Nursing workers health and patient safety : the look of nurse managers *

Objective: To understand the perception of nurse managers about the relationship between nursing workers health and patient safety. Method: A qualitative survey was conducted using the social phenomenology approach of Alfred Schütz, accomplished through individual interviews with nine nurse managers from five Brazilian university hospitals. Results: Nurse managers’ perception of the relationship between nursing workers health and patient safety was evidenced in the following categories: “The suffering to balance workers health and patient safety” and “Interventions in everyday work life”. Conclusion: Managers’ experience showed an everyday work life marked by suffering and concern, due to high rates of absenteeism and presenteeism resulting from illness and incapability of workers, and the need to ensure patient safety through qualified nursing care. DeScriPtOrS Nursing; Nursing Human Resources in the Hospital; Workers Health; Patient Safety; Human Resource Management in Hospitals. correspondence addressed to: Patricia Campos Pavan Baptista Av. Dr. Enéas de Carvalho Aguiar, 419 Cerqueira César CEP 05403-000 São Paulo, SP, Brazil pavanpati@usp.br USP


intrODUctiOn
Workers and patient safety is intrinsically related to the quality of health services, and thus has been prioritized on the agenda of institutions, professional associations and government agencies.Hence, safety is understood as a cross-cutting theme of the care process, involving, in particular, the establishment of trusting relationships between workers and patient.
Therefore, understanding the magnitude of adverse events occurring in health care refers to the need to reflect upon the components that result in unsafe practices and to propose suitable strategies, based on effective processes in order to minimize, as much as possible, harm to users and workers of health services.
Concerning this issue, government agencies have encouraged the movement on behalf of safety, including it in their political agendas.Under this perspective, several initiatives have been recommended, aiming to improve and monitor the systems and work processes in health services.
However, it is noted that such efforts are still insufficient, often resulting in the fragmentation of decision-making, which is required for modifications in assistance and managerial processes.Furthermore, the interests of those involved in the health sector compete with each other, often hindering the implementation of these efforts, namely: satisfaction of the users with their needs and expectations, workers who seek appropriate working conditions, institutions themselves and suppliers (1) .
Concerning workers health, the national and international literature demonstrates that the incapability to work due to health-related harms is a global problem, with considerable socioeconomic cost and psychosocial impairment (2)(3)(4)(5) .
This reality focuses directly on health services, since the technological advancement and the search for excellence in health care quality, allied to increased productivity and cost reduction, are relevant factors that have markedly influenced the morbidity profile of their workers (6) .
Regarding nursing workers incapability, physical and mental restrictions are observed in the national and international scenario, characterized by processes of chronic pain and loss of muscle strength resulting from musculoskeletal disorders, which are predominant in this class, as well as anxiety disorders, depressive episodes, among others, all of which have significant impact on the work organization and, consequently, on quality and patient safety (7)(8) .
Therefore, the object of study of this article was the act of managing nursing workforce, with the aim of describing the perception of nurse managers about the relationship between nursing workers health and patient safety, believing in the need for developing the discussion about safety in health care organizations, aiming at the implementation of actions that contribute to its effectiveness.

MetHOD
A qualitative survey was conducted using Alfred Schütz social phenomenology approach.Social phenomenology is a theoretical and methodological approach that enables accessing the subject consciousness, seeking to understand a particular experience that takes place in life, in a social context (9) .
The subjects selected for this study were individuals appointed as directors of nursing services and/or nurse managers from the South, Southeast, Midwest, North and Northeast of Brazil, excluding individuals who are appointed as directors and/or managers but were not in charge of nursing workforce in hospitals.Twelve interviews were held altogether, three of which were excluded because they did not respond to the object of the study, totaling nine interviews with nurse managers or coordinators analyzed.The participants of the survey were female, aged 40 to 60 years, and had been nursing coordinators for an average of eight years.In order to preserve the anonymity of each one of them, the speeches were identified by the letter "M" -Manager, followed by Arabic numerals, according to the order of the interviews.
In a previous survey carried out by the same researchers to monitor nursing workers health, five university hospitals were selected according to criteria of representativeness, size and infrastructure.For the present study, new Brazilian university hospitals were selected, one per scenario (South, Southeast, North, Northeast and Center-West), intending not only to broaden the areas of study, but also to establish partnerships with other institutions, disseminating the knowledge already developed.Thus, the managers interviewed were linked to large university hospitals that are references in medium and high complexity in the state and part of the Sistema Único de Saúde [Unified Health System] (SUS).
The project was submitted to the Research Ethics Committee of the School of Nursing of the University of São Paulo, and approved under the no.378.047.In accordance with the Resolution no.466/12 on research involving human beings, the subjects received one copy of the Informed Consent Form and had the right to accept or not to participate in the study.To achieve the proposed aim and respond to concerns, interviews were scheduled according to the availability of the managers, in a private place, free of noise and interference, decided with them, and had the following guiding question: How does it feel to be a nurse manager/director and to deal with illness and incapability of nursing workers in your everyday work life?
For recording the interviews, we used a digital recorder and an iPad in order to promote greater freedom of speech and fidelity in the process of capturing ideas.Each interview had an average duration of three hours.Immediately after the completion of the interviews, speeches were transcribed, respecting the sequence, language, pauses and repetitions.
For the analysis of the speeches, first each interview was transcribed entirely, then the whole content was read and reread in order to grasp the significant excerpts, seeking to understand the perception of nurse managers about the relationship between nursing workers health and patient safety.The careful rereading aimed to detect the cores of convergent thoughts or that referred to a given theme.The material was analyzed using the following philosoph-ical assumptions of Alfred Schütz (9) : stock of knowledge, intersubjectivity and social action, considering the objective of the present study.

