Professional realization | 0.78 | |||
Low | 165(58.72) | 116(41.28) | 0.02 | |
High | 106(47.96) | 115(52.04) | ||
Demand | 0.76 | |||
Low | 179(51.73) | 167(48.27) | 0.04 | |
High | 92(58.97) | 64(41.03) | ||
Control | 0.70 | |||
Low | 145(53.70) | 125(46.30) | 0.89 | |
High | 126(54.31) | 106(45.69) | ||
Social support | 0.76 | |||
Low | 177(58.61) | 125(41.39) | 0.01 | |
High | 94(47.00) | 106(53.00) |
The multiple model indicates that dissatisfaction with sleep, high demand and low control over work significantly increased the likelihood of those working the day shift to experience emotional exhaustion. High depersonalization was associated with being a nurse, sedentary and dissatisfied with sleep. Sedentariness was significantly associated with low professional fulfillment. In turn, satisfaction with financial resources decreased the likelihood of high depersonalization and low professional fulfillment (Table 3).
Table 3. Multiple models for the three dimensions of Burnout Syndrome among nursing professionals working on the day shift (n=271). Londrina, PR, Brazil, 2016.
Variables | Odds ratioraw (confident interval 95%) | p-value | Odds ratioadjusted (confident interval 95%) | p-value |
Emotional exhaustion*† | ||||
Dissatisfied with sleep | 2.14(1.26-3.63) | <0.01 | 2.20(1.31-3.72) | <0.01 |
Demand (high) | 2.48(1.42-4.33) | <0.01 | 2.50(1.44-4.35) | <0.01 |
Control (low) | 2.43(1.44-4.13) | <0.01 | 2.43(1.44-4.11) | <0.01 |
Social support (low) | 1.78(1.02-3.11) | <0.01 | 1.87(1.08-3.25) | 0.03 |
Depersonalization*† | ||||
Social support (low) | 3.73(1.53-4.86) | <0.01 | 2.65(1.48-4.75) | <0.01 |
Nurse | 1.96(1.07-3.89) | 0.04 | 1.95(1.08-3.88) | 0.04 |
Sedentariness | 1.74(1.09-3.15) | 0.04 | 1.80(1.00-3.25) | 0.05 |
Satisfied with financial resources | 0.53(0.22-0.89) | 0.01 | 0.64(0.46-0.88) | <0.01 |
Dissatisfied with sleep | 1.76(1.04-3.02) | 0.03 | 1.88(1.11-3.17) | 0.01 |
Low Professional Realization*† | ||||
Social support (low) | 2.30(1.35-3.93) | <0.01 | 2.41(1.42-4.09) | <0.01 |
Sedentariness | 1.90(1.09-3.34) | <0.01 | 2.10(1.22-3.62) | <0.01 |
Satisfied with financial resources | 0.38(0.17-0.83) | 0.01 | 0.38(0.17-0.82) | 0.01 |
Adjustment variables: number of jobs, sex, Hosmer-Lemeshow test of adjusted models: 0.72, 0.93 and 0.79, respectively.
Table 4 shows that those working on the night shift who were dissatisfied with their sleep were more likely to experience emotional exhaustion, while those without children were less likely. Professionals working for three years or more in the institution were more likely to experience high levels of depersonalization. Those who reported satisfaction with leisure and had a religion were less likely to experience a high level of depersonalization and a low level of professional fulfillment, respectively. Nursing technicians and aids were more likely to experience low professional fulfillment.
Table 4. Multiple models for the three dimensions of Burnout Syndrome among the nursing workers from the night shift (n=231). Londrina, PR, Brazil, 2016.
