ABSTRACT

Objective:

To investigate Burnout Syndrome and empathy self-reported by the nursing staff and empathy perceived by the patient.

Method:

Cross-sectional study in a public emergency unit in São Paulo (from October/2020 to March/2021). The nursing staff answered the Maslach Burnout Inventory and the Consultation and Relational Empathy Measure-Nurses (Brazilian version), whereas adult patients answered the Consultation and Relational Empathy Measure (Brazilian version). Descriptive and inferential analysis, with a 5% significance level.

Results:

A total of 92 professionals and 271 patients participated. Most professionals reported impact of COVID-19 (80; 86.96%) and, among them, increased Burnout Syndrome (93; 75%), but with low emotional exhaustion (71; 74%), low depersonalization (59; 78%) and high level of professional accomplishment (72; 83%). Most reported impact and increased empathy, and the results reported by professionals and patients (mean and standard deviation) were: 39.89 (6.44) and 38.25 (9.45), respectively.

Conclusion:

The professionals reported a low level of Burnout Syndrome and a high level of empathy in pandemic.

Descriptors:
Empathy; Burnout; Professional; Emergency Medical Services; Nursing; COVID-19

RESUMEN

Objetivo:

Investigar el Síndrome de Burnout y la empatía auto-reportada por el personal de enfermería y la empatía percibida por el paciente.

Método:

Estudio transversal en un Servicio de Urgencias público de São Paulo (de octubre/2020 a marzo/2021). El personal de enfermería respondió al Maslach Burnout Inventory y al Consultation and Relational Empathy Measure-Nurses (versión brasileña), y los pacientes adultos, al Consultation and Relational Empathy Measure (versión brasileña). Análisis descriptivo e inferencial, con nivel de significancia del 5%.

Resultados:

Noventa y dos profesionales y 271 pacientes participaron. La mayoría de los profesionales informó impacto de la COVID-19 (80; 86,96%) y, entre ellos, aumento del Síndrome de Burnout (93; 75%), pero con bajo agotamiento emocional (71; 74%), baja despersonalización (59; 78%) y alto nivel de realización profesional (72; 83%). La mayoría refirió impacto y aumento de la empatía, cuyos resultados referidos por profesionales y pacientes (media y desviación estándar) fueron: 39,89 (6,44) y 38,25 (9,45), respectivamente.

Conclusión:

Los profesionales informaron bajo nivel de Síndrome de Burnout y alto nivel de empatía en la pandemia.

Descriptores:
Empatía; Agotamiento Profesional; Servicios Médicos de Urgencia; Enfermería; COVID-19

RESUMO

Objetivo:

Investigar Síndrome de Burnout e empatia autorreferida pela equipe de enfermagem e empatia percebida pelo paciente.

Método:

Estudo transversal em Pronto-Socorro público de São Paulo (de outubro/2020 a março/2021). A equipe de enfermagem respondeu o Maslach Burnout Inventory e o Consultation and Relational Empathy Measure-Nurses (versão brasileira), e os pacientes adultos, o Consultation and Relational Empathy Measure (versão brasileira). Análise descritiva e inferencial, com nível de significância de 5%.

Resultados:

Participaram 92 profissionais e 271 pacientes. A maioria dos profissionais relatou impacto da COVID-19 (80; 86,96%) e, entre eles, aumento da Síndrome de Burnout (93; 75%), porém com baixa exaustão emocional (71; 74%), baixa despersonalização (59; 78%) e alto nível de realização profissional (72; 83%). A maioria relatou impacto e aumento da empatia, cujos resultados reportados pelos profissionais e pacientes (média e desvio-padrão) foram: 39,89 (6,44) e 38,25 (9,45), respectivamente.

Conclusão:

Os profissionais reportaram baixo nível da Síndrome de Burnout e alto nível de empatia na pandemia.

Descritores:
Empatia; Esgotamento Profissional; Serviços Médicos de Emergência; Enfermagem; COVID-19

INTRODUCTION

Burnout Syndrome has long been considered as a lasting stress related to work situations, which can be expressed by the word burnout(¹1 Freudenberg HJ. Staff burn-out. J Soc Issues. 1974;30(1):159-65. https://doi.org/10.1111/j.1540-4560.1974.tb00706.x
https://doi.org/10.1111/j.1540-4560.1974... ), and is included in the 11th Revision of the International Classification of Diseases (ICD-11) as an occupational phenomenon(²2 Organização Pan-Americana da Saúde (OPAS). CID: burnout é um fenômeno ocupacional [Internet]. 2019 [cited 2021 Mar 7]. Available from: https://www.paho.org/bra/index.php?option=com_content&view=article&id=5949:cid-burnout-e-um-fenomeno-ocupacional&Itemid=875
https://www.paho.org/bra/index.php?optio... ).

Burnout Syndrome presents nonspecific manifestations by means of physical, psychological and behavioral symptoms(³3 Cândido J, Souza LR. Síndrome de Burnout: as novas formas de trabalho que adoecem [Internet]. 2017 [cited 2021 Apr 4]. Available from: http://www.psicologia.pt/artigos/textos/A1054.pdf
http://www.psicologia.pt/artigos/textos/... ) and is characterized as a three-dimensional psychological syndrome: Emotional Exhaustion, Depersonalization in customer service and feelings of low personal accomplishment, being denominated, in this research, as Professional Accomplishment, by feelings of self-efficacy and accomplishment at work. The Maslach Burnout Inventory- Human Services Survey (MBI-HSS) instrument categorizes the intensity of Burnout Syndrome into low, medium or high level for each dimension, with high scores for Emotional Exhaustion and Depersonalization and low Professional Accomplishment determining the syndrome (⁴4 Maslach C, Jackson SE. The measurement of experienced burnout. J Organiz Behav. 1981;2(2):99-113. https://doi.org/10.1002/job.4030020205
https://doi.org/10.1002/job.4030020205... ).

