Inledning: För barn kan sjukhusvistelser och allt vad de innebär av undersökningar och behandlingar ofta uppfattas som hotfulla och obehagliga. Insättning av perifer venkateter och venös provtagning tillhör de ingrepp som barn uppfattar som mest stressfulla och smärtsamma. Det finns i dagsläget gott om evidensbaserade metoder för att lindra barns oro och smärta i samband dessa ingrepp men det är oklart i hur stor utsträckning dessa metoder tillämpas. Syfte: Syftet är att undersöka sjuksköterskans tillvägagångssätt vid venös provtagning och insättning av perifer venkateter. Utgångspunkten för studien är undersöka sjuksköterskans förberedelser av barnet, hur sjuksköterskan arbetar för att främja barnets självbestämmande, användning av distraktioner, farmakologisk smärtlindring samt hur barn och föräldrar bemöts av sjuksköterskan inför och under provtagning eller insättning av perifer venkateter. Metod: Venös provtagning och insättning av perifer venkateter observerades och registrerades efter ett egenutformat observationsschema. Observationerna gjordes på avdelningar och mottagningar på ett barnsjukhus. Resultat: 18 sjuksköterskor observerades i 25 situationer. Observationerna genomfördes på både avdelningar och mottagningar på ett större barnsjukhus. Alla sjuksköterskorna använde sig av distraktioner och hade ett individuellt anpassat bemötande. Alla barn fick någon form av farmakologisk smärtlindring. I 17 av situationerna förberedde sjuksköterskan barnet genom att gå igenom hur proceduren gick till och i 22 situationer fick barnet vara med och bestämma. Slutsats: Slutsatsen är att sjuksköterskor på det barnsjukhus där studien genomfördes arbetar evidensbaserat i sitt tillvägagångssätt vid venös provtagning och insättning av en perifer venkateter. Vidare forskning skulle behövas för att undersöka hur sjuksköterskor på andra vårdinstanser som exempelvis barnspeciallistmottagningar arbetar. / Introduction: For children, hospitalization and all the means of examinations and treatments are often perceived as threatening and unpleasant. Venepunctures and peripheral catheterization belong to the procedures considered the most stressful and painful. There are plenty of evidence-based methods to alleviate children's distress and pain during these procedures, but it is unclear to what extent these methods are applied. Purpose: The purpose of this study is to examine the nurse´s approach to venepuncture and peripheral catheterization. The starting point of this study is to examine the nurse´s preparation of the child, how the nurse encourages the child´s autonomy, using of distractions and pharmacological analgesia and also how the child and its parents are cared for during the procedure. Method: Venepunctures and peripheral catheterization were observed and registered in a observational chart made for this study. The observations were performed at wards and clinics at achildren´s hospital. Results: 25 observations were performed on 18 different nurses. The observations were performed at both wards and clinics at a children´s hospital. All of the nurses used distractions and treated the children individually. All of the children received some form of pharmacological pain relief. In 17 of the situations the nurse explained the procedure to the child beforehand.In 22 of the situations the child was given the opportunity to participate and decide how the procedure was to be executed. Conclusion: The conclusion of this study is that nurses at the Hospitalare working with an evidence-based approach to venepuncture and peripheral catheterization. Further research is required to determine if nurses inother health facilitiesare working evidence-based or not.

Non-Suicidal Self-Injury (NSSI) is the self-inflicted damage to one’s bodily tissues without the intent to die. Previous research has sought to discover the motivation of an individual to perform such behavior and differences in the experience of pain among those who self-injure. The goals for the current study were to reveal any relationships between the function of NSSI, the subjective experience of pain, and an objective measurement of pressure pain threshold. Participants completed the Inventory of Statements About Self- Injury (ISAS; Klonsky & Glenn, 2009), which measures the functions that NSSI serves, and a measure assessing subjective pain experience, specifically frequency and severity of pain. Pain thresholds were also induced and recorded using a pressure algometer. The findings suggest that pain frequency significantly predicted pain threshold, whereas subjective pain severity did not. Furthermore, marking distress, the function of NSSI which serves as creating a tangible representation of emotional distress, was significantly associated with pain frequency, such that as marking distress increases in relevance, the less often one would be expected to experience pain. Therefore, the current study has implications relevant to both future research and the clinical setting.

