Burnout in the staff of a chronic care hospital

Merino-Plaza, Maria Jose; Carrera-Hueso, Francisco Javier; Arribas-Boscá, Nuria; Martínez-Asensi, Amparo; Trull-Maravilla, Emilia; Fikri-Benbrahim, Narjis

doi:10.11606/S1518-8787.2018052000242

Brasil

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Original Article • Rev. Saúde Pública 52 • 2018 • https://doi.org/10.11606/S1518-8787.2018052000242 linkcopy

Burnout in the staff of a chronic care hospital

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

OBJECTIVE To estimate the prevalence of Burnout in a medium or long-stay hospital, to monitor its evolution and to highlight the importance of cut-off points used to avoid distortions in the interpretation of the results.

METHODS Two cross-sectional studies (2013–2016) were carried out, applying the Spanish version of the Maslach Burnout Inventory to the staff of a chronic care hospital (n = 323). Result variables were: Burnout prevalence and a high degree of affectation of the subscales and predictor variables: sociodemographic characteristics and factors that trigger and modulate the syndrome. The association between variables was quantified using odds ratio.

RESULTS The participation rate went from 31.5% to 39.3%. The professionals presented a mean level of Burnout in both moments, observing a lower degree of affectation of the depersonalization subscales and personal accomplishment in the 2016 cut-off. The average score of the subscales in 2016 was 21.5 for emotional fatigue, 4.7 for depersonalization and 41.7 for personal fulfillment, compared to the values of emotional fatigue = 21.6, depersonalization = 6.9 and personal fulfillment = 36.3 obtained in 2013. The emotional fatigue score was slightly higher than the mean value of the national studies (19.9), while the rest of the values were similar to the mean values of the studies considered. The prevalence of Burnout and the interpretation of the results varied significantly according to the cut-off points considered. In both studies, sociodemographic variables showed little significance, while social support and interpersonal relationships were associated with the degree of burnout among professionals.

CONCLUSIONS Our prevalence of Burnout was similar to that of other studies consulted, although the emotional component is more marked in our environment. The interpretation of the results varied significantly according to the cut-off points applied, due to the cross-cultural differences.

DESCRIPTORS Burnout, Professional, classification; Patient Care Team; Hospitals, Public, manpower; Working Conditions; Socioeconomic Factors

