Strategies for management of stress and burnout among healthcare professionals in Brazil

The objective of this study was to map evidence in the scientific literature regarding the implementation and impact of strategies for prevention and management of stress and/or burnout among healthcare professionals in Brazil. This is a Scoping Review carried out using search terms and Boolean operators to search the databases Latin American and Caribbean Health Sciences Literature (via Virtual Health Library), Scientific Electronic Library Online, and Medical Literature Analysis and Retrieval System Online (via PubMed). The publication period was from 2010 until the dates on which searches were run. A manual search and searches of the reference lists of selected publications were also conducted. Initially, 317 studies were identified and 14 studies were included in the final sample. The studies highlight the implementation of strategies for prevention and management of stress and/or burnout among healthcare professionals in Brazil together with their results. There was evidence of use of integrative and complementary practices, with emphasis on auriculotherapy, as well as stress reduction programs, and care-educational strategies. This review brings together possibilities for prevention and management of stress and burnout, presenting strategies and their results in the target population.


INTRODUCTION
Nowadays, stress has a considerable impact on people's health status and on quality of life. 1 Within this context, the issue of occupational stress merits special attention and has been the object of many studies in a wide range of occupational areas or professional activities. [2][3][4] There is evidence in the literature that occupational stress has a negative impact on healthrelated quality of life. 5 It is also known that chronic exposure to interpersonal/emotional stressors at work can lead to burnout syndrome. [6][7] It should be noted that burnout syndrome is a combination of three dimensions, specifically: (i) emotional exhaustion, (ii) depersonalization, and (iii) ineffectiveness (lack of personal accomplishment). 6,7 Exhaustion is expressed as feelings that represent the excessive effort a worker has to make to perform their activities, resulting in exhaustion of emotional and physical resources. 7 Depersonalization encompasses insensitive or excessively detached behavior at work, while the lack of personal accomplishment dimension constitutes a person's self-assessment with relation to their competencies, achievements, and work productivity. 7 These dimensions are associated with a set of signs or symptoms the demonstrate the worker's burnout, including lack of energy, tiredness, irritability, behavior considered inadequate with relation to clients, and reduced productivity and personal achievement. 6,7 The occurrence of burnout has most frequently been associated with professions linked to serving and caring for people, such as education and medical care. 6 In these areas, professionals perform daily activities that require continuous and intense personal and emotional contact and, depending on the characteristics of their work, for example workload, professional autonomy, remuneration, and interpersonal relationships, they may be more or less vulnerable to burnout. 6 Data demonstrate that stress and burnout are both phenomena present among health professionals. [8][9][10][11] In a study conducted with nursing professionals at a University Hospital in Minas Gerais, Brazil, 71.8% of professionals were exposed to occupational stress. 9 Another study with Brazilian intensive care specialist physicians found a 61.7% prevalence of burnout, considering a high level of at least one of its dimensions, and in 5% of the sample all three dimensions were at high levels simultaneously. 11 In addition to its prevalence, the literature also reveals the negative impact of burnout on workers, on their professions and employers, and on society. 1,[5][6][7][12][13][14] Given the nature of the activities performed by health professionals and their importance to society, it is clear that these workers need to be in good emotional health, be competent at their roles, and feel personal accomplishment, in order that they can provide good quality care. Along the same lines, bearing in mind the effects of stress and of burnout, both on health professionals and on the populations they care for, 1,[5][6][7][12][13][14] it is also clear that strategies or actions aimed to prevent and manage these phenomena are extremely important.
This being so, the objective of the present study was to map evidence in the scientific literature related to the implementation and impacts of strategies for prevention and management of stress and/or burnout among healthcare professionals in Brazil.

