RESEARCH ARTICLES

Nursing work with customers HIV/AIDS: psychic potential for suffering

Rita Elzi Seixas Ferreira^I; Norma Valéria Dantas de Oliveira Souza ^II; Francisco Gleidson de Azevedo Gonçalves ^III; Déborah Machado dos Santos^IV; Claudia Regina Menezes da Rocha Pôças^V

^I Nurse. Master in Nursing from the Post-Graduation Nursing Program from the Nursing Faculty. Rio de Janeiro State University. Brazil.
^II Nurse. PHD in Nursing. Vice-Director at the Nursing Faculty. Rio de Janeiro State University. Adjunct Professor from the Department of Medical-Surgical Nursing from the Nursing Faculty. Rio de Janeiro State University. Permanent Professor from the Post-Graduation Stricto Sensu Program from the Nursing Faculty. Rio de Janeiro State University. Brazil. E-mail: norval_souza@yahoo.com.br
^III Nurse. Master Student in Nursing from the Post-Graduation Nursing Program from the Nursing Faculty. Rio de Janeiro State University. Specialist in Occupational Nursing from the Anna Nery Nursing School. Rio de Janeiro State University. Substitute Professor from the Department of Medical-Surgical Nursing from the Nursing Faculty. Rio de Janeiro State University. Scholarship Student from the Coordination for the Improvement of Higher Education Personnel. Brazil. E-mail: gleydy_fran@hotmail.com
^IV Nurse. Master in Nursing from the Post-Graduation Nursing Program from the Nursing Faculty, Rio de Janeiro State University. Specialist in Occupational Nursing from the Anna Nery Nursing School, Rio de Janeiro State University. Substitute Professor from the Department of Medical-Surgical Nursing from the Nursing Faculty. Rio de Janeiro State University. Brazil. E-mail: debuerj@yahoo.com.br
^V Nurse. Master in Educational Technology in Health from the Educational Technology Nucleus, Federal University of Rio de Janeiro. Coordinator of the Nursing Specialization Course in Modality of Residence, Nursing Faculty, Rio de Janeiro State University. Nurse at the Pedro Ernesto University Hospital. Rio de Janeiro, Brazil. E-mail: cmenezesr@yahoo.com.br

ABSTRACT

This study aimed to identify the perceptions of nursing staff about the characteristics of work in infectious disease unit and analyze its potential for the emergence of psychological distress among these workers. Qualitative research, descriptive, developed in a general hospital in Rio de Janeiro, specifically in the infectious disease unit, with 13 nursing staff. The collection took place from May to August 2010, through semi-structured interviews. The technique of analysis was thematic content analysis. There were discrepancies between the prescribed work and real, as well as there was no material and personnel in adequate quantity and quality, the physical plant of this sample was not suitable for nursing care. It is concluded that the nursing worker psychic suffering linked to the characteristic of work organization, work process and the specificity of customers assisted.

Keywords: Burnout professional; occupational health; nursing; Acquired Immunodeficiency Syndrome.

INTRODUCTION

This study aims at the organization of work in the sector for treatment of infectious and contagious diseases, space to care for customers with Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV / AIDS), and the potentiality for the onset of psychological distress among nursing workers. This object is configured in a master's thesis defended at the Rio de Janeiro State University (UERJ), in 2011¹, whose cutting is presented here.

Organization of work involves both the division of tasks and the division of men. Through the division of tasks, the cadences, the distributions of activities and actions are prescribed, in short, the experimental way. Thus, it creates hierarchies, commands, power relationships, responsibilities, thereby characterizing the division of men. Labor organization is the prescribed work, thought by some people, but conducted by others, who have desires, wants and peculiar manners of performing a task. Accordingly, if this organization does not give rise to the flexibility, creativity and dialogue – by immobilizing workers in their possibilities for achievement, innovation and recognition by peers and by the upper hierarchy –, it raises the suffering, which, consequently, can lead to psychosomatic destabilization, with risk for developing diseases such as occupational stress and Burnout Syndrome. ²

Upon knowing the characteristics of the organization of work of a sector for treatment of infectious and contagious diseases of a general hospital in the city of Rio de Janeiro, it was noted that there were some distinct elements that interfered in the way in which the workers developed and understood the elaborated work Accordingly, it was empirically observed that nursing workers denoted psychophysical wear due to the care towards serious customers, who required numerous procedures, often invasive, thus allowing the working pace to become intense, with little time to rest, or even lack of intervals, during the working day.

