RESEARCH ARTICLES

Psychosocial risks in specialized units: implications for the training and health of nurse residents

Luana dos Santos Vasconcellos Lima^I; Elias Barbosa de Oliveira^II; Maria Yvone Chaves Mauro^III; Márcia Tereza Luz Lisboa^IV; Luciana Guimarães Assad^V; Renata dos Anjos Correa Carvalho^VI

^I Master's degree in nursing. Specialist in Occupational Health Nursing. Nurse at the Military Police Central hospital in Rio de Janeiro. Brazil. Email: lulusvl@gmail.com
^II Post-Doctorate in Alcohol and Drugs. PhD in Nursing. Associate Professor of the Postgraduate (Masters) and Graduate School of Nursing at the State University of Rio de Janeiro. Group leader of Mental Health and Work Studies. Rio de Janeiro, Brazil. Email: eliasbo@oi.com.br
^III PhD in nursing. Full Visitor Professor at the State University of Rio de Janeiro. President of the National Association of Occupational Nursing - Rio de Janeiro Section. Brazil. Email: mycmauro@uol.com.br
^IV PhD in nursing. Associate Professor of the Department of Fundamental Nursing, Anna Nery School of nursing at the Federal University of Rio de Janeiro. Member of Nursing Research Center and Occupational Health and Fundamentals Research Center for Nursing Care. Rio de Janeiro, Brazil. Email: marcialuzlisboa@gmail.com
^V PhD in nursing. Assistant Professor and Coordinator of the specialization (Residence Modality) in nursing from the School of Nursing at the University of the State of Rio de Janeiro. Brazil. Email: lgassad@gmail.com
^VI Master's degree in nursing. Nurse Specialist in Nephrology (Residence). Nurse at the clinic for Renal Diseases. Rio de Janeiro, Brazil. Email: Email: enfaredacorrea@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2015.16507

ABSTRACT

This study aimed to identify psychosocial risks in specialized units in the view of nursing residents, and to examine how psychosocial risks affect this group's health. A qualitative and descriptive method was applied at five specialized units at a university hospital in Rio de Janeiro City, Brazil. Semi-structured interviews of 20 nursing residents were conducted in 2012. Content analysis led to the following results: in the nursing residents' view, psychosocial risks hinder the training process and cause occupational stress. They include: insufficiency of human and material resources, conflicts within work teams, and lack of autonomy. It was concluded that the institutions involved in the training process must engage in risk management at specialized units, so as to minimize harm to the training process and the group's health.

Keywords: Nursing; stress; risk control; mental health.

INTRODUCTION

Health care institutions, especially hospitals, which have residency programs in nursing and other areas, have a great responsibility for the allocation of human and material resources, as well as establishing a structure that enables the training of personnel for the Unified Healthcare System (SUS) and the development of safe practices in technical healthcare and managerial levels¹.

Issues related to the health and disease process and the risks involved in vocational training, should also be included in the human resources policy of the institutions, and the occupational health service, in partnership with the continuing education office and educational institutions, relevant role concerning the promotion of conditions of work and training, in order to promote capacity-building, health and well-being of this group of workers.

To enter the working world and meet the requirements imposed by it, many nurses choose to specialize under the residence modality. This mode of teaching aims to ensure safety on the performance and development of theoretical and practical skills, providing professional development and entry into an increasingly competitive and demanding labor market².

Therefore, the resident, when opting for specialization under the residence modality in complex hospitals and given inadequate working conditions, is exposed to occupational hazards and among them are the psychosocial hazards. Such risks are responsible for occupational stress, which has close ties with the physical and psychological demands of the professional, tied to long hours, the interpersonal relationship issues and the requirements for the care of patients at risk of complications and death³.

Alert to the fact that nursing residents because they are, mostly inexperienced and recent graduates, which have limited strategies for confronting the situations that generate wear, especially in precarious work environments and with personal deficit. The wear is increased in situations where specializing is accounted for as part of the team, performing activities not always related to their function, which is a contradiction to what they propose residency programs⁴.

In a study conducted with nursing residents, identified that the extensive workload, work in shifts, the conflicts in interpersonal relationships and other requirements of hospital organization and the training process itself substantially affected the health of specializing nurse. Among the main findings, problems have surfaced as depressive, psychosomatic, retraction and social inhibition symptoms for work by interfering with the quality of life and at work ⁵.

Considering the importance of institutional programs for the management of occupational stress in resident nurses and the need to contribute to the development of the area, this study aimed to identify the psychosocial risk factors present in specialized units in the resident nurse vision, and analyze how they affect the health of the studied group.

