Nursing practice environment in intensive care unit and professional burnout *

* Extracted from the dissertation “Ambiente de prática de enfermagem em terapia intensiva: implicações na segurança do paciente e Burnout profissional, Universidade Federal do Rio Grande do Sul, 2020. 1 Universidade Federal do Rio Grande do Sul, Programa de Pós-Graduação em Enfermagem, Porto Alegre, RS, Brazil. 2 Universidade Federal do Rio Grande do Sul, Escola de Enfermagem, Porto Alegre, RS, Brazil. ABSTRACT Objective: To evaluate and compare the nursing practice environments in Intensive Care Units of a public and private hospital and the prevalence of burnout among nursing professionals. Method: Cross-sectional, descriptive study with a quantitative approach to the data. The data collection took place between October 2018 and March 2019, and it was carried out through a questionnaire with socio-occupational variables and with metrics of intensity. The practice environment was assessed through the Nursing Work Index Revised (NWI-R); and the burnout was assessed by the Maslach Burnout Inventory (IBM). We included professionals with, at least, six months of employment, and those who were on leave or on a fixed-term employment contract were excluded. Results: The sample consisted of 296 professionals. We found Favorable environments in both institutions, however, low results in the subscales autonomy, control and organizational support in the private hospital. The prevalence of burnout among nurses was 2.5% in the public hospital and 9.1% in the private hospital, and among nursing technicians, it was 9.5% and 8.5%, respectively. Conclusion: The control of the environment, autonomy and support were considered critical points, referring to the importance of assessing institutions factors, that can improve the working conditions for the nursing team.


INTRODUCTION
The management of the quality of health services has been a prominent theme over the years, it is a priority to achieve ways to improve patient safety and the organizational sustainability. Reaching this goal becomes a challenge for nursing leaders due to the complexity involved in care environments and processes. Issues related to physical structure, limitations and financial sustainability, lack of material resources and deficits in the human resources of health professionals are worrisome issues. Thus, the knowledge that seeks to understand the reasons why nursing professionals have high rates of absenteeism, turnover, dissatisfaction with work and emotional exhaustion, compensate by consolidating, considering that these factors are capable of making the individual quality of life of and affecting the quality of care (1) .
Studies about the environment of nursing practice, then, appear as an alternative to contribute to the understanding of the aspects that interfere in the exercise of professional practice and that, consequently, may have repercussions in patient care.
The practice environment consists of factors related to worker satisfaction and professional performance, such as: autonomy; care attendance focused on quality; nursing status in the institution, personal recognition of the professional and his skills, leadership and participation in organizational decisions; career advancement based on qualification and individual development; and relationships with managers, doctors and colleagues (2) These aspects may be relevant to facilitate or hinder the activities of nursing professionals and have an impact on the results of the quality of care, as well as dissatisfaction with the work and development of Burnout (3) . Burnout Syndrome is considered to be a multifactorial condition consisting of emotional exhaustion, depersonalization and low professional achievement. It is observed in people whose work consists of interaction/help with other people (4) . These factors, combined with work environments with high care complexity, such as Intensive Care Units (ICU), reinforce the relevance of this investigation.
The literature so far demonstrates that the perception of professionals varies according to the study context, highlighting the relationship between practice environments perceived as unfavorable by professionals, and low levels of emotional exhaustion/burnout, in addition to a better perception of quality assistance and less intention to quit employment (5)(6)(7) .
Thus, the objective of this study was to evaluate and compare the ICU nursing practice environments of a public and a private hospital and the prevalence of burnout among nursing professionals.

Type of STudy
Cross-sectional, descriptive study with a quantitative approach to the data.

Scenario
It was developed in Intensive Care Units of two hospitals in Rio Grande do Sul.
The public hospital has 39 ICU beds for adults, serving clinical and surgical patients undergoing major procedures, such as cardiac, neurological, lung and heart transplants, lung and liver transplants, among others. It differs from other public hospitals in that it is a teaching hospital, accredited by the Joint Commission International ( JCI), and it has budgets coming from the Ministry of Health and Education. The private hospital has 40 ICU beds for adults and serves clinical and surgical patients undergoing cardiac, pulmonary and neurological surgery in the immediate postoperative period.
In order to characterize the field, aiming to compare the institutions, we have also collected secondary on the severity profile of the assisted patients and on nursing workload, through the Simplified Acute Score (SAPS 3) and Nursing Activities Score (NAS), respectively.
The description of these variables in the fields of study aimed to search for possible intervening variables, related to the profile of the clients served, which could interfere with the studied outcomes. Mean SAPS 59.61 (SD = 17.83) and mean NAS 81.34 (SD = 1.04) were found in the public hospital. In the private hospital, mean SAPS 59.38 (SD = 2.36) and mean NAS of 66.78 (SD = 1.76) were obtained during the data collection period.

