Romênia Kelly Soares de Lima1; Aline Luiza de Paulo Evangelista2; Jéssica Karen de Oliveira Maia2; Priscila Nunes da Silva Travassos3; Francisco José Maia Pinto1; Francisco Jadson Franco Moreira4
BACKGROUND: Work accident (WA) reports are a relevant public health tool as they afford effective knowledge on the actual situation of workers cared within the Unified Health System (Sistema Único de Saúde - SUS).
OBJECTIVE: To analyze the difficulties posed by mandatory WA reporting and suggestions for improvement made by healthcare professionals at sentinel workers’ health units in Fortaleza, Ceará, Brazil.
METHODS: Quantitative and descriptive study conducted at sentinel workers’ health units in Fortaleza, Ceará, from February 2013 through June 2014. An unstructured questionnaire was applied to 78 professionals charged of reporting WA. The collected data were subjected to content analysis.
RESULTS: As difficulties for reporting WA the participants mentioned: lack of knowledge on how to manage required measures, omission and work overload. Suggestions to improve reporting included health continuing education and divulgation of protocols.
CONCLUSION: The results of the present study point to the relevance of training as a means to enhance reporting and to orient professionals on how to fill report forms in order to reduce underreporting.
Keywords: accidents, occupational; mandatory reporting; occupational health; education, continuing.
INTRODUÇÃO: A notificação de acidente de trabalho (AT) é hoje um importante instrumento para a saúde pública, pois a partir dela se tem real conhecimento sobre a situação dos trabalhadores atendidos pelo Sistema Único de Saúde (SUS).
OBJETIVO: Analisar dificuldades e sugestões dos profissionais de saúde sobre a notificação compulsória de AT em unidades sentinela em saúde do trabalhador, no município de Fortaleza, Ceará.
MÉTODOS: Estudo quantitativo de cunho descritivo, realizado em unidades sentinela em saúde do trabalhador, no município de Fortaleza, Ceará, no período de fevereiro de 2013 a junho de 2014. Foram aplicados 78 questionários não estruturados aos profissionais responsáveis pela notificação de AT. A exploração dos dados obtidos foi pautada na Análise de Conteúdo.
RESULTADOS: As dificuldades encontradas pelos profissionais como impedimento para a não notificação foram: falta de conhecimento quanto ao manejo de medidas a serem tomadas, omissão e sobrecarga de trabalho. Foram citadas como sugestões: educação permanente em saúde (EPS) e divulgação de protocolos.
CONCLUSÃO: Com os resultados obtidos pelo presente artigo, fica evidente a importância da capacitação dos profissionais de saúde, incentivando a realização das notificações e orientando tais profissionais para o correto preenchimento da ficha de notificação, a fim de diminuir a subnotificação do agravo.
Palavras-chave: acidentes de trabalho; notificação compulsória; saúde do trabalhador; educação continuada.
Work accidents (WA) are a significant public health problem as a function of their high incidence and impact on morbidity and mortality. Article 19 of Law 8,213, from 24 July 1991, defines WA as:
The ones which occur in the course of work leading to body injury or functional disorders which cause death, loss or permanent or transient reduction of work ability. They also comprise events on the worker’s way from home to work and vice versa1.
According to the International Labor Organization (ILO) about 321,000 people die by WA every year, and 160 million people develop non-fatal occupational diseases2. The annual cost of medical visits, medication, rehabilitation, leaves of absence and retirement is estimated as USD 2.8 trillions. In Brazil, these factors account for more than 60% of the benefits paid by the Social Security administration3-5.
Considering the aforementioned aspects and the need to standardize the procedures for mandatory reporting of WA within the Unified Health System (Sistema Único de Saúde - SUS) WA were included in the national list of diseases and other conditions to be monitored through surveillance at sentinel units6.