LITERATURE REVIEW

According to article 3 of resolution No. 2/2012, the Ministry of higher education of the Ministry of education (MEC), the residence in nursing is a graduate teaching modality latu senso, in the form of a specialization course, characterized by teaching in service, with 60 hours of work a week and lasting a minimum of 2 years⁶. Features based on learning by daily practice, marked by the progressive acquisition of technical and relational attributes of paramount importance in the development of the future professional⁷.

However, this teaching modality when enter the practical nature of training activities that undoubtedly contributes to the process of building skills and technical and relational nature of skills, can expose the resident to occupational hazards. Such risks affect the health and well-being of the group, especially when considering the lack of preparation and experience in the profession as well as the lack of employment at the institution⁴.

Among the risks that affect the health of the resident, there are the psychosocial, which relate to the planning, organization, management of labor and the environmental and social context, which have potential to cause physical, social and psychological damage to the group. Therefore, an appropriate assessment of the risks in the nursing work must perform to prevent them, eliminate them or minimize them, which enables the reduction of problems such as falling productivity, social and economic costs arising from illness and absenteeism from various causes⁸.

In the workplace, psychosocial risks entail hospital occupational stress with implications for the health of the individual and the quality of service offered. In the genesis of stress and its correlation with the psychosocial risk factors should be considered: lack of programs focused on the preparation and/or worker training, inadequate working conditions, ambiguity of roles, long workdays, interpersonal relationship conflict and difficult conciliation between work and social, family activities⁹.

Studies on psychosocial risks are recent and supported in social epidemiology. However, when using somatic and biological criteria in the assessment and focus on quantification, this aspect does not address the elements inherent to the meaning or the subjective experience of workers. That role has fallen to the psychodynamics of work by emphasizing the centrality of work in subjects' lives, analyzing the inherent aspects of this activity that can favor health or disease with research opportunities and intervention in the workplace¹⁰.

Therefore, to understand the residence as a specialization course, which aims to enter the professional world of work, the institutions that develop this modality of education, must have as principle, actions and guidelines settled on worker's health policy for the SUS aiming at health promotion and the reduction of morbidity and mortality in this group of workers¹.

METHODOLOGY

Qualitative and descriptive study that originated from the desire to know the observed facts, registering, analyzing, classifying and interpreting them in order to describe the phenomena of reality¹¹. The field was a large teaching hospital, located in the municipality of Rio de Janeiro, considered the reference center in the areas of undergraduate education and improvement of knowledge for graduates and postgraduates, through specialization programs in various areas.

20 nursing residents participated in the study, which were enrolled in the intensive care, cardiac surgery, neonatology and clinical medicine programs. The criteria adopted for inclusion were residents of the first and second years, regularly attending their programs and that, at the time data were collected; they were overcrowded in specialized units. Residents were excluded who were on vacation and/or out of the program due to health problems and other types of leave.

The invitation, explanations about the research and the schedule for the interviews were made and data were collected individually, at the unit itself, where the resident performed their activities. In consideration of Resolution No. 466/12, the respondent made sure the authorization of the study by the Research Ethics Committee (filed under No. 067/2012) and signed the Term of Informed Consent.

It was reported that the residents' participation would be voluntary and would have the right to withdraw from the research during any stage. They were ensured confidentiality of data and confirmed that the results would be presented at events and published in scientific journals. To obtain the testimony, the semi-structured interview technique was used¹¹ by a script that combined closed and open questions, allowing the resident discuss the training process, working conditions and psychosocial risks. The answers were recorded on digital media and in order to preserve anonymity, in the transcript of testimony, were used the letters Rd in numerical order, according to the entry in the text.

Once the transcription done, the language was analyzed using content analysis technique of thematic type based on decoding of text in various elements, which have been classified and analog groupings formed¹², he arrived to the following categories: assistive and managerial activity of the resident nurse; the reduced autonomy of nurses towards the resident team; and interpersonal conflict.

RESULTS AND DISCUSSION

Assistive and managerial activity of the nurse resident

According to the residency program, the nurse resident integral care to the critical patient. After all, they're unstable patients, therefore subject to complications, requiring highly trained professionals and familiar with the work process. Thus, if residents reported working in specialized units as an activity that requires physical exertion, mental and ongoing interventions, due to the unpredictability of the clinical condition of patients.

Usually the resident gets the most serious patient! [...] it's really care! Sponge bath, administration of medications, care plan! Therefore, you stay, thus managing the complete care for this patient. (Rd2)

The heart patient is a patient, naturally serious! Even if you say, Ah! They are in an easy postoperative!' However, there's always the risk of having a heart attack. (Rd6)

It's a job that requires a lot of strength! A lot of attention! Memory! Because we deal all the time with critical patients, which could become unstable! (Rd10)

Critical units in the general hospital are sectors with greater physical and psychological demands, focusing on cutting-edge technological resources and highly specialized personnel. These sectors, by their characteristics, are considered the most aggressive, tense and traumatic by type of clientele and by requiring the professional expertise and ability to act in the face of unforeseen situations¹³.

