International International Archives of Medicine 2016

Medical Society Section: Psychiatry & Mental Health Vol. 9 No. 240
http://imedicalsociety.org ISSN: 1755-7682 doi: 10.3823/2111

Work Loads of Nursing Professionals in Hospital

Services for Mental Health: an Integrative Review
ORIGINAL

Yanna Gomes de Sousa1, Soraya Maria de Medeiros2,

Sandra Michelle Bessa de Andrade Fernandes3, Jonas Sami Albuquerque de Oliveira3,
Milva Maria Figueiredo de Martino2

1  Nurse. Master student of the Graduate

Program in Nursing, Federal University
Abstract of Rio Grande do Norte/UFRN. Natal
(RN), Brazil.
Objective: To identify the available evidence in the literature on 2  Nurse. Ph.D. in Nursing. Professor of
the Department of Nursing, Federal
the workloads that nursing professionals are exposed in hospital University of Rio Grande do Norte/
mental health services and their impact on the safety of patients in UFRN. Natal (RN), Brazil.
mental distress. 3  Nurse. P.h.D. Teacher’s of Nursing
Department of the Federal University
of Rio Grande do Norte, Natal, Rio
Method: This is an integrative literature review in the databases Grande do Norte, Brazil.
LILACS, CINAHL, SCOPUS (Elsevier), PUBMED, ScienceDirect (Elsevier),
Web of Science (Main Collection - Thomson Reuters Scientific), avai- Contact information:
lable in full in electronic media between January and March 2016
using the descriptors “nursing staff”, “health worker”, “workloads” Yanna Gomes de Sousa.
and “mental health services” reaching the final sample of 08 articles.
[email protected]
Results: The following workloads in mental health services were
identified: biological, physical, physiological, mechanical and psycho-
logical burden, such causing emotional distress of professionals, acci-
dents and health problems directly on the quality of care and safety
of psychiatric patients.

Conclusion: The development of this study found that nursing

professionals involved in mental health services had various types of
workloads in their work process, being psychic as the most present.
From this study, it is observed the need of a better attention to the
existing working conditions in mental health services, searching for
solutions that provide occupational health and safety for workers.

Keywords
Nursing Team; Worker´s Health; Workloads; Mental Health Services.

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 International Archives of Medicine 2016
Section: Psychiatry & Mental Health Vol. 9 No. 240
ISSN: 1755-7682 doi: 10.3823/2111

Introduction There is an urgent need for studies addressing the

The health work involves a collective practice that extent and nature of nurses´ roles in improving pa-
aims to promote the health of people, their fami- tient safety [7].
lies, and community. It works by the relationships In the psychiatric context the current situation of
among professionals in the health services and nursing work is characterized by the transition from
society, permeated by technical and interpersonal care practice within the psychiatric hospital that ai-
actions. Therefore, it must be understood in its ob- med to user behavior containment of mental dis-
jectivity and subjectivity way [1]. tress service for the incorporation of new principles,
The dynamics of the health work has been deter- which seek to adapt to an interdisciplinary practice,
minant for the development of workloads among open to the contingencies of the subjects involved
workers. Workloads constitute the elements of in each moment and in each context, overcoming
the work process that dynamically interact with the disciplinary perspective of their actions, this new
each other and with the worker´s body, triggering perspective comes up with the Brazilian Psychiatric
changes in the health and disease process. They is Reform.
classified into external materiality loads (physical, To contributed and join efforts for continuous im-
chemical, biological and mechanical) and internal provement of nursing care in mental health services
materiality loads (physiological and psychological) and aimed at quality and safety, the development
[2]. of research addressing this theme will discuss and
The workloads in the work processes are not only strengthen communication between health profes-
added, but they potentiate and give consistency to sionals and ensure safety in the environment of the
the production process, characterizing it specifica- mental health services. Also, it provides improved
lly, and may incur in the event of accidents and/or decision-making; a care process aimed at more re-
work-related diseases and also to impair the quality liable professional practices [8].
of assistance and consequently the safety of the Despite efforts towards to investigate the implica-
patient. [3,4] tions of the workload nursing team in patient safe-
The international literature [5] shows that the ty, yet remain many gaps in this area of knowledge.
term patient safety involves, in general, to prevent There is an urgent need for studies addressing the
errors in the care and elimination of damage to extension and nature of nurses’ roles in improving
patients for such errors. The error in health care patient safety
results from unintentional actions caused by some In this sense, the question is what the current
problem or failure during patient care and may be literature to bring the workload of nursing profes-
made by any member of the team and occurring at sionals and what are the impacts of these loads to
any time in the care process. the safety of patients in mental distress?
The focused debate on the association between Thus, this study aimed to identify the theoretical
the nursing staff workload and patient safety is production about the workload of nursing profes-
one of the most persistent themes in health, sionals, evaluating the results of these studies to
mobilizing resources from the World Health Or- identify effects of these loads for the safety of pa-
ganization (WHO) [6] and nursing organizations tients in mental distress.
worldwide. The objective is to contribute to research that put
Despite there are efforts to investigate the impli- in evidence the harmfulness of workloads for the
cations of nursing staff workload in patient safety, mental and physical health of nursing professionals
there are still many gaps in this area of knowledge. working in mental health services and the possible