The COVID-19 (Coronavirus Disease 2019) pandemic, declared by the World Health Organization (WHO) in March 2020(⁵5 World Health Organization (WHO). Coronavirus disease (COVID-19) outbreak: rights, roles and responsibilities of health workers, including key considerations for occupational safety and health: interim guidance[Internet]. 2020 [cited 2021 Mar 27]. Available from: https://apps.who.int/iris/handle/10665/331510
https://apps.who.int/iris/handle/10665/3... ), has impacted healthcare systems worldwide, especially the mental health of frontline healthcare workers(⁶6 World Health Organization (WHO). COVID-19: Occupational health and safety for health workers [Internet]. 2019[cited 2021 Mar 30]. Available from: https://www.who.int/publications/i/item/WHO-2019-nCoV-HCW_advice-2021.1
https://www.who.int/publications/i/item/... ). Among these professionals, the nursing team is the largest contingent providing direct assistance to patients and stands out with high psychosocial risk(⁷7 Ross J. The exacerbation of burnout during COVID19: a major concern for nurse safety. J Perianesth Nurs. 2020;35(4). https://doi.org/10.1016/j.jopan.2020.04.001
https://doi.org/10.1016/j.jopan.2020.04.... ) in urgency and emergency services, herein called emergency units(⁷7 Ross J. The exacerbation of burnout during COVID19: a major concern for nurse safety. J Perianesth Nurs. 2020;35(4). https://doi.org/10.1016/j.jopan.2020.04.001
https://doi.org/10.1016/j.jopan.2020.04....

8 Galanis P, Vraka I, Fragkou D, Bilali A, Kaitelidou D. Nurses’ burnout and associated risk factors during the COVID-19 pandemic: a systematic review and meta-analysis. J Adv Nurs. 2021;77(8). https://doi.org/10.1111/jan.14839
https://doi.org/10.1111/jan.14839... -⁹9 Ministério da Saúde (BR). Terminologia básica em saúde [Internet]. 1985 [cited 2021 Mar 25]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/0111terminologia0.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... ). Emergency unist are 24/7 healthcare units where patients seek primary emergency care when no other service is available(⁹9 Ministério da Saúde (BR). Terminologia básica em saúde [Internet]. 1985 [cited 2021 Mar 25]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/0111terminologia0.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... ).

Studies conducted before the COVID-19 pandemic already indicated risk factors for Emergency Unit nursing professionals to develop Burnout Syndrome, namely: inadequate working conditions, excessive number of patients, lack of material resources and inadequate physical structure, communication failure among multidisciplinary teams, among others(¹⁰10 Oliveira EB, Gallasch CH, Silva PP, Oliveira AV, Valério RL, Dias LB. Estresse ocupacional e burnout em enfermeiros de um serviço de emergência: a organização do trabalho. Rev Enferm UERJ. 2017;25:e28842. https://doi.org/10.12957/reuerj.2017.28842
https://doi.org/10.12957/reuerj.2017.288...

11 Kosits LM, Jones K. Interruptions experienced by registered nurses working in the emergency department. J Emerg Nurs. 2011;37(1):3-8. https://doi.org/10.1016/j.jen.2009.12.024
https://doi.org/10.1016/j.jen.2009.12.02... -¹²12 Souza RB, Silva MJ, Nori A. Pronto-Socorro: uma visão sobre a interação entre profissionais de enfermagem e pacientes. Rev Gaúch Enferm[Internet]. 2007[cited 2021 Mar 30];28(2):242-9. Available from: https://www.researchgate.net/publication/277218168_Pronto-Socorro_uma_visao_sobre_a_interacao_entre_profissionais_de_enfermagem_e_pacientes
https://www.researchgate.net/publication... ). Two systematic reviews with meta-analyses evidenced that emergency unit nurses presented high levels of Burnout Syndrome: high Emotional Exhaustion, Depersonalization and low Professional Accomplishment(¹³13 Gómez UJL, De La Fuente SEI, Albendín GL, Vargas PC, Ortega CEM, Cañadas DLFGA. Prevalence of Burnout Syndrome in Emergency Nurses: a meta-analysis. Crit Care Nurs. 2017;37(5):e1-e9. https://doi.org/10.4037/ccn2017508
https://doi.org/10.4037/ccn2017508... -¹⁴14 Li H, Cheng B, Zhu XP. Quantification of burnout in emergency nurses: a systematic review and meta-analysis. Int Emerg Nurs. 2018;39:46-54. https://doi.org/10.4037/ccn2017508
https://doi.org/10.4037/ccn2017508... ).

With the COVID-19 pandemic, emergency units that had reduced observation bed capacity underwent significant changes in structure and workflow, resulting in overcrowded units with inpatients and critically ill patients(¹⁵15 Branco A, Milanesi R, Sakamoto VTM, Araujo BR, Caregnato RCA. Serviço de emergência hospitalar SUS: fluxos de atendimento a pacientes suspeitos ou confirmados para COVID-19. Enferm. Foco. 2020;11(1.ESP). https://doi.org/10.21675/2357-707X.2020.v11.n1.ESP.3759
https://doi.org/10.21675/2357-707X.2020.... ).

Under this perspective, nursing professionals working in emergency units started to live with increased risk of occupational infection and of developing Burnout Syndrome, due to factors arising from the pandemic: a new coronavirus and insecurity of the team as to proper clinical management; lack of adequate structure, adequate training and personal protective equipment (PPE); conflicting bonds with peers; execution of tasks that are often dramatic and distressing, in addition to dealing with the loss of patients, family members and professional colleagues(⁸8 Galanis P, Vraka I, Fragkou D, Bilali A, Kaitelidou D. Nurses’ burnout and associated risk factors during the COVID-19 pandemic: a systematic review and meta-analysis. J Adv Nurs. 2021;77(8). https://doi.org/10.1111/jan.14839
https://doi.org/10.1111/jan.14839... ). On the other hand, high levels of Burnout Syndrome can negatively impact patient care, being associated with more errors, reduced patient satisfaction, decreased patient compliance to treatment recommendations and greater intention of the professional to leave the job(¹⁴14 Li H, Cheng B, Zhu XP. Quantification of burnout in emergency nurses: a systematic review and meta-analysis. Int Emerg Nurs. 2018;39:46-54. https://doi.org/10.4037/ccn2017508
https://doi.org/10.4037/ccn2017508... ), generating possible conflicts, lack of humanization and reduced empathy(¹⁶16 Thirioux B, Birault F, Jaafari N. Empathy Is a Protective Factor of Burnout in Physicians: new neuro-phenomenological hypotheses regarding empathy and sympathy in care relationship. Front Psychol. 2016;7:763. https://doi.org/10.3389/fpsyg.2016.00763
https://doi.org/10.3389/fpsyg.2016.00763... ).

