Burnout Syndrome among General Hospital Nurses in

Recife

Síndrome de burnout entre enfermeros de un hospital general de

la ciudad de Recife

Renata Hirschle GalindoI; Katia Virginia de Oliveira FelicianoII; Raitza Araújo

dos Santos LimaIII; Ariani Impieri de SouzaIV

I
Medicine undergraduate, Faculdade Pernambucana de Saúde. PIBIC/CNPq/IMIP Fellow.
Recife, PE, Brazil. renatahirschle@hotmail.com
II
Physician. Ph.D. in Preventive Medicine, University of São Paulo. Professor of the
Graduate Program in Maternal-Child Health, Instituto de Medicina Integral Professor
Fernando Figueira. Recife, PE, Brazil. kvofeliciano@gmail.com
III
Medicine undergraduate, Faculdade Pernambucana de Saúde. PIBIC/CNPq/IMIP Fellow.
Garanhuns, PE, Brasil. raitza05@yahoo.com.br
IV
Physician. Ph.D. in Nutrition, Federal University of Pernambuco. Professor of the
Graduate Program in Maternal-Child Health, Instituto de Medicina Integral Professor
Fernando Figueira. Recife, PE, Brazil. arianii@terra.com.br

Correspondence addressed

ABSTRACT

This descriptive, cross sectional, census study identified the occurrence of burnout and
some associated factors among nurses working in obstetrics & gynecology and pediatric
care at a general tertiary hospital in Recife. Sixty-three nurses (98.4%) answered a self-
administered questionnaire (sociodemographic aspects, working conditions, and Maslach
Burnout Inventory). Chi-square was used in the analysis with a 95% confidence level.
Most participants were female (92.1%), with up to five years in the career (68.2%),
52.5% in pediatric area. High levels of emotional stress (49.2%) and depersonalization
(27.0%) were identified, as well as low professional fulfillment (4.8%), and 4.7%
presented burnout. The following factors wee associated: high levels of emotional stress
and often/always perform tasks very quickly (p=0.039) and receiving a salary
incompatible to the effort employed (p=0.016); high levels of depersonalization and with
up to five years in this career (p=0.010) and often/always perform tasks very quickly
(p=0.009). For 19.0%, at least two of the three dimensions pointed to high propensity
to the syndrome.

Descriptors: Burnout, professional; Nursing; Pediatric nursing; Occupational health

RESUMEN

Estudio descriptivo, transversal, censitario, identificó Burnout y factores asociados entre

enfermeros de atención pediátrica y tocoginecología de hospital general de nivel terciario
de atención en Recife-PE. Participaron 63 profesionales (98,4% del total), que
respondieron cuestionario autoaplicable (aspectos sociodemográficos, condiciones
laborales y Maslach Burnout Inventary). Analizado según Qui-cuadrado, nivel de
confianza 95%. Predominó sexo femenino (92,1%), con hasta cinco años de profesión
(68,2%), perteneciendo 52,5% al área pediátrica. Se constataron altos niveles de
agotamiento emocional (49,2%) y despersonalización (27,0%), y bajo nivel de
realización profesional (4,8%), sufriendo 4,7% de Burnout. Mostraron asociación: altos
niveles de agotamiento emocional, realizar frecuentemente/siempre tareas con mucha
rapidez (p=0,039), recibir salario incompatible con esfuerzo (p=0,016); alto nivel de
despersonalización y tener hasta cinco años de profesión (p=0,010) y
efectuar frecuentemente/siempre tareas con mucha rapidez (p=0,009). Para 19,0% al
menos dos de las tres dimensiones marcaban alta propensión al síndrome.

Descriptores: Agotamiento profesional; Enfermería; Enfermería pediátrica; Salud

laboral

INTRODUCTION

Social, economic, judicial, organizational and technical transformations in healthcare

work exercise a profound influence over the health-illness process and the quality of life
in working contexts(1). Worldwide, a crescent trend is observed in approaching negative
aspects of the work experience using the burnout perspective(1-3). The concept used is
Christina Maslach and Susan Jackson's: the burnout syndrome results in a sequential
process involving three dimensions: (a) emotional exhaustion: emotional stress or loss
of emotional resources leading to lack of enthusiasm, frustration and tension; (b)
depersonalization: developing negative feelings and attitudes; (c) decreasing personal
fulfillment in work: tendency to a negative professional self-evaluation, becoming
unhappy and dissatisfied, resulting in feelings of lack of adjustment and failure(1).