In addition to the critical patient care, which implies wear, another aspect pointed out by the group was the incorporation of technologies to work hard and the difficulties in its use. As reported, during graduation, not always the student has the opportunity to develop the skills in terms of technological field, being the residence a theoretical and practical teaching strategy that enables, by specializing, to fill this gap.

As an undergraduate, I haven't had much contact with this more specific technology. Therefore, you have that initial shock and after you get used to it, because I was there every day practicing and having contact with technology. (Rd12)

The issue of equipment, at the beginning is a little more difficult! You're not used to it! After the infusion pump, it's easier for you move around. I think that the respirator is the scariest technology. (Rd17)

Technology is something we stress a lot as a resident [...] several times I get out of intensive therapy and, at home, taking a bath, listening to the mechanical ventilator. (Rd13)

It was identified that the incorporation of technology lasts in specialized units, in view of the resident, is a psychosocial risk factor for causing insecurity, stress and require specific skills and knowledge group in its handling. We emphasize the importance of supervision and conduct of specializing by preceptors, considered more experienced professionals; providing greater security in their performance and minimize the possibility of errors and iatrogenic diseases.

The nursing resident in specialized units is susceptible to occupational stress, and high wear, in the light of the efforts spent in the care of critical patients, who require strenuous observation and control. One should consider, in the genesis of wear, the inexperience and lack of familiarity with the technological tools in use. Therefore, a work which is characterized by the high degree of responsibility³.

As for the incorporation of hard technologies to nursing work, stresses the importance of a policy to prevent risks for patients and staff, through preventive and corrective maintenance of equipment in use, team training, appropriate conditions work and support of specialized services. Thereby minimizing the possibility of errors and iatrogenic diseases, as well as professional involvement in ethical and legal issues related to professional practice¹⁴.

In the opinion of the participants, the resident of the second year, by more closely knowing the problems of the unit and having greater control over the work process, ends up taking the other preceptor responsibility activities, including: the technical level of staff training, manages the shift and unit. At other times, as indicated by the group, the activities are shared with the other professionals.

Therefore, we're responsible for everything! We are responsible for the training of employees. Responsible for managing the shift! In addition, everything that happens on shift is the responsibility of the resident. (Rd4)

We, as residents, assume both the managerial and care roles! When there a nurse on duty, we divide responsibility! When there isn't, we assume everything. In addition, it is a complete care. (Rd7)

It is the resident, who is there every day! Who knows the patient daily! Knows all of the cases! Knows all the stories! Knows from the beginning, the patient! (Rd6)

Such evidence should be analyzed with caution, and although the residence offers growth opportunities, leadership and development of skills related to critical patient care, the presence of the teacher is essential in terms of supervision and support of safe practices. It is for the educational institution providing professional units trained to function, preventing the resident assume functions for which they are not yet prepared. It infers that the managerial nature and assistance activities accumulated can overload the specializing resident and, when added at the same time, the function of teaching learning may reflect negatively on health, training and quality of the service provided.

So that the Nursing Residence Program is legally recognized, requires faculty and specialized preceptors. The nurse preceptor is co-responsible for supervision, guidance and support of resident who draws inspiration from the professional to improve their skills. Therefore, the preceptor's absence can contribute to feelings of frustration experienced by the resident, which in certain circumstances ultimately take responsibility for their own development of skills¹⁵.

The reduced autonomy of the resident nurse given the team

The transition the academic environment to work can be a psychosocial risk factor, which affects the mental health of the recent graduate, given the requirements of the organization, and internal resources that the individual has to face the conflict and / or urgencies. As reported, residents, especially of the first year because they are inexperienced and do not dominate the work process have little autonomy at work, and this problem exacerbated by the fact that they have a role as a nurse recognized by the staff.

Initially you arrive and don't have any autonomy. You're not even regarded as a nurse. People still think you're nursing academic. Therefore, you don't have any autonomy. (Rd14)

In the first year, there is very little autonomy. I even understand! It is a natural process, because you come often, without experience, without practice. (Rd20)

This autonomy is to say what should or should not do to the team! That while R1 I don't agree. I agree more with R2. (Rd11)

Working autonomy is a category that refers to choices of what to do and how to do the job. In work situations where there is reduced autonomy, stress tends to intensify due to the pressures arising from recoveries, the fulfillment of goals and readiness for the resolution of problems. As for the residence itself, there are standards set out in the program in terms of workload to be fulfilled; academic-oriented activities and working of shifts according to the needs of the service, and the resident adapt the requirements of the organization³.