2013 Group	2016 Group	Population characteristics of survey participants		2013	2016	Statistical significance
Mean (SD)/n (%)	Mean (SD)/n (%)	Population characteristics of survey participants		(n = 100)^a a Mantel-Hanzel test.	(n = 101)^a a Mantel-Hanzel test.	p (95%CI)
Age: 44.25 (8.2)	Age: 48.4 (8.7)	Age (years) - mean (SD)		45.1 (8.96)	47.2 (9.68)	p = 0.50
Female: 262 (81.2)	Female: 251 (80.4)	Gender - n (%)				p = 0.71
Type of contract	Type of contract		Women	80 (81.6)	82 (83.7)
Fixed: 78 (24.2)	Fixed: 80 (25.6)	Type of contract - n (%)				p = 0.99^a a Mantel-Hanzel test.
Non-fixed: 245 (75.8)	Non-fixed: 232 (74.4)		Fixed:	38 (38.0)	41 (41.4)
Professional category	Professional category		Interim	53 (53.0)	48 (48.5)	OR = 0.84 (0.47–1.51)
Doctors: 25 (7.7)	Doctors: 25 (8)		Accumulation of tasks	1 (1.0)	0 (0.0)	Not available for evaluation
NUG: 96 (29.7)	NUG: 92 (29.5)		Eventual	8 (8.0)	10 (10.1)	OR = 1.16 (0.41–3.24)
Nursing Assistant: 91 (28.2)	Nursing assistant: 89 (28.5)	Professional category - n (%)				p = 0.02^a a Mantel-Hanzel test. .^b b p < 0.05
Janitors: 42 (13)	Janitors: 41 (13.1)		Doctors	6 (6.1)	16 (16.0)
Others 69 (21.4)	Others 65 (20.7)		NUG	39 (39.4)	44 (44.0)	OR = 0.42 (0.15–1.19)
			Nursing assistant	37 (37.4)	33 (33.0)	OR = 0.33 (0.12–0.95)
			Janitors	11 (11.1)	5 (5.9)	OR = 0.17 (0.04–0.70)
			Others	6 (6.1)	2 (2.0)	OR = 0.13 (0.02–0.80)
		Years of experience - n (%):				p = 0.03^a a Mantel-Hanzel test. .^b b p < 0.05
			< 5	8 (8.0)	4 (4.0)
			5–9	20 (20.0)	17 (17.0)	OR = 1.70 (0.44–6.65)
			10–14	26 (26.0)	19 (19.0)	OR = 1.46 (0.38–5.57)
			15–19	21 (21.0)	21 (21.0)	OR = 2.00 (0.52–7.67)
			≥ 20	25 (25.0)	39 (39.0)	OR = 3.12 (0.85–11.4)
		Years of experience - n (%):				p = 0.90^a a Mantel-Hanzel test.
			< 5	42 (42.4)	40 (39.6)
			5–9	29 (29.3)	30 (29.7)	OR = 1.09 (0.56–2.12)
			10–14	18 (18.2)	8 (7.9)	OR = 0.47 (0.18–1.19)
			15–19	5 (5.1)	7 (6.9)	OR = 1.47 (0.43–5.01)
			≥ 20	5 (5.1)	7 (6.9)	OR = 1.47 (0.43–5.01)
		Marital status - n (%):				p = 0.43^a a Mantel-Hanzel test.
			Single	19 (19.0)	14 (14.6)
			Married or with family	66 (66.0)	67 (69.8)	OR = 1.38 (0.64–2.97)
			Divorced	12 (12.0)	12 (12.5)	OR = 1.36 (0.47–3.90)
			Widowed	2 (2.0)	3 (3.1)	OR = 2.04 (0.30–13.85)
		Firings in the last year - n (%)		23 (23.0)	17 (16.8)	p = 0.27
		Chronic disease - n (%)		30 (30.6)	25 (24.8)	p = 0.36
		Received specific training - n (%)		71 (72.4)	61 (61.0)	p = 0.09
		Feels valued by patients - n (%)		71 (83.5)	80 (92.0)	p = 0.09
		Feels appreciated by family members - n (%)		62 (73.8)	72 (86.7)	p = 0.04 ^b b p < 0.05
		Feels appreciated by co-workers - n (%)		78 (85.7)	78 (84.8)	p = 0.86
		Feels appreciated by bosses - n (%)		59 (66.3)	64 (68.8)	p = 0.72
		What is your overall appreciation of your work experience? - mean (SD)		7.73 (1.78)	7.55 (1.72)	p = 0.48
		Do you consider yourself an optimist? - mean (SD)		7.79 (1.91)	7.83 (1.65)	p = 0.87
		What is the value of your earnings in relation to the work you do? - mean (SD)		4.79 (2.51)	4.89 (2.29)	p = 0.77
		Do you believe that you perform well in your daily work (self-efficacy)? - mean (SD)		8.43 (1.41)	8.37 (1.16)	p = 0.74
		Do you feel supported in your personal life (friends, family etc.)? - mean (SD)		8.55 (1.65)	8.90 (1.17)	p = 0.09

Subscales		2013	2016	Difference (95%CI)^* * Differences = 2016 minus 2013; (t-Student).	Statistical significance p^* * Differences = 2016 minus 2013; (t-Student).
Emotional fatigue	Mean (SD)	21.6 (10.7)	21.5 (12.9)	-0.07 (-3.37–3.23)	-
	33 percentile	17	14	-3.0 (-0.3–6.3)	-
	66 percentile	25	26	1 (-2.3–4.3)	-
Depersonalization	Mean (SD)	6.9 (5.2)	4.7 (5.2)	-2.20 (-3.65– -0.76)	0.003
	33 percentile	4	4	0 (-1.44–1.44)	-
	66 percentile	8	6	-2 (0.56–3.44)	< 0.05
Personal fulfillment	Mean (SD)	36.3 (8.0)	41.7 (6.8)	5.34 (3.27–7.40)	< 0.001
	33 percentile	38	46	8 (5.94–10.1)	< 0.05
	66 percentile	34	40	6 (3.94–8.06)	< 0.05