Variables | Odds ratioraw (confidence interval 95%) | p-value | Odds ratioadjusted (confidence interval 95%) | p-value |
Emotional exhaustion*† | ||||
Dissatisfaction with sleep | 2.58(1.44-4.63) | <0.01 | 2.35(1.30-4.25) | <0.01 |
Social support (low) | 2.30(1.27-4.17) | <0.01 | 2.62(1.47-4.67) | <0.01 |
No children | 0.33(0.18-0.62) | <0.01 | 0.33(0.18-0.61) | <0.01 |
Depersonalization*† | ||||
Time working in the facility | 4.56(2.43-8.57) | <0.01 | 4.80(2.52-9.16) | <0.01 |
Social support (low) | 3.44(1.85-6.38) | <0.01 | 3.45(1.86-6.50) | <0.01 |
Satisfied with leisure | 2.79(1.47-5.29) | <0.01 | 3.02(1.56-5.84) | <0.01 |
Low professional realization*† | ||||
Social support (low) | 4.04(2.29-7.14) | <0.01 | 4.09(2.33-7.20) | <0.01 |
Having a religion | 0.34(0.12-0.96) | 0.04 | 0.33(0.12-0.93) | 0.04 |
Nursing technicians and aids | 2.18(1.21-3.91) | <0.01 | 2.17(1.21-3.89) | <0.01 |
Adjustment variables: number of jobs; sex; †Hosmer-Lemeshow test of the adjusted models: 0.71, 0.32 and 0.99, respectively.
Low social support was associated with all the dimensions of Burnout Syndrome, regardless of work shift.
Discussion
Characterization per work shift shows that those working on the night shift were mostly older male professionals, with higher salaries, who have worked for longer periods in the facility. It is possible this is a way to benefit older workers who have worked longer in the facility, because the night shift has fewer demands compared to the day shift and higher salaries 4 . Even though there is some indication that recently graduated young and single workers with fewer years of experience 24 work on the night shift, recent studies report results similar to this study 2 , 25 .
The levels of emotional exhaustion and low professional fulfillment were significantly higher among nursing professionals on the day shift, which may be related to the fact that a larger number of young women in stable relationships work in this period, which are risk factors for Burnout Syndrome 6 , 26 - 27 . Additionally, the work process is more intense during the day, as there is more strenuous demand due to the greater number of care and nursing procedures, while interpersonal relationships are more frequently established with the multidisciplinary team, due to medical consultations and consultations provided by other health workers, which increase occupational stress and the development of Burnout Syndrome 6 , 28 . Such a fact was corroborated by the multiple model of high emotional exhaustion evidenced for this study’s participants.
In regard to factors associated with high emotional exhaustion, other studies also provide evidence that workload and emotional demands were positively associated, while autonomy in performing tasks (work control) and social support was negatively related to the syndrome 29 - 30 .
High levels of depersonalization were 95.10% (OR:1.95) greater among nurses in comparison to nursing technicians and aids. Even though they have greater autonomy and control over their work tasks, they are in greater demand and work at a more intense pace, which predisposes them to mental diseases 31 and, consequently, disengagement from work.
Most nursing professionals working the day shift were sedentary, a factor associated with high levels of depersonalization and low professional fulfillment. Longitudinal studies conducted with health workers show that physical exercise benefits mental health. These studies also report that the greater the intensity of physical exercises, the lower the levels of burnout, anxiety and depression, because exercises improve mental energy and decreases work fatigue by releasing neurotransmitters, such as serotonin, which produce a feeling of wellbeing. Additionally, it is a protective factor for various chronic conditions, such as cardiovascular diseases 32 - 33 .
Given the physical effort required and lack of time due to the numerous daily activities, which are common motivations for sedentariness, changing behavior is not an easy task, but is one that should be attempted 33 . Therefore, managers should encourage workers to perform moderate to intense aerobic exercise for at least 150 minutes a week, with a minimum of 30 uninterrupted minutes, considering the benefits it provides to health, wellbeing and quality of life 21 - 23 .
The nursing workers satisfied with their salaries were more involved with their work and considered themselves to be efficient professionals. This finding is possibly linked to professional acknowledgment because nursing is a profession with low salaries and is not remunerated in accordance with the qualification required and functions that the professionals perform. Therefore, earning a salary that is higher than those earned by co-workers leads individuals to be more committed to their jobs and feel more competent 34 .