Burnout explanation models have gradually become more complex, encompassing

individual, work and social organizational conditions. International (1-2,4) and national(3,5-
6)
studies demonstrate that, despite being multidimensional, this syndrome maintains a
narrow relationship with the perception of organizational support, demonstrating the
importance of the institution as a mediator for health and well-being at work. Hence,
burnout is considered to be a response to perceived working stress arising when
strategies used by professionals to deal with stress are inefficient, presenting the
organization as the mediating variable between the perceived stress and its
consequences(1). In preventing the syndrome it is necessary to emphasize the required
transformations of situational aspects, specifically regarding the context of work (7-8).

Although burnout occurs in many different professions, those dealing with other people's
suffering demonstrate increased vulnerability(4-5,7-8). Nurses are continually subjected to
elements capable of generating work stress associated with the syndrome: lack of
personnel (resulting in task accumulation and work overload), necessity of shift work
and/or night shifts, dealing with problematic patients, role conflicts and ambiguity, low
participation in decision-making, lack of insurance and salary planning, feelings of
inequality in work relations and conflicts with colleagues and /or the institution. In
addition, continuous task interruptions and the need for reorganization (aggravating
work overload), dealing routinely with death, becoming closely involved with patients
and their suffering and constant exposure to contamination risks and violence make
nurses more vulnerable as a population. The fragile political organization of this
professional category and the lack of acknowledgement of the role of nurses in the
hospital organization have also enhanced vulnerability(4,8-13).

Although nursing is acknowledged as one of the most stressful professions, there are
controversies regarding the relationship between working stress and the expected levels
of burnout among nurses(4). Research studies that have used the same criteria to
identify the syndrome have demonstrated the important worldwide distribution of
burnout in this professional category, with nurses presenting higher levels of exhaustion
and depersonalization, emphasizing a higher bias towards developing the syndrome (10-
11,14)
. On the other hand, low occurrences of burnout have also been observed,
facilitating questions regarding the reasons that justify such a disparity between what is
observed and what is expected and reported in literature regarding the magnitude of the
disorder in nurses(4,13,15). In Brazil, a broad variation of burnout values is found,
identified in the few studies involving nurses and nursing assistants working in
hospitals(9-10,13,15).

After the scientific production review, a low occurrence of burnout and a high level of
work stress was found among nurses who are satisfied with their jobs(4) . Satisfaction
was associated with informational support, social support at work, learning opportunities
and progress in the ability to take part in decision-making. Also, suggestive elements
that may contribute to satisfaction are related to the ability to cope with routine stressful
situations(16), as well as slowing down the sequential process that culminates in burnout.
Abilities to deal with the internal and external demands originating from work stress can
promote control (problem-aimed strategies) or escape (regarding emotions: denying the
situation, distancing, selective attention). Escape activities are associated with a higher
frequency of emotional exhaustion(6,17).

Burnout has consequences over physical and mental health. Cardiovascular alterations,
chronic fatigue, headaches, migraines, peptic ulcer disease, insomnia, muscle and joint
pain, anxiety, major depressive disorder, irritability, and others are among the
symptoms associated with burnout. It can also interfere in domestic life, affecting family
relations when there is regret due to the lack of time to care for children and for leisure.
Work context is affected by absenteeism, turnover, an increase in violent tendencies and
decreasing quality of work(3,8-9). This present study intends to contribute to the search
for effective ways to deal with health promotion at work and prevention of burnout,
actions of great importance for nurses' work quality of life and the quality of care
provided by these professionals(2,6,8).

OBJECTIVE

Identify burnout occurrence, detailing the three dimensions of the syndrome and the
socio-demographic factors and working conditions associated with burnout among nurses
in a tertiary care general hospital in the city of Recife.
METHOD

A cross sectional, descriptive, census study was performed from October to November of
2009, in a tertiary care general hospital of the Unique Health System, in the city of
Recife. This general hospital is a state and regional (Northeast) reference hospital for
children and women's health care. From a list provided by the health service, properly
updated by means of contacting all other involved sectors, all 64 nurses from the
nursing team who provided care in the outpatient clinics, ward and urgency-emergency
care center in Pediatrics, Gynecology and Obstetrics were contacted. After the subjects
were informed regarding the purpose of the research and signed the Free and Informed
Consent Form, they received a self-administered and anonymous questionnaire and
booked a date with the field researcher to return the questionnaire. Of the nurses
contacted, 63 (98.4% of the total) returned the questionnaire. A professional who
stopped working in the hospital was unable to be located.

