ONCOLOGY NURSING PROFESSIONALS' JOB SATISFACTION AND DISSATISFACTION IN BRAZIL AND PORTUGAL

SATISFACCIÓN E INSATISFACCIÓN EN EL TRABAJO DE PROFESIONALES DEL ENFERMERÍA DE ONCOLOGÍA DEL BRASIL Y PORTUGAL

Abstracts

The aim of this research was to identify the reasons for satisfaction and dissatisfaction among oncology nursing professionals working in Brazil and Portugal. A descriptive and qualitative study was conducted with nine Portuguese nurses and 17 Brazilian nursing professionals, using a questionnaire and interview, which were analyzed according to Bardin's proposition. Satisfaction, in both scenarios, was associated, above all, to the patient and the treatment process, and the bond established between the professional and the individual demanding care. Dissatisfaction resulted primarily from the extensive exposure to high workload and to the deaths of oncology patients. The importance of considering the subjectivity that permeates the work scenario is highlighted, which can have vast and, sometimes, costly implications.

Work; Job satisfaction; Oncology nursing; Nursing

El objetivo de esta investigación fue identificar las razones de la satisfacción y insatisfacción entre los profesionales de enfermería que trabajan en la atención oncológica en Brasil y Portugal. Estudio descriptivo y cualitativo realizado con nueve enfermeras portuguesas y diecisiete profesionales de la enfermería brasileña, utilizando cuestionarios y entrevistas, más tarde una transcripción y analizado con la proposición de Bardin. La satisfacción, en ambos escenarios, se asocia, sobre todo, para el paciente y el proceso de tratamiento, y el vínculo que se establece entre el profesional y la persona exigente para su cuidado. La insatisfacción se debió principalmente a la amplia exposición de la carga de trabajo y la muerte de los pacientes oncológicos. Destacó la importancia de considerar la subjetividad que impregna el escenario de trabajo, que puede tener enorme y, a veces, consecuencias costosas.

Trabajo; Satisfacción en el trabajo; Oncología médica; Enfermería

Objetivou-se nesta pesquisa identificar os motivos de satisfação e insatisfação entre profissionais de enfermagem que atuavam na atenção oncológica, no Brasil e em Portugal. Estudo com abordagem qualitativa, descritivo, realizado com nove enfermeiros portugueses e dezessete profissionais de enfermagem brasileiros, utilizando-se de questionário e entrevista. Os dados foram analisados na proposta de Bardin. A satisfação, em ambos os cenários, esteve associada, sobretudo, ao paciente e processo de tratamento, e ao vínculo estabelecido entre o profissional e o indivíduo que demanda por seus cuidados. A insatisfação decorreu, prioritariamente, da exposição à exaustiva carga de trabalho e óbito do paciente oncológico. Foi destacada a relevância de se atentar à subjetividade que permeia o cenário laboral, cujas implicações podem ser vastas e, por vezes, onerosas.

Trabalho; Satisfação no trabalho; Oncologia; Enfermagem

INTRODUCTION

Job satisfaction has been associated with important factors in the quality of staff performance in health services, because relationships have been identified between satisfaction and dissatisfaction at work, and with patient safety and quality of care, as well as with turnover, burnout, and other consequences for the individual, his health, family and quality of life.^1-2

A study highlighted that part of the "nursing personnel is not satisfied with their job, the quality of patient care provided by the whole team of nursing personnel could be affected".^3:664 This explains the importance of evaluating the satisfaction of professionals with their different jobs, so that, according to demand, actions are built and incorporated to promote employee satisfaction and retention of them in the practice environment, aiming for continuity and quality of care for patients and their families.⁴

The concept of job satisfaction refers to the emotional reaction to the work resulting from comparing actual results with those that are desired and deserved, by incorporating "three attributes: autonomy, interpersonal relationships, and patient care".^5:130 Thus, as patient satisfaction is considered a complex and multifaceted construct that includes different relational and environmental elements and organizational context,⁶ it is understood that satisfaction among health professionals permeates the same uniqueness, and should also be studied and receive higher attention, through an expansion of dialogue.

