ORIGINAL RESEARCH

Occupational stress in nursing personnel

Eliana Ofélia Llapa-Rodriguez^I; Júlian Katrin Albuquerque de Oliveira^II; David Lopes Neto^III; Cristiane Franca Lisboa Gois^IV; Maria Pontes de Aguiar Campos^V; Maria Claúdia Tavares de Mattos^VI

^I Nurse. PhD. Associate Professor, Federal University of Sergipe. Brazil. E-mail: elianaofelia@gmail.com
^II Nurse. MS. Mauricio de Nassau College. Aracaju, Sergipe, Brazil. E-mail: jukatrin@yahoo.com.br
^III Nurse. PhD. Associate Professor, Federal University of Amazonas. Manaus School of Nursing. Brazil. E-mail: davidnetto@uol.com.br
^IV Nurse. PhD. Adjunct Professor, Federal University of Sergipe, Brazil. E-mail: cristianeflg@hotmail.com
^V Nurse. PhD. Associate Professor, Federal University of Sergipe, Brazil. E-mail: mapacampos@gmail.com
^VI Nurse. PhD. Associate Professor, Federal University of Sergipe. Brazil. E-mail: mctm@ufs.br

DOI: https://doi.org/10.12957/reuerj.2018.19404

ABSTRACT

Objective: to examine stress factors in nurses at a university hospital in Aracaju, Sergipe, Brazil. Method: in this descriptive, correlational study, data were collected by interview from a sample of 101 nursing personnel, by applying a Nursing Stress Inventory, and analyzed using Student's t-test for independent samples. The study was approved by the research ethics committee. Results: 43% of the items examined were sources of occupational stress among nursing professionals, with stressful career roles being responsible for most influence on stress (54%). Work place was the only variable that displayed significant difference when associated with the factors examined. Conclusion: Nursing revealed itself to be a profession with risk of occupational stress, which was influenced in various manners by the work organization and work process factors examined.

Descriptors: Burnout, professional; nursing team; stress, psychological; occupational health.

INTRODUCTION

Stress is considered the disease of the 21st century according to the World Health Organization (WHO). In this context, stress has been considered a work-related disease worldwide. Due to the magnitude of the problem, it has become the target of research in the social and health areas as it causes psychological and physiological effects that are harmful to the worker.^1,2

The workplace is an environment that is part of people's lives and inevitably causes stress. The human being, in order to promote its adaptation to hostile stimuli, triggers neuroendocrine alterations that allow its reorganization in order to maintain its homeostasis.³ Considered as a response to external demands arising from pressures that exceed people's ability to resist and maintain their natural state, this form of exhaustion has caused physiological and managerial problems, among them work diseases, turnover and absenteeism.²

Considering that work-related diseases compromise the health of the worker, an attempt is made to understand the causes of stress. Therefore, the following research question was raised: what are the factors that predispose nursing professionals to this condition?

This study may serve as a subsidy for the construction of public policies aimed at the health of the worker and especially of nursing professionals. Thus, the objective of this research was to analyze the stress factors in nurses of a teaching hospital in the city of Aracaju, Sergipe, Brazil.

LITERATURE REVIEW

Occupational stress is defined as a deleterious biological reaction state and characterized as a multifactorial aggravation¹ arising from interactional processes between the workers and their environment.⁴ This state originates from multiple personal risk factors, ⁵ environmental, biological, psychological, social and organizational factors that affect the quality of life of health professionals, affecting, mainly, nursing workers.⁶

Researchers explain that individuals, by taking on many roles in life, usually carry a heavy weight both in family life and at work, creating conflicts regarding their professional environment.⁷ Conditions, mainly as a result of long working hours and caring for people in situations of vulnerability (biological and psychological, in psychological suffering and terminal states).⁶

Studies on occupational stress have historically and sequentially shown an increase in their prevalence, raising, throughout the world, the interest of scientists in evaluating it as a public health problem,⁸ especially regarding the measurement of determinants, events and stressors in the work process.^3,7,9,10

Due to the employment status sui generis, with the passing of the years, the service performed by nursing triggers signs and symptoms of occupational diseases. These affect nurses, technicians and nursing assistants by altering their capacity to work and causing the emergence of emotional exhaustion, irritability, chronic fatigue syndrome, sleep disorders, depressive disorders, occupational exhaustion syndrome, and occupational stress.¹¹

Therefore, stress on the work of the nursing professional is a constant and widespread phenomenon in the different positions of nurses, technicians and nursing assistants, being directly related to the environment and working conditions, thus altering their state of physical and mental health.⁷

METHODOLOGY

Quantitative study, with a descriptive and correlational design, developed at the teaching hospital of the state of Sergipe, Brazil. The study population was composed of 123 nursing professionals. As an inclusion criterion, a minimum of six months of work in the direct care provision was required. The sample, intentional and non-probabilistic, was composed of 101 nursing professionals, being 21 nurses and 80 nursing technicians/assistants, located in four clinics (medical I and II, surgical and pediatric). The remaining professionals, part of the population, were not included because they did not fit the established criteria.

