Abstract
Stress is the result of the relationship between the individual and the productive environment, interfering in professional capacity and quality of life. This study aimed at analyzing the impact of stress on the quality of life and health behavior of multiprofessional residents of a university hospital. This is a cross-sectional, quantitative study conducted with all multiprofessional health residents (RMS) (n = 98) of a teaching hospital. Validated questionnaires were used: WHOQOLBREF, evaluating quality of life; National College Health Risk Behavior Survey, to evaluate health behaviors and the 'Lipp Adult Stress Symptom Inventory' for stress evaluation.Student's t-test, chi-square and Fisher's exact tests were applied, obtaining that most (n = 63; 64%) of the RMS showed no sign of stress and 46% (n = 35) some level of stress, being 85% in the resistance phase. Stressed RMS were found to have significantly lower QoL in the physical, psychological, and overall QoL domains (p <0.05). Health behaviors were associated to stress only with suicide attempt (p = 0.0005), other behaviors: tobacco usage, eating behavior, physical activity, alcohol and other drugs usage, sexual behavior, safety in the workplace, traffic and violence-related behaviors were not associated (p> 0.05). It is concluded that the decrease in the quality of life of stress-stricken RMS is worrying, and even with few changes in health behavior with exposure to stress among the investigated, it is defended the relevance and severity of the finding in relation to the variable attempt to suicide.
Keywords: Stress to life aspects; Quality of life; Health Conducts; Specialization; Professional Training in Health.
Resumo
O estresse é resultado da relação entre o indivíduo e seu ambiente produtivo interferindo na capacidade profissional e na qualidade de vida. O presente estudo objetivou analisar o impacto do estresse na qualidade de vida e condutas de saúde de residentes multiprofissionais de um hospital universitário. Trata-se de um estudo transversal, quantitativo, realizado junto a totalidade de residentes multiprofissionais em saúde (RMS) (n=98) de um hospital de ensino. Utilizou-se questionários validados: WHOQOL-BREF, avaliando-se a qualidade de vida; National College Health Risk Behavior Survey, para avaliar condutas de saúde e o 'Inventário de Sintomas de Stress para Adultos de Lipp' para avaliação do estresse. Aplicou-se testes t de student, qui-quadrado e exato de Fisher, obtendo-se que a maioria (n=63; 64%) dos RMS não apresentou nenhum sinal de estresse e 46% (n=35) algum nível de estresse, sendo 85% na fase resistência. Verificou-se que os RMS com estresse apresentaram QV significativamente menor nos domínios físico, psicológico meio ambiente e QV global (p<0,05). Às condutas de saúde, houve associação de estresse apenas com tentativa de suicídio (p=0,0005), as demais condutas: uso do tabaco, comportamento alimentar, prática de atividade física, uso do álcool e outras drogas, comportamento sexual, segurança no trânsito e comportamentos relacionados à violência, não apresentaram associação (p>0,05). Conclui-se que a queda na qualidade de vida dos RMS com estresse é preocupante, e mesmo com poucas mudanças de condutas de saúde com a exposição ao estresse entre os investigados, defende-se a relevância e a gravidade do achado em relação à variável tentativa de suicídio.
Palavras-chave: Estresse Relacionado a Aspectos da Vida; Qualidade de Vida; Condutas de Saúde; Especialização; Formação Profissional em Saúde.
1 Introduction
Current definitions include stress as a set of organism's physical and emotional reactions to aggressions and challenging situations of diverse origins that can disturb the internal balance (Katsurayama, Gomes, Becker, Santos, Makimoto & Santana, 2011).
Specifically in the work environment, stress results from the wide and complex relationship between the individual and their productive environment, and when demands in this field exceed the individual's ability to cope with them, there may be excessive wear on the body, with interference on professional capacity (Freitas, Silva Junior & Machado, 2016) and quality of life (QoL) (Lipp, 2001; Sadir, Bignotto & Lipp, 2010).
In the context of Higher Education and Health Postgraduate, discussions are directed more intrinsically to the quality of life of students, considering the confrontations with the high demands of academic work, the emotions involved in treating patients and the learning of new clinical skills (Faro, 2013).
In fact, general studies on the stress phenomenon cover not only the consequences on the human body and mind, but also broad implications for the human living and illness process, and may affect individual and collective health behaviors, quality of life, feeling of well being (Lipp, 2001) and productivity (Abreu Stoll, Ramos, Baumgardt & Kristensen 2002; Freitas, Silva Junior & Machado, 2016), modifying the relationships of the individual in the family area (Leonelli, Andreoni, Martins, Kozasa, Salvo, Sopezki , Montero-Marin, Garcia-Campayo, & Demarzo, 2017), in the field of studies, work (Freitas, Silva Junior & Machado, 2016) and social interactions (Auerbach, Alharbi, & Irshad, 2012).