Dissatisfaction with sleep patterns was associated with emotional exhaustion among workers of both shifts, as well as a high level of depersonalization among those working the day shift. Studies report that occupational stress and Burnout Syndrome are related to worse quality of sleep among those under shift work schemes. Additionally, various sleep disorders, such as insomnia, sleeping difficulty, early awakenings, non-restorative sleep, somnolence, short periods of sleep (fewer than 6 hours) and sleep deprivation were reported by individuals with high levels of Burnout Syndrome 12 , 35 .
Nursing workers believe that the night shift is a positive aspect in their lives, considering they manage to reconcile their schedule and plan their private and professional lives. They also have some perceived advantages, such as working hours with less supervision, fewer demands, and for the most part, better salaries because of the additional night premium, and greater proximity with the members of their team. It is a fact, however, that the night shift causes disorder in workers’ biological rhythms, leading to diseases of a mental and physical nature 12 , 36 .
For those working on the night shift, not having children, being satisfied with leisure and having a religion, were protective factors against high levels of exhaustion and depersonalization, and low professional fulfillment, respectively. Priorities people establish lead them to relegate leisure, rest, and family life. Leisure, however, contributes to various aspects of life, especially, biopsychosocial health, in addition to preventing and treating Burnout Syndrome 37 . Having a religious belief strengthens people when coping with stress and work problems, and often attenuates the negative impact of these on mental health 38 .
Among those working the night shift, having worked for longer periods in the institution was associated with less involvement with work. There is no consensus in the literature in regard to this aspect. Some studies report that experienced nurses are more committed to their work, and more resilient when coping with unpredictable and stressful situations, manifesting lower levels of depersonalization 39 - 41 . Other studies, however, show workers become more insensitive and detached as a way to protect themselves against fatigue caused by compassion and avoiding distress; that is, they aim to protect their mental health 42 - 43 .
Such a divergence may be explained by individual coping strategies. For some, working with people who are facing distress is a motive for feeling distressed themselves, so they attempt to detach from the source of distress as a self-defense strategy. Other workers, however, have a sense of satisfaction when they help those in need, increasing their engagement with work 44 .
Nursing technicians and aids were more likely to experience low professional fulfillment. Despite the importance of their work, these professionals have less autonomy in comparison to the remaining members of the health staff and are less recognized and appreciated, which may lead to a sense of uselessness and incompetence 45 .
Low social support was associated with all the dimensions of Burnout Syndrome, regardless of work shift, a result that is similar to that reported by a study conducted in Greece 46 . Social support provided by supervisors and co-workers is essential to avoid Burnout Syndrome among nursing workers because, as these professionals experience the same situations, they can exchange impressions and promote a friendlier environment of mutual support 47 - 48 .
In this sense, workplace incivility, manifested through behaviors that violate social norms of courteous and respectful conduct, has been indicated as one of the main predictors of Burnout Syndrome 49 - 50 and this is why working relationships in the healthcare context are important protective factors for this syndrome.
Given the multiple consequences of Burnout Syndrome, such as adverse events experienced during care delivery, decreased quality of care delivery, decreased wellbeing, absenteeism, and increased rates of presenteeism and turnover, managers and the workers themselves need to be sensitized to the problem and make an effort to promote healthier workplaces 9 .
This study’s limitations include its cross-sectional design, which does not allow causal relationships to be established or the “effect of a healthy worker” because it was not possible to determine whether there were individuals on sick leave caused by Burnout. All the information collected was self-reported and the responses may be affected by the respondents’ interests and attitudes. As the authors of the MBI do not recommend establishing cutoff points in the dimensions nor a global score, we could not establish how prevalent the syndrome was. Another limitation involves the convenience sampling of a philanthropic hospital, which impedes the generalization of results.
Nevertheless, this study contributes to knowledge in the field, as it shows that the levels of Burnout Syndrome were greater among nursing professionals working the day shift in comparison to those on the night shift; associated factors were also different. Thus, this study can support future studies addressing interventions so that workers and managers work together to devise strategies that take into account associated factors to avoid or decrease levels of Burnout Syndrome and, consequently, maximize quality of life in the work environment, improving the care delivered to patients and families.