The questionnaire was composed of two parts: (1) socio-demographic aspects,

professional education and working conditions; (2) Maslach Burnout Inventory – MBI,
composed of 22 questions using a Likert scale regarding the three syndrome
dimensions: nine questions evaluate emotional exhaustion, five questions evaluate
depersonalization and eight evaluate professional fulfillment. Increasing degrees of
intensity were attributed to each one of the questions in the MBI: 1 (never), 2 (a few
times per year), 3 (once a month), 4 (a few times per month), 5 (once a week), 6 (a few
times per week) and 7 (every day). The MBI is the most frequently used instrument
worldwide to evaluate burnout. It was translated into Portuguese and validated in 1995
with a Cronbach's alpha of 0.86 in the emotional exhaustion sub-scale, 0.69 in
depersonalization and 0.76 in professional fulfillment (18). A pilot test study was
performed for the necessary adjustments in the first part of the questionnaire.

The Epi Info software 6.04d was used to construct and statistically analyze the data
base. In each sub-scale of the MBI, professionals were classified based on Maslach's
criteria for emotional exhaustion: high level – equal to or higher than 27; medium level
– between 19 and 26; and low level – equal to or less than 18. For depersonalization:
high level – equal to or higher than 13; medium level – between 7 and 12; and low level
– equal to or less than 6. For personal fulfillment: high level – equal to or higher than
40; medium level – between 34 and 39; and low level – equal to or less than 33. High
scores in emotional exhaustion and depersonalization and a low score in personal
fulfillment at work indicate burnout(1-2,7).

Socio-demographic, professional and working education variables and their association

to the three dimensions of burnout were tested. Frequency of the syndrome and the
number of professionals who presented at least one or two of the three dimensions were
established, indicating a bias towards burnout. Significant differences were evaluated
using the Chi-Square test, with a level of significance of 5%. Tendencies was the term
used to describe results in which differences were aligned with a statistical significance
between 0.05 and 0.10. The project was approved by the Research Ethics Committee of
the Professor Fernando Figueira Integral Medicine Institute - IMIP in Brazilian acronyms,
in accordance with statement No 1480 of 08/07/2009.

RESULTS

Nurses researched were predominantly females (92.1%), with a median age of 29 years
(interquartis range of 27 and 36 years) and 50.8% lived in common-law marriage.
Approximately 68.2% had up to five years in the profession (median of four years and
interquartis range of two to nine years); 52.5% worked in pediatrics and 52.5% were
considered to be experts in their working area. A percentage of 45.2% were working two
different jobs and 85.7% were responsible for more than five nursing/administrative
tasks within the service: performing hospital care tasks (95.2%), bureaucracy (66.7%),
graduate program teaching (47.6%), clinics care (23.8%), research (23.8%) and
teaching in postgraduate degree programs (12.7%). Around 71.0% worked night shifts
routinely.

Half of the professionals presented high levels of emotional exhaustion, 27.0% presented
with depersonalization and 4.8% demonstrated low levels of personal fulfillment at work.
Those with medium levels of emotional exhaustion and depersonalization were high in
proportion. About 68.3% of nurses demonstrated at least one of the three dimensions
indicating a high bias towards burnout, while 27.0% presented at least two of the three
dimensions, pointing to a high bias towards the syndrome. About 4.7% presented all of
the dimensions associated with burnout (Table 1).

Regarding the burnout dimension emotional exhaustion, nurses felt burned out after
work every day (17.5%) and a few times per week (23.8%). Every day (12.7%) and a
few times per week (17.5%) they felt they worked too much. Every day (15.4%) and a
few times per week (7.9%) they felt at the edge of their abilities. Once a month they felt
they were working too much (41.3%), that work was burning them out (38.1%), felt
exhausted in the morning when they thought about work (33.3%) and felt exhausted
after work (31.7%). A few times per year, they felt disappointed with their work
(39.7%), tired of working every day dealing with people (38.1%), frustrated about work
(38.1%) and at the edge of their abilities (34.9%).