Empathy is defined as the ability to understand another person, their feelings and thoughts, and to transmit this understanding back to the person, in three ways: cognitive: intellectual ability to understand feelings; affective or emotional: ability to put oneself in another person’s place in a rational way; and behavioral: positive attitudes in understanding the critical situation experienced by the other person(¹⁷17 Yuguero O, Marsal JR, Buti M, Esquerda M, Soler-González J. Descriptive study of association between quality of care and empathy and burnout in primary care. BMC Med Ethics. 2017;18(1):54. https://doi.org/10.1186/s12910-017-0214-9
https://doi.org/10.1186/s12910-017-0214-... -¹⁸18 Savieto RM, Mercer S, Matos CC, Leão ER. Nurses in the triage of the emergency department: self-compassion and empathy. Rev Latino-Am Enfermagem. 2019;27:e3151. https://doi.org/10.1590/1518-8345.3049.3151
https://doi.org/10.1590/1518-8345.3049.3... ).

Acting through effective communication, with the ability to perceive the other and his/her point of view(¹⁹19 Silva MJP. O papel da comunicação na humanização da atenção à saúde [Internet]. 2002 [cited 2021 Apr 20]. Available from: https://revistabioetica.cfm.org.br/index.php/revista_bioetica/article/view/215
https://revistabioetica.cfm.org.br/index... ), that is, acting with professional empathy can be a coping strategy to prevent chronic professional stress and promote well-being(²⁰20 Pinheiro JP, Sbicigo JB, Remor E. Associação da empatia e do estresse ocupacional com o burnout em profissionais da atenção primária à saúde. Ciênc Saúde Coletiva. 2020;25(9):3635-46. https://doi.org/10.1590/1413-81232020259.30672018
https://doi.org/10.1590/1413-81232020259... ).

Furthermore, empathic and communication skills of professionals are essential to avoid unnecessary stress of patients and families in situations of pressure and uncertainty in emergency units, and thus improve patient satisfaction(²¹21 Melnick ER, Powsner SM. Empathy in the Time of Burnout. Mayo Clin Proc. 2016;91(12):1678-9. https://doi.org/10.1016/j.mayocp.2016.09.003
https://doi.org/10.1016/j.mayocp.2016.09... ). Therefore, Burnout Syndrome and empathy are closely linked and are relevant constructs for patientand professional-centered care.

Therefore, and because we have not identified studies with these themes in emergency units in the current pandemic, the guiding question of this study was: What is the impact of the COVID-19 pandemic on nursing professionals regarding the levels of Burnout Syndrome and empathic care provided in a public emergency unit?

OBJECTIVES

To evaluate the impact of the COVID-19 pandemic on nursing professionals regarding Burnout Syndrome levels and empathic care provided in a public emergency unit.

METHOD

Ethical aspects

The project was approved by Ethics and Research Committees recognized by the National Research Ethics Commission, in compliance with the ethical norms and precepts established in Resolution 466/2012.

Study design, period and setting

Cross-sectional study, with a quantitative approach, carried out from October 2020 to March 2021, in a medium-sized public emergency unit in the city of São Paulo. This research was guided by the tool Strengthening the Reporting of Observational Studies in Epidemiology (STROBE).

Population and sample: Inclusion and exclusion criteria

The population was made up of 104 nursing professionals working in the adult observation room (nursing ward) and the patients they cared for. Inclusion criteria were: nurses, nursing technicians and nursing aides working in direct care for at least six months; exclusion criteria were: professionals on vacation and away on medical leave.

The sample of patients was of three patients for each nursing professional participating in the research. Inclusion criteria were: being over 18 years old, with preserved cognition and able to understand the text to answer the questions; and the exclusion criteria were: patients under observation for six hours or less and/or severe and/or unstable clinical condition.

Study protocol

The eligible professionals were approached during working hours, when they were not in service and, after signing a free and informed consent form, they received a link, via WhatsApp, with a questionnaire for sociodemographic characterization and the instruments Maslach Burnout Inventory - Human Services Survey (MBI-HSS)(²²22 Maslach C, Jackson SE. Maslach Burnout Inventory: Human Services Survey (MBI-HSS). Mind Garden [Internet]. 1981 [cited 2021 Jan 15]. Available from: https://www.mindgarden.com/maslach-burnout-inventory-mbi/172-mbi-remote-online-survey-license.html
https://www.mindgarden.com/maslach-burno... ) and Consultation and Relational Empathy Measure (CARE Measure - Nurses), (Brazilian version)(¹⁸18 Savieto RM, Mercer S, Matos CC, Leão ER. Nurses in the triage of the emergency department: self-compassion and empathy. Rev Latino-Am Enfermagem. 2019;27:e3151. https://doi.org/10.1590/1518-8345.3049.3151
https://doi.org/10.1590/1518-8345.3049.3... ), being at the participant’s discretion, the choice of the best place to answer them.

The MBI-HSS is a structured, self-applicable instrument developed by Christina Maslach and Susan E. Jackson(²²22 Maslach C, Jackson SE. Maslach Burnout Inventory: Human Services Survey (MBI-HSS). Mind Garden [Internet]. 1981 [cited 2021 Jan 15]. Available from: https://www.mindgarden.com/maslach-burnout-inventory-mbi/172-mbi-remote-online-survey-license.html
https://www.mindgarden.com/maslach-burno... ), with copyrights acquired by Mind Garden Inc. in 2010. A license to use the instrument was acquired for this research, and it was made available in Brazilian Portuguese by the publisher.

