Abstract

School expansion, changes in the educational model and funding problems have profoundly changed teaching in Brazil, intensifying demands on teachers. Health problems such as burnout are common in the profession. We investigated teacher burnout and its association with occupational factors, including violence. Data were collected using in-depth interviews and two specific instruments (the Maslach Burnout Inventory and Spanish Burnout Inventory). Statistical analysis was performed using Stata, version 13.0. Ninety-three teachers referred to psychotherapy from public schools in different regions of the city of São Paulo participated in the study. Burnout was associated with 11 school setting variables, including having suffered violence in the school (p <0.001), discomfort with interpersonal contact at work (p <0.001) and noise (p <0.001). Sixty percent of the teachers with severe burnout had suffered violence at school in the last year. Both collective and occupational issues were associated with teacher burnout. Among these, interpersonal conflict and violence, which appears as a new and common problem, adversely affect the health of these professionals.

Keywords:
Burnout; Teachers; Mental health; Workplace violence; Occupational health

Introduction

Despite the vital role education plays in personal and social development, the work of teachers in Brazil is undervalued and underpaid¹1 Ribeiro MLS. História da educação escolar no Brasil: notas para uma reflexão. Paidéia 1993; 4:15-30.^-22 Paiva V, Junqueira C, Muls L. Prioridade ao ensino básico e pauperização docente. Cad Pesqui 1997; 100:109-119.. Since the country’s redemocratization in 1988, important changes have been made to the pedagogical model and access to education has improved, in a process known as the democratization of education³3 Carvalho JSFd. "Democratização do ensino" revisitado. Educ Pesqui 2004; 30(2):327-334.. However, chronic education system funding and planning problems¹1 Ribeiro MLS. História da educação escolar no Brasil: notas para uma reflexão. Paidéia 1993; 4:15-30.^-22 Paiva V, Junqueira C, Muls L. Prioridade ao ensino básico e pauperização docente. Cad Pesqui 1997; 100:109-119. and emerging social conflicts, combined with the reformulation of teaching, have led to an intensification of demands on educators. Authors report a large number of professionals involved in teaching in Brazil, underlining the important social function performed by educators⁴4 Souza NA, Leite MP. Condições de trabalho e suas repercussões na saúde dos professores da educação básica no Brasil. Educ Soc 2011; 32(117):1105-1121.

5 Brito J, Bercot R, Horellou-Lafarge C, Neves MY, Oliveira S, Rotenberg L. Saúde, gênero e reconhecimento no trabalho das professoras: convergências e diferenças no Brasil e na França. Physis 2014; 24(2):589-605.^-66 Codo W. Educação: carinho e trabalho. 3a ed. Petrópolis: Vozes; 2002.. However, studies also highlight the occurrence of mental health problems among the teaching profession⁴4 Souza NA, Leite MP. Condições de trabalho e suas repercussões na saúde dos professores da educação básica no Brasil. Educ Soc 2011; 32(117):1105-1121.

5 Brito J, Bercot R, Horellou-Lafarge C, Neves MY, Oliveira S, Rotenberg L. Saúde, gênero e reconhecimento no trabalho das professoras: convergências e diferenças no Brasil e na França. Physis 2014; 24(2):589-605.

6 Codo W. Educação: carinho e trabalho. 3a ed. Petrópolis: Vozes; 2002.

7 Gasparini SM, Barreto SM, Assunção AA. Prevalência de transtornos mentais comuns em professores da rede municipal de Belo Horizonte, Minas Gerais, Brasil. Cad Saude Publica 2006; 22(12):2679-2691.