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 International Archives of Medicine 2016
Section: Psychiatry & Mental Health Vol. 9 No. 240
ISSN: 1755-7682 doi: 10.3823/2111

consequences for the quality of care and conse- studies and offer subsidies to the advancement of
quent safety of the patients in mental distress. nursing in the context of mental health. [9]
This research method includes six phases: the-
me identification or guiding question; sampling or
Method searching the literature; categorization of studies;
The integrative review is a research method that assessment of included studies; interpretation of
allows establishing a synthesis and general conclu- results and synthesis of knowledge evidenced in
sions regarding a particular study area, performed analyzed articles [10].
in a systematic and orderly way to contribute to the The literature search took place between January
knowledge investigated. and March 2016, by the following databases: Latin
This type of evaluation should follow the same America and the Caribbean Literature (LILACS), Cu-
methodological standards of the original research, mulative Index to Nursing and Allied Health Litera-
considering the aspects of clarity, so that the reader ture (CINAHL), Scopus (Elsevier), National Library of
can identify the actual characteristics of the selected Medicine - PUBMED ScienceDirect (Elsevier), Web of

Figure 1: S ynthesis of the extraction process in the databases, searching in SCOPUS, PUBMED, LILACS,
SCIENCE DIRECT, WEB OF SCIENCE and CINAHL. Natal-RN, 2016.

Articles identified in the consulted databases

(N= 12,293)

SCOPUS PUBMED LILACS Science Web Of CINAHL

4,252 1,030 568 Direct Science 1,117
4,091 1,235

#1AND#2 = 887 #1AND#2 = 77 #1AND#2 = 233 #1AND#2 = 1.255 #1AND#2 = 113 #1AND#2 = 301
#1AND#3 = 1.578 #1AND#3 = 352 #1AND#3 = 14 #1AND#3 = 965 #1AND#3 = 560 #1AND#3 =363
#1AND#4 = 825 #1AND#4 = 142 #1AND#4 = 84 #1AND#4 = 799 #1AND#4 = 75 #1AND#4 = 239
#2AND#3 = 220 #2AND#3 = 124 #2AND#3 = 57 #2AND#3 = 430 #2AND#3 = 114 #2AND#3 = 60
#2AND#4 = 586 #2AND#4 = 192 #2AND#4 = 176 #2AND#4 = 408 #2AND#4 = 280 #2AND#4 = 124
#3AND#4 = 156 #3AND#4 = 143 #3AND#4 = 04 #3AND#4 = 234 #3AND#4 = 93 #3AND#4 = 30