Regarding depersonalization, these professionals felt that patients blamed them for their
problems every day (4.8%) and a few times per week (11.1%). Every day (6.3%) and a
few times per week (6.3%) they have become hardened towards others. Every day they
felt they were emotionally hardening (6.3%) and a few times per week they treated
people as impersonal objects (4.7%). A few times per year (27.0%) and once a month
(27%) they felt they were harder towards people. A few times per year (28.6%) and
once a month (22.2%) they felt hardened emotionally. A few times per year (25.4%)
and once a month (20.6%) they felt patients blamed them for their problems; 90.5%
never lack emotions towards the people they provided services to and never treated
people as impersonal objects (65.1%).

None of the nurses answered never to questions regarding personal fulfillment at work.
A few times per year (14.3%) and once a month (7.9%) they felt energetic at work.
Once a month they felt stimulated after working with people (17.5%), created a
favorable environment at work (15.9%), dealt easily with emotional problems (15.9%)
and accomplished important things at work (14.3%). A few times per week they felt
energetic at work (34.9%), dealt easily with emotional problems (28.6%), created a
favorable environment at work (23.8%) and felt stimulated after working with people
(23.8%). Every day they easily care for people (77.8%), dealt efficiently with people's
problems (74.6%) and exercised a positive influence on people's lives (66.7%).

A significantly larger proportion of professionals who frequently/always performed their

tasks too quickly and those who considered their salary below the efforts they employed
presented high levels of emotional exhaustion. There is a tendency towards a higher
percentage of female professionals, with up to five years in the profession, who
demonstrated high emotional exhaustion. We observed that having up to five years in
the profession and performing their tasks frequently/always too quickly were associated
with high levels of depersonalization. A tendency towards low personal fulfillment at
work among nurses who were responsible for performing numerous different functions in
the care service and did not envision any possibilities for professional growth was also
observed (Table 2).

None of the nurses answered never when asked about how often they had enough time
to accomplish all their work tasks and how often they performed them less quickly.
There was no statistical association among the three burnout dimensions and the
following variables: work area, number of places worked in, overlaid care levels, working
hours and time allotted to accomplish tasks.

All three professionals who evidenced burnout were women: two had up to five years in
the profession; two worked in the gynecology and obstetrics area; two were connected
to two different health care services; one performed different functions within the same
care service; two stated they had enough time to accomplish their tasks a few times; all
of them frequently/always performed their tasks too quickly and considered their salary
incompatible with their work performance. A tendency towards burnout was observed
among nurses who had no expectations of professional growth (p=0.090).

DISCUSSION

There is no general agreement in the literature regarding diagnosing burnout. Findings

were stated regarding the syndrome in only a small percentage of the studied literature,
partially due to the adoption of Maslach criteria, mentioned by various authors (1-2,7),
which was considered more strict since the criteria emphasize interrelations among the
three burnout dimensions. In a study performed with a nursing team in a hospital in the
South of Brazil, employing similar criteria, there was an absence of the syndrome.
Hence, other authors(19)diagnosed burnout based on the isolated presence of high levels
of emotional exhaustion or depersonalization, or low levels of personal fulfillment at
work. According to these criteria, in the present research and the one performed in the
South of the country(13), 68.3% of nurses and 35.7% of nursing workers presented
burnout, respectively, since they presented at least one dimension of the syndrome at a
critical level. This definition minimizes the complexity of the sequential process that
results in burnout.

Despite the low frequency of burnout among the evaluated nurses, the high levels of
emotional exhaustion and depersonalization found indicate a strong bias towards
developing the syndrome. The proportion of nurses with high levels of emotional
exhaustion (49.1%) and depersonalization (27.0%) observed in this present research
was considerably higher than those found among nursing staff in a hospital in Madrid, in
which 11.7% exhibited exhaustion and 9.2% exhibited depersonalization, with the
nurses presenting higher levels in both dimensions(12); in Tubarão (SC), 6% presented
with high levels of exhaustion and 21.9% presented high levels of depersonalization(13).
Results in a hospital in Londrina (PR) also demonstrated a lower number of nursing
professionals with high emotional exhaustion (21.3%), but the presence of high
depersonalization was higher (32.8%)(15).

The negative consequences of burnout begin with tiredness and continued physical and
mental stress, leading the professional to emotional exhaustion (1). When trying to
overcome adverse conditions, the gradual tendency to neglect personal needs, together
with the denial of problems and repression of conflicts, may cause negative emotions
and attitudes related to work. Burnout occurs when emotional exhaustion and
depersonalization are overlaid, leading to lack of feelings of fulfillment at work. There are
differences among authors regarding the triggering sequence of negative events and the
meaning of manifestations; however, the three described components are fundamental
to the burnout syndrome(7).