8 Araújo TM, Carvalho FM. Condições de trabalho docente e saúde na Bahia: estudos epidemiológicos. Educ Soc 2009; 30(107):427-449.^-99 Souza KR, Rozemberg B. As macropolíticas educacionais e a micropolítica de gestão escolar: repercussões na saúde dos trabalhadores. Educ Pesqui 2013; 39(2):433-447. and the issue of violence in schools¹⁰10 DTG. Estratégias de prevenção da violência escolar: revisão integrativa da literatura [dissertação]. Ribeirão Preto: Escola de Enfermagem de Ribeirão Preto / Universidade de São Paulo; 2018.^-1111 Tancred T, Paparini S, Melendez-Torres GJ, Thomas J, Fletcher A, Campbell R, Bonell C. A systematic review and synthesis of theories of change of school-based interventions integrating health and academic education as a novel means of preventing violence and substance use among students. Syst Rev 2018; 7:190.. Considering the multifactorial nature of issues involving teaching, we investigated teachers’ experiences of burnout, analyzing the association between the syndrome and occupational factors, including violence.

Burnout is a work-related health problem¹²12 World Health Organization (WHO). International Classification of Diseases 11th Revision; 2018 [cited 2020 mar 10]. Available from: https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/129180281
https://icd.who.int/browse11/l-m/en#/htt... ^-1313 Dias EC, organizador. Doenças Relacionadas com o Trabalho: Manual de Procedimentos para os Serviços de Saúde. Brasília: Ministério da Saúde (MS). Organização Pan-Americana da Saúde(OPAS); 2001. p. 191-194. [acessado 2021 out 16]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/doencas_relacionadas_trabalho1.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... and teachers and other professionals¹⁴14 Silva ATC, Menezes PR. Esgotamento profissional e transtornos mentais comuns em agentes comunitários de saúde. Rev Saude Publica 2008; 42(5):921-929.^-1515 Jenkins SR, Maslach C. Psychological health and involvement in interpersonally demanding occupations: a longitudinal perspective. J Organ Behav 1994; 15:101-127. are considered vulnerable to this condition¹⁶16 Belcastro PA, Gold RS. Teacher stress and burnout: implications for school health personnel. J Sch Health 1983; 53(7):404-407.^-1717 Carlotto MS, Palazzo LS. Síndrome de burnout e fatores associados: um estudo epidemiológico com professores. Cad Saude Publica 2006; 22(5):1017-1026.. Burnout is usually associated with caregiving and human services occupations¹⁸18 Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol 2001; 52:397-422. and specific tools have been used to measure it, such as the Maslach Burnout Inventory (MBI). The MBI measures three dimensions of the syndrome: emotional exhaustion related to the intensity of job demands; depersonalization or unfeeling towards service users’ problems and detachment, which can lead to negative and dehumanizing attitudes at work; and a feeling of reduced personal accomplishment and engagement in work¹⁸18 Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol 2001; 52:397-422.. The MBI is a leading measure of burnout and has been validated in various languages¹⁹19 Schaufeli WB, Leiter MP, Maslach C. Burnout: 35 years of research and practice. Career Develop Intern 2009; 14(3):204-220.^-2020 Santos AA, Nascimento Sobrinho CL. Revisão Sistemática da prevalência da síndrome de burnout em professores do ensino fundamental e médio. Rev Baiana Saude Publica 2011; 35(2):299-319.. Its developers maintain that burnout can be discussed from both a clinical and social psychology perspective: in terms of the interrelations between care providers and recipients in the context of human service and caregiving occupations¹⁸18 Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol 2001; 52:397-422.. We found references to some Brazilian versions of the MBI²¹21 Simões EC. Investigação de esgotamento físico e emocional (burnout) entre professores usuários de um hospital público do município de São Paulo [dissertação]. São Paulo: Universidade de São Paulo; 2014: p. 20-23.: in 1995, Carvalho²²22 Carvalho MMB. Professor: um profissional, sua saúde e a educação em saúde na escola [tese]. São Paulo: Faculdade de Saúde Pública; 1995. validated the educators survey (MBI-ES), presenting four scales; however, the latest version of the original MBI-ES ²³, published in 2010, has only three scales. The versions developed by Lautert²⁴24 Lautert L. O desgaste profissional do enfermeiro [tese]. Salamanca: Universidade Pontifícia de Salamanca; 1995. and Tamayo²⁵25 Tamayo MR. Relação entre a síndrome de Burnout e os valores organizacionais no pessoal de enfermagem de dois hospitais públicos [dissertação]. Brasília: Universidade de Brasília; 1997. in 1995 and 1997, respectively, were not based on the educators survey. In 2002, Garcia et al²⁶26 Garcia LP, Benevides-Pereira AMT. Investigando o Burnout em professores universitários. Inter Ação Psy [acessado 2021 out 16]. 2002; 1(1):79-89. Disponível em: https://gepeb.files.wordpress.com/2011/12/investigando-o-burnout-em-professores-universitc3a1rios.pdf
https://gepeb.files.wordpress.com/2011/1... developed a Brazilian version of the MBI- ES based on the original version developed in 1986. Considering the reformulations and latest version of the inventory, we opted to develop a new Brazilian version of the MBI for the purposes of this study.

