Personal dimension of the work process for nurses in intensive care units

Abstracts

OBJETIVO: Compreender os aspectos da dimensão pessoal do processo de trabalho para enfermeiras que atuam em Unidades de Terapia Intensiva (UTI) de um hospital universitário do interior do Estado de São Paulo. MÉTODOS: Estudo de abordagem qualitativa utilizando o método fenomenológico. Foram entrevistadas 12 enfermeiras que trabalhavam nas UTI de adulto, pediátrica e coronariana dessa instituição hospitalar e para análise dos relatos, utilizou-se o referencial da estrutura do fenômeno situado. RESULTADOS: A análise dos relatos permitiu identificar a categoria: dimensão pessoal do trabalho na UTI, com os temas - trabalho gratificante, trabalho desgastante e (des) valorização do trabalho. CONCLUSÃO: Os resultados do estudo revelam que as enfermeiras das UTI selecionadas identificam-se com o trabalho, porém vivenciam situações desmotivadoras decorrentes da elevada carga de trabalho, que dificulta o desenvolvimento do processo de trabalho e compromete a qualidade do cuidado.

Processos de enfermagem; Cuidados de enfermagem; Serviço hospitalar de enfermagem

ORIGINAL ARTICLE

Personal dimension of the work process for nurses in intensive care units*

Dimensión personal del proceso de trabajo para enfermeras de Unidades de Cuidados Intensivos

Elaine Machado de Oliveira^I; Wilza Carla Spiri^II

^IMaster in Nursing. Nurse at the Adult ICU, Hospital das Clinicas, Universidade Estadual Paulista "Júlio de Mesquita Filho" - UNESP - Botucatu (SP), Brazil

^IIPh.D. Professor at the Nursing Department, Faculdade de Medicina de Botucatu Universidade Estadual Paulista "Júlio de Mesquita Filho" - UNESP - Botucatu (SP), Brazil

Correspondence

ABSTRACT

OBJECTIVE: To understand the personal dimension of the work process for nurses working in intensive care units (ICU) of a university hospital in the state of São Paulo.

METHODS: A qualitative study using the phenomenological method. We interviewed 12 nurses working in adult, pediatric and coronary ICUs in this hospital; to analyze results, we used the phenomenonogical method.

RESULTS: The analysis of the results identified the category, personal dimension of ICU work, which included the themes, "rewarding work", "exhausting work", and, "lack of appreciation of the work".

CONCLUSION: The results of this study revealed that the ICU nurses interviewed identified with their work, but that they experience discouraging situations resulting from high workload, which hinders the development of the work process and compromises the quality of care.

Keywords: Nursing process; Nursing care; Nursing service, hospital.

RESUMEN

OBJETIVO: Comprender los aspectos de la dimensión personal del proceso de trabajo para enfermeras que actúan en Unidades de Cuidados Intensivos (UCI) de un hospital universitario del interior del Estado de Sao Paulo.

MÉTODOS: Se trata de un estudio con abordaje cualitativo en el que se usó el método fenomenológico. Se entrevistaron a 12 enfermeras que trabajaban en las UCI de adulto, pediátrica y coronaria de esa institución hospitalaria y para el análisis de los relatos, se consideró el referencial de la estructura del fenómeno situado.

RESULTADOS: El análisis de los relatos permitió identificar la categoría: dimensión personal del trabajo en la UCI, con los temas - trabajo gratificante, trabajo desgastante y (des) valorización del trabajo.

CONCLUSIÓN: Los resultados del estudio revelan que las enfermeras de las UCI seleccionadas se identifican con el trabajo, no obstante vivencian situaciones desmotivadoras como consecuencia de la elevada carga de trabajo, que dificulta el desarrollo del proceso de trabajo y compromete la calidad del cuidado.

Descriptores: Proceso de enfermería; Atención de enfermería; Servicio de enfermería en hospital.

INTRODUCTION

The construction of work as a process can be considered recent in the Nursing area⁽¹⁾.

The process is complete when it is carried out since objectivity and subjectivity are inherent to it and the object forming it is people. In this perspective, we may highlight the relevant aspects related to the professional individuality and to the needs of the situations and the users. In the work process, nursing interventions will always be based on interpersonal relations and the result of the work is the interaction of these aspects^(2-3).

Thus, some explanations about the work process in nursing become relevant.

A work process is the transformation of an object into a product through the intervention of human beings that use instruments to do so⁽⁴⁾.

To carry out the work process in nursing it is necessary to define its purpose, the object of the process, and the intervention instruments to generate the health products that have to adjust to the dynamics of the health needs.

