id 23580



Job insecurity at a teaching hospital and presenteeism among nurses


Manoel Luis Cardoso VieiraI; Elias Barbosa de OliveiraII; Norma Valeria Dantas de Oliveira e SouzaIII; Marcia Teresa Luz LisboaIV; Tatiane XavierV; Felipe de Oliveira RossoneVI

I Nurse. PhD student in Nursing. Universidade do Estado do Rio de Janeiro. Master in Nursing. Specialist in Occupational Health Nursing. Rio de Janeiro, Brasil. E-mail:
II Nurse. Post-doctorate degree in Alcohol and Drugs. Associate Professor in Nursing. Universidade do Estado do Rio de Janeiro. Brasil. E-mail:
III Nurse. PhD in Nursing. Associate Professor of Universidade do Estado do Rio de Janeiro. Brasil. E-mail:
IV Nurse. PhD in Nursing. Associate Professor of Universidade do Estado do Rio de Janeiro. Brasil. E-mail:
V Nurse. Master student in Nursing. Universidade do Estado do Rio de Janeiro. Brasil. E-mail:
VI Nurse. Master student in Nursing. Universidade do Estado do Rio de Janeiro. Brasil. E-mail:





Objective: to examine job insecurity at a teaching hospital as a factor contributing to presenteeism among nurses. Method: in 2015, with a public university hospital in Rio de Janeiro city as its field, this descriptive, qualitative study used semi-structured interviews of 39 nursing workers. Content analysis was applied to the transcripts. Results: job insecurity contributes to presenteeism among nurses: as temporary workers do not have the labor rights assured by law and suffer fear of unemployment, they continue at work even in poor health. Health problems affect performance, overload health teams, and impair service quality. Conclusion: there is need for an institutional policy directed to assuring job security, which can minimize the occurrence of presenteeism and impairment to service performance and quality.

Keywords: Nursing; presenteeism; occupational risk; occupational health.




The present document is a master's thesis excerpt; whose object is the deregulation of labor at a teaching hospital as a contributing factor of presenteeism in nursing. The interest about the object was due to the finding of a large number of nursing professionals, working at a public university hospital, under the terms of a temporary contract; that is to say, these professionals did not have labor rights provided by law. This working reality was leading to a variety of problems, for management and other components of the nursing staff because, after some time, the temporary worker left the institution for not having their rights guaranteed; thus, the staff turnover, as well as training needs and risks to the service quality, led to a work overload.

According to the Ministry of Health (MOH), precarious work is the one that is carried out in the absence of labor rights, a fact that does not guarantee social protection and quality of life for workers. In the public sector, the precarious or informal working condition was established in the 1990s with the Constitutional Amendment or Amendment of Administrative Reform, which has the purpose of changing the Federal Constitution provisions, related to the public administration and labor relations of public servants with the state. Since then, the adoption of multiple forms of links by public institutions were allowed, including the statutory labor regime, the CLT, outsourced and temporary employment1.

In healthcare area, the labor characteristics and forms of inclusion of professionals in the labor market point to the growing informality in labor relations, with payment reduction, multiplicity of employment relationships, increasing participation of women and high number of shifts. These data indicate that the Brazilian labor market, in the health sector, has been reproducing the general trend of the neoliberal model of the contemporary economy, that is, the trend of using the solution of flexibility in hiring the workforce2.

The multiple forms of employment relationship and, consequently, different earnings among the nursing professionals who have the same education, is the condition that directly affects this group of worker's productivity, leads to feelings of demotivation in relation to innovative projects in their institutions and, consequently, dissatisfaction at the lack of participation in the plan for positions and salaries and no possibility of growth opportunities within the company3.

It is contended that the employment instability, resulting from the weakness of the employment contracts under which temporary workers are subject to, leads these workers to take a presenteeist attitude; that is to say, remaining in the job even with health problems, due to the specter of unemployment4. In its conceptual basis, the presenteeism leads to health problems and loss of productivity as a result of these excessive working hours and the feeling of insecurity; it also develops, in the workers' behavior, the culture of not missing work and working to meet service demands and not lose their jobs. This situation is exacerbated in those individuals who have chronic diseases and are more likely to have a presenteeist behavior as a result of social pressures5.