As a collection instrument, the questionnaire entitled "Nursing Stress Inventory" (IEE - Inventário de Estresse em Enfermeiros, in Portuguese) was used,¹² composed of 44 items, with five options of answers, from never (1) to always (5), detailed below: 1st factor - interpersonal relations (with 17 items); 2nd factor - career stressors (with 11 items); 3rd factor - intrinsic to work (with 10 items). Added to these factors are six more isolated items, which were separated from the others because they did not present commonality, it should be emphasized that the latter is considered by the literature as essential for the determination of stress. The IEE questionnaire was self-administered and presented two parts, the first, concerning the characterization of the professionals; and the second, containing the three factors described above and the group of isolated items.

The data collection was carried out from September 2013 to February 2014. The professionals were individually approached in their work places and clarified regarding the methodological and ethical aspects of the research, being introduced to its the objectives, anonymity level, risks and benefits. After signing the Free and Informed Consent Term, the participants were given the instruments of data collection, and after a period of seven days, these were returned for analysis. The protocol was approved by the Research Ethics Committee of the Federal University of Sergipe, CAAE: 20668713.4.00005546.

The data were analyzed using Student's t-test for independent samples, being the confidence level 95% and the significance level 5%, with p value <0.05 to indicate the existence of a statistically significant difference.

RESULTS AND DISCUSSION

Occupational stress emerges in the health area as a real problem among nursing professionals, due to the exhaustive nature of the work and to the diverse attributions developed by these professionals. That said, the nursing professional experiences daily situations of physical and emotional exhaustion, coupled with excessive administration that generate organizational conflicts, exposing nurses to determinants of occupational stress.^13-15

As for the professionals participating in this study, it was found that the majority were female 90 (89.1%), belonging to the category of nursing technicians/assistants 80 (79.2%), followed by the category of nurses 21 (20.8%). Regarding the workplace, 31 (30.7%) worked in the surgical clinic, 27 (26.7%) in the medical clinic I, 26 (25.7%) in the medical clinic II, and 17 (16.8%) in the pediatric clinic. As for the work shift, the night shift was the one that presented the highest number of professionals 44 (43.6%), followed by the morning shift - 31 (30.7%) and afternoon shift - 26 (25.7%).

The results obtained allowed to identify all factors as predisposing to occupational stress. However, the most important factor was the career stress roles, which presented 54% of significant items, followed by the group of isolated items (50%), intrinsic to work(40%) and interpersonal relationships (35%).

A study shows that fragilities in the relationship with the work team can generate stress situations that make the professional emotionally fragile, weak and sensitive, fact caused by factors that are extrinsic to the relationship, such as wear and tear in the work environment and lack of human and material resources. In addition, subjective factors such as the ineffective relationship with the patient and their relatives, lack of communication, negative relationship with the boss, disunion of the category and difficulty in managing people are highlighted.¹⁶

In the analysis of each of the factors with the variables under study it was possible to identify a significant association between the factor career stress roles with the variable shift (morning and night) in item 30 (0.049) - distance between theory and practice. Still regarding the factor career stress roles, the workplace variable was significant in medical clinics I and II, in item 37 (0.01) – to feel powerless in the face of tasks to be accomplished; between the medical and surgical clinics in items 30 (0.034) and 39 (0.001) - lack of definition of the nurse's role; between the medical clinic I and pediatric clinic in items 34 (0.032) - have a short deadline to accomplish orders, 35 (0.036) - restriction of the professional autonomy, 37 (0.024) e 39 (0.000); between the medical clinic II and surgical clinic in item 39 (0.034), and between the medical clinic II and pediatric clinic in items 39 (0.021) and 41 (0.048) - unable to provide direct patient care, as they are significant.

Regarding night work shift, a study carried out in an intensive care unit identified professionals' dissatisfaction due to the need for attention and redoubled alertness in the care of the patient and overload related to the lack of professionals working in the morning shift, situations that cause in the professional greater physical and cognitive wear,¹⁷ understood as situations that may lead to professional stress.

Regarding the short deadline to comply with work-related orders, a study on stress and psychic disorders with nursing workers showed that the time and speed to perform nursing actions generate psychological pressure, and therefore predispose the individual to occupational stress¹⁸. The minimum time spent to perform nursing actions was identified in a study conducted with 143 nurses from a university hospital as a major stressor in hospital management, corroborating the findings of this study.¹⁹

The shortage of time for carrying out the care provision activities and some factors such as the high number of patients, reduction of human resources and work overload may lead to short deadlines for compliance with actions, compromising the quality of care provision, and leading to physical and emotional exhaustion.

On the other hand, a study with 3,471 nursing workers from five public teaching hospitals in different regions of the country, showed that the lack of definition of roles caused by the lack of autonomy of the nurse in the resolution of managerial and care actions, influence, in particular, on stress, independent of the exposure to different psychic loads. ²⁰

In the analysis of the group isolated items, it was observed significance only with the variable work place when related to medical clinics I and II in item 44 (0.044) – receiving this salary; between the medical clinic I and pediatric clinic in item 1 (0.046) – starting in a new position, in medical clinic II and surgical clinic in item 19 (0.042) - alternate work shifts, and in medical clinic II and pediatric clinic with item 1 (0.041).

