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Illness in nursing workers: a literature review

Nursing work is highly relevant to society but is associated with significant suffering as well as physical and emotional demands that often result in illness. In light of these observations, we sought to explore the profile of illness in nursing professionals in Brazil and identify its relationship to working conditions. This was achieved through an integrative literature review of studies in the Virtual Health Library published between 2010 and 2018, retrieved with the keywords “worker,” “nursing” and “illness.” Twenty-one articles were included in this review. Illnesses described by the articles were categorized according to the International Classification of Diseases. Mental and behavioral disorders, as well as diseases of the musculoskeletal system and connective tissues, were the most frequently cited. The working conditions most commonly mentioned in connection with work-related illness were the work organization, team profiles, professional overload, and understaffing. Most studies involved nurses in emergency care, general hospitals, and intensive care units. Gaps in the knowledge on other areas of nursing work and illnesses were identified, demonstrating the need for further studies on the topic to improve workers’ quality of life, and consequently, the quality of the service offered.


intRoduction
Work is a crucial component of individual health and can contribute to the improvement or deterioration of health status. 1 Occupational accidents and work-related illnesses are not new phenomena, "but as old as the exploitation of work itself [free translation]." 2 Nursing is widely recognized as a stressful occupation, as it deals directly with patient suffering and places significant physical and emotional demands on nursing professionals. The long hours and shift work lead some professionals to take up and commit to additional occupational activities, which may lead to exhaustion and, consequently, illness, causing a negative impact on nurse quality of life and the quality of patient care. 3 According to Resolution No. 0564/2017 of the Federal Council of Nursing (Conselho Federal de Enfermagem), 4 "nursing is a science, art, and social practice that is crucial to the organization and functioning of health care services" and its functions include, among other things, the promotion and restoration of health through interventions provided by individual professionals or groups of nursing workers. However, to be successful in their activities, nurses must have adequate working conditions that allow for the provision of adequate professional care and guarantee their right to fair compensation.
The risk of illness in nursing professionals is high, especially for those working in hospital settings who are in close contact with death and must carry out unpleasant and stressful activities. 3 Factors such as night shifts, personnel shortages, structural deficiencies, and high levels of emotional strain are among the contributors to morbidity among nursing workers, who are placed in the difficult position of providing health care at the cost of their own wellbeing. 1 The challenges faced by nurses, especially those involved with the Family Health Strategy (Estratégia Saúde da Família; ESF), include the psychological impact of a high patient-to-nurse ratio and the deficiencies in other health care sectors, all of which have an unfavorable impact on the well-being of public health workers. 5 Nurses in areas such as mental health care have experienced increasing rates of illness as a result of their cumulative years of patient care and involvement in the management of psychiatric institutions since they assist individuals with psychological disorders in addition to being exposed to the same occupational risks as health care workers in other areas. 6 In light of these observations, we sought to explore the profile of illness in nursing professionals in Brazil and identify its relationship to working conditions. methods An integrative literature review was conducted to determine the current state of knowledge on the topic of study by identifying, analyzing, and synthesizing the results of previous studies. This review was performed according to the six stages described by Souza,7 which consist of the following: 1) development of the research question; 2) literature search or sampling; 3) data collection; 4) critical assessment of included studies; 5) discussion of results; and 6) presentation of the integrative review. In the field of nursing, the integrative review is seen as a useful research tool as it meets the methodological requirements of scientific research. The steps involved in this type of study must be rigorously, carefully, and precisely followed to provide a solid basis for the conclusions drawn in the review. This method is especially suited to nursing as it allows for the inclusion of multiple research questions or hypotheses in the same review, which is often necessary due to the complex and multidisciplinary nature of health care work. Furthermore, this method combines findings across studies with different designs and incorporates them in the same review, without neglecting the epistemological basis of the empirical studies analyzed. 8 This review was guided by the following questions: what are the main reasons for disease in nursing workers? Which working conditions are related to these illnesses? Which areas of work are related to these illnesses?
