Psychosocial aspects of work in mental health : an integrative review

Objective: analyze national and international scientific works regarding the psychosocial factors involved in the health of mental health workers. Method: integrative review in the PubMed, LILACS, and SciELO databases. The data were analyzed by coding and categorizing the content. Results: a total of 13 articles were analyzed, grouped, and discussed in three categories: satisfaction with and impact of working with mental health; quality of life and mental suffering of the professional; and stress in mental health professionals. Final remarks: the studies described, verified, and characterized psychosocial aspects involved in working with mental health. This article aims to contribute to the valorization of workers’ health, quality of life, and job satisfaction, as well as to the minimization of the impact of the


Introduction
The mental healthcare sector underwent many intense transformations over the last three decades.Aligned with the creation of the Unified Health System (SUS -Sistema Único de Saúde), the psychiatric reform movement consolidated significant changes to methods of treating and understanding mental disorders.The consequences of these transformations can be seen mainly in the creation of services to substitute the hospital-centered treatment model.These services result from a historical process of SMAD, Rev. Eletrônica Saúde Mental Álcool Drog.July.-Sept.2016;12(3):188-97 fighting for the democratization of health in Brazil and the quest for overcoming the model of psychiatric care that was based on social exclusion, violence, and chronification of the patient.
The preconditions for psychosocial deinstitutionalization and rehabilitation from Italian Democratic Psychiatry undeniably influenced the social movement called the "Anti-Asylum Fight" in Brazil.This movement played a relevant role in the process of implementing psychiatric reform, aiming to break from the asylum logic of social segregation and violence, replacing it for labor unions and territorial assistance (1) .
Among the changes proposed, the progressive substitution of psychiatric beds for a network of psychosocial care that functions following the logic of territory and which guarantees not only comprehensive, universal, and equanimous rights to health, but also social participation and citizenry.
The Psychosocial Care Centers (CAPS -Centro de Atenção Psicosocial) were designated as the main reference for treatment of mental health, defined by ascending order of size, complexity, population coverage, working hours, and the number of employees and people treated (2) .Initially, the CAPS were presented in the CAPS I, CAPS II, or CAPS III modalities, created for adults (older than 18 years of age) with severe and persistent mental disorders.From 2002 on, this model was adopted to structure other services for users with specific needs: CAPS i, specialized in children and adolescents with mental disorders, and CAPS ad, for people who abusively use or are dependent on alcohol and other drugs.
Thus, new political directives were proposed for a more horizontal organization of the work, focusing on the patient and not on the mental illness, aiming towards concrete possibilities of exercising citizenship and establishing social exchanges (3) .
In this context, CAPS units are the major bet of the Brazilian psychiatric reform regarding comprehensive care for the mental health of children, adolescents, adults, and elderly people, and must be analyzed and understood in their complexity.
In the last few years, the CAPS have significantly grown in number in Brazil; however, few studies consider matters regarding the relationship between work and health in these services (4) .Knowing and understanding the psychological and social factors in the work of the mental healthcare professionals may contribute to new perspectives on the construction of care in the psychosocial field and occupational health of these workers.These matters become relevant when considering the subjective and interpersonal resources of each professional and of the multiprofessional staff that are fundamental to healthcare (5) .
Due to their complexity, the psychosocial factors of work have been defined by various theoretical frameworks.According to the International Labour Office (ILO) (6) , these factors are those that refer to "interactions between and among work environment, job content, organizational conditions and workers' capacities, needs, culture, personal extra-job considerations that may, through perceptions and experience, influence health, work performance and job satisfaction".
In light of the above, the purpose of this study was to analyze the scientific works of national and international periodicals published within the last ten years that address the psychosocial factors involved in working with mental health.The factors considered in this study are: job satisfaction, quality of life, and impact of work on the life and mental health of the worker.

