Risk Factors Identification for Burnout Syndrome in Nurses

Conclusion: In view of this, it is concluded that improvement actions should be thought through activities in education, management and administration enhancing the work quality of nurses in their daily lives. Thus, it is suggested the need for preparation of informative booklets that discuss this syndrome and the creation of conversation rounds among professionals to share their experiences and seek solutions to the identified factors. Risk Factors Identification for Burnout Syndrome in Nurses


Introduction
The fast pace of social changes of the last decades has led to changes at work.This situation affects workers and provides a physical and emotional exhaustion, leading to an excessive accumulation of workload and high-stress levels, directly affecting the physiological stability of the individual, emerging cardiovascular disease, psychiatric disorders, and gastrointestinal disorders.The World Health Organiza-tion (WHO) indicates that stress is in daily life, with a negative impact on quality of life [1].
In this way, by their needs, some types of work require more attention and emotional distress, directly related to the activities.Therefore, the workers need constant interaction with people, such as medicine, nursing, teaching, among others.Thus, when the worker cannot maintain personal balance, he may develop the professional wearing disease, that is, the Burnout Syndrome (BS) [1,2].
Thus, the development of the BS is related to a gradual process of mood and demotivation wearing with physical and psychological symptoms.The worker loses the sense of his relationship to work, making things no longer so important, that is, a labor absenteeism.In this sense, the definition of BS is the result of chronic interpersonal stressors interactions at work and characterized by emotional wearing, depersonalization (or cynicism) and reduction of personal accomplishment (or professional effectiveness) [2].
On this subject, emotional exhaustion (EE) is presented by severe fatigue, lack of strength to face the day´s work and the feeling of being required beyond its limits.Depersonalization (DE) is distinguished by emotional detachment and indifference to work and all who are part of its working cycle, especially with patients.Finally, the reduction of personal accomplishment (PA) is expressed at the lack of prospects for the future, frustration and feelings of incompetence and failure.Moreover, professionals are affected by symptoms of insomnia, anxiety, difficulty concentrating, changes in appetite, irritability, and depression [2,3].
In this perspective, Nursing is classified as the fourth most stressful profession in the public sector because their activities are directly related to pain, disease, and death.In Brazil, it is revealed that most nurses are concentrated in public or private hospitals, dealing daily with these processes and administrative pressures.Thus, the healthcare professional lives in constant anxiety, sense of loss and fragility of patients daily with these processes [3].
Thus, the nursing staff, by its very nature and characteristics of its work is susceptible to occupational stress phenomenon due to the responsibility for the life and the proximity to the clients for whom the suffering is almost inevitable [4,5].The reason for the development of the study is on the importance of knowing the stressors that lead to the development of BS in nursing professionals to optimize measures to prevent disease and promote a better quality of life to these professionals.Given this context, the following question emerged: What are the risk factors for the onset of BS?
Therefore, the study aimed to identify the factors that contribute to the development of BS in nursing professionals.Thus, the relevance of the study is to contribute to the advancement of scientific means on the relationship established between the stressful work factors with the development of labor syndromes.

Method
The integrative review method was used, since it gathers and summarizes results of research on a limited topic in a systematic and organized way, contributing to the deepening of knowledge of the topic investigated and offering support for a professional practice based on scientific knowledge.
For this study, the six stages of the development of the integrative review process were followed: elaboration of a guiding question, establishing the objectives of the review and inclusion and exclusion criteria of the articles; definition of the information to be taken from the research; selection of articles in the literature; analyzing the results; discussion of findings and presentation of the review [6].
The following question was formulated to conduct this review: What are the most incidents risk factors for the onset of the burnout syndrome in nursing professionals?
Original articles answering both or one of the guiding questions were included.Articles in editorial format, letter to the editor or opinion of experts, articles unavailable in full and not freely available on the selected databases were excluded.
The search for articles was held in September 2014 in the databases of the Virtual Health Library (BVS): Latin American and Caribbean Center on Health Sciences (LILACS), Bank of Nursing data (BDENF) and electronic library Scientific Electronic Library Online (SciELO).Uncontrolled descriptors were used, found in the Health Sciences Descriptors (DeCS) and Medical Subject Headings (MeSH): "Professional Burnout" "Occupational Diseases," combined through the Boolean operator "AND" with the descriptor "Nursing." After the procedure of electronic search in the mentioned databases, there was an evaluation of articles by four reviewers, and later the results were compared to ensure that the articles met the inclusion criteria.Articles were evaluated as relevant and methodologically appropriate to maintain quality research studies, using a form for evaluation studies prepared by the Critical Appraisal Skills Program (CASP) [7].Those who have achieved a minimum score of seven or maximum ten points were included in the sample.
Thus, the publications were initially pre-selected, based on reading the title and abstract.Then, they were read in full, and the final sample of this integrative review was identified.
In this step, a total of 233 articles were found (Scielo = 38, LILACS = 143 and BDENF = 52).Thir-teen of them were included in the final study sample.Thus, all research steps can be seen in Figure 1.