To that end, agents use technologies to organize the health products⁽⁵⁾.

In the work process of nursing, although there are organized bases, the outcomes depend on interpersonal relations.

Usually, nurses identify with the work they carry out in the Intensive Care Unit (ICU); however, they live with intense anguish because of the complexity of intensive care, the need to know and handle equipment and to know how to perform these activities with initiative and confidence, as well as the visceral contact with patients and family members that produce different feelings in professionals⁽⁶⁾.

Nurses need to learn how to manage given the fragility of the bond established in the ICU, which is also a stress factor because of the possibility of experiencing a loss⁽⁷⁾.

All these factors contribute to characterize the complexity of the work process in the ICU and the relations that define it⁽⁸⁾.

The factors of tension that are part of the nursing work in ICU trigger the development and the use of strategies to facilitate the adjustment to the environment, and to provide emotional support^(7,9).

The nurses that work in the ICU mention frequently the difficulty to work with patients and relatives' anguish, and show that it is difficult to perceive the feeling that come from the care process⁽⁶⁾.

"[...] being a Nurse is not for everybody! You must have a lot of pluck and love [...]"⁽¹⁰⁾.

Intensive Care Unit requires self-reflection from professionals so they can understand themselves and they can listen to the others before acting, considering their concepts to understand them as part of the relationships and of care⁽¹¹⁾.

The understanding of the human essence and the role of the mind to the vital balance help control the anxiety of professionals and to extend care beyond the physiological needs of the body⁽¹²⁾.

The present study is justified because of the importance to explain the meaning of the personal dimension in the work process of ICU nurses.

Considering the complexity of the relations and the phenomena formed by the meaning nurses give to the work process in the ICU, the objective of the present study was to understand the aspects of the personal dimension of the work process to nurses that work in the ICU of a university hospital in the country side of the State of São Paulo.

METHODS

Human beings are the main object of the investigation of the present study; we have used qualitative research to study the subjectivity of the representations of the experiences of ICU nurses on their work⁽¹³⁾.

We have used phenomenology to carry out the study, which consists on searching for the essence and understanding the meaning of the experience of the study subjects, involving three moments: the description, the reduction, and the understanding of the speeches.

The description has three elements: perception, awareness and subject. At this time, the statements of the study subjects were collected to show their perceptions on the meaning produced by the awareness of the work carried out in the ICU, the setting of the present study⁽¹⁴⁾.

Reduction occurred based on the statements collected and transcribed through the reflection on the speeches and selection of the descriptions that were considered essential. Understanding reveals the essence of subjects. The interpretation of the subjects' statements rescues the units that are significant to show the essence of subjects.

This study was carried out in the adult, pediatric, and coronary ICU of a University Hospital in the country side of the State of São Paulo. The multi-professional team is formed by physicians, nurses, technicians and nursing assistants, a social worker, a psychologist and a physical therapist. The nursing team is formed by a coordinator for each unit and 14 nurse assistants.

The systematization of nursing care is carried out to all patients admitted in the three ICUs assessed in the study. The stages are: nursing history, physical exam, prescription and nursing evolvement.

The subjects of the study were 12 nurses that worked in the ICUs where the study was carried out. After the purpose of the study was explained, semi-structured interviews with the participants, after obtaining their written consent, were carried out.

The number of participants in the study was not previously established and theoretical saturation of the data occurred on the 12^th interview.

The interviews were guided by the following questions:

- What is the meaning of the work process to ICU nurses?

- What does it mean to you to be an ICU nurse?

The study outcomes were built in two different moments, according to the reference of the structure of the adopted phenomenon⁽¹⁵⁾.

The idiographic analysis carried out at the first moment is the individual analysis of each statement. The nomothetic analysis, carried out after the idiographic analysis, is the analysis of the general aspect of all interviews to structure the phenomenon.

The research project has been approved by the Research Ethics Committee at Faculdade de Medicina de Botucatu – UNESP (of. 211/08) on 06/02/2008.

RESULTS

Twelve nurses took part in the interviews, with ages ranging from 23 to 38 years old, time working in the institution ranged from 7 months to 21 years. The time working at ICU ranged from 7 months to 18 years, and four nurses worked in another unit previous to ICU.

To assess the statements, the category "the personal dimension of work at the ICU" was identified and the three themes that formed it are presented in the data of ^{Picture 1}.

