Work process, performance and professional profile of a Hearing Health Network: reference for satisfaction

Purpose : To analyze the correlation between the satisfaction of professionals from the Hearing Health Care network in two micro-regions of Minas Gerais state and the sociodemographic profile, work process, and work performance in the health service. Methods : This is a cross-sectional, observational, analytic study with a non-probabilistic sample including 34 professionals from the Hearing Health Care services. Data collection occurred through individual interviews in the municipality of professional practice. Associations between the Professional Satisfaction variable and the explanatory variables Sociodemographic Data, Work Routine, and Developed Actions were conducted. Results : Professionals with graduate studies were more satisfied with the human resources policy and the activities developed, whereas health civil servants showed more satisfaction with the wage policy and the work schedule. The correlation analysis between work process and satisfaction revealed a moderate positive correlation between items such as Health Promotion Actions, Satisfaction with Diagnostic Equipment, and Satisfaction with Maintenance Equipment. Conclusion : The present study revealed a higher level of satisfaction among professionals with graduate studies (human resources policy and activities developed) and civil servants (wage policy and work schedule). The relevance of this study lies on the important role that health professionals play on the Health Care Network. Additionally, the study of satisfaction level can provide a search for improvements, considering that satisfied professionals not only improve service quality, but also show greater creativity, commitment, and performance.


INTRODUCTION
Care networks of the Sistema Único de Saúde (SUS) -Brazilian Unified Health System -among them the Hearing Health Care Network (HHCN), have their operations based on mutual communication, thus characterizing network action (1) . It is important for their structure and organization to be flexible and able to identify the need of all those who seek care (2) . Thus, healthcare activities are held through meetings and joint work of professionals and users, forming an intricate network of relationships and a final product that is health care (1) , and as a consequence, the user's well-being.
According to the Ministerial Decree No. 587 of October 7th, 2004, Hearing Health Care Networks were introduced, aimed at promoting hearing health (3) and as such, allowing the provision of comprehensive care to users of hearing aid (HA), i.e., from their reception to rehabilitation (4) .
Hearing Health Care Unit (HHCU) teams, distributed in medium and high complexity, are multidisciplinary and composed by an otolaryngologist, speech-language pathologists (qualified to work in audiology and therapy), social worker, psychologist and neurologist and/or pediatric neurologist (3) , the latter belonging only to the high-complexity group. In the municipalities of each micro-region, there is a Decentralized Speech-Language Pathology service, whose function is to receive users referred by primary care, with complaints, suspicion or diagnosis of hearing loss, referring them to basic hearing assessment, then to the Micro-regional Hearing Health Board (HHB) and afterwards, rehabilitation of the post-adapted user in the SUS-MG Hearing Health Care Units (5) . In addition to these functions, it is also the responsibility of the speech-language pathologist to develop primary care actions to promote health and disease prevention, as well as monitor users in their care process (5) .
Being a multidisciplinary network and having as a reference the final product, in other words, health care, it is important to analyze the satisfaction of professionals working in this network, as dissatisfaction at work can have consequences for both the professional and for the organization (6) , as it may change performance at work (7) , the team's well-being (7) and, especially, the user's well-being, a fundamental part of the network (8) .
Job satisfaction is a recurrent topic of discussion in studies and, as such, presents several judgments and views. Being satisfied with work involves interpersonal and environmental aspects as well as organization of activities, associated with personal characteristics, i.e., individual values and expectations (6)(7)(9)(10)(11) . Furthermore, job satisfaction involves motivation for professional development and improved quality of care provided to the population (8) .
In this context, it is important to mention the work process, defined in general, as the way professionals perform their activities (12) . In health care, the work process is, in most cases, a collective activity, designed by associating the individual characteristics of each professional's function, set by the division of labor as a whole (13)(14) . The result of this work process reflects directly in the user's life. Thus, the product will not be a material good, but the well-being of the user receiving the service (13) .
It is important to point out that the user is not only the object of the work process, but also its agent, in other words, through them the necessary changes will occur or not (12) .
Hence, this study aimed to analyze the correlation between satisfaction of Hearing Health Care Network professionals in two micro-regions of Minas Gerais with socio-demographic profile, work process and performance in health care services.