1ª Exclusion
Inclusion and Exclusion Criteria and articles aimed at the theme
on workloads, focused on mental health services (N= 11.998)

Reading in full of the selected material

(n = 295)

SCOPUS PUBMED LILACS Science Web Of CINAHL

116 37 44 Direct Science 30
32 36

Final Sample = (n= 08)

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 International Archives of Medicine 2016
Section: Psychiatry & Mental Health Vol. 9 No. 240
ISSN: 1755-7682 doi: 10.3823/2111

Science (Main Collection - Thomson Reuters Scien- There were 12,293 results identified in the data-
tific). bases. After selection of the inclusion and exclusion
To search in the databases, the descriptors used criteria and articles that do not address the topic
were found in Medical SubjectHeadings (MeSH): from the perspective of workloads, there were 295
1# (“nursing staff”) 2# (“worker health”), 3# studies focusing on health services (Figure 1) distri-
(“workloads”), 4# (“mental health services”). The buted by databases as follows: SCOPUS (116); PUB-
Crossing were performed using the Boolean opera- MED (37); LILACS (44); SCIENCE DIRECT (32); WEB
tor AND: #1 AND #2, #1 AND #3, #1 AND #4, #2 OF SCIENCE (36); CINAHL (30).
AND #3, #2 AND #4 e #3 AND #4. The analysis of the full text was made and all
Inclusion criteria were: full articles available on se- duplicated were removed. After reading, the final
lected databases that show workloads that nursing sample was composed of 08 studies.
professionals are exposed in their work process in
hospital mental health services. Editorials, letters to
the editor, abstracts, reviews expert opinion, were Results and Discussion
excluded, correspondence, reviews, book chapters, The productions of this study are shown in the table
theses and dissertations and articles that do not below, identifying the journal, year of publication,
address the issue. databases, title, classification of study based on ob-
The studies were pre-selected with an attenti- jectives, authors, location of the study and reason
ve reading of the titles and abstracts to identify that causes the workload (Table 1).
whether they were related to the main issue of In Table 1, it is possible to show that regular
the review, and the inclusion and exclusion crite- nursing area was the most reported work on the
ria. Then they were excluded repeated articles in theme. From the classification of studies based
the databases, and text reading was carried out on the objectives, it is found that 62.5% (05) of
in full. the studies are descriptive, 37.5% (03) are cross-
Table 1. C
 haracterization of articles according to journal, year of publication, databases, title, classifica-
tion of study based on objectives, authors, location of the study and reason that causes the
workload. Natal-RN, 2016.
Journal, Year of Classification of
Location of Reason that Causes
Article Publication and Title the Study Based Authors
the Study the Workload
Database on the Objectives
A1 Rev. Latino-Am. Care needs and Descriptive study Helena Neuropsychiatric Excessive work
Enfermage, workload required with a AyakoMukai. public Hospital schedule in the
2013 PUBMED by institutionalized quantitative Marli de psychiatric sector
psychiatric patients. approach Carvalho Jericó. The average workload
Márcia Galan ranged from 119.6 to
Perroca 183 hours
A2 Rev. de Nursing workload in Descriptive study Souza et al Psychiatric Physical and mental
Enfermagem da a psychiatric with a hospital workloads
UERJ, inpatient unit and quantitative Affected by the care
2015 SCOPUS workers’ health approach of patients
in psychiatric
emergencies,
insufficient human
and material resources
and reduced
autonomy

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 International Archives of Medicine 2016
Section: Psychiatry & Mental Health Vol. 9 No. 240
ISSN: 1755-7682 doi: 10.3823/2111

Journal, Year of Classification of the

Location of Reason that Causes
Article Publication and Title Study Based Authors
the Study the Workload
Database on the Objectives
A3 Rev. Acta Paul Work process and its impact on Cross-sectional Souza et al Specialised mental Burden
Enferm. 2015 mental health nursing study with a health service to Multiple functions and dense workday
SCOPUS professionals quantitative approach provide comprehensive
Psychiatric burden
care for users of alcohol
mental exhaustion, verbal aggression, physical
and other drugs
aggression fear and sexual aggression

