Ana Carolina Cavalheiro; Jessica Pereira Trentino; Francine da Costa Alves; Ana Claudia Puggina
OBJECTIVE: To analyze the relationship of the ban on adornments imposed by Regulatory Standard 32 and workers’ characteristics with the professional self-concept of nursing staff.
METHODS: Cross-sectional analytic and quantitative study. Assessment instruments were the Professional Self-concept Scale and a questionnaire for sample characterization. The sample comprised 182 nursing professionals. Descriptive and inferential analysis was performed with Statistical Package for the Social Sciences (SPSS) version 20.0.
RESULTS: The average score on the Professional Self-concept Scale was 113.3 (±12.7). Most participants reported to miss wearing adornments at work. The participants who reported not to miss adornments exhibited higher self-concept, on average. We found statistically significant association between lack of adornments and factors accomplishment (p=0.01) and health (p=0.00), between job position and factor competence (p=0.00) and between time since graduation and factor health (p=0.01).
CONCLUSION: For the present sample professional self-concept was influenced by lack of adornments, time since graduation and job position.
Keywords: work performance; nursing; self concept.
OBJETIVOS: Associar a proibição de adornos imposta pela Norma Regulamentadora 32 (NR32) e as características dos trabalhadores com o autoconceito profissional da equipe de enfermagem.
MÉTODO: Estudo analítico transversal quantitativo. Utilizou-se a Escala de Autoconceito Profissional e um questionário de caracterização. A amostra foi composta de 182 profissionais de enfermagem. Foi realizada análise descritiva e inferencial pelo software estatístico Statistical Package for the Social Sciences (SPSS) versão 20.0.
RESULTADOS: O escore médio total da Escala de Autoconceito Profissional foi de 113,3 (±12,7). A maioria dos participantes referiu sentir falta de adornos no trabalho. Os profissionais que referiram não sentir falta dos adornos possuíam um autoconceito profissional, em média, mais elevado. Houve associação estatisticamente significante nas comparações da falta de adorno com os fatores realização (p=0,01) e saúde (p=0,00); do cargo exercido com o fator competência (p=0,00); e do tempo de formação com o fator saúde (p=0,01).
CONCLUSÕES: O autoconceito profissional da equipe de enfermagem foi influenciado pela falta de adornos, bem como pelo tempo de formação e pelo cargo de atuação dos profissionais na instituição. Palavras-chave: desempenho profissional; enfermagem; autoimagem.
Palavras-chave: desempenho profissional; enfermagem; autoimagem.
The aim of the Ministry of Labor and Employment Regulatory Standard 32 (RS 32) is to establish and regulate basic guidelines for the implementation of measures to safeguard the safety and health of healthcare workers, mainly those exposed to biological hazards1.
Among other safety measures, RS 32 establishes that employers should ban workers from wearing adornments in the workplace, including rings, bracelets, watches, necklaces, earrings, visible piercings, ties and hanging name tags. Banning adornments protects workers from biological hazards derived from the adherence of microorganisms to the surface of objects1.
Outside the workplace, adornments and accessories play a social role and their choice is oriented by the groups to which individuals belong and their status and place within society. As a result, adornments are a form of nonverbal communication of intentions and feelings within different social contexts2. Also culture has influence in this regard and might be decisive in the regulation of human behavior as concerns beliefs, attitudes and values3.
The things people wear might express their self-concept (as e.g. jewelry and clothes) and relationships (wedding and graduation rings) or might indicate their occupation or field of activity. A white coat and a stethoscope, for instance, are nonverbal signs which indicate that the individual who wears them is a health professional3.
Self-concept might be defined as a set of attitudes and beliefs individuals have in regard to themselves, their own characteristics, feelings and inclinations. It is composed of individual perceptions, from the more global to the more specific, which encompass several aspects of the life of people4. Self-concept, therefore, represents how people categorize information about themselves and has evolutionary nature, i.e. individuals are able to change their self-concept over time as a function of their lived experience and acknowledgment of social, academic, professional, personal and physical aspects5.
What people think of themselves and their perception of what others think of them might influence their actions and behaviors also in the workplace6,7. Professional self-concept is specifically related to work and reflects the idea people have of themselves as professionals, their actions at work and relationships with coworkers, supervisors, clients/patients and other circumstances. While self-concept is individual, it directly influences other staff members and consequently also their effectiveness8.
A person’s self-concept is constructed through shared experiences and interactions with coworkers; it does not depend on any single variable, but on the global context of the professional life of people9.