Normative criteria	Subscales	Cut-off points	Degree of affectation	2013	2016	Significación estadística p^* * Differences in the high degree of affectation of the subscales and the prevalence of Burnout (2016 versus 2013) (Chi-square test).
Normative criteria	Mean (SD)	Cut-off points	Degree of affectation	n (%)	n (%)
Cut-off points per tertiles, as recommended by Maslach Cut made in 2013 (n = 100)	Emotional fatigue 21.6 (10.7)	≤ 17	Low	37 (37.0)	46 (45.5)	0.69
		18–25	Medium	31 (31.0)	20 (19.8)
		> 25	High	32 (32.0)	35 (34.7)
	Depersonalization 6.9 (5.2)	≤ 4	Low	33 (33.0)	57 (56.4)	0.007
		5–8	Medium	35 (35.0)	28 (27.7)
		> 8	High	32 (32.0)	16 (15.8)
	Personal fulfillment 36.3 (8.0)	> 38	Low	34 (34.0)	75 (74.2)	< 0.001
		34–38	Medium	33 (33.0)	14 (13.9)
		≤ 34	High	33 (33.0)	12 (11.9)
	Burnout	n (%)		5 (5.0)	3 (3.0)	0.46
Cut-off points of Maslach and Jackson EEUU, 1986 (health personnel) (n = 11,067)	Emotional fatigue 21.0 (10.7)	< 17	Low	32 (32.0)	41 (40.6)	0.24
		17–26	Medium	41 (41.0)	25 (24.8)
		≥ 27	High	27 (27.0)	35 (34.7)
	Depersonalization 8.7 (5.9)	< 7	Low	49 (49.0)	76 (75.2)	0.62
		7–12	Medium	40 (40.0)	16 (15.8)
		≥ 13	High	11 (11.0)	9 (8.9)
	Personal fulfillment 34.6 (7.1)	≥ 39	Low	34 (34.0)	75 (74.3)	0.01
		32–38	Medium	45 (45.0)	20 (19.8)
		< 32	High	21 (21.0)	6 (5.9)
	Burnout	n (%)		3 (3.0)	1 (1.0)	0.31
Cut-off points of Seisdedos Spain, 1997 (multi-occupational sample) (n = 1,138)	Emotional fatigue 22.2 (9.3)	< 15	Low	25 (25.0)	36 (35.6)	0.60
		15–24	Medium	39 (39.0)	25 (24.8)
		≥ 25	High	36 (36.0)	40 (39.6)
	Depersonalization 7.2 (5.2)	< 4	Low	27 (27.0)	56 (55.4)	0.07
		4–9	Medium	47 (47.0)	29 (28.7)
		≥ 10	High	26 (26.0)	16 (15.8)
	Personal fulfillment 36.5 (7.3)	≥ 40	Low	29 (29.0)	70 (69.3)	0.002
		33–39	Medium	49 (49.0)	24 (23.8)
		< 33	High	22 (22.0)	7 (6.9)
	Burnout	n (%)		7 7.0)	3 (3.0)	0.19
Cut-off points of Gil-monte and Peiró Spain, 2000 (multi-occupational sample) (n = 1,188)	Emotional fatigue 20.4 (11.0)	< 16	Low	30 (30.0)	39 (38.6)	0.60
		16–24	Medium	34 (34.0)	22 (21.8)
		≥ 25	High	36 (36.0)	40 (39.6)
	Depersonalization 6.4 (5.3)	< 4	Low	27 (27.0)	56 (55.4)	0.01
		4–8	Medium	41 (41.0)	28 (27.7)
		≥ 9	High	32 (32.0)	17 (16.8)
	Personal fulfillment 36.0 (7.3)	≥ 40	Low	29 (29.0)	70 (69.3)	< 0.001
		36–39	Medium	30 (30.0)	15 (14.9)
		< 36	High	41 (41.0)	16 (15.8)
	Burnout	n (%)		14 (14.0)	5 (5.0)	0.03
Cut-off points of Neira Argentina, 2004 (health personnel) (n = 1,152)	Emotional fatigue 18.7 (11.4)	< 12	Low	17 (17.0)	23 (22.8)	0.61
		12–21	Medium	42 (44.0)	33 (32.7)
		≥ 22	High	41 (41.0)	45 (44.6)
	Depersonalization 6.1 (5.8)	< 3	Low	20 (20.0)	45 (44.6)	< 0.001
		3–6	Medium	29 (29.0)	31 (30.7)
		≥ 7	High	51 (51.0)	25 (24.8)
	Personal fulfillment 37.3 (7.8)	≥ 41	Low	29 (29.0)	70 (69.3)	< 0.001
		36–40	Medium	30 (30.0)	15 (14.9)
		< 36	High	41 (41.0)	16 (15.8)
	Burnout	n (%)		20 (20.0)	5 (5.0)	0.001
Cut-off points of Schaufeli Holanda, 1995 (multi-occupational sample diagnosed with Burnout) (n = 142)	Emotional fatigue 28.6 (10.1)	<26	Low	17 (17.0)	23 (22.8)	0.61
		26-33	Medium	42 (42.0)	33 (32.7)
		≥ 34	High	41 (41.0)	45 (44.6)
	Depersonalization 9.3 (4.9)	< 6	Low	40 (40.0)	66 (65.3)	0.15
		6-11	Medium	42 (42.0)	24 (23.8)
		≥ 12	High	18 (18.0)	11 (10.9)
	Personal fulfillment 27.0 (5.7)	≥ 29	Low	86 (86.0)	98 (97.0)	0.11
		26-28	Medium	6 (6.0)	0 (0.0)
		< 26	High	8 (8.0)	3 (3.0)
	Burnout	n (%)		3 (3.0)	1 (1.0)	0.31^* * Differences in the high degree of affectation of the subscales and the prevalence of Burnout (2016 versus 2013) (Chi-square test).

