The voice of nurses as a means to promote job engagement*

Objective: The objective of this study was to establish the factors that induce nursing professionals to present engagement with their work environment. Method: Qualitative study, using the communicative methodology, with nursing professionals from public and private centers in the city of Huesca. The statements were collected through communicative stories and discussion groups. Result: The methodology used has allowed the establishment of a set of engagement promotion measures in the studied environment. These measures are framed in the three main categories analyzed: the systemic or structural variables, the subject-oriented variables, and those that refer to the relationships between the subjects. Conclusion: Knowledge of the situation regarding engagement among professionals, and the issues that encourage or hinder its appearance, is essential in establishing measures that contribute to its development. The use of qualitative techniques has allowed for the discovery of situations that would have gone unnoticed. After analyzing the interviews and the discussion groups, the following were present: an important lack of recognition that the participants experience, and that contribute, in their opinion, to the appearance of burnout syndrome, and, the lack of cohesion as a collective.

-Two-dimensional model of subjective well-being at work Burnout syndrome appears to a greater extent in those professions in whom continuous contact with people is required, so nursing has been one of the professions in which it has a higher prevalence: in Spain with 33% (6) , and internationally, reaching 55.3% in Brazil (7) , for hospital nurses in Colombia, 25.5% (8) , and 20% in Norwegian nurses specialized in obstetrics and gynecology (9) .
The high presence of burnout syndrome among health professionals in general, and nursing in particular, together with the interest of labor organizations to ensure professionals have a high level of engagement, caused the approach of the present investigation. In order to complement a previous study of quantitative type, the use of the qualitative communicative methodology was proposed, which can provide a novel and very interesting view of these concepts, as the type of study that addresses the prevention of burnout syndrome among nursing professionals follows crosssectional (6,10) , or longitudinal, quantitative sampling (11) .
Few studies use qualitative or mixed methods to address engagement among nursing professionals (12) , and none were found that used communicative methodology for this purpose.
The communicative methodology aims to describe reality, interpret and transform it, emphasizing how meanings are communicatively constructed from interactions between people on an equal level. The researchers will contribute the theoretical knowledge, and the participants, their personal experiences, establishing an equal dialogue at all times, where the contributions of the different participants are considered according to their validity, and not based on the position of power of those who are contributors (13) .
The communicative methodology not only aims to describe and explain, understand, and interpret reality with the aim of studying it, but also to study it in order to transform it, emphasizing how meanings are constructed communicatively through the interaction among people (14) .
The communicative methodology assumes a series of postulates, including: the universality of language and action, people as transforming social agents, communicative rationality, that is, that every person has the capacity for language and action, and common sense, understood as a subjective sense that depends on personal experiences that is formed within the cultural context. There is no interpretive hierarchy, since any assumption has the same strength, and both those being investigated and the researchers are on the same level (equal epistemological level) (14) .
The objective of this study was to establish the factors that induce nursing professionals to present engagement with their work environment, through a methodology rarely implemented on this subject: the qualitative communicative methodology.

Method
The groups. In this selection, the representativeness of each group was taken into account, as shown in Five discussion groups were held, in which 20 nursing professionals participated, whose characteristics are specified in Table 1. To complete the interviews, the interviewers went to the workplaces of the respondents, in order for them to feel comfortable in their environment, so that the discussion could be fluid. Those characteristics are specified in Table 1.
Scripts were prepared to guide the development of the conversation and to address the most important aspects related to engagement among the nursing professionals in the sample, taking into account the previous literature review.
These meetings were recorded and transcribed, and were held in a comfortable space for the respondents. Likewise, the objectives of the story were noted at all times, emphasizing that they are an active part of the research. In addition, informed consent was obtained to verify permission of the participants for the use of the data collected during the discussion groups.
In order to perform the content analysis, as a set of interpretative procedures of communicative products, in this case statements which came from previously registered communications (16) , the information was categorized into different levels of analysis, which were structured in a grid or table. This analysis was organized around the exclusionary and transformative components, characteristic of the communicative methodology, as well as around other components, such as transcription, coding, description, and interpretation of information (14) .
The exclusionary and transformative dimensions are (16) : • Exclusionary dimensions: defined as barriers that people or groups encounter and that contribute to reproducing situations that favor the onset of burnout syndrome, and/or prevent the appearance of engagement.