In this bias, it should be considered that residents of different health professional áreas, focus of the present study, occupy the position of students and professionals simultaneously, facing characteristics of this multiple scenario such as curricular and work overload, the lack of time for academic and personal life, and uncertainties regarding future professional insertion, being factors that can affect their psychosocial adjustment (Pomini, Bordin, Saliba, Moimaz & Fadel, 2018).
In the context of this study and work context, typical of the Multiprofessional Health Residency (RMS) programs, stress and anxiety have also been associated to negative indicators of health behavior, such as increased drug and alcohol usage (White & Hingson , 2013), weight changes (Mori, Cruz, Baptista, Teixeira & Lauria, 2017; Sousa & Barbosa, 2017), non-development of physical activity, improper diet habits, and unhealthy lifestyles in general (Frates, Xiao, Sannidhi, McBride, McCargo & Stern, 2017), indicating social exhaust valves (Pomini, Bordin, Saliba, Moimaz & Fadel, 2018).
Despite these implications, researches that understand the relationship between tensions in the professional environment and health behaviors have been poorly studied (Santana-Cardenas, 2016), and even more scarce in the RMS universe.
Thus, being Multiprofessional Health Residencies a new scenario of collective and multidimensional spaces that involve the association of teaching, learning and work activities (which can be stress triggers), the present study aims at analyzing the impact of stress on quality of life and health behaviors of multiprofessional residents of a university hospital.
2Methodology
The present study is configured in a cross-sectional survey, using a quantitative, exploratory and analytical methodology, being developed among all multidisciplinary residents of a teaching hospital in the state of Paraná, Brazil (n = 98), in 2018.
The multiprofessional residency programs of this institution cover the training areas: Physiotherapy, Pharmacy, Physical Education, Nursing, Social Work, Speech Therapy and Dentistry.
Data were collected by a trained researcher, collectively, in the classroom, at which time the residents were previously informed about the research objectives, their voluntariness and non-identification character, data collection, analysis and destination. Those who agreed to participate completed and signed the free and informed consent form.
To this end, three questionnaires were used: the 'Lipp Adult Stress Symptom Inventory' used for stress screening, proposed and validated by Lipp (2000). The questionnaire has 53 physical and psychological symptoms that occur in the last 24 hours, last week and last month. The WHOQOL-BREF, a tool promoted by the World Health Organization for Quality of Life Evaluation and validated in Brazil (Fleck, Louzada, Xavier, Chachamovich, Vieira, Santos, & Pinzon, 2000) is composed of 26 questions grouped into four social relations domains, psychological, physical and environmental; and evaluation of overall quality of life. Each domain is made up of questions whose answer scores range from one to five. And, "National College Health Risk Behavior Survey" (NCHRBS), validated by Franca & Colares (2010), which evaluates health behaviors such as tobacco usage, eating behavior, physical activity, alcohol and other drug usage, sexual behavior, traffic safety and behaviors related to violence.
Stress data were analyzed following the proposal of the proponent author of the instrument, which tracks patients without stress and those with stress, and the latter are framed in stages of evolution (alertness, resistance, near-exhaustion and exhaustion) (Lipp, 2000). Stress was considered as a dependent variable, which was dichotomized into: 'no stress' and 'stress'. In the group "with stress" were individuals who presented stress indices, regardless to the evolution phase. A single stress group was chosen because 88% of the sample was concentrated in the resistance phase.
The independent variables were the QoL domains and the 36 health conducts. The QoL data were treated according to the recommendations of the World Health Organization (Pedroso Pilatti, Gutierrez, & Picinin, 2010). The variables of health behaviors did not undergo treatment and were individually assessed later.
To compare stress and QoL domains, QoL domains were averaged according to the presence of stress and the unpaired student's t-parametric test was applied, since the data presented normal distribution to the KolmogorovSmirnov test. Stress and health behaviors were analyzed using frequency distributions and Fisher s exact and chisquare tests. For all tests, a significance level of 5% was considered.
The study was approved by the Ethics Committee on Research with Human Beings of a Higher Education Institution (Opinion No. 2,461,494/2018), respecting the dictates of Resolution 466/12 of the National Health Council.
3Results
The final sample consisted of 98 multiprofessional health residents. Most respondents were female (n = 86; 88%); unmarried (n = 77; 79%), with na average age of 25.8 years (21 ± 46).
