STRESS AND BURNOUT SYNDROME IN NURSES OF INTENSIVE CARE

UNITS: AN INTEGRATIVE REVIEW

Jefferson Abraao Caetano Lira1

Gabriel Vitor de Sousa Campelo1
Francisca Aline Amaral da Silva1
Delmo de Carvalho Alencar2
Ana Raquel Batista de Carvalho3
Jadilson Mendes Rodrigues3
Moises Lopes Carvalho4
Larissa Vanessa Machado Viana4
Lais Mayara Machado de Amorim4
Wanderson Carneiro Moreira4
1
Nurse. Medical Sciences College, State University of Piauí. Teresina, Piauí, Brazil.
2
Nurse. Post-Graduate Program in Public Health, Oswaldo Cruz Foundation. Teresina,
Piauí, Brazil.
3
Nurse. Post-Graduate Program in Family Health, University Center UNINOVAFAPI.
Teresina, Piauí, Brazil.
4
Nurse. Post-Graduate Program in Biomedical Engineering, University of Vale do
Paraíba. São José dos Campos, São Paulo, Brazil.

Contact author:
Wanderson Carneiro Moreira
University of Vale Paraíba. São José dos Campos, São Paulo, Brazil.
wandersonm.wm@gmail.com

ABSTRACT
Objective: To summarize the scientific production nationally and internationally about
the triggers of stress and burnout syndrome in nurses in Intensive Care Units, as well as
the consequences of these types of wear to the health of nurses and the provision of
care. Methodology: It is an integrative review, which answers the guiding question:
What are the main factors related to stress and burnout syndrome in nurses in Intensive
Care Units? We sought to in SciELO, LILACS and MEDLINE/PUBMED, published
between 2008 and 2015, using the descriptors: burnout, nursing and intensive care unit
in portuguese, english and spanish. We selected 12 articles, which were subjected to
careful reading and critical analysis by pairs, then grouped and organized in tables,
summarized and discussed. Results and Discussion: The triggers of stress are the
confrontation with suffering, heavy workload and the lack of autonomy, presenting
symptoms such as cardiovascular disorders, musculoskeletal and humor. Already the

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 Burnout Syndrome is characterized by the professional exhaustion, depersonalization
and low professional achievement. Conclusion: These factors must be evaluated in
organizations, in order to establish rational implementations for the satisfaction, quality
of care and the minimization of Stress and Burnout Syndrome.
Descriptors: Burnout; Nursing Care; Intensive Care Units.

INTRODUCTION

The term „stress‟ comes from the Physics; being regarded as the degree of
deformity suffered by a structure subjected to an effort. In medicine, Hans Selye, in
1956, was the first to use the term stress, terming it as the set of physiological or
psychological reactions that an organism develops before certain stressors stimuli. So,
this stress reaction is indispensable for the functioning of the body and it is a
consequence of the act of living.1
Stress can be described in two phases: the General Adaptation Syndrome,
considered as a set of specific defence responses and organic adaptation to the stressor;
and the Local Adaptation Syndrome, where the stressor persists and the body can't
adapt, making it impossible to return to homeostasis, the overhead of an organ or a
system, resulting in somatization disorder or disease.2
Thus, the occupational stress occurs when the professional can‟t return to that
stage of balance at work. To this end, the stress in health care can be associated with
specific situations such as relationship problems, role conflict, a double work and
homeshift pressures by superiors and changes suffering within the context of his
activity. In this sense, the nurse is not exempt from the consequences of laboral stress,
showing problems such as dissatisfaction with the work and the development of
Burnout Syndrome.
The term "Burnout" is a composition of propositions Burn (burn) and out,
suggesting that the person, with that kind of stress, features physical and emotional
problems. Burnout Syndrome is characterized by a chronic emotional stress reaction
generated from direct contact, excessive and stressful work environment, making an
impact in the physical and mental health of the employee. This can lead to feelings of