Conclusion
High levels of Burnout Syndrome were found among the nursing professionals working on the day shift. Psychosocial factors and those from the work context were associated with the dimensions of Burnout Syndrome in both shifts: in the day shift the associated factors included greater demand, low control, low social support, dissatisfaction with sleep and with financial resources, being a nurse, and sedentariness. For the night shift, the associated factors were: low social support; dissatisfaction with sleep and leisure; having children; not having a religion; fewer years working in the institution; and being a nursing technician or aid.
The differences in the levels of Burnout Syndrome and associated factors between shifts suggest that preventive strategies and measures to decrease the syndrome should be individualized according to the shift worked, possibly focusing on physical exercise but mainly on promoting social support at work.
Footnotes
Paper extracted from master’s thesis “Stress, burnout and quality of life in the nursing team”, presented to Universidade Estadual de Londrina, Londrina, PR, Brazil.
References
- 1.Korompeli A, Chara T, Chrysoula L, Sourtzi P. Sleep disturbance in nursing personnel working shifts. Nurs Forum. 2013;48(1):45–53. doi: 10.1111/nuf.12005. [DOI] [PubMed] [Google Scholar]
- 2.Stimpfel AW, Brewer CS, Kovner CT. Scheduling and shift work characteristics associated with risk for occupational injury in newly licensed registered nurses an observational study. Int J Nurs Stud. 2015;52(11):1686–1693. doi: 10.1016/j.ijnurstu.2015.06.011. [DOI] [PubMed] [Google Scholar]
- 3.Matheson A, O'Brien L, Reid JA. The impact of shiftwork on health a literature review. J Clin Nurs. 2014;23(23-24):3309–3320. doi: 10.1111/jocn.12524. [DOI] [PubMed] [Google Scholar]
- 4.McHugh MD, Stimpfel AW. Nurse reported quality of care a measure of hospital quality. Res Nurs Health. 2012;35(6):566–575. doi: 10.1002/nur.21503. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Pereira DS, Araújo TS, Gois CF, Gois JP, Rodriguez EO, Santos V. Occupational stressors among nurses working in urgent and emergency care units. Rev Gaúcha Enferm. 2014;35(1):55–61. doi: 10.1590/1983-1447.2014.01.39824. [DOI] [PubMed] [Google Scholar]
- 6.Yao Y, Yao W, Wang W, Li H, Lan Y. Investigation of risk factors of psychological acceptance and Burnout syndrome among nurses in China. Int J Nurs Pract. 2013;19(5):530–538. doi: 10.1111/ijn.12103. [DOI] [PubMed] [Google Scholar]
- 7.Maslach C, Jackson S. The measurement of experienced Burnout. J Occup Behav. 1981;2:99–113. doi: 10.1002/job.4030020205. [DOI] [Google Scholar]
- 8.Maslach C, Leiter MP. Understanding the Burnout experience recent research and its implications for psychiatry. Wld Psychiatry. 2016;15(2):103–111. doi: 10.1002/wps.20311. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Van Bogaert P, Kowalski C, Weeks SM, Van Heusden D, Clarke SP. The relationship between nurse practice environment, nurse work characteristics, Burnout and job outcome and quality of nursing care a cross-sectional survey. Int J Nurs Stud. 2013;50(12):1667–1677. doi: 10.1016/j.ijnurstu.2013.05.010. [DOI] [PubMed] [Google Scholar]
- 10.Vasconcelos EM, Martino MMF, França SPS. Burnout and depressive symptoms in intensive care nurses relationship analysis. Rev Bras Enferm. 2018;71(1):135–141. doi: 10.1590/0034-7167-2016-0019. [DOI] [PubMed] [Google Scholar]
