NURSING HOSPITAL WORKERS FACING FUNCTIONAL READAPTATION BY ILLNESS: DIFFICULTIES EXPERIENCED AND ACTIONS UNDERTAKEN

Objectives: to know the difficulties experienced and the actions undertaken by hospital nursing workers in the process of functional readaptation by illness. Method: this is a qualitative, descriptive and exploratory study, conducted in a teaching hospital in Rio Grande do Sul, Brazil, with 16 workers, through semi-structured individual interviews. Data were collected from September to November 2018, analyzed according to thematic content analysis and the Socio-Humanist Theory theoretical framework. Results: at the personal level, the difficulties focused on the


INTRODUCTION
The work environment has caused physical and mental consequences on workers' health.The numerous changes raised by innovations in technology and financial globalization directly affect their well-being, the way they work and organize themselves collectively 1 .
In health care settings, workers' health has been a cause for concern due to workers' exhaustion, reflecting numerous conditions such as lack of personnel resources, night work, long working hours, as well as exposure to exhaustive workloads 2 .In addition, mainly for nursing, work activities expose workers to health damage, which may be due to the organization and work process, interpersonal relationship difficulties and inadequate body postures for performing procedures and transporting patients 3 .
Vulnerability to illness in nursing workers resulting from their activity is identified.Working conditions are associated with occupational technical-scientific provisions, which corroborate the mental, physical and social instability of workers, and may trigger pathologies in nursing 4 .
Professionals' illness can cause limitations in their work, generating medical leave that, temporary or permanent, preserve him/her from occupational risks due to the impossibility of performing the tasks conferred on them 5 .These limitations may make functional readaptations necessary 6 .According to Article 24 of Law 8,112 of 1990, functional readaptation constitutes "the endowment of the servant in charge of attributions and responsibilities compatible with the limitation he has suffered in his physical or mental work capacity, verified by expert assessment" 7:13 .
The readapted workers are in a different condition when compared to other professionals in the same field of activity, in view of not being able to develop their attributions in a complete way.It is believed that workers' self-care cannot be overcome in the face of the relationship with triggering elements of their functional limitations 2 .
There is a small number of productions about the functional readaptation of health workers, and these quantitative studies [5][6][8][9] , and, to a lesser extent, qualitative studies 10 that give voice to the nursing worker who experiences this process. In his sense, it is essential to investigate, among other issues, the difficulties experienced and the actions undertaken by them.
Reflecting the particularity of nursing workers in the condition of functional readaptation due to illness, this study is anchored in the Socio-Humanist Theory theoretical framework 11 , proposed by nurses, Brazilian theoreticians who contribute to qualify the "ways of doing" nursing as a sociohumanist practice.
Thus, it was listed as a research question: What are the difficulties experienced and the actions undertaken by nursing hospital workers in the process of functional readaptation by illness?And, as objectives: to know the difficulties experienced and the actions undertaken by nursing hospital workers in the process of functional readaptation by illness.

