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Conteúdo (article):

Burnout Syndrome in Family Health Strategy Managers

Alice Mariz Porciuncula. Secretaria Municipal de Saúde do Rio de Janeiro (SMS-RJ) – Rio de Janeiro, Brasil. alicemarizpresf@gmail.com
Sandra Aparecida Venâncio de Siqueira. Fundação Oswaldo Cruz (Fiocruz), Escola Nacional de Saúde Pública Sérgio Arouca (ENSP) – Rio de Janeiro, Brasil. sandravs@ensp.fiocruz.br
Cosme Marcelo Furtado Passos da Silva. Fundação Oswaldo Cruz (Fiocruz), Escola Nacional de Saúde Pública Sérgio Arouca (ENSP) – Rio de Janeiro, Brasil. cfpassos@ensp.fiocruz.br

RESUMO
Este artigo analisou a Síndrome de Burnout (SB) entre os gerentes da Estratégia de Saúde da Família (ESF) no Município do Rio de Janeiro e suas associações entre os fatores que influenciam a presença/ausência da SB nesses profissionais. Com natureza descritiva, ele utilizou um questionário, composto de duas partes: 1) perfil do gerente e fatores que possam influenciar a presença de Burnout; 2) Inventário Maslach Burnout Inventory. A taxa percentual de retorno foi de 63,5% (143) dos 225 enviados. Os gerentes da ESF são em geral, enfermeiros (68,6%), jovens (74,5% até 39 anos), do sexo feminino (76,9%) e que atuam na gerência há menos de 5 anos (85,2%). A presença da SB foi identificada em 11,2% dos gerentes. Os fatores de natureza organizacional foram os que obtiveram maior número de variáveis com associação. Esses dados apontam para necessidade de realização de mudanças nas práticas organizativas de serviços e de mudanças nos processos de trabalho. A realização de outros estudos, que aprofundem estas questões, pode contribuir neste sentido.
Palavras-chave: Burnout, Atenção Primária à Saúde, Gestor de saúde.

ABSTRACT
This paper analyzed the Burnout Syndrome (BS) among the managers of the Family Health Strategy (ESF) in the city of Rio de Janeiro and its associations with factors that influence the presence/absence of BS among these professionals. This is a descriptive study that used data from a questionnaire consisting of two parts: 1) manager profile and factors that could influence the presence of Burnout; 2) Maslach Burnout Inventory. The return rate was 63.5% (143) of the 225 questionnaires sent. The ESF managers are generally nurses (68.6%), young (63.6% under 39 years) female (76.9%), who have acted as managers for less than 5 years (85.2%). A BS presence was identified in 11.2% of the managers. The factors of an organizational nature were those that obtained the highest number of variables with an association. These data point to the need to make changes in the organizational practices of services and changes in work processes. Further studies on these issues can contribute to this.
Keywords: Burnout, Primary Health Care, Health Manager.
INTRODUCTION
This study analyzed the presence of Burnout Syndrome (BS) among the managers of the Family Health Strategy (ESF) in the city of Rio de Janeiro. The position of professional manager was established in the Municipality as part of the of Primary Health Care (PHC) Management Model Reform conducted by the Municipal Health Secretariat (SMS) in 2009 through the incorporation of management contracts between the SMS and Social Organizations , . The manager must coordinate the means and processes, so the organization fulfills its purpose . It differs from the role of the health manager, who is in charge of directing the health system in the different spheres of government .
The advancement in the conceptual distinction between these functions has not been accompanied by clear definitions of the role and attributions of managers , although their activity is essential for the health production process . Besides the strong pressure for short-term results, low salaries and insufficient numbers of professionals, the development of this function can lead to frustration, anguish, failure and exhaustion, leading to physical illness .
Among other aspects, chronic work stress due to disillusionment, discouragement and intense frustration with work, in which the worker, who was previously extremely involved with the service and with clients, loses energy and gives up, is one of the main characteristics of the BS . Its presence among workers can influence the quality of care provided , , , since well-being and professional satisfaction are important factors for professionals to perform their functions more efficiently.