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 helplessness and culminate in a professional situation hopeless, hurting the
concentration, surveillance and supervision skills of the nurse.3
The Intensive Care Unit is a hospital area for treatment of serious patients,
through a combination of specialized multiprofessional intensive care, applying modern
therapies capable of maintaining vital physiology, as well as the survival of high-risk
patients, more effectively than in any other hospital areas. It is considered to be one of
the sectors of greater severity, complexity, wear and professional stress, characterized
by numerous actions and techniques that develop in the course of 24 hours.4
In this context, the Intensive Care Unit is perceived by the team that works,
patients and family, as one of the most aggressive environments strained and
traumatizing of the hospital.5
Some of the factors present in the environment of intensive care that can
generate stress and trigger the Burnout Syndrome are the little prepare to cope with the
constant presence of death, frequent emergency situations, lack of staff and equipment,
constant noise from stereos, unpreparedness and disorganization for handle the frequent
changes of the technological arsenal, suffering of relatives, degree of responsibility in
decision-making, conflict in the relationship between the professionals, among others.6
This study was justified by the fact that occupational stress and Burnout
Syndrome are growing in the professional context of the nurse, because this care
manager and stay most of the time with patient. In addition, it is imperative that a
reflection about a suitable organizational behavior to prioritize job satisfaction, targeting
improvements in the quality of life of nurses and, consequently, the provision of care.
Thus, the aim of this study was to synthesize the scientific national and
international production about the triggers of stress and Burnout Syndrome in nurses of
Intensive Care Units, as well as the consequences of these wear to nurses‟ health and
health care.

METHODOLOGY

An integrative review that for its development, traveled to six steps: the first step
is defining the guiding question of the survey, in the second step there were delimited
the inclusion and exclusion criteria, in the third step the databases were elected and held

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 the search of scientific productions, in the fourth step there was conducted data analysis,
in the fifth step there was developed the discussion of the data and in the sixth step there
was presented the summary of the review.7-8
The guiding question, first step of this review, there was prepared by PICO
strategy (P: Patient, I: Intervention, C: Comparison and O: Outcomes) as follows: What
are the key factors related to stress and Burnout Syndrome in nurses of Intensive Care
Units?
In the second step was the survey of studies published about the topic, online, on
a computer with internet access. In this way, they hired-if inclusion criteria: articles that
make available the full text, articles with the online version free of charge, national and
international productions published in the languages Portuguese, Spanish or English.
The timeline defined were the years 2008 to 2015, in order to portray the scientific
production of the last eight years. There were excluded theses, dissertations,
monographs and articles after reading the summary, not converged with the object of
study proposed, in addition to the publications that have been repeated in the databases.
The search for scientific production occurred in January 2016, carried out
independently by three investigators respectively trained: a nurse and two academics
undergraduate research scholarship holders, ensuring rigour to the process of selection
of articles in the electronic library of Brazilian scientific journals Scientific Electronic
Library Online (SciELO) and on Latin American literature and Caribbean Health
Sciences (LILACS) and Medical Literature Analysis and Retrieval System Online
(MEDLINE) through the extended Public/Publisher (PUBMED).
There were used for the search, the descriptors “Professional Exhaustion”,
“nursing” and “intensive care unit” for the national bases and “Burnout”, “Nursing” and
“Intensive Care Units” to the international base, searched in dictionaries DeCS
(Descriptors in Health Sciences) and MeSH (Medical Subjects Headings), along with
the Boolean operator AND. So, out of a total of 395 publications, being 205 in
MEDLINE, 184 in LILACS and 6 in SciELO, of which 12 articles were included for
analysis according to established criteria.
In the following step, we applied a test of relevance according to the guidelines
of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses do
(PRISMA)9 which led to the elaboration of an catalogue instrument validated by the

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 authors10, in order to organize and analyze the publications, including the following
items: article ID, methodological features of study, assessment of accuracy of the
method, measured interventions, results and level of evidence: 1 – systematic reviews or
meta-analysis of relevant clinical trials; 2 – evidence of at least one randomized
controlled well delineated; 3 ‐ streamlining clinical trials without randomization; 4 ‐
cohort studies and case-control well delineated; 5-systematic review of descriptive and
qualitative studies; 6 – evidence derived from a single descriptive or qualitative study; 7
– opinion of authorities or expert committees including interpretations of research-based
information.
The final synthesis was developed in descriptive form, with regard to the
objectives, results and conclusions obtained from each of the studies. Such data were
grouped by similarity and organized into thematic categories. Finally the last step,
which corresponded to the elaboration of the document with the complete description of
the steps followed.

RESULTS

The Table 1 presents a summary of the studies included in the review, which
constitute the corpus of the study and represented the essence for the preparation of
results, discussion and conclusion about the subject of stress and Burnout Syndrome in
nurses of the Intensive Care Unit.