Another burnout measure used in Brazil is the Brazilian version of the Spanish Burnout Inventory (Cuestionario para la Evaluación del Syndrome de Quemarse por el Trabajo - CESQT)²⁷27 Gil-Monte PR, Carlotto MS, Câmara SG. Validação da versão brasileira do "Cuestionário para la Evaluación del Síndrome de Quemarse por el Trabajo" em professores. Rev Saude Publica 2010; 44(1):140-147., consisting of four dimensions: enthusiasm towards the job, psychological exhaustion related to emotional demands at work, indolence, and guilt. The SBI assesses both the cognitive and physical aspects of burnout²⁸28 Gil-Monte PR, Carretero N, Roldán MD, Núnez-Román EM. Prevalencia del síndrome de quemarse por el trabajo (Burnout) em monitores de taller para personas com discapacidad. Rev Psicologia del Trabajo y de las Organizaciones; 21(1-2):107-123..

This study sought to identify both quantitatively and qualitatively the sources of burnout among teachers and broaden understanding of the factors that contribute to the development of this work-related health problem. Despite the large number of teachers working in schools in São Paulo (approximately 50.000)²⁹29 Secretaria Municipal de Educação (SME). Portal Institucional/Secretaria Municipal de Educação/Diretorias Regionais de Educação [Internet]. São Paulo: SME; 2020. [acessado 2020 nov 12]. Disponível em: https://educacao.sme.prefeitura.sp.gov.br/mapa-dres/, we found few studies on the mental health of teachers in this city; notably those conducted by Macaia et al.³⁰30 Macaia AAS, Fischer FM. Retorno ao trabalho de professores após afastamentos por transtornos mentais. Saude Soc 2015; 24(3):841-852., Giannini et al.³¹31 Giannini SPP, Latorre MRDO, Ferreira LP. Distúrbio de voz e estresse no trabalho docente: um estudo caso-controle. Cad Saude Publica 2012; 28(11):2115-2124. and Paparelli³²32 Paparelli R. Desgaste mental do professor da rede pública de ensino: trabalho sem sentido sob a política de regularização de fluxo escolar [tese]. São Paulo: Universidade de São Paulo; 2009.. Considering the lack of research on the association between burnout among teachers and occupational factors, we investigated the occurrence of this syndrome among educators working in public schools in different regions of the city of São Paulo.

Methods

The study protocol was approved by the research ethics committees at the University of São Paulo’s Faculty of Public Health and the Municipal Civil Servants’ Hospital (HSPM), which are registered in the National Research Ethics Committee (CONEP) (CAAE: 12684613.5.0000.5421).

All teachers referred to psychotherapy seeking mental health services at the HSPM between May 2013 and May 2014 were invited to participate in the study. Ninety-three of the 101 invited teachers participated in the study. Two opted not to participate, four did not meet the inclusion criteria, and two were ineligible because they did not have their glasses. The participants worked in the city’s four main regions. The number of participants working in each region was proportional to the overall number of teachers in each region.