Study design
It is an analytical observational cross-sectional study with nonprobability sampling of 34 professionals linked to the Hearing Health Care Services of Minas Gerais.

Study scenario
At the time of data collection, according to the Land Use Regionalization Planning (LURP), Minas Gerais had in its territory, 853 municipalities, distributed and organized in 13 health macro-regions with 19 municipal centers and 75 health micro-regions ( Figure 1). The health micro-regions in Curvelo and Sete Lagoas are, as shown on Figure 1, in the Central health macro-region, whose municipal centers are Curvelo and Sete Lagoas, respectively.
Thus, system users can find primary care services in their municipality, secondary care in the micro-region that it belongs, only needing to seek macro-regional centers for highly complex procedures. Currently, in accordance with Resolution CIB-SUS/MG No. 1219 of August 21st, 2012, nomenclatures of health micro and macro-regions have been changed to Health Region and Extended Health Region, respectively (15) .

Casuistry
Given the context, 34 municipalities were selected in two micro-regions in the State of Minas Gerais, Sete Lagoas and Curvelo. The sample was composed of 34 professionals involved in the Hearing Health Care Service, namely: 27 speech-language pathologists and seven others, belonging to the categories otolaryngologist, social worker, psychologist and service coordinator. All professionals worked in one or more municipalities of the aforementioned micro-regions. The average age of professionals was 31.5 years (standard deviation 4.3); 33 (97%) were female; 27 (79.4%), of the same professional category (speech-language pathologist); and 21 (61.8%) had a graduate degree. In addition, average time of service was 38.4 months (standard deviation 24.7); 18 (52.9%) had worked in public service before; 24 (72.5%) were working under agreement; and 21 (61.8%) had an average salary between two and four minimum wages.
Inclusion criteria for the study: Exclusion criteria were: a) Having answered the questionnaire in another opportunity, for working in more than one service in the Network.

Instrument
The collection instrument consisted of a semi-structured questionnaire, divided into six thematic areas, consisting of questions with dichotomous responses (yes/no) or Likert four-point frequency scale (never, rarely, sometimes, and always) and five-point satisfaction scale (very dissatisfied, dissatisfied, neither satisfied/dissatisfied, satisfied, very satisfied), developed by the researchers and published in a previous study (16) .

Data collection
For selection and recruitment of study participants, after approval of the municipality authorities, invitations were conducted via email or telephone contact.
Data collection occurred through interviews conducted by Technical Support speech-language pathology clinical fellows, previously trained, who traveled to the work municipalities of these professionals. The interviews were individual and happened in the municipality where the professional performed his or her activities, with an average of 30 minutes and concomitant digital recording. It should be noted that prior to data collection, a pilot study was conducted in order to calibrate the instrument and check how clear were the questions prepared.

