« Go back to issue 44(5) summary

Burnout syndrome and coping strategies in Portuguese oncology health care providers

Vasco F. J. Cumbe1,2,3, Andrea N. Pala4, António J. P. Palha5,6,7, Ana R. P. Gaio8,9, Manuel F. Esteves5,
Jair de Jesus Mari
3, Milton Wainberg4

1 Department of Mental Health, Ministry of Health, Sofala Provincial Health Directorate, Beira, Mozambique.

2 Department of Medicine – Psychiatry, Beira Central Hospital, Beira, Mozambique.

3 Department of Psychiatry, Paulista School of Medicine, Federal University of São Paulo, São Paulo, SP, Brazil.

4 Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, NY, USA.

5 Psychiatry and Mental Health, Faculty of Medicine of the University of Porto, FMUP.

6 Honorary Member of the World Psychiatric Association (WPA).

7 Former President of the Portuguese Society of Psychiatry and Mental Health.

8 Department of Mathematics, Faculty of Sciences of the University of Porto, FCUP.

9 Centre for Mathematics of the University of Porto, CMUP.

Received: 04/21/2017 – Accepted:05/24/2017

DOI: 10.1590/0101-60830000000135

Address for correspondence: Vasco Francisco Japissane Cumbe. Beira Central Hospital, Department of Medicine, Psychiatry and Mental Health Service, Macúti, Av. Mártires da Revolução – CP 1613. Fax: (00258) 23312080. Telephone: (00258) 844206301. Email: vcumbe@gmail.com

Abstract

Background: Burnout is a multidimensional syndrome and includes symptoms of emotional exhaustion, depersonalization, and reduced personal accomplishment at work. Oncology health care providers are at high risk to develop symptoms of burnout because of work-related stressors. Adaptive coping strategies adopted to deal with stressors may prevent the development of burnout. Objective: The present study aims to assess the association between burnout, functional coping strategies, and occupational factors in a sample of oncology providers, mostly nurses. Methods: Sociodemographic Questionnaire, the Maslach Burnout Inventory, and the Problem Solving Inventory “Inventário de Resolução de Problemas” were administered. Descriptive, correlational, and linear regression analyses were performed. Results: The study showed that emotional exhaustion correlated with lower levels of adaptive coping, less years of experience in Oncology, and a greater amount of hours worked per week. Personal accomplishment was associated with the adaptive coping strategies. No further statistically significant associations were identified. Discussion: Our findings support the importance of adaptive coping strategies in order to prevent symptoms of burnout when health professionals face potentially stressful occupational factors. Training aimed at improving adaptive coping skills may prevent burnout syndrome for health care professionals working in Oncology.

Cumbe VFJ et al. / Arch Clin Psychiatry. 2017;44(5):122-6

Keywords: Burnout, oncology, health professionals, coping strategies.

Introduction

Health professionals, particularly nurses, working in oncology are at high risk for burnout, a complex phenomenon initially identified in parole officers working in community treatment programs1-3. Care providers dealing with situations beyond their skills, power, and energy may develop burnout syndrome2,4. Several definitions of burnout have been produced over the last 30 years, all depicting a general state of fatigue and frustration, feelings of emptiness and personal failure, and an inability to work5-8. Burnout was operationalized as composed by three dimensions: Emotional Exhaustion; Dehumanization; and Reduced Personal Accomplishment. Emotional Exhaustion involves a sense of emotional and physical fatigue as well as lack of energy required to carry out professional activities. Dehumanization represents emotionally distant attitudes and actions toward colleagues and patients. Reduced Personal Accomplishment depicts feelings of personal dissatisfaction and loss of professional fulfillment.

Among the several factors promoting burnout, chronic occupational stress (e.g., night shifts, patient pressure, and work overload) coupled with poor coping strategies may be the most defining9-11. Considering this risk factor, an exceptional number of health professionals show symptoms of burnout, specifically those who work with patients suffering from chronic diseases and cancer3,12-17. For many of these health professionals, interactions with oncology patients heightens an intense fear of death and uncertainty about the future, perpetuating stress and increasingly likelihood of burnout18-21. Occupational-related factors such as insufficient personal, vacation time, and problems concerning care management are also associated with burnout symptoms11,22,23. Burnout negatively affects health professionals’ wellbeing and work performance including job withdrawal, absenteeism, quality of care provided to patients, and increased number of medical errors24-26.