Since the syndrome evolves progressively in a cumulative fashion, and may occur in a
short period of time or take years to appear(1-3), an examination of the answers in the
MBI items demonstrated a concerning situation. The emotional exhaustion subscale
revealed that, almost every day, almost two-fifths of nurses felt overloaded and
exhausted by their work routine, and one-fourth of professionals were at the limit of
their capabilities. Only a few of them did not mention work overload and exhaustion.
Studies have demonstrated that work overload represents a source of chronic stress
among nurses, constituting one of the main predictors of emotional exhaustion (8,10,20), a
burnout dimension considered to be the initial stage and the central factor in the
syndrome(6). Feelings of tiredness due to working with people all day, deception and
frustration, even when sporadic, were present in a great proportion of the studied
population.

In this present research, having to perform tasks too quickly and the perception of
having too low a salary compared to the employed effort in performing tasks - similar to
findings in other researches(3,6,7,21), was demonstrated to be statistically associated to
high levels of emotional exhaustion. A gap between salary and efforts leads to the
perception of lack of appreciation of their dedication. Under these circumstances
exhaustion leads to, above all, a breach in reciprocity among professionals and the
organization to which they are connected, resulting in feelings of being treated unfairly.
Rewards (promotion, raise in salary, care for well-being) represent an important element
of the perceived organizational support. Studies developed in distinct work contexts (2),
including within Brazil(5-6), demonstrate the direct relationship between chronic
exhaustion and the perception of insufficient organizational support.

The challenge of the tasks that need to be done and available time to perform them
subjected workers to extreme tension, especially in light of the responsibility of
performing as a professional, increasing fatigue, emotional stress and chronic
exhaustion. However, exhaustion was not the only negative event resulting from the
pressure of time, negative feelings and attitudes at work that characterize
depersonalization; exhaustion was also more prevalent among nurses
who frequently/always needed to act quickly in performing their tasks. The character of
the relationship between the pressure of time and burnout impacts workers' health more
and more (21).

A tendency to display high levels of emotional exhaustion was identified among women
and among those with less time in the profession - these groups also demonstrated
significantly higher levels of depersonalization, demonstrating consonant features with
national(10) and international(8,11,20) studies. The high concentration of exhaustion and
negative feelings and attitudes related to work among those who have less time in the
profession is associated with being unable to accomplish tasks according to expectations
and to the difficulty in envisioning possibilities to improve working conditions (10,22). Those
with more time spent in the profession also feel emotional stress and tiredness;
however, in order to maintain optimism, they continue to wait and hope for a solution,
perhaps because they feel more complacent or are able to extract positive aspects out of
negative experiences. A study(10) mentions that those who have been in the profession
longer, and were not satisfied with work and had the opportunity for a change, may have
followed different career paths.

A clear predominance of females in this research is congruent with the fact that choosing
nursing as a profession is more frequent among women(8,13,15,20). Many arguments have
been used to support the conclusion that women are more vulnerable to burnout than
men. First, the role attributed to gender in the socialization process, where women tend
to get more emotionally involved with the problems of people who they provide care for,
may make women more vulnerable to burnout. Second, women have a higher probability
of choosing professions involving more direct contact with people. Third, they are
subjected to a double work standard (taking care of the home and their professional
performance). Fourth, women use denial and repression as basic defense mechanisms:
they deny or tend not to perceive their frustrations, negative feelings and exhaustion,
always believing they can surpass their own limitations in each of the multiple roles they
perform in life(10,20).

A study with a nursing team in Spain, concludes the existence of differentiated patterns
for men (higher levels of depersonalization and professional fulfillment are not significant
predictors for depersonalization) and women (emotional exhaustion does not predict
absenteeism). However, the study points out that the strong predominance of women in
this professional category may hide the gender influence regarding burnout. In Brazil, in
the South region, a research with nursing workers found higher values in the
personalization subscale for the male gender and similar levels of emotional exhaustion
in men and women(10). Different authors considered that stress and burnout in women
are presented by special characteristics that need to be understood and taken into
consideration by prevention programs(10,20).

Regarding depersonalization, almost every day a small number of nurses perceived a

lack of reciprocity with patients and became hardened, distancing themselves
emotionally in dealing with their patients. This perception and attitude occurred a few
times per year in approximately half of these professionals. It is important to note that
there may be interference and a social desirability factor in the answers given regarding
the dimension items, since they challenge the human service workers' professional
image(8). In addition, results include a clearly female-predominant population who,
considering hegemonic socialization models, are conditioned to care(8,10,20).