Thus, such characteristics of labor organization represent an encouraging factor to this research, which has the following objectives: to identify the perception of nursing workers about the characteristics of work in the sector for treatment of infectious diseases and analyze its potentiality for the onset of psychological suffering among these workers.

LITERATURE REVIEW

The discussion on the care of customers with HIV / AIDS and the interface with the psychophysical wear of nursing workers have determinants linked to the characteristics of organization of hospital work and also to the specificity of customers, who are often hospitalized in serious conditions and require an intensive and thorough care.

When analyzing the organization of hospital work, one can find a fragmented, bureaucratized and mechanical mode, imbued with rules and routines, often including outdated and overstated requirements. This type of work organization hinders the achievement of quality care and, consequently, results in dissatisfaction on the part of workers and assisted customers³.

The nursing work in the context of care to customers with HIV/AIDS is complex and has a high psychophysical risk, because this context involves a set of situations that pervade the subjective dimension of workers, such as: to experience the everyday of suffering of those who suffer from this disease, the proximity to the experience of death and the dying process and, lastly, the invasive care actions that result in pain to customers. Moreover, such context encompasses the existence of more objective issues involving the act of caring/care, such as biological risk or accidents. These situations are demonstrably potential for the onset of pathologies among workers⁴.

Given this complex context, one can find numerous complaints of nurses with regard to extreme physical and mental exhaustion, difficulty concentrating and memorizing, insomnia and irritability. It is also observed that some workers develop a certain emotional toughening in dealing with customers and their family members. Regarding the developed work, it appears that many professionals are discouraged, as if a conducted activity was not important or enough for the demands of customers, relatives or even for the labor organization. Such situations point to the existence of both psychological suffering and the adoption of strategies to survive this mental fatigue².

Among the most common causes of suffering of workers who work in the sector of infectious and contagious diseases and that admit people with AIDS, one could mention: oppressive workloads, fear of contamination followed by the development of the disease, excessive involvement with customers and their families and a subsequent personal identification with the suffering of these customers and of their family members⁵.

In addition to these situations, there are others related the scope of labor organization, which negatively affect the nursing staff, such as: lack of autonomy in decisions that affect themselves and their work environment; inadequate support, supervision and recognition by the upper hierarchy or even by other professionals in relation to the work developed by the nursing staff; inadequate training, skills and preparation for work; precarious working conditions, which are marked by the qualitative and quantitative lack of human and material resources⁵.

From this perspective, one can list several repercussions for workers who work with customers affected by HIV/AIDS, such as: isolation, insecurity and fear about the future, anxiety and awe in the face the effects of their work in their personal relationships and in their occupational and family dynamics. These situations have strong potential for the onset of diseases among workers⁶.

In contrast, these professionals have little or no therapeutic support or other assistential strategies that aim at assisting the worker in minimizing the suffering generated by means of its working activities. Because, there is probably a so high psychic charge that workers end up succumbing in the face of these pressures, and they may present behavioral disorders, occupational stress, Burnout Syndrome, suicide attempts, among other diseases of psychic character⁵.

For example, it is perceived that the proposal for coping with Burnout Syndrome involves assessing and meeting the individual needs of workers affected by this disease, but also environmental adjustments in the labor organization, by making ​​it flexible and with better working conditions. Accordingly, it is understood that the changes to ensure or restore the health of workers are multifactorial and that the strategies pervade the labor organization, the individual aspect and the combination of prevention and reassessment of adaptation to multiple offending agents⁷.

METHODOLOGY

This is a qualitative and descriptive research, conducted in a general hospital in the municipality of Rio de Janeiro, which is characterized as a large size unit. In this scenario, we selected the sector for treatment of infectious and contagious diseases, which is an assistential unit where patients with HIV/AIDS are predominantly admitted.

