RESEARCH ARTICLES

Nursing workload in a psychiatric inpatient unit and workers' health

Silvia Regina Carvalho de Souza^I; Elias Barbosa de Oliveira^II; Maria Yvone Chaves Mauro^III; Rosane Mello^IV; Celia Caldeira Fonseca Kestemberg^V; Glaudston Silva de Paula^VI

^I Nurse. MS in Nursing. Specialist in Psychiatric Nursing and Mental Health. Rio de Janeiro, Brazil. E-mail: silvinhanurse@yahoo.com.br
^II Nurse. Post-doctorate in Alcohol and Drugs. Associate Professor of Nursing in Mental Health and Psychiatry (Master's degree) and Graduation at the State University of Rio de Janeiro. Brazil. E-mail: eliasbo@oi.com.br
^III Nurse. PhD and MS in Nursing. Professor of the Postgraduate Program of the Nursing School of the State University of Rio de Janeiro. Brazil. E-mail: mycmauro@uol.com.br
^IV Nurse. PhD and MS in Nursing. Specialist in Art Therapy in Education and Health. Adjunct Professor of Nursing in Mental Health and Psychiatry at the Federal University of the State of Rio de Janeiro. Brazil. E-mail: rosane.dv@gmail.com
^V Nurse. PhD and MS in Social Psychology. Adjunct Professor of Nursing in Mental Health and Psychiatry at the Federal University of the State of Rio de Janeiro. Brazil. E-mail: celiaskestenberg@gmail.com
^VI Nurse. MS in Nursing. Family Health Specialist. Assistant Professor, Gama e Souza School. Rio de Janeiro, Brazil. E-mail: glaudston.silva@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2015.19563

Keywords: Workload; nursing staff; mental health; nursing.

INTRODUCTION

The present study emerged from the problematic related to the absenteeism and the leaves for health treatments of nursing professionals who worked in the hospitalization unit of a large psychiatric hospital, which has as main characteristic the embracement of patients in crisis. This modality of mental health care, by embracing patients in the acute phase of the disease, demands from the worker a permanent alertness state and the ability to deal with the unpredictability of several clinical conditions. Thus, the physical and mental stress is accentuated by the long working hours and the need for professionals to intervene in episodes of psychomotor agitation of patients due to the risks of self and hetero-aggressiveness.

Based on the association between complaints and the referred factors, it is indicated that the absenteeism and/or leave for the treatment of workers' health, because it entails problems in the work dynamics and conflicts between the components of the team, have been a source of wear for nurses, technicians and service management. Those who remain at the workplace feel overwhelmed, considering that most of the time there is no immediate replacement of the professional who is on a leave, resulting in the fact that the others are overwork to maintain the quality of the patient care, and attend other professional or non-professional requests inherent to the work in the context teams.¹

Regarding the working conditions in psychiatry, the workers coexist with physical facilities, small spaces, which are inadequate for the development of activities. There are problems related to the insufficiency of professionals, the shortage of materials and equipment, causing the formation of small and overloaded work teams. The precariousness of the labor force is also present in view of the low wages, outsourced (precarious) employment links and insufficient continuing education in service.²

Faced with the new guidelines of the national mental health policy, the work of the psychiatric nursing has undergone important transformations in the last decades, thus, new practices are being assimilated by professionals in an attempt to improve the integral care of the patient with the mental disorder. Consequently, the professionals have felt the need to reflect on their actions, since the work process is constituted by conflicts and resistances, and it needs to be rethought in the daily life in which it is built.³

The evaluation of the mental health services has received increasing attention due to the World Health Organization's encouragement to increase the quality of the services provided to the population. In this perspective, patients, families and teams of professionals have been increasingly emphasized as an integral and necessary part of the services evaluation. However, patients and their families have received privileged attention, to the detriment of the study on the repercussions of the work felt by the team of professionals.⁴

The present study aimed to identify the nursing workload in a psychiatric hospitalization unit and to analyze the repercussions for the workers' health. The aim is to contribute with research that highlights the harmfulness of the workload for the mental and physical health of nursing workers, in addition to ratifying the relevance of measures aimed at the prevention and health promotion of the group.