reSUltS
The nurse managers' perception about the relationship between nursing workers health and patient safety is evidenced in two categories: The suffering to balance workers health and patient safety and Interventions in everyday work life.

The suffering To balance workers healTh and paTienT safeTy
The speeches demonstrate feelings of conflict, anguish and impotence of the nurse managers, for matters regarding the quality of the performed work and, especially, the safety of the care provided to patients, according to the presented excerpts: Listen, nowadays we have been working hard on the issue of patient safety, professional safety.(...) the issue of care from human being to human being is something that leaves much to be desired (M5).

So sometimes I find myself in conflict (...) because we look at it from both sides, right? You have the worker's side, and have the institution's side, the patient's side, that we need to meet as well. So we have to balance the tripod of workers, client and institution (...) And I get a little worried (M1).
The nurse managers report suffering for realizing that the workforce is ill, however, the work process requires that patient care is performed: It's a very tough experience.Because... on the one hand you have the sick employee, the sick professional, who has a disease... On the other hand you have care, you have patients that require... that require work.And who loses in this situation?The patient (M7).
And we are here for what?For people to leave unhappy... or something like that... (M8).

So, safety... well... my goal is actually to make care occur in a safer way for both the professional and the patient (M5).
The anguish about the safety of care provided to patients is perceived in examples of situations that may put the nursing care at risk, in view of the seriousness of the illness of nursing workers that may be frequently neglected in occupational health services and in institutions: The other day a girl decompensated, here in this hospital.She arrived to work, and that crazy thing began... she was giving illogical replies when asked a question, sometimes assaulting the patient, sometimes the employee, just like that..

. (M1).
This makes me anxious for I don't have much to do about it... So... the patient is there, and has to be taken care of, this is something that concerns us a lot.The person has no condition to work, is in a poor con-dition, how will that person take good care of someone else?There's no way... (M9).Some managers report errors in the administration of drugs which, although have had no serious repercussions to patients, may be related to the context of illness and incapability of nursing workers: A conflict with myself to... to manage, you know, the two situations.Once a lady came in, she cried, cried, cried, she administered a wrong medication to a patient in the ICU (M1).
This tough context that is constantly experienced also affects the nurse managers' health.In the following excerpts, they express that the situation of trying to balance the workers and patients needs also favors illness itself: And we somehow also get sick (M4).

So I'm stuck in the middle of this thing, of having the responsibility to provide safe and quality care and also for the health of workers who are at work (M1).
Everybody is distressed... it's a lot of pressure (M8).
You are there, you know?You have to be very careful or else you also get sick (...) That doesn't feel good to me (M3).
The following report shows that the managers of the studied scenarios recognize their ethical and legal responsibility in managing human resources and in the care provided to patients: Regarding the responsibility for the illness of the employees, if they continue working, I answer for them, because I have civic responsibility, etc... the responsibility for the failure to care or the inadequate care to the patient is mine too, I answer for it.And the responsibility of maintaining the institution, the concept of the institution.Then I'm in the middle.So, what do we do?(M1).
The presenteeism problem is also noted by managers as a factor to be considered in the quality of the care provided.In their speeches, managers report that, although the staff is frequently adequate in quantitative terms, it is not in qualitative terms, since most of them present physical and/or mental health-related limitations, which may compromise the organization and the final quality of work: In addition to pressure for the quality assurance of nursing care and patient safety, managers describe the pressures for goals and productivity: I feel, because there is pressure, you are in a hospital, you're taking care of people, there is a long line, and you have to... to work with quality and also productivity (M8).

