Burnout syndrome and its prevalence in primary care nursing: a systematic review and meta-analysis

RESEARCH ARTICLE Open Access Bu nou synd ome and i s p e alence in p ima y ca e nu sing: a sys ema ic e iew and me a-analysis Ca olina S. Monsal e-Reyes 1,2 , Concepción San Luis-Cos as 3 , Jose L. Gómez-U quiza 4,8* , Luis Albendín-Ga cía 5 , Raimundo Aguayo 6 and Guille mo A. Cañadas-De la Fuen e 7 Abs ac Backg ound: bu nou synd ome is a signi ican p oblem in nu sing p o essionals. Al hough, he uni whe e nu ses wo k may in luence bu nou de elopmen . Nu ses ha wo k in p ima y ca e uni s may be a highe isk o bu nou . The aim o he s udy was o es ima e he p e alence o emo ional exhaus ion, depe sonaliza ion and low pe sonal accomplishmen in p ima y ca e nu ses. Me hods: We pe o med a me a-analysis. We sea ched Pubmed, CINAHL, Scopus, Scielo, P oques , CUIDEN and LILACS da abases up o Sep embe 2017 o iden i y c oss-sec ional s udies assessing p ima y ca e nu ses’bu nou wi h he Maslach Bu nou In en o y we e included. The sea ch was done in Sep embe 2017. Resul s: A e he sea ch p ocess, n= 8 s udies we e included in he me a-analysis, ep esen ing a o al sample o n = 1110 p ima y ca e nu ses. High emo ional exhaus ion p e alence was 28% (95% Con idence In e al = 22–34%), high depe sonaliza ion was 15% (95% Con idence In e al = 9–23%) and 31% (95% Con idence In e al = 6–66%) o low pe sonal accomplishmen . Conclusions: P oblems such as emo ional exhaus ion and low pe sonal accomplishmen a e e y common among p ima y ca e nu ses, while depe sonaliza ion is less p e alen . P ima y ca e nu ses a e a bu nou isk g oup. Keywo ds: Bu nou , P ima y ca e nu sing, Nu sing, Family nu sing, Me a-analysis, Epidemiology, P e alence Backg ound The de elopmen o bu nou among heal hca e p o es- sionals has been widely s udied in ecen yea s, since he la ge numbe o s ess-inducing ac o s in he hospi al en i onmen heigh ens he isk o p esen ing bu nou synd ome [1–3]. In addi ion, ela ionships and con in- ued con ac wi h pa ien s and hei amilies can be di i- cul , which os e s he de elopmen o ch onic s ess ha can p o oke bu nou among heal hca e s a [4]. The bu nou synd ome has been ex ensi ely s udied, e en hough he mos widely accep ed de ini ion o bu nou is ha p oposed by Maslach & Jackson [5], who iden i ied i as a h ee-dimensional synd ome in ol ing emo ional exhaus ion (EE), cynical ea men and nega- i e hough s owa ds pa ien s and he heal hca e eam (o depe sonalisa ion, DP), and a low deg ee o pe sonal accomplishmen (PA) ega ding he own wo k pe - o med. The s udy o bu nou is impo an because i s nega i e e ec s can impac bo h on he p o essional who su e s i , causing di e en signs and symp oms [6], and also on he heal h ins i u ion i sel , by inc easing s a absen eeism, and on he quali y o ca e p o ided by in- c easing medical e o s and diminishing pa ien sa e y [7,8]. In hospi al se ings, nu ses a e among he p o es- sionals mos a ec ed by bu nou [9] and o his eason nume ous s udies ha e been conduc ed o iden i y p o- ec i e ac o s and elemen s o isk. Fo example, some sociodemog aphic ac o s such as age, gende o ma i al s a us and i s in luence ha e been assessed [10,11]. Psy- chological ac o s like he big i e pe sonali y ai s [12] * Co espondence: [email p o ec ed] 4 Nu sing Depa men , Uni e si y o G anada, G anada, Spain 8 Facul y o Heal h Sciences, Uni e si y o G anada, Co adu a del Valle S ee S/N, 51001 Ceu a, Spain Full lis o au ho in o ma ion is a ailable a he end o he a icle © The Au ho (s). 