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Psychosocial risk factors in neonatal intensive care unit: impact to the nurse's health


Elias Barbosa de OliveiraI; Alexandre Vicente da Silva II; Eugenio Fuentez Perez JuniorIII; Helena Figueiredo da CostaIV; Luana Pedro NascimentoV

I Nurse, Post Doctorate Degree in Alcohol of Drugs, PhD in Nursing, Associate Professor in the Postgraduate (Masters) and Graduate program, School of Nursing at the State University of Rio de Janeiro, Rio de Janeiro, Brazil, Email:
II Nurse, Master's in Nursing, PhD in Psychiatric Nursing, Gestalt Therapist, Cognitive Behavioral Therapist, Assistant Professor at the School of Nursing, State University of Rio de Janeiro, Rio de Janeiro, Brazil, Email:
III Nurse, Master's in Nursing, Specialist in Higher Education Teaching, Azevedo Lima State Hospital (Niterói), Rio de Janeiro, Brazil, Email
IV Nurse, Institute of Basic Care and Health Care, Sonia Ferreira Machado Family Clinic Rio de Janeiro, Brazil, Email:
V Nurse, Specialist in high complexity Nursing, Albert Schweitzer State Hospital, Rio de Janeiro, Brazil, Email:
Luciana Aparecida Moraes de SouzaVI Nurse, Specialist in Public Health Nursing, Resident Obstetric Program, School of Nursing at the State University of Rio de Janeiro, Rio de Janeiro, Brazil, Email:




This study aimed both at identifying psychosocial risks factors at a neonatal intensive care unit under the nursing´ view and at analysing how psychosocial risks affect the health of that group. The qualitative descriptive method was applied at a neonatal intensive care unit in a university hospital in the municipality of Rio de Janeiro (Brazil). Semi-structured interviews of 11 nurses were conducted in 2011. Content analysis led to the following results: the psychosocial risks identified by that group cause occupational stress according to some of them: insufficient of material resources, conflicts inside of the work teams and enhancement the rhythm of work. Conclusions show that therefore preventive actions and changes need to me implemented by the organization so that it could improve the work environment. Nursing have an important role in helping the organization managers the risks to set a healthier work environment.

Keywords: Nursing; neonatal intensive care unit; risk control; occupational health.




The technological advances in the healthcare sector has contributed to a significant change in neonatal care, making the neonatal intensive care unit (NICU) a place of conservation, recovery of well being and ensuring survival of the newborn (NB). On the other hand, it is also an environment conducive to discomfort, physical wear and emotional conflicts because of the nature of the work and the specific characteristics of the sector. The majority of nursing professionals, even though they feel pleasure in taking care of beings so defenseless, they experience intense anxieties by fact of performing complex and painful procedures on the NB, waging a daily struggle between life and death1.

In view of the need for safety in the implementation of techniques and manipulation of complex machines and equipment that require efficiency and updating of knowledge, it is necessary to promote the training and investing in training of healthcare professionals for this area of activity. This emphasizes the importance of the professional to develop skills of relationship, sensitizing them to plan assistance guided us foundations of humanization and the integrality of care, in order to provide the NB and their family a peaceful and cozy environment2 .

Being a NICU healthcare professional demands some characteristics as well as being competent, committed and have a good interpersonal relationship. It also requires qualification, because workers deal with life at its beginning and with the imminence of death only a process with an uncertain future that involves the NB and anxieties of their family and the healthcare team and the expectation of errors and successes for their own actions3. Reflecting on the reality itself, can lead the nursing workers to seek coping strategies aimed at the working conditions offered and mobilizes them in the struggle for alternatives that enable work and take pleasure while preserving their physical and mental health.After all, how nursing work is organized and carried out, especially in the hospital setting, workers have subjected to strong physical and emotional burdens, leading them to biological and psychological changes that may lead the professional to give up the profession in the search for other horizons, as the physical and psychological presented.4

Modern society is constantly touched by the pain of the families and especially mothers of babies admitted to the NICU, a fact that is reflected even in the number of studies on the experiences of the mothers. However, few studies have been conducted on the experiences and the reality of healthcare professionals who work there , it is also important to know the needs of these professionals in their work environment 5. In order to contribute with their knowledge and reflections on the experiences of the nurses on the job in the NICU and the implications for their health, this study aimed to identify the psychosocial risk factors present in the neonatal ICU in view of nurses and analyze how they affect the group's health.