SelecTion criTeria
As an inclusion criterion, we considered nursing professionals (nurses and nursing technicians) with at least six months of employment in the investigated ICUs. The sample excluded professionals who were on leave for any reason, or who were on an employment contract for a specific period (trial period or temporary vacancy), during data collection.

Sample definiTion
In the public hospital, the population (N = 215) consisted of 59 nurses and 156 nursing technicians. In the private hospital, the population (N = 162) consisted of 26 nurses and 136 technicians. We evaluated the sample size based on a study that evaluated the professional practice environment of the nursing staff in the ICU, which obtained mean score ranging from 2.1-2.4 with a standard deviation of 0.52-0.62 in the evaluated subscales (8) . Considering, then, a standard deviation of approximately 0.62, a 95% confidence interval and a 0.1 margin of error on the scale, we performed the sample calculation. Adding 10% for possible losses or refusals, the sample size of 235 individuals was reached, distributed as follows: 134 professionals in the public hospital -86 nursing technicians and 48 nurses; and 101 professionals in the private hospital -80 nursing technicians and 21 nurses.
As the sample size calculation were very close to the totality of the study population, we decided, then, to invite all eligible professionals to participate in the research. The investigated sample was composed by 296 nursing professionals, surpassing the sample calculation; 63 nurses and 232 nursing technicians, distributed as follows: 180 professionals in the public hospital -138 nursing technicians and 42 nurses; and 116 professionals in the private hospital -94 nursing technicians and 22 nurses.

daTa collecTion
Data collection was carried out, from October 2018 to March 2019, through a structured questionnaire, composed of three parts: the first with information on socio-occupational characterization, such as age; sex; working time at the institution; if you have other employment relationships; number of professionals under their supervision per shift (in the case of nurses); number of patients under their responsibility per shift; and finally, it questions the opinion on the dimensioning and structural support. In addition to this characterization, participants were asked about their job satisfaction, their perception of patient safety and the quality of care at the unit, and also their intention to leave their job next year, through intensity scales, analogous-visual, with score from 1 to 10.
The second part of the questionnaire contained the Nursing Work Index-Revised (NWI-R) instrument, translated and adapted to Brazilian culture, for nurses (9) and for nursing assistants/technicians (10) in order to assess work environment traits that favor the practice of nursing professionals. This instrument has four subscales: the autonomy subscale (composed of 5 items) refers to the freedom that the nursing professional has to solve care problems, the control subscale (composed of 7 items) refers to the domain of situations that occur in their working environment; the relations between doctors and nursing subscale (composed of 3 items) deals with issues related to respect among these professionals, and finally, the organizational support subscale (composed of 10 items derived from the other three subscales) which refers to support for that nursing develops its activities. The answers have a likert scale format, ranging from "totally agree" to "totally disagree", with a score of 4 points. Values below 2.5 represent favorable environments for professional practice and above 2.5 points unfavorable environments, that is, the lower the score, the greater the presence of attributes favorable to professional nursing practice (6,11) .
The reliability of the instrument validated in Brazil for nurses was assessed using the Cronbach alpha coefficient and resulted in a satisfactory internal consistency that varied between 0.63-0.75 in the subscales (9) . In the study that validated the scale for nursing technicians and nursing assistants, the reliability assessed by means of Cronbach's alpha coefficient ranged from 0.58-0.82 in the subscales (10) .
The last part of the instrument contained the Maslach Burnout Inventory (MBI), adapted and validated for Brazilian culture to assess Burnout Syndrome among professionals. The inventory has 22 items covering three evaluated subscales: emotional exhaustion (consisting of nine items), depersonalization (eight items) and personal fulfillment (five items) and they are measured using a Likert scale, which varies from the frequency "never" to "always", in a score of five points. The higher the score, the greater the level of emotional exhaustion and depersonalization and the lower the feeling of personal fulfillment (12) . A The reliability of this instrument varied between 0.72-0.92 in the subscales (12) .

daTa analySiS and STaTiSTical TreaTmenT
The data were entered and managed in the SPSS version 21.0 software for statistical analysis. Categorical variables were described by frequencies and percentages and continuous variables by mean and standard deviation or median and interquartile range. The normality test used was the Kolmogorov-Smirnov. To compare the averages between hospitals, the t-student test was applied. In case of asymmetry, the Mann-Whitney test was used. Categorical variables were compared using the Chi-square or Fisher's exact test, considering a significance level of 5% (p < 0.05), for all statistical tests. To assess the internal consistency of the NWI-R and MBI instruments, we calculated the Cronbac's alpha coefficient.

eThical aSpecTS
The study was approved by the Research Ethics Committee of the two hospitals, both in 2018, under opinions 2940250 and 3011343, respectively, in compliance with the provisions of Resolution #466/12, of the National Health Council. Professionals who agreed to participate in the research signed the Free and Informed Consent Form (ICF) and were guided and assured in relation to confidentiality issues regarding non-identification in the questionnaire, confidentiality in relation to information, in addition to the right to refuse and clarify in at any time during the study, without prejudice to their employment. The exclusive use of the data was ensured only for the purposes of this research. The possible benefits of the investigation were clarified, as well as the lack of awareness of the risks arising from the study for the participants, however, it was considered that there could be some discomfort due to the time spent to answer the questionnaire.