Given the aforementioned considerations, the aim of the present study was to investigate the relationship of RS 32 ban on adornments and workers’ characteristics with the professional self-concept of nursing staff.
The present cross-sectional, analytic and quantitative study was performed with the nursing staff of two hospitals in the interior of the state of Sao Paulo, Brazil.
A mean value was estimated for the population of interest. Considering an average score of 111.6, standard deviation (SD) ±13.3, on the Professional Self-concept Scale10 obtained in a previous study, maximum error of the estimate of 15% of SD (1.995) and significance level of 5%, the minimum sample size required for administering this scale was 171 participants.
Participants were nursing professionals from both sexes selected by convenience sampling. The inclusion criteria were: nurses, nursing technicians or assistants aged 18 to 59 years old who provided direct patient care at the selected hospitals. All three categories of nursing professionals were considered in the present study.
Despite the requirement to consider all health workers at the analyzed institutions, supervisors and employees allocated to administrative tasks were excluded, because job position, hierarchical level and power relations can behave as confounding factors in data analysis.
Data collection was performed at two time-points: January and February 20014 and January through June 2015. The former period corresponds to Hospital #1 and included 46 employees; the latter corresponds to Hospital #2 and included 136 nursing professionals.
Hospital #1 is a secondary university hospital in which low- and medium-complexity surgical procedures are performed, mainly within the context of mother-child care.
Hospital #2 is a tertiary philanthropic high-complexity hospital that mainly provides care to Unified Health System (Sistema Único de Saúde–SUS) patients. Both hospitals apply RS 32, therefore, they impose the same restrictions to adornments.
As a function of structural and contextual differences, as well as in the mission of the selected hospitals, our initial idea was to make a comparative analysis. However, both samples of nursing professionals proved to be homogeneous according to the results obtained on the Professional Self-concept Scale (p=0.42, Mann-Whitney test).
Each participant responded the administered questionnaires only once. For administration, the participants’ shifts and hospital department of allocation were taken into consideration. The questionnaires were delivered in the workplace and collected two hours later.
We administered two questionnaires, one to characterize the sample, which included the independent variables: social characteristics (age, sex and marital status), personal aspects (time since graduation, academic degree, hospital department, job position and working hours) and perception relative to lack of adornments.
The other instrument was the Professional Self-concept Scale, developed by two Brazilian psychologists. The procedures for development and validation were efficacious, and the scale was found to be reliable to measure the intended construct. Cronbach’s alpha for the scale four factors varied from 0.76 to 0.904.
The scale comprises 28 items distributed across the following factors: accomplishment — items #1, 2, 5, 9, 13, 16, 17 and 26, which concern the respondents’ perception of their professional success, aspirations and ideals achieved through work; competence — items #7, 12, 14, 19, 22 and 27, which correspond the respondents’ perception of their skills, competencies and fitness to perform their work; self-confidence — items #4, 8, 11, 18, 20, 21, 24, 25 and 28, which represent the respondents’ perception of their self-confidence to perform their work; and health — items #3, 6, 10, 15 and 23, which investigate the respondents’ perception of the possible interference of work and related factors with their state of health4.
The items included in domain health are reverse scored,i.e. they must be recoded before the total score is calculated. Items are responded on a five-point Likert scale (ranging from “never” to “always”). The total score ranges from 28 to 140, the higher the score, the higher the respondent’s self-concept4.
To store, organize and process the data we created a database using software Microsoft Excel. The data were subjected to descriptive (mean, SD and median) and inferential analysis, which was performed with IBM software Statistical Package for the Social Sciences (SPSS) version 20.0. Categorical variables and scores were compared by means of the Kruskal-Wallis or the Mann-Whitney test. The significance level was set to p<0.05.
For imputing missing data, we replaced them by the mode obtained for each item, after excluding the participants who failed to respond more than 20% of the items. We believe that with the application of this criterion, imputation did not compromise the final scores on the scale, besides the fact that missing data in scales which measure psycho-emotional aspects might be meaningful.
The present study complied with the Resolution no. 466/2012, in force in Brazil, which concerns ethics in research involving human beings, and was approved by the research ethics committee of School of Medicine of Jundiai, ruling no. 459,959, CAAE 16977513.7.0000.5412. The anonymity of participants was ensured. All the participants were explained and signed an informed consent form.
The sample comprised 182 participants, with average age 32.7 (±8.3) years old; most were female (n=168; 92.3%) and married or lived with a partner (n=97; 53.3%).
