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
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