Antalet patienter som söker sig till akutmottagning på grund av smärta är mycket omfattande. Smärta är en subjektiv upplevelse, därför är smärtlindring en komplex omvårdnadshandling som ställer höga krav på sjuksköterskans kompetens. Syftet med litteraturstudien var att belysa vad som påverkar sjuksköterskors omvårdnad vid smärtlindring av vuxna patienter på akutmottagning. Studien genomfördes med en systematisk litteratursökning med utgångspunkt i problemformuleringen. Genom strukturerade sökningar identifierades, granskades och analyserades relevant forskning inom området. I resultatet framkom tre övergripande teman som påverkar sjuksköterskors omvårdnad vid smärtlindring av vuxna patienter på akutmottagning; Sjuksköterskors smärtbedömning, Sjuksköterskors uppfattningar och prioriteringar samt Sjuksköterskors arbetsförhållanden. Resultatet visar att majoriteten av sjuksköterskor underskattar patienters smärta. Sjuksköterskors individuella uppfattning av smärta har en stor påverkan på omvårdnaden vid smärtlindring. Prioritering av smärta som företeelse är en förutsättning för smärtlindring. Miljön på akutmottagningar gör att sjuksköterskor upplever sig oförmögna att ge tillfredställande omsorg till patienter i smärta. Stöd från ledning samt andra professioner är en förutsättning för sjuksköterskor att kunna tillgodose bästa möjliga omvårdnad vid smärtlindring. Vidare forskning angående patienters upplevelse av omvårdnad vid smärtlindring kan öka förståelsen och medvetenheten hos sjuksköterskor. / Pain is one of the most frequent reason for patient´s seeking emergency care. Pain management is a crucial task in nursing due to the fact that pain is a subjective experience. This study aimed to illuminate what affects nursing care of adult patient´s seeking emergency care because of pain. Through a systematic literature search relevant research were identified, reviewed and analyzed. The results presents three themes; Nurse´s pain assessment, Nurse´s perceptions and priorities and Nurse´s working conditions. The results indicates that a majority of nurse´s underestimate patient´s pain. Nurse´s individual perception of pain has a large impact on nursing care regarding pain management. Priority of pain as a phenomenon is essential for pain management. Nurse´s define themselves as patients advocates but because of the emergency department environment they feel unable to provide satisfactorily care for patient´s in pain. Organizational support and teamwork is a presumption to enable best-practice in nursing pain management. Further research regarding patient´s perceptions of nursing care in pain management is required to enhance nurse´s understanding and awareness of pain and pain management.

Aim of the Study The aim of this study was to determine if the nursing interventions of patient education and multidisciplinary coordination of care were able to improve pain control in the cancer patient in an acute hospital setting. Background of the Study The role of the nurse in cancer pain management has been defined as being that of an educator, coordinator of care and advocate. A nurse with adequate knowledge of pain and its application to the cancer population and functioning in the role as defined is believed to be able to overcome many of the barriers that exist in implementing adequate analgesia and improve pain management in cancer patients. Design of the Study A randomized experimental control group design was utilized. The study comprised 3 experimental groups and one control group incorporating pre and post testing. The Intervention of the Study Experimental group one: subjects received education regarding their pain management which was tailored to meet their specific needs. Experimental group two: subjects underwent a pain assessment and construction of a care plan which was communicated verbally to the treating medical and nursing team and followed up with a written report which was documented in the history and sent to the treating medical physician. Experimental group three: subjects received the combined interventions administered to groups one and two. Control group four: subjects were assessed and all information was record in the same manner as for the experimental groups. The control group received their usual care during the study and their pain scores were measured at the same time intervals as the three experimental groups. Instrumentation The Wisconsin Brief Pain Questionnaire was used for the assessment of all subjects. The McGill Pain Questionnaire was used as the outcome measure following intervention. Data Analysis A one-way analysis of variance was used to detect the differences between the intervention groups and the control group. T-Tests were used to detect the differences between the groups incorporating a Bonferroni adjustment for frequent T tests. Results The main effect demonstrated a significant difference between the treatment groups and control at a significance level of 0.002. T-Tests showed no significant difference between control and communication groups and no significant difference between education and combined groups. A significant difference was detected between education and control and between combined and control. Conclusions Nursing interventions of patient education, coordination of care and advocacy can significantly improve cancer pain management. Intervention was tailored to meet the specific patient needs based on findings from the assessment and was dependent upon an adequate knowledge base. The nursing intervention of education was the most powerful of the three intervention types and its success was in tailoring to each individual. However, it is believed that with further recognition of the role of the nurse as coordinator of care will lead to greater improvements in cancer pain management.