METHOD
This is a qualitative, descriptive and exploratory study, part of a master's dissertation entitled "Percepção de trabalhadores de enfermagem frente ao processo de readaptação funcional por adoecimento".It was carried out in a teaching hospital, which has 403 beds for admission and provides care exclusively through the Unified Health System, with workers hired via the Brazilian Hospital Services Company and Single Legal Regime.
The identification of possible study participants was done through the indication of the coordinators of their respective sectors/units.According to a survey, 51 nursing workers were in the process of functional rehabilitation due to illness in 2018.Sixteen workers in the process of functional readaptation due to illness from 14 different units/sectors participated in the study.Nursing workers in 4/14 functional readaptation due to illness, governed by the Single Legal Regime, in the exercise of their work activities during the period of data collection were included.The choice of workers governed by the Single Legal Regime was due to the fact that it mandatorily provides for the functional readaptation of workers.
For the selection of participants, we chose to perform a simple random draw in the units/ sectors according to the inclusion criteria.There were four refusals to participate in the study due to participating in many researches at the institution or not enjoying participating in research.
For data production, an individual semi-structured interview was chosen, in which the first topics of the script included data on nursing worker characterization in the process of functional readaptation due to illness.In the sequence, there were topics for the realization of open-ended questions, referring to the difficulties and actions taken of them.Data productio from the study took place from September 13, 2018 to November 12, 2018.
A pilot test was carried out in order to verify the clarity and understanding of the proposed script for the individual semi-structured interview, with the first participant interviewed.There was no need for adjustments; therefore, the pilot test was included in the study.The interviews were carried out at the workplace at participants' request.With prior authorization of participants, an audio recorder was used to facilitate the subsequent data transcription.The interviews lasted, on average, 50 minutes.Data collection closure occurred through data saturation, involving its quantity and depth, with respect to several dimensions of a determined phenomenon 12 .
The data were described in a file in the Microsoft Word program, version 2010 and analyzed based on thematic content analysis, observing pre-analysis, material exploration and treatment of results, inference and interpretation phases 13 .In this perspective, the first contact with the documents was made, with text skimming.After, performing readings and repeating them, the themes that were repeated in the collected data were chosen.Finally, from the selected themes, the data was decomposed, organized and coded.The categories were organized, and the discussion and interpretation were carried out.
Data were analyzed from the Socio-Humanist Theory theoretical framework, through its content, assumptions and concepts.The conception of this Theory occurred due to the authors' need to reflect the way nursing work is carried out, as well as to suggest other possibilities for its development.It has, as essence, the valuation of subjects, with emphasis on the perspective of a global, whole being, in what it has in its sociability and subjectivity, reporting both to the "working subjects" and to the "subjects with health disabilities" 11 .
In order to guarantee participants' confidentiality, the researcher chose to identify them by the letter W for "Worker", followed by an Arabic number (W1, W2, W3...), randomly.Participants were given the Informed Consent Form in two copies, remaining one with workers and the other with the responsible researcher.
The research project was approved by the Research Ethics Committee.The ethical precepts set forth in Resolution 466/2012 of the Brazilian National Health Council (Conselho Nacional de Saúde), which establishes the Regulatory Guidelines and Norms for Research, involving Human Beings, were faithfully followed.

RESULTS
Fifteen women and one man participated in this study, aged between 33 and 62 years old, with participants aged between 41 and 49 years, with 15 workers having completed higher education, one participant had an undergraduate course in progress and another participant had a second undergraduate course in progress.Nine participants had completed a postgraduate course.As for the position/function exercised in the institution, four workers worked as nurses and 12 workers worked 5/14 as nursing technicians.The length of experience at the institution ranged from six to 23 and a half years, with a predominance of 11 years.No participant had another employment relationship.Prior to the readaptation process, no worker had any restrictions on the performance of his duties in the work environment.
Regarding the search for services prior to the readaptation process, most workers reported having sought medical professionals, inside and/or outside the institution, for reasons related to the diagnoses that caused their readaptation.
Among the 16 study participants, 13 worked in more than one unit/sector for functional readjustment due to illness.It was possible to verify, through the content brought in the interviews, that some workers, with the opening of the process of functional readaptation, initially remained in the same unit/sector of activity with restrictions on the work activities performed.The justifications for these behaviors involved the institutional need such as lack of human resources to replace them or at workers' option, in the sense of making an attempt to remain in their work environment.
According to participants' reports, there was no opening for more than one functional readaptation process.The diagnosis that determined the need for readaptation, for most workers, was of a physical order, mainly due to musculoskeletal problems, followed by psychic order, mainly by depression.
The restrictions at work were mostly related to weight lifting, body positioning, moderate to intense physical effort, performance in highly complex sectors, direct patient care.Four workers reported the presence of comorbidities, such as diabetes, hypertension, celiac disease and kidney problems.The request for the opening of the functional readaptation process was made based on the medical report or determination sent, sometimes by the boss, sometimes by workers.
The period of leave prior to returning to work in the readaptation process ranged from one month to two years and six months and three workers reported not having been away from work.The choice of the new sector of activity was carried out through the Nursing Department and the institution's psychology professional, sometimes with workers and the head of the unit/sector.
Analysis of the collected material allowed the construction of the following categories: difficulties of personal scope; Difficulties of organizational scope; Difficulties of interpersonal relationships scope; Actions undertaken by hospital nursing workers for functional readaptation due to illness.

