Work Loads of Nursing Professionals in Hospital Services for Mental Health : an Integrative Review

Method: This is an integrative literature review in the databases LILACS, CINAHL, SCOPUS (Elsevier), PUBMED, ScienceDirect (Elsevier), Web of Science (Main Collection Thomson Reuters Scientific), available in full in electronic media between January and March 2016 using the descriptors “nursing staff”, “health worker”, “workloads” and “mental health services” reaching the final sample of 08 articles.


Introduction
The health work involves a collective practice that aims to promote the health of people, their families, and community.It works by the relationships among professionals in the health services and society, permeated by technical and interpersonal actions.Therefore, it must be understood in its objectivity and subjectivity way [1].
The dynamics of the health work has been determinant for the development of workloads among workers.Workloads constitute the elements of the work process that dynamically interact with each other and with the worker´s body, triggering changes in the health and disease process.They is classified into external materiality loads (physical, chemical, biological and mechanical) and internal materiality loads (physiological and psychological) [2].
The workloads in the work processes are not only added, but they potentiate and give consistency to the production process, characterizing it specifically, and may incur in the event of accidents and/or work-related diseases and also to impair the quality of assistance and consequently the safety of the patient.[3,4] The international literature [5] shows that the term patient safety involves, in general, to prevent errors in the care and elimination of damage to patients for such errors.The error in health care results from unintentional actions caused by some problem or failure during patient care and may be made by any member of the team and occurring at any time in the care process.
The focused debate on the association between the nursing staff workload and patient safety is one of the most persistent themes in health, mobilizing resources from the World Health Organization (WHO) [6] and nursing organizations worldwide.
Despite there are efforts to investigate the implications of nursing staff workload in patient safety, there are still many gaps in this area of knowledge.
There is an urgent need for studies addressing the extent and nature of nurses´ roles in improving patient safety [7].
In the psychiatric context the current situation of nursing work is characterized by the transition from care practice within the psychiatric hospital that aimed to user behavior containment of mental distress service for the incorporation of new principles, which seek to adapt to an interdisciplinary practice, open to the contingencies of the subjects involved in each moment and in each context, overcoming the disciplinary perspective of their actions, this new perspective comes up with the Brazilian Psychiatric Reform.
To contributed and join efforts for continuous improvement of nursing care in mental health services and aimed at quality and safety, the development of research addressing this theme will discuss and strengthen communication between health professionals and ensure safety in the environment of the mental health services.Also, it provides improved decision-making; a care process aimed at more reliable professional practices [8].
Despite efforts towards to investigate the implications of the workload nursing team in patient safety, yet remain many gaps in this area of knowledge.There is an urgent need for studies addressing the extension and nature of nurses' roles in improving patient safety In this sense, the question is what the current literature to bring the workload of nursing professionals and what are the impacts of these loads to the safety of patients in mental distress?
Thus, this study aimed to identify the theoretical production about the workload of nursing professionals, evaluating the results of these studies to identify effects of these loads for the safety of patients in mental distress.
The objective is to contribute to research that put in evidence the harmfulness of workloads for the mental and physical health of nursing professionals working in mental health services and the possible   consequences for the quality of care and consequent safety of the patients in mental distress.