The Virtual Health Library (Biblioteca Virtual da Saúde; BVS) was searched for full-text Portuguese language articles published from 2010 to 2018 using the keywords "worker" (trabalhador) and "nursing" (enfermagem) and "illness" (adoecimento). Seventyfour results were initially obtained. After title, abstract, and full-text screening, 53 duplicate or theoretical studies that did not address the research questions were excluded. This led to the inclusion of 21 articles The articles reviewed were identified by the letter "A" followed by a number to facilitate the presentation of results in this study. The results will be presented descriptively with the aid of charts. Illnesses were categorized according to the International Classification of Diseases (ICD-10).

Results
Of the 21 articles included in this study, four   The processes of illness and suffering discussed by the studies were classified according to the ICD-10, 30 as shown in Chart 2. In addition to the illnesses, we also examined occupational accidents and the human cost of work, which refers to the cognitive, emotional, and physical energy spent by individual workers or groups in the performance of their occupational activities. 27 Two studies mentioned work-related infectious and parasitic diseases (group I). 17,26 The diseases mentioned in the articles were originally zoonoses, which are especially likely to affect agricultural workers and the health care professionals who are directly exposed to patients, their body fluids, and secretions. 30 Workrelated endocrine, nutritional, and metabolic diseases (group IV) were addressed in one article where eight (16.3%) patients reported hypothyroidism; four (8.1%) reported hyperinsulinemia; and two (4%) had diabetes mellitus. 20 Work-related mental and behavioral disorders (group V) were the most frequently mentioned in the studies reviewed (n = 16). The studies in this category included terms such as occupational stress, minor psychological disorders, mental and behavioral disorders, emotional distress, depersonalization, lack of accomplishment, irritability, feelings of fear, stress, depression, discouragement, demotivation, emotional fatigue, sadness, feelings of impotence, suffering, and emotional exhaustion. [9][10][11]13,14,[16][17][18][19][20][21][22]25,26,28,29 Work-related nervous system diseases (group VI) and diseases of the eye and adnexa (group VII) were investigated by two studies each. 14,20,24 Work-related circulatory system diseases (group IX) were discussed in three 14,17,20 studies. In one of these investigations, "the second most common disease was systemic arterial hypertension (SAH), which was reported by seven subjects (14.2%) [free translation]." 20 In the context of cardiovascular illness, individual factors such as sedentary behavior, smoking, and diet have received far more research attention than current or past occupational activities. 30 Four 11,17,26,29 studies mentioned terms related to respiratory system diseases (group X), ou como motivo desencadeador do absenteísmo. Work-related diseases of the digestive system, skin, or subcutaneous tissues (groups XI and XII, respectively), such as dermatitis of the hands, were mentioned by two studies. 17,22 Work-related musculoskeletal system and connective tissue diseases (group XIII) were the second most frequently mentioned issue by studies in this review, with 13 investigations discussing these conditions 10,11,[14][15][16][17]20,[22][23][24]26,28,29 The reviewed studies identified that diseases of the musculoskeletal system were one of the biggest causes of absenteeism among nursing workers.
Work-related genitourinary system diseases (group XIV) were investigated by a single study which concluded that "this problem might be attributable to the fact that this occupation is predominantly female." We also identified studies three studies that discussed occupational accidents. 22,26,29 In these investigations, accidents are described as "the main cause of absence due to toe fractures, sprains in different parts of the body, and falls, which demonstrate the lack of safety in the hospital environment." 26 Attention must also be paid to categories that do not refer to an illness per se, such as the physical costs of labor, defined as the "physiological and biomechanical efforts imposed on workers by the context of production" 27 which was moderately associated with the risk of illness. Similarly, cognitive costs "constitute the second factor of the ECHT scale and represent the intellectual efforts dedicated to learning, problem resolution. and decision-making in the workplace." 27 The same article found that emotional costs, "defined as the emotional expenditure required by affective reactions, feelings and mood states," 27 were moderately associated with illness in nursing professionals.