Maslach et al. are among the authors who have studied Burnout syndrome with great frequency. They believe that this syndrome stems from the presence of three elements: emotional exhaustion, depersonalization and low professional achievement . Emotional exhaustion is its most obvious manifestation, involving organizational and individual factors. It is a response to chronic stress caused by work, which accompanies the feeling of not having the emotional resources to address stressful situations13, . The declining professional achievement is related to disbelief in the value of their work activity, low self-esteem, dissatisfaction and demotivation, referring to the negative self-assessment of professionals regarding the quality of the work performed. The subjects become unhappy with themselves and dissatisfied with their achievements at work14, . Besides the personal characteristics, aspects related to poor working conditions, due to the recent transformations in the world of work, expressed among other aspects by the productive restructuring, mass layoffs, precariousness and increasing demands of workers are described as the main determinants of the Syndrome13.
In some countries, the diagnosis of Burnout allows the worker to receive financial compensation, as well as counseling, psychotherapy and rehabilitation. In others, however, the condition is not recognized as a work-induced disease . In Brazil, the Ministries of Health and Social Security consider the BS as a work-related occupational disease , . However, as Zorzanelli points out, it remains hardly known in the medical and social security spheres.
Recent studies on the presence of BS in the ESF identified their presence among Community Health Workers (29.3%) and PHC professionals (7%) in the city of Aracaju, Sergipe.
Our study seeks to identify factors associated with the development of BS among the managers of the ESF of the Municipality of Rio de Janeiro and would contribute to the reflection on the position of manager and the processes in which he/she is involved. Thus, we are led to think of new ways to prevent and take care of the sickness of this professional, as well as its consequences.
METHODS
This is a cross-sectional, descriptive study carried out in the entire territory of the city of Rio de Janeiro with managers working in health facilities with ESF in the municipality at the time of their development, excluding those working in health facilities without the presence of the ESF, as well as those who did not respond to the questionnaire.
The questionnaire used consisted of two parts: one containing questions aimed at outlining the profile of the interviewed managers and identifying factors that could influence the presence or absence of the BS, and another containing the Maslach Burnout Inventory (MBI).
The first part consisted of 39 questions regarding the personal and professional characteristics of the participants (age, gender, marital status, children, profession, working in another job, qualification, length of service, personality, appearance of symptoms), those of the facilities (number of teams, presence of another manager, physical conditions, frequency of conflicts and presence of armed violence in the work territory) and possible triggering or protective Burnout agents (deadlines, responsibilities, community expectations, demands, workload, working outside work hours, valorization, stability, ascension, remuneration, institutional support, autonomy, instruments of support and respect for decision-making). These variables were chosen considering their possible relationship with the BS shown in several studies on the subject13,14,28.
MBI, the second part of the questionnaire, was created by Maslach and Jackson15 in 1981 to evaluate the BS. This scale was chosen because of its extensive use in studies on the subject in the world and because it is a material already validated in Brazil. Approximately 90% of BS studies used MBI or some adapted versions of the MBI14.
The Scale contains three realms to evaluate the relationship of workers with their work: Emotional Exhaustion (9 questions), Professional Realization (8 questions) and Depersonalization (5 questions). For its use in the research, the questionnaire validated by Tamayo10 was adopted. This instrument contains 22 questions, with 5 possible answers, as follows: “Never” – 1 point, “Sometimes in the year” – 2 points, “Sometimes in the month” – 3 points, “Sometimes in the week” – 4 points and “Daily” – 5 points. The psychometric properties of the scale have a satisfactory internal consistency of the three realms, presenting a Cronbach’s alpha ranging from 0.71 to 0.90 . Thus, the score attributed to each varied between the realms according to the number of questions and the score assigned by each respondent to the questions: Emotional Exhaustion (9 to 45); Professional Achievement (8 to 40) and Depersonalization (5 to 25).