The MBI-HSS is made up of 22 items, distributed into three independent subscales. The Emotional Exhaustion subscale has nine items (1, 2, 3, 6, 8, 13, 14, 16, and 20), the Depersonalization subscale has five items (5, 10, 11, 15, and 22), and the Professional Accomplishment subscale, eight items (4, 7, 9, 12, 17, 18, 19, and 21). The evaluation of all items adopts a Likert-type scale ranging from 0 to 6, being: (0) never, (1) a few times a year or less, (2) once a month or less, (3) a few times a month, (4) once a week, (5) a few times a week, (6) daily. Each dimension is divided into three levels, according to the sum of the items: high, moderate, and low. For Emotional Exhaustion: ≥27: high level, from 19 to 26: moderate, and ≤18: low level; Depersonalization: ≥10: high level, from 6 to 9: moderate, and ≤5: low level; and Professional Accomplishment: ≥40: high level, from 34 to 39: moderate, and ≤33: low level(²²22 Maslach C, Jackson SE. Maslach Burnout Inventory: Human Services Survey (MBI-HSS). Mind Garden [Internet]. 1981 [cited 2021 Jan 15]. Available from: https://www.mindgarden.com/maslach-burnout-inventory-mbi/172-mbi-remote-online-survey-license.html
https://www.mindgarden.com/maslach-burno... -²³23 Alves MCeC, Barilli SLS, Specht AM, Herbert NDR. Burnout Syndrome prevalence among nursing technicians of an Adult Intensive Care Unit. Rev Bras Enferm. 2021;74(suppl3). https://doi.org/10.1590/0034-7167-2019-0736
https://doi.org/10.1590/0034-7167-2019-0... ). At the end of the MBI-HSS instrument, there were questions about the impact of the COVID-19 pandemic on Burnout Syndrome levels, with Yes and No alternatives. If the answer was YES, there were two alternatives: increased or decreased.

The second instrument was the Consultation and Relational Empathy Measure Nurses (CARE Measure - Nurses), (Brazilian version), adapted and validated by Roberta Savieto et al. in 2019(¹⁸18 Savieto RM, Mercer S, Matos CC, Leão ER. Nurses in the triage of the emergency department: self-compassion and empathy. Rev Latino-Am Enfermagem. 2019;27:e3151. https://doi.org/10.1590/1518-8345.3049.3151
https://doi.org/10.1590/1518-8345.3049.3... ), for self-evaluation of these professionals regarding empathy towards the care provided. The instrument contains 10 items, with six possibilities of evaluation each, with one “not applicable” and the other options ranging between “poor” and “excellent”, resulting in a score between 10 and 50, where 10 means unsatisfactory empathic behavior and 50, highly satisfactory(¹⁸18 Savieto RM, Mercer S, Matos CC, Leão ER. Nurses in the triage of the emergency department: self-compassion and empathy. Rev Latino-Am Enfermagem. 2019;27:e3151. https://doi.org/10.1590/1518-8345.3049.3151
https://doi.org/10.1590/1518-8345.3049.3... ). At the end of the CARE Measure - Nurses instrument, there were questions about the impact of the COVID-19 pandemic on empathic care, with Yes and No alternatives. If the answer was YES, there were two alternatives: increased or decreased.

Eligible patients were approached and invited to participate in the research individually. After the acceptance and signature of the informed consent form, the researcher holding a tablet, next to the patient’s bed, asked the question and the patient answered, avoiding contact between the patient and the tablet. Thus, the patient answered the sociodemographic questionnaire questions and the CARE Measure instrument (Brazilian version) about the care provided by the nurse, nursing technician, or nursing aide who had provided care.

The Consultation and Relational Empathy (CARE) instrument - Brazilian version -, translated and validated by et al.(²⁴24 Scarpellini GR, Capellato G, Rizzatti FG. Silva GA, Baddini-Martinez JA. Escala CARE de empatia: tradução para o Português falado no Brasil e resultados iniciais de validação. Medicina (Ribeirão Preto). 2014;47(1):51-8. https://doi.org/10.11606/issn.2176-7262.v47i1p51-58
https://doi.org/10.11606/issn.2176-7262.... ), consists of 10 items, with 6 possibilities of evaluation each, with one “not applicable” and the other options varying between “poor” and “excellent”, resulting in a score between 10 and 50, where 10 means unsatisfactory empathic behavior and 50, highly satisfactory.

All data were collected using the REDCap platform(²⁵25 Harris PA, Taylor R, Minor BL, Elliott V, Fernandez M, O’Neal L, et al. The REDCap consortium: building an international community of software platform partners. J Biomed Inform. 2019;95:103208. https://doi.org/10.1016/j.jbi.2019.103208
https://doi.org/10.1016/j.jbi.2019.10320... -²⁶26 Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap): a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-81. https://doi.org/10.1016/j.jbi.2008.08.010
https://doi.org/10.1016/j.jbi.2008.08.01... ). Biosafety protocols were followed during data collection: disinfection of materials and equipment and hand hygiene before and after participation in the study.

Analysis of results and statistics

A 10% loss was estimated to constitute the sample of nursing professionals, with a correlation coefficient of 0.3 and a power of 91.3%, with the aid of the pwr package(²⁷27 Champely S. pwr: Basic Functions for Power Analysis. Version 1.2-2 [Program] [Internet]. 2018 [cited 2021 Jan 20]. Available from: https://github.com/heliosdrm/pwr
https://github.com/heliosdrm/pwr... ).

Numerical variables were described by mean and standard deviation or median and interquartile range [IIQ (minimum and maximum)], and qualitative variables were described by absolute and relative frequency(²⁸28 Faraway JJ. Extending the linear model with R: generalized linear, mixed effects and nonparametric regression models. Chapman and Hall/CRC; 2006.). The association between perceived empathy and Burnout Syndrome categories was assessed by a generalized linear model with gamma distribution(²⁹29 Paula GA. Modelos de regressão com apoio computacional São Paulo: IME-USP; 2004.). Chi-square test was applied for qualitative variables and Analysis of Variance (Anova) for quantitative variables, to verify the association between sociodemographic variables of the professionals and to verify the association between questions regarding the COVID-19 pandemic and the dimensions of the MBI-HSS among the categories of professionals(³⁰30 Pagano M, Gauvreau K. Princípios de Bioestatística. Ed. Cengage; 2015.).

The Kruskal-Wallis test was applied to compare the mean scores obtained by the CARE Measure and the CARE Measure-Nurses, by professional category(³⁰30 Pagano M, Gauvreau K. Princípios de Bioestatística. Ed. Cengage; 2015.). Sperman’s correlation coefficient was used to correlate the scores of the MBI-HSS dimensions and the CARE Measure and CARE Measure-Nurses; to calculate the correlation, the mean of patients per professional was used for the indicator “empathic behavior reported by patients”(³⁰30 Pagano M, Gauvreau K. Princípios de Bioestatística. Ed. Cengage; 2015.)_. For all analyses, a significance level of p = 0.05 was adopted. The analyses were performed with SPSS software(³⁰30 Pagano M, Gauvreau K. Princípios de Bioestatística. Ed. Cengage; 2015.).