Nursing professionals working in oncology live with high emotional commitment, extended working hours, inadequate staffing, and not infrequently, they experience another's suffering, pain and death.⁷ Moreover, they are currently experiencing high rates of cancer cases in the population and therefore it is of interest to health institutions to attract and retain qualified professionals in oncology, which has patients undergoing complex treatment regimens, such as chemotherapy and radiation.⁴ Therefore, assessing the satisfaction of these professionals working in highly specialized area is of great significance.

Given the above, this study was constructed from the following research question: what are the reasons for job satisfaction and dissatisfaction in nursing staff who work in cancer care in Brazil and Portugal?

The care scenarios were selected for having a partnership with the educational institution of the researchers, which allow graduate students to have an exchange in Portugal. In addition, research aimed at investigation of job satisfaction are recent, especially when congregated, in one study, two working services in health from different countries, with diversified historical, cultural and social characteristics, which tend to be reflected in the workplace settings and in the level of staff satisfaction. Still, it is worth considering that cancer care has proved to be an emblematic area in health care in both countries.

Overall, in both of these care contexts, the professionals provide care to users during the course of long-term chemotherapy; when performing diagnostic test research, preclinical and post-surgery oncology care, among other procedures. Both corroborate with respect to the aging population and the increased demand for health services due to chronic diseases, including cancer. On the other hand, some differences are observed between the care processes and job aspects in oncology of these countries, regarding the organization of work shifts and personal schedules, multidisciplinary approach model, structuring of the nursing staff and guidelines regarding companions staying in hospital, and others.

Thus, verifying the importance of the analysis in two countries, allowing for the identification of specific characteristics in two work contexts, the objective was to identify the reasons for satisfaction and dissatisfaction among nursing professionals working in cancer care in Brazil and Portugal.

METHOD

This was a qualitative and descriptive study, conducted with nursing professionals who worked in two scenarios of care in oncology, one in Brazil and another in Portugal.

Twenty-six nursing professionals participated in the study, nine Portuguese nurses from a Clinical Service of Medical Oncology in a hospital situated in the north of Portugal and 17 nursing professionals working in the oncology inpatient unit of a general hospital in southern Brazil (two nurses and 15 nursing technicians). Within Brazil, nurses and nursing technicians comprise the health workforce, so it was decided to include both in the study and, therefore the term nursing staff is used when referring to the Brazilian context. In Portugal these subdivisions do not exist and, in this context, nursing care, management and care, is fully exercised by the nurse.

The inclusion criteria used were: nursing staff professionals, working at least for six months in the area (because after this length of time, professionals tend to know more about the work process of the unit in which they work, and they have more contact with the elements of that place). Professionals who were not working, were on vacation or sick leave for maternity, illness, or other reasons were excluded.

The largest number of eligible nursing professionals was included for data collection, starting from the proposal for comparative studies in which "the selection must be made so that several cases are always included in a single comparison group". Further, in these studies, "the case is not observed as a whole or in all its complexity; Instead, there is a multiplicity of cases related to certain excerpts".^8:133-5 Thus, the ending of data collection in both countries occurred after having sought to address all eligible nursing professionals, respecting the availability of subjects in each scenario, and reaching saturation in the findings.

In the Brazilian scenario, from the total of 33 professionals (five nurses and 28 nursing technicians), ten nursing technicians and three nurses were working less than six months in the unit, two nursing technicians were absent and did not take part in the study, justifying the number of two respondents in this category in Brazil. In Portugal, 19 professionals were working on the collection date, and nine agreed to participate in the study.

The instruments used for data collection were a questionnaire composed of semi-open questions, which were manually responded to by the professionals in Portugal and in Brazil; semi-structured interviews were used and conducted at the workplace of the subjects, individually. These were recorded using a MP3 player, with their consent. Both instruments had the same guiding questions, focused on the construction of the professional profile and occupational aspects; on labor elements in oncology that generate job satisfaction and dissatisfaction; if, in the perception of workers, these influence the quality of care provided; the strategies used to achieve job satisfaction; and resources that could be adopted to promote and enhance the quality of care. This study presents the profile of the subjects and the reasons for work satisfaction and dissatisfaction in oncology.