As the inventory creators guide, we evaluated each realm individually15. Statistically, cut-off points were set as “low”, “moderate” and “high”, based on the low, medium and high tertiles of the score distribution, as recommended by the MBI manual16, described in Table 1.
Tabela 1
The questionnaires were distributed face-to-face or online submission. The online version, identical to the paper questionnaire, was built with Google Drive and aimed to increase the participation of the target audience, given the difficulty observed among the managers of making time available for completion. Telephone contacts with managers and the resubmission of the questionnaires were made up to four times to reduce losses. At the time of the survey, 225 ESF managers were operating the Municipality of Rio de Janeiro, and the instrument was forwarded to all. The return was 63.5%, that is, a total of 143 participants.

SPSS was the software used to analyze the data, distributed in a table with frequencies (absolute and relative) and in summary measures (minimum, maximum, mean, standard deviation, variance and coefficient of variation). Associations were assessed using the Chi-square independence test (2) and, when necessary, Fisher’s exact test. A significance level of 5% was adopted. Because it is not a probabilistic sample, we do not intend to generalize the findings of this study, but only to test the association between the variables in the sample.
The study was submitted to and approved by the Research Ethics Committees of the Sérgio Arouca National School of Public Health (ESNP) and the Municipal Health Secretariat of Rio de Janeiro, and the consent form was shown to and signed by the participants.
RESULTS
The managers of the ESF facilities are generally young people under 39 years of age (74.5%), female (76.9%), almost half is married (49.7%) and most have children (53.8%). Nursing is the prevailing profession (68.6%) and the work as a manager is the only employment relationship (73.4%). The experience with management is recent, between 2 and 5 years (50%), and 35.2% have been engaged in this activity for less than two years, and 55.9% work in an area experiencing armed violence.
Tabela 2
The presence of the BS, where the individual shows the three realms at a critical level14, , was identified in 11.2% of the managers.
Table 3 shows the findings regarding each BS realm found among the participants. Of these, 29.4% showed the emotional exhaustion dimension at a high level, 25.2% depersonalization at high levels and 32.8% professional achievement at a critical level.
Tabela 3
Contrary to other studies that perform data cross-referencing between variables and realms separately, we have chosen a linear combination with the results regarding the presence/absence of Burnout, since we intend to identify possible explanations for the syndrome in its total context. The explanatory variables were clustered into common themes to facilitate reading and understanding, as follows: individual characteristics, characteristics of health facilities and organizational characteristics. In Table 4, we show those in which we find an association.
Tabela 4
Concerning the individual characteristics, the variables were: age, sex, marital status, children, profession, presence of another job, professional experience, qualification, personality (overly involved, idealist, controlling and competitive), presence of symptoms after assuming the position and the three most commonly found symptoms (anxiety, insomnia and blood pressure problems).
There was an association between age (p=0.043), anxiety (p=0.019) and the “overly involved” personality (p = 0.050). The syndrome was present among young managers (under 40 years) and among those reporting the onset of anxiety after taking office, a fourth evidenced BS. Approximately 30% were identified with BS among those who did not consider themselves overly involved, while only 9.8% presented burnout among those who considered themselves overly involved.
Regarding the characteristics of the facilities, the following variables were used: number of teams, the presence of another manager, physical conditions, the experience of conflicts and presence of armed violence in the work territory. A relationship was found only between the last two: the experience of conflicts (p=0.014) and presence of armed violence (p=0.007).
The conflict situation is experienced (often/always) by 66.4% of the managers. Of these, 15.8% evidenced BS, which was seven times higher than those who did not experience conflict at the same frequency. The percentage of BS among those managers who worked (often/always) in areas marked by armed violence (55.9%) was 17.8% and of 3.2% among those who did not work.
The following variables were tested in the organizational characteristics: deadlines, responsibilities, demands, valuation, ascension, institutional support, autonomy, support tools, community expectation, respect for decision making, workload, work beyond working hours, stability and remuneration. Only the last four variables were not associated with BS.