Due to the negative impacts of WA, ambitious strategies are being developed to overcome the problems derived from underreporting7. One such strategies is the National Integrated Workers’ Health Care Network (Rede Nacional de Atenção Integral à Saúde do Trabalhador - RENAST) created in 2002 and linked to mandatory WA reporting by units enrolled with the Sentinel Work Accident and Work-Related Diseases Mandatory Reporting Network, established in the Ministry of Health Administrative Ruling GM/777, article 2, from 20048.
According to Administrative Ruling no. 204, from 17 February 2016, the sentinel surveillance model is based on health services considered strategic for the surveillance of morbidity, mortality and etiologic agents of interest within the public health setting. The aim of health services accredited as “sentinel units” is to monitor relevant indices that provide early warnings to the workers’ health surveillance system9.
Sentinel units are further charged of the diagnosis, treatment and reporting of work-related diseases, being categorized per type of reported conditions10.
Currently, WA reporting is a relevant public health instrument. Within the sentinel network, reporting is made by means of Severe Accidents Reporting Forms, System of Information for Notifiable Conditions (Sistema de Informações e Agravos e Notificações - SINAN) which covers all workers independently from their employment relationship11,12.
Countless factors contribute to underreporting WA within the SUS sentinel network. Some such factors are: fragmentation of information systems, particularly the ones for workers’ health; poor acquaintance of the involved professionals with the instruments used for reporting; large numbers of workers without stable employment relationship, resulting in high turnover at health units; and lack of continuing education support13-15.
The aim of the present study was to detect difficulties and gather suggestions on mandatory WA reporting at workers’ health sentinel units in Fortaleza, Ceará, Brazil, from the perspective of healthcare professionals
The present study is a part of a larger research project entitled Surveillance accidents and violence: factors related to underreporting within the SUS network in Fortaleza-CE performed from February 2013 through June 2014. The study had a descriptive quantitative design, as the quantitative approach proved to be more adequate to the study aims.
Along the study period, there were seven secondary and tertiary sentinel units in Fortaleza accredited to report severe and fatal work-related accidents through an agreement with the Bipartite Inter-manager Committee (Comissão Intergestores Bipartite - CIB). Establishment of sentinel service networks is a strategy to decentralize SUS actions. The five units with the largest healthcare demand were selected for questionnaire application.
The inclusion criterion for unit selection was: 24/7 availability of outpatient and emergency care. The following five units met this criterion: Doctor José Frota Institute, General Hospital of Fortaleza, Evandro Aires de Moura District Hospital, Maria José Barroso de Oliveira District Hospital and Governor Gonzaga Mota District Hospital. The criteria for selection of professionals were: complete higher education and being involved in direct care delivery to accident victims and/or WA reporting.
An unstructured questionnaire was used for data collection. The questionnaire was applied by 12 field investigators supervised by four tutors (1 tutor per four investigators). All the research team members received 40-hour training delivered by a group of supervisors. The aims of training were to acquaint investigators with the instrument and achieve greater uniformity in its application.
Questionnaires are inquiry tools able to gather information rapidly while ensuring anonymity16. On these grounds, following explanations on the study confidentiality, the instrument was responded by the members of different teams at the workplace, on variable shifts and days of the week.
Exploratory data analysis was based on the content analysis technique17 to identify the meaning of the data, followed by inferential analysis to verify the veracity of the information. Content analysis is a research method that involves objective, systematic and quantitative analysis of the content of communication for the purpose of interpretation17.
The results described here were subjected to inferential analysis and interpretation, seeking to relate simple percentages representing the frequency of elements in narratives to the theoretical-interpretative dimension through analysis of the collected material.
Analysis included encoding the information on difficulties perceived by healthcare professionals and the suggestions they made. The frequency and consistency (exhaustiveness) of the terms found in the responses to the questionnaire were analyzed in theoretical discussions on mandatory reporting of WA, workers’ health and health continuing education.
The study was approved by the research ethics committee of Federal University of Ceará, CAAE 11070813.9.0000.5054, ruling no. 237,406. Since the study involved research with human beings, all the procedures complied with Resolution no. 196/96 which was the one in force at the time when the study was conducted. All the participants read and signed an informed consent form.