RESULTS

Ninety-four nursing professionals (eligible) participated in the research, but two were excluded because no patient was interviewed. All the analyses considered: 92 professionals, namely 23 nurses (25%), 28 nursing technicians (30.43%), and 41 nursing assistants (44.57%), and 271 patients who were assisted by these professionals.

Sociodemographic characteristics of nursing professionals and patients

Table 1 presents the sociodemographic characterization of nursing professionals by professional category. The overall mean age (standard deviation) was 42.07 (7.81) years. Most participants were female (79; 85.87%), white (45; 48.91%), and mixed race (31; 33.70%), working during the daytime (57; 61.96%) and with a time of graduation of “11 years or more” (60; 65.22%). About the time of work in the emergency unit - study setting - most professionals had worked, in general, from “6 months to 5 years” (46; 50%), especially nurses and nursing technicians: 15 (65.22%) and 21 (75.00%), respectively (p=<0.001). Most had CLT jobs (77; 83.70%) and had no other employment in health care (52; 56.52%).

Table 2 presents the sociodemographic characterization of patients seen by professional category. The median age was 54.10; IIQ: 38.00 - 66.60, and most of them were male (158; 58.30%), white (145; 53.51%), with an education level of “up to complete elementary school” (155; 57.20%). The service was performed mainly during daytime (170; 62.73%) and in the nursing ward (168; 61.99%).

Impact of COVID-19 on Burnout Syndrome and Empathy

The results regarding the impact of COVID-19 on Burnout Syndrome and empathic care of nursing professionals and the data related to the dimensions of the MBI-HSS by professional category are presented in Table 3.

Most professionals (80; 86.96%) reported an impact on Burnout Syndrome and, of these, 75 (93.75%) reported an increase. As for empathic behavior, 61 professionals (66.30%) reported that the pandemic had an impact on it, and of these, 51 (83.61%) reported an increase in empathic care.

Most professionals reported a “low level” of Emotional Exhaustion: 66 (71.74%) and Depersonalization: 55 (59.78%), but a “high level” of Professional Accomplishment: 67 (72.83%). The professionals who reported a “high level” of Emotional Exhaustion and Depersonalization were 13 (14.13%) and 17 (18.48%), respectively, and a “low level” of Professional Accomplishment: 17 (18.48%). No significant differences of Burnout Syndrome were observed in relation to the three nursing professional categories.

Nursing professionals’ empathy self-reported and perceived by patients

The results of the evaluation of empathic care are described in Table 4. There was no evidence of significant difference between self-reported empathy among professional categories, as well as that reported by patients.

The patients had the following distribution of medical diagnoses grouped into infection (38; 14%), neurological (46; 17%), COVID-19 (42; 15.5%), cardiovascular (30; 11.1%), general gastroenterology (30; 11.1%), and other diagnoses (98; 36.2%).

Table 5 describes the results for patient perceived empathy and medical diagnosis categories, with the infection category as the reference for comparison, as it had the highest perceived empathy (39.8; 95% CI: 36.6 - 43.3). The only evidence of a significant difference was for neurological diagnoses, with lower perceived empathy (34.9; 95% CI: 32.4 - 37.7; p = 0.025). For patients with a COVID-19 diagnosis, the estimated perceived empathy was 39.0; 95% CI: 36.0 - 42.3.

Correlation of Burnout Syndrome dimensions with empathy self-reported by professionals and perceived by patients

In evaluating the correlation between the dimensions of the Burnout Syndrome and the empathy self-reported by the professionals, a significant, negative, and weak association was observed between the empathic behavior evaluated by the professionals and Emotional Exhaustion and Depersonalization, whose values were -0.32 and -0.26, respectively, that is, the greater the self-reported empathy, the lower the Emotional Exhaustion and Depersonalization, and vice-versa. In relation to self-reported empathy and Professional Accomplishment, this presented a significant, positive and moderate association (0.49), that is, the greater the empathy, the greater the Professional Accomplishment and vice-versa.

On the other hand, the correlation between empathy perceived by patients and Emotional Exhaustion (-0.05) and Depersonalization (0.01) was not significant or almost non-existent. As for the empathy perceived by the patients and Professional Accomplishment, there was a significant, positive and weak association (0.22), that is, the greater the empathy perceived by the patient the greater the Professional Accomplishment and vice-versa.

DISCUSSION

This study investigated the impact of the COVID-19 pandemic on the Burnout Syndrome and empathy of nursing professionals in a public emergency unit.

Although most professionals reported that there was an impact of the COVID-19 pandemic increasing Burnout Syndrome, the results of this study showed that, overall, the levels of Emotional Exhaustion and Depersonalization were low, and the level of Professional Accomplishment was high (positive results).

The results of this study differ from the literature data published on the current pandemic, with most studies pointing to a negative impact on the mental health of healthcare professionals(³3 Cândido J, Souza LR. Síndrome de Burnout: as novas formas de trabalho que adoecem [Internet]. 2017 [cited 2021 Apr 4]. Available from: http://www.psicologia.pt/artigos/textos/A1054.pdf
http://www.psicologia.pt/artigos/textos/... ,¹⁰10 Oliveira EB, Gallasch CH, Silva PP, Oliveira AV, Valério RL, Dias LB. Estresse ocupacional e burnout em enfermeiros de um serviço de emergência: a organização do trabalho. Rev Enferm UERJ. 2017;25:e28842. https://doi.org/10.12957/reuerj.2017.28842
https://doi.org/10.12957/reuerj.2017.288...

11 Kosits LM, Jones K. Interruptions experienced by registered nurses working in the emergency department. J Emerg Nurs. 2011;37(1):3-8. https://doi.org/10.1016/j.jen.2009.12.024
https://doi.org/10.1016/j.jen.2009.12.02...

