Job insecurity among nurses , nursing technicians and nursing aides in public hospitals Precarización del trabajo de enfermeras , técnicas y auxiliares de Enfermería en los hospitales públicos

www.ee.usp.br/reeusp Rev Esc Enferm USP · 2018;52:e03411 * Extraído da tese: “Precarização do trabalho em enfermagem nos hospitais públicos: 2013-2017”, Programa de PósGraduação, Escola de Enfermagem, Universidade Federal da Bahia, 2018. 1 Universidade Federal da Bahia, Escola de Enfermagem, Salvador, BA, Brasil. 2 Universidade Federal da Bahia, Escola de Enfermagem, Programa de Pós-Graduação em Enfermagem, Salvador, BA, Brasil. ABSTRACT Objective: To identify the contribution of all the dimensions involved in job insecurity among nursing professionals in Brazilian state public hospitals. Method: This was a quantitative descriptive study conducted between March 2015 and February 2016, with nurses, nursing technicians and nursing aides. The data were analyzed using exploratory factor analysis. Results: The sample consisted of 265 nurses (n=161 with job security and n=104 outsourced) and 810 nursing technicians and nursing aides (n=597 with job security and n=213 outsourced). Among the nurses, “Working conditions” accounted for 46.8% of their job insecurity. Among nursing technicians and nursing aides “intensity of work due to work process organization” best explained the construct of job insecurity (51.2%). Conclusion: Job insecurity is expressed differently depending on the type of nursing professional. The difference in the distribution of the dimensions showed that job insecurity is related to the hierarchical position of each nursing professional in the technical division of nursing work and the role of each professional in the work process.


INTRODUCTION
Job insecurity refers to a political regime based on the instability and permanent insecurity of workers, submitting them to further exploration.In Brazil, job insecurity among public servants was driven by changes resulting from the Reform of State Apparatus.During the 1990s and early 2000s, job insecurity in public service emerged through lack of wage correction for almost all workers; the implementation and expansion of different types of remuneration; increased outsourcing of workers; and intolerance and authoritarianism of employers in their relationship with public sector unions (1)(2)(3) .
Public servants had an impact during the administration of former president Fernando Henrique Cardoso, creating the idea in the public eye of excess public servants, with privileges in terms of career and wages (4) .During the administrations of Luís Inácio Lula da Silva and Dilma Rousseff 2002-2012 and 2012-2016, respectively, of the Worker's Party (PT) changes were made to the pension regulations for these workers -their right to full retirement pay was eliminated, outsourcing was expanded, and wage policies went unchanged (5) .
In 2017, the government alliance of President Michel Temer, who took over as President after a legal-parliamentary-media coup in 2016, increasing the impact on public servants and approving, in the Constitution and Justice Commission in October 2017, Bill 116, which regulates the dismissal of public servants by subjective criteria, and Temporary Decree 805/2017, which postponed or canceled the wage increase scheduled for 2018.Then, once again, public servants had an effect from the economic and political crisis in the country.
Considering that in the health sector, the government is the greatest employer of nurses, nursing technicians and nursing aides, these workers are also affected by job insecurity (6) .The types of job insecurity in nursing include type of employment relationship, instability, income, working hours, the right to free association, and work conditions (7) , which affect the health and quality of life of these workers, predisposing them to physical exhaustion and psychological issues (8) .
In addition, nursing professionals are the largest professional group in the health field.In hospitals, they carry out continuous and uninterrupted patient monitoring and surveillance activities, coordinating the work of other health professionals and ensuring care delivery.With job insecurity, nursing professionals are exposed to greater suffering, as they are unable to do everything that is best for patients.
Job insecurity in public health services directly affects the population.It limits access to services and exposes hospitalized patients to risks during care provision, since poor work conditions demand improvised actions that negatively affect patient safety (8) .
An analysis of this topic in the main databases of the Virtual Health Library (VHL) showed incipient scientific production about the relationship between job insecurity and public health services.Thus, it is important to investigate job insecurity in public services to understand its complexity and implications in nursing.Therefore, a better understanding of job insecurity among nurses, nursing technicians, and nursing aides provides a window into how job insecurity has infiltrated public health services.
Considering the above, the purpose of this study was to identify the contribution of all dimensions involved in job insecurity among nursing professionals in Brazilian state public hospitals.