The theme – Rewarding job –shows that the work in the ICU involves enjoying taking care of severe patients and the need to make an effort to provide care with safety. When the result of care leads to patients' recovery, professionals experience feelings of happiness and gratitude for their effort.

The nurses of the present study identified with the work in ICU because it enables professionals to develop the necessary perception and knowledge to plan care with quality and, thus, meet the needs of patients. However, knowledge must be shared and applied in behaviors that value the work of nurses in the health team.

"... and the meaning for me is rewarding... I have worked; I have always done my best... I do my best for the patients' well being..."(I-1,6)

"... we do our best, we have graduated for that, and we like what we do... I like what I do here; I like to work at the ICU..." (V-16)

"... for me, it is very rewarding to be a nurse at the ICU..." (VI-10)

The next theme – Nerve-wracking environment –reveals that the work in the ICU is exhausting and stressful. An Intensive Care Unit is a critical place to work because of the complexity of patients' diseases, and the visceral relationship that professionals develop with patients and family members, experiencing their sufferings and answering their questions regarding recovery.

In the institution where the study was carried out, we could observe a huge amount of professionals that quit work, searching for better conditions of life, leading to other problems such as hiring temporary employees and excessive increase in the shifts of those working in the unit to remedy the lack of human resources.

The health team should follow-up and treat stress when it occurs otherwise it can bring negative results to the care provided.

"... the work is hard, it is very nerve-wracking..." (II-4)

"... professionals that are satisfied with the work place have a higher commitment with the institution...we don't see that here, because of the high number of nurses that get in and out of the unit... the number of professionals that leave is very high... it is necessary to hire more professionals, many times there is not enough time to train professionals, you put them to work in the unit with a continuous work schedule, there are also the relationship problems..." (III-2)

"... we work in an unhealthy environment, with these dreadful hours..." (IV-9)

"... the ICU is a stressful place, we work with noise, in a closed place, it is a place where there is a lot of pressure, the severity of patients and the health care are complex..." (V-14)

The last theme - (De) Preciation –shows that nurses in the present study feel depreciation and lack of encouragement from the coordinator. Thus, nurses wait for the positioning of the nursing management to organize their work and see the difficulties of the service as negligence of the nursing management. For that reason they feel depreciated and discouraged to carry out their work.

"... We work because we need the money, and because we like our profession, but that doesn't mean we like to work on a unit where we have no recognition..." (IV-12)

"... I have been in this sector for 5 years, and I have never been complemented... the bosses have never thanked us, or collaborated with us, understood us, nothing... we have been criticized a lot here... there is a lot of pressure; everything that happens is the nurses' fault... I realized a feeling of indifference towards me...I have never been valued..." (I-5)

The statements show that nurses from this ICU do not feel encouraged to work because of the lack of financial and professional recognition, high work load, shifts that are difficult to meet, especially the night shifts that make it difficult to organize the time to take part in courses and meetings.

"... wage, we cannot even think about it, the institution will never be able to solve it, but I believe that if the shift was better..." (IV-13)

"... if the hospital offered courses in the area of ICU to professionals, it would be an encouragement, we would be more encouraged to work... as for the wage, I am not happy with it because the minimum wage is lower compared to other hospitals and that makes many people quit and leads to conflicts: covering up for shifts... need for new training to the new staff..." (V-18)

"... for encouragement I think that the main thing is the work shift, to pay more attention to training, these small classes just make you tired, instead of teaching something... it should be richer, rather than just a discussion.. sometimes, you come here for this discussion and it has been cancelled and nobody tells you..."(IV-12)

DISCUSSION

The development of the present study helped to understand the dimension of the work process to ICU nurses.

ICU has work characteristics that can be seen as stressful because there are many work hours and long shifts that are frequently changing and affect the biological rhythm of the professionals.

The excessive work load and lack of organization and competence to perform the work are factors that lead to stress and dissatisfaction in the workplace^(16-17).

Excessive workload was observed as the most commonly mentioned stress factor by the study individuals. Lack of nursing professionals increase the work load because it decreases the amount of people. In this sense, there is also decrease in work satisfaction because stressful factors increase⁽¹⁸⁾.

The literature shows that nurses are the professionals who suffer most from diseases and are more prone to the effects of stress than other workers. Untreated chronic stress, suffered over the years, has consequences in professionals' health such as digestive symptoms, hypertension, head ache, insomnia and anxiety⁽¹⁶⁾.

Another stressful factor, closeness to death and the possibility of recovering or not from the disease makes professionals develop strategies to cope with a stressful situation, to understand that even by using all possible resources, recovery may not occur. The times of pleasure among the family should be appreciated and encouraged to strengthen individuals and to prevent them from getting sick.

