ORIGINAL ARTICLE
Monalisa de Cássia Fogaça1,
Werther Brunow de Carvalho2,
Paulo Cesar Koch Nogueira3, Luiz
Antonio Nogueira Martins4
Occupational stress and repercussions on the
quality of life of pediatric and neonatal intensivist
physicians and nurses
Estresse ocupacional e suas repercussões na qualidade de vida de
médicos e enfermeiros intensivistas pediátricos e neonatais
1. Psychologist Universidade Metodista
de São Paulo and a PhD from the
Psychiatry Departament, Universidade
Federal de São Paulo – UNIFESP – São
Paulo (SP), Brazil.
2. Adjunct Professor, Pediatrics
Department, Universidade Federal de
São Paulo – UNIFESP – São Paulo (SP),
Brazil.
3. Adjunct Professor, Pediatrics
Department, Universidade Federal de
São Paulo – UNIFESP – São Paulo (SP),
Brazil.
4. Adjunct Professor, Psychiatry
Department, Universidade Federal de
São Paulo – UNIFESP – São Paulo (SP),
Brazil.
Received from Universidade Federal de
São Paulo UNIFESP – São Paulo (SP),
Brazil.
Submitted on December 1st, 2008
Accepted on August 18, 2009
Author for Correspondence:
Werther Brunow de Carvalho
Universidade Federal de São Paulo /
Escola Paulista de Medicina
Departamento de Pediatria
Rua Botucatu, 598 - Vila Clementino
CEP: 04023-062 - São Paulo (SP),
Brazil.
Phone/Fax: 55 (11) 3081-9877
E-mail: wertherbru.dped@epm.br;
monalisa.cassia@uol.com.br
ABSTRACT
Objective: To investigate the relationship between work and quality of
life of doctors and nurses in pediatric
intensive care units and neonatal.
Methods: Cross-sectional study
with 37 doctors and 20 nurses. The
Job Content Questionnarie (JCQ) e
Effort-Reward Imbalance (ERI), and
World Health Organization Quality of
Life (WHOQOL-100) were used. The
correlation was estimated by Spearman
correlation coefficient.
Results: The effort is inversely correlated with the areas physical, psychological, level of independence, environment (p<0.01) and social relationship
(p<0.05). The reward is inversely correlated with the areas and psychological (p<0.05) level of independence
(p<0.01). Control over the work is
directly correlated with the physical
domain (p<0.05). The psychological
demands are inversely correlated with
the areas physical (p<0.05), psychological (p<0.01) and level of independence
(p<0.01). The physical demand is inversely correlated with physical areas,
level of independence, environmental
(p<0.01) and psychological (p<0.05).
Job insecurity is inversely correlated
with the psychological fields, level of
independence (p<0.05) and the environment (p<0.01). Support the supervisor is directly correlated with degree
of independence (p <0.05).
Conclusion: Doctors and nurses
showed high efforts, demands psychological, physical and job insecurity that
impact on quality of life.
Keywords: Intensive care units,
pediatric/manpower; Burnout, professional; Quality of life; Job satisfaction;
Questionnaires
INTRODUCTION
The concept of quality of life has been used in the fields of health and of
work to verify indicators found in a series of social contexts that might undergo interventions through health policies or business management strategies.(1)
Quality of life at work (QLW), has been a concern of man since the beginning of his existence. Under other titles, in other contexts, but it is always
directed towards facilitating or giving satisfaction and well being to workers
in the performance of their job.(2)
For Lacaz(3) there are different definitions for QLW, sometimes associating them to characteristics intrinsic to the technologies introduced and their
impact, sometimes to economic aspects such as salaries, incentives or even
connected to physical, mental and safety factors and the overall well being of
workers.
Rev Bras Ter Intensiva. 2009; 21(3):299-305
300
Fogaça MC, Carvalho WB,
Nogueira PCK, Martins LAN
In view of this, it is advocated that of the aspects explaining the definition and implementation
of quality (of life) work, is the control – encompassing the autonomy and power the worker has over the
working processes, and the reward – which is the
crucial link between self-regulating functions as selfesteem and self- efficacy and the framework of social
opportunity. (4)
One of the situations of physical and mental wear for
healthcare workers is the accumulation of two or more
jobs, causing an excessive work load.(5,6)
In the setting of intensive care units (ICU) the process of physical and mental wear, resulting from work
overload, may cause stress, harming the working conditions and the organizational relationships.