In line with these results, a study of nursing occupational stressors revealed that a low wage was considered a source of stress, due mainly to the fulfillment of double working hours.²¹ Studies show that overload, work rhythm, double shifts and the existence of unfair wage can affect the physical, mental and emotional performance, resulting in exhaustion and depersonalization^22,23 in the lives of nursing professionals. On the other hand, it is assumed that if the professional is satisfied with their work environment, having a positive relationship with colleagues, among other satisfaction variables, these positive situations are likely to transform the pressure into a source of emotional and professional growth.

Regarding the factor intrinsic to work, significance was observed with the gender variable, with emphasis on item 6 (0.005) - making physical effort to complete the work. Regarding the workplace, there was significance between the medical clinic I and pediatric clinic, in items 10 (0.027) - taking work to do at home, and 15 (0.029) - lack of human resources; between the medical clinic II and surgical clinic, the items 6 (0.042) and 9 (0.007) - fulfill a higher workload; between the medical clinic II and pediatric clinic, the items 6 (0.028), 9 (0.014) and 15 (0.037); and between the surgical and pediatric clinics, item 10 (0.039).

According to these findings, a study that applied the same instrument to health professionals in the state of Paraíba identified physical exhaustion as a source of stress during the development of therapeutic activities of different nature, situation that would interfere significantly with the quality of care provision and the productivity of these professionals. ²⁴ On the other hand, research in a neonatal ICU has shown that the reduced number of employees was a stress factor among professionals, interfering with the pace of work and the quality of care provision. ²⁵ Also, it has been observed that nursing professionals have developed high rates of emotional fatigue, stress and burnout when activities involved critical care, palliative care, and ethical dilemmas. ^9,10,26 In this regard, human resources play a key role in health services and its inadequate distribution greatly limits the performance of the professional justifying their significance and influence on the stress factors analyzed.

Within the same logic, an Irish study showed that ensuring an adequate number of professionals, taking into account the needs of the patient, contributed to the reduction of occupational stress.²⁷ This finding once again reaffirms the need for the adequacy of human resources in order to avoid that the nursing professional has a very exhausting workload. The analyzes showed that when the factor interpersonal relationships was associated with the shift variable (morning and night) the items 14 (0.040) – keeping oneself up to date and 25 (0.007) - relationship with the boss, were significant. In the association with the workplace variable, related to medical clinics I and II, the item 33 was highlighted (0.041) - performing quick procedures; and for medical clinic I and surgical clinic, the items 33 (0.016) and 40 (0.047) - being responsible for the quality of the service provided by the institution. For the medical clinic I and pediatric clinic, the itens 42 (0.024) - the specialty in which I work and 43 (0.006) were highlighted - see a large number of people; for the medical clinic II and surgical clinic, highlighting item 14 (0.035) and, finally, item 42 (0.049) was distinguished between the pediatric and surgical clinics, for being relevant to this study.

These results were similar to other studies, since they show the excessive number of patients as one of the main causes for occupational stress. Still, in these articles, it was observed that the work process, the psychic loads and the injuries generated in nursing workers are related to the insufficient number of professionals and management fragility. ^20,25,28 Factors that lead to an accelerated work pace and, as a consequence, to a shorter time to rest and to the organization of care activities.²⁰

On the other hand, the management exercise requires the development of interpersonal skills and competences, being pointed the relationship with the team as one of the greatest difficulties in the performance of managerial activities. This situation can be a trigger for exhaustion, physical exhaustion and job dissatisfaction.^29,30 Based on this reflection, it is important to emphasize the need for the nurse, as manager and born leader of the nursing team, to develop strategies that favor negotiation and conflict resolution, so that the team can work in an integrated way and in line with the professional and organizational goals for reducing occupational stress.

CONCLUSION

Nursing has proved to be a profession of risk for occupational stress, suffering various influences related to the organization and the work process. The factor stressors of the career was responsible for the greater influence that generated the problem, followed by the group of isolated items, the intrinsic factor to work and the interpersonal relationships factor.

The work place variable was highlighted as being the only one that directly influenced all the factors studied. The shift variable presented a relationship with stress when associated with interpersonal relationships and career stressors. The morning and night shifts indicated the major influences for the study question. The gender variable was significant when associated with the factor intrinsic to work. The inadequate distribution of human resources was a determining factor for most of the responses among the factors studied.

In view of the results, it is necessary to create management strategies that can mitigate the stressful effects caused by the factors analyzed, such as: adequacy of the professional quantitative, implementation of improvements in management actions, adequate distribution of the work scale, effective communication among teams, improvement of the working conditions and continuing education.

The main limitation of the study was the cross-sectional typology, which allowed us to focus on the analysis of frequencies and associations of the constituent items of the instrument used, without the possibility of establishing causal relations. It is recommended that more comprehensive quantitative research and qualitative research with a thematic depth are carried out at different levels of care, with the aim of increasing the knowledge about occupational stress in nursing.

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