From the foregoing, the question is: how the deregulation of labor in teaching hospitals can contribute to presenteeism in nursing workers? What are the effects of presenteeism for the working process of hospital nursing? In order to answer these questions, the present study aims to analyze the deregulation of labor in teaching hospitals as a contributing factor to presenteeism in nursing.

In order to support the study of presenteeism in nursing, a survey of the state of the art was carried out in Virtual Health Library (VHL), in an integrated manner with the Brazilian Nursing Database (BDENF), Latin American and Caribbean Health Sciences Database (LILACS), Medical Literature Analysis and Retrieval System Online (MEDLINE) and Cumulative Index to Nursing and Allied Health Literature (CINAHL), through the CAPES Periodicals. In the material selection, the study has been carried out without temporal cut and with the theme words, presenteeism and nursing and presenteism and nursing. Excepting some review articles, only eleven studies were found, showing the lack of production and the need to discuss these issues in nursing.



The recessive policy disseminated by the State Reform of the Federal Government, from the 1990s on, advocating the flexibility of the public employment and a strict government control over personnel costs, boosted a crisis situation for university hospitals, which began to experience the gradual reduction of staff. This reduction was due to the lack of civil service competitive examinations, linked to the scarcity of investments in technology and infrastructure, necessary to meet the demands of teaching, research, extension and assistance. In this context, it can be observed that the process of flexibility of work relationship also results in the disruption of services, because the hospitals did not provide a human resources management policy, compatible with the expansion of the demand of services6.

The neoliberal model and the effects of globalization, in which the temporary (precarious) bonds prevail, and marked by the flattening of wages and the expropriation of labor rights, have contributed to the loss of status of the majority of employees in organizations, leading them to a most subjection to adverse working conditions. These processes of domination mix uncertainty, submission, competitiveness, insecurity, distrust and individualism. The other dimensions of social life of the individual tend to be also affected, added to the destabilization and vulnerability that lead to symbolic devaluation, rather than the representations of each one in the social structure7.

Given this reality and due to the way how the organization of hospital work is established — strongly influenced by the neoliberal model —, there are some negative repercussions for the health-disease process of professionals, such as stress, systemic arterial hypertension, physical and mental exhaustion, depression and fatigue. Among the risk factors that contribute to the illness, it is important to observe the inadequacy of the quantitative of human resources, the hiring of temporary workers, the intensification of work rate; finally, these are characteristics of an organization that prioritizes profit rather than the worker's health8.

Aiming to combat the deregulation of labor, which directly affects the consolidation of the SUS - Single Health System, and thus recognize and value human labor in all its dimensions, it has been created the National and Interinstitucional Committee of Regulation of Labor ( Comitê Nacional Interinstitucional de Desprecarizaçao do Trabalho) in SUS. Managers of the three spheres of government and labor leaders have been analyzing and debating alternatives to combat the precarious work, whose agenda tries to rescue the precarious workers' condition, promoting their reinsertion in the labor market, through a way of constitutionality, thus ensuring their labor and citizenship rights. It is necessary to ratify that precarious work has a direct impact on the quality of services offered and the regularity of the professionals' work1.

In parallel to the movements for regulation of labor, it is also necessary to ratify that the nursing management practice needs to be established on a scientific basis, in order to better justify the promotion of the adequate number of professionals, continuing education, formulation of strategies to promote better working conditions and prevention of professional illness. Such strategies aim at improving and minimize or eliminate workloads, that are recognized for their harmfulness to the professionals' welfare and health9.



This is a descriptive study, with a qualitative approach, in which the knowledge of people is possible due to the description of the human experience as it is experienced and defined by its actors, providing a free field for the exploration of the perception capacity and for the subjectivities of human beings10. The project was approved by the Institution's Ethics Committee, in which the study was conducted and registered in the National Committee for Ethics in Research, under the number (CAAE - 23356414.6.0000.5259).