Data collection occurred in June of 2013 in both countries. In Portugal, the collection was made possible by the exchange of a graduate student from the researchers' institution during the first half of 2013, and, in Brazil it was performed by researchers of a study group.

The initial reports of interviews and questionnaires were fully transcribed by members of the research group in Brazil, and later analyzed according to the proposal of thematic analysis,⁹ with nine being subjected to pre-analysis, material exploration, and treated to results inference and interpretation. These steps were operationalized by researchers from the reading of the transcripts, allowing contact with the data and highlighting stories or excerpts. Then, the identified data were organized in central thematic categories, which highlighted the reasons for dissatisfaction and satisfaction at work, in both scenarios, considering the purpose of the study, and were then subsequently discussed based on of scientific literature.

To guarantee their anonymity, the participants were recognized by the acronym representing the professional category, followed by the sequence number of the transcription of the instruments, and acronym of countries of origin (for example, te1B, first transcribed interview conducted with a Brazilian nursing technician).

The study met the ethical aspects recommended by resolution 466/2012 of the National Health Council, and was approved by the Ethics Committee of the State University of Santa Catarina (UDESC), by Platform Brazil, Protocol n. 275 106/2013 and by the Ethics Committee of the Research Center of the Hospital Institution of Portugal, according to reference number 31/2013. The professionals were invited to participate and, after reading, and acceptance, signed the Informed Consent and Informed (IC) and the Consent Form for Recording, where appropriate.

PRESENTATION AND DISCUSSION OF RESULTS

In the profile analysis of participants of the study, a predominance of Portuguese nurses was identified, aged between 40 and 59 years (66.7%) (minimum of 29 and maximum of 57 years). All professionals were female, most with length of working time in oncology from one to five years (55.5%), on the morning shift (66.7%), and more than 20 years after graduation (44.4%) without other employment (88.9%).

Of the nursing professionals investigated in the Brazilian scenario, all were female, aged 30-39 years (41.2%) (minimum age of 27 and maximum of 52 years). These professionals mainly worked on the night shift (64.7%), between six to ten years after graduation (58.8%), working from one to five years in the same area (41.2%), and without other employment (94.1%). The fact that most Brazilian professionals work during the night relates to data collection, since it included the morning and afternoon teams, as well the two night teams, who have 12-hour shifts and 36 hours off.

These findings show that the oncology workforce consisted of women in both scenarios, corroborating other studies that show a preponderance of female workers in this area.^10-11

A significant number of the professionals worked in this specialty for less than five years, which is an early-stage population in oncology, or refers to the representative rates of staff turnover, given the stressful characteristics of the work in oncology, such as caring for patients with severe disease that is often life-threatening.⁴

Two main categories emerged from the data analysis: reasons of job satisfaction in oncology and reasons of job dissatisfaction in oncology, with their respective sub-categories and based on each investigated scenario (Table 1). The reasons were organized in tables in descending order; namely, the most frequently mentioned reasons by the participants are found at the top of the tables, and in the lower part were those with lower numbers.

Table 1
- Reasons for job satisfaction and dissatisfaction among oncology nurses. Brazil and Portugal. 2014^*

Reasons for job satisfaction in oncology
Brazil	Portugal
- Improvement and recovery of the patient; - Professional recognition by the patient; - Possibility of helping the other; - Promoting human well-being; - Affinity with the profession; - Affection for oncology; - Team work.	- Relationship with the work team; - Work hours (morning); - Relationship with patients; - Helping patients and family; - Providing a dignified end of life; - Patient healing; - Affinity with cancer patients.
Reasons for job dissatisfaction in oncology
Brazil	Portugal
- Death of the patient; - Work overload; - Clinical and psychological worsening of the patient; - Difficulties with teamwork; - Suffering of companion during in-hospital stay; - Dissatisfaction with the institution; - Lack of materials; - Patient desisting with the treatment; - Professional devaluation; - Low remuneration;	- Work overload; - Difficulty in operationalization of the computerized program; - No preparation of the in-hospital chemotherapy; - Not enough time to assist the patient and family; - Difficulties with teamwork; - Medical disorganization; - Disorganization of service and circuit (flow) of the patient; - Deficit in vocational training; - Absence of palliative care unit; - Extension of the suffering of the user; - Contact with the suffering of the patient and family.