12 Souza RB, Silva MJ, Nori A. Pronto-Socorro: uma visão sobre a interação entre profissionais de enfermagem e pacientes. Rev Gaúch Enferm[Internet]. 2007[cited 2021 Mar 30];28(2):242-9. Available from: https://www.researchgate.net/publication/277218168_Pronto-Socorro_uma_visao_sobre_a_interacao_entre_profissionais_de_enfermagem_e_pacientes
https://www.researchgate.net/publication... -¹³13 Gómez UJL, De La Fuente SEI, Albendín GL, Vargas PC, Ortega CEM, Cañadas DLFGA. Prevalence of Burnout Syndrome in Emergency Nurses: a meta-analysis. Crit Care Nurs. 2017;37(5):e1-e9. https://doi.org/10.4037/ccn2017508
https://doi.org/10.4037/ccn2017508... ). A study conducted with nurses and physicians between January and February 2020, in China, showed high levels of distress, depression, anxiety, and insomnia(³¹31 Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al. Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019. JAMA Network Open. 2020;3(3):e203976. https://doi.org/10.1001%2Fjamanetworkopen.2020.3976
https://doi.org/10.1001%2Fjamanetworkope... ). A systematic review conducted by WHO, with studies published between December 2019 and February 2021, evidenced that, regardless of geographic location, health professionals presented, in addition to the symptoms mentioned above, fear, Burnout Syndrome, and post-traumatic stress disorder(³²32 World Health Organization (WHO). Repercussões psicológicas da COVID-19 entre prestadores de cuidados de saúde [Internet]. 2021 [cited 2021 Sep 15]. Available from: https://apps.who.int/iris/handle/10665/340311
https://apps.who.int/iris/handle/10665/3... ).

Few studies used the MBI-HSS instrument in the current pandemic, making comparisons of the Burnout Syndrome of the nursing team in emergency units difficult. However, results contrary to the present research were found in a systematic review and meta-analysis study that analyzed publications from January 1st to November 15th, 2020, about the Burnout Syndrome among nurses, pointing to a higher prevalence of Emotional Exhaustion (34.1%), followed by Depersonalization (12.6%) and lack of Professional Accomplishment (15.2%). This study also revealed the main risk factors for Burnout Syndrome among nurses: younger age, less social support, low preparedness of family and colleagues to face COVID-19, increased perceived threat of COVID-19, longer working time in quarantine areas, in a high-risk environment, in hospitals with inadequate and insufficient material and human resources, higher workload and lower level of training(⁸8 Galanis P, Vraka I, Fragkou D, Bilali A, Kaitelidou D. Nurses’ burnout and associated risk factors during the COVID-19 pandemic: a systematic review and meta-analysis. J Adv Nurs. 2021;77(8). https://doi.org/10.1111/jan.14839
https://doi.org/10.1111/jan.14839... ).

Another study showed that women in nursing had a higher risk of negative impact on mental health(³²32 World Health Organization (WHO). Repercussões psicológicas da COVID-19 entre prestadores de cuidados de saúde [Internet]. 2021 [cited 2021 Sep 15]. Available from: https://apps.who.int/iris/handle/10665/340311
https://apps.who.int/iris/handle/10665/3... ). In the present study, none of the demographic variables of the participants showed a significant difference for occurrence of Burnout Syndrome: most of the participants were women (79; 85.87%), whose is common among nursing professionals in health services in Brazil(¹⁰10 Oliveira EB, Gallasch CH, Silva PP, Oliveira AV, Valério RL, Dias LB. Estresse ocupacional e burnout em enfermeiros de um serviço de emergência: a organização do trabalho. Rev Enferm UERJ. 2017;25:e28842. https://doi.org/10.12957/reuerj.2017.28842
https://doi.org/10.12957/reuerj.2017.288... ,²³23 Alves MCeC, Barilli SLS, Specht AM, Herbert NDR. Burnout Syndrome prevalence among nursing technicians of an Adult Intensive Care Unit. Rev Bras Enferm. 2021;74(suppl3). https://doi.org/10.1590/0034-7167-2019-0736
https://doi.org/10.1590/0034-7167-2019-0... ,³³33 França FM, Ferrari R. Síndrome de Burnout e os aspectos sociodemográficos em profissionais de enfermagem. Acta Paul Enferm. 2012;25(5):743-8. https://doi.org/10.1590/S0103-21002012000500015
https://doi.org/10.1590/S0103-2100201200... -³⁴34 Garcia GPA, Marziale MHP. Satisfaction, stress and burnout of nurse managers and care nurses in Primary Health Care. Rev Esc Enferm USP. 2021;55. https://doi.org/10.1590/S1980-220X2019021503675
https://doi.org/10.1590/S1980-220X201902... ), professional experience (65.22% had graduated over 11 years ago) and age (mean of 42 years). These characteristics may be related to a greater personal and professional maturity.

In a study conducted among emergency service nurses in Belgium comparing Burnout Syndrome in the periods before and after the beginning of the COVID-19 pandemic, there was a significant difference in the high risk of Professional Accomplishment (5.71, p = 0.017), with an increase from 23.3% before to 33.4% post-pandemic, but not in the high risk of Emotional Exhaustion and Depersonalization. For the latter two dimensions, there was a slight decrease after the pandemic (high risk for Emotional Exhaustion from 50.9% to 45.8%; high risk for Depersonalization from 59.1% to 55.5%)(³⁵35 Butera S, Brasseur N, Filion N, Bruyneel A, Smith P. Prevalence and associated factors of burnout risk among intensive care and emergency nurses before and during the Coronavirus Disease 2019 Pandemic: a cross-sectional study in Belgium. J Emerg Nurs. 2021;47(6):879-91. https://doi.org/10.1016/j.jen.2021.08.007
https://doi.org/10.1016/j.jen.2021.08.00... ).

In this study, there was no comparison between the periods before and after the start of the COVID-19 pandemic, however, the results of this study on Burnout Syndrome during the pandemic are better than those cited in the Belgium study.

The critical levels of the Burnout Syndrome dimensions were high level of Depersonalization at 18.48% and low Professional Accomplishment at 18.48%, followed by high Emotional Exhaustion at 14.13%. However, nursing technicians and aides had higher levels of Emotional Exhaustion (14.29% and 17.07%, respectively), when compared to nurses (8.70%), which may be related to these nursing categories, for spending most of the time at the bedside with the patient, developing actions in a direct and continuous relationship, associated with stress factors in the fight against the COVID-19 pandemic, such as higher workload, insomnia, fear, pace of the virus dissemination, lack of support and uncertainty about epidemiological issues(³⁶36 Barbosa DJ, Gomes MP, Souza FBA, Gomes AMT. Fatores de estresse nos profissionais de enfermagem no combate à pandemia da COVID-19: síntese de evidências. Comum Ciênc Saúde. [Internet]. 2020 [cited 2021 Apr 25];31(Suppl 1):31-47. Available from: http://www.escs.edu.br/revistaccs/index.php/comunicacaoemcienciasdasaude/article/view/651/291
http://www.escs.edu.br/revistaccs/index.... ).