2018 Open Access This a icle is dis ibu ed unde he e ms o he C ea i e Commons A ibu ion 4.0 In e na ional License (h p://c ea i ecommons.o g/licenses/by/4.0/), which pe mi s un es ic ed use, dis ibu ion, and ep oduc ion in any medium, p o ided you gi e app op ia e c edi o he o iginal au ho (s) and he sou ce, p o ide a link o he C ea i e Commons license, and indica e i changes we e made. The C ea i e Commons Public Domain Dedica ion wai e (h p://c ea i ecommons.o g/publicdomain/ze o/1.0/) applies o he da a made a ailable in his a icle, unless o he wise s a ed. Monsal e-Reyes e al. BMC Family P ac ice (2018) 19:59 h ps://doi.o g/10.1186/s12875-018-0748-z o occupa ional ac o s, such as job senio i y o job sa - is ac ion, ha e been also s udied [13–15]. Howe e , one key ac o ha may be associa ed wi h bu nou synd ome is he hospi al se ice in which nu ses wo k; he asks pe o med and he ole played by he heal hca e s a , as well as he ype o pa ien s ea ed, all a y acco ding o he ype o se ice p o- ided, and his di e ence could in luence he de elop- men o he synd ome. Fo example, nu ses wo king in oncology [16], acciden and eme gency uni s [17] o in- ensi e ca e [18], due o hei di e en daily asks, a e likely o expe ience di e en le els and p e alence a es o bu nou . P ima y heal hca e uni s di e in many espec s om he a en ion p o ided in hospi al uni s, in ha p e en - i e and emedial ea men is p o ided o ch onic dis- eases, o p e-assigned g oups o pa ien s. P ima y heal hca e is p o ided in he communi y i sel , and may ake place o e a p olonged pe iod [19]. By con as , in he hospi al en i onmen he medical ea men is o a sho e - e m na u e, and he e is g ea e a iabili y among he pa ien s. Al hough bu nou and i s isk ac- o s in nu sing p ima y ca e p o essionals, such as age, job senio i y, anxie y and dep ession, ha e been s udied p e iously [20], he p e alence esul s epo ed by he s udies a y widely, wi h some au ho s epo ing a high EE o 5,2% [21] while o he s epo 31,3% [22]. Simila si ua ions occu wi h high DP and low PA, whe e some au ho s ind 92,8% o he sample wi h low PA [23] and o he s ind a 4,3% o he sample wi h low PA [22]. So, i is di icul o asce ain he eal impac o bu nou syn- d ome on p ima y heal hca e nu ses. To ou knowledge, no p e ious me a-analysis has been unde aken o ad- d ess his ques ion, as has been done in he case o nu ses wo king in se ices such as Acciden & Eme - gency [24] o oncology [25]. Taking in o accoun he abo e conside a ions, we aimed o conduc a sys ema ic e iew and me a-analysis o he p e alence o high le els o EE, high le els o DP and low le els o PA among p ima y ca e nu ses. Thus, he ques ion ha guided his me a-analysis was: Wha is he p e alence a e o high EE, high DP and low PA in p ima y ca e nu ses? Me hod This s udy consis s o a me a-analysis, pe o med in ac- co dance wi h he PRISMA ecommenda ions [26]. Li e a u e sea ch and s udy selec ion The ollowing sea ch e ms we e used: “bu nou AND p i- ma y ca e nu sing”,“bu nou AND amily nu sing”, “bu nou AND communi y heal h nu sing”and “bu nou AND dis ic nu sing”. The sea ch was ca ied ou in Sep- embe 2017, consul ing he ollowing esea ch da