LITERATURE REVIEW

In the health sector, few areas of knowledge and performance are so complex and have as much transversality of knowledge and practices as psychiatry. The work in this field causes the professionals to be confronted daily with the pain and suffering of patients who, because they have chronic and recidivates diseases, have a great dependence on the workers and the service. Living with the precariousness of the existence and its fragility brings great suffering to the workers who, at all times, are reminded of the vulnerability that the psychic suffering produces.⁵

It should be added that the transition in the profile of the characteristics of the work in psychiatry has been accompanied by serious managerial problems. The lack of investment in human resources has worsened and generated a shortage of qualified professionals, flattening of salaries and the non-replenishment of personnel. In an attempt to solve this problem, many institutions hire temporary and outsourced workers, which, in addition to not solving the problem, implies on work overload due to the turnover and resulting in high levels of stress, depressive and anxious symptoms in the group.⁶

Thus, nursing workers are submitted to workload that represent the set of efforts expended by the worker to meet the demands of the task, including physical, cognitive and psycho-affective efforts that happen in an integrated manner. The quantitative burden (too much work, concentrated attention and continuous pressure of time and others) refers to the volume of mental work required within a given unit of time. The qualitative burden refers to the level of complexity of the activity and the possibility of its application, concomitantly with significant interests, experiences, capacities and potential of the worker.⁷

In nursing, studies indicate that the workload is associated with the ergonomic conditions of the work environment, causing health damages due to musculoskeletal injuries when dealing with situations that are very prolonged, intense or frequent. The study also revealed the significant increase in costs due to the absenteeism and accidents at work, being emphasized the importance of knowing the resources that workers have to face, especially the psychic burden, which causes the physical and emotional exhaustion of the nursing and health team.⁸

METHODOLOGY

Qualitative study of a descriptive character, considering that the object investigated belongs to a reality linked to the labor world with meanings, motives, aspirations, beliefs, values and attitudes resulting from the human action, apprehended through the everyday life, from the experience and explanation of the people who experience a certain situation. ⁹ The project was approved by the Research Ethics Committee and registered in the National Research Ethics Committee with the number (CAAE - 23356414.6.0000.5259).

In compliance with the Resolution 466/12, after the signing of the free and informed consent term, 30 nursing workers from a hospitalization unit of a large psychiatric hospital in the city of Rio de Janeiro participated in the study. The criteria adopted for the inclusion of the participants were: to be a permanent staff member or hired to work in psychiatry and to work for at least six months in the field of study, being excluded the workers with less than six months in that service and those who were on vacation or other types of leave.

It was reported that the participation of the deponents would be voluntary and that they would have the right to withdraw from the research at any stage. The secrecy of the testimonies was guaranteed and it was ratified that the results would only be presented in events and published in scientific journals. In the transcription of the statements, the following conventions were adopted: nurses (letter E) and nursing technicians (TE) followed by a number according to the order of entry in the text.

Data collection took place in the second half of 2014, at their own workplace after the selection and the invitation. It was used the semi-structured interview technique that combined closed and open questions with the possibility of the individual to discuss the subject in question favoring the contextualization of experiences and senses.⁹ In order to obtain the data, an instrument was used to record the sociodemographic and professional characteristics of the subjects, followed by a script containing questions related to the environment, working conditions and workload, whose responses were recorded in a digital medium.

After the transcription, the statements were analyzed through the content analysis technique and through a set of communications analysis techniques, aiming to obtain through systematic procedures and objectives to describe the content of the messages, indicators (quantitative or otherwise) that allow the inference of knowledge regarding the conditions of production/reception (inferred variables) of these messages.¹⁰ Using the criteria of representativeness, homogeneity, reclassification and aggregation of the elements of the set, the following results were obtained: unpredictability and vigilance; psychic burden; inadequate working conditions; the lack of autonomy in the work organization and the implications of the workload for health: suffering at work.