The field of study was a large university hospital, located in the municipality of Rio de Janeiro, and this choice was due to the fact that the institution is going through an intense process of deregulation of labor, as a result of the hiring of temporary staff in nursing. In compliance with Resolution 466/12, and after signing the Informed Consent Form, 39 nursing workers participated in the study (fourteen nurses and twenty-five nursing technicians), all of them working in the Clinical Nursing Service and selected by the following inclusion criteria: to be working at least a year in statutory, CLT and/or temporary regime. Those professionals, with less than a year of working in this service, were excluded from this study, as well as those on vacation, medical leave or other types of work leaves.

It was stated that the participation of these deponents would be voluntary and that they would have the right to withdraw from the research at any of its stages. There was also a guarantee about the anonymity of the statements, and it was ratified that the results would be presented at events and published in scientific journals. In the transcript of the testimonies, the following conventions were adopted: nurse (letter E) and nursing technician (TE), followed by a number according to the entry order in the text. The data collection was carried out in the second half of 2014, in their own workplace and after the selection and invitation. The semi-structured interview10 was the selected technique, through a script that combined open and closed-ended questions, with the possibility of the individual talk about the subject in question, favoring the contextualization of experiences, perceptions and senses. In the survey of the respondents' socio-demographic and professional profile, a self-applied instrument was used.

Once held the transcript, the corpus of the text was submitted to the thematic content analysis, which consisted of a set of analytical techniques of communications, in order to obtain, by systematic procedures and description objectives of message contents, the indicators (quantitative or not) that allowed the inferential knowledge related to the conditions of production/reception (inferred variables) of these messages 11. In a last moment, and using the criteria of representativeness, homogeneity, reclassification and aggregation of the elements of the set, the following categories were elaborated: fear of unemployment and presenteeism; work overload and damage to the quality of service.



Characteristics of participants and presenteeism

The study included 39 professionals, working in the Clinical Nursing Service, divided into two groups: 14 (35.8%) nurses and 25 (64.1%) nursing technicians. A total of 32 (82%) were women and 7 (17.9%), men. Among them, 19 (48.7%) were married, 18 (46.1%) were single, 1 (2.5%) was divorced and 1 (2.5%), widowed. The largest age group corresponded to the range between 25 to 44 years (64.1%), that is, of the production phase. According to their labor relationship, 22 (56.4%) reported not having job security (temporary contract) and 17 (43.6%) were public servants (statutory servants)

As seen, an aggravating and exhausting factor at work, that can contribute to presenteeism, is gender, because the majority of workers are women — they are married and accumulate more than one job. Because they are responsible for a third working time, related to their home activities, they can develop fatigue12, especially when considering the shift work and total hours of work — that, in addition to increasing physical and mental fatigue, also exposes the staff to risk of errors and accidents at work

In terms of labor relationship, 28 (71.8%) participants had more than one job — and all temporary workers reported double and/or triple working hours, fulfilling more than 50 hours of workload per week. Today, we can observe the existence of cooperative and temporary workers, among other forms of hiring, who do not have rights as paid holidays, sick pay, Christmas bonus salary or job stability13. The labor relationship accumulation can be double-sided: it can be a source of pleasure, for it confers a better financial contribution and therefore creates a better quality of life; or it can be a source of fatigue and exhaustion at work in front of the excessive workload and the difficulties in reconciling social and familiar life14.

When asked about their health conditions and use of medicines, it was observed that 21 (53.8%) participants reported musculoskeletal, cardiovascular, respiratory and common mental disorders, with concomitant use of medicines. We can infer that such health problems favor presenteeism and may be associated with exhaustion related to double and triple working hours, as well as the extensive weekly working hours and shift work.

The shift work in nursing is one of the risk factors for presenteeism due to the fatigue12, as professionals spend 12 hours or more taking care of patients with varying levels of dependence and continuous assistance needs, that range from drug administration, baths, feeding, monitoring and care of emergencies. It can be added that the deregulation of labor transforms the workplace into a breeding ground for suffering and illness of professionals, an important feature in the new settings of contemporary work marked by flexibility, multi-skilling and insegurança15.

Fear of unemployment and presenteeism

Because the study was performed with 22 (56.4%) precarious workers, it was observed that presenteeism, in the view of participants, was associated with precarious work, face to the contracted worker's impossibility to leave the work to treat his health problems, due to the fear of unemployment. Because of the lack of job security and remuneration below the statutory work, the professionals in precarious regime remain at work even in poor health, demonstrating feelings such as fear and insecurity, for not being able to be absent from work and for threats of punishment, as indicated:

The contractor has no other possibility, although sick he has to come to work, because he cannot be absent, even with a doctor's certificate. So, no way, he must come to work, because he has fear of being dismissed. (E12).