The ways health professionals face work-related stressors largely determines the development of burnout10,27. Two general categories of coping may be identified: adaptive and maladaptive28-30. Adaptive strategies, such as reappraisal, are proactive, as they involve challenging the problem with direct changes in behavior. Alternatively, maladaptive strategies, such as avoidance and denial, may alleviate stress temporarily without elimination or modification of the source31,32. Moreover, coping strategies play an important role in determining the resulting levels of burnout. Burnout levels are higher among individuals who adopt maladaptive coping compared to those who enact adaptive coping strategies13.

The aims of the current study were: (1) to explore the association of burnout’s dimensions (i.e. Emotional Exhaustion, Dehumanization, and Personal Accomplishment) with functional coping strategies; and (2) to explore the association between burnout and occupational-related variables, in a sample of oncology health care providers. Overall, we hypothesized to find high scores on burnout dimensions correlated (aim#1) with low levels of adaptive coping strategies and (aim#2) greater amount of hours worked per week, and less work-related experience in Oncology.

Methods

Participants and procedures

Participants were health care professionals (N = 46) recruited in four Portugal Multipurpose Hospital Day Oncology Units: Hospital São João (n = 28), Hospital Geral Santo António (n = 9), Hospital de Faro (n = 5) and Hospital de Beja (n = 4). Participants were included if they had history of working in the outpatient Oncology clinic for at least one year and signed the informed consent. Participants were recruited using a convenience sampling method.

Instruments

The sociodemographic questionnaire administered included gender, age, marital status and occupation-related variables (years of work in oncology, hours worked per week). Burnout was assessed using the Portuguese version of the Maslach Burnout Inventory5,33. The Maslach Burnout Inventory is a 22-item instrument assessing personal feelings and attitudes of the professional in relation to their work. The three dimensions assessed include: Emotional Exhaustion which assesses the feelings of the subject in relation to the emotional state caused by the work (9 items); Dehumanization which describes what may be a cold and impersonal response of the individual towards their patients (5 items); and Personal Accomplishment which evaluates feelings of competence and professional effectiveness in carrying out their work (8 items). Each item is rated on a 7-point Likert – type scale ranging from 0 (never) to 6 (everyday). Higher levels of burnout are indicated by higher scores on Emotional Exhaustion and Dehumanization, and lower score on Personal Accomplishment. Cronbach’s alpha coefficients indicated good internal consistency for the sub-scales Emotional Exhaustion and Personal Accomplishment, alpha 0.85 and 0.80, respectively. Internal consistency of Dehumanization was low yet acceptable, alpha 0.67.

Coping strategies were assessed by Problem-Solving Inventory “Inventário de Resolução de Problemas”34, a 40-item questionnaire assessing 9 coping strategies. These strategies include: ‘request for help’, ‘confrontation and active problem solving’, ‘emotional abandonment in the face of the situation’, ‘internal = external locus of control’, ‘emotional control strategies’, ‘active attitude in not allowing incidents interfere with daily living’, ‘internalized = externalized aggression’, ‘self-responsibility and fear of the consequences’, and ‘facing the problem and planning strategies’. The score of the sub-scales measuring maladaptive coping were reversed, so that the total score reflects the overall levels of adaptive coping strategies. The Brazilian Portuguese version of Maslach Burnout Inventory’s cut-off scores was adopted35: Emotional Exhaustion was considered high if ≥ 26; Dehumanization score equal to or greater than 9 was considered high; and a Personal Accomplishment score equal to or lower than ≤ 33 corresponded to diminished Personal Accomplishment. Although results were primarily analyzed using the Brazilian Portuguese Maslach Burnout Inventory cut-off scores, results were also compared to the cut-off scores utilized in the United States6. High levels of burnout corresponded to Emotional Exhaustion scores ≥ 21; Dehumanization scores ≥ 8; and Personal Accomplishment scores ≤ 285. The scale had good internal consistency, as indicated by Cronbach’s alpha 0.85.

Data analysis

Descriptive analysis was conducted using SPSS version 23 (IBM, 2015). Descriptive statistics included the mean and the standard deviation (SD) for continuous variables (e.g., age), and frequencies for nominal variables (e.g., gender). Shapiro-Wilk test was used to assess variables’ distribution. Cronbach’s alpha was used to evaluate the internal consistency of the Maslach Burnout Inventory sub-scales and Problem Solving Inventory. Spearman’s rho coefficient and Spearman correlation test were used to identify and test the variables’ correlation. Linear regression was conducted using Mplus 7.336. Maximum likelihood estimation with robust standard errors was used since it demonstrated to be robust against departure from the normal distribution37. Statistical analyses were performed using SPSS version 23 and Mplus 7.3 software. The significance level was set at 0.05.