The study subjects were 10 nursing technicians, two nursing assistants and one nurse. The inclusion criterion of subjects is related to the working time in the sector of infectious and contagious diseases, which should be equal or less than two years. Such criterion was based on the perception that this would be long enough for that the workers had already seized the labor dynamics and the specificities related to the care of customers with HIV/AIDS. The criterion for the amount of subjects was based on the recurrence of information, i.e., when its content began to repeat itself, thus indicating the time to finish the collection. Furthermore, as it is a research with qualitative approach, the concern was not focused on the amount of subjects, but on the quality, richness and depth of information about the study object⁸.

Data collection took place from May to August 2010, by using individual semi-structured interviews as instrument for collection. The technique for the treatment of information was the thematic content analysis⁹, whose procedure demands three chronological stages: pre-analysis; material exploration; treatment of results, inference and interpretation. After applying this technique, the following category emerged: prescribed organization x organization of actual work: the predominance of the suffering of workers.

This work followed the scientific and ethical requirements for researches involving human beings. Thus, the project was approved by the Ethics Committee of the investigated hospital, according to the Resolution 196/96 of the National Research Board, under the registration protocol number 2597/2010¹⁰ .

It should also be informed that, to meet the principle of anonymity of the surveyed subjects, we created codes to preserve their identities, started by the letter E, which corresponds to the word entrevista (interview in Portuguese), accompanied by a number, which means the chronological sequence of data collection. Thus, the subject who gave the first interview obtained the encoding of E1 and the last of E13.

RESULTS AND DISCUSSION

Prescribed organization x organization of actual work: the predominance of the suffering of workers

In this category, we learned what the workers think about the work in the sector of infectious and contagious diseases, the characteristics of the labor organization of the institution in which the unit under study is located and the meaning of work for these workers. Moreover, we perceived that there are striking discrepancies between prescribed work and actual work, which has generated a significant psychological suffering, thus requiring from the worker a psychic-cognitive and physical mobilization to keep up the job tasks.

The task, what is needed to be done, according to the prescribed organization of work, is characterized as an assignment of the worker to meet the objectives set to achieve the goals of the labor organization. Accordingly, the prescribed task is reflected in the social framework of obligations and requirements that the worker must meet¹¹.

Nonetheless, the larger the gap between the prescribed work and the actual work, the greater the suffering of the worker and higher its potential for getting sick, because this worker will need to intensely mobilize its psychic-cognitive and physical capacities to follow the working pace; such circumstance, when daily experienced, makes the worker weary¹².

I don't like the way in which the work is being done. They require [the labor organization of the institution] that the work is done, but the staff is small, there is lack of supplies, the hospital structure is poor. And I have to fit myself in this work system [...] . (E7)

The actual work comes into play in a more proactive manner when the technique and the prescribed procedure are flawed. Under this perspective, the actual is consubstantially linked to failure, thereby becoming a riddle to be solved. That is why the actual is not a result of knowledge and know-how, but is seized in the form of experience and presents itself to the subject in an effective way, which can end up causing a nasty surprise¹³.

The nursing workers, due to constantly meet admitted customers, maintain a closer relationship to them and detect their needs; therefore, they feel emotionally and professionally compelled to provide direction and resolution to their demands. Consequently, for meeting the health demands of their customers, the nursing staff must use hospital equipment, instruments and supplies to provide care. Nevertheless, these materials are often not available in quantity and/or quality suitable for the use and/or the purposes demanded by the necessary care of customers, which hampers the nursing work and negatively alters the health-disease process thereof¹⁴.

Another important issue for the analysis is related to the consequences of the neoliberal model in precarious employment relationships, thus leading to the outsourcing of services, i.e., the great shortcoming of professionals in public services generates temporary hiring of workers to complement the staff before the new organization of work imposed by the neoliberal model¹⁵. This factor provokes a high staff turnover, because these contracted employees can only remain in a public service by a maximum of five years.

Nowadays, with this contract system, it even let the things more difficult for us, because, although they get the service, one can perceive an unprepared and inexperienced staff. When the employee is ready to work, already knowing everything and able, there is an exchange. When the contract time is over, they put others. So, it starts all over again ...Then I think this kind of situation is not good, so it is really tough [...]. (E9)

This fact ends up generating anguish and conflicts among professionals, because the immediate managers need to periodically perform the initial training of these hired employees, in order to enable them to care of customers with HIV/AIDS. Theoretically, this situation takes place every five years, if the hired employee is not dismissed or quit the job before, and until that this employee is able to develop the work, the others are overloaded, causing, therefore, conflicting situations, tensioning and increased workload.