Other studies are in agreement with this^(18-20) and suggest that in Intensive Care Units the stressful factors are more evident because professionals are very close to more severe diseases and to the patients' death. Because of that, nurses working at ICU tend to be less satisfied with work.

The consequences of the anxiety generated by stress at work can lead to increase in mistakes in nursing procedures and decrease in the quality of care and safety to patients due to lack of attention⁽¹⁶⁾.

ICU professionals need psychological support to help cope and solve their problems.

Nurse managers have the challenge of applying strategies to promote decrease in the stress of the team by making individual and organizational interventions through training, capacity building for work to develop the potential of nurse teams so they can have the skills and autonomy to perform their work. They should also consider the personal needs of the team, enabling professionals to conciliate their personal life with work⁽¹⁶⁾.

Professional satisfaction can be defined as the activities professionals enjoy performing. The concept includes a cognitive component, the perception that work fulfills the personal needs, and an affective component, the feelings and attitudes in this context^(19,21).

A study carried out in Belgium shows that the professional development is closely connected to work satisfaction and decrease in the turnover of nurses in the institution⁽²¹⁾.

A study⁽²²⁾ shows that work satisfaction in ICU nurses decrease with the years, especially when the experience does not interfere with the hierarchical position and in the plans of the institution regarding the professional. These professionals are usually dissatisfied with: the wage, the work conditions, the lack of encouragement from the manager for professional development, the status and with capacity building.

Professional satisfaction is an important component in the life of nurses and may have an impact in the following: patients' evolvement, teams' morale and productivity, quality of care, turnover, and commitment with the institution⁽²²⁾.

The wage is the main concern of nurses, followed by autonomy, flexibility and organization, development in the work and capacity building⁽²²⁾.

However, the wage is not only a governability issue and managers should establish strategies to develop the potentialities of professionals and insert nurses in the decision making process to develop the skills to cope and solve problems to increase professional motivation. Work satisfaction is the main predictor of nurse retention in the institution⁽²¹⁾.

The identification of nurses with the work process in ICU occurs when there is new knowledge being acquired, professional development, fast thinking to care for emergencies and to solve problems. Additionally, this work requires professionals to use their technical-scientific knowledge.

With this knowledge, decisions can be made with competence and ethics and the rights of patients and their families are ensured, it also prepares nurses to any professional activity.

This is in agreement with a study from two authors ⁽¹¹⁾, who observed that the nursing work process in ICU, in addition to providing the opportunity for constant learning because of the different situations faced, requires thinking and acting promptly in emergency situations, because it is developed to provide intensive care to severe patients who need continuous control of the personal and clinical aspects in life-threatening situations.

According to the professional profile required and developed by ICU nurses, care for emergencies, lack of routine and the design of a specific work to assist severe patients are factors that encourage the work. ICU nurses have more autonomy and involvement in decision making in the work process.

Autonomy is an important professional satisfaction factor; the ICU nurses studied reported they are more satisfied with their work regarding these aspects.

CONCLUSION

The study allowed understanding two personal aspects regarding the work process of ICU nurses where the study took place.

The work has stressful factors connected to the visceral contact with severe patients that face the most severe part of their lives and also the suffering of family members.

There are other stressful factors connected with the work process. In this ICU the high job load was a characteristic, leading to professional turnover and shortage of human resources, affecting the quality of care, and the safety of patients.

The nurses who were the subjects of the present study, however, identified themselves with the work because when they develop the knowledge and the skills to perform the necessary interventions to provide health care, they have autonomy and are recognized by the team because of their professionalism and so they are satisfied.

The literature presents many studies on the personal aspects of ICU nurses. However, new studies should be carried out and published, considering these aspects connected to the workload, patients' safety and quality of life at work. The present study raised the need for developing effective coping of the stressful factors to prevent professionals from getting sick.

The institution should give better work conditions and favor satisfaction and encouragement factors for the work of ICU nurses where the study took place so that these professionals remain in the institution because they feel encouraged and identify themselves with the work.

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*

Trabalho extraído da dissertação de Mestrado intitulada "O significado para o enfermeiro do processo de trabalho nas UTIs de um hospital universitário da Faculdade de Medicina de Botucatu - UNESP, Botucatu (SP, Brasil.

Publication Dates

• Publication in this collection
  23 Sept 2011
• Date of issue
  2011

History

• Received
  14 Sept 2010
• Accepted
  22 Jan 2011