- 11.Ribeiro VF, Ferreira C, Filho, Valenti VE, Ferreira M, Abreu LC, Carvalho TD, et al. Prevalence of Burnout syndrome in clinical nurses at a hospital of excellence. Int Arch Med. 2014;7(22) doi: 10.1186/1755-7682-7-22. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Dall'Ora C, Griffiths P, Ball J, Simon M, Aiken L. Association of 12h shifts and nurses job satisfaction, Burnout and intention to leave findings from a cross-sectional study of 12 European countries. BMJ Open. 2015;5(9):e008331. doi: 10.1136/bmjopen-2015-008331. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Bae SH, Fabry D. Assessing the relationships between nurse work hours/overtime and nurse and patient outcomes systematic literature review. Nurs Outlook. 2014;62:138–156. doi: 10.1016/j.outlook.2013.10.009. [DOI] [PubMed] [Google Scholar]
- 14.Eldevik MF, Flo E, Moen BE, Pallesen S, Bjorvatn B. Insomnia, excessive sleepiness, excessive fatigue, anxiety, depression and shift work disorder in nurses having less than eleven hours in between shifts. PLoS One. 2013;8(8):e70882. doi: 10.1371/journal.pone.0070882. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Carlotto MS, Câmara SG. Psychometrics properties of Maslach Burnout Inventory in a multifunctional sample. Estud Psicol. 2007;24(3):325–332. doi: 10.1590/S0103-166X2007000300004. [DOI] [Google Scholar]
- 16.Medeiros-Costa ME, Maciel RH, Rêgo DP, Lima LL, Silva MEP, Freitas JG. Occupational Burnout Syndrome in the nursing context an integrative literature review. Rev Esc Enferm USP. 2017;51:e03235. doi: 10.1590/s1980-220x2016023403235. [DOI] [PubMed] [Google Scholar]
- 17.Loera B, Converso D, Viotti S. Evaluating the psychometric properties of the Maslach Burnout Inventory-Human Service Survey (MBI-HSS) among italian nurses how many factors must a research consider? PLoS ONE. 2014;9:e114987. doi: 10.1371/journal.pone.0114987. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Alves MGM, Chor D, Faerstein E, Lopes CS, Werneck GL. Short version of the "job stress scale": a Portuguese-language adaptation. Rev Saúde Pública. 2004;38(2) doi: 10.1590/S0034-89102004000200003. [DOI] [PubMed] [Google Scholar]
- 19.Leiter MP, Maslach C. Latent Burnout profiles A new approach to understanding the Burnout experience. Burnout Res. 2016;3(4):89–100. doi: 10.1016/j.burn.2016.09.001. [DOI] [Google Scholar]
- 20.Pu J, Zhou X, Zhu D, Zhong X, Yang L, Wang H. Gender differences in psychological morbidity, Burnout, job stress and job satisfaction among Chinese neurologists a national cross-sectional study. Psychol Health Med. 2017;22(6):680–692. doi: 10.1080/13548506.2016. [DOI] [PubMed] [Google Scholar]
- 21.Rosenbaum S, Tiedemann A, Sherrington C, Curtis J, Ward PB. Physical activity interventions for people with mental illness a systematic review and meta-analysis. J Clin Psychiatry. 2014;75(9):964–974. doi: 10.4088/JCP.13r08765. [DOI] [PubMed] [Google Scholar]
- 22.Lima DF, Levy RB, Luiz OC. Recommendations for physical activity and health: consensus, controversies, and ambiguities. Rev Panam Salud Pública. 2014;36(3):164–170. https://www.scielosp.org/article/rpsp/2014.v36n3/164-170 [PubMed] [Google Scholar]
- 23.Fang YY, Huang CY, Hsu MC. Effects of physical activity program on weight, physical fitness, occupational stress, job satisfaction, and quality of life of overweight employees in high-tech industries a randomized controlled study. Int J Occup Saf Ergon. 2018;21:1–23. doi: 10.1080/10803548.2018.1438839. [DOI] [PubMed] [Google Scholar]