Furthermore, the contracted employee has a lower salary and no warranty of permanence at work, without mentioning the few employment rights that it has, but having the same assignments of a statutory worker. Thus, there is a working environment characterized by uncertainty, social injustices and, therefore, dissatisfaction and psychological suffering. Such characteristics are presented as promoters of emotional stress and become an important factor in the development of occupational stress and Burnout Syndrome^16:61.

Equivalent to that found in this investigation, another study showed that the majority of nurses (63,12%) had temporary employment contract with the surveyed institution. Moreover, it showed that a high number of contracted professionals (11,2%) developed the Burnout Syndrome, because there was great anxiety to each end of contract, since these workers did not know if there would be a renewal of the employment agreement¹⁵.

The expansion of this type of labor contract is a result both of the process of labor flexibility – within the framework of State reforms, in force since the 1990s, in a context of expansion of the municipal labor market in health – and of the search for alternatives to meet the limits imposed by the Fiscal Responsibility Law, for the effectuation of professionals as public servants in the municipalities¹⁷.

Another gap between the prescribed work and the actual work is linked to the desire of providing a care with excellence, in other words, an ethical, humanitarian, scientific and technical assistance. However, the lack of staff practically invalidates this desire, since often the high demand of procedures, due to the severity of customers, makes the care with excellence very difficult. Therefore, such a situation culminates in decreased motivation to work and negatively impacts on the subjectivity of workers, by making them suffer and by becoming a potential for triggering work-related diseases.

The physical plant also emerged from the speeches as another negative factor on the subjective dimension of the worker, since these individuals perceive the labor organization as incoherent and misguided, because such physical structure often does not offer occupational conditions, due to their poor planning and the lack of the minimum required for a health care unit, thus generating large distances to be traveled and hindering the work. In other words, the physical plant is also distant from the prescribed for a sector of infectious and contagious diseases, through which it is intended to provide quality care to hospitalized customers and preserve the health of workers.

Accordingly, the nursing post of the unit at stake is poorly located, nestled among other administrative rooms, distant from the room intended for customers with the need for some kind of precaution. This location makes it difficult to get an overview of the beds and makes the workers to perform constant displacements to achieve materials required for the accomplishment of care^18,19. Therefore, the physical structure of the sector of infectious and contagious diseases does not meet the demands of this type of work. One can perceive this situation through the speech exposed below:

The difficulties are the distances; the isolation is at the entrance of the sector, thus you have to walk more and more. We spend a lot of time coming and going. We have to catch everything here in the post. It takes a long time. We are very tired by the distance. Thus, it makes us angry, sad, very sad [...]. (E1)

The planning and execution of the physical plant of assistential units, in many cases, are performed without relevant information and fundamental knowledge of ergonomics, including without consulting those who perform tasks in the space in question. In addition, one can perceive the accomplishment of such activities by professionals without qualification in public administration or production engineering. Most often, designers are unaware of the activities actually performed by the workers and end up disregarding essential elements for the design of the new organization. Thus, important aspects are left out, since participatory methods are not employed in conducting technical-organizational projects^18,19.

In light of the foregoing, the nurses of the surveyed unit felt tired and reported that they usually worked at the limit of their physical and emotional capacity, and that became annoyed with the charges of customers because of the delay in carrying out the activities. With regard to this delay, the professionals said that it was not their fault, but rather a flaw of the physical space organization, since it was necessary to walk considerable distances to gather materials for providing the care.

Workers pointed to unpredictability and variability of the workload of a journey that has negative repercussions on performance and health of the employee. The speech below depicts the above mentioned:

Occasionally, there are some situations in which the patient has a cardiac arrest and we have to search stuff here, then you go and come. You search for trays and have to take what is not in the unit, then the patient have to be transferred. At this moment, it's even calm. But, suddenly, you arrive and see a rush, because another patient worsened, and it's one more who wants to escape or commit suicide. So, the things become confused [...]. (E13)

These characteristics of the organization of hospital work – where we observe shifting and complex situations, with continuous changes – generate negative effects on the health of workers, as the need for continuous mobilization of their motor and psychic-cognitive capacities to follow the variability of the working process characterizes a high workload and, therefore, results in psychophysical wear²⁰.