Normative criteria	Emotional fatigue		Depersonalization		Personal fulfillment		Burnout
	2013	2016	2013	2016	2013	2016	2013	2016
	n (N)	n (N)	n (N)	n (N)	n (N)	n (N)	n (N)	n (N)
	p^* * Statistical significance of the differences observed in the results of a high degree of affectation of the subscales and Burnout prevalence (Gil-Monte criteria versus the other normative criteria considered) (Chi-square test).	p^* * Statistical significance of the differences observed in the results of a high degree of affectation of the subscales and Burnout prevalence (Gil-Monte criteria versus the other normative criteria considered) (Chi-square test).	p^* * Statistical significance of the differences observed in the results of a high degree of affectation of the subscales and Burnout prevalence (Gil-Monte criteria versus the other normative criteria considered) (Chi-square test).	p^* * Statistical significance of the differences observed in the results of a high degree of affectation of the subscales and Burnout prevalence (Gil-Monte criteria versus the other normative criteria considered) (Chi-square test).	p^* * Statistical significance of the differences observed in the results of a high degree of affectation of the subscales and Burnout prevalence (Gil-Monte criteria versus the other normative criteria considered) (Chi-square test).	p^* * Statistical significance of the differences observed in the results of a high degree of affectation of the subscales and Burnout prevalence (Gil-Monte criteria versus the other normative criteria considered) (Chi-square test).	p^* * Statistical significance of the differences observed in the results of a high degree of affectation of the subscales and Burnout prevalence (Gil-Monte criteria versus the other normative criteria considered) (Chi-square test).	p^* * Statistical significance of the differences observed in the results of a high degree of affectation of the subscales and Burnout prevalence (Gil-Monte criteria versus the other normative criteria considered) (Chi-square test).
Gil-Monte (Reference category)	36 (64)	40 (61)	32 (68)	17 (84)	41 (59)	16 (85)	14 (86)	5 (96)
Maslach	27 (73) 0.17^* * Statistical significance of the differences observed in the results of a high degree of affectation of the subscales and Burnout prevalence (Gil-Monte criteria versus the other normative criteria considered) (Chi-square test).	35 (66) 0.467^* * Statistical significance of the differences observed in the results of a high degree of affectation of the subscales and Burnout prevalence (Gil-Monte criteria versus the other normative criteria considered) (Chi-square test).	11 (89) < 0.001^* * Statistical significance of the differences observed in the results of a high degree of affectation of the subscales and Burnout prevalence (Gil-Monte criteria versus the other normative criteria considered) (Chi-square test).	9 (92) 0.09^* * Statistical significance of the differences observed in the results of a high degree of affectation of the subscales and Burnout prevalence (Gil-Monte criteria versus the other normative criteria considered) (Chi-square test).	21 (79) 0.002^* * Statistical significance of the differences observed in the results of a high degree of affectation of the subscales and Burnout prevalence (Gil-Monte criteria versus the other normative criteria considered) (Chi-square test).	6 (95) 0.02^* * Statistical significance of the differences observed in the results of a high degree of affectation of the subscales and Burnout prevalence (Gil-Monte criteria versus the other normative criteria considered) (Chi-square test).	3 (97) 0.005^* * Statistical significance of the differences observed in the results of a high degree of affectation of the subscales and Burnout prevalence (Gil-Monte criteria versus the other normative criteria considered) (Chi-square test).	1 (100) 0.09^* * Statistical significance of the differences observed in the results of a high degree of affectation of the subscales and Burnout prevalence (Gil-Monte criteria versus the other normative criteria considered) (Chi-square test).
Seisdedos	36 (64) 1^* * Statistical significance of the differences observed in the results of a high degree of affectation of the subscales and Burnout prevalence (Gil-Monte criteria versus the other normative criteria considered) (Chi-square test).	40 (61) 1^* * Statistical significance of the differences observed in the results of a high degree of affectation of the subscales and Burnout prevalence (Gil-Monte criteria versus the other normative criteria considered) (Chi-square test).	26 (74) 0.35^* * Statistical significance of the differences observed in the results of a high degree of affectation of the subscales and Burnout prevalence (Gil-Monte criteria versus the other normative criteria considered) (Chi-square test).	16 (85) 0.85^* * Statistical significance of the differences observed in the results of a high degree of affectation of the subscales and Burnout prevalence (Gil-Monte criteria versus the other normative criteria considered) (Chi-square test).	