inTervenTions in everyday work life
The speeches show that despite the suffering context experienced to balance workers health and patient safety, those nurse managers envision interventions in everyday work life to minimize those problems.They highlight the need for institutional tools to perform the nursing workers health surveillance in order to obtain specific data about workers illnesses, as in the following accounts: Because then... for you to manage, you got to have planning, so I hope to have concrete data to diagnose the situation, to make a plan of action, and be able to work... (M7).

I said -I have to know what is making these workers sick and what HR can do to, at least, try to mitigate the situation (M3). I wanted to make this research I'm telling you about, to see our reality here, why people are getting sick. (...) Then let's see what's going to happen (M1).
In addition, questions regarding teamwork and unity of the professionals are also retrieved:

We are the largest group, you may not know how strong we are, but we are the largest group. So we have to unite so we can do it. You can't work disunited. There already is the technical division, within the staff... (M2).
I believe in fighting to strengthen the direction, strengthen the nurses... we as a team, nursing as a whole... (M9).

So, I think it is a fight of the nursing class, and I think I have to be in it as a manager (M5).
Another point mentioned by the managers is the importance of conducting an analysis of the characteristics of the clinics, the specificity of the activities that are performed, in addition to developing a careful look at the limitations presented by the nursing workers, minimizing the risk to patients and preserving workers health: (...) so, it is a puzzle.You have to join little pieces and it is not always easy (M4).(...) And I will seek to relocate her somewhere where she can be indirectly contributing to the care, right?(...) and put them to work where they really like working, do you understand? (M2).

(...) we have to redistribute and prioritize care (M7).
(...) we have also sought to direct them to activities which are not related to direct care to the patient, so that we could help this professional (...) but we have to be very careful in everyday life so that this disease will not be aggravated (M5).