abases: Pubmed, CUIDEN, CINAHL, LILACS, P oques , Scopus and Scielo. Condi ions o inclusion we e ha he pape s should be p ima y s udies, o a quan i a i e ype, based on a sample o p ima y heal hca e nu ses and p o iding da a on he p e alence o any bu nou dimension (EE, DP o PA), measu ed by he Maslach Bu nou In en o y (MBI) [5]. The s udies should ha e been published in English, Spanish o Po uguese, bu no es ic ion was placed e- ga ding he da e o publica ion. The sea ch and s udy selec ion p ocess was conduc ed by wo membe s o he esea ch eam, wo king inde- penden ly, o ensu e he eliabili y o he p ocess. I hey disag eed ega ding he inclusion o o he wise o a pape , a hi d membe o he esea ch eam was con- sul ed. The selec ion p ocess in ol ed an ini ial eading, o he i le and abs ac . The pape s ini ially selec ed we e hen ead in ull, and hose conside ed a p io i sui - able o inclusion we e hen subjec ed o a c i ical ead- ing o de ec possible me hodological bias. F om he pape s inally selec ed, backwa d and o wa d ci a ion checking was hen pe o med. C i ical eading All o he s udies included we e c oss-sec ional, and hei me hodological quali y was e alua ed by he check- lis sugges ed by Ciapponi [27], using he i ems co e- sponding o he s udies in e nal alidi y: numbe s 2, 3, 4, 5, 6, 11, 12, 13, 14,2 15, 16, 17 and 18. The c i ical ead- ing esul s a e shown in Addi ional ile 1. Da a coding The ollowing s udy a iables we e collec ed: a) su name o he i s au ho ; b) da e o publica ion; c) language o he s udy; d) coun y whe e he esea ch was ca ied ou ; e) s udy me hodology; ) ype o sampling; g) MBI ype (Human Se ices Su ey s. Gene al Su ey); h) sample o p ima y heal hca e nu ses; i) sample o p i- ma y heal hca e nu ses wi h high EE; j) sample o p i- ma y ca e nu ses wi h high DP; k) sample o p ima y heal hca e nu ses wi h low PA. These da a we e com- piled using a Coding Manual. The in aclass co ela ion coe icien and Cohen’s kappa coe icien we e calcula ed o e alua e he eliabil- i y o he da a coding, p oducing mean alues o 0.99 (minimum = 0.98, maximum = 1) and 0.97 (minimum = 0.95, maximum = 1), espec i ely. Da a analysis Da a analysis was pe o med using S a sDi ec so wa e, wi h he me a-analysis package, and he possibili y o publica ion bias was es ed by Egge ’s linea eg ession me hod. Finally, a sensi i i y analysis was ca ied ou o de ec whe he exclusion o any o he s udies would Monsal e-Reyes e al. BMC Family P ac ice (2018) 19:59 Page 2 o 7 ha e p oduced signi ican changes in he esul s ob ained. The p e alence and he con idence in e al o each di- mension o bu nou we e calcula ed by h ee independ- en andom-e ec s me a-analyses. Sample he e ogenei y was analysed wi h he Coch an Q es and he I 2 index. Resul s The sea ch p ocess ini ially ob ained n= 1430 esul s, which a e eading i le and abs ac , ull- ex and he applica ion o he inclusion and exclusion c i e ia we e educed o n= 8 o high EE and n= 7 o high DP and low PA [21–23,28–32]. The selec ion p ocess is illus- a ed in Fig. 1. All o he included s udies we e ans e sal and de- sc ip i e, and used he HSS e sion o he MBI. Only one s udy used andom sampling, and 75% we e con- duc ed in Eu ope. The cha ac e is ics o hese s udies a e lis ed in Table 1. The sensi i i y analysis pe o med, o he in luence o each s udy on he o e all esul , e ealed no s a