Seventy-eight healthcare professionals were interviewed at the five selected units. Most were nursing professionals (48.0%), female (78.0%), had worked in the healthcare sector for 15 to 20 years (52.0%) and were aged 31 to 40 years old (29.5%). The median number of years since graduation from high education was 16 to 21 (50.0%). About 44.0% of the participants reported to have attended training on WA, and 44.0% to have already reported WA.
Quantitative analysis of the responses to the questionnaire allowed establishing two categories:
I: main difficulties to report WA;
II: suggestions to improve WA reporting.
CATEGORY I: MAIN DIFFICULTIES TO REPORT WORK ACCIDENTS
Twenty participants did not respond this item. The main difficulty, reported by 47.0% of the participants, was lack of knowledge on how to handle WA or what measures should be adopted, followed by omission (12.0%) and work overload (Table 1).
Lack of a clear protocol at the units also contributed to poor-quality reporting, and was mentioned by the participants as a difficulty. Some participants mentioned lack of the necessary materials, as e.g. SINAN report forms, which made impossible for them to report occurrences (Table 2).
Several factors are relevant for adequate reporting, such as technical-scientific knowledge, human resources adequate to the service characteristics and continuing training. The suggestions made by the participants to improve mandatory WA reporting are described in the table discussed below.
CATEGORY II: SUGGESTIONS TO IMPROVE WORK ACCIDENT REPORTING
Health continuing education (HCE) was suggested by 65.0% of the sample (Table 3). Wider divulgation of the steps to follow facing WA was also mentioned.
As they had stated upon describing difficulties, in their suggestions all the participants stressed the need for greater support to receive the training needed to overcome the lack of knowledge exhibited by professionals (Table 4).
Since work-related health problems are complex, support from other SUS areas related to notification of diseases and other events is necessary. These indicators are relevant guides for the formulation of policies and programs targeting workers’ health, increasing knowledge and defining the process and flow for reporting outcomes and continuing training.
According to Rodrigues et al.18, practical, concise and efficient protocols contribute to effective reporting by enhancing compliance with norms and adherence to processes. Having healthcare professional report events is relevant, because the resulting information contributes to the identification of possible hazards and vulnerabilities in the workplace. Thus reporting is useful for the planning of public actions for prevention of WA and promotion of safety measures19.
On occasions, healthcare professionals fail to report events for not having assimilated the corresponding information. This suggests they might have not understood the relevance of reporting, resulting in difficulties, or makes evident its non-mandatory nature, whereby the purpose of reporting is not taken into account, leading to underreporting.
Underreporting reflects the scarce knowledge of healthcare professionals on how to behave vis-à-vis WA and on how to properly fill report forms20. Therefore, they need to receive training by means of HCE actions21.
The results of the present study evidence the difficulties met by professionals responsible for reporting WA at healthcare units. It is worth emphasizing that the participants observed they were not trained to report WA properly. Moreover, the training effectively received was not able to correct considerable flaws, since HCE was the main suggestion made by 65.0% of the participants.
The diversity among the participants was a relevant factor, which made possible the construction of perception which has made possible the same theme interdisciplinary work and aligning the mentioned difficulties and suggestions. This situation corroborates the idea that HCE promotes constructing knowledge with interdisciplinary links by prioritizing the teaching-learning relationship at healthcare services based on problems derived from concrete reality22.
According to Ceccim and Feuerwerker23, “HCE contributes [to establish] interfaces, interactions and inter-complementarity among states and municipalities for the construction of a unified health system” (p. 16) through incentives to the processes of production of knowledge about SUS. The decentered and collegiate nature of SUS management should be thought over as concerns decision making on the training of healthcare professionals.
As was observed, “health continuing education seeks to reunite theory and practice through on-the-job training, thus overcoming the mere development of professional skills24.” On these grounds, the results of the present study point to an urgent need for professional training to improve the quality of work as concerns mandatory WA reporting, when one considers the emphasis given by the participants to their lack of information and poor knowledge about this subject.