In May 2000, the Ministry of Health (MOH) regulated the National Program for the Humanization of Hospital Care (PNHAH), whose main objective would be to enhance the relations between professionals, between professionals/users and between hospital and community. With regard to the quality of services rendered, implies in articulating the technological advances with the good relationship and improving working conditions for professionals with infrastructure investments6. However, a fundamental and underexplored in the program with respect to structural conditions of work of health professionals, often underpaid, often little encouraged and subject to a considerable work burden.

Thus, certain work environments, which should contribute to the acquisition of knowledge, skills development and serve as a basis for the exchange of experiences among the professionals, can generate biopsychosocial order disturbances and exacerbate the occupational stress. Thus, it is possible to correlate the degree of complexity of symptoms and diseases caused by occupational stress, how the individual reacts to the incidence and frequency of psychosocial risks that they trigger7.

In the hospital context, nursing is the largest work force, being a profession that has its own characteristics with activities often marked by psychosocial risks arising from the rigid hierarchical structure, the prolonged work days, accelerated pace of production by excess of tasks, fragmented division of labor, automation of repetitive actions, lack of personnel and material, fragmentation of activities, shifts various and complexity of actions performed, among others8.

Such characteristics of the organization of the hospital work constitute sources of pressure for the professionals in the exercise of their activities and the extension of the working day has just intensifying physical and psychological wear of the worker, resulting in triggering a stress factor and mental suffering, contributing to the onset of disorders such as anxiety, depression and somatization. It is emphasized that death, pain complaints and patients under the care of the hospital staff, are able to trigger intense anxiety in those who work daily with these factors 9.

As healthcare professionals and by virtue of our training we should be sensitized to the issues related to mental health, the work conditions and the role of the organization in promoting the health of workers. Therefore, it is of unquestionable importance for the participation of institutions in developing strategies for the identification of risks present at work. Ofwhich can lead to illness, as well as the implementation of interventions that promote beneficial results to the worker, thus minimizing the effects, irritating these risks and the social and economic costs arising from accidents and sick leave have reduced4.



A qualitative study was opted for10 that, to be applied in nursing, contributes with a variety of methods and techniques, enabling uncover emerging problems of daily life of their practice, because it focuses on the contextualized reality. The place of study was a public hospital located in the city of Rio de Janeiro, which received the award of Child-Friendly Hospital by the United Nations Children's Fund (UNICEF), for promoting, protecting and supporting breastfeeding, as well as meet some criteria of excellence in terms of cutting-edge technological resources, adequate physical plant and skilled professionals.

The study participants were 11 nurses who worked in the NICU. As inclusion criteria the following were adopted: being a member of the permanent staff of the institution and work for at least one year in the service, because we believe that these criteria are relevant in that they refer to knowledge, skills and competencies related to the experiences and learning about the risks present in the workplace and its implications for group health.

In data collection, held in the second half of 2011, the interview technique through the application of a script was used containing questions, which have enabled the nurse to discuss the work in NICU, the problems faced in daily institutional and repercussions for their health. The statements were recorded in mp3 and transcribed in its entirety for later analysis. The interviews were conducted in a private place, after the invitation, the schedule, the appropriate clarifications, science of the opinion delivered by the Committee for Ethics in Research (3023/2011) and signature of Free and Informed Consent in attention to Resolution no. 196/96 of the National Health Council. He assured them that the anonymity and ratified that the participants could withdraw from the study at any stage. It was explained that the results of the study would be presented at events and published in journals of scientific nature. In the construction of the corpus of text were adopted the following conventions: interviewee (letter E) followed by a number in accordance with the order of entry in the text.

The categories of the study resulted from the application of the technique of content analysis of the thematic type11, in which he reflected on the conditions of production of the text through exhaustive reading of the material and identification of frequency of presence, homogeneity or items of sense. The statements were analyzed, words of meaning or registration units were grouped and formed thematic units, which together permeated the experiences / experiences of nurses in relation to the risks present in the NICU and the repercussions to their health. The results are presented in the following order: the need for knowledge and updating of praxis; precarious conditions of work; intense pace of work and conflict of roles.