Most RMS (64%) showed no sign of stress, (36%) some level of stress, 85% were in the resistance phase, 9% in the near exhaustion phase, and the others in the alert and exhaustion phases. (Table 1). The results also showed 94% (n = 33) of residents with stress showed psychological symptoms and only 6% (n = 2) physical events.
Table 02 shows that the quality of life of residents with stress has lower QoL in all domains assessed, with significant difference for the physical, psychological, environment and overall QoL domains (p <0.05).
Table 03 shows the distribution of residents according to health and stress behaviors. It was found that in the grouping of the eight variables consistent with traffic safety and violence, only suicide attempt was significantly associated to the group of individuals with stress (p <0.0005).
In the set of variables related to the consumption of tobacco, alcohol and other drugs, of the 12 variables analyzed with the presence of stress, none showed a significant association (p> 0.05). Similar condition was observed in questions related to sexual behavior and diet, physical activity and weight (p> 0.05) (Table 2).
4Discussion
In the present study, the universe of multiprofessional resident in health was widely evaluated, bringing into discussion the influence of stress on quality of life and health behaviors, an unprecedented approach to the group in study.
In the literature, there are few studies with emphasis on the health of multiprofessional residents in health, given the recent implementation of the programs by government entities. Thus, the unprecedented reflects the importance of launching in-depth discussions about the subject so that healthy conditions and learning environments can be guaranteed to those who experience this different formative process of professional qualification.
Immediately, attention is drawn to the high prevalence of stress found among RMS, reaffirming the hypothesis that the universe and the process that permeates multiprofessional residency in health constitute etiological factors to stress. This condition is also observed in studies with postgraduate students (Paulino, Prezotto, Frias, Bataglia, & Aprile, 2010; Ribeiro, Pereira, Freire, Oliveira, Casotti, & Boery, 2018).
However, most of the investigated subjects who presented stress were in the resistance phase, recognized by the disruption of the organism's intrinsic balance and considered the initial phase of the phenomenon (Cahú, Santos, Pereira, Vieira & Gomes, 2014). According to the world literature, it is at this stage that the subjects with stress are commonly found (Serinolli, Oliva & El-Mafarjeh, 2015; Sousa, Cury, Oliveira, Salatiel, Santos, Santos, Silva & Silva, 2017; Santana , Beljaki, Gobatto, Haeffner, Antonacci & Buzzi, 2018), and favorably, individuals who are in the resistance phase are more likely to reestablish normal functional conditions if appropriate and timely intervention is performed.
Thus, it is indispensable, firstly, to understand stress as a condition that deserves special attention, and subsequently, to pay attention to stress-predisposing factors, which induce the individual to experience unsatisfactory routines, so that effective changes in the form of stress may be achieved living and working are performed on a daily basis, with a view to reducing these alarming prevalences (Wahed & Hassan, 2017; Freitas, Silva Junior & Machado, 2016; Teixeira, Souza & Viana, 2018).
Stress has the potential to significantly affect various spheres of life, such as quality of life, a condition observed in the present study. The impact of stress on residents' QoL was so significant that when compared the scores of the quality of life domains between the stressed and non-stressed groups, the stressed subjects had significantly lower values for almost all investigated domains, including the quality of life. global life, which encompasses all dimensions evaluated, except in the domain of social relations.
The findings are consistent with a systematic review that showed in all analyzed articles a negative association between stress and quality of life of college students, concluding that stress is capable of incisively degrading various aspects related to human physical and mental health (Ribeiro, Pereira, Freire , Oliveira, Casotti, & Boery, 2018). The authors still point out that stress is common among college students, regardless of their level of education and that added to this factor, the period in which the subject is in the student figure suffers pressures for taking time off to study, without guarantee of satisfactory return (Ribeiro, Pereira, Freire, Oliveira, Casotti, & Boery, 2018). This pressure can lead to a worse perception of QOL in its various aspects (health, physical, psychological, environmental and social aspects) (Ribeiro, Pereira, Freire, Oliveira, Casotti, & Boery, 2018).
As mentioned above, the social relations domain was not impacted by stress to the investigated residents. The routine sustained in a shared space, of help and mutual exchange of knowledge, experiences, feelings and experiences, transcending what is called social support, and confers the core of multiprofessional residency programs in health, in analysis may be a protective factor to maintain the quality of life in this dimension, since social support facilitates coping with crises and changes in life and helps with adaptation.