Most participants had attended technical education as the highest level of training and worked as nursing assistants. Indeed, despite their level of training, nursing technicians worked as nursing assistants and nurses as nursing technicians. Most participants had graduated 2 to 5 years earlier, were allocated to inpatient departments and worked during the day (Table 1).
Missing data were found in 41 Professional Self-conceit Scale forms corresponding to a total of 68 items; these participants were not excluded as per the aforementioned imputation criterion. Item #18 was the one with the highest frequency of missing data (n=9) which suggests that the respondents choose not to state whether they had or not cordial relationships with coworkers.
The average global score on the Professional Self-conceit Scale was 113.3 (±12.7), i.e. above the scale midpoint (84) (Table 2).
We found statistically significant association of lack of personal adornments with factors accomplishment (p=0.01) and health (p=0.00), which indicates that for the participants with better perceived professional success, aspirations and ideals accomplished through work, and those more aware of the effect of work on health not wearing adornments in the workplace had no impact (Table 3).
Most participants reported to miss wearing adornments at work, particularly earrings, watches and wedding rings. These participants exhibited poorer self-concept. In turn, the participants who reported not to miss wearing adornments exhibited higher self-concept, on average (Figure 1).
We found statistically significant association between job position and factor competence (p=0.00) and between years since graduation and factor health (p=0.01). Perceived skills, competences and fitness for work was better for nursing technicians compared to nursing assistants and nurses. The largest number of participants who reported to feel more strongly the influence of work on their health were those who had graduated more than 10 years earlier (Table 3).
Several studies10,11 evidenced a relationship between professional self-concept and workers’ performance, autonomy, satisfaction with body image and wearing adornments. In a study, 99.9% of the participants with good or excellent performance had task autonomy and 72.2% reported to feel professionally accomplished and competent. All the participants who stated their health was not affected by work (38.8%) exhibited good or excellent performance11.
The authors of a previous study that compared self-concept and satisfaction with body image concluded that the individuals with higher levels of accomplishment, self-confidence, awareness of the effect of work on health and satisfaction with their appearance did not miss wearing adornments during work at hospital10.
The professional image workers have of themselves might result in significant contributions to the affective aspects of a group and to the performance of work teams. Some authors observed that such perception might be directly related to motivation and satisfaction with coworkers8. According to other authors, professional self-concept is influenced by several factors and institutional opportunities, such as training courses, which might change the self-perception of individuals in regard to their work and how they perform their tasks7.
The relationship between training and professional self-concept might explain the association we found between job position within the nursing staff and professional self-concept. The tasks performed by nursing technicians have medium technical level, and these professionals are charged of providing direct care to severely ill patients in addition to other activities, except for those exclusive to nurses12. Technicians are possibly the members of the nursing staff most directly involved in patient care, which condition makes them perform repeatedly the same tasks and procedures.
The better perception of competence and self-confidence manifested by the nursing technicians probably derives from practice. Practice promotes confidence, which is often related to repeated experiences and a realistic perception of individual weaknesses and strengths. Confidence in their ability to act in an adequate manner is crucial for professionals, since poor self-confidence leads to flaws in the care provided, higher levels of anxiety and larger numbers of errors13.
Deserving of attention is the fact that although most participants responded “always” to the item on “having cordial relationship with coworkers,” this was the item for which data missed most frequently. This contradiction might be due to discrepancies between ideals and the actual situation, as although people acknowledge the relevance of cordiality, interpersonal relationships pose one of the major challenges in the workplace. Interpersonal relationships in the workplace are necessary for teamwork14. Harmonious relationships favor emotional involvement with others and collaboration in daily activities.
Socioemotional competencies are the means through which all other competencies are expressed and develop. In other words, the relational, motivational and affective domain ensures the development and transfer of skills in the workplace. These competencies seem to contribute to increase self-confidence and to create work environments characterized by more interactions and more favorable to collaborative learning15. By contrast, tense and unfavorable relationships hinder the development and performance of teamwork. Workers become isolated, do not communicate adequately, do not collaborate with the team and become individualistic. This situation unavoidably has implications for their professional action. These factors further influence interpersonal relationships between nursing professionals, multiprofessional teams and the workers’ satisfaction and have direct impact on the quality of their work14.
Another relevant finding was the statistically significant association between missing wearing adornments at work and professional self-concept. The participants who reported not to miss wearing adornments were the ones with highest professional self-concept.