is ically signi ican changes in he p e alence a es. Nei he was any signi ican publica ion bias de ec ed, being Egge ’s linea eg ession sco e 1.66 (p= 0.43) o high EE, 1.09 (p= 0.77) o high DP and 5.29 (p= 0.67) o low PA. Coch an’s Q alue was 33.10 (p< 0.001) o EE, 46.31 (p < 0.001) o DP and 697.45 (p < 0.001) o low PA. The I 2 index e ealed a high le el o he e ogenei y, a 78.9% o EE, 87% o DP and 99.1% o low PA. The o al popula ion o he me a-analysis was com- posed o n= 1110 p ima y ca e nu ses. The p e alence a e ob ained o high emo ional exhaus ion was 28% (95% CI: 22–34%). Figu e 2shows he o es plo o high EE. In depe sonaliza ion dimension he p e alence a e was 15% (95% CI: 9%–23%). The o es plo o high DP is shown in Fig. 3. Finally, a 31% (95% CI: 6–66%) was ound o low pe - sonal accomplishmen . Figu e 4show illus a e he o - es plo o low PA. Discussion Ou me a-analysis shows ha low pe sonal accomplish- men is he mos widely a ec ed dimension o bu nou in p ima y ca e nu ses, being p esen in 31% o he sam- ple. This is ollowed by emo ional exhaus ion, which was obse ed in 28% o he nu ses in he sample. The lowes le el o p e alence co esponded o depe sonalisa ion, which a ec ed 15% o hese nu ses. To ou knowledge, no p e ious me a-analysis has been pe o med ega ding he p e alence o bu nou in p i- ma y ca e nu ses. The numbe o s udies included in he p esen me a-analysis is lowe han in hose wi h A&E nu ses [24] o oncology nu ses [25]. Me a-analy ical s udies o he p e alence o bu nou among A&E nu ses ha e epo ed alues simila o ou own o EE and low PA, wi h p e alence a es o 31% and 29%, espec i ely. Howe e , hese p e ious pape s measu ed a much highe p esence o DP (36%) han in ou sample o p ima y ca e nu ses [24]. On he o he hand, a me a-analysis ocusing on bu nou among oncology nu ses obse ed highe le els o EE, lowe le els o DP and PA, han in he p i- ma y ca e nu ses in ou sample [25]. Ne e heless, i is o eseeable ha p ima y ca e nu ses will expe ience less DP han A&E nu ses, because hey o en ollow he e o- lu ion o ch onic pa ien s o yea s, pe haps isi ing pa- ien s in hei homes and in hei communi y. This si ua ion a ou s empa hy and he o ma ion o a close ela ionship wi h he pa ien , which is o c ucial impo - ance o he quali y o ca e [33]. The impo an deg ee o EE and low PA obse ed among p ima y ca e nu ses may be due, among o he ac o s, o hei some imes encoun e ing di icul pa- ien s, who can be e y demanding and may con inually seek medical a en ion, necessa y o o he wise. Such pe - sons dis up he ou ines o he se ice and ha e a nega- i e impac on medical p o essionals [34–36]. In addi ion, he impo ance ha p ima y ca e is gaining in heal h se ices, and he g owing demand o se ices in his a ea, o ces nu ses o mee he new challenges and eques s ha a e gene a ed, adding mo e p essu e o Fig. 1 Documen s sea ch low diag am Monsal e-Reyes e al. BMC Family P ac ice (2018) 19:59 Page 3 o 7 hei wo k [37]. To all his, we mus add he di icul ies o nu sing wo k, such as con ac wi h ulne able people and amilies in consul a ion and in pa ien s´ homes [38], he inc easing wo kload, o he lack o con ol o e hei own wo k en i onmen [39], which may a ou EE and dec ease PA. Some limi a ions o his s udy should be acknowl- edged. The numbe o s udies included is low, because no all s udies o bu nou in p ima y ca e nu ses