22 (78) 0.003^* * Statistical significance of the differences observed in the results of a high degree of affectation of the subscales and Burnout prevalence (Gil-Monte criteria versus the other normative criteria considered) (Chi-square test).	7 (94) 0.04^* * Statistical significance of the differences observed in the results of a high degree of affectation of the subscales and Burnout prevalence (Gil-Monte criteria versus the other normative criteria considered) (Chi-square test).	7 (93 0.1^* * Statistical significance of the differences observed in the results of a high degree of affectation of the subscales and Burnout prevalence (Gil-Monte criteria versus the other normative criteria considered) (Chi-square test).	3 (98) 0.47^* * Statistical significance of the differences observed in the results of a high degree of affectation of the subscales and Burnout prevalence (Gil-Monte criteria versus the other normative criteria considered) (Chi-square test).
Neira	41 (59) 0.46^* * Statistical significance of the differences observed in the results of a high degree of affectation of the subscales and Burnout prevalence (Gil-Monte criteria versus the other normative criteria considered) (Chi-square test).	45 (56) 0.47^* * Statistical significance of the differences observed in the results of a high degree of affectation of the subscales and Burnout prevalence (Gil-Monte criteria versus the other normative criteria considered) (Chi-square test).	51 (49) 0.006^* * Statistical significance of the differences observed in the results of a high degree of affectation of the subscales and Burnout prevalence (Gil-Monte criteria versus the other normative criteria considered) (Chi-square test).	25 (76) 0.16^* * Statistical significance of the differences observed in the results of a high degree of affectation of the subscales and Burnout prevalence (Gil-Monte criteria versus the other normative criteria considered) (Chi-square test).	41 (59) 1^* * Statistical significance of the differences observed in the results of a high degree of affectation of the subscales and Burnout prevalence (Gil-Monte criteria versus the other normative criteria considered) (Chi-square test).	16 (85) 1^* * Statistical significance of the differences observed in the results of a high degree of affectation of the subscales and Burnout prevalence (Gil-Monte criteria versus the other normative criteria considered) (Chi-square test).	20 (80) 0.25^* * Statistical significance of the differences observed in the results of a high degree of affectation of the subscales and Burnout prevalence (Gil-Monte criteria versus the other normative criteria considered) (Chi-square test).	5 (96) 1^* * Statistical significance of the differences observed in the results of a high degree of affectation of the subscales and Burnout prevalence (Gil-Monte criteria versus the other normative criteria considered) (Chi-square test).
Schaufeli	41 (59) 0.46^* * Statistical significance of the differences observed in the results of a high degree of affectation of the subscales and Burnout prevalence (Gil-Monte criteria versus the other normative criteria considered) (Chi-square test).	45 (56) 0.47^* * Statistical significance of the differences observed in the results of a high degree of affectation of the subscales and Burnout prevalence (Gil-Monte criteria versus the other normative criteria considered) (Chi-square test).	18 (82) 0.02^* * Statistical significance of the differences observed in the results of a high degree of affectation of the subscales and Burnout prevalence (Gil-Monte criteria versus the other normative criteria considered) (Chi-square test).	11 (90) 0.22^* * Statistical significance of the differences observed in the results of a high degree of affectation of the subscales and Burnout prevalence (Gil-Monte criteria versus the other normative criteria considered) (Chi-square test).	8 (92) < 0.001^* * Statistical significance of the differences observed in the results of a high degree of affectation of the subscales and Burnout prevalence (Gil-Monte criteria versus the other normative criteria considered) (Chi-square test).	3 (98) 0.001^* * Statistical significance of the differences observed in the results of a high degree of affectation of the subscales and Burnout prevalence (Gil-Monte criteria versus the other normative criteria considered) (Chi-square test).	3 (97) 0.005^* * Statistical significance of the differences observed in the results of a high degree of affectation of the subscales and Burnout prevalence (Gil-Monte criteria versus the other normative criteria considered) (Chi-square test).	1 (100) 0.09^* * Statistical significance of the differences observed in the results of a high degree of affectation of the subscales and Burnout prevalence (Gil-Monte criteria versus the other normative criteria considered) (Chi-square test).