In view of this, some studies (7-13) show the outcomes of organizational aspects on the physical and
mental health of physicians and nurses working in
pediatric and neonatal ICU such as|: burnout, psychological changes generating professional stress,
alteration of salivary cortisol and amylase due to excessive noise, difficulties of team relationships with
family members and patients. Two recent Brazilian
studies that assessed intensivist nurses and physicians are also noteworthy. (14,15) They show that stress
in the occupational environment brought about job
dissatisfaction, affected physical health, shift of personnel, absenteeism and the state of the art technology in these units, in addition to high prevalence of
physicians burnout.
Thus, considering that the job is one of the factors
that may influence the quality of life of pediatric and
neonatal intensivist physicians and nurses, the purpose
of this study was to investigate relationships in work
conditions using the Job Content Questionnaire (JCQ)
and Effort-Reward Imbalance (ERI), and their effect on
the quality of life (World Health Organization Quality
of Life -WHOQOL-100).
METHODS
A cross sectional study including physicians and
nurses, who worked in the Pediatric (35) and Neonatal
(22) ICU of the Universidade Federal de São Paulo/
Escola Paulista de Medicina (UNIFESP/EPM) was
carried out. A total of 25 physicians and 10 nurses of
the Pediatric ICU and 12 physicians and 10 nurses of
the Neonatal ICU were assessed, constituting the total
sample of 57 professionals who accepted to spontaneously participate in the study. Inclusion criterion was
to be physician or nurse hired to work in the ICU and
resident physicians in clerkship at the ICU. Distribution of sample loss is in table 1. That completed questionnaires that were not returned caused this sample
loss (50%).
Table 1 – Number of professionals in the intensive care unit
invited to participate in the study
Physicians
Nurses
Accepted Did not Accepted Did not
accept
accept
Pediatric ICU
25
26
10
1
Neonatal ICU
12
28
10
4
Total
37
54
20
5
ICU – Intensive care unit
Research protocol was approved by the Research Ethics Committee UNIFESP/EPM (nº 1604/04) and all
participants signed a term of informed consent.
Participants replied to the Brazilian version of ERI,
JCQ and WHOQOL-100. The intensive care units
studied presented the following characteristics when the
assessment tools were applied (2005):
Pediatric Unit:
Reference: cardiac surgery – congenital heart disease,
neurosurgery, orthopedic surgery and liver transplantation.
Number of beds: 09
Medical staff comprised:
- 02 head physicians on day duty (total of 10
physicians)
- 01 day worker
- 02 physician on night duty, alternating every 15
days (total of 10 physicians)
- 01 residency coordinator, specialization and
graduation
- 01 head of the PICU
Hourly load of the physician team:
- 20h/week: 12h in care and 8 hours in scientific production
Residents
- 09 Residents
- Hourly load: 60 h/week
Nurses
5 nurses (1 in charge, 2 morning, 1 afternoon, 1
night: on duty)
7 hours work daily, hired by Hospital São Paulo
6 hours work daily as employees of the Universidade
Federal de São Paulo
Rev Bras Ter Intensiva. 2009; 21(3):299-305
Occupational stress and repercussions on the quality of life
Neonatal Unit
Number of beds: 20
Age: premature and newborn
Medical staff comprised
- Teachers: 6
- Assistants: 14
- 4th year trainees: 6
- 3rd year trainees: 7
- On duty: 13
- Medical staff hourly load
- Teacher – 40h/week
- Assistants either 20h or 40h/week
On duty – 12hours
Nurses
13 nurses (3 morning, 3 afternoon, 6 nightly, 1 nurse
from Continued Education)
Hourly load: those in charge work 7 hours, the others
work 6 hours and a 12/36 for night shifts.
Effort-Reward Imbalance (ERI)
Translated and adapted by Liliana Andolpho
Guimarães (UNICAMP),(4) is applicable to a large variety of occupational scenarios. It describes situations
where there is lack of reciprocity between effort and reward on the job, for instance high effort/low reward conditions, that cause ongoing reactions at emotional and
physiological levels.