Methods
This study is an integrative review defined as an ample methodological approach regarding the revisions, which allows the inclusion of experimental and non-experimental studies for optimized understanding of the current knowledge on the theme analyzed.Integrative reviews identify, analyze, and synthesize the results of independent studies on the same subject, contributing to the expansion of the knowledge of the phenomenon investigated (7) .
To perform the integrative review, the following steps were taken: elaboration of a guiding question; definition of the criteria for inclusion and exclusion of the articles found; extraction of the data from the selected articles; critical analysis of the studies and discussion of the results, linking them to the theoretical frameworks; and the presentation of the review through the categorization of the data.The guiding question was: "What are the psychosocial factors (job satisfaction, quality of life, impact of work on life and mental health) that impact the occupational health of mental healthcare workers?".
The data were collected between the months of May and June 2015, and the databases used were Public Medical (PubMed), Latin American Health Sciences Literature (LILACS -Literatura Latino-americana em Ciências da Saúde) and the Scientific Electronic Library Online (SciELO).These databases were chosen because they are the main sources of publications in the health sector.The following descriptors were used, controlled by DeCS Trevisan ER, Castro SS.
The criteria for including the articles found were: texts in Portuguese, English, and Spanish, available in full and for free in the abovementioned databases, published between January 2005 and May 2015.Articles in the form of workbooks, letters, and editorials were excluded from this study because they do not meet the criteria required for this scientific survey, as the focus is to seek scientific evidence on the theme.
The authors themselves performed the searches, using a data extraction instrument for integrative reviews, adapted by Ursi (2005) (8) , which includes the following information: article number, article data (title, year of publication, language, authors, periodical title, location of study), objectives, method, results, recommendations, and identification of limitations and biases.The works selected were identified and numbered, and the information extracted through the tool was organized into tables for the purpose of the analysis, based on the patterns and differences found through the evaluation processes performed in the studies.
The data were analyzed in the following phases: reading of the abstracts of all the articles found, according to the inclusion and exclusion criteria; full reading of the articles of the partial sample; exploration of the articles; codification of the emerging and relevant content; and categorization based on the incidence of the content and on the characteristics of the studies, as proposed by Bardin (2009) (9) .

Results
We identified 119 articles, of which, after reading the titles and abstracts, 103 (87%) were excluded, as they did not meet the inclusion criteria or were not related to mental health professionals or services (Table 1).Of the 16 (13%) pre-selected articles, after a full reading, three (2.5%) were eliminated, which did not fit the theme.Therefore, in total, 106 (89%) of the articles were excluded and the final sample was composed of 13 (11%) publications (Figure 1).The synthesis of the articles selected will be presented in Figure 1, according to the year of publication, title, language/country, authors, title of the periodical, and type of study.

Spanish/ Chile
Martínez, R.A. (14) Revista Chilena de Terapia Ocupacional Quantitative 2011 BREATHE: a pilot study of a one-day retreat to reduce burnout among mental health professionals.
Figure 1 -Characterization of articles according to the year of publication, title, language/country, authors, title of the periodical, and type of study.
Of the 13 articles selected, most were published in the year 2011 (30.7%).The majority were studies published in national periodicals (76.9%).As for the methodological approach of the studies, they were classified as quantitative (n = 9; 69.2%) and qualitative (n = 4; 30.8%), the most common of which were crosssectional studies with the application of standardized, structured questionnaires, validated in the country where the study was performed.
The locations where the studies were performed are greatly diversified.Among the national ones, we highlight CAPS, CAPS i, CAPS ad, the Income Generation Program for people with psychiatric disorders, a psychiatric hospital, a psychiatric unit in a general hospital, and the psychiatry department of a university.As for the international publications, the locations are: private and public mental health rehabilitation centers; institution for treating burnout syndrome; long-term mental health institution; and a service for treating the abusive use of psychoactive substances.
The full reading of the articles of this revision allowed them to be grouped into three categories by similarity of content, indicating the psychosocial aspects that influence the occupational health of mental health workers.These are: 1) satisfaction with and impact of working with mental health; 2) quality of life and mental suffering of the professional; and 3) stress in mental health professionals, as shown in Figure 2.