Results
For a better understanding, the results were categorized.The information provided by the 13 studies were listed, addressing some stressor in nursing labor activity.The characterization of the articles regarding the origin, authorship, title, stressors, the type of research and scientific evidence level are described in Table 1.
In this perspective, regarding the year of publication of the studies, 2013 ( About the BS, the stressors are intensified in daily care actions.Thus, the selected studies address several factors, which include: professional dissatisfaction, poor working conditions, interpersonal relationships, lack of resources materials, extensive working hours and low wages.It is noteworthy that many of these conditions reflect the great responsibility of the professional nurse in various sectors of activity, but it is a determining factor in the professional quality of life, especially in leaving him susceptible to developmental disorders.

Discussion
The stress situation is generated by the perception of stimuli that cause emotional and disturbance exhaustion.It is an adaptive process, characterized by physiological and psychological disorders.In the workplace, stress is together with the phenomena present in the body, and it can affect the worker´s health, giving different responses among individuals, leading to personal friction [9,10].
The nursing staff, by its very nature and characteristics of its work, shows to be susceptible to occupational stress phenomenon due to the responsibility for the life and the proximity to the clients for whom the suffering is almost inevitable.A study conducted in a large hospital showed the intensive care unit and emergency care sector as the most stressful working places, not absolving the other sectors to emerge stressful conditions [11].
In this sense, in a research developed at the University hospital to detect psychosomatic repercussion in nursing workers, most of them had headaches caused by tension or muscle pain and then a sense of fatigue, being the cause for upwelling of these symptoms is the excessive workload due to poor remuneration and poor working conditions [11,12].
Contrasting the findings of the above research, a study developed with 28 nursing professionals in basic health units in the state of Maranhão showed that the casuistic factors for this negative impact outcropping behavioral disorders are the instability of social relationships, family or interpersonal, or in situations leading frustration [13].
Moreover, due to this situation, the nursing professional is susceptible to the development of the BS, characterized as a chronic labor response involving negative attitudes and behavioral changes related to the work context to disregard the human side.The concept of Burnout diverges directly from stress conditioning that is facing reactions of the organism to aggressions of various origins, able to disturb the internal balance of the human being [14].
Thus, when the stressors are not stopped, through ways of improving both the nursing professional and management, in the private sector, or public sector, the BS becomes a chronic disease causing a change in people´s lives, not only in the structure and functioning of the body, but in quality of life, the development of new habits, review of the roles and members of the syndrome of development as a process of living.Thus, the nurse is vulnerable to develop personality disorders which directly affects their psyche [15] - [16].
In some centers that study the BS at the University of São Paulo (USP), it is shown that the output for this work pauperization to nursing workers is encouraging their activities through wage improvements, lower hourly workload, tasks distributed equally and favorable conditions because from these precepts, the managers of public and private institutions produces quality [17].However, this scenario is still an achievement to be pursued by the working class, as many managers do not care about the health of their workers, just aiming to production and profit.[18] However, simple actions can mitigate this stressor environment of nursing professionals in the workplace, as elucidations on ergonomics, the practice of gymnastics to reduce the possibility of work-related illnesses, software that optimizes the practical assistance, practical invasive devices and fast and switching professionals across the sectors.From this action and especially the participation of workers, the missing days of these professionals tend to de-crease and assistance be holistic and not technicalities grounded in the pharmacological treatment model [19].
Thus, through a continuing or permanent education, health promotion practices are mechanisms to improve the quality of life of professionals.In this respect, it is believed that education, along with the nursing professionals have an essential role in controlling stressor factors and developments syndromes since their complications are closely linked to knowledge of proper daily personal care and style healthy life [20].
Educational activities contribute to a better quality of life.However, some issues should be considered to achieve effective results, as the phase of the life cycle and its peculiarities, given that awareness and education are key factors for proper control and prevention.Currently, there is an increase in life expectancy, as a higher incidence of chronic noncommunicable diseases.Therefore, it is considered crucial that health professionals target their professional practice to actions that lead to independence, autonomy and quality of life [21].

Conclusion
When analyzing the studies that the main stressors of nursing professionals are in the excessive workload, low wages, and poor working conditions were found, in addition to the emotional instability due to a negative experience in the social sphere, such as family and sentimental disappointments.
Therefore, it can be inferred that changes and improvements in the workplace should be developed by managers.Prevention and promotion of functional labor quality are one of these actions important in health education practices.
It is suggested then, actions incorporated into the daily work, exemplified with the preparation of informative booklets that discuss this syndrome, creating conversations rounds where professionals can share their needs are effective strategies that can guide the nursing professional as the involvement of stressors and mitigate the effects of the syndrome.
In this context, it was necessary to create laboratory programs for health professionals, especially nurses, as they remain much of their journey in relation to families, patients and other professionals.

Table 1 .
Characterization of articles according to the origin, authorship, title, objective, type of research and level of scientific evidence.Natal/RN, Brazil, in 2014.
This article is available at: www.intarchmed.comandwww.medbrary.com4Toomany families; insufficient organizational support and pressures from demands of patients; overload in the division of tasks in the team.Nurses´ work in public health and stress: analysis of a realityThere were not factors that related to burnout identified, work is regarded as significant, which denotes an encouraging picture.However, it highlights wear from poor customer service and lack of awareness of the population.