RESULTS
Regarding the characterization of the sample, there was an average age in the public hospital of 40.4 ± 8.0 and 44.26 ± 7.78 years old, for nurses and nursing technicians, respectively, while in the private hospital it was evident 34.1 ± 4.4 and 38.01 ± 7.78 years old, for nurses and nursing technicians, respectively, showing a significant difference (p < 0.001) in the average age of professionals, showing a higher difference for nurses and nursing technicians at the public hospital.
The female gender was prevalent in the sample of both hospitals, being above 80% among nurses and above 60% among nursing technicians. The marital status of nursing professionals was predominantly married in the public hospital, with 56.1% being nurses and 57.3% for nursing technicians, in contrast, the predominant marital status of the private hospital, was the condition of singles. The other socio-occupational characteristics are shown in Table 1.  Table 2 shows data on job satisfaction, professionals' perception of patient safety in the unit, perception of the quality of care in the unit and intention to quit their job. Table 3 shows the results on the practice environment in the hospitals studied and the burnout of the nursing team.
The reference values calculated for the description of burnout in the studied sample are shown in Chart 1.
The internal consistency of the instruments was calculated using Cronbach's alpha with the following results for the NWI-R domains: 0.76 in autonomy; 0.82 in environmental

DISCUSSION
The characterization of the sample allows us to know the profile of the participants and their work context, contributing to clarify the differences found among the nursing practice environment of the study hospitals, since from the point of view of assistance (nursing workload and the patients severity status) there was no substantial difference among institutions as it was verified with the results of SAPS between ICUs.
We found that a higher average age and working time in the ICU, in the public context, can be justified due to job stability and the granting of benefits, which can contribute to the retention of nursing professionals in public hospitals compared to private hospitals. Corroborating this finding, a study carried out in ICUs of three hospitals in Paraná found a higher average age in the public institution, which reinforces this labor dynamics (7).
These characteristics of public hospitals influence the turnover and permanence of professionals, which is a positive factor, as it is known that intensive care units are sectors of high care complexity and, therefore, need trained professionals to meet these demands. The flow of "new" people in the team can hinder this dynamic due to the constant need for training and qualifications.
The finding of a higher prevalence of nursing technicians with more than one job in the private hospital adds to these considerations about the best working conditions in the public hospital. It is noteworthy that the need to stay in more than one job can harm the quality of life of these people in addition to income at work, increasing the chances of accidents at work, iatrogenies and illnesses of professionals (13) .
The nurses sample in the private hospital disagreed that the nursing dimension was adequate to the care needs, unlike nurses in the public context. In fact, it was shown that in the private hospital, nurses were responsible for a greater number of patients (10 ± 2.2), while in the public hospital this number was half (5.1 ± 0.4).
There are several studies that explore the issue of deficit in the number of nurses as an international problem. The results are alarming and demonstrate nursing actions neglected due to lack of time, association of the adequacy of the staff with better pain management and reduction of falls, increased workload with repercussions for patients, medication errors and increased mortality in units with fewer nurses (14)(15)(16) .
When asked about the adequacy of structural support, the study showed that professionals, both nurses and nursing technicians, consider this question appropriate in both institutions. However, among nurses, the percentage of agreement with the adequacy of structural support was significantly higher (p = 0.002) in the public hospital 38 (92.7%) compared to the private hospital 12 (57.1%). It appears from these data that in the studied private context, there may be some limitations of administrative and bureaucratic support that place demands on the nursing team, since more than 40% of them do not agree that the support is compatible with the requirements of the service.
Even with some differences, previously discussed between the two hospitals, the intention to quit the job was low in both of them. We find it interesting to note that, in the private context, the oscillation of intention is greater, mainly, among nursing professionals with a median equal to 3 (percentiles 1-6), on an intention scale from 1 to 10. This finding indicates that the nurses from private institutions are more likely to seek new job opportunities, with better pay and working conditions.
Despite some divergent aspects related to the adequacy of personnel, structural support and working conditions, the results on job satisfaction, the perception of safety and the quality of care in the unit presented averages considered high, all above 7.5, in both hospital contexts.
Studies show that salary remuneration, autonomy to make decisions, professional growth, free time for leisure, team work, and the very involvement in patient care, which generates spiritual satisfaction, are factors that influence professional satisfaction (17)(18) . In the absence of these attributes, dissatisfaction may be inevitable, in addition to the risk for the development of burnout syndrome, the increase in absenteeism, the turnover of professionals and the physical wear and tear of the team, in addition to losses in the provision of assistance such as the occurrence of incidents and inappropriate practices (19)(20)(21) .
