Burnout syndrome in Brazilian and Spanish nursing workers*

Objective: to analyze the burnout dimensions scores in Brazilian and Spanish nursing workers. Method: quantitative, cross-sectional and comparative study conducted with 589 Nursing workers who answered the Sociodemographic and Professional Characterization Questionnaire and the Maslach Burnout Inventory. Descriptive and analytical analysis of the data was performed. Results: Spanish Nursing workers presented higher averages in the Depersonalization dimension (p = 0.004) and Brazilians, higher scores in the Professional Achievement dimension (p = 0.031). In both Spain and Brazil, nursing assistants / technicians were found to have higher Emotional Exhaustion than nurses; In Brazil, Depersonalization is higher in nurses and in Spain it is higher in Nursing assistants / technicians. Statistically significant results were found in the association of burnout dimensions with sociodemographic and work characteristics: age; professional category; workplace; work regime; work shift; time of professional experience; working time in the same workplace and consider stressful work. Conclusion: Although Brazilian and Spanish nursing workers score low levels of Depersonalization and high Professional Achievement, there are average levels of Emotional Exhaustion, indicating an important preventive factor to be worked on, since Emotional Exhaustion is considered the first stage of burnout.


Introduction
Mental disorders in nursing workers have become more expressive in the last decade, highlighting a serious problem in the field of occupational health and for health services in the international context (1)(2)(3) .
Among mental disorders, burnout, a psychosocial syndrome that arises in response to chronic work stressors, consisting of Emotional Exhaustion (EE), Depersonalization (DE) and Professional Achievement (PA) (4) , has been the subject of many investigations.
Recent systematic review found that countries around the world are recognizing the impact of worker burnout and mental strain on productivity, especially the number of days lost and the impact on work ability (1) .
Other studies indicate psychic disorders and burnout as responsible for most of the restrictions in nursing, intention to leave the profession, poor quality of care, increased errors, reflecting on patient safety (3,(5)(6) .
Despite some peculiarities, the nursing work process happens similarly in different countries due to the inherent characteristics of care and its practical implications related to constant emotional tension, need for concentration, attention and great responsibility (7) .
In addition, the nature of health work, characterized by the experience of pain, suffering and loss of patients, may affect workers, leading to the emergence of burnout syndrome (2) .

However, burnout and other psychic disorders
have been the target of investigations from the perspective of working conditions analysis and detailing of the variables that permeate this construct (8)(9)(10)(11) .

In this sense, organizational issues in Brazilian and
European Nursing work have also been reflected in the physical and mental illness of workers due to adverse working conditions aggravated by the recent economic crisis, which exposed the workers of these scenarios to increased work overload, poor dimensioning of human resources, increased informal ties and fear of unemployment (8,10,12) .
These results have implications for the field of studies and practices in occupational health, revealing the need for protective measures to the mental health of health team professionals, especially Nursing.  In both Brazil and Spain, the following data collection procedures were adopted: previously, the managers of the health institutions were verified the most favorable days and times for the invitation to Nursing workers to participate in the study; these were addressed individually in the workplace and,   Portuguese (14) and Spanish (15) . In both Brazil and Spain, the MBI-HSS consists of 22 items. In the Brazilian version, each item is distributed on a five-point scale, ranging from zero to four ("never" to "daily"), and in the Spanish version, on a seven-point scale, ranging from zero to six (" never "until" daily "). Thus, to enable the comparison of scores between countries, it was necessary to normalize them, which was performed by and Professional Achievement (PA) (items 4, 7, 9, 12, 17, 18, 19 and 21). High values in the EE and DE dimensions, associated with low scores in the PA dimension, indicate burnout (14) . In this study, no cutoff was adopted: the analyzes were performed by

Results
Of the 589 study participants, 47.20% are Brazilian and 52.80% are Spanish; 89.47% are female, and 60.61% live in stable marital union ( Table 1). The average age is 39.5 years (SD 9.36; minimum 20; maximum 64).