The absence of articles regarding work-related neoplasms (tumors), diseases of the blood and bloodforming organs, and diseases of the ear (groups II, III, and VIII, respectively) should not be interpreted as an indication that nursing workers are not affected by these conditions, and should instead encourage further studies on the topic. However, it is also possible that the lack of articles on these illnesses is due to the method used in this literature review.
In addition to categorizing disease processes, we also listed the working conditions to which nursing workers are exposed according to the articles reviewed (Chart 3). Studies that did not address working conditions were not included in the chart. Articles that addressed more than one condition were included in all corresponding categories.
The patient profile category includes factors such as patients who relapse into substance use, idleness, and norm violations (especially in the case of psychiatric patients), all of which were identified as stress triggers. 9 Workplace structure refers to issues such as a lack of material resources, inadequate physical space, environmental pollution, and inadequate ergonomic conditions.
Team profile and work organization were the most frequently discussed contributors to illness. This  category included a total of 12 articles. [9][10][11][13][14][15][16][21][22][23]26,29 These studies mentioned a lack of training among professionals; difficult team relationships; manipulation of sharp instruments; repetitive work; night work; psychological pressure due to the high psychological demands of the job; low control over occupational activities; constant demand for results and supervision of performance; and the need to deal with suffering, patients' relatives, and workplace violence. One study noted that "intra-and intergroup relationships can trigger conflicts since, although all members of the team share the same goals, they have different perspectives and ways of seeing the world." 21 Professional overload and understaffing were most commonly discussed using terms such as personnel shortage, occupational overload, fast-paced work, long shifts, long hours, and excessive tasks. This was the second most commonly cited category, and appeared in nine articles 9,11,13,14,16,19,21,23,26 : "The professionals engage in a variety of fragmented activities, resulting in occupational overload and accelerated work." 23 The job plan, career plan, and wages category included variables such as length of employment, professional devaluation, low pay, lack of recognition, and lack of support. Four 11,14,19,21 articles mentioned items in this category, with one study affirming that the expectation of recognition by the institution can lead workers to feel dissatisfied and distressed when this expectation is not met. 14 The third classification system focuses on the area of work of the nursing professionals studied in the articles reviewed (Chart 4). Studies that did not address the area of work of nursing professionals were not included in the chart. Articles that discussed more than one area of work were included in all corresponding categories.
The areas of work addressed by the studies were also organized into categories. The most frequently mentioned areas were urgency and emergency care (six articles), 9,13,14,17,19,25 followed by intensive care units, 17,20,21,25,27 and general hospitals, 11,14,24,26,28 discussed by five articles each. Teaching hospitals (three articles) 11,14,17 and inpatient units (two articles) 9,10 were also analyzed. Nurses employed in primary care, 11 psychiatric hospitals, 12 hemodialysis services, 14 oncology units, 14 mobile urgent care, 15 and long-term care institutions 18 were evaluated by one study each.

discussion
The main causes of illness among nursing workers were mental disorders resulting from a work process in which these professionals must routinely deal with stressors such as excessive activities, a high emotional load, constant demands, and patient vulnerability. 31 All nursing professionals face similar stressors regardless of their area of work. 32 The pressure from superiors, feelings of impotence in the face of pain and death, and a lack of time for rest and leisure further increase their levels of stress, contributing to the results observed in this review. Nurses and nursing teams show higher levels of emotional exhaustion, depersonalization, and lack of accomplishment than other workers involved in direct patient care. 31 Work-related musculoskeletal system and connective tissue diseases were the second most commonly cited in the studies reviewed and were highly prevalent in nursing workers. Musculoskeletal symptoms were reported by 91.81% of nursing workers in one study 33 where most individuals reported pain in the low back, shoulder, or neck. Factors related to the organization of work, such as an accelerated pace, high levels of pressure, and the small number of workers, also contributed to participants' symptoms. The authors noted that "back muscles suffer the most during heavy lifting since when we lift objects with our hands, the effort is transferred to the spinal column [free translation]." 33 Nurses are frequently exposed to these activities, resulting in negative effects on their health.
