Márcia Astrês Fernandes1; Leone Maria Damasceno Soares2; Joyce Soares e Silva3
Work-related mental disorders have several causes and might affect all healthcare professionals. Nursing professionals are exposed to high physical and psychological demands which contribute to the development of mental illnesses. The aim of the present study was to survey studies conducted in Brazil to investigate the causal relationship between mental disorders and nursing professionals’ work. Integrative review of studies conducted in Brazil from 2010 to 2017. The literature search was performed on the Virtual Health Library database. Combination of descriptors and application of filters resulted in seven articles. Duplicates, doctoral dissertations and articles which did not meet the study aims were excluded. Mental suffering impairs the family, social, personal and professional life of nursing professionals, their studies, self-comprehension and understanding of others, self-criticism ability, acceptance of problems and possibility to take pleasure in life as a whole. The physical load resulting from a large volume of activities, understaffing, large numbers of patients and psychological pressure in the workplace contribute to the development of mental disorders. The pressure to which nursing professionals are exposed in the workplace and double shifts, together with coping modalities and low salary contribute to sick leaves due to mental disorders. However, broader scoped studies are needed.
Keywords: nursing; occupational diseases; mental disorders; occupational health.
A relação entre os transtornos mentais em decorrência do trabalho decorre de várias causas e pode atingir todos os profissionais de saúde. A equipe de enfermagem se submete a altas demandas físicas e psicológicas que colaboram para o adoecimento mental. Dessa forma, o presente trabalho objetivou levantar estudos brasileiros com vistas a identificar a relação causal entre os transtornos mentais e o trabalho dos profissionais da enfermagem. Trata-se de uma revisão integrativa de estudos brasileiros do período de 2010 a 2017. Para o levantamento bibliográfico foi utilizado o banco de dados da Biblioteca Virtual em Saúde. Por meio da associação entre os descritores e filtragem foram obtidos sete artigos. O método de exclusão foi aplicado àqueles que correspondiam a artigos repetidos, teses e os que não se enquadravam no objetivo do estudo. Com isso, descobriu-se que o sofrimento psíquico prejudica a vida familiar, social, pessoal, laboral, os estudos, a compreensão de si mesmo e dos outros, a capacidade de autocrítica, a aceitação dos problemas e a possibilidade de ter prazer na vida em geral. A carga física através de grande volume de atividades, déficit de pessoal e número elevado de pacientes, bem como a pressão psicológica sobre o trabalho, contribuem para o surgimento de transtornos mentais. Portanto, as pressões sofridas pelo trabalhador da enfermagem no ambiente laboral e as jornadas duplas de trabalho, associadas ao modo de enfrentamento do trabalhador e à baixa remuneração contribuem para o afastamento por transtornos mentais. Entretanto, se faz necessária a realização de estudos mais amplos.
Palavras-chave: enfermagem; doenças profissionais; transtornos mentais; saúde do trabalhador.
Work-related mental health (WRMH) discusses the relationship between mental disorders and work in different environments. More in particular, the relationship between occurrence of mental disorders and healthcare work has several causes. Extended working hours, associated or not with low salary, having more than one job and temporary/precarious employment relationship might account for the development of some mental disorder at some point in life. Other causes include: daily care of patients with different problems, having to cope with pain, suffering and death, excessive work, high levels responsibility and shift work1,2. In the case of professionals who provide direct mental care, vulnerability to emotional overload, fear of aggression and tiredness at the end of the working day might favor the occurrence of stress, anxiety and depression, among other disorders. However, such problems do not affect all the professionals who daily deal with psychiatric patients. Similarly to other professionals who work in psychiatry, also they tend to develop mental disorders derived from their work3. The approach to mental diseases that result from excessive work and the cognitive and emotional overload derived from the nature and efficacy of tasks and the conditions under which they are performed should focus on the health and feelings of workers. Conditions such as stress and depression symptoms might interfere with their work and impair their work ability. Monitoring the health of these professionals has thus paramount importance, as suffering and mental exhaustion are often banalized. Indeed, many workers do not attribute the due relevance to their health problems, which might result in impairment of the care they provide in the short run, in turn leading to a more complicated emotional and health state4,5. Workload is associated with occupational hazards and interacts with the body and mind of workers in such a way that whenever the body suffers, also does the mind. As a result, mental exhaustion is considered to be the main cause of work-related mental disorders. Workers subjected to high psychological demands exhibit low levels of support at work, for illnesses and absence of protective factors. Stressors derived from the abovementioned problems account for the prevalence of common mental disorders among healthcare workers. For this reason, attention should be paid to the paradox represented by working conditions that contribute to make sick workers whose activities precisely aim at the promotion and maintenance of health5-7. These considerations led to the research question that guided the present study: what is the causal relationship between mental disorders and nursing professionals’ work? The aim of the study therefore was to review studies conducted in Brazil to investigate the causal relationship between mental disorders and nursing professionals’ work.