Results

Sample characteristics

Table 1. General description of the sample

Table 1. General description of the sample

Table 2. Comparison of burnout dimensions score with other studies

Table 2. Comparison of burnout dimensions score with other studies

The sample consisted of 46 health care professionals, of whom 37 were nurses (80.4%) and 9 doctors, with greater representation of females (n = 42, 91.3%) compared to males (n = 4, 8.7%). The majority was married (n = 36, 78.26%; single n = 8, 17.39%, and divorced n = 2, 4.35%). Participant mean age was 40.13 years (SD = 9.79); mean number of years working in health care settings was 16.78 (SD = 9.30); mean number of years working in oncology was 8.62 (SD = 6.72). Hours of work per week: 35 hours/week (n = 28, 60.87%), 40 hour/week (n = 13, 28.26%), more than 40 hour/week (n = 5, 10.87%). Participants’ mean scores on Maslach Burnout Inventory sub-scales were: Emotional Exhaustion = 20.89 (SD = 9.95); Dehumanization = 3.28 (SD = 4.28); and Personal Accomplishment = 37.11 (SD = 7.78) (Table 1).

Adopting the Brazilian cut-offs of the Maslach Burnout Inventory38, participants revealed low Emotional Exhaustion, low Dehumanization, and high Personal Accomplishment. When the US based cut-offs5 were used, our sample showed moderate levels of Emotional Exhaustion and Dehumanization, and high levels of Personal Accomplishment.

The Maslach Burnout Inventory dimensions’ mean scores were comparable to previous studies conducted in similar contexts, except for the levels of Dehumanization that were higher among physicians in Horta’s39 study (Table 2). The mean of the overall score of the Problem Solving Inventory was 153.89 (SD = 14.45; Table 1). The average was higher compared to the study by Carvalho40, (Mean = 149, SD = 12.13).

Burnout dimensions, coping strategies, and occupational characteristics

Table 3. Spearman correlation coefficients between burnout dimensions, IRP, age, years of profession, years of work in oncology and hours of work per week

Table 3. Spearman correlation coefficients between burnout dimensions, IRP, age, years of profession, years of work in oncology and hours of work per week

Preliminary analyses of the associations between the independent variables were performed to test for collinearity. The results (Table 3) illustrate the presence of high collinearity between three variables: age, years of profession, and years of work in oncology. Therefore, and due to the sample size, only the variable “years of work in oncology” was included in the regression models. The spearman correlations between the dependent and the independent variables were also considered. Most of the correlation coefficients were statistically non-significant although of magnitude greater than 0.20. We hypothesize this to be caused by the small size of the sample. Only coefficients greater than .30 resulted in statistically significant values.

Overall, the Maslach Burnout Inventory sub-scales were inter-correlated, only Emotional Exhaustion and Dehumanization were not significantly associated. High score on Problem Solving Inventory was reported by health professionals essentially with low levels of Emotional Exhaustion and with high levels of Personal Accomplishment. Greater levels of Problem Solving Inventory were reported by health professionals with older age and with more years of work experience, but were not associated with years of work in oncology.

Linear regression models

Table 4. Standardized regression coefficients of the regression model of each burnout dimension (EE, D, PA) with years of work in oncology, hours per week and IRP

Table 4. Standardized regression coefficients of the regression model of each burnout dimension (EE, D, PA) with years of work in oncology, hours per week and IRP

Table 4 reports the results of the 3 linear regressions performed. Lower Emotional Exhaustion was significantly associated with more years of experience in oncology, and with greater levels of coping strategies measured by Problem Solving Inventory. A significantly positive association between Emotional Exhaustion and the number of hours of work per week was also identified. The dimension Dehumanization was not significantly associated with any of the independent variables included in the model. Greater levels of Personal Accomplishment were only significantly associated with greater level of coping strategies measured by Problem Solving Inventory (Table 4).