Discussion
Currently, few studies analyze burnout syndrome in nursing workers from a multicultural perspective. The sample of this study consisted of Brazilian and Spanish young adult workers, with female predominance, corroborating the results obtained in other studies (16)(17)(18)(19) .
This study also demonstrates that the technical division of labor, the lack of job stability and the perception that work is stressful are factors that permeate the Brazilian and Spanish scenario.
There was a great variation in the international literature when comparing, in Nursing workers, the averages of each dimension of burnout, even within the countries studied here (2,17,(20)(21)  to distance oneself from the recipients of one's work due to EE, which leads the worker to a negative response in the interpersonal context, treating the recipients of his work with cynicism or coldness as if were objects, such as those responsible for their problems, and the reduced PA results from the self-assessment process, when the worker feels incompetent, failed, low self-esteem and poor work performance (4) .
In addition, EE is associated with job dissatisfaction, intention to quit next year and feeling overworked (17) .

This data differs from research conducted with
Italian hospital health workers (22) , but corroborates a Brazilian study that showed high levels of EE associated with low educational level (23) .
Regarding the higher levels of DE in Brazilian nurses than in Nursing assistants / technicians, the data coincide with the results of a survey (22) conducted in Italy and a study (23)   nurses. It is assumed that the higher level of education is linked to the attribution of higher responsibilities and higher expectations of these workers in relation to the profession. However, another study was consistent with results in the Spanish population, which showed higher levels of DE in nursing technicians / assistants (24) .
In Considering stressful work showed an association with burnout, since these nursing workers had higher levels of EE and DE, and lower PR, corroborating the literature, which indicates stress as a predictor of burnout (22,25) . Other authors found an association between stress and two of the burnout dimensions: EE and DE (26)(27)(28) .
The data also showed that Brazilian and Spanish workers without stability have higher levels of PR.
While on the one hand, instability may be linked to the uncertainty of not having a stable job, on the other, job stability may imply lower expectations for professional growth. The association and comparison of EE with job stability in this study were not significant, contrasting a study with hospital health workers in Brazil, where higher EE scores were found in workers with stability than in those without stability (29) .
Moreover, the results showed that, contrary to what happens in Brazil, Spain, younger nursing workers with shorter professional experience have lower PR.
These results are similar to those previously found in the occupational environment (22,30) . Thus, another Brazilian study with hospital health workers also found an association between older age and higher PR (29) .
In Brazil, as the length of professional experience increases, so do the levels of EE, while in Spain this correlation is nil. The influence of working time in the same workplace also points to contradictory data: while in Spain, working in the same workplace for a longer time is associated with lower EE, in Brazil, the opposite occurs, collaborating with the study conducted in Italy (22) . This may be due to Spanish Nursing workers developing a more effective work adaptation process and not accumulating time responsibilities in the same workplace.
Considering the data related to both contexts, the need to implement intervention measures to reduce the risks of burnout development is evident. In this regard, the studies reinforce greater effectiveness and durability of interventions that address both the individual and organizational levels. The individual approach includes psychoeducational actions, with discussion of risk factors, relaxation practices, development of coping strategies, among others (31)(32) . At the organizational level, interventions interfere with working conditions, as can be seen in the study with Australian nurses, which evaluated the impact of an organizational intervention in reducing occupational stress, using a tool to assess workloads, increasing staff numbers, access to professional development, among others, and achieved a significant reduction in psychological distress and emotional exhaustion and a significant improvement in job satisfaction (33) .
It is worth highlighting teamwork as a health strengthening for nursing workers, given that it can provide a collaborative practice in which roles are well defined and there is a focus to be achieved, although there is the specificity of each action. From this perspective, it is essential to involve the subjects in the process of construction and redesign of the work with a view to improving the work climate, team climate and, consequently, valuing professionals.
The limitations of this study are related to its design, which makes the cause and effect relationship impossible, the number of participants and the lack of some variables that may interfere with burnout levels, such as resilience (34)(35) , which can lead the subject to act positively in the face of adversity, becoming a protective factor in the development of this problem. It may be interesting that the study also includes other health workers, including those in primary care, considering the various scenarios of action and their relevance to health at the international level. However, the data show similarities in the contexts and support the planning of actions at the individual and collective levels in the face of illness at work and the need to maintain patient quality and safety.

Conclusion
In conclusion, despite cultural, economic and social