The present study consisted in an integrative review of Brazilian studies on mental disorders associated with nursing professionals’ work published from 2010 to 2017. While we intended to include studies published in 2016 and 2017, we only located one article from 2016 and two from 2017. In addition, none of these studies met the review aims, but addressed the perceptions of individuals with mental disorders in general, and not of workers in particular. In the present review we followed the method described by Ganong, which includes the following steps:
selection of the hypothesis or question for the review;
sampling: definition of inclusion and exclusion criteria;
categorization of studies: aspects related to the extraction of information from articles;
evaluation of studies: critical analysis of the extracted data;
discussion and interpretation of results;
presentation of the integrative review and synthesis of knowledge8.
The Virtual Health Library (VHL) database was searched. The health descriptors considered were: nursing, occupational diseases, mental health and workers’ health. Application of combined descriptors retrieved 97 articles, which were reduced to 39 following application of filter year of publication (2010 to 2017). Seventeen articles were located in database Latin American and Caribbean Health Sciences Literature (Literatura Latino-Americana e do Caribe em Ciências da Saúde - LILACS), 17 in Medical Literature Analysis and Retrieval System Online (MEDLINE), 4 in Nursing Database (Base de Dados de Enfermagem - BDENF) and one was a doctoral dissertation. A total of 33 articles were available and 3 were duplicates. Inclusion and exclusion criteria were established for article selection. Inclusion criteria were: Brazilian studies with full text available online and meeting the review aims. Exclusion criteria were: duplicates, doctoral dissertations and studies which only tangentially addressed the subject of interest. As a result, 7 articles were included in the present integrative review.
To summarize and organize the information in the selected articles, the data were entered in a chart with the following headings: title, journal, authors, results and main conclusions (Chart 1). Next we categorized and discussed the data as per the review aims. The titles of articles provide a general view of subject mental health of nursing professionals. In regard to the distribution of articles per year of publication, 2 studies were published in 2010 (28.57%), 2 in 2012 (28.57%), 1 in 2014 (14.29%) and 2 in 2015 (28.57%). No Brazilian studies published in 2016 and 2017 met the aims of the present review. Therefore, one might conclude that publication of scientific articles on the subject of interest is incipient, despite the high rate of sick leaves for mental problems among healthcare professionals. Upon correlating source and place of publication, we found that the articles had been published in nursing, public health and medical journals. As to their methodological approach, all the selected articles described quantitative fieldwork with cross-sectional design.
Analysis of the studies centered on WRMH led to identify two thematic categories: causal relationship between mental disorders and work activities and consequences of mental disorders for nursing professionals.
CAUSAL RELATIONSHIP BETWEEN MENTAL DISORDERS AND WORK ACTIVITIES
Several factors contribute to the occurrence of work-related mental disorders including: work overload, excessive working hours, altered sleep/wake pattern, low salary, having more than one job and work process. Workers subjected to high demands in the workplace tend to develop more musculoskeletal pain in some body areas compared to the ones subjected to low demands. In addition, this population exhibits more psychosocial variables in central areas compared to others. Acceleration of the work rhythm due to increased workload, together with staff shortage and the level of dependence of patients, represents a risk factor for localized pain9.
The psychological pressure to which workers are subjected in the workplace might be also due to the amount of work they must perform along an insufficient period of time and not attuned to the workers’ skills. In addition, the odds for reduced work ability are higher among individuals with minor mental disorders (anxiety and depression symptoms, somatization). Work involves a direct relationship between the mental and physical sides, which might be balanced and afford satisfaction, or cause tension and physical and mental diseases through organizational stress10.
A study that analyzed indicators of sickness absenteeism at a hospital found a relationship between absenteeism and work. The predisposing factors listed are the same as the ones for work-related mental disorders. The rate of sick leaves was higher for women, especially among the hospital nursing staff. The explanations given for this finding included double burden and stress factors, such as having to care for their families in addition to their professional activities. The authors of this study further observed that the precarious working conditions of the nursing staff, their life situation and lack of recognition of their efforts might result in dissatisfaction with life and behave as basis for mental disorders, such as depression, in the long run11.
The physical workload resulting from a high volume of activities, understaffing, too large numbers of patients to care, the psychological pressure to perform work faster, stress induced by conflicting job demands, responsibility with patient care and safety, conflicting relationships among the staff or with others, lack of recognition, problems with equipment and materials, inadequate workstations and inappropriate posture all day long - which increases the frequency of musculoskeletal pain, contribute to the occurrence of minor mental disorders, which might become more severe over time9.