Over the last 25 years, inadequate pain management for postoperative children continues to be reported in the literature. Inadequate postoperative pain management leads to detrimental physiological and psychological effects, and lengthens children's hospitalisation. Parental participation can improve the quality of care in hospital and after discharge. Both pain management and parental participation are influenced by the attitudes of nurses and parents. However, only little attention has been paid to this field particularly in Taiwan. The purpose of the present study was: firstly, to understand nurses' and parents' attitudes toward pain management and parental participation in postoperative child care. Secondly, to explore the personal factors affecting their attitudes to pain management and parental participation. The third purpose was to compare nurses' and parents' attitudes toward pain management and parental participation in postoperative care of children in Taiwan. A descriptive, cross sectional design was used to survey paediatric nurses (n=63) and parents (n=133) of children from 0 to 17 years old who had undergone surgery in three Taiwan teaching hospitals. The findings indicate that misconceptions about pain medications were found in both parents and nurses. Both parents and nurses held neutral to positive attitudes towards parental participation and postoperative pain management. Both parents and nurses who had higher education levels had more positive attitudes toward the use of pain medication. Parents who were younger, had a higher education level, had previous experience of caring for their child during hospitalisation, had previous experience with their child having surgery and who had younger children, had more positive attitudes toward parental participation. Nurses who had more working experience with children had more positive attitudes toward parental participation. Nurses and parents all had higher agreement in using non-pharmacological methods for children's postoperative pain relief. Nurses had more agreement than the parents in the subscale of "parent-professional collaboration" and another five items in the PPAS questionnaire which included parents being allowed to change simple dressings, restrain their child, and feed their baby; parents being informed; and enhanced professional-patient relationship with parental involvement. Parents had more positive attitudes than nurses to the subscale of "parent presence" and the parents were more in favour than nurses of the provision of facilities such as free meals or parking fees. Improvement in the quality of children's pain management requires more education to enhance nurses' and parents' knowledge and attitudes toward children's pain management and parental participation. Additional programs are needed that target nurses with less paediatric experience as well as older parents to develop more positive attitudes to parental participation. Paediatric nurses need to be aware and satisfy parents' desire to be present during their child's hospitalisation, as well as help parents to clarify their misconceptions about side effects and tolerance of analgesics utilisation.

Despite the fact that as many as 80-90% of patients with cancer pain can be effectively treated using pharmacological therapies and other advanced approaches, 31% to 85% of cancer patients in Taiwan still experience varying levels of pain. Pain is one of the symptoms that patients fear most; it overwhelms all aspects of patients' lives and creates a sense of uncertainly and hopelessness. Pain control is, therefore, a high priority in the treatment of cancer patients. Pharmacological therapy is the cornerstone of cancer pain management. With the current trend toward outpatient care, many patients are being required to assume greater responsibility for self-management of prescribed analgesics at home to deal with the variable and complex nature of cancer pain and side effects of opioids. Patients however, have misconceptions regarding analgesics and a series of difficulties when attempting to put a pain management regimen into practice. This research addressed the hypothesis that self-efficacy beliefs might play an important role in analgesic adherence and pain experience in Taiwanese outpatients with cancer. The purpose of this study was to develop a scale to measure the self-efficacy expectations relating to opioid-taking in Taiwanese outpatients with cancer. Another purpose was to explore how opioid-taking self-efficacy and beliefs about opioid analgesics contribute to patients' analgesic adherence and pain experience in Taiwanese outpatients with cancer. In the first stage semi-structured interviews were conducted to collect data from a purposeful sample (n=10) of oncology outpatients from two teaching hospitals in the Taipei area of Taiwan. The purpose of this phase was to identify behaviours and situational impediments associated with analgesic taking. Findings from this phase were used to develop a scale to measure opioid-taking self-efficacy. In the second stage a pilot test with a convenience sample (n=30) was conducted to test the validity and reliability of the new scale and to identify the feasibility of using the scale in a cross-sectional survey. In the third stage a cross-sectional survey was undertaken (n=92) to describe pain experiences, analgesic adherence, beliefs about opioid analgesics, and opioid-taking