p o ide p e alence da a. Mo eo e , he s udies included a e all c oss-sec ional and desc ip i e, which accoun s o hei low le el o e idence (al hough his design is usually conside ed app op ia e o p e alence s udies). Fu he - mo e, he included s udies, despi e mee ing almos all he i ems o he c i ical eading guide, ha e small sample sizes. To his, we mus add he high he e ogenei y ound in he esul s, which may be due o he di e en coun- ies whe e he s udies ha e been done, because he heal hca e sys ems o each coun y ha e di e en wo k- place condi ions, sala y, shi s and compe encies o he nu sing wo k o ce [40], which may in luence nu ses´ bu nou and should be aken in o accoun when in e - p e ing he esul s. Fu u e esea ch in his a ea should include a longi u- dinal e alua ion o he sociodemog aphic, occupa ional, and psychological ac o s ha may in luence he de el- opmen o bu nou synd ome among p ima y ca e nu ses. I would be in e es ing o examine in e en ions aimed a p e en ing and/o educing emo ional exhaus- ion in his occupa ional g oup. Finally, in iew o he e- sul s ob ained in his me a-analysis, ac ion should be aken o enhance eelings o pe sonal accomplishmen Table 1 Cha ac e is ics o included s udies (n=8) Au ho , yea . Coun y S udy ype; Sampling me hod Type o MBI Sample size (Females%; Response a e%) n wi h high EE n wi h high DP n wi h low PA Das Me ces e al., 2016. B asil [28] O; In en ional HSS n= 28 (100%; 90,32%) 8 6 13 Fau a e al., 1995. Spain [29] O; In en ional HSS n= 116 (90.5%; ND) 27 –– Hay e , 1999. England [30] O; In en ional HSS n= 30 (80%; 94%) 8 0 6 Holmes e al., 2014. B asil [31] O; Random HSS n= 45 (100%; 100%) 24 5 5 Na a o-Gonzalez e al., 2005. Spain [21] O; In en ional HSS n= 178 (73,3%; 48%) 28 33 84 So o Cáma a e al., 2005. Spain [23] O; In en ional HSS n= 208 (86.5%: 83,87%) 60 67 193 Tomas-Sabado e al., 2010. Spain [32] O; In en ional HSS n= 160 (89.7%; 67%) 35 19 14 Vila Fague a e al., 2015. Spain [22] O; In en ional HSS n= 345 (80.2%; 44.5%) 108 51 15 DP Depe sonaliza ion, EE Emo ional exhaus ion, HSS Human Se ices Su ey, MBI Maslach Bu nou In en o y, ND No Da a, OObse a ional, PA Pe sonal Accomplishmen Fig. 2 Fo es plo o high emo ional exhaus ion Monsal e-Reyes e al. BMC Family P ac ice (2018) 19:59 Page 4 o 7 among p ima y ca e nu ses, o example by os e ing p o essional empowe men , by es ablishing p ima y ca e nu ses’g oups so hey can exp ess hei eeling [41], p o- mo ing leade ship capabili ies and posi i e psychological capaci ies [42] o imp o ing he wo kplace condi ions. Conclusions P oblems such as emo ional exhaus ion and low pe - sonal accomplishmen a e e y common among p ima y ca e nu ses om he coun ies included in he me a- analysis, wi h a p e alence be ween 22 and 34% and a ound 31% espec i ely. Depe sonalisa ion is less p e a- len in his popula ion, a a ound 15%, which indica es ha p ima y ca e nu ses included in he me a-analysis ela e well wi h hei pa ien s. Addi ional ile Addi ional ile 1: C i ical eading. Desc ip ion o da a: S udies c i ical eading esul s (DOCX 18 kb) Abb e ia ions CI: Con idence In e al; DP: Depe sonaliza ion; EE: Emo ional Exhaus ion; MBI: Maslach Bu nou In en o y; PA: Pe sonal Acomplishmen Funding This wo k was unded by he Excellence Resea ch P ojec P11HUM-7771 (Jun a de Andalucía-Spain). A ailabili y o da a and ma e ials The da