Risks of illness in the work of the nursing team in a psychiatric hospital 1

ABSTRACT Objective: To analyze the risks of illnesses related to the work context of nursing workers in a psychiatric hospital. Method: Cross-sectional and quantitative study, developed in a psychiatric hospital with 74 nursing workers. The Work Context Assessment Scale was used to measure the risks of illness at work. Descriptive analyzes were performed with mean and standard deviation. To test the reliability of the data, the Cronbach’s alpha test was used. The correlation between the factors of the work context was tested using the Spearman correlation coefficient. Results: The organization of work was considered serious, social-professional relationships were considered satisfactory and working conditions were considered severe for risks of illness at work. The repetitiveness of tasks, work conditions that pose risks to safety, inadequate furniture and physical structure of the workplace, and the existence of noise in the work environment were indicated as severe risks to workers’ health. Conclusion: The factor working conditions is the one that contributes the most to illness among nursing workers.


Method
This is a cross-sectional and quantitative study, conducted in a psychiatric hospital, that is, a reference center for the care of patients with mental disorders,  (11) . The EACT is a Likert-type scale composed of 31 questions divided into three factors: organization of work (11 questions), social-professional relationships (10 questions) and working conditions (10 questions).
Its interpretation is based on questions (items) and factors (11) , and the reliability of the factors is evaluated by estimating the internal consistency using Cronbach's Alpha Coefficient (α).
The data collected were analyzed in the software Statistical Package for Social Sciences (SPSS) version 21.0, with descriptive analysis of each item and later of each factor, considering arithmetic means and standard deviations (SD). The correlation between EACT factors was analyzed using the Spearman correlation coefficient.
The classification of the risk of illness considered the values established by the authors of the instrument: means above 3.70 -more negative evaluation, severe risk of illness; between 3.69 and 2.30 -moderate evaluation, serious risk of illness; below 2.29satisfactory evaluation, with an environment that can favor worker's health (11) .     In the context of nursing work in the psychiatric hospital, the items referring to the repetitiveness of tasks, the working conditions that pose risks to the workers' safety, the furniture and physical structure of the inadequate workplace and the existence of noise in the work environment were those who were considered as a severe risk of illness for the worker. Table 3 presents the correlation matrix between the factors organization of work, social-professional relationships and working conditions.