Although the factors that contribute to professional satisfaction and dissatisfaction are quite elucidated, we found that they feel satisfied in carrying out their nursing practice, even in the presence of some factors that could contribute to professional dissatisfaction and it is observed that the national literature presents similar results (22) , which reinforces the importance of observing other personal motivators, such as working in the desired unit and being able to provide assistance to those in need, who contribute to feelings of pleasure and being useful, among professionals. That is why it is imperative for managers to devise strategies in addition to remuneration, to promote satisfaction and thereby avoid the evasion of their employees.
Even though the nursing practice environments were considered favorable in both institutions, the scores were close to the cutoff point of the scale among nurses in the private  hospital in the autonomy (2.32 ± 0.51), control (2.37 ± 0.53) and organizational support subscales (2.25 ± 0.45). There was a significant difference between the groups, suggesting that in these subscales there may be difficulties encountered by nurses in the private context. The demands of work in the intensive care environment require nurses to constantly make quick decisions in order to maintain the care and flows of the unit, which leads to the need for institutional support/ backing. Therefore, difficulties related to these subscales can weaken nursing care and patient safety. We note that, in other national studies carried out in ICUs, emergencies and inpatient units, these dimensions were also shown to be weakened (6,22) , identifying, occasionally, some of the vulnerabilities of nursing practice environments.
Our findings and data in the literature indicate that, in our country, nursing has difficulties to have control over the work environment, which is more critical and evident for the category of nurses, since these professionals are responsible for managing the nursing team and work units. The fact that they perceive that they have these responsibilities, but at the same time know that they cannot control important factors for assistance, can impair the planning of nursing care and even cause incidents to patients.
It is assumed that the subscales for organizational support and autonomy, which were also shown to be weakened in our study, may be related to the unfavorable perception of the environment control, since this subscale covers precisely the factors that may be beyond the reach of nurses' control can impair their perception of autonomy. It can be mentioned: insufficient support services that can overburden professionals with bureaucratic tasks, reducing time for assistance and planning, problems related to dimensioning, as the nurse assistants need to manage staff scales according to demand. However, they usually do not participate in hiring decisions, in addition to conflicts related to management and leadership competencies of managers, which directly impact decision making at the bedside.
The relationship between nursing and doctors was favorable, both in the findings of this study and in several other national studies (6,(22)(23) . This collaboration between different professional categories in intensive care units can also be explained by the sector's own characteristics, in which the cooperation of the multiprofessional team is more required for the recovery of critically ill patients with complex care.
There was a low prevalence of burnout among professionals in both hospitals, with moderate levels of professional fulfillment, emotional exhaustion and depersonalization. These findings are in line with the other results of the present study, which found high averages of professionals satisfied with their work, positive perception of the work environment, unit safety and quality of care, in addition to low intention to quit their job. Several studies corroborate these results and show the beneficial relationships between environments favorable to professional practice, the low prevalence of burnout/emotional exhaustion and less intention to quit the job (5,(24)(25) .
This study presents as a limitation the cross-sectional design and with regard to the comparison between public and private contexts, the particularity of the investigated public hospital, being an institution of excellence, university, accredited by JCI. These characteristics limit the possibility of generalization of the results of this study to other public hospital contexts in Brazil.
The studies on the nursing practice environment, although expanding, are still concentrated in the Southeast region of Brazil. Therefore, it is considered opportune the possibility of mapping the practice environments by the different regions of the country, in order to obtain information that can provide subsidies for nursing leaders to act more punctually in improving processes and working conditions for the nursing team and thereby also qualifying patient care.

CONCLUSION
The results of the study indicate that the environments were considered favorable to the practice of nursing in the ICUs of the two hospitals, according to the perception of the nursing team. It is worth mentioning that the autonomy, control of the environment and organizational support subscales obtained lower scores in the private hospital, close to the cutoff point (2.5) to be considered favorable. It is considered that some socio-occupational characteristics and the working conditions of this hospital may be related to these results, such as younger teams with less time working in the unit, a greater number of nursing technicians with more than one job and greater number of patients per nurse in comparison with the public hospital.
The prevalence of burnout among professionals ranged from 2.5% to 9.5%, being considered low in both hospitals and presenting moderate levels in the subscales of professional fulfillment, emotional exhaustion and depersonalization. In both hospitals, the nursing teams showed high averages of job satisfaction, positive perceptions regarding the quality and safety of care in their units, in addition to low averages regarding the intention to quit their jobs.