ase s used and/o analysed du ing he cu en s udy a e a ailable om he co esponding au ho on easonable eques . Fig. 3 Fo es plo o high depe sonaliza ion Fig. 4 Fo es plo o low pe sonal accomplishmen Monsal e-Reyes e al. BMC Family P ac ice (2018) 19:59 Page 5 o 7 Au ho s’con ibu ions CSM-R (design o he me a-analysis, c ea ion o da abase, analysis and in e - p e a ion o da a, and elabo a ion o he manusc ip ). CSL-C (design o he me a-analysis, c ea ion o da abase, analysis and in e p e a ion o da a, and elabo a ion o he manusc ip ). JLG-U (design o he me a-analysis, sea ch o s udies, c ea ion o da abase, analysis and in e p e a ion o da a, and elabo - a ion o he manusc ip ). LA-G (sea ch o s udies, c ea ion o da abase, ana- lysis and in e p e a ion o da a, and elabo a ion o he manusc ip ). RA (c ea ion o da abase, analysis and in e p e a ion o da a, and elabo a ion o he manusc ip ). GAC-DF (c ea ion o da abase, analysis and in e p e a ion o da a, and elabo a ion o he manusc ip ). All au ho s ead and app o ed he inal manusc ip . E hics app o al and consen o pa icipa e No applicable. Compe ing in e es s The au ho s decla e ha hey ha e no compe ing in e es s. Publishe ’sNo e Sp inge Na u e emains neu al wi h ega d o ju isdic ional claims in published maps and ins i u ional a ilia ions. Au ho de ails 1 Depa amen o de Ciencias Sociales, Uni e sidad Ca ólica de La San ísima Concepción, Concepción, Chile. 2 Doc o ado en Psicología de la Salud, Facul ad de Psicología, Uni e sidad Nacional de Educación a Dis ancia (UNED), Mad id, Spain. 3 Spanish Uni e si y o Dis ance Educa ion, Mad id, Spain. 4 Nu sing Depa men , Uni e si y o G anada, G anada, Spain. 5 Andalusian Heal h Se ice and Uni e si y o G anada, G anada, Spain. 6 Psychology Depa men , Uni e si y o G anada, G anada, Spain. 7 Nu sing Depa men , Uni e si y o G anada, G anada, Spain. 8 Facul y o Heal h Sciences, Uni e si y o G anada, Co adu a del Valle S ee S/N, 51001 Ceu a, Spain. Recei ed: 6 Decembe 2017 Accep ed: 23 Ap il 2018 Re e ences 1. Maslach C, Schau eli W, Lei e MP. Job bu nou . Annu Re Psychol. 2001;52: 397–422. 2. Pe e son U, Deme ou i E, Be gs öm G, Samuelsson M, Asbe g M, Nyg en A. Bu nou and physical and men al heal h among Swedish heal hca e wo ke s. J Ad Nu s. 2008;62(1):84–95. 3. Wood BD, Killion JB. Bu nou among heal hca e p o essionals. Radiology Manag. 2007;29:30–4. 4. Sablik Z, Sambo ska-Sablik A, D ozdz J. Uni e sali y o physicians´ bu nou synd ome as a esul o expe iencing di icul y in ela ionship wi h pa ien s. A ch Med Sci. 2013;9(3):398–403. 5. Maslach C, Jackson SE. The measu emen o expe ienced bu nou . J O ganiza ional Beha . 1981;2:99–113. 6. Schau eli WB, Lei e MP, Maslach C. Bu nou : 35 yea s o esea ch and p ac ice. Ca ee De elopmen In e na ional. 2009;14:204–20. 7. Shana el TD, Balch CM, Bechamps G, Russell T, Dy bye L, Sa ele D, e al. Bu nou and medical e o s among Ame ican su geons. Ann Su g. 2010; 251(6):995–1000. 8. Teng CI, Shuy YI, Chiou WK, Fan HC, Lam SM. In e ac i e e ec s o nu se- expe ienced ime p essu e and bu nou on pa ien sa e y: a c oss-sec ional su ey. In J Nu s S ud. 2010;47(11):1442–50. 9. Cañadas-De la Fuen e GA, Va gas C, San Luis C, Ga cía I, Cañadas GR, De La Fuen e EI. Risk ac o s and p e alence o bu nou synd ome in he nu sing p o ession. In J Nu s S ud. 2015;52(1):240–9. 