Difficulties of personal scope
In the process of functional readaptation due to illness, difficulties in the personal sphere were reported by nursing workers.The lack of knowledge about the existence of the functional readaptation process was evidenced: [...] I returned [from retirement] and my co-workers commented that there was a green folder of restrictions that I had to send.

[…] But it was due to guidance from co-workers that I went to do it, otherwise I wouldn't have done it, I didn't know it existed (W16).
Faced with the need to change the sector in which they work, workers reported difficulties related to adapting to different work activities, standards and routines: […] it is that in the [unit] I worked only with people, here I have to work with machines […] with other things that I was no longer used to working with.So, it caused me a certain anxiety, it seemed that everything was new, although it was not, although at some point, of all the years that I work in the hospital, I had already seen (W12).
Still regarding the change of sector of activity, especially the lack of negotiation or consultation with nursing workers in this process, it was perceived as negative: [...] it was not my choice.Another difficulty related to adapting to the new sector of activity was evidenced when workers were transferred from a sector of direct patient care to a sector of indirect assistance, impacting their 6/14 identity as a professional: […] disconnect from patient care.How many years I worked with it […].Nurse in my head, he was the one who took care of a patient, if he didn't take care of a patient, he was not a nurse.I cost to put in my head that working here is also being a nurse.[…] when I came here it was material, material, and I couldn't feel like a nurse.I took a while to see it like that, I'm also a nurse here, I'm important, I have my role (W7).
The restrictions resulting from the illness had an impact on workers' personal lives and on their relationship with the work environment.The change in monthly income had repercussions in their financial context, leading to an early return to work, which can also aggravate the established damages: [...] the cost that I was having with my rehabilitation in terms of physiotherapy, medications and consultations weighed heavily, so I asked my [doctors]  Sometimes, living with limitations led to feelings of guilt and worthlessness, because in the face of their restrictions in the work environment, workers felt overwhelming their co-workers in professional activities, as well as being uncomfortable in asking for help to carry them out: [...] you overload the team a little, because you can't help 100% in that activity.Flipping patients over, it had to be all very carefully so as not to make my situation worse.[…] and all the time asking for help, "how do I do that?There came a time when I was so distressed that I was left blank because of that situation.And you say, "I will not ask again".But, I asked, I'll ask again because I don't know how to do it.Not that anyone caused me this, I felt bad about asking for help all the time (W10).

Difficulties of organizational scope
Difficulties were listed that have consequences for workers and for the institution, such as the shortage of staff reported in the face of the need to change the sector in which workers work: […] I received this physical restriction and my boss really wanted [that workers remain in the sector] because she was short of staff.For her, losing myself at that moment would not be good.[…] I have to respond to an entire administrative process if I don't comply with the doctor's orders and my doctor says that I am sick.They [referring to management] have to take this straight (W1).
In addition, the reallocation of workers in another sector of activity may be delayed, due to the need for training of new human resources in the sector of activity: [...] I knew that the sector [...] needed people [...] so, I applied.[…] But people didn't want to give me up because I had to train all the new people who arrived.[…] In the case between the patient and workers, the manager is on the patient's side.So, between you leaving the unit because you are sick and someone is missing to attend to the patient, you will be working sick.And they [management] are right, because they are first [patients] (W11).
Another difficulty mentioned was the work overload by workers, as well as the performance of activities that do not belong to them, due to the lack of personnel in the sector in which they operate: [...] we work, it is overloaded, I am alone in the afternoon, there is no other co-worker to help me, so everything is me.If you need something, I have to take someone from the sector to come here to 7/14 help me, and sometimes there is only one nurse.There is no way to handle it and it overloads.At the end of the day, I can't stand the pain, so I take pain medication.It is well sacrificed and, according to the direction, there is no expectation of anyone coming here (W8).
Infrastructure issues in the work environment were also raised as a difficulty: a difficulty [in the unit], for instance, is the physical issue.We don't have an adequate attitude; we don't have an adequate space.But, as I go through it, my co-worker also passes by and we adapt accordingly (W16).
Institutional charges also have a negative impact on readaptation: [...] it was very difficult to accept both myself and the institution itself.Because what they told me was that I was new, that I still had to produce.So much so that they put me there [in the unit], because as I was a nursing technician, I was new and I had just entered the [hospital], so I had to return to the institution and I couldn't do it, and that part was the one that left me most depressed at the time.Because I was in pain, I was limited and I was being asked to give what I couldn't get (W6).
With regard to monitoring and institutional monitoring of the process, workers are unaware of the existence, either by the management of the institution, or by the immediate head: […] simply, they asked what you are feeling, but there is no monitoring.Even though I was away for almost two years, no one ever came to my house to find out if I was okay, if I died, if I didn't (W8).
Also, the follow-up of immediate manager reported refers to the process of functional readaptation of workers in the sector and not to their health, properly speaking: The follow-up, only when we arrive in the new sector by the head of nursing.She is the one who is directly supporting us, if we are feeling well, if we are adapting on the spot (W6).
Another point brought up is the ignorance of the existence of care for workers within the institution: […] I had chronic headaches at the time of work and care was denied.[.