Variable			Emotional fatigue		Depersonalization		Personal fulfillment		Burnout
Variable			High affectation total; n (%)	Adjusted OR (95%CI)	Alta afectación/total; n (%)	Adjusted O (95%CI)	Burnout/total n (%)	Adjusted OR (95%CI)	Burnout/total n (%)	Adjusted OR (95%CI)
Age (years)	2013	< 50	26/65 (40.0)	2.5^a a Adjusted for gender, time in the job, type of contract and professional category.	22/65 (33.8)	2.1^a a Adjusted for gender, time in the job, type of contract and professional category.	28/65 (43.1)	5.9^a a Adjusted for gender, time in the job, type of contract and professional category. ,^g g p < 0.05	9/65 (13.8)	2.6^a a Adjusted for gender, time in the job, type of contract and professional category.
	2013	≥ 50	6/25 (24.0)	(0.8–8.1)	6/25 (24)	(0.6–6.9)	6/25 (24.0)	(1.5–23.9)	3/25 (12.0)	(0.4–15.8)
	2016	< 50	26/58 (44.8)	1.7^a a Adjusted for gender, time in the job, type of contract and professional category.	14/62 (22.6)	7.4^a a Adjusted for gender, time in the job, type of contract and professional category.	10/60 (16.7)	1.0^a a Adjusted for gender, time in the job, type of contract and professional category.	5/63 (7.9)	No
	2016	≥ 50	8/25 (32.0)	(0.6–5.2)	1/28 (3.6)	(0.8–66.1)	10/27 (11.1)	(0.2–4.7)	0/28 (0)	valorable
Specific training	2013	No	8/27 (29.6)	0.7^f f Adjusted for age, professional category, type of contract and time in the job.	8/27 (29.6)	0.8^f f Adjusted for age, professional category, type of contract and time in the job.	14/27 (51.9)	2.1^f f Adjusted for age, professional category, type of contract and time in the job.	4/27 (14.8)	1.3^f f Adjusted for age, professional category, type of contract and time in the job.
	2013	Si	27/71 (38.0)	(0.3–2.2)	23/71 (32.4)	(0.3–2.4)	26/71 (36.6)	(0.8–6.0)	9/71 (12.7)	(0.3–5.7)
	2016	No	15/34 (44.1)	1.4^f f Adjusted for age, professional category, type of contract and time in the job.	7/38 (18.4)	0.5^f f Adjusted for age, professional category, type of contract and time in the job.	10/38 (26.3)	4.5^f f Adjusted for age, professional category, type of contract and time in the job. ,^g g p < 0.05	3/39 (7.7)	1.5^f f Adjusted for age, professional category, type of contract and time in the job.
	2016	Si	21/58 (36.2)	(0.5–4.0)	9/62 (14.5)	(0.1–2.1)	5/59 (8.5)	(1.1–17.9)	2/62 (3.2)	(0.2–13.5)
Appreciated by patients	2013	No	7/14 (50.0)	3.7^f f Adjusted for age, professional category, type of contract and time in the job.	7/14 (50.0)	3.2^f f Adjusted for age, professional category, type of contract and time in the job.	10/14 (71.4)	5.3^f f Adjusted for age, professional category, type of contract and time in the job. ,^g g p < 0.05	4/14 (28.6)	4.2^f f Adjusted for age, professional category, type of contract and time in the job.
	2013	Si	22/71 (31.0)	(0.9–15.6)	18/71 (25.4)	(0.8–13.5)	23/71 (32.4)	(1.2–24.8)	6/71 (8.5)	(0.8–22.9)
	2016	No	5/6 (83.3)	8.4^f f Adjusted for age, professional category, type of contract and time in the job.	2/7 (28.6)	3.1^f f Adjusted for age, professional category, type of contract and time in the job.	4/7 (57.1)	4.4^f f Adjusted for age, professional category, type of contract and time in the job.	2/7 (28.6)	15.4^f f Adjusted for age, professional category, type of contract and time in the job.