10. Gómez-U quiza JL, Va gas C, De la Fuen e EI, Fe nández-Cas illo R. Cañadas- De la Fuen e GA. Age as a isk ac o o bu nou synd ome in nu sing p o essionals: a me a-analy ic s udy. Res Nu s Heal h. 2017;40(2):99–110. 11. Ayala E, Ca ne o AM. De e minan s o bu nou in acu e and c i ical ca e mili a y nu sing pe sonnel: a c oss-sec ional s udy om Pe u. PLoS One. 2013;8(1):e54408. h ps://doi.o g/10.1371/jou nal.pone.00544081. 12. Hudek-Kneze ic J, Kalebic Maglica B, K apic N. Pe sonali y, o ganiza ional s ess, and a i udes owa d wo k as p ospec i e p edic o o p o essional bu nou in hospi al nu ses. C oa Med J. 2011;52(4):538–49. 13. Cañadas-De la Fuen e GA, Albendín-Ga cía L, De la Fuen e EI, San Luis C, Gómez-U quiza JL, Cañadas GR. Sínd ome de bu nou en p o esionales de en e me ía que ealizan jo nada ísica complemen a ia en se icios de cuidados c í icos y u gencias. Re Española de Salud Pública. 2016;90:e1–9. 14. Dickinson T, W igh KM. S ess and bu nou in o ensic men al heal h nu sing: a li e a u a e iew. B J Nu s. 2008;17(2):82–7. 15. Va gas C, Cañadas GA, Aguayo R, Fe nández R, De la Fuen e EI. Which occupa ional isk ac o s a e associa ed wi h bu nou in nu sing? A me a- analy ic s udy. In J Clin Heal h Psychol. 2014;14(1):28–38. 16. Gómez-U quiza JL, Aneas-López AB, De la Fuen e-Solana EI, Albendín-Ga cía L, Díaz-Rod íguez L. Cañadas-De la Fuen e GA. P e alence, isk ac o s and le els o bu nou among oncology nu ses: a sys ema ic e iew. Oncol Nu s Fo um. 2016;43(3):E104–20. 17. Albendín L, Gómez JL. Cañadas-De la Fuen e GA, Cañadas GR, San Luis C, Aguayo R. Bayesian p e alence and bu nou le els in eme gency nu ses. A sys ema ic e iew. Re La inoam Psicol. 2016;48(2):137–45. 18. Chuang CH, Tseng PC, Lin CY, Lin KH, Chen YY. Bu nou in he in ensi e ca e uni p o essionals: a sys ema ic e iew. Medicine 2016; 95(50):e5629. h ps://doi.o g/10.1097/MD.0000000000 005629. 19. Gi a d A, Hudon C, Poi as M, Robe ge P, Chouina d M. P ima y ca e nu sing ac i i ies wi h pa ien s a ec ed by physical ch onic disease and common men al diso de s: a quali a i e desc ip i e s udy. J Clin Nu s. 2017;26(9–10):1385–94. 20. Gómez-U quiza JL, Monsal e-Reyes CS, San Luis-Cos as C, Fe nández-Cas illo R, Aguayo-Es eme a R. Cañadas-De la Fuen e GA. Fac o es de iesgo y ni eles de bu nou en en e me as de a ención p ima ia: una e ision sis emá ica. A en P ima ia. 2017;49(2):77–85. 21. Na a o González D, Ayechu-Díaz A, Hua e-Labiano I. P e alence o bu nou synd ome and i s associa ed ac o s in p ima y ca e s a . SEMERGEN. 2015;41:191–8. 22. Vilá Falgue as M, C uza e Muñoz C, O ila Pe nas F, C eixell Su eda J, González López MP, Da ins MJ. Bu nou and eamwo k in p ima y ca e eam. A en P ima ia. 2015;47(1):25–31. 23. So o Cama a R, San ama ía CI. P e alence o bu nou in p ima y ca e nu ses. En e m Clin. 2005;15(3):123–30. 24. Gómez-U quiza JL, De la Fuen e-Solana EI, Albendín-Ga cía L, Va gas-Pecino C, O ega-Campos E. Cañadas-De la Fuen e GA. P e alence o bu nou synd ome in eme gency nu ses: a me a-analy ic s udy. C i Ca e Nu se. 2017;37(5):e1–9. 25. Cañadas-De la Fuen e GA, Gómez-U quiza JL, O ega-Campos EM, Cañadas GR, Albendín-Ga cía L, De la Fuen e-Solana EI. P e alence o bu nou synd ome in oncology nu sing: a me a-analy ic s udy. Psychooncology. 