It ratifies that autonomy is possible only for the nurse when this focuses on activities that he really dominates, being able to act in the face of situations not provided for. Thereby, the autonomy is possible insofar as the professional, throughout their professional practice, develops skills and abilities in technical fields, and relational assistance¹⁶.

The nurse resident, for not being part of the effective workers and have reduced autonomy in terms of decision-making power, faced with conflicting situations regarding the performance of nursing staff, which generates tension and anguish. Thus, the testimony permeate the need felt by specializing the recognition of their role by the nursing team, missing by of all workers, clarity of their role and responsibilities in the workplace.

Specifically the problem is that I spent more compared to the same team! Because it has moments where we are charged for by our residents. Now we are not supported in charge of the team things, in theory not being part of the team. We are only students interning. (Rd11)

You do not have the autonomy to do things! You will only have this autonomy when you are on a shift that does not have the preceptor, or a nurse! (Rd12)

The lack of clarity on the part of the team, about the roles and responsibilities of the nurse resident on organizational structure reflects the fragility of the training process and the perception of reduced autonomy reported by the specializing resident. It is therefore the preceptorship specific actions to work together as a team, the role played by the resident, which can minimize conflicts and create opportunities for conducting a collective work. It is inferred that the resident, by opting for specialization, has improved expectations and professional growth, which, if not met, could lead to demotivation and even program evasion.

Therefore, think of the hospital, as the unit of care and vocational training is to aim for the organization of this system, considering the importance of the subjective aspects involved and between them. They are the need for autonomy of specializing, recognition of the work done, the relationships based on respect the differences and attitudes host by the other team members - fundamental aspects and that will influence the performance of the resident nurse in among healthcare areas¹⁶.

Interpersonal relationship conflict

The good interpersonal skills is essential in the conduct of teamwork, and may be a factor of fulfillment and satisfaction. And if not it leads to situations of conflict and disputes involving various professions, due to differences in training and world views. Residents reported the interpersonal relationship conflict in their daily work, involving members of the nursing staff and preceptors.

I had personal relationship problems with the team! In fact, some professionals seem to have some resistance with the residents. (Rd10)

The problem that I have is more in relation to the same team [...] and often the lack of respect for residents. (Rd11)

The biggest problem during the residence is the complicated interpersonal relationship, especially with the preceptors. (Rd16)

Among the situations experienced in the nursing routine, the interpersonal relationship is identified as the main driver of stress in these professionals as a result of factors such as a lack of power and influence, incompatibility in the interaction with superiors, subordinates little competent and fact that nurses feel alone regarding the need for decision-making¹⁷. A problem that can occur in nursing residence programs is the conflict between resident and preceptor, when nurses delegate their activities for the resident without providing the technical guidance of the procedures or the referrals related to learning strategies⁶.

CONCLUSION

The study showed that the nurse, by opting for residence in specialized units, is exposed to psychosocial risk factors related to the structure and organization of work that affect their well-being and health. With regard to the management activity, the resident, especially the second year, in the face of social pressures of work, is counted as part of the team, replacing the work of the preceptor and, in some situations, the nursing technician.

This work/learning situation, although it is a challenge for professional practice and contribute to its formation in terms of acquisition of skills, team leadership and other skills, must be analyzed with caution, since the presence of the preceptor is essential in terms of guidance, group support and supervision of safe practices.

With regard to the care of critical patients and the entire technological arsenal used, it is up to the trainer institution provide the personal service and adequate infrastructure, in order to minimize the wear of specializing given the high degree of responsibility involved in critical patient care.

As for the reduced autonomy of the resident team, it is a dialectical issue, insofar as the resident himself, especially the first year, acknowledges that the work in specialized units, has technical and healthcare demands that go beyond their resources and for which you don't feel prepared, doing, so part of the vocational training process.

On the interpersonal relationship, it was identified that the same thing sometimes becomes troubled by the lack of clarity of team in relation to the role of the resident, who despite sometimes assume leadership of the group in other situations must undergo conducting technical assistance activities without proper guidance.

Despite the limitations of the study, arising from the reduced number of participants and only scenario sample and the impossibility of generalizations to other training contexts ratifies its relevance by identifying the influence of psychosocial factors of the job for training, satisfaction and health of residents. By the fact that residence is a theoretical and practical training relevant modality in the training of human resources, confirms the role of the institutions involved in this process by promoting risk management, appointed by the resident in order to minimize losses caused in the vocational training process and group health.

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