In the present study, the psychological domain was the most affected by stress. Reduced QoL in this domain was expected to be significantly linked to stress levels, as the issues that address this domain, related to feelings, cognition (thinking, learning, memory and concentration), self-esteem, body image and appearance (Fleck, Louzada, Xavier, Chachamovich, Vieira, Santos, & Pinzon, 2000) configure aspects that guide stress screening, as in the case of the instrument used (Lipp, 2000).
The low quality of life in the psychological field, portrayed by stressful RMS, can be triggered and or aggravated by the various critical situations to which they are exposed in their work routines, when experiencing situations of intense suffering and death (Paro & Bittencourt, 2013; Silva, Tavares, Alexandre, Freitas, Breda, Albuquerque & Melo, 2015; Almeida, Benedito & Ferreira, 2017); in dealing with the insecurity arising from the transition from new graduate to professional lacking experience with great responsibility within the service; lack of autonomy; charging for practical skills; academic pressure, perfectionist standards, and the demanding nature of health practice; and frustration about not meeting expectations (Silva, Tavares, Alexandre, Freitas, Breda, Albuquerque & Melo, 2015; Sanches, Ferreira, Veronez, Koch, Souza, Cheade, & Christofoletti, 2016; Ribeiro, Pereira, Freire, Oliveira, Casotti, & Boery, 2018).
Quality of life in the physical and environmental domains was also lower among residents with stress, showing that stress negatively influences sleep and rest, work ability, physical safety, and recreation and health care activities, in line with the findings and findings. reinforcing that QoL impairment in these domains may lead to increased health problems, irritability, depression, fatigue, reduced attention and concentration and poor academic and professional performance (Ribeiro, Pereira, Freire, Oliveira, Casotti, & Boery, 2018). The 60-hour weekly workload of the residence, the specificities of multiprofessional residency and the high demand for activities support and may justify these findings (Abdulghani, Alharbi, & Irshad, 2015; Brigola et al., 2016), as they influence job satisfaction. and lack of time for the development of decisive activities for a satisfactory QoL.
However, when evaluating the impact of stress on health behaviors, it was found that for most unhealthy health behaviors, stress was not associated to. This result may reflect that lifestyle habits related to road safety and violence, licit and illicit drug use, sexual behavior, diet, physical activity and weight are more difficult to change quickly, and often are rooted from time to time in the subject's daily life and these behaviors may be more influenced by other factors, such as individual, social, historical and cultural preferences (Borine, Wanderley & Bassitt, 2015; Benavente, Silva, Higashi, Guido & Costa, 2017 ; Belem, Rigoni, Santos, Vieira & Vieira, 2016).
Unlike the suicide attempt, which is directly related to stress, a well-established condition worldwide and strongly linked to the academic universe and health professions (Smith, Smith-Carter, Karczewski, Pivarunas, Suffoletto & Munin, 2014; Who, 2014; Tang & Qin, 2015; Vasconcelos-Raposo, Soares, Silva, Fernandes & Teixeira, 2016; Teixeira, Souza, & Viana, 2018). According to Sudol & Mann (2017), subjects with high levels of stress predispose to presenting signs such as anxiety, anger, hopelessness, low ability to deal with adverse situations and psychic reactions of the most diverse. And when in persistent circumstances, stress can alter the concentrations of noradrenaline, serotonin, dopamine and their receptors, which can culminate with suicidal thinking (Sudol & Mann, 2017).
However, there are several other risk factors for suicide besides stress that should be considered, such as social stigma, trauma, abuse, lack and/or difficulty of social support, troubled interpersonal relationships, mental disorders, history of suicide attempts, hopelessness and family history of suicide (Who, 2014). In addition, the risk factors for suicidal idealization are conditions that are often experienced by RMS, such as living alone, living away from family (Vasconcelos-Raposo et al., 2016), suffering academic pressures and difficulties (Abdulghani, Alharbi, & Irshad, 2015; Brigola et al., 2016).
Suicide is considered a serious public health problem, as its incidence is increasing (Teixeira, Souza, & Viana, 2018). In the universe of university students, the study by Gonçalves (2014) found a prevalence of 6.5% for suicidal idealization, a value similar to that found in the present study. And according to the integrative review, when it comes to health professionals, the suicide rate is significantly higher at the expense of the general population (Silva, Tavares, Alexandre, Freitas, Breda, Albuquerque, & Melo, 2015). In addition, suicide is an injury that is difficult to prevent, given the complexity of discovering the imminent risk of suicidal behavior and the need for multifactorial and intersectoral action (Silva, Tavares, Alexandre, Freitas, Breda, Albuquerque & Melo, 2015; Teixeira , Souza, & Viana 2018).
