RESEARCH ARTICLES

Working at central supply and sterilization: health implications for nursing workers

Carolina Cabral Pereira da Costa^I; Norma Valéria Dantas de Oliveira Souza^II; Patrícia Alves dos Santos Silva^III; Elias Barbosa de Oliveira^IV; Manoel Luís Cardoso Vieira^V

^I PhD in Nursing from the State University of Rio de Janeiro. Nurse at the Aloysio de Castro Cardiology Institute. Professor at the Celso Lisboa University Center. Rio de janeiro Brazil. E-mail: carolcuerj@hotmail.com
^II PhD in Nursing. Associate and Permanent Professor of the Post-Graduate Nursing Course of Rio de Janeiro State University. Brazil. E-mail: norval_souza@yahoo.com.br
^III Master Student in Nursing from the State University of Rio de Janeiro. Brazil. E-mail: papatyenf@gmail.com
^IV Post-PhD on Alcohol and Drugs. Associate and Permanent Professor of the Post-Graduate Nursing Course of Rio de Janeiro State University. Brazil. E-mail: eliasbo@gmail.com
^V Master in Nursing. Specialist in Occupational Health Nursing and in Surgical Center and Material and Sterilization Center. Rio de janeiro Brazil. E-mail: mlcv22@bol.com.br

DOI: http://dx.doi.org/10.12957/reuerj.2015.15934

ABSTRACT

This qualitative, descriptive study examined the hospital Central Supply and Sterilization (CSS) organization and work process from the perspective of its role in health-disease processes among nursing workers. In 2013, 34 nursing workers at a university hospital CSS in Rio de Janeiro underwent semi-structured interviews, associated with non-participant observation. The data were transcribed, analyzed and interpreted in the light of thematic content analysis. Respondents reported that, during work activities, they were exposed to risks and injuries related to ergonomic, biological, and other factors, and pointed out that the repetitive tasks can lead to health problems for workers. It was concluded that it is important to raise managers' and workers' awareness to this work environment, which is conducive to undesirable health conditions and to the development of diseases in workers.

Keywords: Nursing; workers' health; nursing work; sterilization.

INTRODUCTION

Materials and Sterilization Centers (MSC) provide support to health care units, for sterilize and disinfect permanent hospital supplies and prepare consumables, providing them to the operating room and to other sectors of hospitals¹. Most MSC is characterized by incipient ventilation systems, reduced and isolated physical spaces, ergonomically inappropriate furniture, among other things that contribute to the deterioration of workers' health².

From a search in the Virtual Health Library databases, it was evidenced an incipient scientific production involving the subject, strengthening thus the justification of the study. However, the first and most important rationale is anchored in the fact that this study seeks to unravel the intricacies of a nursing workspace that has been overlooked by managers, both in terms of research and in the need to improve working conditions.

This study strengthens this profession by encouraging the education, care and research related to occupational health, by glimpsing more effective strategies for working dynamics in this scenario in order to ensure the well-being of those professionals. In addition, it contributes to broaden the understanding of some of the factors that have caused physical and/or mental illness of nursing workers and presents a deeper understanding of the effects of the work on MSC in the worker's body.

Thus, this study focused on the repercussions of working in the Material Center for the health of nursing workers and aimed to analyze the configuration of the organization and the work process in the MSC, on the interference in the health-disease process of nursing workers.

LITERATUR REVIEW

Work can be understood as a producer of use values, an expression of a metabolic relationship between social being and nature. It should be seen as a source of pleasure and accomplishment, since it favors the socialization and the search for self-fulfillment, and ensure livelihoods. However, work does not always represent the personal satisfaction and appreciation of human beings, although it is highlighted as a way to meet the basic material needs ³.

Currently, with the neoliberal model, there have been negative repercussions for workers, such as fear of unemployment, due to the reduction of jobs; multiplicity of employment relationships, especially of precarious relationships; reduction and/or end of labor rights. Such circumstances make workers submit to adverse working conditions and start to be limited to performing claims, which weakens therefore the collective struggles for change. The precariousness of work is a phenomenon that affects most workers due to deregulation and loss of labor and social rights, which certainly causes suffering and increases vulnerability to occupational diseases⁴.

This context of adversity requires the managers of hospital care the challenge of establishing policies concerning the organization of work which are not simply limited to the control of risks already known and identified - such as biological, physical, chemical risks – but that also protect the subjective dimension of workers faced with the psychological suffering inflicted by such productive model, together with the challenge to ensure productivity with excellence⁵.