Reasons for job satisfaction in oncology

The Portuguese nurses reported job satisfaction in oncology, corroborating the results found in other research,¹² that, in assessing occupational stress of Portuguese health professionals, positive levels in the dimensions of satisfaction and accomplishment were identified.

When asked about the reasons for satisfaction, nurses referred to the relationship with the team's work, including the nursing, medical, and housekeeping staff, in addition to working hours and relationships with patients. The contact with the patient. Being able to support the patient and the family in this difficult time (e5P); Work time. Team relationship (E8P); Medical and nursing staff; Operational assistants [...] (e1P). Professionals that associated the work time with job satisfaction, activities conducted during the morning shift.

One study indicates that the support of managers and physician assistants can facilitate or hinder the provision of high quality care and job satisfaction, as well as the fact that efficient communication between team members tends to enhance patient safety.¹³ The work time should be organized in order to allow time for shift change, social support and training of health teams.¹⁴

The aid to the patient and family, palliative care and, although less frequently, the patient's healing and an affinity for cancer patients emerged as reasons for satisfaction of the Portuguese nurses. Helping people who need a lot of support. Alleviating the suffering of people with oncological diseases [...] (e3P); [...] there are patients who are cured. The quality of life that we are able to deliver despite the poor prognosis [...] the patient's smile when he has been discharged from hospital (e2P); Supporting the terminal patient. Support and preparation of the family of the terminal patient. Participate actively in the preparation of a dignified end of life (e4P).

The regency of the principles of palliative care was perceived as strongly present in the statements of Portuguese nurses. This context involves the continuous reformulation and resignification of beliefs and symbols surrounding the death and dying process by the professionals, and not being afraid of the death of another, making them compassionate and sensitive to human suffering.¹⁵

The presented findings are similar to the reasons of satisfaction of the Brazilian nursing teams working in oncology, since many of these aspects are also associated with the relationship with the patient being treated for cancer. The improvement and recovery of the patient, the recognition of the professional who assists, the possibility to help another and promote the welfare of the human being resulting from care, emerged as the main reasons of job satisfaction at this context. When you see that patient who, when admitted the day before was pretty weak, the days go by , the shifts, you come here and the patient is much better [...] (te10B); [...] He [patient] becomes a needy person and you, with the care you have with him [...] you can find him, in case of last thirty years, if well treated , he will remember of you [...] (te3B); [...] Is about doing something for the human being [...] (te5B); Well-being of the patient [...] (e2B).

There exists, in oncology, the development of strong emotional bonds between the nursing staff, patients and their families as a result of the treatment that, in general is extended, going on over long periods. The development of ties with sharing of experience, and contact with the suffering and vulnerability of the patient and family, elevates the feeling of empathy from the professional as well as the perception of doing something to help the other that permeates difficult moments of life, often with poor prognosis. One study noted that help and involvement with patient care contributed to the spiritual feeling of the nurses, ¹ which is one of factors that influenced their job satisfaction.

The Brazilian nursing professionals highlighted the affinity with the profession and affection with the field of oncology, in addition to teamwork, as reasons for job satisfaction. [...] I love working here on onc, it brings me great satisfaction [...] (te3B); [...] The question of staff being structured (e2B). The professionals feel satisfied when the work team is structured and integrated and when the professionals are working together to perform job functions.

The reports of the Portuguese nurses and Brazilian nursing team show the incipient reasons of satisfaction relating to the environment, organization and work conditions. This emphasizes the importance of paying attention to the staff's subjectivity, and raises awareness of the need to reflect on the way the work process in oncology occurred in these institutions.

Reasons for job dissatisfaction in oncology

Several reasons were listed in this category which generate concern, by nursing professionals of both countries, since job dissatisfaction emerged as a strong predictor of the intention of the professional of leaving employment.¹⁶ The workload was presented as the primary reason for labor dissatisfaction in this care context. Overwork, overload [...] performing work of other professionals (e5P); Excessive number of working hours/week (e2P).