Inclusion criteria: teachers who were working or on leave of absence; readapted teachers working or on leave of absence (functional readaptation due to medical reasons supported by a medical certificate. Readapted teachers are assigned to other functions outside the classroom); and medically retired teachers.

Exclusion criteria: retired teachers; staff in other education-related functions (school agent, principals, education coordinators) and teachers who had been receiving psychotherapy for more than eight weeks.

Interview: after participants gave their consent to participate in the study, in-depth interviews were conducted in which the researcher administered questionnaires and a topic guide designed to identify, characterize and detail the reasons why the teachers sought psychotherapy. The participants were invited to fill in the questionnaires themselves during the interview.

Survey of occupational issues: we developed a questionnaire consisting of 90 questions about the work environment and organization (attached).

Burnout assessment

To broaden data collection and make the investigation of the syndrome more consistent, we used two inventories specifically designed to assess burnout among educators. This also allowed us to compare the results of each instrument:

Maslach Burnout Inventory - Educators Survey (MBI)²³23 Maslach C, Jackson SE, Leiter MP, Schwab RL. Maslach burnout inventory - Manual and non-reproducible instrument and scoring guides. 3ª ed. Califórnia: Mind Garden; 2010., translated into Portuguese with the authorization of Mind Garden, Inc. (Translation Contract Number TA-346);

Spanish Burnout Inventory (SBI), validated for use with teachers in Brazil²⁷27 Gil-Monte PR, Carlotto MS, Câmara SG. Validação da versão brasileira do "Cuestionário para la Evaluación del Síndrome de Quemarse por el Trabajo" em professores. Rev Saude Publica 2010; 44(1):140-147..

Data analysis

The psychological instruments were analyzed using the respective instructions for each instrument. The results of the MBI and SBI are expressed in categories, allowing comparisons with the school setting variables, which were also categorized.

Associations between the occupational variables and results of the MBI and SBI scales were determined using the chi-squared test and Fisher’s exact test. The analyses were performed using Stata, version 13.0.

The interviews and guide allowed participants to express their feelings and talk about events that were not included in the questionnaires. Facts and perceptions linked to their experience as teachers were welcomed and contributed to the understanding of work dynamics and their impact on the participants.

Results

The number of teachers in the study sample in each of the city’s four major regions was proportional to the overall number of teachers in each region. The São Paulo City Department of Education’s website ²⁹29 Secretaria Municipal de Educação (SME). Portal Institucional/Secretaria Municipal de Educação/Diretorias Regionais de Educação [Internet]. São Paulo: SME; 2020. [acessado 2020 nov 12]. Disponível em: https://educacao.sme.prefeitura.sp.gov.br/mapa-dres/ states that the city’s schools are managed by 13 regional education offices: five in the East region; four in the South region; three in the North region; and one in the West region. According to the information provided by the Department of Education³³33 Portal da Transparência. Prefeitura de São Paulo. Portal da Transparência/e-sic acesso à informação/pedidos respondidos/protocolo 44205 de 2019. São Paulo: Prefeitura de São Paulo; 2019 [acessado 2020 mar 10]. Disponível em: http://transparencia.prefeitura.sp.gov.br/acesso-a-informacao/Paginas/default.aspx, the distribution of the sample across the four regions was proportionally similar to the overall distribution of teachers in the city in 2014. The two distributions are shown in Figures 1 and 2.

The large majority of the 93 participants (90.3%) were women. At the time of the assessment, 64.5% of the sample were working, 14.0% were readapted, 18.3% were on medical leave, and 3.2% were on work accident leave. The mean age of the participants was 46.4 years (ranging between 28.6 and 69.1 years; standard deviation 9.1 years), 7.5% of the sample were aged over 60 years, and only 3.2% were aged under 29 years.