For Siegrist(16) there are two sources of effort: extrinsic
(job requirements) and intrinsic (individual motivations
of the worker facing requirements), the latter follow the
same concept (“need of control” defined as a standard to
deal with job requirements and that has two variables:
vigor and immersion. Vigor is defined as active effort,
with high probability of reward (positive feedback) and
immersion as a state of exhaustive competition.
The instrument is comprised by 46 items, divided
into three parts: effort (6 items) reward (11 items) and
over-commitment (6 items on need for approval, 6 items
on competitiveness, 8 items on irritability and 9 items
on difficulty to disconnect from the job environment).
Response measure for each item is ranked in 4 levels (1=
does not bother me; 2 = bothers me a little; 3 = bothers
me a lot and 4= bothers me very much ; or 1 = I do not
agree at all; 2 = I do not agree; 3= I agree and 4= I fully
agree). Cronbach’s alpha value for extrinsic effort is 0.68,
for job reward is 0.78 and for over-commitment 0.78.(17)
Balance between effort and reward is given by the index
(Σ E÷[Σ R x c]), where E = extrinsic effort and R= reward
multiplied by the correction factor (c=0.545455). As a
result, the values lower or equal to 1, indicate balance
301
between effort and reward, while values higher than 1
indicate imbalance condition between effort and reward.
In relation to the over-commitment scale a value over
19 points is indicative of a higher risk of developing occupational stress.
Job Content Questionnaire (JCQ)
Prepared by Robert Karasek*, is comprised by 49 issues queries.
The variables analyzed were: control over the job (authority to decide and decision authority at macro level)
psychological demands of the job, physical effort; physical isometric load; physical demands of the work; job
insecurity; social support from supervisor; social support
from colleagues. The response measure for each item is
ranked in 4 levels: 1= I strongly disagree, 2 = I disagree,
3= I agree and 4= I strongly agree. Cronbach’s alpha coefficient generally accepted for women is 0.73 ands for
men = 0.74.(18)
World Health Organization Quality of Life
(WHOQOL-100)
Instrument used to assess the quality of life. It is based
upon the assumption that quality of life is a subjective
set (perception of the individual in question), multidimensional and comprised by positive (i.e. mobility) and
negative (i.e. pain) dimensions.
The WHOQOL Portuguese version was developed in
the WHOQOL Center for Brazil, in the psychiatry and
forensic sciences department of the Universidade Federal
do Rio Grande do Sul, under coordination of Professor
Marcelo Pio de Almeida Fleck PhD.
It comprises one hundred queries covering six domains: physical (I), psychological (II), level of independence (III), social relationship (IV), environment (V)
and spirituality/religiousness/personal beliefs (VI). These
domains are divided in 24 features. Each feature comprises four questions.
Replies to the WHOQOL questions are given in a
Likert type scale. Questions are replied by four types of
scales: intensity (nothing – extremely), capacity (nothing – completely), frequency (never – always) and assessment (very dissatisfied, very satisfied, very bad, and very
good). The score for each domain may be transformed
into a scale ranging from 0 to 100, with zero the worst
and 100 the best result.(19)
Mean and other central tendency measures of the
variations that comprise the instruments ERI, JCQ and
WHOQOL-100 were calculated. Associations were measured by the Spearman correlation coefficient.
Rev Bras Ter Intensiva. 2009; 21(3):299-305
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Fogaça MC, Carvalho WB,
Nogueira PCK, Martins LAN
RESULTS
Physicians were predominantly female (76%) with a
mean age 34.70 ± 7.11 years and had on the average
worked in the ICU for 7.17 ± 6.89 years. Nurses were
mostly female (95%), with a mean age of 31.55 ± 6.37
Table 2 – Descriptive analysis
Variables
ERI
Effort
Reward
JCQ
Job control
Psychological demand of work
Physical effort
Physical isometric load
Physical demand of work
Job insecurity
Support by supervisor
Support by colleagues
WHOQOL-100
Physical
Psychhological
Independence level
Social relationship
Environment
Spirituality/personal
beliefs/religiousness
Results
SD
8.07 ± 2.70
13.4 ± 2.89
2.7
2.89
34.04 ± 6.37
34.32 ± 5.40
6.56 ± 1.50
4.88 ± 1.19
11.44 ± 2.09
5.77 ± 2.25
11.67 ± 5.65
6.37
5.40
1.50
1.19
2.09
2.25
5.65
13.45 ± 2.68
13.91 ± 2.41
15.90 ± 2.67
14.73 ± 2.84
13.15 ± 1.97
16.14 ± 2.80
2.68
2.41
2.67
2.84
1.97
2.80
ERI - Effort Reward Imbalance; JCQ – Job Content Questionnaire;
WHOQOL-100 - World Health Organization Quality of Life ; Results
expressed in mean ± standard deviation
years and had on the average worked in the ICU for 5.85
± 4.40 years.