The MSC is an essential unit in the hospital setting and is responsible for receiving, purging, cleaning, decontamination, preparation, sterilization, storage and distribution of materials used by various sectors in the organizational structure⁶. However, the work process in MSCs brings psychological distress to employees, expressed by feelings of abandonment, sadness, psychosomatic and mental illnesses. There is also presenteeism at work and discontentment in face of the lack of recognition and appreciation of the activities these workers perform in hospitals^7,8.

The work performed on MSC is repetitive and requires attention of those who perform it; thus it is difficult to maintain in the sector stimulated professionals and in sync with the tasks to be performed. Furthermore, most of the MSC contains occupational hazards that can cause disease, and temporary or permanent disabilities⁹.

METHODOLOGY

This is a qualitative and descriptive research. The scenario is a MSC at a university hospital in Rio de Janeiro. Study participants are 34 nursing professionals (nine nurses and 25 nursing technicians) who worked in that MSC.

The inclusion criteria used are: having been working in the same sector for at least 6 months; and the type of relationship with the hospital, in which the professional may have been hired formally by the Consolidation of Labor Laws (CLT), or even be working in another form of employment (precarious contract) under any duty scales.

The exclusion criteria are: being on vacation or leave of any kind during the data collection period; being a resident nurse, since the institution has a Residency Program in Nursing, however, the residents spend only a short period in the unit and this could compromise the perception of the organization and the work process due to a superficial view of this work.

To develop a research proposal, individual interviews of semi-structured type were performed. In addition, it was used the non-participant observation, guided by a form with aspects related to the physical structure of the MCS and to the work process and organization, which can interfere with the health-disease process of nursing workers. A total of 20 hours were recorded, in different days and times.

Data collection was performed from March to May 2013, and the average length of interviews was 15 minutes and all of them were performed by only one researcher. In order to meet the ethical requirements, the study protocol was submitted to the Research Ethics Committee (REC) of the State University of Rio de Janeiro, being approved in that REC under Protocol 081.3.2012.

Each participant received and signed an Informed Consent Form, and the privacy of participants was preserved by identifying them by an alphanumeric code in the descriptions of reports (N for nurses and NT for nursing technicians; the numbering followed chronological order of interview transcriptions). All these procedures are in line with Resolution No. 466/2012 of the National Health Council/Ministry of Health¹⁰.

The data were transcribed, analyzed and interpreted in the light of the thematic content analysis ¹¹. The categorization of data followed these steps: pre-analysis (initial reading); formation of the corpus; formulation of hypotheses and objectives; exploration of the material; and processing the results¹¹. Data collected through observation were inserted into the analysis and discussion in order to reaffirm, enrich or even demonstrate the link between the speeches and the observation made. So two categories were organized for this study, namely: health-disease process of workers: determinants and conditioning factors; and factors that rescue and ensure occupational health.

RESULTS AND DISCUSSION

Health-disease process of workers: determinants and conditioning factors

Results deal with situations relevant to the characteristics of the process and the organization of work which predispose nursing staff to health or disease.

In this context, participants reported that they understand the exposure to risks and injuries related to ergonomic factors in daily work.

Our work area is located on two floors, the material is heavy, we take that material and have to climb a ramp to bring this material to another floor and be sterilized. We carry much weight; it is bad for our spine. (NT6)

I think the excessive weight that we carry is harmful to our health, these super-heavy boxes of orthopedic material, for example. This affects a lot and affects the spine of any human being. (NT1)

During field observations, it was found that nurse practitioners are subjected to overload weight, since the working material in MSC is heavy and subsectors are far apart. It is noteworthy that professionals need to go up and down by stairs as there are no ramps and/or elevators; there is also no transport equipment to minimize the overload weight.

It is worth noting that the physical load is very high, since the manipulation of weight is constant, because there is need to carry the surgical instruments boxes, which demands intense physical strength. Such activities, when carried out with inadequate postures, can further enhance the occurrence of serious back problems and/or musculoskeletal injuries¹².

It is noteworthy the repetition of actions performed during the work, as a factor that can cause some kind of illness.

Here in MSC, the work is quite repetitive, exhausting, can lead to an injury. We always do the same things, sometimes it is tiring. You can even desire to get out of here. (N1)

The labor process in MSC has peculiarities due to its organization and development, exposing workers to specific workloads that bring negative consequences to the physical and mental health of nursing workers.