Discussion

The current study investigates the association between burnout, coping strategies, and occupational factors (e.g., years of work in health care settings, hours worked per week) in a Portuguese sample of health care professionals. The 46 participants recruited in four Portuguese hospitals are predominantly nurses, a work category at a greater risk to develop burnout due to their close involvement in the care of patients2,3,17. Participants have low emotional exhaustion, low depersonalization, and high personal accomplishment, according to the Brazilian cut-offs of the Maslach Burnout Inventory38. Whereas, based on the US cut-offs5, our sample shows moderate levels of emotional exhaustion and depersonalization, and high levels of personal achievement. This discrepancy demonstrates the importance of the cultural background in determining and interpreting the levels of burnout symptoms. The lack cut-offs based on Portuguese samples may represent a limitation to the study. The cut-offs identified in different cultural and working contexts, should be used and interpreted with caution and skepticism41. Therefore, we decided to use the Maslach Burnout Inventory sub-sales raw score in our analysis. The mean scores on the burnout inventory5 are comparable to the mean scores obtained in studies conducted in Portugal on samples of physician and nurses39,42. Though, physicians in Silva’s study42 have slightly higher levels of depersonalization compared to nurses in our and Horta’s study39.

The results of the linear regression analysis suggest that Portuguese health professionals who have high levels of emotional exhaustion are characterized with low levels of functional coping, less years of experience in Oncology care, and report a greater amount of hours worked per week. Emotional exhaustion may occur as a consequence of poor adaptive strategies of coping enacted to deal with work-related stressors. Health care professionals with less work experience in Oncology show high levels of emotional exhaustion. We hypothesized that work experience may help health professionals developing functional coping strategies to deal with work-related stressors. This is supported by the association between functional coping and the years of work in Oncology clinics. In addition, work experience in such settings may change health professionals’ perception and attitudes towards their job43. For instance, as age progresses the health professionals might improve their confidence in work tasks, which reduces their vulnerability to work-related stressors13,44. Lastly, the amount of hours worked per week is an important stressor that health professionals have to deal with45.

Participants with high levels of personal accomplishment are characterized with high levels of adaptive coping, whereas, depersonalization does not correlate with coping and occupational factors. Overall, the results of our study support the importance of the adoption of functional coping strategies in order to prevent symptoms of burnout46,47. Structural adjustment including reducing hours worked per week might limit the risk of developing symptoms of burnout. Training aimed at improving coping skills to deal with work-related stress may prevent burnout syndrome in health professionals48,49.

Conclusions

Further investigation with probabilistic samples will be necessary to better understand the role of coping strategies in determining the levels of burnout in oncology. Interventions aimed to improve individuals’ adaptive coping skills should be tested longitudinally on a larger sample of health professionals.

Limitations and future directions

Our study presents methodological limitations. The small sample size, predominantly composed by female nurses, and the use of non-probabilistic sampling method are the main limitations. Therefore, we consider our findings preliminary.

Competing interests

The authors declare no competing interests.

Ethical approval

This study was approved by the institutional review boards at Hospital São João do Porto, Hospital Geral Santo António, Hospital de Faro, Hospital de Beja.

Author’s contributions

VFJC worked to develop the research and data collection protocol, data collection, cleaning, database management, data analysis, and draft the first manuscript. AJPP worked to develop the research and bibliography revision. MFE worked in the study design, bibliography revision, and statistical analysis. ARPG worked in study design and statistical analysis. ANP, JDJM, MW worked in bibliography revision, statistical analysis, and helped to draft the manuscript. All authors provided creative input on the final manuscript version and approved it for publication.

Acknowledgements

Special thanks to Maria Lídia Chaúque Gouveia, Head Officer of Mental Health Department in the Ministry of Health – Mozambique. We thank Prof Dr. Miguel Ângelo Marques Ferreira Bragança from Psychiatry Department in Hospital São João – Porto. Thanks to
Dr. Hipólito N’Zwalo who helped collecting data in Faro and Beja. Also thanks to Prof. Dr. Adriano Vaz Serra and Prof. Dr. Cristina Queirós in helping with some instruments.

Conflict of interest and funding

The authors acknowledge that they have no conflicts of interest. This work was supported by the Department of Mental Health – Ministry of Health in Mozambique (MISAU). The content is solely the responsibility of the authors.

