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SPCI - Sociedade Portuguesa de Cuidados Intensivos

Revista Brasileira de Terapia Intensiva

AMIB - Associação de Medicina Intensiva Brasileira


ISSN: 0103-507X
Online ISSN: 1982-4335

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Fogaça MC, Carvalho WB, Cítero VA, Nogueira-Martins LA. Fatores que tornam estressante o trabalho de médicos e enfermeiros em terapia intensiva pediátrica e neonatal: estudo de revisão bibliográfica. Rev Bras Ter Intensiva. 2008;20(3):261-266



Original Article

Factors that cause stress in physicians and nurses working in a pediatric and neonatal intensive care unit: bibliographic review

Fatores que tornam estressante o trabalho de médicos e enfermeiros em terapia intensiva pediátrica e neonatal: estudo de revisão bibliográfica

Monalisa de Cássia FogaçaI, Werther Brunow de CarvalhoII, Vanessa de Albuquerque CíteroIII, Luiz Antonio Nogueira-MartinsIV

IMaster, Psychologist and PhD student in Psychiatry from the Discipline of Medical Psychology, Department of Psychiatry of the Universidade Federal de São Paulo - UNIFESP, São Paulo (SP), Brazil
IIPhD, Professor from the Department of Pediatrics of the Universidade Federal de São Paulo - UNIFESP, São Paulo (SP), Brazil
IIIPost-Doutorate Degree, Physician from the Discipline of Medical Psychology, Department of Psychiatry of the Universidade Federal de São Paulo - UNIFESP, São Paulo (SP), Brazil
IVPhD, Physician from the Discipline of Medical Psychology, Department of Psychiatry of the Universidade Federal de São Paulo - UNIFESP, São Paulo (SP), Brazil

Submitted on May 19, 2008
Accepted on August 13, 2008

Corresponding author:

Werther Brunow de Carvalho
Departamento de Pediatria Rua Botucatu, 598
Vila Clementino 04023-062 São Paulo - (SP), Brazil
Phone/Fax: (55-11) 3081-9877
Email: [email protected]; [email protected]



OBJECTIVES: Bibliographic review on occupational stress and burnout presence in physicians and nurses that work in pediatric and neonatal intensive care units.
METHODS: The articles were selected from the MedLine, LILACS and Sci-Elo data base using the key words: stress, burnout, physicians, nursing, intensive care unit, pediatric intensive care unit and neonatal intensive care unit. The studied period was from 1990 to 2007.
RESULTS: Health professionals who work in pediatric and neonatal intensive care units are strong candidates for developing stress, psychological alterations and burnout syndrome. Researches on this subject identified important alterations suffered by these physicians and nurses, such as: work overload, burnout, desires of giving up their jobs, high levels of cortisol, among other alterations.
CONCLUSIONS: Professionals, who work in pediatric and neonatal intensive care units, due to the specificity of their job, are liable of developing occupational stress, and consequently burnout. These results suggest the need to research the matter further, with the objective of developing preventive measures and intervention models.

Keywords: Burnout, professional; Intensive care units, neonatal; Nursing; Stress/etiology; Physicians




In the last years, the relationship between occupational stress and the workers' mental health has been the subject of many studies1-3 in our environment as well as in other countries, due to the alarming levels of temporary incapacitation, absenteeism, early retirements and health risks associated to professional activity.4

Several studies5-9 developed theoretical models in order to evaluate the prevalence of emotional problems and professional dysfunctions in the occupational setting and to identify the phenomena which are comparable in multiple working places and with different occupational groups. These models include the evaluation of the capacity of the professional to adapt to stress10, the development of the burnout syndrome,7-8,11 the control over the job and the psychological demands that result from it5-6 and the balance between effort and reward in the job that continuously provokes emotional and physiological reactions.9

Nowadays, there is enough information affirming the need to dedicate more attention related to the physicians' and nurses' health,3,12-13 especially to their mental health.1,13-18 Candeias et al. point out that the hospital setting in itself generates stress in different levels. Death, an inherent fact in hospitals, demands a very strong emotional control of the health professionals in relation to the patients and their relatives19 Physicians and nurses of high complexity specialties, who often work in the limit of life and death, such as emergency and intensive care units, are more exposed to psychological stress.20-22

The effect of occupational stress in physicians and nurses from intensive care units, as well as the physical and mental overload is emphasized in literature.20-32 Stress can be of outmost importance in a pediatric and neonatal intensive care unit (PNICU), as the interpersonal relations between staff and relatives can create dysphoric and depressive reactions in the professionals.31

Burnout is present in these units, and it has been identified in considerable levels, due to working conditions and specific characteristics of the work that create physical and emotional demands in regard to critically ill patients.32

In face of these results, it is valid to affirm that the studies in question agree to the fact that working in intensive care units creates occupational stress and burnout in physicians and nurses, but there is not a consensus as to which factors trigger these phenomena and how they express themselves. This review aims to identify the organizational and professional factors related to the presence of stress and burnout, and to verify if the literature presents evidence if occupational stress is a consequence in these factors (overload of work, turnover, overcrowding, inadequate physical space, high levels of noise, professional unprepared ness, professional dissatisfaction, among others).