Methodological Evidence
Authors/Year Journal/Qualis
Title approach level
Professional practice
environment and
PANUNTO, M. Latin American emotional exhaustion
R.; GUIRARDELLO, Nursing among intensive care VI
E. B./ 2013 Journal/A1 nurses Quantitative

CAVALHEIRO, A.
M.; MOURA Latin American
JUNIOR, D. F.; Nursing Journal / Stress of nurses working
LOPES, A. C./ 2008 A1 in intensive care unit Quantitative VI

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 Stress of professional
MONTE, P. F. et al./ Acta paul. nurses who work in
2013 Nursing /A2 intensive care unit Quantitative VI
SMAD,
Electronic
Journal Mental
Health, AlcoholThe stress of nurses in VI
SANTOS, F. D. et and Drugs. (Ed. adult intensive care units: Literature
al./ 2010 port.) / B2 a literature review review
Factors that make
stressful the work of
doctors and nurses in
Brazilian Journal pediatric and neonatal
FOGAÇA, M. C. et of Intensive intensive care: literature Literature VI
al. /2008 Care/ B2 review study review

Influence of workload
and self-efficacy on
GIL-MONTE, P. R.; syndrome of burning
GARCIA-JUESAS, (burnout) work in nurses:
J. A.; HERNANDEZ, Interam. j. a study in nursing
M. C./ 2008 psychol. /B1 professional Quantitative VI

Psychosocial factors and

Brazilian Journal prevalence of Burnout
SILVA, J. L. L. et al./ of Intensive Syndrome among
2015 Care/B2 intensive nursing workers Quantitative VI

GASPARINO, R. C.; Professional practice

GUIRARDILLO, E. environment and Burnout
B./2015 Rev. Rene/ B1 in nurses Quantitative VI

Occupational stress in
nurses working in closed
BARBOZA, M. C. N. Nursing Journal sectors of a hospital in
et al./2013 UFSM/ B2 Pelotas/RS Qualitative VI

Evaluation of stress and

Burnout Syndrome in
AFECTO, M. C. P.; Online Brazilian nurses who work in
TEIXEIRA, M. B./ Journal of intensive care unit: a
2009 Nursing/ B1 qualitative study Quantitative VI

Stress of nurses in
ROCHA, M. C. P.; Online Brazilian different sectors of the
MARTINO, M. M. Journal of hospital environment: a
F./ 2009 Nursing/ B1 descriptive study Quantitative VI

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 Preliminary study on
occupational stress of
doctors and nurses in
pediatric and neonatal
INTENSIVE CARE
Latin American UNIT: the balance VI
FOGAÇA, M. C. et Nursing between effort and
al./ 2010 Journal/A1 reward Quantitative
Source: Direct survey.

As for the year of publication of the articles, it was found that there was no
change in the growth curve, as occurs in some thematic. The analysis shows that the
years of 2008 and 2013 were the ones who presented a higher number of publications,
with 25% (n = 3) of articles each year.
Selected articles were published in 8 different journals, especially the Latin
American Journal of Nursing of the University of São Paulo, with 25% (n = 3) of
productions on the subject. To review the guidelines of the research is that 75% (n = 9)
used quantitative methodological approach, 8.3% (n = 1) qualitative and 16.7% (n = 2)
of the studies they were literature review.
As to the qualification of journals according to the stratification of CAPES
(Nursing Area assessed in 2015, it was observed that: 25% (n = 3) are rated as A1; 8.3%
(n = 1) A2; 25% (n = 4) in B1 and 33.3% (n = 4) as B2. With regard to the training of
the author of the articles, most professionals published were nurses (33), followed by
physicians (6) and psychologists (5). In relation to language, prevailed the Portuguese in
91.7% (n = 11) of items and 8.3% (n = 1) in Spanish.
As the analysis of the classification of the articles evidence has been found that
all selected studies present evidence level VI, characterized as non-experimental studies,
descriptive, correlative and comparative research and qualitative approach case studies.
The analysis of the goals, results and conclusions of the 12 selected studies
allowed the grouping into three categories: triggering factors of stress in labor activity,
signs and symptoms arising from occupational stress and characterization and effects of
Burnout Syndrome.