RESULTS AND DISCUSSION

Characteristics of the study participants

Six (20%) nurses and 24 (80%) nursing technicians were investigated, of which 25 (83.4%) were female and 5 (16.6%) were male. As for their marital status, 15 (50%) were married, 7 (23.3%) were single, 6 (20%) divorced, and 2 (6.6%) were widowers. Their age ranged from 26 to 60 years old, the majority – 20 (66.6%) aged from 35 to 55 years old. Regarding the number of employment links, 15 (50%) had a link and 15 (50%) had two links, with a workload of 30 hours per week – 22 (73.3%) and 08 (26.7%) more than 50 hours, including the two links. With regards to the working hours, 24 (80%) worked day and/or night shifts (on call) from 12 to 60 hours, and the rest were distributed in the morning and afternoon.

The shift work or night shift is characterized as an activity performed in unusual hours, which includes alternating or fixed shifts, with very varied working hours. Given this, it is necessary to pay special attention to the cumulative effects caused by factors that cause important damage to the worker, associated with physical and psychological health problems, biological, behavioral changes and social difficulties. The shift work and night shift were included in group V of ICD-10: Mental and Behavioral disorders related to work, considered as poor adaptation to the organization of the working hours, for the development of sleep-disordered cycle due to non-organic factors.¹¹

Although a large part of the workers are in the productive life stage, an aggravating factor of the wear and tear is the gender, since the majority is female, married and they accumulate more than one employment link. Because they develop a third period of work related to the activities done at home, there is a greater psychophysical waste, especially when considering the total weekly workload. This reality of work, in addition to increasing the physical and mental fatigue, also exposes the worker to the risk of errors due to fatigue and accidents at work.⁷

Unpredictability and vigilance: psychic burden

Although the Psychiatric Reform has in its scope the multidisciplinary and interdisciplinary work, it is still up to the nursing to perform some activities traditionally recognized and, among them, to keep the patients' care under hospitalization and intervene in situations that pose a potential risk to the patient and the team itself. Thus, the psychic burden is intensified due to the alertness of the professionals and the unpredictability of the clinical condition of the patients, as reported:

In this work situation, the negative effects of the exercise of vigilance on the mental health of the worker should be considered, since these effects imply on intensifying psychic burden, especially in the absence of a motor activity used as a strategy for extravasate the accumulated pulsional energy. As energy accumulates, it gives rise to anxiety, tension, and psychosomatic illnesses.¹²

The damages caused by the psychic workload are expressed in the body of the worker, among which the most important are those of the hospital environment, since they add to the other workload, and seem to greatly enhance them. Specifically in the nursing area, the wear and tear as a consequence of tasks is notorious, triggering the emotional overload, with feelings of anguish, psychological stress, depressive syndromes, among other injuries, often associated with physical disorders as well. ¹³

There is the recognition of the hospital environment as unhealthy, painful and dangerous for workers, being a place that is conducive to illness and accidents. There is also the high social and psychological pressure to which nursing professionals are subjected, both in the labor sphere – due to the inadequate working conditions – and in the quality of life, which can lead to occurrences of mental disorders, such as anxiety and depression.⁸

Inadequate working conditions

It was evidenced in the study that, besides the psychic burden resulting from the care of the patient with mental disorder, there are those represented by the inadequate working conditions. The lack of material resources affects the work of the team, mainly due to clinical intercurrences and the need to provide care for patients who, in addition to a mental disorder, have comorbidities that require specific knowledge and care technologies, being the wear accentuated, as referred by the group:

The precariousness of the working conditions contributes to the intensification of the work, and attention must be paid to structural and organizational factors such as increased working hours, the accumulation of roles and greater exposure to risk factors for the workers' health. These aspects point to the risk of an excessive increase in the workload among these professionals and the need for measures to reduce/eliminate this burden, such as investments in improving the working conditions of these professionals.⁸

The exposure of the nursing worker to occupational hazards occurs from a variety of agents, including workload such as biological, psychic, physical and ergonomic. The institutional experience in some situations is permeated by health problems, such as stress, fatigue and musculoskeletal disorders due to structural inadequacies in terms of physical space, equipment in quantity and quality, and insufficient number of nursing professionals, being necessary the planning of actions to promote the health of these workers.¹⁴