The repetitiveness of the actions in this environment, physical fatigue and MSC work overload are factors that stimulate, in workers, the desire to be transferred to other units that allow interaction with the patient and improvement of psychomotor skills during direct care to the customer¹³. Moreover, the repetitiveness of actions contributes to the increased prevalence of work-related diseases such as repetitive strain injuries (RSI) and work-related musculoskeletal disorders (WMSDs), which increase the suffering at work^3,14.

RSIs and WMSDs consist of functional or organic disorders resulting from occupational fatigue. It is noteworthy that these conditions may affect tendons, synovial, fascia, ligaments, in isolation or in association, with or without degeneration of tissues, mainly affecting the upper limbs, shoulder and neck. It has occupational origin, arising from the combined or not-combined repetitive and forced use of muscle groups, and also due to inadequate maintenance of posture¹⁵.

Participants also described experiencing situations that caused occupational stress by different factors: the difficulties imposed by the organization of work, and the scarcity of material and human resources; ignorance on the part of other assistance units on the activities developed by MSC, devaluing the work on that place; and the intense pace of work:

The stress level here is very high, even by the very difficulties of service because the enzymatic drugs are missing, the toilet paper is missing, it all interferes with health. So this is the reason why I said I have migraines, insomnia, hypertension, all because of this level of stress, and it's even worse because people do not know the work of MSC. (N1)

We face situations where the stress level rises, the blood pressure rises and we try to manage as best as we can. This stress is due to the lack of material and human resources and due to the high responsibility of nurses in this work. (N5)

Occupational stress can occur due to the complexity of the relationship between, on the one hand, labor and extra-labor conditions, and on the other, workers' characteristics. Thus, there is wear and/or reduction of the body's ability to work, arisen from the difficulty to tolerate, to overcome and to adapt to the psychological demands perceived as unfair, insurmountable and inexhaustible. The effects of exposure to work stress are manifested by triggering other diseases such as hypertension, migraine and gastric ulcers, which warn on the need for changes in work organization and implementation of actions for the promotion of the health of such workers^16,17.

In this sense, stress affects the psychic dimension, which eventually leads to worker's physical wear, causing diseases and blocking creativity and development of solutions to labor problems. All this circumstance not only impairs concentration and attention in activities, but also reduces or eliminates satisfaction in working and in being productive and useful¹⁸.

Another relevant situation is the excessive heat to which workers are exposed daily during the work shift.

It is very hot in here, more than forty degrees [Celsius]. It's really hot! If it were more comfortable in terms of temperature, people would have more willingness to work. (NT3)

Exposure to physical risks due to high temperatures and poor ventilation prevails in speeches, which was verified during the field observation, since most of the subsectors was very hot, not only damaging the health of workers, but also the storage of materials.

Thermal discomfort can cause damage to the health of workers, resulting in decreased ability to concentrate and increased fatigue, and favoring the incidence of accidents. It should be noted that high temperatures are not appropriate to healthcare work environment because the proliferation of microorganisms is accelerated with heat, raising the risk of infections¹⁹.

Another issue cited by participants is the high exposure to biological risk, mainly related to the handling of contaminated sharps.

Sometimes, the staff sends contaminated sharps, without any care. So we have a high risk of accident. Last week they sent a scalpel handle, and sometimes the patient is hepatitis or HIV carrier, and it is not flagged on the labels. We handle these materials, and they can contaminate us. (NT13)

The handling of objects contaminated with biological material requires great attention and care from professionals. For this, standard precaution measures should be established, regardless of contamination level of the object. Furthermore, the use of personal protective equipment (PPE) is essential in preventing accidents and in professional protection against contamination, giving greater security to workers in their work environment²⁰.

Thus, professionals who work in the health services have chances of acquiring illnesses and suffer work accidents due to exposure to multiple risk factors, especially the biological, physical and ergonomic risks²⁰.

In this perspective, work in hospital settings has been risky and unhealthy, and has led the workers to do their tasks, sometimes inappropriately, without the use of PPE or without proper working conditions, resulting from inappropriate physical structure. Such factors compromise the routine of work and the quality of life of individuals in their work environment, causing accidents²¹.

It is important to reflect on the work process and on occupational health on MSC, since it is verified the presence of specific occupational hazards of this activity and how vulnerable is the nursing staff to these conditions.

Factors that rescue and ensure occupational health

Here, work situations that help to ensure occupational health were discussed, because they result in personal satisfaction and a sense of usefulness, which help workers to beware of diseases and overcome pre-existing limitations related to the specificity of work developed. However, there are also issues that, in the worker's perspective, are seen as good for health, but that when confronted with the literature, they show a mistaken and distorted view of the subject.