Satisfaction with and Impact of Work in Mental Health
Work in the health sector is a technological function that is essentially relational and acting, wherein all health services are linked to productive processes of caretaking acts that can be "castrating caretaking acts" or "liberating caretaking acts" (22) .The work processes in the health sector consist of relationship spaces, micro-politics, and encounters of power plays between subjects and territories (22) .The subjectivity of the workers can be regarded as one of the fundamental characteristics in the social production of mental health.
The field of mental health is full of specificities that demand of workers skills to deal with human beings and understand them with the aim of providing integral SMAD, Rev. Eletrônica Saúde Mental Álcool Drog.July.-Sept.2016;12(3):188-97 healthcare.This reality is directly related to daily life alongside suffering and insanity, which permeates the environment with intense subjective and intersubjective production.In this context, the workers are exposed to numerous situations that can provide greater or lower (dis)satisfaction (16) .
Thus, the worker is the main instrument in mental healthcare.These workers do not rely on the latest technologic equipment to aid in nursing and integral care for the health of the users of these services, and frequently do not have an articulated assistance, social, and legal network regarding the comprehensiveness of the care.
Bandeira, et al. ( 2007) point out that professionals are the agents that are most overloaded, similarly to the families of the users of mental health services.In the investigation on the satisfaction and overloading of mental health professionals, it was found that an evaluation of these workers is necessary, as both variables have been considered predictive of the quality of service (10) .
In relation to the impact of work on the health of mental health workers, the most notable aspects are: factors related to the effects of work on the physical and mental aspects, such as physical problems described by the worker, doctor's appointments, use of medication, effect of work on emotional stability and on their need to seek professional help; functioning of the team, which can be perceived in the frequency with which the professional thinks of changing jobs, in the frequency with which they think of another type of job that would make them feel healthier, withdrawal from work due to stress at the job, fear of being aggressed at work, quality of sleep and health in general; feeling of being overloaded, expressed by feeling frustrated with the results of their work, feeling overloaded by constant contact with patients, feeling tired after work, feeling depressed from working with patients with mental disorders, and feeling stressed from working with mental disease (23) .
The studies selected showed that people who are more satisfied with their jobs present better physical and mental health conditions and lower rates of disease, as well as a longer lifespan.On the other hand, dissatisfied workers have greater risk of developing health problems and grievances.However, the authors advise that the results be considered carefully, as there may be factors of confusion that influence the level of job satisfaction and health conditions.Thus, physical conditions should be considered covariates and not consequences of the level of job satisfaction, given that, at this time, the link between physical health and job satisfaction is difficult to ascertain (4) .
The relationships established with the users were reported as the main cause of satisfaction, while the working conditions and salary were the main reasons for dissatisfaction.Aside from these aspects, consequences emerged in the lives of the CAPS workers, particularly in physical and mental health (16) .Rebouças, et al. (2008) in their study observed that the higher the schooling of the professional, the lower their satisfaction level.The impact of work is not associated with any of the variables studied by these authors.The impact of work on these professionals is reduced, and no differences were observed between the hospital and community staff (12) .Most of the participants of another study presented intermediate satisfaction levels, influenced by personal monthly income, position, work shifts, and the impact of work on these levels (17) .
In the evaluation process, the workers showed pleasure and fulfillment with their work, narrating feelings such as pride, fulfillment, and valorization of that which they produce.Pleasure can be perceived in the construction of psychosocial care, since during their shifts they are free to reorganize their work, allowing activities and attitudes to be developed that can provide non-professional pleasure at a CAPS (18) .
One of the studies in this category was qualitative and had the objective of obtaining knowledge on the perceptions and feelings of professionals regarding the practice of mental healthcare services, with focus on professional satisfaction.The results highlighted the impasses experienced and the obstacles to professional satisfaction, displaying the workers' struggle when faced with demands of the ideals of the Brazilian psychiatric reform, to which they adhere, and the absence of resources necessary for its application, presenting a conflicting situation of dealing with the anguish of not being able to do their jobs according to what they believe should be done (20) .
For data collection, most of the studies in this category (4) used the evaluation scale SATIS-BR (Satisfação da Equipe em Serviços de Saúde Mental -Team Satisfaction in Mental Health Services) and the IMPACTO-BR scale for assessing work overload.One of the studies (10) had the objective of evaluating the construct validity of the two scales, elaborated by the World Health Organization (WHO) and adapted and validated for Brazil by Bandeira et al.. (1999 and 2000) (12) .The result of this assessment showed that the scales had construct validity and are adequate for monitoring the quality of mental health services.The overload scale consisted of a predictor of stress presented by the mental health workers.