As an option to overcome their difficulties, one of the suggestions made by the participants was to reduce their working hours, since this factor behaves as an hindrance to reporting, in addition to being a risk factor for occurrence of WA. Long working hours cause exhaustion, leading to reduced work ability, illnesses and absenteeism, besides increasing the workload of the employees who remain active at services25,26.
The participants’ suggestions strongly pointed to the need for greater support for the training required to fill the gap in knowledge exhibited by professionals. The transcripts in Table 4 evidence the need to qualify healthcare professionals for mandatory reporting through access to the corresponding information, once its relevance within the public health setting is duly discussed. This process requires both theoretical-practical training and working conditions favorable to the performance of activities.
Independently from their professional category, another suggestion evident in the participants’ narratives was to socialize the information on workers’ health through dialogue. This dialogue should involve healthcare services and professionals, social control actors and the public policy makers, considering the relevance of promoting intersectoral approaches to meet the healthcare demands.
In addition to instances of incorrect filling, the report form does not provide relevant information. As a result, in-depth epidemiological investigation cannot be performed, with consequent negative impact on planning, since managers depend on epidemiological data to make decisions on healthcare needs.
WA are a relevant component of the reality at healthcare services. The present study succeeded in detecting hindrances and possible means to improve reporting and reduce underreporting based on the perception of the healthcare professionals who work at such services. The reason is that they are the reference for the identification and reporting of cases in everyday practice.
Among the described difficulties to report WA, lack of knowledge on how to manage accidents and on the measures to be adopted, omission and work overload stood out.
HCE and divulgation of protocols were the main suggestions made to correct underreporting. All other suggestions derived from the need of access to information on reporting and of dialogue among healthcare services and professionals, managers, social control actors and the public policy makers.
The discussion of the results of the present study points to the relevance of providing training to healthcare professionals, promote reporting and orient professionals on how to fill the report forms correctly, since when then they are not, SINAN records untrustworthy data.
The authors of this article thank the health units of the city of Fortaleza, where the research was carried out, the Federal University of Ceará and Professor José Gomes Bezerra Filho.
1. Brasil. Lei nº 8.213 de 24 de julho de 1991. Brasil; 1991.
2. International Labour Office. World employment and social outlook: trends 2016. Genebra: International Labour Office; 2016.
3. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Inquérito sobre Atendimentos por Violências e Acidentes em Serviços Sentinela de Urgência e Emergência do Sistema de Vigilância de Violências e Acidentes (VIVA): Capitais, Distrito Federal e municípios selecionados. Brasília: Ministério da Saúde; 2014.
4. Cardoso MG, Romero LO, Bachi ZC, Eid VRT, Beretta D, Jericó MC. Caracterização das ocorrências de acidentes de trabalho graves. Arq. Ciênc. Saúde. 2016;23(4):83-8.
5. Martins MDS, Silva NAP, Correia TIG. Accidents at work and its impact on a hospital in Northern Portugal. Rev Latino-am Enfermagem. 2012;20(2):217-25. http://dx.doi.org/10.1590/S0104-11692012000200002
6. Brasil. Portaria nº 205, de 17 de fevereiro de 2016. Brasil: Ministério da Saúde; 2016.
7. Almeida IM, Vilela RAG, Silva AJN, Beltran SL. Modelo de Análise e Prevenção de Acidentes - MAPA: ferramenta para a vigilância em Saúde do trabalhador. Ciênc Saúde Coletiva. 2014;19(12):4679-88. http://dx.doi.org/10.1590/1413-812320141912.12982014