self-efficacy in Taiwanese outpatients with cancer and to explore how opioid-taking self-efficacy and beliefs about opioid analgesics contributed to analgesic adherence and pain experience. Results of this study highlight an important issue - under-treatment of cancer pain in this group of Taiwanese outpatients. As well, low adherence rates to opioid analgesics in cancer outpatients arose as an important issue in this study. A range of misconceptions about using opioids for pain was also common amongst the sample. Despite these misconceptions, patients reported being moderately confident in their ability to perform self-management behaviours related to their prescribed opioid-taking. Results of this research supported the notion that patients' self-efficacy in relation to taking their prescribed opioid regimen was a significant independent predictor of patients' adherence behaviour and pain relief, but not of pain severity. Beliefs about opioid analgesics were also an independent predictor of patients' adherence, but not of pain relief or pain severity. In addition, findings from this study provided support for the validity and reliability of the opioid-taking self-efficacy scale. Results suggested there is a need for systematic assessment of beliefs affecting patients' opioid adherence behaviours for cancer pain control, including perceived personal self-efficacy and beliefs about opioid analgesics. Educational programs that focus on overcoming patients' misconceptions (beliefs) about taking opioid analgesics may be particularly beneficial. In addition, this study advocates that conducting self-efficacy-enhancing interventions may improve medication adherence for patients and therefore pain relief. More research is needed to demonstrate the construct validity of the self-efficacy scale and to evaluate self-efficacy enhancing interventions in cancer pain management.

Despite the expansion of research into chronic nonmalignant pain, a majority of reported studies are based on patient populations of specialised pain management clinics, which may not adequately represent older people with chronic nonmalignant pain in the general community. Therefore, the overall aim of the present thesis was to fill some gaps in this knowledge base. / The findings of the present thesis support the notion that older people who attend multidisciplinary pain management centres are probably not representative of those with pain who live in the general community but do not attend specialised treatment centres. Indeed a conceptual framework developed from the findings suggest that less than 3 percent of a random community sample of older people with chronic pain share the profile of those who attend a multidisciplinary pain management centre. The majority (86 percent) of the community sample were found to have mild chronic pain that can be adequately managed in the community. However, about 11 percent of the community sample have moderate chronic pain, and it is probable that additional community-based pain management services can improve the management of pain. / Development of instruments to measure the perceived helpfulness and use of pain management strategies by community-dwelling older people with chronic pain is another area that has not received adequate attention. A preliminary survey questionnaire was developed to measure the use and perceived helpfulness of pain management strategies in community dwelling older people. The findings have provided new insight from the user’s perspective regarding the relative effectiveness of different pain management strategies, and highlighted the potential clinical application of strategies that are less commonly used, such as TENS (transcutaneous electrical nerve stimulation), and relaxation techniques that are beneficial for specific subgroups of older people with chronic pain. / The evaluation of the efficacy of a community-based intervention program that provides free choice of intervention for improving outcomes for older people with chronic pain showed that the program was successful in reducing pain and improving level of physical activity for those who completed the program when they were compared with matched subjects who did not participate. The findings also suggest that an educational seminar can have a positive impact that empower participants to make a more informed choice regarding interventions for managing pain. However, the long-term effect of the program has not been established. Therefore, further research will be needed to evaluate whether this approach is a viable alternative clinical option for effective, accessible, and low cost pain management for the general community of older people with chronic pain. / The pain management service model was developed based on a synthesis of the findings. The model was based on a targeted approach that focuses on community-based interventions designed to improve access and outcomes for the majority of community-dwelling older people with chronic non-malignant pain who do not use specialised pain management services. / Overall, the findings of the present thesis have enhanced our understanding of the management of chronic non-malignant pain in community-dwelling older people, which has important implications for the development of services, and has generated hypothesis for future research that may contribute to improve outcomes for older people with chronic non-malignant pain.