This result reflects the imminent need to invest in public health policies as well as educational, for the case of residents, that foster guiding strategies along the risk factors for suicidal idealization, and this includes mainly stress, seen as a potential trigger for the execution of the act (Vasconcelos-Raposo, Soares, Silva, Fernandes, & Teixeira 2016; Brazil, 2017; Teixeira, Souza, & Viana 2018). Among the practices, it is necessary to elucidate discussions about the subjects' awareness about mental health, addressing the theme suicide, self-knowledge, demystification of prejudices about mental disorders and depression; and qualify health services for adequate and timely reception of subjects with suicidal ideation (Opp, 2013).
Given the above, it was found that stress, even at the initial level of evolution, had a high impact on the health of multiprofessional residents in health, especially on quality of life and suicidal idealization, denoting a great warning sign to the urgent need decision-making to change these indicators. Since, if the RMS continues to be exposed to stressors and does not have strategies to deal with the stressful situation, they will be subject to the exhaustion and progression of stress levels, leading to illness (Lipp, 2003) and consequent progressive changes in stress. their health behaviors, professionals and quality of life (Silva, 2010).
It is noteworthy that even though the data are representative of an educational institution, they can be expanded to other institutions, because the literature was in line with the findings elucidated here.
In this sense, it is important to promote stress prevention actions in educational institutions, especially in teaching hospitals that work with the dual function, teaching and service, which allow residents to have a better quality of life (Vieira & Schermann , 2015). Encourage physical activity, meditation, group therapy (Carpena & Menezes, 2017; Wang, Zhou, Yu, Ran, Liu & Chen, 2017; Fan, Tang & Posner, 2014; Greeson, Juberg, Maytan, James & Holly, 2014; Regehr, Glancy & Pitt, 2013), as well as enhancing strategies that promote good health behaviors, especially awareness (Campos, Isensse, Rucker, & Bottan, 2016), among residents may be quite viable alternatives for this end.
It is noteworthy that the institution evaluated after recognizing these data, implemented a group mental health monitoring program and rethought some pedagogical practices with a view to making the RMS environment more humane and healthy.
5CONCLUSION
The multiprofessional residents in health had a high prevalence of stress, mostly at the level of evolution in the pre-pathological stage, resistance phase.
Even in its early stages, stress has the potential to significantly affect various fields of quality of life, with emphasis on overall quality of life and the psychological, physical and environmental domains. Regarding to the impact of stress on health behaviors, the vast majority of health behaviors analyzed in the present study had no significant association, only suicide attempt, a variable that outlines severity.
Thus, it is suggested to managers of multiprofessional households to recognize stress as a disease propellant and quality of life reducer of their RMS and to invest in the evaluation of risk factors for stress in the universe that permeates RMS and multifactorial strategies which aim at reducing sources of stress and (re)achieve the quality of life of residents.
Corresponding Author:
Danielle Bordin
Department of Nursing and Public Health, Ponta Grossa State University. Carlos Cavalcante 4748, Block M, Uvaranas Campus, Ponta Grossa, PR 84030-000, Brazil. Phone: (42) 3220-3104. Email: [email protected]
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Abstract
Stress is the result of the relationship between the individual and the productive environment, interfering in professional capacity and quality of life. This study aimed at analyzing the impact of stress on the quality of life and health behavior of multiprofessional residents of a university hospital. This is a cross-sectional, quantitative study conducted with all multiprofessional health residents (RMS) (n = 98) of a teaching hospital. Validated questionnaires were used: WHOQOLBREF, evaluating quality of life; National College Health Risk Behavior Survey, to evaluate health behaviors and the 'Lipp Adult Stress Symptom Inventory' for stress evaluation.Student's t-test, chi-square and Fisher's exact tests were applied, obtaining that most (n = 63; 64%) of the RMS showed no sign of stress and 46% (n = 35) some level of stress, being 85% in the resistance phase. Stressed RMS were found to have significantly lower QoL in the physical, psychological, and overall QoL domains (p <0.05). Health behaviors were associated to stress only with suicide attempt (p = 0.0005), other behaviors: tobacco usage, eating behavior, physical activity, alcohol and other drugs usage, sexual behavior, safety in the workplace, traffic and violence-related behaviors were not associated (p> 0.05). It is concluded that the decrease in the quality of life of stress-stricken RMS is worrying, and even with few changes in health behavior with exposure to stress among the investigated, it is defended the relevance and severity of the finding in relation to the variable attempt to suicide.