Difficulties of interpersonal relationships scope
Some difficulties encountered by workers are also permeated by interpersonal relationships, such as the fact of not feeling well received in the new sector of activity: [...] I was very badly received.

It was horrible, so she [doctor] took me out of [direct care for] patients, because I started to sink again. I left during the nine months, I spent 30 days [working] and started to sink, because I was badly received by fellow nurses (W7).
In addition, the competitive work environment has been reported as a difficulty in the process.Sometimes, the sector of activity was adequate with regard to physical restrictions resulting from illness, however, inadequate when considering emotional issues: [...] I went to a sector where there was a very big competition between nurses, and I did not I was able to be part of these competitions, so I suffered.[...] I asked to leave this sector, I don't say that the sector was not good, but for me it was difficult [...] it closed everything with my limitations that were put, but there was the emotional issue (W16).
In the process of functional readaptation due to illness, the work team also needs to adapt to nursing workers in this condition: [.

..] the others [work team] also have to adapt to me, because I also have an experience, I also have different knowledge (W14).
In this sense, the team's lack of acceptance was listed, taking into account the constant use of medications by workers, as a difficulty in the process.Still, the use of medication and/or psychiatric treatment can be reasons for the establishment of labels by co-workers: [...] they didn't want me there because I took too much medication, then you're coming back from a treatment, you need the medication to keep you up and you may not be accepted in a certain place because of medication [...] 8/14 you know how heavy that is for a person who is returning to take a liking to life? […] then you think "where are they going to accept me?" (W1).
The high number of certificates was also brought by workers as a complicating factor:

[…] I feel pain, and I can't keep myself going, going, entering with a certificate, you know how it works, you are not very well liked. So, what you end up doing is working with pain, but doing things (W8).
Workers highlighted the lack of understanding, dialogue and empathy as factors that negatively influence the process: […] maybe if I had come [back to work] stronger, that I could impose myself, defend myself, it would be better, but I came very fragile, physically and, mainly, emotionally [...] unfortunately, I think that other workers still can't do it put yourself in the place of the other, the coworker.Often, we are concerned with listening to patients' histories, which is one of our functions, but we still need professionals to put ourselves on the shoes of other professional co-workers, to understand the limitations (W16).

Actions undertaken by hospital nursing workers for functional readaptation due to illness
Nursing workers undertook actions for functional rehabilitation due to illness, such as seeking help from health professionals, co-workers, complementary therapies as well as spiritual actions: [...] I was accompanied by a psychiatrist and psychologist, direct therapy, therapy saved me, therapy made me a different person […] so, my strategy was therapy and getting attached to the people [...] who were willing to help me help, to show me the way of how to do it, of what the work routine was like (W1).[…] very careful, a lot of therapy, I even do reiki.This is also for us to get to know ourselves, start taking care of myself, I do pilates (W10).What helped me a lot was spiritual strengthening.I started to participate in a spiritist center.There I energized myself, and that strengthened me.It helped me (W6).
Furthermore, they identify as an action undertaken the search for self-acceptance of a situation experienced and the construction of new bonds with other people: [...] work, because not everything is how we want it.Not all things in life are going to happen as we would like (W6).[…] trying to make connections with people who are not from my place of work, I strengthened this (W16).