2018; In p ess. doi:h ps://doi.o g/10.1002/pon.4632 26. U ú ia G, Bon ill X. PRISMA decla a ion: a p oposal o imp o e he publica ion o sys ema ic e iews and me a-analysis. Med Clín. 2010;135:507–11. 27. Ciapponi A. Guía de lec u a c í ica de es udios obse acionales en epidemiología (p ime a pa e). E idencia: ac ualización en la p ác ica Ambula o ia. 2010;13:135–40. 28. Das Me ces MC, Co dei o TM, San ana AI, Lua I, Sil a DS, Al es MS, e al. Bu nou synd ome in nu sing wo ke s o he p ima y heal h ca e. Re Baiana En e m. 2016;39(3):1–9. 29. Fau a T, Roige M, Se a R, O ega C, Monegal M, e al. P e alencia del sínd ome de bu nou en en e me as de hospi alización y de a ención p ima ia. En e m Clin. 1995;5(3):105–10. 30. Hay e M. Bu nou and AIDS ca e- ela ed ac o s in HIV communi y clinical nu se specialis s in he no h o England. J Ad Nu s. 1999;29:984–93. 31. Holmes ES, San os SR, Fa ias JA, Cos a MB. Bu nou synd ome in nu ses ac ing in p ima y ca e: an impac on quali y o li e. J Res Fundam Ca e Online. 2014;6(4):1384–95. 32. Tomás-Sábado J, Mayneg e-San aula ia M, Pé ez-Ba olomé M, Alsina- Rod íguez M, Quin a-Ba be o R, G anell-Na as S. Bu nou synd ome and suicide isk among p ima y ca e nu ses. En e m Clín. 2010;20(3):173–8. 33. Bikke AP, Fi zpa ic B, Mu phy D, Me ce SW. Measu ing empa hic, pe son- cen ed communica ion in p ima y ca e nu ses: alidi y and eliabili y o he consul a ion and ela ional empa hy (CARE) measu e. BMC Fam P ac . 2015; 16:149. h ps://doi.o g/10.1186/s12875-015-0374-y. 34. Mas Ga iga X, C uz Doménech JM, Fañanás Lanau N, Allué Buil A, Zamo a Casas I, Viñas VR. Di icul pa ien s in p ima y ca e: a quan i a i e and quali a i e s udy. A en P ima ia. 2003;31(4):214–21. 35. Smi s FT, Moh s JJ, Beem EE, Bindels PJ, Van Wee HC. De ining equen a endance in gene al p ac ice. BMC Fam P ac . 2008;9:21. h ps://doi.o g/10. 1186/1471-2296-9-21. Monsal e-Reyes e al. BMC Family P ac ice (2018) 19:59 Page 6 o 7 36. Zoboli EL, San os DV, Sch ei e MC. Adap a ion o he in en o y o e hical p oblems o he child heal h con ex . Ac a Paulis a En e magem. 2016;29(5): 586–94. 37. Duhoux A, Menea M, Cha on M, La oie-T emblay M, Alde son M. In e en ions o p omo e o imp o e he men al heal h o p ima y ca e nu ses: a sys ema ic e iew. J Nu s Manag. 2007;25:597–607. 38. Sou o Sil a CC, De Ca alho Li a ALB, Rod igues Feijao A, Fe nandes Cos a IK, De Medei os SM. Bu nou and heal h echnologies in he con ex o p ima y heal h ca e nu sing. Escola Anna Ne y. 2017;21(2):e20170031. 39. Regina Lo enz V. De B i o Gui a dello E. The en i onmen o p o essional p ac ice and bu nou in nu ses in p ima y heal hca e. 2014;22(6):926–33. 40. Van de Schoo E, Oginska H, Es yn-Beha M. Bu n- ou in he nu sing p o ession in Eu ope. In: Hasselho n HM, Tackbenbe g P, Mülle BH, edi o s. wo king condi ions and in en o lea e he p o ession among nu sing s a in Eu ope (pp. 53–57). S ockholm, Sweden: Na ional Ins i u e o Wo king Li e and Au ho s; 2003. 41. Jennings BM. Wo k s ess and bu nou among nu ses: ole o he wo k en i onmen and wo king condi ions. In: Hughes RG, edi o . Pa ien Sa e y and Quali y: an e idence based handbook o nu ses. Rock ille (MD): Agency o Heal hca e Resea ch and Quali y (US); 2008. 42. Spence Laschinge HK, Fida R. New nu ses bu nou and wo kplace wellbeing: he in luence o au hen ic leade ship and psychological capi al. Bu nou Resea ch. 2014;1(1):19–28. Monsal e-Reyes e al. BMC Family P ac ice (2018) 19:59 Page 7 o 7