METHODS
A Scoping Review Study following the structure described by Arksey & O'Malley, 15 including five phases: (i) identify the research question; (ii) identify relevant studies, (iii) select studies; (iv) map the data; and (v) synthesize and report the results.
As a starting point, the first step was to define the following research question: Is there evidence related to the implementation and impact of strategies for prevention and management of stress and/or burnout among healthcare professionals in Brazil?
This research question was used to construct search strategies to identify relevant studies (the second step in the review). 15 The following keywords were chosen for the search: Estresse Ocupacional, Burnout, Brasil, Occupational Stress, Brazil, and Brazilian, on the basis that using these keywords would return publications related to the research question. Searches for studies were run on the databases LILACS (Literatura Latinoamericana e do Caribe em Ciências da Saúde) via the Biblioteca Virtual em Saúde (BVS), SciELO (Scientific Electronic Library Online), and MEDLINE (Medical Literature Analysis and Retrieval System Online), via PubMed, using these keywords and Boolean operators (Table 1).
Additionally, manual searches were run using the Google search engine, in order to identify additional studies that fell within the scope of the review. Moreover, the references of the publications selected were analyzed, adding four more publications to the final sample. These different strategies were utilized with the objective of contributing to identification of relevant studies. 15 In the next step, study selection, 15 the titles and abstracts of all of the studies returned in the searches were analyzed by two reviewers. The following inclusion and exclusion criteria were applied to select the studies: Inclusion criteria: i -research articles, reports of experiments or dissertations reporting on the implementation of strategies and evaluation of their impact for prevention and management of stress and/ or burnout among healthcare professionals in Brazil; ii -published from 2010 up to the search date -March 27, 2020 (Table 1); iii -published in English, Portuguese, or Spanish.
Exclusion criteria: i -literature reviews, books, book chapters, publications in summary form or others not referenced in the inclusion criteria, and studies for which it was not possible to clearly identify the context in which the research was conducted from the published text; and ii -publications that were repeated or not fully identified. Figure 1 illustrates the process on which this review was based.
The data from the 14 studies were mapped after extraction of characteristics such as: authors, year and journal of publication, objectives, type of study and strategy reported, study participants and setting, instruments/assessments, and summary of results.

RESULTS
It was found that the publications selected were published from 2012 to 2019 and all were in article format. The studies were predominantly conducted in hospital settings (78.6% of the studies). Other settings included Primary Care and the Fire Service. The majority of articles were published in Brazilian periodicals, and 21.4% were published in foreign periodicals ( Table 2).
The most common type of study was clinical trial, of which there were seven, all conducted in hospitals, six with nursing professionals and one with health professionals and workers from related areas. [17][18][19][20][21][22][23] There were two pilot studies focused on nursing professionals and primary care workers; 24,25 and there were two reports of experience with interventions, one with a group of firefighters and another with primary care workers. 26,27 One study administered a therapeutic intervention to volunteers at a private hospital; 28 another study assessed the influence of auriculotherapy on stress among nursing professionals working in intensive care units; 29 and one study employed a  (Table 2). With regard to the strategies employed, actions were implemented to reduce stress using a range of different practices, such as organizing a wellbeing room at the workplace, 30 educational workshops targeting prevention and management of stress, burnout, and professional exhaustion, 26,27 and stress reduction programs including mindfulness practices and loving kindness meditation. 24,25 Other strategies used were auriculotherapy with seeds and needles, [18][19][20][21][22][23]29 music therapy for stress reduction, 28 and a self-care intervention mediated by the senses 17 (Table 2).
Authors reported that these interventions yielded positive results in terms of stress reduction or were rated positively by participants, although not all studies observed statistically significant stress reduction. [17][18][19][20][21][22][23][24][25][26][27][28][29][30] It was observed that these interventions could also influence other dimensions; for example, increasing quality of life and life satisfaction, and strengthening teams. 17,21,24,27 Table 2 lists the characteristics of the studies reviewed, including their objectives, methodological or procedural aspects, and summaries of their results.