References

  1. Bradley H. Community-based treatment for young adult offenders. Crime Delinq. 1969;15:359-70.
  2. Le Blanc PM, Bakker AB, Peeters MC, et al. Emotional job demands and burnout among oncology care providers. Anxiety Stress Coping. 2001;14:243-63.
  3. Villani D, Grassi A, Cognetta C, Toniolo D, Cipresso P, Riva G. Self-help stress management training through mobile phones: an experience with oncology nurses. Psychol Serv. 2013;10(3):315-22.
  4. Trufelli DC, Bensi CG, Garcia JB, Narahara JL, Abrão MN, Diniz RW, et al. Burnout in cancer professionals: a systematic review and meta-analysis. Eur J Cancer Care (Engl). 2008;17(6):524-31.
  5. Maslach C, Jackson SE, Leiter MP. Maslach burnout inventory manual. Mountain View, CA: CPP. Inc., and Davies-Black, 1996.
  6. Schaufeli WB, Buunk BP. Burnout: An Overview of 25 Years of Research and Theorizing. In: Schabracq MJ, Winnubst JAM, Cooper CL (eds). The Handbook of Work and Health Psychology, Second Edition. Chichester, UK: John Wiley & Sons, Ltd, 2002. doi: 10.1002/0470013400.ch19.
  7. Gama G, Barbosa F, Vieira M. Personal determinants of nurses’ burnout in end of life care. Eur J Oncol Nurs. 2014 Oct;18(5):527-33.
  8. Maslach C, Jackson SE. Maslach Burnout Inventory Manual. 2nd ed. Palo Alto, Calif: Consulting Psychologists Press; 1986.
  9. Maslach C, Leiter MP. The Truth about Burnout: How Organizations Cause Personal Stress and What to Do About it. San Francisco, CA: Jossey-Bass; 1997.
  10. Rodrigues AB, Chaves EC. Stressing factors and coping strategies used by oncology nurses. Rev Lat Am Enfermagem. 2008;16(1):24-8.
  11. Poulsen MG, Poulsen AA, Baumann KC, McQuitty S, Sharpley CF. A cross-sectional study of stressors and coping mechanisms used by radiation therapists and oncology nurses: Resilience in Cancer Care Study. J Med Radiat Sci. 2014;61(4):225-32.
  12. Olkinuora M, Asp S, Juntunen J, Kauttu K, Strid L, Aärimaa M. Stress symptoms, burnout and suicidal thoughts in Finnish physicians. Soc Psychiatry Psychiatr Epidemiol. 1990;25(2):81-6.
  13. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol. 2001;52(1):397-422.
  14. Korkeila JA, Töyry S, Kumpulainen K, Toivola JM, Räsänen K, Kalimo R. Burnout and self-perceived health among Finnish psychiatrists and child psychiatrists: a national survey. Scand J Public Health. 2003;31(2):85-91.
  15. de Carvalho EC, Muller M, de Carvalho PB, de Souza Melo A. Stress in the professional practice of oncology nurses. Cancer Nurs. 2005;28(3):187-92.
  16. Sá LO. Burnout e controle sobre o trabalho em enfermagem – Resultados. Enfermagem Oncológica. 2006;34:15-24.
  17. Orzechowska A1, Talarowska M, Drozda R, Mirowska D, Florkowski A, Zboralski K, et al. [The burnout syndrome among doctors and nurses]. Pol Merkur Lekarski. 2008;25(150):507-9.
  18. Maguire P, Faulkner A. Communicate with cancer patients: 2. Handling uncertainty, collusion, and denial. BMJ. 1988 Oct 15;297(6654):972-4.
  19. Hinds PS, Puckett P, Donohoe M, Milligan M, Payne K, Phipps S, et al. The impact of a grief workshop for pediatric oncology nurses on their grief and perceived stress. J Pediatr Nurs. 1994;9(6):388-97.
  20. Breitbart W, Rosenfeld B, Pessin H, Kaim M, Funesti-Esch J, Galietta M, et al. Depression, hopelessness, and desire for hastened death in terminally ill patients with cancer. JAMA. 2000;284(22):2907-11.
  21. Sherman AC, Edwards D, Simonton S, Mehta P. Caregiver stress and burnout in an oncology unit. alliat Support Care. 2006;4(1):65-80.
  22. Lyckholm L. Dealing with stress, burnout, and grief in the practice of oncology. Lancet Oncol. 2001;2(12):750-5.
  23. Girgis A, Hansen V, Goldstein D. Are Australian oncology health professionals burning out? A view from the trenches. Eur J Cancer. 2009;45(3):393-9.
  24. Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. 2002;136(5):358-67.
  25. Dyrbye LN, Thomas MR, Massie FS, Power DV, Eacker A, Harper W, et al. Burnout and suicidal ideation among U.S. medical students. Ann Intern Med. 2008;149(5):334-41.
