Márcia Astrês Fernandes; Denilma Carvalho Sousa; Thays Rezende Lima; Ana Lívia Castelo Branco de Olveira; Hellany Karolliny Pinho Ribeiro
BACKGROUND: Psychosocial factors represent interactions between the content of work and environmental and organizational conditions, and reflect on the competencies and needs of workers. In the case of substance-dependent or mentally ill patients, the workload is maximized due to the need to provide constant care.
OBJECTIVE: To analyze the perception of nursing professionals who provide care to users of alcohol and other drugs in regard to the psychosocial factors which interfere with their mental health.
METHOD: Exploratory and descriptive study with qualitative approach conducted with 22 nursing professionals. Data were collected in interviews, processed with software IRAMUTEQ, and analyzed based on the descending hierarchical classification technique.
RESULTS: In general the participants were aware of the psychosocial factors which interfere with their work, and being unpleasant, they represent a risk to health and mental overload. The women reported more job demands and stress symptoms. The perceived influence of psychosocial factors on physical and mental health increased with the time in the job. Most participants complained of occupational stress derived from the workload and pace of work.
CONCLUSION: Most participants reported occupational exposure to unfavorable psychosocial factors at work. However, accurate analysis of such factors is hindered by conceptual aspects, in addition to the fact they are not always recognized.
Keywords: nursing; occupational health; mental health; street drugs.
INTRODUÇÃO: Os fatores psicossociais se constituem, por um lado, em interações entre o conteúdo do trabalho e as condições ambientais e organizacionais e, por outro, nas competências e necessidades dos trabalhadores. Quando se trata da assistência ao usuário dependente químico ou com adoecimento mental, o serviço é maximizado pela necessidade de cuidado constante.
OBJETIVO: Analisar a concepção do trabalhador de enfermagem que atua na assistência aos usuários de álcool e outras drogas acerca dos fatores psicossociais que interferem na sua saúde mental.
MÉTODO: Trata-se de um estudo exploratório, descritivo, de abordagem qualitativa, no qual participaram 22 profissionais da saúde integrantes da equipe de enfermagem. Os dados foram obtidos por meio de entrevista, processados no software IRAMUTEQ e analisados pela Classificação Hierárquica Descendente (CHD).
RESULTADOS: Em geral, os participantes percebem os fatores psicossociais que influenciam seu trabalho e, sendo estes desagradáveis, representam riscos para a saúde e sobrecarga mental. As mulheres reportaram maiores exigências laborais e mais sintomas de estresse. Em relação à saúde física e à psicológica, a percepção dos fatores psicossociais aumenta ao longo dos anos na organização, e a maioria referiu a existência, principalmente, de estresse ocupacional decorrente de carga e ritmo de trabalho.
CONCLUSÃO: A exposição ocupacional a fatores psicossociais desfavoráveis no trabalho esteve presente no relato da maioria dos trabalhadores da enfermagem. Contudo, a correta avaliação desses fatores nas situações de trabalho apresenta dificuldades conceituais e, provavelmente, nem sempre há o seu reconhecimento.
Palavras-chave: enfermagem; saúde do trabalhador; saúde mental; drogas de abuso.
Mental health influences the quality of life and well-being of people, and enables personal and interpersonal regulation. Mental disorders seem to develop whenever environmental and occupational demands exceed the ability of individuals to adjust. For this reason, mental health is affected by several factors. Even when individuals seem to maintain their mental health, various psychological and occupational factors exert significant impact, to the point of interfering with adequate behaviors and responses. These are known as psychosocial factors, this is to say, coexisting psychological and social aspects which affect the environment and are related to health and mental disorders1.
Psychosocial factors represent interactions between the content of work and environmental and organizational conditions, and reflect on the competencies and needs of workers. Within this context, globalization and technological development caused significant changes in the content and nature of work, imposing increasing demands of qualification and availability, with negative impact on the social and work life balance2.
As a result, these factors contribute to cause exhaustion among nursing professionals in their various fields of activity. Mental exhaustion is potentiated by exposure to a high mental load, not as a function of the daily experience of the object of work, but of the working conditions to which these workers are subjected. In the case of substance-dependent or mentally ill patients, the workload is maximized due to the need to provide constant care. Within such context, support and due orientation to perform tasks stand out, as overwork not seldom makes also caregivers fall ill3,4.