Introduktion: Smärta är en subjektiv känsla som endast den som upplever smärtan kan beskriva, men är något som nästan alla som genomgår ett kirurgiskt ingrepp upplever. Det finns olika typer av smärta och olika sätt att analysera och behandla den på. Bristfällig postoperativ smärtbehandling kan leda till svåra komplikationer och kan medföra stora kostnader för samhället och lidande för patienter. Syfte: I den här studien var syftet att med hjälp av vetenskaplig litteratur beskriva patienters upplevelser av postoperativ smärtlindring. Metod: Studien är gjord som en litteraturstudie med tio vetenskapliga artiklar vilka granskades med hjälp av innehållsanalys. Artiklar söktes via sökmotorerna PubMed och CINAHL. Resultat: Resultatet visade att patienter som var välinformerade om den postoperativa smärtbehandlingen både muntligt och skriftligt före och efter operationen, upplevde att de var mer nöjda med sin postoperativa smärtbehandling. Dessa patienter kände sig tryggare i att tillkalla sjukvårdspersonalen vid smärta och de upplevde att de var förberedda på postoperativ smärta redan innan operationen. Patienterna uppgav att ett bra bemötande från sjukvårdspersonalen hade en positiv inverkan på deras smärtupplevelse. Patienterna lyfte också fram aspekter som kunde förvärra patienternas upplevelse och beskrev då svårigheter att förmedla sin smärta, bristfällig information, ett dåligt bemötande med mera. Slutsats: Majoriteten patienter var nöjda med den postoperativa smärthandlingen men det fanns faktorer som påverkar upplevelsen till det sämre. För att förbättra möjligheten till en god postoperativ smärtbehandling är det viktigt att utveckla en arbetsmiljö för sjukvårdspersonal som tillåter ett gott bemötande och en tydlig kommunikation med patienter både före och efter operation. / Introduction: Pain is a complex and subjective experience, it is hard for any other else than the patient to understand it. All patients that undergo surgery will experience some sort of postoperative pain and therefore it is important to understand what pain is and what the patient goes through. Insufficient pain management could lead to postoperative complications that could be life threatening and increases the cost to society. Aim: The aim of this study was to examine the patient’s experiences of postoperative pain management. Methods: This study used a descriptive literature review. The searches were performed in the databases PubMed and CINAHL. Results: Results show that patients who were well-informed both pre- and postoperatively about the pain management were the most satisfied with their experience. Good communication and good treatment heightened the well-being of patients. Negative aspects could be communication difficulties and troubles describing the pain, lack of information and overstrained staff. Conclusion: The majority of patients were satisfied with their postoperative pain management but there were different things that had a negative influence on their experience. Improvements can be made, especially in the staffs’ individual behavior and in the organization as such.

Objetivo: Avaliar os efeitos da estimulação elétrica nervosa transcutânea (TENS) comparada com TENS placebo e grupo controle sobre a dor, função pulmonar, força muscular respiratória e medicações analgésicas no pós-operatório de cirurgias torácicas em uma Unidade de Tratamento Intensivo (UTI). Método: Pacientes entre 31 e 76 anos submetidos a toracotomia póstero-lateral, foram incluídos e alocados aleatoriamente em três grupos: TENS (GE), TENS placebo (GP) e controle (GC). O GE recebeu a aplicação da TENS (frequência=100 Hz, duração de pulso=100 μs, intensidade no nível sensorial, durante 30 minutos, três vezes ao dia, durante a internação na UTI), associada a fisioterapia convencional (respiratória e motora). No GP foi realizada a TENS placebo além de fisioterapia convencional; e o GC recebeu apenas a fisioterapia convencional. Os desfechos foram avaliados no pré-operatório, pós-operatório (PO), e 48 horas após a internação na UTI: dor através da Escala Visual Analógica, função pulmonar através de espirometria (VEF1 e CVF), força muscular respiratória através de manovacuometria (PImáx e PEmáx), e medicações através da análise dos prontuários. Resultados: Foram incluídos 45 pacientes, sendo 15 em cada grupo. Em relação a percepção dolorosa, não houve diferença entre os grupos (P=0,172), porém houve redução na dor após o término do primeiro atendimento no GE (4,7±3,2 vs. 3,3±2,6; P<0,05). Em relação a função pulmonar e força respiratória não houve diferença significativa entres os grupos nos momentos avaliados. Entretanto, nas avaliações intragrupo, observou-se melhora na CVF, todos os grupos apresentaram redução no momento PO e 48 horas comparado com o pré (P<0,001), e somente o GE promoveu um aumento na CVF nas 48 horas em relação ao PO (P<0,001). A PImáx e PEmáx diminuíram em todos os grupos comparando o pré com o PO e 48 horas (P<0,001). Não houve diferença entre