  26. Coffeng JK, Hendriksen IJ, Duijts SF, Twisk JW, van Mechelen W, Boot CR, et al. Effectiveness of a combined social and physical environmental intervention on presenteeism, absenteeism, work performance, and work engagement in office employees. J Occup Environ Med. 2014;56(3):258-65.
  27. Zander M, Hutton A, King L. Coping and resilience factors in pediatric oncology nurses. J Pediatr Oncol Nurs. 2010;27(2):94-108.
  28. Folkman S, Lazarus RS, Dunkel-Schetter C, DeLongis A, Gruen RJ. Dynamics of a stressful encounter: cognitive appraisal, coping, and encounter outcomes. J Pers Soc Psychol. 1986;50(5):992-1003.
  29. Folkman S, Moskowitz JT. Stress, Positive Emotion, and Coping. Curr Dir Psychol Sci. 2000;9(4):115-8.
  30. Folkman S. Stress, coping, and hope. Psycho-Oncology. 2010;19(9):901-8. http://doi.org/10.1002/pon.1836.
  31. Cherniss C. Professional burnout in human service organizations. New York: Praeger, 1980.
  32. Folkman S, Moskowitz JT. Coping: pitfalls and promise. Annu Rev Psychol. 2004;55:745-74.
  33. Manita C. Quando escutar faz mal… Prevenção do Burnout num grupo de profissionais de atendimentos a vítimas de violência doméstica (projecto de investigação-acção). Porto: F.P.C.E.U.P. (policopiado, não publicado), 2003.
  34. Vaz Serra A. Inventário de Resolução de Problemas – IRP. Documento fornecido pelo autor. Faculdade de Medicina da Universidade de Coimbra, FMUC, 1987.
  35. Benevides-Pereira AMT. Burnout: o processo de adoecer pelo trabalho. In: Benevides-Pereira AMT (ed). Burnout: Quando o trabalho ameaça o bem estar do trabalhador. São Paulo, BR: Casa do Psicólogo, 2002. p. 21-92.
  36. Muthén LK, Muthén BO. Mplus User’s Guide. Seventh Edition. Los Angeles, CA: Muthén & Muthén, (1998-2012).
  37. Yuan KH, Bentler PM. Three likelihood-based methods for mean and covariance structure analysis with non-normal missing data. In: Sobel ME, Becker MP (eds). Sociological Methodology. Washington, DC: ASA, 2000. p. 165-200.
  38. Truzzi A, Souza W, Bucasio E, Berger W, Figueira I, Engelhardt E, et al. Burnout in a sample of Alzheimer’s disease caregivers in Brazil. Eur J Psychiat. 2008;22(3):151-60.
  39. Horta AM. Síndrome de Burnout nos Médicos do Serviço de Urgência do Hospital de São João. Tese de Mestrado. Faculdade de Medicina da Universidade de Porto, FMUP, 2005.
  40. Carvalho AIAD. Sintomatologia Depressiva e Estratégias de Coping em Adultos em Idade Laboral. Tese de Mestrado. Faculdade de Ciências Sociais e Humanas da Universidade da Beira Interior, FCSH – UBI, 2002.
  41. Morse G, Salyers MP, Rollins AL, Monroe-DeVita M, Pfahler C, et al. Burnout in mental health services: a review of the problem and its remediation. Adm Policy Ment Health. 2012;39(5):341-52.
  42. Silva MP. Ansiedade e Burnout em Enfermeiros dos Cuidados de Saúde Primários do Interior – Norte de Portugal. Tese de mestrado integrado. Faculdade de Psicologia e de Ciências de Educação da Universidade do Porto – FPCEUP, 2008.
  43. Pines A. On burnout and the buffering effects of social support. BA Farber (Ed.), Stress and burnout in the human service professions. New York: Pergamon Press; 1983. p. 155-74.
  44. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol. 2001;52:397-422.
  45. Karasek R, Theorell T. Healthy work: stress, productivity, and the reconstruction of working life. New York: Basic Books; 1990.
  46. Hätinen M, Mäkikangas A, Kinnunen U, et al. Recovery from burnout during a one-year rehabilitation intervention with six-month follow-up: Associations with coping strategies. Int J Stress Manag. 2013;20(4):364-90.
  47. Shin H, Park YM, Ying J, Kim B, Noh H, Lee SM. Relationships between coping strategies and burnout symptoms: a meta-analytic approach. Prof Psychol Res Pr. 2014;45(1):44-56.
  48. Zimber A, Rudolf A, Teufel S. [Reducing work stress in geriatric care: a training program for nursing team and administrators]. Z Gerontol Geriatr. 2001;34(5):401-7.
  49. Gillman L, Adams J, Watts R, et al. Strategies to promote coping and resilience in oncology and palliative care nurses caring for adult patients with malignancy: a systematic review. JBI Database System Rev Implement Rep. 2012;10(56):75-90.