	2016	Si	24/76 (31.6)	(0.9–82.0)	11/81 (13.6)	(0.4–26.1)	10/77 (13.0)	(0.7–27.0)	2/81 (2.5)	(0.9–260)
Appreciated by relatives	2013	No	11/22 (50.0)	4.2^f f Adjusted for age, professional category, type of contract and time in the job. ,^g g p < 0.05	10/22 (45.5)	2.9^f f Adjusted for age, professional category, type of contract and time in the job.	13/22 (59.1)	3.1^f f Adjusted for age, professional category, type of contract and time in the job.	6/22 (27.3)	4.6^f f Adjusted for age, professional category, type of contract and time in the job. ,^g g p < 0.05
	2013	Si	18/62 (29.0)	(1.2–14.7)	16/62 (25.8)	(0.9–0.8)	21/62 (33.9)	(0.9–10.5)	5/62 (8.1)	(1.01–21)
	2016	No	8/10 (80.0)	5.7^f f Adjusted for age, professional category, type of contract and time in the job. ,^g g p < 0.05	4/11 (36.4)	2.5^f f Adjusted for age, professional category, type of contract and time in the job.	5/11 /45.5)	5.4^f f Adjusted for age, professional category, type of contract and time in the job. ,^g g p < 0.05	3/11 (27.3)	24.4^f f Adjusted for age, professional category, type of contract and time in the job. ,^g g p < 0.05
	2016	Si	20/68 (29.4)	(1.1–32.5)	8/73 (11.0)	(0.4–15.3)	8/70 (11.4)	(1.1-29.0)	1/73 (1.4)	(1.3–450)
Appreciated by superior	2013	No	8/30 (26.7)	0.6^f f Adjusted for age, professional category, type of contract and time in the job.	8/30 (26.7)	0.9^f f Adjusted for age, professional category, type of contract and time in the job.	13/30 (43.3)	1.4^f f Adjusted for age, professional category, type of contract and time in the job.	4/30 (13.3)	1.0^f f Adjusted for age, professional category, type of contract and time in the job.
	2013	Si	24/59 (40.7)	(0.2–1.8)	18/59 (30.5)	(0.3–2.7)	22/59 (37.3)	(0.5-3.8)	7/59 (11.9)	(0.2–4.7)
	2016	No	14/25 (56.0)	3.3^f f Adjusted for age, professional category, type of contract and time in the job. ,^g g p < 0.05	6/28 (21.4)	1.3^f f Adjusted for age, professional category, type of contract and time in the job.	9/29 (31.0)	9.7^f f Adjusted for age, professional category, type of contract and time in the job. ,^g g p < 0.05	5/29 (17.2)	No
	2016	Si	18/60 (30.0)	(1.1–10.1)	10/65 (15.4)	(0.3–4.8)	4/61 (6.6)	(1.7–54.3)	0/65 (0)	valorable
Professional experience	2013	^↑ ↑ Perception: High perception of the modulating variable considered, considering that it reached this level when its score was higher than 8. Perception	11/31 (35.5)	1.1^c c Adjusted for age, gender, time in the job, and professional category.	9/31 (29.0)	1.1^c c Adjusted for age, gender, time in the job, and professional category.	5/31 (16.1)	0.3^c c Adjusted for age, gender, time in the job, and professional category. ,^g g p < 0.05	4/31 (12.9)	1.2^c c Adjusted for age, gender, time in the job, and professional category.
	2013	Rest	24/68 (35.3)	(0.4–2.8)	23/68 (33.8)	(0.4–2.9)	35/68 (51.5)	(0.08–0.8)	10/68 (14.7)	(0.3–4.8)
	2016	^↑ ↑ Perception: High perception of the modulating variable considered, considering that it reached this level when its score was higher than 8. Perception	5/21 (23.8)	0.6^c c Adjusted for age, gender, time in the job, and professional category.	1/26 (3.8)	0.4^c c Adjusted for age, gender, time in the job, and professional category.	2/26 (7.7)	0.2^c c Adjusted for age, gender, time in the job, and professional category.	0/26 (0)	No