DISCUSSION
The lack of knowledge about the functional readaptation process due to illness corroborates what was observed in the initial survey of possible participants in this study, in which some coordinators of the units/sectors had difficulty in identifying workers in this condition, or even made mistakes in their indications.Thus, it appears that the functional readaptation as a whole in the institution is still little discussed and reflected among workers and managers, although this knowledge is present in some.
Reflection on the health/disease process creates complexity, surpassing technical, biological, emotional, cultural, theological, philosophical, ideological, economic and political content.The denial of one element to the detriment of another or the overvaluation of one aspect to the detriment of another, at the very least, weakens and diminishes any more solid possibility to understand and explain such a complex topic 11 .
A survey of hospital workers emphasized that quality of life at work is characterized by favorable working conditions, sufficient staff and material resources, adequate furniture and ventilation, quality materials, harmony in the environment, appreciation and listening by the board and coordinators, and good relationship with co-workers, respect, recognition, taste for what you do, a decent salary, fair workload, job security, development opportunities and incentives for qualification 14 .
A study carried out with nurses showed, among potent predictors of quality of work life, the monthly income, the environment and the unit of action.Among other results, the majority of participants reported heavy workload and lack of satisfactory supervision and support feedback by the supervisor/ 9/14 nurse managers, failure to receive adequate opportunities for career advancement and income not corresponding to the nature of the activities performed 15 .
Another investigation about quality of life identified that even after the readjustment and functional readaptation, no change in health status was reported by workers.Physical performance was shown to be impaired and may have been achieved as a result of body pain, which influenced the exercise of work activities, which were developed to a limited extent 6 .In this study, the functional readaptation process also had an impact on the financial context of workers, demanding an early return to work, which may have consequences in view of their limitations.
Labor is constituted as the objectification of the human being and it is through work that workers produce their existence.With the meaning of freedom, this same work, excluding the possibility of workers to place themselves full and whole in what should consist of the act of their fullness and creation, becomes strangeness and loss of self 11 .The feeling of displacement in the face of sector change and impact on workers' professional identity, feelings of worthlessness and guilt in the face of limitations and the difficulty in accepting health and life conditions were difficulties presented by participants.
A survey conducted with workers in functional readaptation showed feelings of estrangement and devaluation considering the adjustments required in work activities.The consequences imposed by the process in the exercise of the professional role generate insecurity, loss of identity and a feeling of worthlessness, which leads to negative feelings about their value in the family and in society, leading to self-collection, resistance to acceptance and denial of the illness process 10 , corroborating this study.
As for the lack of participation of workers in important decisions in the process of functional readaptation, a study shows that the conducts that take place in an imposing way have a negative impact for workers in this condition 10 .At the same time, they impact on the management and organization of work, considering that in the units, the nurse needs to manage the care including these workers, so that the restrictions presented by them are preserved 16 .
Participants reported difficulties in relation to adapting to norms and routines.A research carried out highlights some elements that make it difficult to adapt to the new work environment, such as the exercise of a certain function without identifying with it, relocation in a sector without communication with other workers, the fear of returning to work after a long time away from work, establishment of bonds with new co-workers and acceptance of the limitations imposed by the pathology or the accident at work 17 .
As emerged in the results, the change in the sector of activity also has an impact on the organization, in relation to the change in the existing staff.Human resources are essential for the provision of health care.However, when insufficient or limited, they cause conflicts in the management process and are not always allocated equitably 18 .
Participants reported the need for training new staff as a difficulty in the readaptation process.Workers show the influence of a present historical context, where patient care overcomes workers' self-care 10 .In health services, the needs presented by the subject with a lack of health, under any condition, need to precede those of the other actors in a health institution.The service provided must respect respect for their beliefs, their right to privacy and the creation of routines and rules aimed at their integrality 11 .
Another issue that emerged from data analysis, refers to work overload due to staff shortages and inadequate postures due to the infrastructure presented.An investigation carried out identified that nurses with high workload and low support received by the supervisor have a stronger relationship between depressive state and emotional exhaustion 19 .When working with overload of work activities, quality is replaced by quantity, which contributes to the emergence of conditions such as mental stress and workers' stress, contributing to the appearance of health problems 20 .