Most participants of the present study reported having only one employment relationship, unlike the study in a public emergency service of Rio de Janeiro, in which the majority (56.76%) reported having more than one employment relationship and high levels of Emotional Exhaustion and Depersonalization(¹⁰10 Oliveira EB, Gallasch CH, Silva PP, Oliveira AV, Valério RL, Dias LB. Estresse ocupacional e burnout em enfermeiros de um serviço de emergência: a organização do trabalho. Rev Enferm UERJ. 2017;25:e28842. https://doi.org/10.12957/reuerj.2017.28842
https://doi.org/10.12957/reuerj.2017.288... ). Having an employment relationship can be considered a positive characteristic for not developing Burnout Syndrome, corroborating the data analyzed in a study of a public emergency room in Minas Gerais(³⁷37 Pires FC, Vecchia BP, Carneiro EM, Castro JPR, Ferreira LA, Dutra CM, et al. Síndrome de Burnout em profissionais de enfermagem de pronto-socorro. Rev Enferm UFPE. 2020;14. https://doi.org/10.5205/1981-8963.2020.244419
https://doi.org/10.5205/1981-8963.2020.2... ).

A study conducted with nurses from 40 public health institutions in São Paulo revealed that institutions with the worst working conditions resulted in high levels of Emotional Exhaustion and Depersonalization and low levels of Professional Accomplishment, unlike those with favorable conditions, that is, autonomy, organizational support and control over the environment are important factors that interfere with Burnout Syndrome(³⁸38 Nogueira LS, Sousa RMC, Guedes ES, Santos MA, Turrini RNT, Cruz DALM. Burnout and nursing work environment in public health institutions. Rev Bras Enferm. 2018;71(2):336-42. https://doi.org/10.1590/0034-7167-2016-0524
https://doi.org/10.1590/0034-7167-2016-0... ). Thee aspects were not evaluated in this study.

A cross-sectional study carried out with nurses in an emergency service corroborates the findings of this study, presenting a high score for Depersonalization and a low score for Professional Accomplishment(¹⁰10 Oliveira EB, Gallasch CH, Silva PP, Oliveira AV, Valério RL, Dias LB. Estresse ocupacional e burnout em enfermeiros de um serviço de emergência: a organização do trabalho. Rev Enferm UERJ. 2017;25:e28842. https://doi.org/10.12957/reuerj.2017.28842
https://doi.org/10.12957/reuerj.2017.288... ). Another study in an emergency unit with nurses and nursing technicians also presented depersonalization as the most critical dimension(³⁷37 Pires FC, Vecchia BP, Carneiro EM, Castro JPR, Ferreira LA, Dutra CM, et al. Síndrome de Burnout em profissionais de enfermagem de pronto-socorro. Rev Enferm UFPE. 2020;14. https://doi.org/10.5205/1981-8963.2020.244419
https://doi.org/10.5205/1981-8963.2020.2... ). It is known that Depersonalization is evidenced by the professional’s behavior, that is, distancing and negligent treatment towards the patients, as a way to relieve the weariness(³⁹39 Maslach C, Leiter MP. New insights into burnout and health care: strategies for improving civility and alleviating burnout. Med Teach. 2017;39(2):160-3. https://doi.org/10.1080/0142159X.2016.1248918
https://doi.org/10.1080/0142159X.2016.12... ), and this dimension of the Burnout Syndrome can compromise the professional’s empathy, since it requires guarantee of human presence and attention in the experience with the other.

In the present study, nursing professionals reported that COVID-19 had an impact on increasing empathic care, which is congruent with the findings of another study in the context of COVID-19 that emphasizes that the professional’s understanding of the situation experienced by the patient is a coping strategy against Burnout Syndrome, since paying attention to the feelings of others increases levels of professional well-being and, consequently, Professional Accomplishment(⁴⁰40 Delgado N, Bonache H, Betancort M, Morera Y, Harris LT. Understanding the Links between Inferring Mental States, Empathy, and Burnout in Medical Contexts. Healthcare. 2021;9(2):158. https://doi.org/10.3390/healthcare9020158
https://doi.org/10.3390/healthcare902015... ).

Self-reported empathy showed no difference between the professional categories (p=0.2056), unlike the findings of another study with nursing professionals working in urgency and emergency services that showed that nurses are more empathic than nursing technicians (p=0.039)(⁴¹41 Albuquerque MCS, Souza DFS, Maynart WHC, Bezerra LFD, Cassimiro ARTS, Cavalcante JC. Nurses’ Empathy In An Emergency Hospital Service. Texto Contexto Enferm. 2019;28. https://doi.org/10.1590/1980-265X-TCE-2017-0406
https://doi.org/10.1590/1980-265X-TCE-20... ).

Although the correlation between the empathy self-reported by the professional and that perceived by the patient is not the objective of this study, both have their relevance, empathy being a unique element not only for nursing professionals but also for patients(⁴²42 Pomponi M, Ricciardi L, La Torre G, Fusco D, Morabito B, Ricciardi D, et al. Patient's Loss of Empathy Is Associated With Caregiver Burden. J Nerv Ment Dis. 2016;204(9):717-22. https://doi.org/10.1097/nmd.0000000000000568
https://doi.org/10.1097/nmd.000000000000... ).