Through the interviews, it seems that the work is often costly and with potential for transmitting diseases, especially of psychic nature, such as Burnout Syndrome, syndrome of voluntary servitude, labor stress, suicide, among other diseases/ health changes⁵. Because in many reports, one can capture expressions that denote psychophysical wear arising from the high demand for affective, cognitive and physical abilities of nursing workers. Thus, it should be cited expressions like:

It's tiring, it's stressful. We get very tired by distance, but we have to do everything in a fast manner. I think this kind of situation isn't good, it is even tough. (E4)

Moreover, there is a fear due to contamination caused by the work accidents with biological material, since it is a scenario that requires invasive procedures, which, in turn, increases the risk of accidents involving sharps, thus generating fear of contamination in the worker.

The biological accident with the patient is my major concern. Once, I suffered an accident and it was horrible. You know that you had an accident and that it could contaminate you. It's difficult, but the contamination can happen. Then, such care procedures are great concerns to us. You have to be very careful in dealing with the patient not to contaminate yourself [...]. (E6)

The risk of HIV infection in health workers, after contact with biological material, is about 0,3%, which is a index characterized as low. Nevertheless, although the risk of infection "[...] presents itself in low levels, it is important to pay special attention to this possibility due to the lethality of AIDS, which leads to gradual loss of cellular immunity, whose consequence is the emergence of opportunistic infections" ^21:56.

In addition to causing infections, accidents involving exposure to biological material emotionally affect the worker, thereby creating the feeling of being between life and death²². This is an overwhelming feeling to the health professional, due to the fear of acquiring a disease like AIDS ^22,23.

CONCLUSION

The nursing worker of the sector of infectious and contagious diseases, who works with customers with HIV/AIDS, has psychic suffering due to multiple factors related to the characteristics of the labor organization, to working process and the specificity of the assisted customers, who are involved with stigmas, prejudices and the presence of death, which are constant reasons for haunting them. In the scope of work organization, it should be cited low autonomy in decisions that affect itself and its working activities; incipient recognition by the upper hierarchy or by other professionals from the nursing staff; inadequate continuous training program; shortage of human and material resources and, lastly, precarious mode of hiring staff. Such characteristics influence the perception of the professional before its ability to perform tasks that, in turn, affect the health of workers and can cause mental suffering.

The characteristics of the labor organization in the surveyed institution, especially in the sector of infectious and contagious diseases, have unveiled a gap between the prescribed work and the actual work. This situation is in conflict with the subjectivity of nursing workers, since it becomes a potential factor for the onset of mental diseases, due to the constant psychic suffering.

Under this perspective, this worker has high psychophysical risk as it experiences the daily sorrow of those suffering with HIV / AIDS. The fact of dealing with an incurable and lethal illness, coupled with the fact that it is heavily stigmatized and surrounded with prejudices, is a strong factor of psychic suffering. Other situations are added to this context, such as: the absence of a healing method for the disease, the high rate of infected people, the need to care for customers of their age range and social group, the aggressiveness and resentment of the customers and their family members, the ostracism that the disease imposes and the frequent exposure to death. Even alone, all these situations are factors generating stress and psychic exhaustion, thus causing the psychological suffering.

It is considered that further studies analyzing the issue of psychological suffering by means of working activities in the sector of infectious and contagious diseases, especially in caring for customers with HIV / AIDS, should be conducted. One of the limitations of this study focuses on the small number of participants, which prevents the generalization of the findings. Another points to the complexity of the phenomenon that involves the health of the nursing workers and its subjectivity, which requires a deeper study, with a view to ensuring its health, quality of life and better working conditions, which, in turn, will be reflected in care with excellence.

REFERENCES

1. Ferreira REDS. A organização do trabalho na unidade de doenças infecto-contagiosas e a ocorrência de Burnout nos trabalhadores de enfermagem [dissertação de mestrado]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro; 2011.

2. Dejours C. A loucura do trabalho: estudo de psicopatologia do trabalho. 5^a ed. São Paulo: Cortez; 1992.

3. Cavalcante CAA, Enders BC, Menezes RMP, Medeiros SM. Riscos ocupacionais do trabalho de enfermagem: uma análise contextual. Cienc Cuid e Saúde. 2006; 5(1): 88-97.