A high proportion of professionals are exposed to situations involving high physical and psychological demands in the workplace. This is a source of much concern, because these factors predispose to disease, while, as a rule, workers are not aware of their long-term effects on health11.
Both the high prevalence of mental disorders and reduced work ability denote a health problem among this population of professionals. The demands and pressure to perform welldone work and directly coping with human suffering and disease might further potentiate the development of these conditions. Special attention must thus be paid to healthcare workers, as by providing care to the sick they might become tomorrow’s patients. Health institutions should seek to promote health through prevention of mental and physical disorders among workers10.
One further causal factor is related with workplace violence. Nursing is the healthcare field most exposed to violence in the workplace. Reasons might be the predominance of females and constant contact with patients. As a result, in addition to workplace violence also gender violence stands outs, and this exposure might lead to stress and depression, which might become worse and have negative repercussion on job satisfaction and recognition. It is worth stressing that the causes that lead workers to develop work-related mental disorders are multiple. Depression and stress are the aspects that most contribute to these disorders, which might also derive from situations that pose a risk to health12.
CONSEQUENCES OF MENTAL DISORDERS FOR NURSING PROFESSIONALS
Mental disorders are signs and symptoms related to functional abnormalities of unknown origin which result in the loss of the emotional balance. They often develop when the work process exceeds the capacity of workers to adapt, enhance feelings of dissatisfaction, indignity and useless and feed the sensation of intellectual numbness and lack of imagination. Thus, they interfere with productivity13.
Mental disorders manifest through subjective symptoms and do not immediately affect the lives and/or physical health of workers. For not being evident symptoms of any disease, they are often confounded with occupational stress. These symptoms are not duly investigated within the health system, even though they represent one of the problems most often associated with the phenomenon of medicalization. Professionals with mental disorders exhibit a considerable diversity of symptoms, such as irritability, sleeplessness, fatigue, forgetfulness, impaired concentration, poor physical and intellectual performance, pain and physical complaints. In turn, the work structure and life conditions are the factors that determine the occurrence of mental disorders. Symptoms might be transient or long-lasting, recurrent or not, seldom fatal, but disabling14.
The physical, emotional and mental exhaustion caused by work might lead to apathy, despondency, hypersensitivity, emotivity, anger, irritability and anxiety. It might also cause depersonalization and inertia, with consequent decrease of the workers’ productivity, performance and statisfaction15.
A study conducted at 240 basic health units (HBU) in the urban areas of 41 municipalities in the Brazilian Southern and Northeastern regions emphasized the assessment of the healthcare workers’ health as a function of their relevance within the workforce globally. The results showed that healthcare workers are exposed to different workloads as a function of the activities they perform, which might potentiate the development of health problems14.
Precarious working conditions and the need to accomplish tasks despite understaffing are determinants in the process of development of mental disorders. The reason is that the higher workload demands greater expenditure of physical and mental strength, with consequent impairment of the quality of life of workers and reduction of the time available for their families and leisure. As a result, mental suffering impairs the family, social, personal and professional life of workers, their studies, self-comprehension and understanding of others, their self-criticism ability, acceptance of problems and the possibility to have pleasure in life as a whole. The fact that disabling injuries and precarious working conditions impair the quality of life of healthcare workers and might interfere with the quality of the care they provide is increasingly recognized. The prevalence of health problems, including mental health problems, is high among primary care workers. Assessment of the prevalence of minor psychiatric disorders includes screening for depression, anxiety, insomnia, fatigue, irritability, forgetfulness, difficult concentration and physical complaints14.
Occupational stress might result from imbalance between job demands and the workers’ ability to cope with them. The reason is that the job demands are established at the workplace, and workers exhibit different degrees of control over the tasks they perform13.
Analysis of the studies performed in Brazil allows concluding that the various forms of pressure to which nursing professionals are exposed in the workplace, double shifts associated with how workers cope with them, low salary, workplace violence resulting in stress and depression. Therefore, more qualified attention is needed from managers and employers in regard to the formulation of more effective public policies for the promotion of the mental health and well-being of this professional category devoted night and day to the care of the Brazilian population and which not seldom becomes disabled to perform activities of daily living and work due to work-related diseases.
We call the attention to the need for more broad-scoped studies including careful analysis of the relationship between mental health and healthcare professionals’ work to achieve a more thorough understanding of the activities performed by the various categories of professionals, their sociodemographic and occupational characteristics and health and working conditions. In addition, studies should investigate the relationship between these variables and factors that motivate or predispose to the development of mental disorders to formulate strategies for health promotion and interventions targeting this population of workers.
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2 de Fevereiro de 2018.
Aceito em 28 de Maio de 2018.
Fonte de financiamento: nenhuma