METHOD
This was a quantitative descriptive study conducted at 15 public hospitals directly managed by the Health Department of the State of Bahia (SESAB -Secretaria da Saúde do Estado da Bahia) and seven hospitals indirectly managed by SESAB, which accepted to participate in the study.
Stata Statistical Software Release 11 and the information from hospital medical records were used to estimate the size of the study population.As the prevalence of studied phenomena was unknown (p=0.50), a sampling error of 3% (d=0.03) and 95% confidence level (α=0.05) were considered.The sample of the nursing professionals consisted of 265 nurses (n=161 with job security and n=104 outsourced) and 810 nursing technicians and nursing aides (n=597 with job security and n=213 outsourced).
Data collection was performed between March 2015 and February 2016, in various care sectors, including outpatient clinics, wards and high-complexity units.A 96-item questionnaire was used to collect data, validated by the researchers via pre-testing.The researchers approached and invited nursing workers to participate at their respective sectors during their work hours.The inclusion criteria were: nurses, nursing technicians, and nursing aides who had worked for at least 6 months at the health organization and who were able to answer the questions.Nursing professionals who had been working for less than 6 months at the health organization or who had participated in the study's development were excluded.
Exploratory factor analysis (EFA) was used in data analysis to identify latent variables (factors) with relevant explanatory power for the object of study.The main reasons for using EFA are: to validate the results of an evaluation and to develop a theory, because this technique analyzes the construct and the synthesis of its relations, resulting in factors that can be used in other analyses (9) .
Considering that the construct of job insecurity comprises several factors and the absence of studies in nursing that identifies such factors, EFA was used to identify how the dimensions contribute to nursing job insecurity.
This process was carried out in two steps: 1.As per the study conducted by Druck (10) , the dimensions of job insecurity were defined by distributing all 96 variables among these dimensions and building a factorization matrix; 2. The matrix was submitted to factorization according to professional category and type of employment relationship.The Kaiser-Meyer-Olkin (KMO) test was performed, with an overall score of 0.8307 for nurses and 0.8794 for nursing technicians and nursing aides.The scree test was used to extract factors.Next, factorial rotation was performed, with the cut-off point at 0.40.Two forms of factorial rotation were tested: orthogonal rotation (matrix of independent factors) with varimax, and oblique rotation (matrix of dependent factors) with promax, using 4, 5 and 6 factors, respectively.The decision to use a matrix with 4, 5 or 6 factors and whether they should be dependent or independent was made by the researchers.
After the factorization process, of the 96 initial variables, 32 variables remained in the matrix for nurses and 33 in the matrix for nursing technicians and nursing aides, distributed among the following dimensions of job insecurity: Working conditions; intensity of work due to work process organization; intensity of work due to multiple jobs; intensity of work due to extended working hours; work process management; elimination of employment rights.
To evaluate the contribution of every dimension to the construct of "job insecurity," eigenvalue, difference, proportion of explanation, cumulative and uniqueness were calculated.These matrices were debated and evaluated at six separate moments with experts in the field of nursing work, job insecurity, epidemiology and statistics.
Cronbach's alpha coefficient was used to validate the internal consistency of all variables and dimensions of job insecurity, with an overall score of 0.8822 for nurses and 0.8839 for nursing technicians and nursing aides, which shows a strong correlation between the answers (11) .
This study fulfilled the ethical requirements of Resolution 466/12 issued by the Brazilian National Health Council and was analyzed and approved by the Research Ethics Committee of the Nursing School at the Federal University of Bahia, protocol 398.772/2013.
Figure 1 illustrates the results of the scree test.A sharp reduction can be observed at factor 5, with a decreasing curve of variance, indicating the elimination of the other factors.
Table 1 shows the dimensions of the job insecurity matrix for nurses."Working conditions" accounts for 46.8% of job insecurity.The dimensions related to "intensity of work" account for 29.3%, and "work process management", 11.7%.
The eigenvalue for a given factor measures the variance in all the variables which is accounted for by that factoronly factors with a value greater than 1 should be extracted.The "Working conditions" dimension presented the greatest contribution to variance (Table 1).
The matrix for job insecurity among nursing technicians and nursing aides (Table 2) shows that "Intensity of work due to work process organization" was the dimension that most contributed to explaining the construct of job insecurity (51.2%), and its eigenvalue presented the highest shared variance.
Chart 1 and Chart 2 show the factor matrixes for job insecurity among nurses, nursing technicians and nursing aides, respectively.In both matrixes, the categories "work process management' and "intensity of work due to multiple jobs" presented the variables with the greatest factor loading.
"Intensity of work due to work process organization" was the only dimension whose variables presented negative factor loading, which means they contribute to reducing "intensity of work due to work process organization".