	2016	Rest	31/71 (43.7)	(0.2–2.2)	15/74 (20.3)	(0.04–3.5)	13/71 (18.3)	(0.03–2.1)	5/75 (6.7)	valorable
Optimism	2013	^↑ ↑ Perception: High perception of the modulating variable considered, considering that it reached this level when its score was higher than 8. Perception	16/45 (35.6)	1.0^e e Adjusted for age, gender, type of contract and professional category.	13/45 (28.9)	0.7^e e Adjusted for age, gender, type of contract and professional category.	9/45 (20.0)	0.2^e e Adjusted for age, gender, type of contract and professional category. ,^g g p < 0.05	5/45 (11.1)	0.6^e e Adjusted for age, gender, type of contract and professional category.
	2013	Rest	19/54 (35.2)	(0.4–2.5)	19/54 (35.2)	(0.3–1.9)	31/54 (57.4)	(0.07–0.6)	9/54 (16.7)	(0.2–2.2)
	2016	^↑ ↑ Perception: High perception of the modulating variable considered, considering that it reached this level when its score was higher than 8. Perception	8/31 (25.8)	0.3^e e Adjusted for age, gender, type of contract and professional category.	6/35 (17.1)	1.6^e e Adjusted for age, gender, type of contract and professional category.	3/33 (9.1)	0.3^e e Adjusted for age, gender, type of contract and professional category.	0/35 (0)	No
	2016	Rest	28/61 (45.9)	(0.1–1.0)	10/65 (15.4)	(0.4–5.8)	12/64 (18.8)	(0.07–1.8)	5/66 (7.6)	valorable
Social support	2013	^↑ ↑ Perception: High perception of the modulating variable considered, considering that it reached this level when its score was higher than 8. Perception	20/63 (31.7)	0.4^e e Adjusted for age, gender, type of contract and professional category.	19/63 (30.2)	0.9^e e Adjusted for age, gender, type of contract and professional category.	21/63 (33.3)	0.3^e e Adjusted for age, gender, type of contract and professional category. ,^g g p < 0.05	7/63 (50.0)	0.4^e e Adjusted for age, gender, type of contract and professional category.
	2013	Rest	16/37 (43.2)	(0.2–1.1)	13/37 (35.1)	(0.3–2.7)	20/37 (54.1)	(0.1–0.9)	7/37 (18.9)	(0.1–1.6)
	2016	^↑ ↑ Perception: High perception of the modulating variable considered, considering that it reached this level when its score was higher than 8. Perception	19/59 (32.2)	0.6^e e Adjusted for age, gender, type of contract and professional category.	8/65 (12.3)	1.1^e e Adjusted for age, gender, type of contract and professional category.	4/63 (6.3)	0.07^e e Adjusted for age, gender, type of contract and professional category. ,^g g p < 0.05	1/65 (1.5)	0.2^e e Adjusted for age, gender, type of contract and professional category.
	2016	Rest	17/33(51.5)	(0.2–1.6)	7/34 (20.6)	(0.3–3.8)	10/33 (30.3)	(0.01–0.4)	3/35 (8.6)	(0.02–2.1)

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Faculdade de Saúde Pública da Universidade de São Paulo Avenida Dr. Arnaldo, 715, 01246-904 São Paulo SP Brazil, Tel./Fax: +55 11 3061-7985 - São Paulo - SP - Brazil
E-mail: revsp@usp.br

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[TFN1] SD: standard deviation; NUG: nursing university graduate; OR: odds ratio

[TFN2] ^a
Mantel-Hanzel test.

[TFN3] ^b
p < 0.05

[TFN4] The reference category is the first.

[TFN5] Values with statistical significance are highlighted in bold.