- 24.Siqueira K, Griep RH, Rotenberg L, Costa A, Melo E, Fonseca MJ. Interrelationships between nursing workers' state of nutrition, socio demographic factors, work and health habits. Ciênc Saúde Coletiva. 2015;20(6):1925–1925. doi: 10.1590/1413-81232015206.00792014. [DOI] [PubMed] [Google Scholar]
- 25.Fernandes JC, Portela LF, Griep RH, Rotenberg L. Working hours and health in nurses of public hospitals according to gender. Rev Saúde Pública. 2017;51:63–63. doi: 10.1590/S1518-8787.2017051006808. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Gómez-Urquiza JL, Vargas C, De La Fuente EI, Fernández-Castillo R, Cañadas-De La Fuente GA. Age as a risk factor for Burnout syndrome in nursing professionals a meta-analytic study. Res Nurs Health. 2017;40(2):99–110. doi: 10.1002/nur.21774. [DOI] [PubMed] [Google Scholar]
- 27.Orsal O, Duru P, Unsal A, Barlas N. Evaluation of the factors associated with Burnout of nurses working at a state hospital in turkey. Nurs Pract Today. 2017;4(1):21–34. http://journals.research.ac.ir/files/site1/rds_journals/357/article-357-351328.pdf [Google Scholar]
- 28.Teixeira C, Ribeiro O, Fonseca AM, Carvalho AS. Burnout in intensive care units a consideration of the possible prevalence and frequency of new risk factors a descriptive correlational multicentre study. BMC Anesthesiol. 2013;13(1):38–38. doi: 10.1186/1471-2253-13-38. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Bakker AB, Demerouti E, Sanz-Vergel AI. Burnout and work engagement the JD-R approach. Annu Rev Organ Psychol Organ Behav. 2014;1:389–411. doi: 10.1146/annurev-orgpsych-031413-091235. [DOI] [Google Scholar]
- 30.Vander Elst T, De Cuyper N, Baillien E, Niesen W, De Witte H. Perceived control and psychological contract breach as explanations of the relationships between job insecurity, job strain and coping reactions towards a theoretical integration. Stress Health. 2016;32(2):100–116. doi: 10.1002/smi.2584. [DOI] [PubMed] [Google Scholar]
- 31.Johansson G, Sandahl C, Hasson D. Role stress among first-line nurse managers and registered nurses - a comparative study. J Nurs Manag. 2013;21(3):449–458. doi: 10.1111/j.1365-2834.2011.01311.x. [DOI] [PubMed] [Google Scholar]
- 32.Lindwall M, Gerber M, Jonsdottir IH, Börjesson M, Ahlborg G. The relationship of change in physical activity with change in depression, anxiety, and Burnout a longitudinal study of Swedish healthcare workers. Health Psychol. 2014;33(11):1309–1318. doi: 10.1037/a0034402. [DOI] [PubMed] [Google Scholar]
- 33.Vries JD, Claessens BJ, Van Hooff ML, Geurts SA, Van Den Bossche SN, Kompier MA. Disentangling longitudinal relations between physical activity, work-related fatigue, and task demands. Int Arch Occup Environ Health. 2016;89(1):89–101. doi: 10.1007/s00420-015-1054-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Bacha AM, Grassioto OR, Gonçalves SP, Higa R, Carvasan GAF, Machado HC. Job satisfaction of nursing staff in a university hospital. Rev Bras Enferm. 2015;68(6):1130–1138. doi: 10.1590/0034-7167.2015680619i. [DOI] [PubMed] [Google Scholar]
- 35.Portela LF, Kröning Luna C, Rotenberg L, Silva-Costa A, Toivanen S, Araújo T. Job strain and self-reported insomnia symptoms among nurses what about the influence of emotional demands and social support? Biomed Res Int. 2015;2015:820610–820610. doi: 10.1155/2015/820610. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Geiger-Brown J, Rogers VE, Trinkoff AM, Kane RL, Bausell RB, Scharf SM. Sleep, sleepiness, fatigue, and performance of 12-hour-shift nurses. Chronobiol Int. 2012;29(2):211–219. doi: 10.3109/07420528.2011.645752. [DOI] [PubMed] [Google Scholar]