Data analysis
The interviews were digitally recorded, transcribed and categorized in a database to then be analyzed statistically. For data analysis, associations were created between the Professional Satisfaction response variable and the explanatory variables Sociodemographic data, Service routine (Work process) and Developed actions. The response variable has its items outlined in a Likert five-point frequency scale, distributed as follows: 1-very dissatisfied; 2-dissatisfied; 3-neither satisfied/dissatisfied; 4-satisfied; and 5-very satisfied. For further analysis, the items were processed, standardized in a scale with values ranging between -1 and 1, in which the negative values nearest to -1 indicate dissatisfaction; those close to 0, neutrality; and those positive, near 1, satisfaction. Results featuring p≤0.05 were considered as statistically significant associations. As for correlation data, the Spearman correlation coefficient was used, measuring the degree of association between two variables and used in cases where none of the variables have a normal distribution (17) . The magnitude of the correlation was measured by the following parameter: low = 0.0 to 0.4; moderate = 0.4 to 0.7; and strong = 0.7 to 1.0 (17) . Correlations with moderate and strong magnitude were considered statistically significant. For input, processing and analysis of data, version 2.15.0 of the R software was used.
This study was funded by Fundação de Amparo à Pesquisa do Estado de Minas Gerais (FAPEMIG) -Research Support Foundation of the State of Minas Gerais -and is part of the project "Assessing the implementation of the hearing health care network: a case study in the micro-regions of Sete Lagoas and Curvelo, Minas Gerais", approved by the Research Ethics Committee of the Universidade Federal de Minas Gerais -Federal University of Minas Gerais, under ETIC 186-10.
The association between education level and items related to professional satisfaction demonstrated that professionals who have only an undergraduate degree are more dissatisfied with Human Resources policies (p = 0.02) and the activities performed (p = 0.03) than those with graduate degrees. The other variables showed no statistically significant difference (Table 1). By associating salary range with professional satisfaction, there was no statistical significance in any of the items analyzed ( Table 2).
The association between the variables related to the work process and the education level of professionals was not statistically significant in any of the items analyzed ( Figure 2).
On Table 3, by associating the employment relationship type (approved in public contest or under agreement) to professional satisfaction, there was a statistically significant difference in the items salary policy and schedule, both with p = 0.02, i.e., professionals approved in a public contest were more satisfied with these items than professionals working under agreement. The other associations showed no significant difference.
The correlation between the professional's job and their satisfaction, Table 4, showed no statistically significant correlation in any of the analyzed items. Table 5 presents the correlation analysis between the variables "Work Process" and the variables related to "Professional Satisfaction", using Spearman's correlation. A positive correlation with statistical significance was presented by the items "Satisfaction with diagnostic equipment and Satisfaction with Equipment Maintenance" with the item "Health Promotion Actions" (0.47 and 0.43, respectively), significance level of p ≤ 0.05.