The mean length of time working as a teacher was 21.1 years (ranging between 3.1 and 41.6 years; standard deviation 8.3 years). A third of the women (33.3%) had exceeded the number of years of service required to retire, which at the time of data collection was 25 years. The results of the MBI Personal Accomplishment scale show that prevalence of burnout was lower in women who had completed more than 25 years of service than in those with less time of service (p = 0.036). This association was repeated in the overall sample, with the results of the MBI Emotional Exhaustion scale (p = 0.001) and SBI Psychological Exhaustion scale (p = 0.007) showing that prevalence of burnout was lower among teachers who had more than 22.5 years of service (50.5% of the sample) than in those with less time of service.

With regard to education, 3.2% of the sample had only completed high school (did not have a degree) and 42.0% reported having postgraduate qualifications. However, more than three grammar and spelling errors were found in the answers to the open-ended questions in 17.2% of the questionnaires. One-third of the participants (33.33%) provided written answers containing mistakes and frequent lack of punctuation and accents. Furthermore, 34.41% of the respondents expressed their ideas and feelings in writing in a limited manner.

We examined the associations between the results of the MBI and SBI to determine the level of agreement between the two measures. The most significant p-values were found for the scales measuring similar aspects of burnout: Emotional Exhaustion/MBI and Psychological Exhaustion/SBI (p<0.001); Depersonalization/MBI and Indolence/SBI (p<0.001); Depersonalization/MBI and Enthusiasm towards the Job/SBI (p<0.001); Personal Accomplishment/MBI and Enthusiasm towards the Job/SBI (p<0.001); and Personal Accomplishment/MBI and Indolence/SBI (p<0.001).

Based on the rules of statistical standardization, the MBI and the SBI define the intensity of the syndrome as follows: mild, moderate or severe. In the present study, the results of the MBI and SBI showed that 35.48% and 40.86%, and 52.69% and 32.26% of the sample, respectively, had moderate and severe burnout. Four people (4.3%) did not experience the syndrome, while 26.9% of the participants showed severe burnout according to both the measures.

In addition to the association with length of service referred to above, the findings showed an association between burnout and having suffered violence in the school, issues relating to interpersonal contact at work, and aspects related to physical structure and work organization. Table 1 shows the number and percentage of individuals who had burnout according to the MBI and the p-values of the associations with occupational variables. Table 2 shows the number and percentage of individuals who had burnout according to the SBI and the p-values of the associations with the school setting variables.

Discomfort in contact with students, discomfort in contact with students’ parents, having experienced physical or verbal aggression in the school during the twelve months prior to the study, feeling unfulfilled professionally, feeling lack of support from teaching colleagues, and feeling lack of support from school directors/coordinators were associated with burnout.

Teacher discomfort with classroom noise, teacher discomfort with school noise, regarding classroom acoustics as unacceptable most of the time, perception of lack of participation in institutional decision-making, regarding bureaucracy as excessive, regarding the number of students per class as high, and regarding yourself as overloaded with activities were associated with burnout.

Slightly over half the participants (50.5%) reported having experienced physical or verbal aggression in the school during the twelve months prior to the study. In addition, the findings show that there was an association between having experienced aggression and the presence of burnout in both measures: MBI (p = 0.001) and SBI (p = 0.001) (Tables 1 and 2). Violence in schools was also related to the severity of the syndrome: 60% of the 25 participants who showed severe burnout in both inventories reported having suffered violence in the school in the 12 months prior to the study.