In the ERI analysis, mean values found for effort and
reward were 8.07 ± 2.7 and 13.46 ± 2.89, respectively.
In JCQ mean values for the variables were: control over
the job – 34.04 ± 6.37; psychological demand of work
– 34.32 ± 5.40; physical effort – 6.56 ± 1.50; physical
isometric load – 4.88 ± 1,19; physical demand of work
– 11.44 ± 2.09; job insecurity – 5.77 ± 2.25; support
by supervisor – 11.67 ± 5.65 and support by colleagues
– 11.54 ± 1;09. Mean values found in the domains that
comprise WHOQOL-100 were: physical- 13.45 ± 2.68;
psychological – 13.91 ± 2.41; level of independence 15.90 ± 2.67; social relationship – 14.73 ± 2.84; environment- 13.15 ± 1.97 and spirituality/religiousness/
personal beliefs (16.14 ± 2.80) (Table 2).
The ERI, JCQ and WHOQOL correlation assessed
by the Spearman correlation coefficient was significant
in some variables of the respective questionnaires (Tables
3 and 4).
ERI: Effort is inversely correlated with the physical (r
= - 0.57. p < 0.01); psychological (r = - 0.54, p < 0.01);
independence level (r = - 0.64, p < 0.01); social relationship (r = - 0.32, p < 0.05) and environment (r = - 0.44, p
< 0.01) domains. Reward is inversely correlated with the
psychological (r = - 0.32, p < 0.05) and independence
level (r = - 0.40, p < 0.01) domains.
JCQ: Control over job is directly correlated with
the physical (r=0.29, p<0.05). Psychological demand of
work is inversely correlated with the physical (r = - 0.31,
p < 0.05); psychological (r = - 0.36, p < 0.01) and independence level (r = - 0.30, p < 0.05) domains. Physical
Table 3 - Spearman correlation coefficient with variables of the Job Content Questionnaire - JCQ
DOM 1
DOM 2
DOM 3
DOM 4
Job control
0.295*
0.243
0.249
0.038
Psychological job demand
-0.316*
-0.366**
-0.302*
-0.237
Physical effort
-0.189
-0.125
-0.217
-0.159
Physical isometric load
-0.395**
-0.332*
-0.358**
-0.150
Physical job demand
-0.392**
-0.307*
-0.382**
-0.227
Physical job insecurity
-0.251
-0.331*
-0.312*
-0.217
Social support by supervisor
0.118
0.065
0.285*
0.150
Support by colleagues
0.031
0.190
0.022
0.206
DOM 5
0.212
-0.131
-0.195
-0.355*
-0.354**
-0.461**
0.062
0.241
DOM 6
0.020
0.000
0.500
0.047
0.061
-0.122
-0.167
0.216
*p<0.05; **p<0.01; DOM - domain
Table 4 - Spearman correlation coefficient with the variables effort and reward of the Effort Reward Imbalance - ERI
DOM 1
DOM 2
DOM 3
DOM 4
DOM 5
DOM 6
Effort
-0.571**
-0.544**
-0.641**
-0.322*
-0.448**
-0.119
Reward
-0.253
-0.327*
-0.406**
-0.161
-0.234
-0.118
*p<0.05; **p<0.01; DOM - domain
Rev Bras Ter Intensiva. 2009; 21(3):299-305
303
Occupational stress and repercussions on the quality of life
demand at work is inversely correlated with the physical
(r = - 0.39, p < 0.01); psychological (r = - 0.30, p < 0.05);
independence level (r = - 0.38, p < 0.01) and environment (r = - 0.35, p < 0.01) domains. Job insecurity is
inversely correlated with the psychological (r = - 0.33, p
< 0.0 5); independence level (r = - 0.31, p < 0.05) and
environment (r = - 0.46, p < 0.01) domains. Support by
supervisor is directly correlated with independence level
(r = 0.28, p < 0.05).