Quality of Life and Mental Suffering of the Professional
Work developed in the sphere of mental health, as occurs in various countries in the world that propose changes in the caretaking model (in other words, the replacement of the asylum model guided by psychiatric hospitalization for the psychosocial model, based on territory and community care), demands new attitudes from professionals for the act of caretaking.
This transformation of the mental healthcare practice allows different conceptions and knowledge to be established in the interdisciplinary practice of the day-to-day of mental health services, mainly supported by the experiences and subjectivity of the professional through their relationship with the users.
Thus, healthcare is no longer a procedure or an intervention and becomes a relationship where help is in regard to the quality of the other person to be or become, respecting and understanding them, and reaching them more affectionately (24) .Borges, et al. (2002) call attention to the emotional costs and needs that surround the mental health of workers in the health sector.Thus, for an institution to reach its goals regarding its services and the quality of care provided, it must have satisfied professionals who enjoy good quality of life (25) .
The studies selected and contained in this category demonstrate that professionals in the area of mental healthcare feel more satisfied in relation to the quality of the services offered and the work done as a team.The factor that expresses least satisfaction is that related to working conditions.De Marco, et al. (2008), in their studies, observed higher scores in the subscale for emotional impact, as well as greater presence of minor psychiatric disorders in professionals of occupational therapy and social service.In addition, they describe that professionals who work over 20 hours per week have their quality of life impaired (11) .
Another article addressed the responsibilities of the reference mental health care professional, reported as generating mental suffering.It is understood that in this case, the reference is one of the clinical devices of work in mental health that has the purpose of narrowing the link between professionals and users, interdisciplinarity, and dialogue and articulation with family, social, cultural, and socio-educational networks, among others.The results showed three categories related to mental suffering: 1) bond with the user and mental suffering of the professional; 2) organization of the work and the role of the professional; and 3) institutional support and clinical dimension in the work of the reference professional (13) .
The work of the reference professional in mental health demands an articulation of a wide span of knowledge and various relational fields, with multiple possibilities for exchanges and conflicts (13) .
Martinez (2010) performed a study in Chile regarding the psychosocial risk factors in the work and quality of life of the workers of a mental health rehabilitation center, specifically the factors that cause stress.The results showed that 77.8% of the participants in the study perceived their job with a high level of mental work.For the psychosocial evaluation, 78.6% perceived psychological demands with an elevated risk level.There is a large demand for healthcare workers that care for people with psychiatric disorders.The way the work is systematized and the organizational structure are particularly relevant, since the conception of the work location, the clarity of the technical and professional functions, the pertinence of information, the team, leadership, motivation of the workers, and the work environment directly influence the work and lives of the workers and their health, as well as the quality of care provided to the patient (14) .
Athayde and Hennington (2012) developed a study with the objective of analyzing concrete work situations at CAPS, with focus on the health-illnesswork process of the mental health professionals.The method chosen was a case study and the discussions were guided by the theoretical frameworks of Ergology and Psychodynamics of Work.The results indicated three analytical categories defined based on the material produced through interviews: 1) work collective, 2) dynamics of recognition, and 3) suffering and defenses.The first category showed that the day-to-day activities of mental health professionals demand great subjective involvement and are draining, causing suffering and diseases.The unsatisfactory working conditions reverberated in the services offered and in the health of the workers.Nevertheless, it was possible to identify creative power and aspects of satisfaction with the work developed.The main strategies used by the professionals for facing and overcoming adversities at work were to adhere to the ideals of SUS and the psychiatric reform, the support of the staff, and the recognition of the work performed (19) .