A4 Journal of Stressors, burnout, and social A descriptive study of Richard Jenkins Psychiatric hospital Physical and mental workloads
Advanced Nursing, support: nurses in acute mental quantitative Peter Elliott Lack of qualified personnel in service to help
2004 SCOPUS health settings. approach in psychiatric nursing care; Stress and Burnout
A5 International Impacts of unit-level nurse Cross-sectional study Bogaert Psychiatric hospital Workload
Journal of Nursing practice environment, workload with a quantitative It was associated with Burnout
Studies 2013 and burnout on nurse-reported approach
SCOPUS outcomes in psychiatric hospitals:
A multilevel modeling approach

A6 Journal of Investigating the impact of Cross-sectional study S. Leka, J. Hassard, Psychiatric hospital Workload
Psychiatric and psychosocial risks and occupational with a quantitative A. Yanagida High psychological job demands.
Mental Health stress on psychiatric hospital approach
Nursing. nurses’ mental well-being in Japan
2012 SCOPUS
A7 Rev Latino-am Study on the absenteeism Descriptive study Sandra Greice Psychiatric hospital Workload
Enfermagem 2008 of nursing professionals in a with a quantitative Becker Maria High demand for labor and illness reasons
SCOPUS psychiatric center in Manaus, Brazil approach Luiza Carvalho de
Oliveira

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 International Archives of Medicine 2016
Section: Psychiatry & Mental Health Vol. 9 No. 240
ISSN: 1755-7682 doi: 10.3823/2111

Journal, Year Classification of

Location of Reason that Causes
Article of Publication Title the Study Based Authors
the Study the Workload
and Database on the Objectives
A8 Rev Psychiatric Descriptive study Marissol Psychiatric Workload
Latino-am nursing work with a qualitative Bastos de hospital Physical loads
Enfermagem and workers' approach Carvalho exposure to poor lighting and
2006 health problems anda Elisa humidity
LILACS Andres Felli Physiological loads
physical effort, time standing during
the workday, weight handling
and the distance traveled by the
institution.
Biological loads
exposure to parasite infestation and
contact with human bodily fluids.

Mechanical loads
physical aggression committed by
patients.

Psychic loads
fear of being physically assaulted and
the threats of physical violence made
by psychiatric patients
Source: Authors´ Databases (2016).

sectional studies. The descriptive research showed ring the workday, weight handling and the distance
a description of relevant characteristics of a po- traveled by the institution; biological workloads due
pulation or phenomenon studied, and there are to exposure to parasite infestation and contact with
relationships between variables. human bodily fluids, mechanical workloads caused
The methodological analysis showed that 07 stu- by physical assaults committed by psychiatric pa-
dies (87.5%) have a quantitative approach, and 01 tients.
(12.5%) have a qualitative approach. Of them, 8 This study demonstrated that the psychic
(100%) of the studies were conducted in a psychia- workloads were mainly responsible for the emotio-
tric hospital. nal charge of professionals and poor working con-
Concerning the quantitative approach, its collec- ditions contribute to intensify these problems.
tion, and processing of information statistics show A study [12] conducted with nursing professionals
that it accurately tests hypotheses for research and working in mental health services showed that 75%
provides indices that can be compared with others of nurses said they were moderately overloaded
[11]. due to the care given to patients. In the same con-
In this study, the types of workloads were: phy- text, the workload related to the physical structure
sical workloads demonstrated by excessive working (19.4%), the dynamics of travel and work (13.9%),
hours and expressed by exposure to poor lighting mental exhaustion (13.8%), fear of physical aggres-
and humidity; psychic workloads by the direct care sion (11 1%) and verbal abuse (11.1%) of patients
to patients in psychiatric emergencies and lack of were identified.
qualified personnel in service to help in psychia- Research [13] conducted with 69 psychiatric nur-
tric nursing care, stress and burnout; physiological ses working in a hospital service to the Irish com-
workloads due to physical effort, time standing du- munity revealed that the main causes of burnout