DISCUSSION
The sample characterization revealed that professionals were in average 31.54 years old, most were female, had a graduate degree, their employment relationship type was under agreement and they belonged to the professional category speech-language pathologists. Previous studies containing profile design showed that professionals had a mean age of 28 (18) , 41.4 (7) and 43.8 (19) years, were predominantly female, their employment relationship either approved in public contest or under agreement, and predominantly their professional categories ranging from nurses and doctors to other professionals with high school education. However, such studies are not related to Hearing Health Care teams, but to the programs Family Health (18) and Mental Health (7,19) .
Associations found with statistical significance revealed important points to be discussed, such as the human resources policy and activities performed. Regarding the human resources policy and the activities performed, it was observed in this study that professionals who have only an undergraduate degree are more dissatisfied than those with a graduate degree. A study aiming to analyze the job satisfaction of 321 workers from a mental health service, located in Rio de Janeiro, found that professionals who only had a high school education were more satisfied than others (7) , and this fact can be related to fear of retaliation by managers.
It is also important to note another study (20) performed with professionals from a psychiatric hospital, which revealed that the level of satisfaction is negatively associated to the level of education, which is not supported by the results of this study. Regarding the activities performed, it is considered that professionals with higher level of education sometimes have greater job security and compensation (7,10) , factors that may be associated with higher job satisfaction, while those with lower education levels feel more pressure to perform at work and find themselves often carrying out undesirable activities or that do not match their education level. In addition, a previous study (21) points out that a higher education level also provides greater decision power over the work to be performed, which contributes to the feeling of satisfaction with the activities performed.
Among the associations with statistical significance, it should also be noted the higher dissatisfaction among professionals under agreement with the variables salary policy and schedule. Similar results were found in national studies (7,22) . Such results may reflect the instability perceived by these workers, due to the tenuous employment relationship, that neither provides them job security, and often, nor satisfactory financial return. In addition, many professionals need to work in more than one place to meet their needs, which increases fatigue (7) and, hence, job dissatisfaction.
Regarding the schedule, i.e., the activities carried out by professional, despite not having found similar discussion in other studies, the fact that dissatisfaction is higher in professionals under agreement can be justified by the fear of losing their jobs, causing professionals to perform activities non-compatible with their positions, as a way to show their value and seek recognition within the institution (22) .
It is worth to discuss the association between satisfaction and salary range, although this association has not shown results with statistical significance. Similar results were found in a study with doctors from the Family Health Program (23) , however, such study refers to the satisfaction of professionals belonging to a single professional category, which does not happen in this study.
Another study, conducted with professionals responsible for the nutrition department of a hospital, showed that a good salary was directly related to job satisfaction (24) . Through attractive compensation, it is assumed that professionals feel valued and motivated to perform their activities, which reflects on the quality of service provided to the user, a key part of health services. However, what can be seen in public services is that higher-level employees, who have invested in their careers and are waiting for recognition, receive less than their equivalents in the private sector (7) , which can contribute to job dissatisfaction.
In this study, there was no association with statistical significance between work process and academic education, neither other studies that related these variables were found. However, it is worth noting the importance of the work process in health care, which must be collective, and thus performed by several professionals. Workload must be shared and each professional must perform the specific activities linked to their qualifications, thus encompassing different professional categories and specializations relevant to each one (13)(14) . It is essential that work process studies in health care extrapolate the statistics of the labor force (25)(26) and normative discussion, to reach its dimension as a social process (27) .
In the analysis between job and satisfaction, no positive correlations were found. These data confirm a previous study (7) performed with mental health professionals. It is, however, important to emphasize the composition of the sample in this study, where most professionals were speech-language pathologists and the results may reflect the opinion of these professionals.
The analysis of correlation between job satisfaction and process demonstrated that there is a positive association, with statistical significance, between health promotion actions with diagnostic equipment and equipment maintenance. These data allow us to infer that professionals who are linked to the diagnostic process also conduct health promotion actions, highlighting the diversity of work in the Health Hearing Care Network. In addition, there are few professionals who are involved in the diagnosis. It should be noted that most professionals belong to the category of decentralized speech-language pathologists and in the Hearing Health Network of Minas Gerais, diagnosis is not an assignment of these professionals. This may explain the low number related to involvement in this process.
This paper brings contributions to the discussion of configuration in the organizational and structural dimensions of the hearing health care network. Its limitations include the design of cross-sectional study and the fact that the sample consists mostly of speech-language pathologists, so the results may represent the opinion of this professional category. However, this fact is justified by the network configuration, where full teams are located only in middle and high complexity services. Smaller cities have only professional Decentralized Speech-Language Pathologists, whose function is to receive users, and on suspicion of hearing loss, refer them to perform hearing tests and practice in medium or high complexity. It should also be mentioned the difficulty of discussion and comparison of data found in previous studies, since they were related to health teams with different settings and goals. Also, it is noteworthy the importance of the study, since there has been little content in literature about Hearing Health Care Networks. Analysis of professional satisfaction, a key part of the Network, will allow better evaluation and provide opportunities for improvements, since having a motivated team plus a favorable environment and perspectives are essential to minimize the impacts caused by work routine and that directly reflects on the quality of service. Therefore, it is inferred that a satisfied professional does not only improve the quality of service, but also presents greater creativity, engagement and performance.

CONCLUSION
This study showed a higher level of satisfaction among professionals with graduate degrees (human resources policy and activities performed) and approved in public contests (salary policy and schedule). Work diversity was also identified in the Hearing Health Care Network, where professionals responsible for diagnosis also conduct health promotion activities.
The key role that healthcare professionals play in the Hearing Health Care Network stands out, as well as the importance of tracing the profile of these professionals and, consequently, designing the team that currently works in the Hearing Health Network, thus contributing to the assessment of the Network as a whole. Professional satisfaction analysis will provide opportunities for improvements, since the expectation is that satisfied professionals present more creativity, commitment and better performance. Furthermore, the analysis of professional satisfaction can contribute to relevant conceptual, theoretical-methodological as well as theoretical-practical reflections for advances in health care.