It should be highlighted that not all institutions are willing to invest in resources to interrupt or minimize the process of occupational exposure and illness of the professionals, nor in actions that promote the quality of life at work. Therefore, it is necessary to promote a change of attitude towards the occupational health surveillance, considering the impacts on the health of the worker, social and financial costs resulting from absences, medical leaves, leaves and impairment of the quality of the service provided.¹⁵

Low autonomy due to the work organization

Faced with the psychic and physical burden arising from the care provided to the patient with mental disorder and the precariousness of the working conditions regarding the inadequate physical plant and the human resources deficit, the nursing workers, in addition to feeling overwhelmed in their function, have showed in their reports the lack of autonomy at work.

The psychiatric nursing workers, despite performing relevant work in the context of mental health care, do not always feel recognized by the other members of the multiprofessional team. The reduced participation in decisions regarding the treatment leads to dissatisfaction in the group, especially considering that they are workers who, because they provide continuous care to patients, have practical knowledge, which is essential, but not always considered by the organization.⁶

Therefore, there is the need to reflect on the subjectivity of these professionals, in relation to their involvement with the services and the perspective they have of their work, which directly influence their commitment to the professional practices. Added to this there are also other factors, such as the exposure to the users' difficulties, conditions and quality of life, apathy and lack of autonomy in relation to practice and resources, as well as the involvement with the other, which directly influences the professional satisfaction of the mental health services team.^l4

Implications of the workload for the health: suffering at work

The psychological stress in the field of study was the main complaint reported by the nursing workers, who went through the implications of the workload for the mental health of the group. Other subjective complaints, such as annoyance, nervousness, irritation, tension, weariness, anxiety, impatience and anguish, are added as reported below:

Frequently, in the literature, the psychiatric nursing professionals are referred to as a category particularly exposed to occupational stress, as a consequence of the patients' continuous physical and emotional demands. It is added that the worker generally has more than one employment relationship, mostly belonging to the female gender, forming the triple working day, due to domestic activities, with little time spent for leisure, exercise and care for their own health.⁶

The mental suffering of health workers can lead to diverse morbidities, with structural determinants, given that health institutions experience inadequate working conditions with low service levels, resulting in overwork and stress. In addition, they allude to the characteristics of the work in health, which involves dealing daily with the pain, economic need and illness of users, situations that emotionally affect the professionals.¹⁶

FINAL CONSIDERATIONS

It was evidenced in the study that psychiatric nursing workers are exposed to excessive physical and psychic workload, because they experience the psychic suffering of the users and their families and develop their work activities under inadequate conditions. At the origin of the burden, other technical requirements, which require marked physical efforts, due to the care of patients with partial and/or total dependency of nursing because they are bedridden, sedated and/or contained should also be considered. In addition, the lack of professional autonomy and the organization of the work contribute to the results.

Other evidences contribute to the excessive workload in the nursing role in a psychiatric hospital, as the precariousness of the working conditions in which the insufficiency of human and material resources was verified, overloading the teams due to the volume of work to be executed. Regarding the organization, the workers mentioned the limited autonomy at work and they feel sorry for the fact that they did not have a head of nursing that represented them and also because they did not feel supported by the coordination, reason of dissatisfaction and demotivation at work.

Due to organizational, structural and relational factors, the workload is intensified leading to suffering at work and implications for the workers' health in the face of complaints such as: stress, physical and mental fatigue, body aches, anxiety and fatigue. It should be highlighted that psychological stress was the main complaint reported by workers regarding the charges in a psychiatric hospital, which can lead to sickness at work if the organization does not adopt preventive measures for treating this waste. In spite of the limitations of the study, which were related to the small number of participants and because they were performed in a single hospitalization unit, relevant issues were pointed out about the workload arising from the work in a psychiatric hospital and its repercussions on the health of the nursing worker. It is suggested the continuity of research of this nature, as well as the creation of a space dedicated to the discussion and the confrontation of the problems mentioned by the service workers, considering that the field of study did not have a health service for the worker when the data were collected.

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