- 37.Maciel RH, Martins JCO, Pimentel FHP, Pinheiro AAG. Leisure experience as prevention for Burnout syndrome. Psic Rev. 2015;24(2):311–326. https://revistas.pucsp.br/index.php/psicorevista/article/view/27803/19631 [Google Scholar]
- 38.Galea M. Assessing the incremental validity of spirituality in predicting nurses' Burnout. Arch Psychol Religion. 2014;36(1):118–136. doi: 10.1163/15736121-12341276. [DOI] [Google Scholar]
- 39.Portero de la Cruz S, Vaquero Abellán M. Professional Burnout, stress and job satisfaction of nursing staff at a university hospital Rev. Latino-Am. Enfermagem. 2015;23(3):543–552. doi: 10.1590/0104-1169.0284.2586. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40.Karanikola MN, Papathanassoglou EE. Exploration of the Burnout syndrome occurrence among mental health nurses in Cyprus. Arch Psychiatr Nurs. 2013;27(6):319–326. doi: 10.1016/j.apnu.2013.08.004. [DOI] [PubMed] [Google Scholar]
- 41.Myhren H, Ekeberg O, Stokland O. Job satisfaction and Burnout among intensive care unit nurses and physicians. Crit Care Res Pract. 2013;2013:786176–786176. doi: 10.1155/2013/786176. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 42.Aytekin A, Yilmaz F, Kuguoglu S. Burnout levels in neonatal intensive care nurses and its effects on their quality of live. Aust J Adv Nurs. 2013;31(2):39–47. https://search.informit.com.au/documentSummary;dn=285597367080297;res=IELHEA [Google Scholar]
- 43.Yu H, Jiang A, Shen J. Prevalence and predictors of compassion fatigue, Burnout and compassion satisfaction among oncology nurses a cross sectional survey. Int J Nurs Stud. 2016;57:28–38. doi: 10.1016/j.ijnurstu.2016.01.012. [DOI] [PubMed] [Google Scholar]
- 44.Gleichgerrcht E, Decety J. Empathy in clinical practice how individual dispositions, gender, and experience moderate empathic concern, Burnout, and emotional distress in physicians. PLoS One. 2013;8(4):e61526. doi: 10.1371/journal.pone.0061526. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 45.Ferreira NN, Lucca SR. Burnout syndrome in nursing assistants of a public hospital in the state of São Paulo. Rev Bras Epidemiol. 2015;18(1):68–79. doi: 10.1590/1980-5497201500010006. [DOI] [PubMed] [Google Scholar]
- 46.Özden D, Karagözoglu S, Yildirim G. Intensive care nurses' perception of futility job satisfaction and Burnout dimensions. Nurs Ethics. 2013;20(4):436–447. doi: 10.1177/0969733012466002. [DOI] [PubMed] [Google Scholar]
- 47.Li L, Ruan H, Yuan WJ. The relationship between social support and Burnout among ICU nurses in Shanghai a cross sectional study. Chinese Nurs Res. 2015;2(2):45–50. doi: 10.1016/j.cnre.2015.04.003. [DOI] [Google Scholar]
- 48.Woodhead EL, Northrop L, Edelstein B. Stress, social support, and Burnout among long-term care nursing staff. J Appl Gerontol. 2016;35(1):84–105. doi: 10.1177/0733464814542465. [DOI] [PubMed] [Google Scholar]
- 49.Laschinger HKS, Read EA. The effect of authentic leadership, person job fit, and civility norms on new graduate nurses' experiences of coworker incivility and Burnout. J Nurs Adm. 2016;46(11):574–580. doi: 10.1097/NNA.0000000000000407. [DOI] [PubMed] [Google Scholar]
- 50.Oyeleye O, Hanson F, O'Connor N, Dunn D. Relationship of workplace incivility, stress, and Burnout on nurses' turnover intentions and psychological empowerment. J Nurs Adm. 2013;43(10):536–542. doi: 10.1097/NNA.0b013e3182a3e8c9. [DOI] [PubMed] [Google Scholar]