Discussion

The aim of this study was to determine the association between occupational factors and burnout among teachers referred to psychotherapy. We found significant p-values for 14 of the 90 variables tested - p-value is defined as the probability of obtaining a result equal to or more extreme than what was actually observed, based on an assumed or known probability curve. The following variables stood out in the associations found between school setting and presence of burnout: having experienced aggression in the school, problems involving interpersonal contacts, and structural issues such as noise. On the other hand, we found that prevalence of burnout was lower in teachers with a greater number of years of service in education than in those with less years of service. We expected that spending more years in the profession would have led to an intensification of the symptoms of the syndrome; however, this was not the case. To the contrary, both measures showed that prevalence of burnout was lower in teachers who had more than 22.5 years of service (slightly over half of the sample) than those with less time in the profession. In addition, 33.3% of women were eligible to retire, yet continued to work and showed lower prevalence of strain in relation to personal accomplishment than those with less time in the profession. These findings may reflect the resilience of more experienced professionals and the fact that some individuals are able to withstand adversity in their careers, while others leave the profession due to the health risks they are exposed to at work. Occupational epidemiologic studies show that the fact that certain individuals resist occupational stressors is explained by the phenomenon known as survival bias. The term survivor in this sense indicates a special type of worker, meaning that for each survivor many other workers leave their job³⁴34 Bernard BP, editor. Musculoskeletal disorders and workplace factors: a critical review of epidemiologic evidence for work-related musculoskeletal disorders of the neck, upper extremity, and low back. U.S. Department of Health and Human Services; Public Health Service; Centers for Disease Control and Prevention; National Institute for Occupational Safety and Health; July 1997. [cited 2020 mar 10]. Available from: http://www.cdc.gov/niosh/docs/97-141/pdfs/97-141.pdf
http://www.cdc.gov/niosh/docs/97-141/pdf... ^-3535 Garcia AM, Checkoway H. A glossary for research in occupational health. J Epidemiol Community Health 2003; 57:7-10..

There are certainly “survivors” among the 33.3% of the women in the sample who continue working after 25 years in the education profession and showed lower prevalence of burnout related to Personal Accomplishment than their colleagues with less years of service. These women include teachers who have already retired in one job and continue to work to complete the time of service required to retire in a second teaching job, suggesting that they are better off, at least financially, than other colleagues. In addition, it is possible that the fact that longer serving teachers have priority over workplace transfers contributes to lower levels of strain among teachers with more than 22.5 years of teaching experience. This criterion means these teachers are able to choose schools where they feel more fulfilled or less exhausted. On the other hand, higher levels of burnout among teachers with less time in the profession raises issues related to leaving teaching and the interest of young people in becoming teachers.

Work organization and burnout

Although our findings do not show any association between salary and burnout, this issue should not be underestimated. Teaching in Brazil has become increasingly undervalued²2 Paiva V, Junqueira C, Muls L. Prioridade ao ensino básico e pauperização docente. Cad Pesqui 1997; 100:109-119.. A recent OCDE report³⁶36 Organization for Economic Cooperation and Development (OECD). OECD Indicators, OECD Publishing, Paris: "Brazil", in Education at a Glance 2019; Key facts for Brazil in Education at a Glance 2019; Table D3.1a: Annual statutory salaries of teachers in public institutions, based on most prevalent qualifications, at different points in teachers' careers; 2019. [cited 2020 mar 19]. Available from: https://doi.org/10.1787/246ea76 d-en
https://doi.org/10.1787/246ea76 d-en... shows that the average salary of teachers at the primary and secondary level is below the average of member countries considering the purchasing power parity index. Low salaries reduce the appeal of a career in teaching, negatively affecting professional activity and the qualifications offered in the training of educators. Our results are consistent with the findings of a longitudinal analysis of teaching in Spain carried out by Esteve³⁷37 Esteve JM. O mal-estar docente: a sala de aula e a saúde dos professores. 3a ed. Bauru: Editora da Universidade do Sagrado Coração; 1999., who reported that “malaise” among teachers is triggered by factors such as the devaluation of teaching by society, constant work demands, violence in school and indiscipline. Esteve suggests that social changes have affected the role played by teachers, reducing social consensus on the function of schools and teachers in society. He argues that teacher training should be tailored to the new challenges of educational practice, overcome the idealization of the teacher’s role and be oriented towards the real possibilities of work in education³⁷37 Esteve JM. O mal-estar docente: a sala de aula e a saúde dos professores. 3a ed. Bauru: Editora da Universidade do Sagrado Coração; 1999.. Aranda³⁸38 Aranda SM. Um olhar implicado sobre o mal-estar docente [tese]. Porto Alegre: Universidade Federal do Rio Grande do Sul; 2007. addresses school violence and discusses support for school managers and teachers. According to these authors³⁷37 Esteve JM. O mal-estar docente: a sala de aula e a saúde dos professores. 3a ed. Bauru: Editora da Universidade do Sagrado Coração; 1999.^,3838 Aranda SM. Um olhar implicado sobre o mal-estar docente [tese]. Porto Alegre: Universidade Federal do Rio Grande do Sul; 2007., adequate training could protect these professionals from burnout. Considering the grammar errors and difficulties the teachers of our sample had expressing their ideas in writing, we are lead to question the quality of training offered to the teachers.