os grupos em relação as medicações analgésicas, porém o GC apresentou maior consumo de morfina (p=0,037) e o GP maior consumo de paracetamol (p=0,035) 24 vs 48 horas, o que não foi alterado no GE. Conclusão: Não foi observado diferença entre os grupos em relação aos desfechos avaliados no pós-operatório de cirurgia torácica, porém, a TENS 13 promoveu redução da dor e aumento mais precoce da CVF, além disso, não promoveu aumento no consumo de medicação. / Objective: To evaluate the effects of transcutaneous electrical nerve stimulation (TENS) compared to placebo TENS and control group on pain, pulmonary function, respiratory muscle strength and analgesic medications in the postoperative period of thoracic surgery in an Intensive Care Unit (ICU). Methods: Patients between 31 and 76 years submitted to postero-lateral thoracotomy, were included and randomly allocated into three groups: TENS (GE), TENS placebo (GP) and control (GC). The GE received TENS (frequency = 100 Hz, pulse duration = 100 μs, intensity at the sensory level for 30 minutes, three times a day during ICU stay), associated with conventional physiotherapy (respiratory and motor). In GP, TENS was performed in addition to conventional physiotherapy; And GC received only conventional physiotherapy. The outcomes were evaluated in the preoperative, postoperative (PO) or 24 hours, and 48 hours after ICU admission: Pain through Visual Analog Scale, pulmonary function through spirometry (FEV 1 and FVC), respiratory muscle strength Through manovacuometry (MIP and MEP), and medications through the analysis of medical records. Results: 45 patients were included, 15 in each group. Regarding pain perception, there was no difference between the groups (P = 0.172), but there was a reduction in pain after the end of the first treatment in the GE (4.7 ± 3.2 vs. 3.3 ± 2.6; P <0.05). Regarding pulmonary function and respiratory force, there was no significant difference between the groups at the moments evaluated. However, in the intragroup evaluations, improvement in FVC, all the groups had a reduction at the time PO and 48 hours compared to the pre (P <0.001), and only the GE promoted an increase in FVC at 48 hours in relation to PO (P <0.001). The MIP and MEP decreased in all groups comparing the pre with PO and 48 hours (P <0.001).There was no difference between the groups in relation to analgesic medications, however, the CG had higher morphine consumption (p = 0.037) and the GP had a higher paracetamol consumption (p = 0.035) 24 vs 48 hours, which was not altered in the GE. Conclusion: No differences were observed between the groups in relation to the outcomes evaluated in the postoperative period of thoracic surgery, however, TENS promoted pain reduction and earlier increase in FVC, in addition, did not promote increase in medication consumption.

The interest in the burnout syndrome issue has been increasing in recent years, particularly in the context of increasing psychosocial and work related stress in the sector of health and social services. The care of patients with chronic pain requires specific approach from the professional, psychological and ethical points of view from pain therapists. Unless a doctor is able to tolerate work related stress or to use mitigating strategies, the burnout syndrome threat occurs. The aim of the present thesis was to find out what the subjective approach to the burnout syndrome issue is among selected algiatry experts including its prevention. Qualitative research was conducted from January to February 2012 in the form of semi structured interview. The research sample consisted of respondents from 10 workplaces involved in chronic pain therapy (5 private, 5 in hospitals). The data were complemented with quantitative questionnaire research (Burnout Syndrome Symptom Inventory ? ?BSSI?) conducted from November 2011 to January 2012 to obtain a deeper insight into the content analyses of the semi structured interviews. The quantitative research sample consisted of 47 doctors from pain management workplaces from the whole Czech Republic. The demographic data were processed by means of basic descriptive statistics. Qualitative interviews were transcribed to text form and consequently analyzed. Score points of the monitored levels of the ?BSSI? questionnaire were then calculated and differences between pair variables (gender, age category, type of practice) tested. The mixed research showed statistically higher rate (p < 0.05) of tendency to burnout syndrome in pain therapists working at hospitals compared to their colleagues from private facilities. No significant differences were found in terms of age, sex, number of children in a family and number of treated patients. The most frequent symptoms of the syndrome in the respondents were irritation, lack of empathy, tiredness or loss of work enthusiasm. The most frequent protective factors are humour, breaks, discussion with colleagues, sport activities, hobbies or spending free time with families.