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 International Archives of Medicine 2016
Section: Psychiatry & Mental Health Vol. 9 No. 240
ISSN: 1755-7682 doi: 10.3823/2111

were lack of resources, workload and organizatio- vealed that workload, mental health and job satis-
nal/process structures. faction were correlated with the energy to work.
Converging on the findings of this study, research The managers of mental health services must
[14] held examined the workload of nursing staff seek to ensure improvements in the working con-
and its potential relationship to patient safety in ditions of nurses, with implementation of indivi-
hospitals showing significant associations between dual and collective coping strategies, with a view
workload and patient safety, increased load work to mental health promotion worker in his working
or number of patients by nursing staff, reducing the environment. The quality of psychic well-being of
patient’s satisfaction with the care received. the worker may have direct relation to safety in
Measuring workloads that health workers are ex- the care of patients, and the risk-free and damage
posed and promoting adequate dimension of nur- in the process of health care [20]. However, given
sing staff will contribute to improved quality of care. the problems identified in this study on the pro-
Lack of resources at work such as personnel, mate- fessional nursing workloads are exposed to mental
rial or physically associated with the perception of health services, the safety of psychiatric patients is
poor conditions of service is an important stressor worrying.
for these professionals since it can limit their action, In 2004, The World Health Organization - WHO
influencing directly on the quality of service [15]. launched the World Alliance for Patient Safety. The
For that, the mental health services should combine program includes strategies, guidelines, and inter-
physical resources to the demands of work, decrea- national goals, which aim to disseminate and ensure
sing the workload of the nursing team [16]. practices that enable patient safety in different cou-
From the critical analysis of the selected studies, ntries. The Alliance operates in different areas, from
articles were categorized by the similarity of content hand washing, safe surgery to taxonomy, which
and a category for analysis was built: Implications of aims at organizing the taxonomic aspects related
workloads for the safety of the patients in mental to patient safety and care quality provided [21, 22].
distress. Donabedian [23], one of the leading scholars of
the health quality, developed a fundamental con-
Implications of workloads for the safety ceptual framework for understanding the evalua-
of the patients in mental distress tion of health quality, from the concepts of struc-
The common reality in the activity of professionals ture, process, and outcome, classically considered
from psychiatric hospitals is marked by physical, a triad, which is the concepts of General Systems
emotional and mental stress generated by work and Theory: input-process-output.
can produce apathy, depression, emotional hyper- In this context of quality of care, responsible for
sensitivity, anger, irritability and anxiety and even the management of patient care, the nurse plays an
cause depersonalization and the resulting inertia important role in achieving the quality of health ser-
production, performance and employee satisfaction vices [24]. He contributes significantly to the cons-
decrease [17]. truction of quality of care indicators and keeps up
Mental suffering of workers who are included in the results and the quality improvement process.
hospital services mental health can cause various In mental health services, the promotion of safety
morbidities with structural determinations. A study culture with an emphasis on learning, organizational
[18,19] conducted with health professionals to iden- improvement, and secure systems should be achie-
tify organizationally and personal factors causing ved. The mental health services managers need to
professional engagement and occupational stress implement policies to promote mental health for
of nursing and other health team professionals re- the worker in the workplace, as well as sensitize

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 International Archives of Medicine 2016
Section: Psychiatry & Mental Health Vol. 9 No. 240
ISSN: 1755-7682 doi: 10.3823/2111

them as the coping outside the work environment, to contribute to the professional development of
with the adoption of sports and family life, among coping strategies to work situations, both individual
others. and organizational point of view.
Other indicators of workloads also need to be
corrected as the decrease in weekly hourly load and
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