Violence, interpersonal conflict and burnout

Like Maia et al.³⁹39 Maia EG, Claro RM, Assunção AÁ. Múltiplas exposições ao risco de faltar ao trabalho nas escolas da Educação Básica no Brasil. Cad Saude Publica 2019; 35(1); 2-13., we found structural work issues, problems involving interpersonal contact, and teachers who experienced violence in the school. Our findings show an important association between school violence and burnout. The results of the MBI and SBI showed that 40.86% and 32.26% of the participants, respectively, had severe burnout. In addition, 60% of the participants who had severe burnout according to both tests (26.9% of the sample), reported having suffered violence in the school in the 12 months prior to the study. It is important to note that the probability that the association between having experienced aggression in the school and having burnout is due to chance is very low (p = 0.001, for both measures). These results are consistent with the findings of Wilson et al.⁴⁰40 Wilson CM, Douglas KS, Lyon DR. Violence against teachers: prevalence and consequences. J Interpers Violence 2011; 26(12):2353-2371., who reported significant associations between violence against Canadian teachers and physical and emotional effects. It seems that violence in schools is a social phenomenon and has been the object of studies and literature reviews addressing various contexts^{10-11, 39-40}.

Minayo and Souza⁴¹41 Minayo MCS, Souza ER, organizadoras. Violência sob o olhar da saúde: infrapolítica da contemporaneidade brasileira. Rio de Janeiro: Editora Fiocruz; 2003. organized a review of the literature in Brazil on violence and its impact on health services. The authors analyzed various types of studies and methodological approaches and discussed the multi-causality of violence and the dialectics of cause and effect. We understand that, as with other types of violence, it is important to address the multi-causality of violence in schools, as the determinants of this violence are not absolute. On the other hand, despite uncertainty about the causes of school violence, the association found between having suffered violence and having burnout appears to show the need to consider violence as an occupational hazard. The high prevalence of burnout among the study participants and strong associations between burnout and occupational factors, including violence, highlight the risk of developing burnout in the reference population. We observed that, although violence was associated with the problems that led to referral for psychotherapy, the participants did not seek therapy specifically due to the violence they had suffered, which appears to have become normalized in school settings. However, they complained about the countless conflicts and social problems that have become part of everyday life at school. It is known that educational settings are shared by individuals from different social classes, beliefs and ethnic groups. This plurality can promote coexistence and mutual respect as long as conflicts are mediated, and it is hoped that educators conduct this mediation. In other words, it is expected that teachers handle conflicts from an educational perspective. Therefore, when teachers are the target of violence, this aggression may be viewed by these professionals as a sign of failure. Thus, in the absence of institutional support, primarily for mediation of conflicts, teachers tend to become discouraged, often leading to burnout, unless they find ways of coping with their problems. Institutional programs and training focusing on conflict mediation in school settings could support teachers to this end.