Adornments might convey positive or negative nonverbal signals and have different functions for different people: embellishment, protection, sex appeal, self-affirmation, self-denial, hiding, group identification and ostentation of status3. However, more than one convergent signal are necessary to draw inferences in analysis of nonverbal communication.
Independently from their social meaning, RS 32 bans wearing adornments in the workplace. According to some authors, the implementation of RS 32 was particularly significant, because no previous piece of legislation in Brazil had had specifically addressed the safety and health of health workers. This fact notwithstanding, this occupational group is still exposed to inadequate and hazardous working conditions, even when scientific evidence demonstrates occupational hazards in the workplace16.
Resistance to change and improper behaviors might be related to how individuals feel within their particular context. The results of the present study indicate that changes of behavior are complex and require time. The participants who reported to feel higher professional accomplishment were not bothered by the prohibition to wear adornments. The opposite is also true: individuals more dissatisfied with their professional accomplishments need adornments to feel protected, increase their self-affirmation and as means of ostentation of status.
A group of investigators performed a study five years after RS 32 was passed ( June 2010) and found that implementation was difficult at the analyzed hospital. While RS 32 formally bans adornments and open footwear, the hospital authorities did not effectively prohibit employees involved in patient care from wearing them. The investigators recommended preparing a list of mandatory items to ensure a proper professional attitude at healthcare facilities, including the ban on adornments17.
One study published in 2012 found that reasons which hindered the implementation of RS 32 included the employees’ behavior, lack of integrated collaboration between managers and employees and of awareness of the relevance of the ban on adornments among employees18.
The function of uniforms for health workers is similar to that of adornments and also they play a role in the identification of individuals within society. Lack of a dress code enabling the identification of nursing staff might give rise to uncertainty among healthcare teams, patients and their families. In turn, wearing adornments might lead to variable interpretations, raise doubts as concerns the professional skills of this occupational group and their adjustment to the work environment19.
Yet adornments might also represent individual, differential, meaningful and self-affirmation aspects, and were described as necessary by the participants in the present study with the poorest self-concept. People unavoidably develop a self-concept that helps them adjust to the external world. Through social interactions and interpersonal relationships people seek to repel some self-concepts which cause doubts and distress, or to accept positive and valuable self-concepts more easily5.
Standard uniforms for definite occupational categories are recommended; they facilitate the identification of professionals and might have direct influence on the image of a given occupational group. Patients, their families, physicians and other members of health teams should be able to identify who is providing care to a patient20.
In the present study, the participants with longer time since graduation were the group most aware of the influence of work on their health. This finding is coherent, since time provides individuals opportunities to improve their self-knowledge, change, deal better with work pressures and identify more clearly the effects of work on them.
Some authors reported higher levels of self-awareness among older workers. A study on burnout and sociodemographic characteristics of nursing professionals found statistically significant association between age and burnout, the prevalence of the latter being higher among the older participants. The older, more professionally mature workers, with better self-control under stressful conditions proved to be more accurately aware of the hazards inherent to their occupation, which involves healthcare and education21.
Institutions are responsible for helping employees identify occupational hazards. Some authors recommend continuing education programs and creating institutional lists of mandatory items to ensure a proper professional attitude at healthcare facilities, including the ban on adornments among other legal requirements, with emphasis on the responsibility of professionals in the prevention of occupational hazards17. Becoming aware of and understanding the relevance of RS 32 has paramount importance. Knowledge of and understanding this regulatory standard are necessary for compliance not to become merely formal22.
Despite the social role of adornments, compliance with RS 32 should be seen as a professional duty. The implications of the present study for the nursing profession derive from the fact it provides an occasion for this occupational group to learn about factors which might be associated with their professional self-concept, as well as about the impact of RS 32 on labor relationships and individuals so that they might intervene and suggest changes to improve their professional satisfaction and the quality of nursing care.
The limitations of the present study arise from the non-randomized selection of participants, the fact it was performed at two hospitals in one and the same Brazilian municipality and its cross-sectional design, which restricted its scope to the analysis of possible associations.
Self-confidence was the self-concept factor that stood out relative to the analyzed sample of nursing professionals, being influenced by the ban on adornments imposed by RS 32, time since graduation and job position.
The participants with higher levels of professional accomplishment and aware of the influence of work on their health reported not to miss wearing adornments in the workplace. The participants with longer time since graduation were found to be more aware of the influence of work on their health and nursing technicians reported higher levels of perceived competence.
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1 de Setembro de 2018.
Aceito em 22 de Abril de 2019.
Fonte de financiamento: nenhuma