Lack of reciprocity, including gratitude and respect for caregivers, results in feelings of
unfairness, compromising the patient-professional connection. Studies demonstrate a
significant positive correlation between nurses' perception and lack of reciprocity towards
patients and the two dimensions of burnout, emotional exhaustion and
depersonalization(7-8). Non-productive emotional distancing, where professionals refer to
escaping strategies and dealing indifferently with patients, is a way of coping with
emotional exhaustion that evidences an urgent need for a commitment towards action
on the part of the institution, regarding work health and quality of life. The search for
individual solutions for collective problems facilitates burnout (16-17). The importance of
nurses who provide services to the people is emphasized as a positive aspect.

High levels of personal fulfillment at work were found (84.1%), which is much higher
than the 35.0%, 50.3% and 37.7% mentioned, respectively, by researchers in other
studies(12-13,15). Most professionals who easily provide care for people and acknowledge
the importance of the work they perform routinely are not affected by negative feelings
and a sense of failure. There is a perception that their own work provides an undeniable
value for the workers' self-esteem(10,21). Therefore, some difficulties are encountered but
are dealt with, and these workers easily deal with emotional problems and feel energetic
at work. Low professional fulfillment, aside from the place it occupies in the sequence of
burnout-associated manifestations, is a key element of this syndrome, motivating a
lower involvement at work and causing nurses to want to give up(7).

Approximately one-fourth of these professionals evidence an overlay of high emotional

exhaustion and depersonalization, allowing to suggest that they were at the "almost-
burnout" point, where their initial energy at work is transformed by chronic fatigue and
increasing feelings of frustration(2,18). High fulfillment at work certainly constitutes a
fundamental element for avoiding this transition state towards the syndrome in the
evaluated population. Professionals who perceived themselves as being at the end of
their resistance limitations can still be receptive to feelings of satisfaction (21). Studies
performed in different countries evidence satisfaction at work despite high levels of
stress(4). In a study performed in a Brazilian hospital organization, satisfaction as a
protection factor against burnout(16) is identified.

A fundamental dimension to accomplishing the transition from almost-burnout to

burnout, low personal fulfillment at work showed a higher tendency to be identified
among professionals who performed several different functions and ceased to believe
professional growth was possible. Overlaid tasks lead to the perception that the available
resources are smaller than needed to accomplish predicted tasks. Many authors related
the syndrome of burnout with tasks accumulation, being unable to grow professionally
and obtaining acknowledgement at work, emphasizing the importance of the perception
of insufficient organizational support regarding health at work(3,5-6,10). All of these
aspects, isolated or enhanced by interaction, can lead to feelings of chronic imbalance, in
which the work requires much more than the person can give, in order to provide less
than what is needed.

CONCLUSION

The frequency of burnout was low in the studied population; however, results generate
concerns, especially due to the hidden character of the syndrome, since some of the
nurse's feelings and attitudes may be intermittently present and may increase over time.
Work overload, emotional stress and resourcing to emotion-centered strategies, among
other aspects, resulted in the identified high and medium levels of emotional exhaustion
and depersonalization, demonstrating the need for commitment towards quality of life at
work. Overlaying exhaustion and depersonalization resulted in an "almost-burnout"
situation in which organizational support was perceived as insufficient, mainly by nurses
who were professionally active for less than five years.
The ambiguity regarding the experience of work cannot be overemphasized since, even
under unfavorable conditions, work can produce some degree of satisfaction. Such
complexity of interactions that can be sources of both pleasure and suffering enhance
the need for diversification of strategies to deal with emotional stress and satisfaction as
a fundamental element to promote quality of life at work. Therefore, dealing with
burnout may emphasize neither individual nor organizational processes that better
support team work and the health of its members. It is probable that alternative ways of
finding a balance between differentiations and integrations can be found this way, since
it is considered to be a central problem for the organized group.

In addition, searching for personal solutions for work problems must draw our attention,
since it discourages health and work performance. Professionals may feel more fulfilled
and satisfied by adjusting their work expectations. However, on a long term basis,
persisting in stressful work conditions enhances emotional exhaustion, depersonalization
and feelings of low fulfillment at work. Certainly, the challenge of promoting health at
work and preventing burnout is even larger than once thought, and a permanent
dialogue among planning, executing and managing functions is required.

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