Stress in Mental Health Professionals
The articles selected also addressed burnout syndrome in mental health professionals.This concept is characterized as a psychological syndrome produced as a response to chronic interpersonal stressors at work, associated with the exhaustion of energy due to SMAD, Rev. Eletrônica Saúde Mental Álcool Drog.July.-Sept.2016;12(3):188-97 poor adaptation and prolonged exposure to a stressful work environment, with an elevated level of tension, describing a condition of professionals whose work requires an elevated degree of interpersonal contact.Burnout can be manifested through three aspects: 1) emotional draining: feeling of being overwhelmed; 2) depersonalization: development of a cold and distanced attitude towards colleagues and the work; and 3) reduced personal fulfillment: feelings of incompetency and lack of productivity and fulfillment at work (26) .
The two articles that address this theme had quantitative studies developed in the United States.The objective of the first study was to examine the perceptions and job satisfaction of case managers of community centers for mental health in the state of Ohio.A total of 114 professionals participated and the results suggest that mental health case managers perceive that the higher the levels of the services aimed at recuperation, the lower the levels of depersonalization and emotional depletion and the higher the levels of professional and job fulfillment ( 21) .Although the demographic variables have contributed to the prediction of depersonalization, personal realization and the job satisfaction rates, their effects were discreet in most cases.The results suggest that the older professionals were more likely to report greater feelings of pride in their work (21) .
The second study selected on this theme had the objective of testing an intervention to reduce burnout among mental health professionals through training to learn methods that can ease this syndrome, in which all the employees of a public agency for treating mental health and psychoactive substance abuse were invited to participate (15) .The training was provided through a six hour workshop at a hotel with 84 participants, composed of a brief introduction, principles of burnout prevention, experimental exercises, and construction skills in six large areas: contemplative, social, physical, cognitive-philosophical, and appearance practices, as well as other activities of self-care.The results showed that, after six weeks of training, the staff reported significant decreases in emotional exhaustion and depersonalization, and a considerable rise in the positive evaluation of users of the services where they work.There was no relevant change in relation to personal fulfillment, job satisfaction, or in the intention to leave their professional position.Of the professionals that participated in the study, 91% declared that the training was useful (15) .

Final Remarks
In this investigation, studies were found that describe, verify, and characterize the psychosocial aspects involved in working with mental health.It is hoped that the knowledge revealed by this study contributes to the creation of spaces for developing work that values the health of the worker, their quality of life, and job satisfaction, and minimizes the impact of work on the lives of these professionals.
It is necessary to perform further studies on this topic, considering that, since 2013, there have not been any publications on the topic in national and international periodicals, demonstrating the difficulties in developing resources to deal with the adversities inherent to work in mental healthcare.
Systematic strategies for investigating workers' health provide reflections on the work processes and also enable the elaboration of intervention proposals that provide support to the mental health professional, which are fundamental to the protection of the health of these workers, and, consequently, of the patient population.
Despite the criteria used, this integrative review of the literature may present a few limitations in terms of the descriptors used and the cross-links between them, and some articles that were not in this scope may have been excluded.

Figure 2 -
Figure 2 -Grouping of articles by similarity of content.

Table 1 -
Distribution of the articles found, excluded, and selected in the electronic databases.Publication period -January 2005 to May 2015.
Article Title Satisfaction with and Impact of Work in Mental Health 1. Satisfação com o trabalho e impacto causado nos profissionais de serviço de saúde mental.2. Satisfação e sobrecarga de profissionais de saúde mental: validade de construto das escalas SATIS-BR e IMPACTO-BR. 4. O trabalho em saúde mental -um estudo de satisfação e impacto.9. Análise dos níveis de satisfação de trabalhadores de saúde mental de um hospital público de referência psiquiátrica em Belém (PA).10.Work as a source of pleasure: evaluating a Psychosocial Care Center team.12. Practices in mental health services: interface with professionals' satisfaction.