These are some statements obtained:

We struggle very hard to achieve improvement in the quality of our inputs. And when we got it, it's rewarding, it gives a feeling that we did our job. (N1)

We, working up there [sterilization subsector], we exercise because we carry boxes, we walk from one side to the other, so we do gymnastics. (NT18)

Due to its characteristics, the process and the organization of work are so alienating that blunt the worker's reflecting and judging capacity. Thus, what literature interprets as harmful to health ends up being distortedly perceived by the employee as healthy²². The last deponent's speech appears as a clear example of this analysis, as carrying weight daily without ergonomic orientation or appropriate equipment, and still walking constantly long distances, with inadequate shoes and clothing and without considering the biopsychosocial specifics of each worker are factors that favor the onset of disease.

Staff at the MSC does not have an effective assistance program focused on occupational health in order to provide occupational exercises for a period of working hours. So there is a mistake relating weight lifting and long walks during the working day as a positive factor for health.

In this context, programs promoting health and improvement of quality of life, which incorporate gymnastics as an activity that promotes physical and mental health of workers are essential and should be part of the institutions' culture. Such exercise prevents problems arising from the occupational exercise in unsuitable conditions, which can cause great harm to workers' health²³.

In the field observation, it was found that the professional group of MSC lifts weight and often travels long distances, overloaded with weight. However, through interviews, it was found that certain subjects believe there is no need for physical exercise in extra-labor environment and that it is not important to have a program focusing on the practice of gymnastics in the unit, as the professionals end up working out during the work shift, even without any guidance from an expert professional in the field.

Another distortion in the perception of certain subjects concerns the satisfaction in getting material to work with. However, this should not be considered a positive factor, since the worker must be provided with material resources for the performance of their labor exercise and should have no sense of gratification to have achieved inputs to work, which is an obligation of the work organization and not the worker, who needs to have resources and infrastructure to account for tasks that are prescribed by of the labor organization, according to RDC No. 63/2011²⁴.

In addition, there is the report that currently the use of new technologies in the studied working environment has contributed to improve or ensure the health of workers in this sector, which is another distorted view of the subject, since during the field observations, it was identified a precariousness of material resources and little technological innovation.

Nowadays, things got better for our health, because the technology helped a lot, we have more equipment easy to handle, quick and lighter, for example. (NT8)

In the health area, there has been an accelerated process of transformation and technological innovation, characterized by the introduction of large volumes of techniques, tools, diagnostic and therapeutic resources. This phenomenon has produced significant changes in daily health practices and forms of organization and reorganization of health services²⁵. However, during the observation made in the sector, it was found that professionals work with difficult handling, archaic and very heavy equipment, distant from innovative technologies that benefit workers' health, contradicting the last interviewee.

It was evident, during the observation, that the MSC studied is still going through a modernization process. And, despite having some more new machinery, such as autoclaves and ultrasonic washer, the sector is still far below of what could offer to workers when compared to other MSC already visited and after consulting the manuals for companies that produce such technologies.

Some participants indicated that the way the work environment is constituted promotes the cooperation among peers, which is perceived as a factor that promotes health.

The working environment here is good, the staff is always willing to help, they are very good people, seeking solutions when problems arise. (N1)

Here we never let the staff working alone, we have an incredible partnership. If someone needs help, we help them, and vice versa. (NT18)

This mutual help among workers in the sector was widely observed during field observation period. The different skills of each member are employed in order to achieve the desired result and, in the workplace, there is highlight for the respect and stimulus to creativity²⁶. Thus, workers at MSC have such an understanding of teamwork and positively benefit from cohesion among its members.

CONCLUSION

It is considered that the nursing staff works in undignified conditions and experiences the most diverse types of occupational hazards. Thus, it becomes important the awareness of managers and workers to this difficult work environment, which clearly leads to undesirable manifestations in health and to the development of disease in workers. It is essential that improvements to enhance the quality of working life are implemented, investing, for example, in the climatization and in the restructuring of the physical area of work environments and in encouraging effective participation of workers in political struggles involving the health sector, seeking decent working conditions.

It is also highlighted the importance of expanding the opportunities for discussion among workers, managers and professional associations, as well as increased scientific research in this area. This will encourage and increase workers' critical and reflective capacity, helping them to think of strategies that improve working conditions and strengthening them in the implementation of such strategies.

Regarding the limitations of the study, there was the inability to generalize the results to other contexts of work, considering that it is a specific group of workers and limited to a single hospital.

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