Need for knowledge and updating of praxis

The NICU is, of excellence, the environment for the care of high risk infants and, therefore, requires a repair team that supports the complexity of the activities, especially considering the many aggressive therapies resulting from technological advances, that produce physiological and behavioral disorganization in neonates, reflecting negatively on their care 2. Therefore, the scientific knowledge and technical skills are essential characteristics for the strict control of vital functions in an attempt to reduce morbidity and to ensure the survival of newborns at risk, as evidenced:

[...] has to be the whole time studying, even because of the advance in technology. Once I was on leave and when I returned and there was already system online and I had to ask help to use it and learn how it worked. (E2)

[...] so for you to work in the neonatal ICU I think you need a training! At least one training! In addition, there, you will learn something every day. (E1)

An essential procedure within the neonatal ICU and there is already an entire training in dealing with the PICC! There, is just one example, but we have many other qualifications. (E5)

The NICU nursing workers must receive institutional support to integrate the ability to answer before the new technical activities; once the imminent risk or likely to expose the patient to undergo diagnostic and therapeutic procedures is not always viewed properly or even if detected in time by the professional. It is, therefore, for the work organization to stimulate and promote the completion of training courses on service with views to the work field process12. This may increase the employee satisfaction and contribute to the well-being at work, and minimize the chances of errors and injuries to NB, as reported by one of the nurses:

The hospital gives us much study, courses, the topic of the meetings on medications! I think that it is very rewarding. I am improving my skills. (E2)

Precarious working conditions

In addition to the in-service training and stimulus to upgrade of knowledge for the field of the work process, there is a need for support for the resolution of problems in which relate to dismissal of inputs materials in quantity and quality, and preventive maintenance of the apparatus used in the assistance of the NB. However, as identified in this study, the dependence of other services, the excessive bureaucracy and the slowness in resolution of structural problems, are factors that intensify the stress, which can affect the professional performance and the quality of service provided.

[...] Lack of material in sometimes, lack of maintenance of materials and equipment [...] chasing the same things every day! This is a stressful environment. (E9)

[...] The slowness in resolution of maintenance problems ... then, these are situations that make me stressed. (E7)

I get tired of fighting for the same things because of bureaucratic issues. (E8)

It is emphasized that the lack of resources for the job can cause damage to clients and employees, because human and material resources are essential parts in the work context and its scarcity harms the development of tasks. The worker is forced to live with the lack of understanding and the inadequacy of resources, leading to dissatisfaction, tension and irritability. Therefore, the search for a quality environment should be a concern for administrators to meet the organization's objectives and the satisfaction of the worker7.

The nursing involvement with activities of imprint managerial associated with the intense pace of work in the search for troubleshooting, constitute factors generating motivation and illness at work. Fight for obtaining of conditions to facilitate the work is perceived as a process extremely stressful and generator of suffering and a climate of dissatisfaction among the professionals. In this sense, the practice of nurses must sustain in scientific bases for better substantiate the defense of appropriate quantitative staff, continuing education, formulation of strategies for the promotion of better working conditions and the prevention of occupational illness13.

Intense work pace

In addition to the precarious nature of working conditions that affect the quality of the service and the performance of the professionals, it is important to consider the wear of the workers of the NICU resulting from the realization of uninterrupted care rendered to NBs.Which require experience and capacity to intervene quickly and effectively, being the greater monitoring due to the risk of complications. Such demands, in view of the nurse, characterize the work in NICU as a complex activity that requires concentration, by working in a situation limit due to the severity of the babies, causing physical and mental overload workers identified through complaints such as fatigue, stress and emotional distress.

[...] this is a work pace, sometimes very tiring! Some days I have a lot of serious child! Then it is very much work. (E4)

[...] the people work in a situation of limit, in a situation of stresswith severe patients who are extremely preterm infants andchildren are complex! Then there is a whole emotional exhaustion. (E11)

It is a specialized job, which requires much concentration! You have to be very attentive to everything. (E10)

It is noteworthy that the theme workloads of nursing has been globally discussed, with a view to their involvement in the quality of care provided to patients, the quality of life of health professionals and hospital costs. In addition, the theme is particularly important in the ICUs, due to the impact of new technologies on care, the changes in the profile of severe patients and the needs of specialized labor with increased costs in this sector.It adds that the interest of researchers in relate the work loads and the occurrence of work-related accidents and search for the resources of the workers to make ahead, mainly, the load mental, found as a cause of physical and emotional exhaustion of the nursing staff and health 14.

They are completely frozen andunable to workin the NICU of high and medium risk involves taking care of newborns that presents an unstable clinical condition, permanently oscillating between states of improvement and worsening. Such situationexposes the nursing professional to a range of emotional stimuli harmful to your health by dealing with the challenge of a daily work permeated by experiences related to pain, suffering and the constant threat of death5.It is added that it is an environment filled with equipment and technology-rich, being necessary to have security in the implementation of techniques and in the handling of machinery and equipment, for which the primary responsibility for the maintenance and recovery of the life of human beings who totally depend on the teams are factors generate stress as mentioned:

The environment is very stressful because you're dealing with life and death and have the equipment.I think that the professional that deals with people who deal with death, he has to have an emotional support, and I think we have to have this. (E4)