DISCUSSION
The Brazilian studies included in the final sample of this review reported different strategies for prevention/ management of stress and burnout among healthcare professionals. Of the strategies implemented, use of integrative and complementary practices stands out. These types of treatments have been gaining space in Brazil, particularly since 2006, when the National Policy on Integrative and Complementary Practices was approved within the scope of the country's Unified Health System (SUS -Sistema Único de Saúde). 31 In this context, a study with hospital nursing professionals demonstrated that auriculotherapy contributed to reduction of stress levels and/or was capable of minimizing its signs and symptoms. 18   Strategy: three groups -control, protocol (Shenmen, brain stem, kidney, and liver Yang 1 and 2 points) and no protocol (same number of sessions and points, but chosen in accordance to response to treatment).  In another study, with a different protocol to previous studies, auricular acupuncture was used in a stress reduction program together with other strategies, but in this case the reduction in stress was not statistically significant, although the nursing team's occupational stress levels were lowered. 30 Music therapy is another integrative and complementary practice that is now covered by the SUS 32 and researchers report that the practice has benefits for stress reduction. 28 Authors claim that music therapy is not only effective for stress, but also for coping with situations that generate feelings such as anguish and anxiety, contributing to people's wellbeing and to patient-professional interaction. 33,34 As such, it is clear that integrative and complementary practices are being used both for stress reduction and to reduce anxiety, pain, and depressive symptoms. 35 Use of these practices is justified, among other reasons, by the possibility of spiritual wellbeing, improved mood, increased compassion, and improved sleep. 35 Another practice mentioned in these studies was mindfulness, 24,25 which, in addition to its implications for stress reduction, 24,25 has also been described as having positive effects on vitality, emotional regulation, and life satisfaction. 36 This review also identified implementation of educational strategies aimed to aid in understanding stress and burnout and contribute to coping with these situations or conditions. 26,27,30 The strategies employed included educational workshops, lectures, or preventative programs with activities of an educational nature. 26,27,30 It is therefore appropriate to stress that discussions related to care-educational technologies are recent, since for a long time they were dealt with separately, i.e. either care technologies or educational technologies. 37 Nowadays, care-educational technologies are considered an innovative option for design of products and processes, since educating and caring do not have to be dissociated. 37 It should be emphasized that these studies demonstrated many consequences of stress and burnout, such as physical and psychological symptoms among workers, impairment of quality of life, and negative impacts on work processes and on care. 1,13,14 Working from these considerations and the fact that this subject and its implications have only been discussed recently, emphasis is put on the importance of focusing on strategies that demonstrate efficacy and feasibility for reduction of stress and burnout among healthcare professionals.
It is also important to recognize the relevance of new studies describing research conducted and experiences with caring for the health of workers and students on healthcare courses in the realm of prevention and promotion, in addition to provision of care and rehabilitation when conditions have already set in. 38 This is because studies undertaken with nursing and medicine students have demonstrated that many students in these areas already have elevated stress levels and conditions suggestive of burnout before they finish their academic training. 39,40 It is understood that if these individuals are already suffering burnout while still in academic training, it is possible that in the future they will be less empathetic and less attentive to the needs of the users of health services, which can trigger reduced quality of care and sickness among the professionals themselves. 40 It is valid to point out that this review has its limitations. Although attempts were made to ensure identification of relevant studies using several different means, as recommended by the method adopted, 15 the strategies employed may not have been sufficient to identify other studies that make contributions on the subject, but were not included. Moreover, evaluation of the quality of evidence is not one of the objectives of the Scoping Review method. 15

FINAL COMMENTS
This Scoping Review collected recent Brazilian studies that report on strategies for prevention and management of stress and/or burnout among healthcare professionals and highlighted their results using both objective and subjective approaches. The review thus presents possibilities for prevention and management of stress and burnout, describing strategies and their results in healthcare professionals in Brazil. Analysis of prior experiences may offer a guide for future studies or innovative actions.
It was found that published reports exist of research, interventions, and experiences, that describe strategies designed to prevent and intervene in stress and burnout. Among the results reported, use of integrative and complementary practices, educational strategies, and programs for stress reduction stand out. It is considered that, taken together, these publications offer a wider view of strategies that have been implemented and assessed, facilitating analysis of their effects and feasibility. Strategies for prevention and management of stress and burnout are especially necessary, bearing in mind the implications of both these phenomena and their current prevalence, particularly in healthcare settings.

Author contributions
MAB was responsible for study conceptualization, data curation, methodology, formal analysis of data, and writing -original draft of the text. MB was responsible for study conceptualization, data curation, investigation, formal analysis of data, methodology, supervision, and writing -review & editing of the text. The authors have read and approved the final version submitted and take public responsibility for all aspects of the work