A bibliographic review on occupational stress and burnout in physicians and nurses who work in PNICU was done. The articles studied were researched in Med-Line, LILACS and SciElo data bases, using the key words: stress, Burnout, physicians, nursing staff, intensive care unit, pediatric intensive care unit and neonatal intensive care unit. The studied period was from 1990 to 2007. We included all articles that reported original investigations on the matter, excluding all systematic reviews and meta-analysis.



We identified 18 studies, of which 11 were descriptive investigations, 3 were longitudinal prospective studies and 4 were qualitative studies (Chart 1). Only three studies (two descriptive investigations and one prospective study) evaluated stress among physicians and 17 evaluated the nursing staff.

Five of the transversal descriptive studies33-37 measured the burnout levels of the professionals, pointing out the relationship between burnout due to professional exhaustion and lack of personal accomplishment, and therefore, greater stress.

Oehler et al., evaluating nurses intensive care units in both studies, found in the first a percentage of 24% for emotional exhaustion, 7% for depersonalization and 32% for lack of personal accomplishment in the work, in other words, suggestive scores for burnout, in moderate level in the subscales emotional exhaustion and depersonalization, and high in subscales personal accomplishment.34The percentage for burnout in the second study was of 66%, including the total of the three subscales.35

In the studies of Fields et al36 and Arriortua et al.,37 that evaluated pediatric doctors from intensive care units, it was found 36% and 41%, respectively, with risks to develop burnout; while the study of Jofré and Valenzuela informs that 65% of the studied population (nurses, paramedic and nursing assistants) had not presented propensity for burnout in the subscales emotional exhaustion and depersonalization, 53.8% had presented one high score for personal accomplishment and 7.7% only showed lack of personal accomplishment in the work.33

Psychological alterations were prevalent in 32% of the nurses and 27% of physicians in neonatal intensive care units38-39 and these levels were associated to the presence of professional stress. With the objective of identifying the factors associated to stress, the studies agree in stating that the main factors were lack of professional formation, as well as an inappropriate intensive care setting.40-43 The same results were found in a qualitative approach.44

In an attempt to evaluate objectively the levels of stress in a difficult situation, 2 prospective studies were performed by Fischer et al.45,47 and one by Morrison et al.46 showing the rise in salivary cortisol and amylase salivary levels in a neonatal intensive care setting, due to the excess of noise.

Out of the four qualitative studies found44,48-50 three showed48-50 an association between professional stress of the nursing staff of a neonatal intensive care unit, and these issues go beyond the working place, such as: having to deal with the patient's unpredictability, the professional's relationship with the patient's relatives and with the team itself, as well as the death of newborn patients.



The results found in the studies about stress and burnout in PNICU were consistent, confirming the presence of stress in these units.

Regarding the methods of study, by a bibliographic review, we had an overall view of the types of outlines used in the investigations, in the area of occupational stress and burnout in pediatric and neonatal intensive care units. The studies thus presented, which used both a qualitative and quantitative approach, showed the need to pursue the matter further, stressing the necessity of developing a greater number of cohort longitudinal prospective studies, in order to establish the incidence of occupational stress and burnout in pediatric and neonatal intensive care units, enabling the evaluation of the relationship of stressing factors with certain diseases.

Regarding the burnout syndrome, it seems adequate to consider differentiated patterns to analyze the answers, that is, to discriminate the answers according to gender, adaptability to the organizational space, environmental and occupational factors. These characteristics should be taken into consideration for future studies that aim to investigate the professional wear out found in health professionals, as a great number of the samples studied in pediatric and neonatal intensive care units, mostly in the nursing area, are formed by female subjects, which could compromise the study regarding male professionals included in the same organizational environment.

It is a known fact that PNICU are places that generate tensions and stress, motivated by interpersonal relationship, intense emotions caused by the constant exposure to risks of dying, by the frequent oscillation between success and failure and by the demands imposed on the team. With all these stimuli, feelings such as inadequacy, insecurity and impotence arise, which can influence negatively in the interpersonal relationships and the professional ability, thus creating a vicious circle, marked for the difficulties in the interpersonal relation with patients´ family , difficult relationships with some members of the multiprofissional team39, desire to abandon the work, the emotional exhaustion, the lack of professional accomplishment33-37, the overload of work (overcrowding, unprepared ness of the team technique, inappropriate physical space) among others factors, will influence negatively in the quality of life in the work. Inasmuch, these sectors have their own characteristics, with the need of restraining personal contact outside the boundaries of the working place, they become environments with a high health liability. Then, the attention given to patients in these units is differentiated, requiring agility and ability, as they are situations of extreme urgency, where the patient's life is in risk. Also, it is an environment with very advanced technology, demanding constant updating of the team.

No prospective study was found, be it clinical trial or longitudinal cohort study, which analyzed more deeply stress and burnout, and their relation with psychological symptoms and its impact on the attention. We found studies which show the impact of the intensive care unit environment on the health professionals, suggesting that stress and burnout are caused by working conditions. More efficient personal management models need to be adopted in order to solve the conflicts for the health professionals working in this environment.

Another aspect to be considered is the need to adequate the use of technology with scientific knowledge, and the relationship between the staff and patients' relatives.

The current study presents some limitations, as a systematic review and meta-analysis of the subject in focus were not performed, because defining a single measurement to evaluate stress and burnout is very complex.



Professionals, who work in pediatric and neonatal intensive care units, due to the specificity of their job, are liable of developing occupational stress, and consequently burnout. These results suggest the need to research the matter further, with the objective of developing preventive measures and intervention models.



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