Those who are not public servants have a worse situation, as the doctor's certificate is not worth anything! They feel threatened by their superiors that say: I will dismiss you and that´s it. (E13).

Because he (the sick worker) comes to work without conditions, and most often comes because of the employment and not to lose the job, because he is hired. The contracted worker comes to work because he is afraid of losing the job or even be punished by his superior! This fact leaves the staff insecure. (TE14).

An aggravating factor for presenteeism is the fear of unemployment, which results in the worker's postponement of his health treatment and affects the early detection of diseases such as hypertension, diabetes, musculoskeletal problems, mental disorders and others16. Initially, for some companies, the fact that the employee does not leave his functions can be advantageous, but the managers are beginning to realize how much this kind of attitude can be harmful to both the organization and the worker, due to the absenteeism by disease and the worsening of quality of life17. At present, given the precariousness of labor relations, the disease took more subjective forms, making it difficult to link them to labor activity, and it is not possible to say that insomnia, obesity, fear and insecurity are symptoms of health problems in precarious workers. However, we can infer that new occupational diseases are affecting workers and have unsafe and precarious work as one of its causes2.

In the hospital sector, we can consider the undignified working conditions of the facilities, furniture and insufficient human and material resources18 as contributing factors to presenteeism, because they represent a risk generating environment that causes health damage, regardless of the labor relationship. It also can be added the inadequate remuneration, the increase in working hours and the tension generating characteristics of the services (because of the nature of care provided to people and the social division of labor), among other factors, thus reflecting in the health of workers and the quality of care provided to patients5.

In relation to the informal or precarious insertion at work, it is known that the employee knows about their rights and social guarantees. However, the professional eventually undergoes the temporary condition, face to the specter of unemployment, to social pressures from the occupational environment, to the competitiveness and the few integration perspectives in the formal market. This situation reflects an entire social and political environment, which influences the management and an organization with no labor protection, whose disregard for the employee's physical and mental limitations greatly contributes to the occurrence of accidents and diseases related to work2.

Work overload and damages to the quality of service

In relation to the consequences of the presenteeism in the hospital organization, we can identify the workload, the need to redistribute the activities in the group, the damages to the employee's performance due to health problems, all contributing to the reduced productivity, to the interference in the quality of service offered and the dissatisfaction of those who remain on the job, as seen below:

Here we have an intensive workload, when there is a sick employee working. I think there should be a staff redirection. But, as we do not have it, the workload increases, because the other employees will have to cover the tasks of that one who is sick. (TE05)

I've worked even when I was sick and my desire was to leave. So this fact disturbs a little. I was bewildered! My productivity fell a lot! The patient care was not good at all. (TE03)

Working with someone sick in the same shift disturbs everything! The work dynamics changes completely! Instead of having a patient, actually I have four patients! The colleagues became dissatisfied! The patients' companion's complaint! Just because you begin to not give an ideal service. (TE16)

The presenteeism occurs more frequently among those workers subjected to physical and mental work overload, like the nurses of the country, as a consequence of the inadequate quantity of staff in the institutions19. Nursing is one of the occupations at high risk of exhaustion, stress and illness, because it is a category severely affected by the absence of a proper sizing of human resources, both in quantitative and qualitative terms. On the other hand, the management is the responsible for the sizing of human resources, which positively affects the quality of service and the employee's health because, as the extent of the workload is shared by the group, the load is minimized as well as the workers' psychophysical exhaustion20.

One rather worrying aspect, concerning to the administration of human resources in nursing, has been the loss of productivity due to presenteeism, whose workers have chronic health problems and physical limitations. Such limitations hamper or even disable the performance of activities that require physical strength and resistance, especially when considering repetitive movements, weight lifting, displacement and the need to be standing for long periods21.