Method
The integrative review is a research method that allows establishing a synthesis and general conclusions regarding a particular study area, performed in a systematic and orderly way to contribute to the knowledge investigated.This type of evaluation should follow the same methodological standards of the original research, considering the aspects of clarity, so that the reader can identify the actual characteristics of the selected studies and offer subsidies to the advancement of nursing in the context of mental health.[9] This research method includes six phases: theme identification or guiding question; sampling or searching the literature; categorization of studies; assessment of included studies; interpretation of results and synthesis of knowledge evidenced in analyzed articles [10].
The literature search took place between January and March 2016, by the following databases: Latin America and the Caribbean Literature (LILACS), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus (Elsevier), National Library of Medicine -PUBMED ScienceDirect (Elsevier), Web of
Inclusion criteria were: full articles available on selected databases that show workloads that nursing professionals are exposed in their work process in hospital mental health services.Editorials, letters to the editor, abstracts, reviews expert opinion, were excluded, correspondence, reviews, book chapters, theses and dissertations and articles that do not address the issue.
The studies were pre-selected with an attentive reading of the titles and abstracts to identify whether they were related to the main issue of the review, and the inclusion and exclusion criteria.Then they were excluded repeated articles in the databases, and text reading was carried out in full.
There were 12,293 results identified in the databases.After selection of the inclusion and exclusion criteria and articles that do not address the topic from the perspective of workloads, there were 295 studies focusing on health services (Figure 1) distributed by databases as follows: SCOPUS (116); PUB-MED (37); LILACS (44); SCIENCE DIRECT (32); WEB OF SCIENCE (36); CINAHL (30).
The analysis of the full text was made and all duplicated were removed.After reading, the final sample was composed of 08 studies.

Results and Discussion
The productions of this study are shown in the table below, identifying the journal, year of publication, databases, title, classification of study based on objectives, authors, location of the study and reason that causes the workload (Table 1).
In Table 1, it is possible to show that regular nursing area was the most reported work on the theme.From the classification of studies based on the objectives, it is found that 62.5% (05) of the studies are descriptive, 37.5% (03) are cross-

Mechanical loads physical aggression committed by
patients.

Psychic loads fear of being physically assaulted and the threats of physical violence made by psychiatric patients
Source: Authors´ Databases (2016).
sectional studies.The descriptive research showed a description of relevant characteristics of a population or phenomenon studied, and there are relationships between variables.The methodological analysis showed that 07 studies (87.5%) have a quantitative approach, and 01 (12.5%) have a qualitative approach.Of them, 8 (100%) of the studies were conducted in a psychiatric hospital.
Concerning the quantitative approach, its collection, and processing of information statistics show that it accurately tests hypotheses for research and provides indices that can be compared with others [11].
In this study, the types of workloads were: physical workloads demonstrated by excessive working hours and expressed by exposure to poor lighting and humidity; psychic workloads by the direct care to patients in psychiatric emergencies and lack of qualified personnel in service to help in psychiatric nursing care, stress and burnout; physiological workloads due to physical effort, time standing du-ring the workday, weight handling and the distance traveled by the institution; biological workloads due to exposure to parasite infestation and contact with human bodily fluids, mechanical workloads caused by physical assaults committed by psychiatric patients.
This study demonstrated that the psychic workloads were mainly responsible for the emotional charge of professionals and poor working conditions contribute to intensify these problems.
A study [12] conducted with nursing professionals working in mental health services showed that 75% of nurses said they were moderately overloaded due to the care given to patients.In the same context, the workload related to the physical structure (19.4%), the dynamics of travel and work (13.9%), mental exhaustion (13.8%), fear of physical aggression (11 1%) and verbal abuse (11.1%) of patients were identified.
Research [13] conducted with 69 psychiatric nurses working in a hospital service to the Irish community revealed that the main causes of burnout were lack of resources, workload and organizational/process structures.
Converging on the findings of this study, research [14] held examined the workload of nursing staff and its potential relationship to patient safety in hospitals showing significant associations between workload and patient safety, increased load work or number of patients by nursing staff, reducing the patient's satisfaction with the care received.
Measuring workloads that health workers are exposed and promoting adequate dimension of nursing staff will contribute to improved quality of care.Lack of resources at work such as personnel, material or physically associated with the perception of poor conditions of service is an important stressor for these professionals since it can limit their action, influencing directly on the quality of service [15].For that, the mental health services should combine physical resources to the demands of work, decreasing the workload of the nursing team [16].
From the critical analysis of the selected studies, articles were categorized by the similarity of content and a category for analysis was built: Implications of workloads for the safety of the patients in mental distress.