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For the full exercise of nursing, it is necessary to have available adequate means, a skilled workforce and also, qualified support services 11 .A survey conducted in Australia, with the aim of identifying practices and processes used in the return to work for injured nurses, demonstrated by the majority of participants, support by employers in this process, involvement in return to work planning and good communication between employers and nurses about the demands in the workplace 21 .The readaptation process needs to involve the training of workers for the new assignments conferred and multidisciplinary support, considering helping them in this adaptation 22 .
Institutional charges and the lack of monitoring and follow-up on the part of the institution, the follow-up carried out by the immediate supervisor and the lack of care in the institution were perceived as negative by the participants.An investigation carried out with nurses who received workers undergoing functional readaptation at their units showed that the work organization process needs to be rethought, so that it can stimulate appreciation, respect and sensitivity towards professionals who return to work, considering limits and potentials 16 .About this, it is mentioned that in addition to physical access conditions, it is urgent to rethink humanization in the work context for workers 10 .
The functional readaptation process requires adaptation of the work team.Even being part of the nursing team, nursing workers in rehabilitation feel isolated.When changing the sector in which it operates, it is not always qualified for the performance of activities and, sometimes, it is not well received.The new assignments of these workers are sometimes considered to be less complex, thus devalued 10 .
In this study, feelings of not being well received by the team, the lack of acceptance, dialogue, understanding and empathy of co-workers and the competitive work environment were listed.These results highlight the impact of interpersonal relationships with peers in the process of functional readaptation and point to the need for actions that involve teams and managers and provide reflections on this process.The support of co-workers and supervisors, as well as work involvement contribute to workers' satisfaction 23 .
In the face of the readaptation process, actions were taken by workers, in order to seek help and support, whether from health professionals, co-workers and other people.Still, through the use of coping strategies of a spiritual nature, brought in different studies in the face of situations of illness [24][25][26] or suffering at work [27][28] .
The search for strategies aimed at health promotion and the prevention of the emergence of other pathologies on the part of managers along with workers is urgent, with the aim of promoting health and preventing injuries and illnesses, reducing the chances of functional readaptation 8 .Based on this result, it is worth reflecting on the importance of strategies for promoting mental health at work, considering the specificity of health care.
As a limitation of this study, it is considered that the memory failures resulting from the period of time that elapsed between the illness/functional readjustment and the conduct of interviews may have influenced the accuracy of some specific data in the semi-structured interview script, such as the time of absence from work.
It is suggested to carry out further research in the studied setting, in order to continue theme deepening.It is understood that, as knowledge about functional readaptation is expanded, data about workers may be better systematized in the institution, allowing, for instance, a general survey of this population.
The Socio-Humanist Theory, the theoretical framework of this study, proved to be important for a broader and more in-depth, considering the complexity that involves the process of functional readaptation due to illness.It is suggested its application not only in research in the areas of occupational health and human resources management, but also involving the development of nursing work with the patient.There is the possibility of its use also as a methodological reference in the studies, considering steps proposed by the authors.
[…] I cried a lot when I had to leave [the unit] [...] when the boss spoke, you are going to work [in another sector].I asked, "what is this?"I didn't even know what [the sector] was, I didn't even know how it worked [the sector] […] (W14).
to go back to work.I came with a lot of restrictions and it was very heavy, because I was not really in a position to return […] I came unprepared, neither physically nor emotionally (W16).Acceptance of new life and health condition, restrictions and living with limitations also presented difficulties for workers: […] I can't stand for a long time, sit for a long time, I have to alternate.Do not take too much weight, do not walk a lot.[…] so, I always have to be taking care of myself.Not only at work, but also in my life.That's why I don't accept my limitations […] I come, work, but I have to have that period at home to rest.I lie down for a while, relax, so that the next day I can be well to work.So, everything changes, you can't have a busy life, and work directly.Because afterwards I will not have the quality to come to work.Then readapt your whole life.Not only the professional part, but also the personal part (W6).