The presenteeism in nursing has its greatest impact on quality of care provided to the patient, because the professional with health problems will not always be able to fully meet the demands that his activity requires. Among the health problems, associated with presenteeism in the category, the most common are musculoskeletal pain and depression. It is important to highlight that presenteeism can be prevented and/or minimized through factors related to the worker himself (by the experience gained over years of work, the development of specific skills, exhaustion coping mechanisms in the workplace) and also related to the work organization, when promoting a consistent plan of positions and salaries, according to the function held by the employee22.

It is known that, despite the pressures at work and the requirements of the social life, it is important that the worker recognize his psychophysical limitations and seek treatment for his health problems. In this way, it is possible to find internal and/or external available resources and improve the skills of individuals, in order to face the adverse situations, they may encounter in their laboral environment20.



It was demonstrated in the study that the deregulation of labor in teaching hospital is a factor that contributes to presenteeism in nursing, as temporary workers, for not having guaranteed labor rights in the Constitution, are pressured to attend the service even healthily debilitated, exposing themselves to the risk of aggravating a pre-existing problem. As they feel compelled to go to work even in poor health, we could also identify the psychological distress, due to feelings of insecurity, fear of punishment and dismissal.

The presenteeism in nursing leads to problems for the hospital organization, such as: work overload, need for a staff redistribution of activities, damage to the employee's performance and other workers' dissatisfaction. We can observe a fall in productivity and damage to the quality of service. The problem of presenteeism is intensified, for when the employee does not leave the work, his replacement cannot be carried out, thus contributing to the worsening of his healthy conditions and adversely affecting his interpersonal relationships, due to the overload of the team.

Therefore, the work organization of work is the responsible for the adequate sizing of its staff; an essential strategy for preserving workers' health and the quality of service offered. Because the health problem affects the job performance, it is important to create an Occupational Health Service, that can have a good performance in terms of admission and periodic exams, as well as the worker's rehabilitation or even his replacement. Such measures can minimize the social and economic burden of presenteeism, whose worker, as reported, is not able to meet the demands of service.

Considering the deregulation of labor in the health sector as a result of government policies and of the limitations of the worker himself, as well as of associations and trade unions with regard to changes in the current legislation, it is necessary to ratify the importance of a regulation policy concerning to the effectiveness of civil service competitive examinations, as well as plan for jobs and salaries, consistent with the workers' needs. In faced of the limitations of the study, due to the small number of participants and a unique institution in study, it is recommended to carry out further researches on presenteeism, focusing on gender issues.



1. Ministério da Saúde (Br). Secretaria de Gestão do Trabalho e da Educação na Saúde. Departamento de Gestão e da Regulação do Trabalho em Saúde. Programa Nacional de Desprecarização do Trabalho no SUS: DesprecarizaSUS: perguntas & respostas: Comitê Nacional Interinstitucional de Desprecarização do Trabalho no SUS. Brasília: Editora do Ministério da Saúde, 2006. 32 p. Available at:

2.Costa DO Tambellini AT. A visibilidade dos escondidos. Physis: Rev saúde coletiva. [serial on the Internet] 2009 [cited Feb 2015] 19: 953-68. Available at:

3.Ribeiro AC, Souza JF, Silva JL. A precarização do trabalho no SUS na perspectiva da enfermagem hospitalar. Cogitare Enferm. [serial on the Internet] 2014 [cited Feb 2016] 19:569-75. Available at:

4.Johns G. Presenteism in the workplace: a review and research agenda. J. Organiz. Behav [serial on the Internet] 2010 [cited Jan 2016] 31: 519-42. Available at:

5.Flores-Sandi G. Presentismo: potencialidad en accidentes de salud. Acta méd. Costarric [serial on the Internet] 2006 [cited 2015 Nov 10] 48:30-4. Available at:

6.Alves, MP, Coelho MCR, Borges LH, Cruz CAM, Massaroni L, Maciel PMA. A flexibilização das relações de trabalho na saúde: a realidade de um Hospital Universitário Federal. Ciência & Saúde Coletiva [serial on the Internet] 2015 [cited May 2016] 20:3043-50. Available at:

7.Franco MS, Seligmann-Silva E. As novas relações de trabalho, o desgaste mental dos trabalhadores e os transtornos mentais no trabalho precarizados. Revista Brasileira de Saúde Ocupacional [serial on the Internet] 2010 [cited Oct 2015] 35(122): 229-48. Available at:

8.Gonçalves FGA, Souza NVDO, Pires AS, Santos DM, Brecht, Ribeiro LV. O modelo neoliberal e suas repercussões para a saúde do trabalhador de enfermagem. Rev enferm UERJ [serial on the Internet] 2014 [cited Aug 2014] 22:519-25. Available at:

9.Schmoeller R, Trindade LL, Neis MB, Gelbckel FL, Pires DEP. Cargas de trabalho e condições de trabalho da enfermagem: revisão integrativa. Rev Gaúcha Enferm [serial on the Internet] 2011 [cited 2015 Aug 15] 2:368-77. Available at:

10.Minayo, MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 13ª ed. São Paulo: Hucitec; 2013.

11.Bardin L. Análise de conteúdo. Lisboa (Pt): Edições 70; 2011.

12.Mello MT. Trabalhador em turno: fadiga. Belo Horizonte (MG): Editora Atheneu; 2013.

13.Antunes RLC. Os sentidos do trabalho: ensaio sobre a afirmação e a negação do trabalho. São Paulo: Bom Tempo; 2009.

14.Urbanetto JS, Magalhaes MCC, Maciel VO, SantAnna VM, Gustavo AS, Poli-de-Figueiredo CE. Estresse no trabalho segundo o Modelo Demanda-Controle e distúrbios psíquicos menores em trabalhadores de enfermagem. Rev esc enferm USP [serial on the Internet] 2013 [cited June 2015] 47(5): 1180-6. Available at:

15.Franco T, Druck G, Seligmann-Silva E. As novas relações de trabalho: o desgaste mental do trabalhador e os transtornos mentais no trabalho precarizado. Rev. bras. saúde ocup [serial on the Internet] 2010 [cited Aug 2015] 35(122): 229-48. Available at:

16.Elkeles T, Seligmann-Silva E. Trajetórias recentes dos distúrbios osteomusculares em dois contextos nacionais – Brasil e Alemanha. In: Glina D, Rocha L. (Org.). Saúde mental no trabalho. São Paulo: Roca; 2010. p. 22-53.

17.Demetouti E, Le Blank PM, Bakker AB, Schaufeli WB, Hox J. Present but sick: a three-wave study on job demands, presenteeism and burnout. Career Develop. Internat [serial on the Internet] 2009 [cited Nov 2015] 14(1): 50-68. Available at:

18.Mauro MYC, Paz AF, Mauro CCC, Pinheiro, MAS, Silva VG. Condições de trabalho da enfermagem nas enfermarias de um hospital universitário. Esc. Rev Anna Nery [serial on the Internet] 2010 [cited Jan 2016] 14(2):244-52. Available at:

19.Paschoalin HC, Griep RH, Lisboa MTL. A produção científica sobre o presenteísmo na enfermagem e suas repercussões no cuidado. Rev. APS [serial on the Internet] 2012 [access in November 2014] 15(3): 306-11. Available at:

20.Umann J, Guido LA, Grazziano ES. Presenteísmo entre enfermeiros hospitalares. Rev. Latino-am. Enfermagem [serial on the Internet] 2012 [access in July 2015] 20(1):159-6. Available at:

21.Letvak SA, Ruhm CJ, Gupta SN. Nurses' presenteeism and its effects on self-reported quality of care and costs. Am. J. Nurs [serial on the Internet] 2012 [access in October 2015] 112 (2):30-8. Available at:

22.Inoue KC, Matsuda LM. Dimensionamento de pessoal de enfermagem em Unidade de Terapia Intensiva para Adultos. Acta Paul Enferm [serial on the Internet] 2010 [access in August 2015] 23(3): 379-4. Available at:

Direitos autorais 2016 Manoel Luis Cardoso Vieira, Elias Barbosa de Oliveira, Norma Valeria Dantas de Oliveira Souza, Marcia Tereza Luz Lisboa, Tatiane Xavier, Felipe de Oliveira Rossone

Licença Creative Commons
Esta obra está licenciada sob uma licença Creative Commons Atribuição - Não comercial - Sem derivações 4.0 Internacional.