Working conditions that may increase the likelihood of disease in nursing workers include the interpersonal relationships in the team, which can have a positive influence on work when relationships are harmonious, but a negative influence when they are tense and unpleasant, as this interferes with professional practice and development. 34 Interpersonal relationships can be a source of weakness for the team when there are communication difficulties in the work environment. 35 Another factor that negatively affects worker health is night work. It is "inherent to the work of nurses, especially those in hospital settings, for whom the provision of 24-hour care can be tiresome and exhausting [free translation]." 36 Studies show that a single night of sleep cannot reverse the effects of a 12hour night shift and that daytime sleep is fragmented and unrefreshing, and does not provide sufficient rest. The lack of a fixed sleep schedule leads to circadian rhythm disorders, which increase vulnerability to issues such as gastric dysfunction, physiological and psychological disorders, and aging. 36 Another feature of the work organization in nursing is the high frequency of occupational violence, especially in emergency care settings. The most common form of violence directed at nursing professionals is verbal aggression, followed by mobbing, sexual harassment, and racial discrimination, which are most frequently reported by nurses, followed by nursing technicians and assistants. 37 Most of these acts are perpetrated by patients, patients' relatives or companions, colleagues of equal rank, and, least frequently, by managers or bosses. 37 Professional overload and understaffing were also mentioned by several studies as contributors to illness in nursing professionals. 9,11,13,14,16,19,21,23,26 However, a study in Brazil has reported a 5% unemployment rate among nurses, which corresponds to over 100 thousand workers. These figures are higher in some regions of the country due to the unequal distribution of the nursing workforce in Brazil. 38 On the other hand, some individuals work long and strenuous hours, which can exceed 40 or even 60 hours a week, even for those who only have one job. 38 The reason that most of the studies in this review have conducted their investigations in hospital departments, such as emergency and intensive care units, can be explained by the fact that the hospital is the place where nurses carry out most of their activities, even though nursing work is tiresome and exhausting, especially in hospital settings.
Machado et al. 38 observed that "even though nursing work is tiresome and exhausting, especially in hospital settings, this is where nurses carry out most of their activities," which may explain why most studies in this review were conducted in hospital departments such as emergency and intensive care units. However, this does not mean that illness is not an issue in other areas of nursing work. A study that addressed the work of nurses in ESF teams concluded that "the increase in work hours and the overload of nursing professionals affects the efficacy and quality of care as well as the way patients are received and treated in health services, consequently affecting the quality of access." 39 Nurses in the field of teaching can also be negatively affected by issues pertaining to interpersonal relationships. 40 The lack of studies on these topics in the present review may be due to the search strategy used, or an actual lack of these studies in the literature.

RefeRences conclusions
The illness profile of nursing workers is mainly characterized by mental and behavioral disorders as well as musculoskeletal and connective tissue diseases. The working conditions that contribute most significantly to the onset of these disorders are the work organization and the conditions of teamwork, as demonstrated by most of the studies reviewed. Some occupational illnesses appear to have been far less studied, with neoplasms, ear diseases, and blood disorders not discussed by any of the studies included in this review. However, this may be due to the search strategy used in this review or the difficulty in determining whether these diseases are related to work. The same can be said of studies on different areas of nursing work since most studies focused on hospital workers.
This study makes a relevant contribution to the field of occupational health in nursing by demonstrating the forms of illness that affect these professionals and the work conditions to which they are exposed. Gaps in the knowledge on other areas of nursing work and illnesses were identified, demonstrating the need for further studies on the topic to improve workers' quality of life, and consequently, the quality of the service offered.