DiScUSSiOn
From the perspective of social phenomenology, the different social groups contain typical structures that are consistent with the groups.Thus, this study expresses, from the managers reports, the anguish and the concern to maintain workers health and patient safety.
The social world, as concrete phenomenon, implies variability of perspectives and interests.It contains typical structures that diversify it from varied interests and which are experienced by participating social groups (10)(11) .It was observed that, in the face-to-face relationship, nurse managers from all Brazilian scenarios acknowledge the seriousness of the health problems of nursing workers and the impact on patient safety.
Issues regarding the work environment and the health of health care workers have been increasingly discussed nationally and internationally, to recognize trigger elements of illness processes, considering the health harms and the impact on the quality of the care (12)(13)(14)(15) .
On the other hand, in recent years, results-based management brought to organizations, competition in the market and the performance of each worker, staff or department, have reduced the sense of work in practice, promoting the devaluation of human beings for the interest in productivity (16) .
In the present study, it was possible to notice that the interface between workers health and patient safety causes great suffering in nurse managers, since they recognize and care about the illness of workers.However, they need to engage and commit to the proper functioning of hospitals and productivity, trying to balance the harm to the health of workers and patient protection.
To Schütz, the human life is not free of interest, indifferent or neutral, human life in natural attitude is engaged, committed, responsible.The world of everyday life is not private, but intersubjective, shared with my peers, where we know something about the way each of us is tuned with our conscious experiences, in other words, about the attention modifications of each one (9)(10) .
The speeches reveal the nurse managers perception about neglecting attitudes and other risky behaviors by nursing workers in the everyday work life.Recent research verified a fragile affective commitment of nursing workers with the organization and doubts regarding the degree of involvement in work (17) .Thus, the managers' anguish and concern with patient safety is also related to the fragility of the mental health of many workers, evidenced by disinterest, apathy and neglect, forcing them to adopt a behavior characterized by constant surveillance and concern.Some of the main causes of illness in nursing workers are tendonitis, tenosynovitis, bursitis, carpal tunnel syndrome and de Quervain's injury, associated with depression and anxiety disorders (4,(17)(18)(19)(20)(21) .
This context causes high rates of absenteeism and presenteeism, directly impacting on the nursing workforce and on the dynamics of the work process. www.ee.usp.br/reeusp Recent study on the burdens and stresses among nursing workers of a Brazilian university hospital reveals that they repeatedly go on leaves of less than 15 days, often for the same reasons.These short periods, when analyzed over the course of 12 months, represent a significant amount of working days lost.Moreover, absences and medical leaves cause not only an impact on workers health, but also on the employer, such as financial loss and a decline in the quality of the services provided (22) .
Concerning nursing workers incapability, Brazilian researchers have been describing the severity of physical and/or psychological restrictions, noting that although the labor restrictions are prescribed to keep the worker away from exposure to a certain activity and aggravation of his/ her illness, they have led to a complex situation for the functioning of health services, especially if there is a significant reduction in human resources (4,8) .
The need for advances in human resource management in public health services has been a matter of debate for years, and difficulties in this area generate challenges for managers in the three spheres of government.The production of health services especially depends on qualified and motivated professionals to transform inputs into outputs (23) .
Schütz focuses on the world of social life referring to a method of descriptive analysis of the world of everyday life as being a social reality, starting from social structures of meaning since the moment we are born and throughout our existence with other similar people.Therefore, since our birth we are in a relational context of mutual motivation with structures of meaning that constitute a social stock of knowledge.The author recognizes that knowledge -both general and specific -and society are intertwined in an array of action and experiences shared and conditioned by others (24) .
The biographical history of the nurse managers reveals a watchful eye to the other, with the use of a stock of knowledge and a set of skills, formulas and models of action to manage the problems of nursing human resources characterized by high levels of absenteeism and presenteeism and to maintain the quality of services.
Thus, researchers underline the importance of nursing management, which can, through the knowledge of their staff, promote organizational and educational actions to improve the quality of life at work, not only by the actions that they are responsible for, but also through the articulation with institutional levels that interact with the problem (25) .
The importance of management practice, as well as the participation of nurses and the space they occupy in the dynamics of the organizational process of the contemporary health institutions, leads us to think about the complex and controversial nature of management, which therefore constitutes a theoretical and practical challenge for managers of the health sector, especially nurses, who have the responsibility of managing units and services.In this manner, knowledge represents an important action resource and a tool that legitimates work, and they also revert into autonomy, authority and power sources of the subjects in the context of their practices (26) .
This study also highlights managers' perception about commitment and ethical and legal engagement with the profession and the institution, in the care for the population and in the nursing workforce management.To understand social phenomena it is necessary to apprehend them by the code of human motivations, of the purposes and means, of the planning, of the categories of human action (27) .
Therefore, nurse managing is not isolated or detached from the world of life, but in complete harmony with the social reality that managers experience.The daily lives of nursing managers is evidenced by the concern with their human resources and patient safety, by the attempt to balance the institution's productivity and offer a more qualified care, as we could perceive by the study.

cOnclUSiOn
When approaching the world of nursing managers, we could understand their perception about the relationship between nursing workers health and patient safety.The experience of the managers showed an everyday work life marked by suffering, anguish and concern, considering the high rates of absenteeism and presenteeism resulting from illness and incapability of workers and the need to ensure a qualified nursing care.Whereas the managers experience suffering, they seek to organize everyday work life from their stock of knowledge, conducting an analysis of the workstation and the characteristics of the units.They also direct a watchful eye, in the face-to-face relationship, to the limitations of workers, with a view to preserving the health of their staff.reSUMO Objetivo: Compreender a percepção de gerentes de enfermagem sobre a relação entre a saúde dos trabalhadores de enfermagem e a segurança dos pacientes.Método: Trata-se de uma pesquisa qualitativa, com abordagem da fenomenologia social de Alfred Schütz, realizada por meio de entrevistas individuais, com nove gerentes de enfermagem de cinco hospitais universitários distribuídos no Brasil.Resultados: A percepção dos gerentes de enfermagem sobre a relação entre a saúde dos trabalhadores de enfermagem e a segurança dos pacientes foi evidenciada nas categorias: "O sofrimento para equilibrar a saúde dos trabalhadores e a segurança dos pacientes" e "Intervenções no cotidiano de trabalho".Conclusão: A vivência dos gerentes evidenciou um cotidiano de trabalho marcado por sofrimento e preocupação, devido aos altos índices de absenteísmo e presenteísmo decorrentes do adoecimento e incapacidade dos trabalhadores, e à necessidade de garantir a segurança dos pacientes por meio de uma assistência de enfermagem qualificada.