DISCUSSION
Since the 1990s, the Brazilian government has adopted neoliberal prerogatives, such as the reduction of public expenditures, not fulfilling its constitutional duty to ensure the right to health to the Brazilian population.The government cannot refrain from providing health services; however, by adopting such neoliberal prerogatives, it causes job insecurity in public services and among public workforce, for instance, in the form of pay gaps, infrequent selection processes, and expansion of outsourcing (1,8) .In this context, the dimensions of job insecurity in nursing work indicate government errors and omissions in the maintenance of health services and the exploration to which nurses, nursing technicians and nursing aides are subjected.
The dimensions of job insecurity described in Tables 1 and 2 were distributed differently among nursing professionals.For nurses, "Work conditions" is the dimension that most contributes to job insecurity (46.8%), while for nursing technicians and nursing aides, "Intensity of work due to work process organization" (51.2%).The place occupied by middle management nurses in a work process of care and management nature (12) demands working conditions such as infrastructure, administrative and medical-hospital inputs, sizing and qualification of nursing staff, availability of information including patient clinical information, access to other professionals such as physicians, work relations, among others.
In this work process, nurses have to deal with the pressure exerted by the nursing staff themselves, other health workers, patients and leaders of the organizations to mobilize and articulate the resources required in care provision.
For nursing technicians and nursing aides, who in the work process assume care activities and tasks, the dimension of "Intensity of work due to work process organization" is significant to explain job insecurity.These workers highlight work requires more than they can perform, as described in Chart 2. In addition, in the hierarchy created by the technical distribution of nursing work, technicians and nursing aides are pressured by nurses, to whom they are subordinated in the activities.The variable of "Assumes multiple assignments due to staff shortage" (Chart 2) indicates undersized nursing staff, which also implies this dimension.Other studies also highlighted the intensity of work as a relevant factor in job insecurity in nursing (13)(14) .
In addition to performing their own tasks, nursing technicians and nursing aides, who represent most professionals in health workforce, also help other professionals, particularly physicians.Therefore, these workers receive demands from three groups during their work process: from nurses, other health professionals, and patients, who refer to them to fulfill their immediate needs.
However, another factor should be highlighted which moves away from the Taylorist logic of nursing work, but increases the intensity of such work in the context of job insecurity: the nursing work, like any other health work, is active and relational, because the object of health work, that is, the needs expressed by patients, is changeable.
Then, although tasks are performed in a fragmented way, and there is pressure to achieve goals (particularly in outsourced hospitals, a legacy of Toyotism), patients conduct part of the health work process according to their needs, demanding more or less actions of nursing professionals.
Studies on nursing work in Brazil, Argentina and Germany found similar results regarding the elements of job insecurity: inadequacies in physical and material structure, high workload, undersized staff, greater work intensity, and uncorrected wages that force nursing professionals" to have more than one job (8,(15)(16)(17) .
The nurses, nursing technicians and nursing aides who participated in this study work in public hospitals that do not always ensure proper organizational or material working conditions for the provision of health services and services, as indicated in several studies (17)(18)(19) .
The hospitals with direct management of SESAB do not have local autonomy to replace or purchase materials or hire employees, limiting the performance of their managers and offering poor conditions to staff.It occurs in the context of the work process organization based on the tripartite of Neoliberal State -job insecurity -Toyotism, with deterioration of public services as a strategy to promote privatization of these services.
Two dimensions that are not shared among nursing workers are also highlighted: "Intensity of work due to extra hours", which is relevant for nurses, and "Elimination of employment rights", relevant for nursing technicians and nursing aides.
The dimension of "Intensity of work due to extra hours" includes variables related to proper rest period and place and daily working hours.This study found this dimension is relevant only for nurses due to its care and management nature, which generates excessive activities and tasks.Also, there is no definition of a rest period and place in the hospitals analyzed in this study, which can generate deeper stress on nursing professionals, even if the daily work day does not exceed the limit defined in the employment agreement.
The dimension of "Elimination of employment rights" includes variables related to wage and career.These variables contribute to job insecurity among nursing technicians and nursing aides, given these workers receive the lowest salaries in nursing (6) .The explanation is given by the social and technical division of work and the characteristics that make up the value of the workforce of nursing technicians and nursing aides.They have shorter training and perform manual work.Then, the perception of the value of such workforce is affected by two factors that contribute to its reduction, and reduction of the price paid to these professionals (20)(21) .
The study limitation referred to its long period of data collection due to the conditions of the research field.

CONCLUSION
The results indicate job insecurity in public health services and in nursing work; however, job insecurity was expressed differently by the nursing professionals.
The nurses, nursing technicians and nursing aides are subject to intensity of work, poor working conditions, and models of work process management that increase the exploration of their work.The dimensions of job insecurity analyzed in this study affect nursing professionals and the clinical practice, since they prevent or limit the care provided to patients, considering that some minimum working conditions are not fulfilled.In addition, the intensity of work due to multiple jobs subjects workers to physical, mental and psychological fatigue, which may contribute to errors in care provision.
The differences in the distribution of job insecurity dimensions show that it is related to the hierarchical position of each worker in the technical division of work in Nursing.The differences observed among nurses and nesting technicians and nursing aides show the continuity of work division, a legacy of Taylorist work organization.This division enhances job insecurity in nursing and explains the differences among women workers.
This study may be extended to other states of Brazil so its results may be compared to the results of future investigations.

Table 1 -
Eigenvalue, difference, proportion of explanation, and cumulative value of the dimensions of the matrix for job insecurity of Nurses -Salvador, Bahia, Brazil, 2017.Factor matrix -job intensity of nurses by dimensions, variables and factor loading -Salvador, BA, Brazil, 2017.

Table 2 -
Eigenvalue, difference, proportion of explanation, and cumulative value of the dimensions of the matrix for job insecurity of Nursing technicians and nursing aides -Salvador, BA, Brazil, 2017.