Mental overload is directly related to the unpredictability of the clinical state of patients, as despite apparent stability, they might develop psychomotor agitation at any time, with potential to progress into aggression. Monitoring the state of health of professionals is indispensable to recognize and change the actual conditions of nursing work in mental health. The reason is that such monitoring allows developing indicators to measure their workload and characterize the morbidity profile of workers5,6.
Accurate knowledge of the working conditions and stressors or causes of (physical or mental) exhaustion allows channeling health actions in a way to minimize it, sensitizing nursing professionals to detect problems in the workplace, and making more suggestions on how they might perform their tasks based on the work demands7.
As a function of the aforementioned considerations, the aim of the present study was to analyze the perception of nursing professionals who provide care to users of alcohol and other drugs in regard to the psychosocial factors which interfere with their mental health.
The present exploratory and descriptive study with qualitative approach analyzed the perception of nursing professionals who provide care to psychoactive substance users in regard to the psychosocial factors which interfere with their mental health. Qualitative, widely narrative research is essentially based on language and behavior, as numerical calculations and statistical procedures are not particularly relevant in this case8. The study was conducted at a referral hospital for substance dependent patients included in the psychosocial care network of Piaui, Brazil.
Participants were 22 nursing professionals (nurses, nursing technicians and assistants) who provided direct patient care. Professionals with other functions were excluded. The number of participants was established based on data saturation as determined by the investigators through a data treatment technique9, and were identified as P1, P2, P3, [...], P22 to ensure anonymity.
Data collection took place from February through May 2016 by means of individual interviews based on a script to gather information on the four following aspects: sociodemographic characteristics; behavioral variables; occupational aspects including psychological factors which influence work; and the health and working conditions of participants. The interviews were conducted at the workplace at a time and place indicated by interviewees as favorable for dialogue.
The interviews were recorded as audio files and fully transcribed. For treatment of the data we used software Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires (IRAMUTEQ, which enables five different types of analysis: classic textual statistics, investigation of specificities and groups, descending hierarchical classification (DHC), similitude analysis and word clouds. Thus the vocabulary is organized in an easily understandable and visually clear manner, which allows integrating quantitative and qualitative aspects, resulting in greater objectivity and advances in data interpretation10.
It should be noticed that this software is not a method for data analysis, but a tool to process data. Therefore, it does not provide a final analysis, as the data must still be interpreted, which is a task to be performed by the investigator11. Data processing was based on DHC, i.e., relationships between semantic classes extracted from the participants' narratives. The criterion to include elements in classes was frequency twice higher than the mean number of occurrences in the corpus; class association was determined by χ2≥3.84 and significance of 95%9. Each interview was characterized as a text, and the set of texts represented the analyzed corpus. The method further allows for definitive classification illustrated by means of a dendrogram.
The step following software-based analysis consisted in the identification and analysis of textual domains and interpretation of meanings according to the following categories:
Broadening the scope of multiprofesional care as resource for treatment of substance-dependent patients;
Precarious resources and safety at work;
Influence of working conditions on care delivery;
Need for resources and professional qualification to provide specialized care;
Nursing staff problems with managers and working conditions.
The study complied with the ethical and legal principles in Resolution no. 466/12 and was approved by the research ethics committee of Federal University of Piaui, on 30 June 2015, ruling no. 1,132,021.
The full service staff included 30 nursing professionals, 22 of whom agreed to participate, being 7 (31.82%) nurses, 14 (63.63%) nursing technicians and 1 (4.54%) nursing assistant. The participants' age ranged from 27 to 63 years old, and most were female (n=19, 86.36%). Half of the participants reported to be married (50%). None smoked, but 6 (27.27%) reported to drink socially at least once per week. Twelve participants (54.54%) performed physical activity on a regular basis (Table 1).
The hospital where the study was conducted comprises a low-complexity emergency department and inpatient wards, and its profile includes care provision to individuals with substance-related disorders. Ten participants (31.82%) were allocated to the inpatient area, 7 (31.82%) to the emergency department, and 5 (22.73%) worked in both (Table 2).
A large part of the participants had worked in the profession for 10 to 25 years, mean 18.64 years. Twelve participants (54.54%) had worked at the analyzed hospital for less than 10 years, 7 (31.82%) 10 to 25 years, and 3 (13.64%) more than 25 years, mean 11.09 years. The weekly working time was more than 30 hours for most participants (72.73%).
When inquired on occurrence of occupational stress as a function of the workload and pace of work, 12 participants (54.55%) gave affirmative answers and listed some triggers, such as: patient profile, lack of training, rate of return to substance use, shortage of professionals, patient idleness and non-adherence to norms. Ten participants (45.45%) stated there were no stressors in the workplace.