There was a more significant presence of Burnout in the group of managers who found that demands and responsibilities required are above/far above their capacity to respond and in those who consider the deadline for the tasks to be insufficient.
Most of the managers (55.3%) identified a great deal of professional autonomy to carry out their work, which is an essential aspect for the professional to work satisfactorily. Among these, the BS was 3.8%; among those who believe that they do not have autonomy or describe it as partial, the presence of BS was 20.3%. Managers feel (often/always) supported by management – 62.5% by Social Organizations (OS) and 68.5% by the Planning Coordination Office (CAP) – and trust in these organizational levels (74.8% % in the OS and 71.3% in the CAP). The presence of the Syndrome was lower in these groups than among those who do not feel supported/do not trust.
Large associative impacts were found regarding professional valuation. No cases of BS were found in the group that always/frequently feels valued. In contrast, all cases of the disease were among those who never, rarely or occasionally feel valued. Only 22.4% of the participating managers believe in the possibility of professional advancement, of which none developed the Syndrome.
DISCUSSION
The presence of BS can vary according to the definition/methodology adopted. In this study, based on the definition of Ramirez23, the percentage of 11.2% was found, similar to that observed in other studies on Brazilian PHC. Trindade24 identified the percentage of 6.9% Burnout among ESF professionals in Santa Maria (RS); Silveira et al. found 18% among the PHC workers in Porto Alegre (RS)25. Silva et al21 observed 7% of professionals in the PHC network with BS, and Poletto et al26 identified 9.5% of Burnout among municipal health managers in the state of São Paulo. These findings lead us to suppose that the rates found in ESF managers of Rio de Janeiro may be above the national average for this level of health care.
However, the existence of several scales to identify the syndrome and indications of cut-off points makes this comparison difficult. Also, no national and international studies on Syndrome among PHC managers were identified.
It is also necessary to understand the effects of BS presence among the managers for the operation of the ESF. The lack of energy to fulfill their tasks and generate the necessary results compromises work, which often ends up leading these managers to take leave or abandon the service, increasing turnover in managerial positions. Also, people with Burnout can negatively influence the work environment, causing conflicts and hindering the development of tasks13.
Regarding explanatory variables, few personal characteristics were associated with BS. Our findings reinforce Maslach et al.’s argument13 that describes Burnout as a more social than an individual phenomenon.
One of the few variables with a positive association, age is pointed out in the literature as an essential aspect in the onset of BS13,27. The existence of BS in relatively young people, such as we have found, is explained in studies because of the worker’s little experience in this age group. Besides possible insecurity, it is common for young people to have great idealism, as well as anxieties and desires, which generate high expectations about work. However, the reality found hinders these expectations, bringing frustration, stress and discouragement13,24.
There is still no consensus in the literature regarding the link between BS and gender. Some studies report a higher frequency in men and others in women13. No relationship between BS and gender was identified in this study. Likewise, we also did not find any association between BS and profession. A similar result had already been described by Trindade24. This data may indicate that the syndrome may be more associated with the attributions exercised in the managerial position than with its formation.
Although several authors13 point out that the existence of more than one work relationship may increase the probability of developing BS, by increasing overload, no such relationship was found in this study. Thus, as in the study of Trindade24, no association was found between PHC length of service and the emergence of BS.
Although the qualification of health management professionals is indispensable to operate complex systems such as the Unified Health System4, we did not identify an association between the qualification and presence of BS in managers, which does not rule out its relevance, since the lack of qualification possibly impairs the effectiveness of professionals. As Maslach et al13 point out, the workload is unbalanced not only when there are many tasks to be fulfilled, but also when the worker does not have the necessary qualities to perform a particular service. The level of involvement of professionals with work is described in the literature as a factor that influences the presence/absence of BS. In general, workers who evidence in their personality characteristics of greater involvement, with extreme dedication, motivated by their ideals end up overworking, often coming to exhaustion and are disappointed when they do not achieve the expected results13,28. Our findings do not corroborate with this vision; among the managers who consider themselves to be overly involved, the percentage of BS identified is significantly lower than among those who did not identify themselves as such. The reasons for this difference should be better understood by other studies.