Despite the resilience demonstrated by teachers, classroom conflict appears to be reflective of society’s ambiguity in relation to education. According to Azanha, cited by Carvalho³3 Carvalho JSFd. "Democratização do ensino" revisitado. Educ Pesqui 2004; 30(2):327-334., the São Paulo State Department of Education estimated that less than 20% of school-age children in the state would reach the fifth year of primary school by 1968. In other words, in the country’s richest and most developed state, less that 20% of school-age children would go beyond the fourth year of primary school. Until recently, the restricted number of places in schools, grade retention and dropout led to social exclusion and the maintenance of social inequalities in Brazil’s education system⁴²42 Ferraro AR, Ross SD. Diagnóstico da escolarização no Brasil na perspectiva da exclusão escolar. Rev Bras Educ 2017; 22(71):1-26.^-4343 Ferraro AR, Machado NCF. Da universalização do acesso à escola no Brasil. Educ Soc 2002; 23(79):213-241.. According to data presented by Ferraro⁴²42 Ferraro AR, Ross SD. Diagnóstico da escolarização no Brasil na perspectiva da exclusão escolar. Rev Bras Educ 2017; 22(71):1-26., in 2010, despite significant advances stemming from the constitutional precept of universalization of primary education, 3.2 million children and adolescents aged between four and 17 years were excluded from school in Brazil. In addition to the excluded children, seven million students⁴²42 Ferraro AR, Ross SD. Diagnóstico da escolarização no Brasil na perspectiva da exclusão escolar. Rev Bras Educ 2017; 22(71):1-26. repeated the school year (grade retention) in 2010. The shift from exclusion to inclusion led to a qualitative transformation of the entire education system, forcing professionals to adapt. Furthermore, the profession seems to carry both the expectations of success of the new model and responsibility for its failure. In addition to the criticism it receives, Brazil’s education system appears to be underfunded, considering that according to the OCDE³⁶36 Organization for Economic Cooperation and Development (OECD). OECD Indicators, OECD Publishing, Paris: "Brazil", in Education at a Glance 2019; Key facts for Brazil in Education at a Glance 2019; Table D3.1a: Annual statutory salaries of teachers in public institutions, based on most prevalent qualifications, at different points in teachers' careers; 2019. [cited 2020 mar 19]. Available from: https://doi.org/10.1787/246ea76 d-en
https://doi.org/10.1787/246ea76 d-en... spending per student and teachers’ salaries are well below the average.

Conclusions

Brazil’s educational model has undergone changes as a result of wide-ranging social and economic processes. Some participants mentioned changes in the pedagogical model, highlighting its advantages and shortcomings. Teaching is undergoing a process of transition accompanied by a large expansion of staff and work demands, suffering a real pay drop since the period prior to redemocratization. Teacher training and the appeal of the profession appear to have been adversely affected. In addition to the uncertainties of this transition, the findings of this study show that occupational factors are associated with burnout.

Considering that the symptoms experienced by the participants are related to occupational factors, actions designed to address the sources of burnout should be implemented in addition to medical or psychological treatment with the aim of creating a healthy working environment, thus improving the appeal of a career in teaching. The following occupational factors were associated with burnout: having experienced aggression in the school, interpersonal conflict in the school and structural problems (such as classroom and school noise). Understanding the relationship between burnout and occupational factors can help avoid the “individualization” of collective problems, preventing processes triggered in the external environment (and capable of affecting a large number of professionals) from being mistakenly considered solely as “personal issues”, restricted to the individual.

Although burnout was first described in the 1970s and studies on this topic have been conducted in various countries, the symptoms experienced by teachers in the city of São Paulo appear to have received scant attention from researchers and health and education departments. Thus, burnout among teachers apparently constitutes a field that requires further study. Actions that can prevent or reduce burnout among teachers include improvements in training, pay and support for resolving conflicts in the workplace. Programs designed to encourage support from school managers and teaching colleagues could also help teachers handle interpersonal issues related to burnout, while actions directed at structural factors and work organization can help improve teacher health, reducing the need to seek treatment and request medical leave of absence, thus benefitting teachers, students and the school.

References

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