When occupational stress experienced by nurses in Portuguese hospitals and health centers was analyzed, the presence of a high level of this event was identified in 30% of professionals, which may be associated, among others, with overwork. ¹⁷ In this sense, the literature shows that managers committed to quality care should strive for meeting the needs of staff, from the appropriateness of staffing, availability of internal ombudsman spaces, and others. These actions aim to reduce the occupational diseases and accidents that are detrimental to professionals, limit their exposure to internal and external risks in the workplace, and to potential situations of stress, contributing to the humanization of practices and promotion of workers' health.¹⁸

In the Portuguese scenario, the electronic health record and the difficulty operating it that was sometimes observed, appeared among the reasons for dissatisfaction; the lack of preparation of in-hospital chemotherapy, causing delays in chemotherapy administration, and the lack of time to assist the patient and family, which can be linked to role stress [...] Very confusing computer program; the chemotherapy is prepared outside the hospital [...] (e7P); [...] Lack of time and resources to provide comprehensive care (e9P).

Moreover, among the dissatisfactions are the difficulties with the teamwork, mostly related to the lack of moments for sharing the clinical cases and, subsequently, the weakness in communication and decision-making in a multidisciplinary approach. Lack of sharing moments between the multidisciplinary team (e4P); Psychologist absence in service to patients, whether for professionals or family members (e2P). Medical disorganization should also be noted as generating dissatisfaction for nurses who work in the oncology area of a hospital in Portugal, with respect to their lack of completion of their tasks and timetable, the disorganization in service, the circuit (flow) of the patient, and deficient vocational training, as shown by reports. Lack of training of the professionals for caring for this type of disease (E3P). Poor organization of the flow of patients [...] Disorganization with infringements of the clinical part of their tasks (e7P).

The presence of training deficits instigates the reflection on the importance of training processes for the work, particularly when referring to professionals working in healthcare, where knowledge is dynamic, and who had a mean of 17 years after graduation in Portugal, and seven years and six months in Brazil. In this study, the presence of a significant portion of Portuguese and Brazilian professionals with work experience in oncology of less than five years (55.6 and 64.7%, respectively) brings the need for training regarding the specificities of oncology, since many of these individuals recently stepped into this place of highly complex care.

The fact that most of the professionals are new in this area may be associated with high rotation at work. Authors emphasize that high professional transfers may be associated with poor quality working conditions, lower educated staff, a sense of insecurity in one's employment, and labor dissatisfaction.^19,16

Dissatisfaction of the Portuguese nurses also stems from the absence of a palliative care unit, of extending the patient's suffering, and the contact with this suffering and that of their family. The incipiency of units designed to contribute to a dignified end of life is also a reality in Brazil, which requires investment of managers to provision resources and improve care practices at this moment in life.²⁰

In the Brazilian context of oncological care, the primary reason for dissatisfaction of nursing professionals was the death of the patient. [...] Here in the unit we have several losses, and it gets to be frustrating [...] any care, that the more I give myself, I might have given to him, ah, but we ask, what I did, what did I fail to do, what could I have done. That's what I feel (e2B). Some professionals facing the loss of another, who was in her care for some time, end up rethinking their daily practice, and ask themselves about any occurrence of error in nursing care or if there was a chance to have done anything differently, even though they are aware of the unfavorable clinical conditions of the patient, and their limited therapeutic possibilities of cure.

During the training course, the majority of the health staff deal with technical learning, seeking the preservation of human life. ²¹ Considering this outlook and the historical, cultural and subjective aspects, we realize that sometimes the phenomenon of death is not recognized as something natural, ²² which ends up generating frustration among health professionals who cannot reverse the finiteness, especially when it involves young patients.

Also, the Brazilian nursing staff showed the workload and the clinical and psychological deterioration of the patient's condition as reasons for dissatisfaction. [...] When he is getting worse, or depressed [...] (te7B); [...] Due to high demand and few employees [...] and so sometimes you can barely get to the room, and another bell is ringing, it makes me very [dissatisfied] (te13B). Thus, it is important to address the exposure to high workloads, due to the large amount of tasks, many of which are detailed, and the reduced number of professionals in this occupational category.