DISCUSSION
Association between occupational stress and quality
of life of the worker has been assessed in different studies.(20-24)
Quality of life at work of healthcare professionals,
mainly nursing, has been highlighted in current literature,(25-27) showing that physical and psychological
health are somewhat impaired: chronic pain, dissatisfaction with sleep, medication dependence and depression among others, when assessed by WHOQOLBREF and SF-36. In the population assessed we observed that effort on the job, interferes negatively in
relation to the physical, psychological and level of independence domains in the subjects assessed using the
WHOQOL-100.
The study by Stansfeld(21) shows that stress at work,
lack of reward and high demands have an impact on the
worker’s quality of life. Men and women who participated in the Stansfeld study presented with physical and
mental health problems due to the poor control over
work and lack of support by supervisor. In our study
psychological as well as demand at work had a negative
effect on the domains assessed using WHOQOL-100.
The variable job insecurity also presented a negative correlation in relation to the psychological, level of independence and environment domains.
In literature we found correlation studies(20-24) between JCQ, ERI and some instrument to assess quality
of life (WHOQOL, SF-36, SF-12), that substantiate our
data, showing that less job control, great psychological
demands and poor social support have an impact on the
worker’s quality of life.
We observed that support by the supervisor is correlated to a higher level of independence l which was also
acknowledged by Probst,(24) who verified that professionals who participate in decisions tend to a lower turnover
and less indifference in behavior.
Recent studies by Rusli(28) and LaMontagne,(29)
showed that great demand at work is directly related to
stress and that women present higher prevalence of stress
at work and depression.
Although no comparison between genders was carried out for level of tension and quality of life at work,
the studied population was mostly of the female gender
and in a certain way studies mentioned above may serve
as reference for comparison of our sample.
Study limitations
This study makes a descriptive outline, with frequency survey carried out in a single center and with a small
sample. Fifty percent of the sample did not return the
questionnaires which may have jeopardized results.
CONCLUSIONS
Relationships between work conditions and quality of
life of intensivist pediatric and neonatal physicians and
nurses assessed in this study are impaired. Physicians as
well as nurses present high efforts, psychological, physical demands and job insecurity that affect quality of life
at work.
Our study stresses the need to carry out longitudinal studies to assess the work conditions and their aftermaths on the quality of life of critical care pediatric and
neonatal physicians and nurses.
RESUMO
Objetivo: Investigar as relações entre trabalho e qualidade de vida de médicos e enfermeiros em unidades de terapia
intensiva pediátrica e neonatal.
Métodos: Estudo transversal com 37 médicos e 20 enfermeiros. O Job Content Questionnarie (JCQ), Effort-Reward
Imbalance (ERI), e World Health Organization Quality of Life
(WHOQOL-100) foram utilizados. A correlação foi estimada através do coeficiente de correlação de Spearman.
Resultados: O esforço é inversamente correlacionado
com os domínios: físico, psicológico, nível de independência, meio ambiente (p<0,01) e relação social (p<0,05). A recompensa é inversamente correlacionada com os domínios
psicológico (p<0,05) e nível de independência (p<0,01).
Controle sobre o trabalho é diretamente correlacionado com
o domínio físico (p<0,05). A demanda psicológica é inversamente correlacionada com os domínios físico (p<0,05),
psicológico (p<0,01) e nível de independência (p<0,05). A
demanda física é inversamente correlacionada com os domínios físico, nível de independência, meio ambiente (p<0,01)
e psicológico (p<0,05) . Insegurança no trabalho é inversamente correlacionada com os domínios psicológico, nível de
Rev Bras Ter Intensiva. 2009; 21(3):299-305
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Fogaça MC, Carvalho WB,
Nogueira PCK, Martins LAN
independência (p<0,05) e meio ambiente (p<0,01). Suporte
do supervisor é diretamente correlacionado com nível de independência (p<0,05).
Conclusão: Médicos e enfermeiros apresentaram altos
esforços, demandas psicológicas, físicas e insegurança no tra-
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