[...] be under stress continuously, by the type of clientele that is working, is to live under the stress. (E5)

[...] you failed to restore health to the child then it is something that shakes you, you get upset. [...] I become saddened. (E6)

It is Important to ratify that the psychological burden suffered by professionals who take care of high-risk NB refer their own weaknesses and limitations of the worker and among them are: the fear of going through the experience of having a child in a similar situation;the fear of not being competent enough to attend fully to the NB in their needs;failing and be judged by members of the profession, by the family of the baby and by themself. The professional may feel limited for having already used all the technological equipment available for child survival, without the expected results, which can isolate them from the situation experienced by parents as a means of psychological protection3.

Conflict of roles

In case of nursing work there are difficulties in relations intra and inter, which can generate conflicts and disputes involving issues of autonomy and power of the agents. It is added that the nursing work is complex, continuous and unpredictable, and may by their nature, cause wear and mental suffering to workers, especially when subjected to conflicting situations where there is not a conducive environment for their achievement 15, as reported by nurses.

[...] I think we cannot have an individual decision, not just that it's all together, decision of the shift [...] takes a bit to your liking making [...]With the passing of time can irritates and stresses me. (E2)

[...] because it is not always you alone can take a decision, then there are many things that you have to enter into an agreement with the physical therapy and with the medical team. (E8)

[...]Therefore, it is not easy [...] or then because if missing, I dunno, the nipple of the bottle for a baby, I depend on someone of milk nurse to bring [...] Ah, I think that everyone is frustrated up to a certain point. (E6)

The problems of interpersonal relationship has considerable weight on the well-being and the income of the worker16, also putting significant influence on the illness process. In this sense, it is important that the institution can evaluate its procedures in relation to the management and development of people in the organization, trying to adopt practices that will enhance the participation of individuals in the process of organizational change.

Despite the problems faced, the nurses create strategies and develop actions with the aim of facilitating the work, constituting a source of pleasure, as far as they share the difficulties and value the good interpersonal relationship. Even though some nurses arguing there are conflicts, the team is targeting a healthy relationship, seeking to remedy problems that may hinder the progress of the service and the relationship, as mentioned:

I am nurse routine and I have access to all shifts! I maintain a healthy relationship! This is because we have periodic meetings! Therefore, there are no problems. (E9)

Sometimes we have differences of opinions, but we sit and talk and I can't deal well with this. I never had a problem with any professional both physical therapist, nutritionist and the nursing team also. (E10)

[...] However, it is also important to be careful with the other, but at the same time, you need to be careful with yourself! Do you understand? (E1)

Seen from another angle, when the worker has made clear to you what your role, this helps to position itself in face of situations, it gives him more confidence and fosters the development of a concept about themselves even more consistent9. The good relationships in the workplace needs to be secured so that it reduces the maximum dissatisfaction in the employment context. It is necessary to have a reception space for workers to express feelings and reflection on the work, making them reconsider their relationship with the team and the patients under their care, as well as have a space for self-care17. This ratifies greatly, the importance of the practice of integrality, in which we must seek a joint action of professionals, considering its multiple knowledge and practices. It is in this understanding, the importance of diversity and of actions, which are not confined, to make specific to each component of the team that potentiate the actions of the assembly of professionals18.



The NICU is characterized as a dynamic work environment, complex and highly specialized, whose seriousness of NB requires of the nursing worker knowledge and skills specific for as care free of risks. It is, therefore, a job with high demand and need for control by the employee and the organization, especially when considering the incorporation of technology into the work process, the possibility of complications and death of the NB. In this perspective, the study showed that the nurses and staff are exposed to numerous risks in the workplace and among them the psychosocial because of the need to update the knowledge of precarious working conditions, the intense pace of work and the conflict of roles.

The psychosocial risk factors in the NICU, pointed out provoke dissatisfaction, lack of motivation, affect the performance and quality of service offered, because the worker's internal resources are not enough for their coping, causing damages to their physical and mental health as identified through complaints fatigue, wear and tension. Therefore, there is an urgent need to adopt a policy of institutional control of risks with effective participation of workers who, through their knowledge and practices, may contribute with measures for your coping and among them the improvement of working conditions, the investment in vocational training and the support of specialized technical service.

In spite of the limitations and inability to generalize the results to other contexts of work, ratifies the importance of knowledge produced about the psychosocial risk factors present in the NICU. As well as the measures proposed for their coping that, to be adopted by the organization will be able to minimize the social and economic burden of illness, absenteeism and decline of the quality of the service offered.



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