Implications of workloads for the safety of the patients in mental distress
The common reality in the activity of professionals from psychiatric hospitals is marked by physical, emotional and mental stress generated by work and can produce apathy, depression, emotional hypersensitivity, anger, irritability and anxiety and even cause depersonalization and the resulting inertia production, performance and employee satisfaction decrease [17].
Mental suffering of workers who are included in hospital services mental health can cause various morbidities with structural determinations.A study [18,19] conducted with health professionals to identify organizationally and personal factors causing professional engagement and occupational stress of nursing and other health team professionals re-vealed that workload, mental health and job satisfaction were correlated with the energy to work.
The managers of mental health services must seek to ensure improvements in the working conditions of nurses, with implementation of individual and collective coping strategies, with a view to mental health promotion worker in his working environment.The quality of psychic well-being of the worker may have direct relation to safety in the care of patients, and the risk-free and damage in the process of health care [20].However, given the problems identified in this study on the professional nursing workloads are exposed to mental health services, the safety of psychiatric patients is worrying.
In 2004, The World Health Organization -WHO launched the World Alliance for Patient Safety.The program includes strategies, guidelines, and international goals, which aim to disseminate and ensure practices that enable patient safety in different countries.The Alliance operates in different areas, from hand washing, safe surgery to taxonomy, which aims at organizing the taxonomic aspects related to patient safety and care quality provided [21,22].Donabedian [23], one of the leading scholars of the health quality, developed a fundamental conceptual framework for understanding the evaluation of health quality, from the concepts of structure, process, and outcome, classically considered a triad, which is the concepts of General Systems Theory: input-process-output.
In this context of quality of care, responsible for the management of patient care, the nurse plays an important role in achieving the quality of health services [24].He contributes significantly to the construction of quality of care indicators and keeps up the results and the quality improvement process.
In mental health services, the promotion of safety culture with an emphasis on learning, organizational improvement, and secure systems should be achieved.The mental health services managers need to implement policies to promote mental health for the worker in the workplace, as well as sensitize them as the coping outside the work environment, with the adoption of sports and family life, among others.
Other indicators of workloads also need to be corrected as the decrease in weekly hourly load and increasing the number of workers in the nursing team, as the organizational aspects also play a significant role in the burnout of the worker.Organizational solutions such as increasing the number of nurses, reducing the number of hours worked positively impact the perception of work overload [25].
If the workload is not excessive, and professionals feel emotionally balanced and resolute in their professional activity, there will be greater satisfaction in their daily working day [12].The efforts of health organizations to improve the quality of management need to mobilize pursuing patient safety and finding ways to work together more effectively and efficiently to ensure that their organizations provide safe, and high-quality care to patients [26].

Conclusions
The development of this study found that nursing professionals involved in mental health services had various types of workloads in their work process, being psychic as the most present.The main causes of workload generation identified in the study are: physical assaults committed by patients in mental distress, excessive working hours, high demand for psychological work, working hours and working conditions with reference to the work overload.
Workloads identified are associated with the specifics of work in the hospital mental health services, which require the skills of workers to deal with the human being, in order to understand it from the perspective of comprehensive health care, mainly because dealing with the everyday suffering and madness, which makes the environment pervaded by intense the subjective and intersubjective.
In the care of the caregiver context of users with mental suffering, more studies are needed in order to contribute to the professional development of coping strategies to work situations, both individual and organizational point of view.
International Archives of Medicine is an open access journal publishing articles encompassing all aspects of medical science and clinical practice.IAM is considered a megajournal with independent sections on all areas of medicine.IAM is a really international journal with authors and board members from all around the world.The journal is widely indexed and classified Q1 in category Medicine.

Figure 1 :
Figure 1: Synthesis of the extraction process in the databases, searching in SCOPUS, PUBMED, LILACS, SCIENCE DIRECT, WEB OF SCIENCE and CINAHL.Natal-RN, 2016.

Table 1 .
Characterization of articles according to journal, year of publication, databases, title, classification of study based on objectives, authors, location of the study and reason that causes the workload.Natal-RN, 2016.