An exhaustive workload has been identified as one of the most stressful factors in nursing work, and the stress experienced by this professional can have a harmful effect on the nurse, his family, patients and the health services.²³ The limited professional retention rates, high turnover, exhaustive workload, reduced number of staff - or the absence thereof - contribute to creating a difficult working environment for health professionals, and they can experience professional exhaustion, due to their significant efforts to provide high quality care.²⁴ This shows the importance of proper planning for the healthcare work force.

Difficulties in the work related to team work also emerged among the reasons for dissatisfaction, primarily, the lack of commitment of some professionals to humanized care for the patient, as well as the suffering experienced by the companion during their stay in the hospital, due to the lack of conditions for comfort. When [...] someone doesn't do his part, both the human part that some lack - they are more mechanical, they go there, do their work and leave - and the technical tasks (te1B); [...] They [companions] suffer too much, for example, in these cold days [...] they have to be sitting in the chair [...] have to sleep in the chair or stretch a little mattress in the floor.

It is understood that the search for high levels of quality and productivity is closely linked to how well individuals feel working in the organization.²⁵ In this sense, the establishment of participatory management models and valuing of professionals are alternatives to achieve improvements in working conditions and ambience.¹⁸

Other reasons for dissatisfaction were also cited by the Brazilian nursing team, such as the lack of material, the withdrawal of treatment from the patient, professional devaluation and low remuneration. The instability in the professional career and the discomfort arising from the remuneration were also identified among the Portuguese nurses.¹²

When the characteristics related to salary were analyzed, a study showed that employees who had low income or low salary satisfaction were less likely to state their intent to stay in the organization, evidencing that a salary increase policy can be one of the strategies used in retention management of the health workforce.¹⁶

The reasons for dissatisfaction listed by nursing professionals make it possible to know the aspects of work that need to be reevaluated by health institutions, in order to adopt measures to transform the reality experienced by healthcare professionals, minimizing their dissatisfaction related to the functions that they perform. Thus, there is the challenge of meeting high quality demands with the patient and his family that use the health service and to provide the health producers with favorable working conditions.

FINAL CONSIDERATIONS

The results obtained in both oncology scenarios investigated indicated that the job can be a source of satisfaction and, at the same time, dissatisfaction. The overload of activity is shown as a reason for significant dissatisfaction in both scenarios, and therefore, appropriateness and balance in the workloads of nursing professionals are certainly necessary. Also, aspects related to care at the end of life, which is seen as both a reason for satisfaction and dissatisfaction, was found to be remarkable in the reports of Portuguese nurses, a fact that was different from what was found in Brazil, where the patient's death and the worsening of clinical condition were mentioned as the main reasons for dissatisfaction. This indicates the importance of the approach about death and dying in professional and continuing education, particularly for the nursing staff in Brazil.

Although they share a very close historical past, Brazil and Portugal maintain historical, social and cultural characteristics that are distinct from one another and that impact the way in which the working processes in healthcare, and specifically in oncology, are organized, with possible repercussions on professional subjectivity. This study, by encompassing these two countries, sought to unveil the viewpoint of Brazilian and Portuguese nursing professionals working in oncology; the reasons for satisfaction and dissatisfaction resulting from processes of care and aspects of work, occasionally converged, whereas others differed in their analysis.

In this way, the study offers information from different national health contexts, which can guide the incorporation of strategies aimed to minimize sources of professional dissatisfaction and enhance satisfaction in the workplace. Investment in vocational and continuing education, as well as improvement of the environment, organization and working conditions, were found to be potential allies in preventing exhaustion and physical and mental illness of staff working in oncology. It is important that job satisfaction levels in the various environments in work and occupational categories are assessed, allowing the development of proposals that can be investigated by other studies.

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• *
  In the course of the paper different designations referring to the user of oncology services will be used. While in Brazil the term patient or user is more frequent, the Portuguese lexical field opts for user or ill.

Publication Dates

• Publication in this collection
  24 Nov 2015
• Date of issue
  Oct-Dec 2015

History

• Received
  12 Dec 2014
• Accepted
  01 July 2015