The association between anxiety and BS identified in this study deserves attention on the part of the worker’s health. Many managers identify their appearance after assuming the position of ESF managers, which leads us to two hypotheses: anxiety could induce illness due to burnout, or among the symptoms brought about by BS, in the ESF managers, anxiety can be the most frequent symptom. However, Maslach et al13 show that the presence of the Syndrome can lead to the development of mental health-related problems, among them anxiety. Regarding the characteristics of the facilities, we find a connection with the BS in only two points: the experience of conflicts and the presence of armed violence. The physical conditions were not shown to be linked to the BS, as well as the type of facility, number of teams and the presence of another manager or director.
Conflict often produces negative feelings of frustration and hostility and reduces the possibility of social support13. The feeling of insufficiency brought about by this type of event possibly triggers emotional instability and a self-perception of impotence, causing these professionals to minimize empathy by users as a type of defense, thus configuring the Syndrome. Data combination in this study confirmed the connection of this variable with BS.
In the case of Rio de Janeiro’s PHC, considering the principle of equity, many teams attend areas of significant social vulnerability with the constant presence of armed individuals. Work in these territories often exposes workers to violence, resulting in the suspension of the programmed activities, which triggers in the professionals the feeling of not performing the service correctly. This difficulty experienced by PHC workers was described by Polaro29.
This scenario compromises the physical and mental health of these workers, besides leading them to feelings of fear, anxiety, impotence and frustration. Lancman24 adds that faced with armed violence, professionals feel exposed, and fearing for their physical integrity, are concerned about possible reprisals and lament the invisibility of their efforts. This set of factors may explain the relationship between BS in ESF managers and the presence of armed violence in the territory of action found in this study.
It is worth noting that although many teams work in a territory with armed violence in the country, studies are still rare. It was not possible to locate papers that studied the relationship between the presence of armed violence and the existence of the Syndrome, possibly because the countries that have been studying BS for a longer time do not coexist with this experience.
Organizational characteristics were those with the highest association with BS, corroborating the view of Maslach et al13. This is because the organization expects the employee to devote increasingly more time, effort, talent and flexibility to work without having to secure adequate career opportunities, stability and security13 reciprocally.
Among the organizational variables, the weekly workload and the uncontracted work beyond working hours were not associated with BS. However, according to Schaufeli et al.16, these factors would be linked to the BS, since not having sufficient time to rest and regenerate the reduced energy aggravates the impact of exhaustion generated by the imbalance between demand and available resources.
The managers’ perception that deadlines are not always enough to carry out the proposed tasks is echoed in the study by Maslach et al.13, who affirm that the pressure for meeting deadlines is strongly and consistently associated with BS. The excessive demand and responsibility beyond their ability, on a routine basis, contributes to the professionals developing a sense of incompetence13,28. This explains the association identified between Burnout and ESF managers who consider the deadlines insufficient and the demands and responsibilities beyond their ability.
The relationship between the syndrome and the lack of management tools available to support the work can be explained according to Maslach et al.13 because of the excess efforts to perform the tasks, which induces professionals’ exhaustion. Likewise, the association with the lack of autonomy found in this study is also shared by Trigo28, who considers this variable as one of the explanatory factors of high Burnout rates. Workers feel that they have a great responsibility, but they do not have the authority to take the actions they deem effective, leading to a feeling of inability to generate the results that are demanded of them and a feeling of incompetence13.
According to Feliciano24, there is a direct relationship between organizational support and BS. This association was shown in this study in the combination of data. Our attention was drawn to the fact that the level of confidence in their supporters is low among BS-affected participants. In this case, the lack of trust in institutional support can have an opposite effect to which it is proposed, generating exhaustion, coldness and professional dissatisfaction. According to Maslach et al.13, the support of supervisors is especially more important than the team’s support. Trigo28 reports that when organizational support is deficient, it causes feelings of helplessness, mistrust, disorientation and disrespect.