DISCUSSION

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 Triggering factors of stress in labor activity

The stress, through the view of nursing care, is described as a result of emotional
wear, lack of control of situations of high job requirement, feeling tired, fatigue and
changes in health.11
According to quantitative study that examined the stress levels of nurses
working in different sectors of a hospital in Campinas, the nursing activity-related
stressors are divided into social, labor and professionals.12 Between the social highlight
the domestic work, sexual harassment in the workplace, racism and homophobia. The
employment is related to excessive workload13, night work, violence and insecurity.
Professional stressors include the organization of nursing work, permanent
confrontation with suffering, biological, chemical, physical hazards, accidents and
hospital basic training.14
A study conducted in a large hospital in the city of São Paulo, by means of a
self-appliable questionnaire with 75 nurses from intensive care unit, noted, in its results,
that 58.6% of nurses were said unhappy with the work and presented a score of critical
situations of stress. In this sense, highlighted that the triggering of stress are the
meetings with the leadership, critical leadership, coping with criticism of subordinates,
and crises at home, feeling only in decision making, lack of power and influence, fear of
losing your job, perform tasks below or above your level, unpleasant odors, mistakes,
death of patient and feeling unappreciated.11
In this context, besides the possibility of living with death, pain and constant
charges, the nurses in the intensive care units dealing with human resources deficiency,
sophisticated equipment and/or loud, artificial lighting, demanding routines and, often,
lack of materials and equipment. However, these stressors can resonate in exhaustion
and minimise the quality of life of nurses and assistance services provided.
Thus, the lack of human resources, distribution of shifts, it's a stressful situation
for both the manager and the other nurses. As the number of people assigned to each
shift must be continuous for all shifts and days when there is a lack of employee, your
coverage is provided by another that can sometimes be no rest. However, when there is
no substitutability, workload and therefore wear for those who are on duty, as the
demand of the service is constant.12

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 Study in a tertiary attention hospital situated in the city of Fortaleza, which
aimed to assess the stress in the work environment of nurses in intensive care, showed
that the wear and stress factors are in meeting the needs of family members (100%), in
guiding the patient for self-care (68%), in supervising and coordinating nursing care
provided (90.9%), in meeting emergencies unit (95%) and in the confrontation of death
of the patient (90.9%). In addition, the physical environment of the unit (81.8%), the
noise level (100%) and bureaucratic activities (77%) are also stress triggers. Thus,
intensive care units, because it is a hostile environment and dealing with critical patients
with continuous care needs, is one of the most stressful for the nurse.15
Qualitative study conducted in a large hospital of Rio Grande do Sul was found
also that the problems of relationship between the nursing staff and multidisciplinary
team are a determining factor of stress. And, in this sense, communication becomes an
important tool for enabling this relationship and the sharing of opinions and
expressions.16

Signs and symptoms arising from occupational stress

Occupational stress as a result of tensions associated with the work and

professional life, can cause many health disorders and the quality of life of nurses. So,
review study found that the main signs and symptoms of physiological stress developed
by nurses in an adult intensive care unit are increased sweating, muscle tension,
tachycardia, hypertension, tightening of the jaw, teeth grinding, hyperactivity, nausea,
cold hands and feet. Already in psychological terms, include anxiety, tension, anxiety,
insomnia, interpersonal difficulties, doubts about oneself, excessive concern and
difficulty concentrating.17
In this context, stress symptoms are caused by the exhaust phase in which the
body returns to homeostasis and occurs the workload of organs and systems, resulting in
diseases. With this, cross-sectional study carried out with 75 nurses to a private hospital
in the city of São Paulo, identified that the cardiovascular, musculoskeletal changes
generates stress and digestive tract, and may cause mood changes, allergies, headaches,
anxiety, gastritis, increased blood pressure and heart rate, as well as musculoskeletal
pains.11

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 At the same time, review study points out that the younger nurses, due to the
large number of professionals in the labor market, are required to carry out extensive
journeys. This factor the exposes any longer to workplaces and, concomitantly, to
factors that are potential causes of stress, leading to the appearance of symptoms
suggestive that can trigger stress as irritability, fatigue and inattention.17
In this sense, quantitative study showed that these symptoms related to stress
generate an intense psychological wear labor. Thus, the cumulative stress, if untreated,
can trigger many disorders, such as depression, pathological anxiety, panic, phobias and
psychosomatic illnesses.12
However, these signs and symptoms of stress are considered most often by the
nurse, as something common and intrinsic a profession so arduous. Thus, the symptoms
of stress are not perceived as aggravating and neither treated. However, the worsening
of these symptoms can resonate in serious health problems and on limiting the quality
of life of nurses.