This study showed a negative and weak correlation in the Emotional Exhaustion and Depersonalization dimensions of Burnout Syndrome with self-reported empathy. A study carried out with primary care health professionals evidenced that empathy was a protective factor against Burnout Syndrome(²⁰20 Pinheiro JP, Sbicigo JB, Remor E. Associação da empatia e do estresse ocupacional com o burnout em profissionais da atenção primária à saúde. Ciênc Saúde Coletiva. 2020;25(9):3635-46. https://doi.org/10.1590/1413-81232020259.30672018
https://doi.org/10.1590/1413-81232020259... ). Another study with primary care physicians also showed that high levels of self-reported empathy were associated with low levels of Burnout Syndrome(⁴³43 Yuguero O, Esquerda M, Marsal JR, Soler-González J. Association between Sick Leave Prescribing Practices and Physician Burnout and Empathy. PLoS One. 2015;10(7):e0133379. https://doi.org/10.1371/journal.pone.0133379
https://doi.org/10.1371/journal.pone.013... ). A study with emergency physicians also showed a weak negative correlation between self-reported empathy and Burnout Syndrome(⁴⁴44 Wolfshohl JA, Bradley K, Bell C, Bell S, Hodges C, Knowles H, et al. Association Between Empathy and Burnout Among Emergency Medicine Physicians. J Clin Med Res. 2019;11(7):532-8. https://doi.org/10.14740/jocmr3878
https://doi.org/10.14740/jocmr3878... ).

A cross-sectional study carried out with nurses and users assisted by these professionals, in primary care in Porto Alegre, evaluated the empathy self-reported by the professionals and perceived by the users and the impact of occupational stress, and the users evaluated that professionals with higher levels of stress presented less empathy(⁴⁵45 Dullius L. Congruência entre a empatia autorreferida de enfermeiras (os) da atenção primária em saúde e a percepção do usuário sobre a relação empática. Universidade Federal do Rio Grande do Sul [Internet]. 2020 [cited 2021 Mar 7]. Available from: https://www.lume.ufrgs.br/handle/10183/218078
https://www.lume.ufrgs.br/handle/10183/2... ). In this study, there was evidence that the greater the empathy perceived by the patient, the greater the Professional Accomplishment and vice-versa. Therefore, it is understood that self-reported empathy is related to the way the individual is in his occupational environment, and may be a protective factor for Burnout Syndrome, since the professional, by understanding the importance of empathy in care, deals better with the patient and with problematic situations at work(²⁰20 Pinheiro JP, Sbicigo JB, Remor E. Associação da empatia e do estresse ocupacional com o burnout em profissionais da atenção primária à saúde. Ciênc Saúde Coletiva. 2020;25(9):3635-46. https://doi.org/10.1590/1413-81232020259.30672018
https://doi.org/10.1590/1413-81232020259... ,⁴⁰40 Delgado N, Bonache H, Betancort M, Morera Y, Harris LT. Understanding the Links between Inferring Mental States, Empathy, and Burnout in Medical Contexts. Healthcare. 2021;9(2):158. https://doi.org/10.3390/healthcare9020158
https://doi.org/10.3390/healthcare902015... ).

It is important to emphasize that empathy is not only related to the ability to understand patients’ experiences and feelings, but also to the ability to communicate their feelings through behavior, whose essence is altruistic, resulting in greater adherence to treatment and patient satisfaction(⁴⁶46 Hojat M, Louis DZ, Markham FW, Wender R, Rabinowitz C, Gonnella JS. Physicians' empathy and clinical outcomes for diabetic patients. Acad Med. 2011;86(3):359-64. https://doi.org/10.1097/acm.0b013e3182086fe1
https://doi.org/10.1097/acm.0b013e318208... ). Moreover, professionals develop a closer relationship with their patients and care that is full of energy, enthusiasm(⁴³43 Yuguero O, Esquerda M, Marsal JR, Soler-González J. Association between Sick Leave Prescribing Practices and Physician Burnout and Empathy. PLoS One. 2015;10(7):e0133379. https://doi.org/10.1371/journal.pone.0133379
https://doi.org/10.1371/journal.pone.013... ), and engagement(⁴⁷47 Martos MÁ, Pérez-Fuentes MDC, Molero FMDM, Simón MMDM, Barragán MAB, Gázquez LJJ. Empathy, Affect and Personality as Predictors of Engagement in Nursing Professionals. Int J Environ Res Public Health. 2021;18(8):4110. https://doi.org/10.3390/ijerph18084110
https://doi.org/10.3390/ijerph18084110... ), with the ability to transform the extremely emotional and stressful experience, through resilient emotional management and consequent progressive adaptation(⁴⁸48 Diogo PMJ, Lemos e Sousa MOC, Rodrigues JRGV, Almeida e Silva TAAM, Santos MLF. Emotional labor of nurses in the front line against the COVID-19 pandemic. Rev Bras Enferm. 2021;74(Suppl 1):e20200660. https://doi.org/10.1590/0034-7167-2020-0660
https://doi.org/10.1590/0034-7167-2020-0... ).

No studies were found evaluating Burnout Syndrome and empathy in the nursing team in the Emergency Unit, in the context of COVID-19, making comparisons difficult. The current study was carried out between October 2020 and March 2021, when, in Brazil, there was a substantial drop in the number of cases and deaths of patients with COVID-19(⁴⁹49 Ministério da Saúde (BR). COVID-19 no BRASIL 2021 [Internet]. 2021 [cited 2021 Apr 25]. Available from: https://qsprod.saude.gov.br/extensions/covid-19_html/covid-19_html.html
https://qsprod.saude.gov.br/extensions/c... ), which may have influenced the results.

Study limitations

The study was carried out in a single public emergency unit, with members of the nursing team, and it is not possible to generalize the results. The cross-sectional study design has limitations in relation to changes over time; furthermore, risk factors for Burnout Syndrome and empathic care were not evaluated.

Contributions to the field

Professional empathy is associated with low levels of Emotional Exhaustion and Depersonalization and high Professional Accomplishment, being a fundamental factor in the mental health of professionals and in the quality of care provided to patients.

Thus, the empathic and communicational skills of professionals may be essential for the nursing work to be meaningful and rewarding and, therefore, should be developed and improved for greater involvement and well-being of professionals and possible positive repercussions for patients and the organization as a whole.

CONCLUSIONS

The COVID-19 pandemic impacted Burnout Syndrome, however most professionals reported “low level” Burnout Syndrome for Emotional Exhaustion and Depersonalization and high level of Professional Accomplishment. The professionals reported a positive impact on empathic care.

There was evidence of a significant association: negative - the higher the self-reported empathy, the lower the level of Emotional Exhaustion and Depersonalization; and positive - the higher the self-reported empathy, the higher the Professional Accomplishment. Regarding the empathy perceived by the patients, there was no significant association between the Emotional Exhaustion and Depersonalization dimensions, but there was evidence of a significant positive association with Professional Accomplishment.

REFERENCES

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