Analysis of the working conditions and their influence on care delivery based on the participants' narratives on their work experience with substance-dependent patients allowed identifying five categories (Figure 1).
Class 1 concerns broadening the scope of multiprofesional care as resource for treatment of substance-dependent patients, and included 12 text segments, corresponding to 16.7% of the total number of segments extracted from the corpus. Class 2 corresponds to precarious resources and safety at work, 13 segments (23.3%). Class 3, with 9 segments (20%) represents the working conditions as exerting direct influence on care delivery. Class 4 corresponds to the nursing professionals' qualification to provide specialized care. Class 5 represents the nursing staff 's problems with managers and the working conditions, with 6 segments (23.3%).
In general the participants were aware that their job was associated with psychosocial factors which represent risks to health and mental work overload. This type of factors lead to occupational stress and other health and safety problems, and comprise workplace aspects such as the organizational culture or climate, job functions, interpersonal relationships and design and content of tasks12.
Although the health of the workforce is directly related to their job and employment conditions, the psychosocial factors related to them differ among workers as they are determined by aspects of structural nature. Difference was found in perceived stress as a function of sex. Women reported higher job demands and higher levels of stress symptoms compared to men with similar jobs and tasks13.
Younger workers were more susceptible to psychosocial factors related to exposure to work-related violent behaviors. Age influences the performance of tasks involving heavier physical loads, and is associated with higher psychosocial resistance and resilience14.
Most participants in the present study were married, which allows inferring they had to cope with more tasks and responsibilities. It is healthy for workers to adjust their work and family life in a way none of them is impaired. The reason is that the respective demands might conflict, workers might often suffer from lack of support at home, and thus the home-work interface might become one further psychosocial factor affecting nursing professionals.
None of the participants reported to smoke, but six (27.27%) drank socially at least once per week. Twelve participants (54.54%) performed physical activity on a regular basis. The perceived influence of psychosocial factors on physical and mental health increases with the time in the job. This is to say, workers with longer time in the job are at higher risk of suffering the influence of psychosocial factors at work. In regard to the weekly working hours, one should consider the need for mental and physical recovery. The working time is a psychosocial factor, and might be related to psychosocial hazards, such as nightshift work, non-flexible or too long working hours and unpredictable schedule15.
Nursing professionals, particularly the ones who work at mental health services, are exposed to conditions likely to cause stress and physical and mental exhaustion, which often lead to illness. Stress impairs the quality of professional performance by reducing the levels of satisfaction and well-being, hindering personal development and increasing absenteeism16. These aspects were evidenced in some of narratives, as follows:
Precarious, unsafe and unhealthy. In addition, diseases such as the mental [ones], because most patients end by developing mental disorders, which together with abstinence make us feel insecure. All this weakens me (P1).
There's conflict among patients, and the rate of relapse is very high; most of the patients currently discharged come back less than one month later (P5).
The hospital infrastructure is not good, there are no activities to develop with patients. We try to do our job as best as we can and overcome daily challenges (P8).
I do go and perform the procedures I must, but in fear. Moreover, I still focus on insecurity, because all of us, the nursing technicians, are locked inside alone with the patients, while everybody is outside, even the security guards (P14).
In regard to the psychological aspects likely to influence work at the hospital, 15 participants (68.18%) mentioned fear, insecurity, anxiety, frustration, conflict among patients and treatment refusal. Seven participants (31.82%) did not associate psychological aspects to nursing work:
I believe that negative factors only affect people who don't like or don't know this field, it's a peculiar population, therefore you have to understand, when you're afraid it becomes a problem (P14).
Fear. I don't get too close to patients, I don't feel safe at all (P9).
Anxiety, fear caused by the situations I described [...] patients here aren't psychologically well, some are criminals (P11).
As they're admitted for detox, you're not sure they'll get better [...] the care we provide is kind of palliative, there's no certainty they'll get better, can't say we minimize the damage, the best description is that we're drying ice (P21).
To analyze the level of job satisfaction, we asked the participants how they felt in regard to working at a referral hospital for substance dependence treatment. Job satisfaction is considered highly relevant, as it is related to the quality of care delivery, interpersonal relationships, and better adjustment to services17. Positive adjectives were detected in the narratives of 13 participants (59.09%), such as gratifying, privileged, proud and educational. Seven participants (31.82%) described their experience of work at the hospital in negative terms, such as insecure, unprepared and dissatisfied. Two participants (9.09%) were indifferent in this regard.