8. Brasil. Política Nacional de Segurança e Saúde do Trabalhador. Brasil; 2004.
9. Brasil. Portaria nº 204, de 17 de fevereiro de 2016. Brasil: Ministério da Saúde; 2016.
10. Ceará. Resolução nº 149/2010 - CIB/CE. Ceará: Governo do Estado do Ceará; 2010.
11. Baldo RCS, Spagnuolo RS, Almeida IM. O Serviço Integrado de Atendimento ao Trauma em Emergência (SIATE) como fonte de informações de acidentes de trabalho em Londrina, PR. Rev Bras Saúde Ocup. 2015;40(132):147-55. http://dx.doi.org/10.1590/0303-7657000091714
12. Bahia. Secretaria da Saúde do Estado. Superintendência de Vigilância e Proteção da Saúde. Centro Estadual de Referência em Saúde do Trabalhador. Manual de normas e rotinas do sistema de informação de agravos de notificação - SINAN - saúde do trabalhador. Salvador: CESAT; 2009. 58p.
13. Ferreira MJM, Viana Júnior MM, Pontes AGV, Rigotto RM, Gadelha D. Gestão e uso dos recursos hídricos e a expansão do agronegócio: água para quê e para quem? Ciênc Saúde Coletiva. 2016;21(3):743- 52. http://dx.doi.org/10.1590/1413-81232015213.21012015
14. Almeida PCA, Barbosa-Branco A. Acidentes de trabalho no Brasil: prevalência, duração e despesa previdenciária dos auxíliosdoença. Rev Bras Saúde Ocup. 2011;36(124):195-207. http://dx.doi.org/10.1590/S0303-76572011000200003
15. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Notificação de acidentes de trabalho fatais, graves e com crianças e adolescentes. Brasília: Ministério da Saúde; 2006. 32p.
16. Gil AC. Como elaborar projetos de pesquisa. 5ª ed. São Paulo: Atlas; 2010.
17. Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 14ª ed. São Paulo: Hucitec; 2014.
18. Rodrigues FMS, Nogueira-Junior C, Amaral EMS, Fernandes ACP. Notificação de acidentes de trabalho com perfurocortantes: Experiências de uma equipe de enfermagem. Rev Enf-UFJF. 2015;1(2):145-52.
19. Villarinho MV, Padinha MI. Conduta pós-acidente no cuidado às pessoas com HIV/Aids. Rev Bras Enferm. 2015;68(4):656-61. http://dx.doi.org/10.1590/0034-7167.2015680412i
20. Ravazio NB. A rede sentinela de notificação de agravos em saúde do trabalhador segundo a visão de gestores e trabalhadores da regional de saúde Rondonópolis/MT. 141f [dissertação]. Goiânia: Pontifícia Universidade Católica de Goiás; 2013.
21. Guimarães IF, Corvino MPF. Estratégias de educação permanente em saúde na percepção dos profissionais de vigilância sanitária. Visa Debate. 2016;4(1):58-63.http://dx.doi.org/10.3395/2317-269x.00477
22. Sarreta FO. Educação permanente em saúde para os trabalhadores do SUS. São Paulo: Cultura Acadêmica; 2009.
23. Ceccim RB, Feuerwerker LCM. O quadrilátero da formação para a área da saúde: ensino, gestão, atenção e controle social. Physis. 2004;14(1):41-65. http://dx.doi.org/10.1590/S0103-73312004000100004.
24. Evangelista ALP. Os reflexos da implementação da residência integrada em saúde mental coletiva do Ceará na atenção psicossocial [dissertação]. Fortaleza: Faculdade de Medicina, Programa de Pós-graduação em Saúde Coletiva, Universidade Federal do Ceará; 2017.
25. Felli VEA, Tronchin DMR. A qualidade de vida no trabalho e a saúde do trabalhador de enfermagem. In: Kurcgant P, Ed. Gerenciamento em enfermagem. Rio de Janeiro: Guanabara Koogan; 2010. p.89-107.
26. Costa TF, Felli VEA, Baptista PCP. Nursing workers’ perceptions regarding the handling of hazardous chemical waste. Rev Esc Enferm USP. 2012;46(6):1453-61. http://dx.doi.org/10.1590/S0080-62342012000600024
16 de Fevereiro de 2018.
Aceito em 22 de Maio de 2018.
Fonte de financiamento: nenhuma