On the other hand, the low presence of Syndrome among professionals who feel supported may indicate that institutional support provided on a regular basis can generate trust, and possibly serve as a protective factor against BS for managers. Benevides-Pereira14 say that the existence of people with whom one can count, trust and reflect in the occupational environment has been shown by several studies as a possible way of coping with BS.
In the same way, professional appreciation and the possibility of professional advancement are essential for the development of good work. Their absence leads professionals to high turnover in the labor market13,31 and the increased probability of developing emotional exhaustion and depersonalization24. These findings are similar to those identified in this study, where Syndrome was more present among those managers who did not consider themselves valued and did not believe in the possibility of professional growth.
The lack of association between job stability and BS is worth mentioning because they are stress-generating elements. One possible explanation is the contradiction that the existence of special contracts entails for the public sector. According to Victora et al.24, while these contracts facilitate the admission and dismissal of employees, they allow more competitive remunerations vis-à-vis the labor market.
The Municipality of Rio de Janeiro, through a partnership established with the Social Organizations, pays the outsourced PHC professionals a higher salary than the one received by public servants24. We hypothesize that this fact can generate compensation for the situation of instability, equalizing the weight of these variables and limiting their effects on the explanation of the factors identified by the managers for the onset of the syndrome.
On the other hand, there is a feeling that the salary of the manager is not fair given the complexity and social relevance of the position, as well as compared to the salary of other professionals such as doctors, who are responsible for smaller territories and population size. Such a wage discrepancy deviates from the law of the market, where greater professional competence generates more significant financial investment for its payment6. This feeling of injustice between unequal workload and compensation is pointed out by Maslach et al13 as one of the factors that contribute to the Syndrome.
The associated variables were mostly related to organizational issues, indicating the need for municipal management to develop measures that can minimize these problems, to ensure the physical and mental health of its managers and promote their engagement and satisfaction with work12, thus reducing the possibility of professionals developing Burnout25.
To this end, it is necessary to reorganize the work process to adjust the work volume to the workload and encourage the establishment of a cooperative and creative work environment, with fair and adequate rewards and recognition mechanisms, so that professionals feel valued and satisfied7,13.
Family Health Strategy managers are immersed in a territory that produces and reproduces relationships of power and production of subjects, which requires these professionals to understand the political, social and cultural processes of their territory. This poses several conflicts to these professionals, including ideological ones24, often causing suffering and dissatisfaction, because of the dissonance between expectations and the reality imposed by the organization of work.
In this context, the permanent provision of training processes is a fundamental mechanism, since it enables professionals to produce together a reflection and new meanings for work, in its complexity and contradictions, which can contribute to the more integrated management and greater professional engagement12,34.
These issues cannot be understood dissociated from the effects of the transformations of the world of work on health work, marked by the precariousness of the ESF labor relationships and, according to several authors24,25, its most visible face is in the weak employment links and changes in the organization and the meaning of work.
Given this, it is suggested that further studies be performed to understand the syndrome in this specific group better. An essential aspect of this process is to understand the consequences of armed violence in the territory on the health of ESF professionals and health practices since they are not dissociated from the way society reproduces38. These efforts could support the implementation of prevention measures and the development of an intervention plan for those already affected by Burnout.
Finally, the limitations of this study should be emphasized: the first one concerns the difficulty of comparing the results found with the literature, either by the way the authors chose to show data, displaying only results referring to the BS realms, or by the variety of existing scales for the identification of the syndrome, or even the variation between cut-off points. Failure to identify studies performed with ESF/PHC managers also hindered comparisons.
Another limitation refers to respondents, as only 63.5% of the managers answered the questionnaire. It may be that those who feel healthy have not had an interest in participating in the research because they did not see benefits in their participation, which may have influenced the research results. Finally, sectional studies are portraits of the moment, not allowing the understanding of Syndrome behavior over time.

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