Gratifying, because it's a unique population. They need professionals who know how to deal with them, who know how to listen and treat them in an individualized way (P7).
It's a high-risk area and we deserve much safety (P16).
I don't feel satisfied, it needs much more to be a referral hospital [...] patients lack a lot of stuff, and it's us who pay the price (P19).
In regard to the impact of work on their health, 10 participants (45.54%) reported health problems related to work at the hospital, 11 (50%) reported none and 1 (4.55%) did not know how to respond. The most frequent health problems were stress, sleeplessness, depression, physical exhaustion, panic attacks and anxiety.
I even had depression episodes related to work, once a patient threatened to stab me with a knife (P8).
I've already had problems, and I had to see a physical therapist, they were due to stress, to situations which ran out of control (P1).
I believe [they are due to] night shift work, not to the fact of working at this hospital (P14).
Inadequate working conditions, lack of organization and difficult social relationships have negative impact on the quality of life of nursing professionals18. Sleep deprivation and difficult recovery are some of the main factors which cause physical and mental exhaustion. However, despite its frequent association with negative factors, workers choose the night shift to meet personal and/or professional needs19.
The training required to work with this particular population of patients was a source of disagreement among the interviewees. Some participants reported problems, such as lack of the due competencies, while others stated they had received training in courses, and even graduate education supported by the institution.
Lack of investment in our training, lack of training in this field [...] we learned on the job, there was no training course (P1).
It's not good to work with addicts, because I'm not prepared to work with them, no matter the courses taught at the hospital (P9).
The hospital gives me conditions to do a good job, it provided training to professionals (P14).
They presented us the proposal, we took up this cause [...] we received training, however, we're still far from the ideal model, we've already made much advance, but we're walking slowly (P8).
In regard to multiprofesional care as resource for treatment of substance dependent patients (Class 1) the participants' narratives pointed to the need to broaden its scope. The staff currently comprises psychiatrists, nursing professionals, psychologists and social workers. In addition to encompassing social relationships, availability of multiprofesional staffs minimizes the vulnerabilities derived from the use of psychoactive substances. The staff needs to combine specific interventions and goals to reduce the direct manifestations of drug use and abuse through actions seeking to minimize damage and strategies to prevent relapse20.
Also precarious resources and safety at work (Class 2) were a cause for concern among the participants. Scarcity of resources, such as medications and equipment, was specifically mentioned within the context of the patients' treatment. The most frequent mentions corresponded to the emergency department. The participants' concern with safety at work was indicated by mentions to insufficient number of security guards, treatment refusal, and association of patients with criminality.
According to the patients' narratives, the working conditions (Class 3) do exert direct influence on care delivery to substance-dependent patients. Job satisfaction and recognition might contribute to improve the quality of life of workers, with consequent repercussion on patient safety. Therefore, detecting adverse situations and associated psychosocial factors which interfere with safety within the hospital environment is essential, as also are actions to fill current gaps in the health system21,22.
In regard to their qualifications to provide specialized care (Class 4), training for work at the hospital was mentioned by all the participants, however, it was rated insufficient for the actual demands. The participants also pointed to the relevance of continued education, which is not available at the institution.
As concerns the nursing professionals' problems with managers and the working conditions (Class 5), the demands for productivity and pressure to meet goals are continuously growing, while the material and structural conditions and human resources are usually precarious. Therefore, the organizational context favors the development of mental symptoms and poses risk to the mental health of employees. Frustration and lack of motivation are emphasized by workers under mental suffering and illness23.
The present study evidenced the perception of nursing professionals who provide care to substance-dependent patients in the hospital setting. The participants considered they were exposed to unfavorable situations with negative impact on their well-being and health. Such situations were related to psychosocial factors, mainly workload and pace of work, work environment and availability of equipment, organizational culture and function, interpersonal relationships, level of satisfaction, and the home-work interface. Occupational exposure to unfavorable psychosocial factors at work was mentioned by most participants. Nevertheless, an accurate analysis of such factors is hindered by conceptual aspects, in addition to the fact they are not always recognized, or are underestimated.
Despite its limitations — derived from the small sample size, the fact it was conducted at a single center, and the impossibility to generalize the results to other work settings — the present study is relevant, since it evidenced the influence of psychosocial factors at work on the satisfaction and health of nursing professionals. We call the attention to the need for hospitals to implement management practices which include effective participation of workers in the work process to contribute to their well-being and mental health promotion.
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8 de Abril de 2018.
Aceito em 20 de Setembro de 2018.
Fonte de financiamento: nenhuma