Discussion
The EACT is composed of three interdependent factors: organization of work, social-professional relationship and working conditions (11) . The discussion of each of the factors will be presented sequentially, considering the risk of illness for the nursing worker of the psychiatric hospital.
The organization of work in the psychiatric institution studied presented a serious risk for the nursing worker's illness. This result was similar to that found in a study in a hemodialysis service (6) with health care workers in basic care (9) , which was still considered positive compared with the severe evaluation reported by intensive care nurses (4) .
This result is a warning signal, an indicator of a threshold situation, which may increase work suffering and require immediate attitudes for its confrontation.
Among the 11 items related to the organization of work, the one that obtained the highest mean, indicating severe risk of illness, was "the tasks are repetitive," which was also observed in other studies with nursing workers (6,13) and with healthcare workers (9,14) . High task repetition, evaluated as a severe risk of illness in the organization of the nursing work in the psychiatric institution, deserves to be highlighted, since it is pointed out in studies as a trigger for musculoskeletal injuries, fatigue, monotony, anger and tiredness (6,(15)(16) .
Research in a psychiatric hospital showed that, among ergonomic risks at workplace, the monotony/ repetitiveness of work is one of the factors most reported by workers (17) . This situation may be related to the experience that nursing workers have in the mental health field of nursing, which consists of repetitive and mechanical movements and is full of rules, routines, norms and based on performing tasks without feelings (18) .
Among the eleven items in the work organization factor, five were considered serious risks for worker's A study with nursing workers in an emergency service in the city of Natal found that the first condition reported by the workers as unsatisfactory was the fragmentation of work, which involves the division of labor, division of tasks, elements of control and exploitation of the structure of capital (19) .
In nursing, the fragmentation of work is intensified when the professional graduation itself determines the division of tasks and the level of control over work. While nurses are responsible for intellectual work, management, supervision, and control of the whole care process, workers without a college degree are responsible for manual labor, with the function of executing tasks delegated (20) .
As mentioned, the insufficient quantity of human resources was considered a serious risk of illness for the nursing worker. A study pointed out deficiency of professionals as one of the obstacles to the consolidation of a mental health policy in the context of psychiatric hospitals, along with other issues related to political and institutional management (21) . Staff-sizing is a responsibility of the nurse; however, this debate is still incipient in the context of mental health, while in other areas it is already advanced (22) .
The need for patient care is at the core of this  (22) , updated the parameters for nursing staff sizing and included concepts and calculation methodologies for nursing staffing for mental health services (23) .
The item "the results expected are disconnected from reality" discussed in this study was considered as serious risk of illness. Studies point out that issues inherent to psychiatry are sources of frustration and suffering for the worker, causing dissatisfaction and dismay about the work performed, since few changes can be made and visualized by these professionals (24)(25) .
This frustration is evident when the patient is only pathologized and monitored and also when the revolving door phenomenon is constant, which is characterized by frequent readmissions, which indicate failure in the continuity of treatment by the user and by the management of the Psychosocial Care Network (RAPS) (21) .
"Norms for performing tasks are rigid", "the pace of work is too fast", "the tasks are discontinued" and "there is no time to take breaks and rests at work." were considered satisfactory items that can favor the health of the worker. This situation is difficult to understand, because these are items that are related to a rigid model of administration that makes the worker exhausted.
However, in this study, these items did not represent conditions unfavorable to the health of the worker.
It is evident that the organization of work can have a significant role in worker illness among nurses in mental health. In addition, despite the classifications of serious risk of illness, this study presented positive items when compared to the intensive care sector (4) and basic health care (9) , which did not demonstrate any item with satisfactory evaluation in this factor.
In the present study, social-professional relationships were evaluated as satisfactory for risk of illness among nursing workers in mental health.
Similar results were found with nursing workers in a hemodialysis service (6) and nursing workers of a mobile emergency service (26) . This satisfactory evaluation diverges from the results of studies conducted with intensive care workers in Rio de Janeiro (4) and Rio Grande do Norte (13) , and primary health care nurses in Minas Gerais (27) , for whom the social-professional relationships were evaluated as serious risks of illness. In this same direction, a study with workers from primary health care teams in the Federal District evaluated socialprofessional relationships as severe risk of illness (14) .
In the social-professional relationships factor, none institutions (4,6,9,(13)(14)32) . In private care institutions for critically ill and hemodialysis patients, the evaluation was satisfactory, while in public institutions of basic and intensive care the evaluation was serious/moderate.
These data indicate the public institutions face difficulties to provide adequate environment and material.
The items "working conditions pose risks to the safety of people", "the furniture in the workplace is inadequate", "there is a lot of noise in the work environment" and "the work place is not suitable for the tasks" presented the highest averages, representing severe risk for worker's illness.
Similar results were found regarding the risks to the safety of people, inadequate furniture and excessive noise in a study with nursing professionals of an intensive care unit in Natal, Rio Grande do Norte (13) , and a study in a hemodialysis service in Santa Maria, Rio Grande do Sul (6) .
A study conducted in two hospitals located in Egypt considered the physical and psychosocial workload of the nursing team as stressors and possible causes of illness, absenteeism, work shifts and worse physical and psychological health (33) .  (19,32) .
In a work context where work conditions are inadequate, nursing professionals are exposed to occupational hazards both for themselves and for patients. In addition, precarious conditions lead to work overload, to a feeling of waste of the vocation of the service, and to underutilization of technical preparation (36) .
It is important to consider the item "there is a lot of noise in the work environment". Studies in an intensive care unit (4) and in a hemodialysis service (6) showed high means in the noise item. These results are consistent and acceptable in sectors characterized by closed environments with unfavorable local acoustics, air conditioning and alarm sounds essential for safe patient care, since they facilitate the quick identification of abnormal situations.
It should be noted, however, that even in the absence of conditions such as those previously mentioned, psychiatric services have their particularity: the type of patient. It is known that the patient