Characterization and effects of Burnout Syndrome

Burnout Syndrome is characterized by physical, psychic and emotional

exhaustion as a result of the hard work and excessive, resulting from the poor man's
adaptation to his work. Thus, it is understood as a reaction to chronic stress and is
characterized by emotional and physical exhaustion, lack of accomplishment at work,
diminished productivity, and negative attitudes at work and feeling of exhaustion.
Although any person is susceptible to occupational stress, Burnout Syndrome focuses
primarily on professionals who help, provide assistance and care, nurse.18
Thus, cross-sectional study developed with 278 nurses in three educational
institutions in the State of São Paulo described the Burnout Syndrome is a psychological
problem that develops in individuals exposed to chronic sources of stress present in the
workplace and affects mainly the professionals that relate intensely with other people.
This syndrome is characterized by three related components: emotional exhaustion,
depersonalization, and diminished personal accomplishment.19
Emotional exhaustion, considered the key component to define the syndrome, is
the first reaction caused in response to workload, social conflict and stress caused by the

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 constant demands. Thus, the main features of exhaustion are irritability, tension, fatigue
and cognitive and emotional detachment of the professional with regard to work.20
Depersonalization consists of professional distance in relation to other people as
a result of the attempt by the worker in the workplace exhaustion. The main features are
the lack of empathy and assistance in relation to other professionals. However, in the
context of nursing in the intensive care unit, these feelings of indifference generate loss
of self-confidence, inability to stand out and, in some cases, abandonment of the
profession.
The lack of personal fulfillment occurs as a result of the lack of autonomy,
workload, and social status of the profession and of the low pay.21 Furthermore, 128
study nurses intensivists of São Paulo that evaluated the environmental characteristics
of the professional practice of nursing staff and your relationship with the Burnout,
found that 30 percent of the nurses said dissatisfied with the work, due to the lack of
structure and the absence of the support of a multidisciplinary team, and it affects
directly in the absence of personal fulfillment.22
Qualitative study that assessed the occupational stress factors faced by nurses
working in an intensive care unit showed that the Burnout process is individual and its
evolution can take years. In this way, because this gradual, cumulative and progressive
emergence in severity, the Burnout Syndrome goes unnoticed by the nurse, who
generally refuses to believe that is something wrong with him.18
Burnout Syndrome has consequences for the physical and mental health of
nurses, cardiovascular changes, chronic fatigue, headaches, migraine, peptic ulcer
disease, insomnia, muscle or joint pain, anxiety, depression, irritability, among others.
In addition, may interfere in the personal life, in family relationships and the quality of
life. Already the work context is affected by absenteeism, job turnover, by the increase
of violent conduct and by the diminishing quality of work.20
In this way, the nurses have been identified in studies how professionals who
exhibit high measures different dimensions of Burnout Syndrome and its consequences
range from reduced ability to work up industrial disputes and may lead to suicide. These
professionals suffer specific occupational stress and tensions; there's precept of facing
high levels of stress at work, these levels that rise in the intensive care unit.

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 CONCLUSION

In view of the results of this study, it can be concluded that the main factors
related to stress and Burnout Syndrome in nurses of intensive care units, reported in the
literature, involve organizational aspects, such as the lack of materials and equipment,
critical leadership and coping of subordinates, workload, low pay and autonomy, as well
as the lack of human resources and the incessant contact with suffering and death. Thus,
these aspects should be considered in the evaluation of the nurse working environments
to minimize the occupational damage.
In this way, the Burnout Syndrome marked by emotional and physical
exhaustion, lack of achievement at work and feeling of exhaustion. However, it is a
single process and its development can take years and, generally, the nurse refuses to
believe that he is with this syndrome, which contributes to a greater physical and
psychological deterioration of a trader.
Therefore, the intensive care unit is one of the areas that cause most damage in
hospital nurse. In this sense, it is imperative that organizations carry out evaluations and
implementations of rational, flexible practices and establish multiprofessional teams
consistently cohesive as this affects on satisfaction and quality of care, necessary for
minimizing the stress and Burnout Syndrome.

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