4. Santos EI, Gomes AMT, Oliveira DC, Santo CCE. Entre o sofrimento e o prazer: a vulnerabilidade para enfermeiros nas relações interpessoais com pacientes com HIV/AIDS. Rev enferm UERJ. 2013; 21: 9-15.

5. Armstrong S. Cuidar dos prestadores de cuidados: como controlar o stress dos que cuidam de pessoas com HIV e SIDA. Coleção Boas Práticas. Maputo, Moçambique, 2005. [citado em 21 abr 2010]. Disponível em: http://www.unaids.org.

6. Garrido PB, Paiva V, Nascimento VLV, Sousa JB, Santos NJS. HIV/AIDS, estigma e desemprego. Rev Saude Publica. 2007; 41(suppl 2): 72-9.

7. Moreno FM, Gil GP, Haddad MCL, Vanucchi MTO. Estratégias e intervenções no enfrentamento da Síndrome de Burnout. Rev enferm UERJ. 2011; 19: 140-5.

8. Minayo MCS, organizadora. Pesquisa social: teoria, metodologia e criatividade. Petrópolis (RJ): Vozes; 2010.

9. Bardin L. Análise de conteúdo. Tradução de Luis Antero Reto e Augusto Pinheiro. São Paulo: Livraria Martins Fontes; 2011.

10. Ministério da Saúde (Br). Conselho Nacional de Saúde, Comissão Nacional de Ética em Pesquisa. Resolução n° 196 de 10 de outubro de 1996: diretrizes e normas regulamentadoras de pesquisa envolvendo seres humanos. Brasília (DF): Ministério da Saúde; 1996.

11.Dejours C. O fator humano. 3^a ed. rev. Rio de Janeiro: FGV; 2002.

12.Dejours C. Subjetividade, trabalho e ação. Revista Produção. 2004; 14(3): 27-34.

13.Dejours, C. Cadernos de TTO, 2: a avaliação do trabalho submetido à prova real. São Paulo: Blucher; 2008.

14. Souza NVDO, Santos DM, Anunciação CT, Thiengo PCS. O trabalho da enfermagem e a criatividade: adaptações e improvisações hospitalares. Rev enferm UERJ. 2009; 17: 356-61.

15. França FM, Ferrari R, Ferrari DC, Alves ED. Burnout e os aspectos laborais na equipe de enfermagem de dois hospitais de médio porte. Rev Latino-Am Enfermagem. 2012; 20 (5): 9 telas.

16.Maslach C. Burnout: the cost of caring. Englewood Cliffs (NJ): Prentice-Hall; 2003.

17.David HMSL, Mauro MYC, Silva VG, Pinheiro MAS, Silva FH. Organização do trabalho de enfermagem na atenção básica: uma questão para a saúde do trabalhador. Texto contexto - enferm. 2009; 18: 206-14.

18.Jackson Filho MJ. Desenho do trabalho e patologia organizacional: um estudo de caso no serviço público. Revista Produção. 2004; 14(3): 58-66.

19.Ministério da Saúde (Br). Resolução RDC nº 50, de 21 fev. 2002. Regulamento técnico para planejamento, programação, elaboração e avaliação de projetos físicos de estabelecimentos assistenciais de saúde. [citado em 05 mar 2013]. Disponível em: http://www.redeblh.fiocruz.br/media/50_02rdc.pdf.

20.Cruz EJER, Souza NVDO. Repercussões da variabilidade na saúde do enfermeiro intensivista. Rev Eletr Enf. 2008;10:1102-13.

21.Sailer GC, Marziale MHP. Vivência dos trabalhadores de enfermagem frente ao uso dos anti-retrovirais após exposição ocupacional a material biológico. Texto contexto - enferm. 2007; 16: 55-62.

22.Magagnini MAM, Rocha SA, Ayres JA. O significado do acidente de trabalho com material biológico para os profissionais de enfermagem. Rev Gaúcha Enferm. 2011; 32: 302-8.

23. Ribeiro CG, Coutinho MPL, Saldanha AAW, Azevedo RLV. Concepção da Aids: o que pensam os profissionais e os pacientes? Concepção da aids. DST-j bras doenças sex transm. 2006; 18(3): 185-9.