Results
The results obtained in this study will expose those expressions or statements valued as transformers, that is, that promote the appearance of engagement in the work environment, and in turn, can be assessed as proposals for improvement for workplaces, where they can be implemented to combat the onset of burnout syndrome.
Analyzing the discourse of the participants in search of those elements considered transformative has allowed the establishment of a set of measures to promote engagement in the studied environment.
Next, these measures are exposed according to the three main categories analyzed: systemic or structural variables, variables that refer to the subject, and those that refer to the relationships between the subjects.
Within these main categories, the most specific ones will be developed, as specified above.
Regarding the structural category, the first measure

Discussion
The welfare of workers within the work environment is an important part of the efforts of companies and organizations, this is especially relevant among companies dedicated to health care. Knowing the variables associated with engagement and burnout syndrome, within a specific health environment, will provide the relevant tools to implement plans and strategies that foster engagement, so as to promote worker welfare, improve the quality of the services and care offered, and reduce patient safety.
Most of the proposals put forward by the participants coincided with previous proposals exposed by other authors, such as the reflection on the size of the centers and the cities of work; in their opinion, this represents an important influence on the burnout syndrome (17) .
Small centers are more accessible, comfortable, and less stressful, which could favor the development of engagement. On the other hand, some participants suggested that the environment in which the study was conducted greatly encouraged post-university training, and that this fact could also favor the development of engagement.
Most participants state that the gender of professionals influences the relationships established between them, with other professionals, and with families and patients. In addition, participants emphasize the fact that the majority of nursing professionals are women, since until recently work was considered secondary for women, while this did not occur among the group of men. In the opinion of the participants, this would also be related to marital status and familywork conciliation, since, in their opinion, these facets are difficult to separate, and the conciliation between the two is complex, which can favor the development of burnout syndrome. Previous studies conclude that femalesappearmore likely to suffer from burnout syndrome, since they have higher percentages of high levels of exhaustion, cynicism, and less efficacy than do males, but this relationship isunclear. It could be explained by considering thatthe experience of stress seems to be linked to gender roles (18) .
Participants associate job instability with greater insecurity, which makes reconciliation difficult, decreases the quality of care, and hinders continuous training, making it difficult to develop engagement. In the opinion www.eerp.usp.br/rlae 7 Sanclemente-Vinue I, Elboj-Saso C, Iñiguez-Berrozpe T.
of the participants, labor instability is fostered by health organizations, in order to give workers less rights than those who have a fixed contract, although in the previous bibliography emotional fatigue is associated with having a fixed post (19) .
In Health professionals feel that the organizations they work for treat them unfairly, so developing models that improve these feelings of justice would directly improve the engagement of individuals with the organization.
These results are similar to those in other studies (21) , where it is observed that when organizations behave with greater justice, nurses have less burnout syndrome.
Measures aimed at developing this sense of justice could be the implementation of transformational leadership models (22) , or the aim towards the objectives, which has been found to be related to occupational well-being (23) .
The relationship between workload and the appearance of burnout syndrome is referred to in the interviews and discussion groups conducted. In them, the participants indicate that the lack of personnel and material resources increases the level of stress, and promotes the appearance of burnout syndrome, in the same way that other authors have associated it previously (24) .  (26)(27) .
On to positions of responsibility (28) .
The confrontation in the definitions of nursing as a vocation or as a profession is, therefore, a continuing fact that impacts the current reality, althoughcontradictory opinions were obtained among the participants of the present study. This aspect should be studied more deeply, and the communicative methodology could provide an innovative viewin terms of its approach.
Regarding the relationships between professionals, the importance of having healthy interprofessional relationships in order to achieve engagement in the workplace is clear (29) .  (30) .
Regarding the relationships with the relatives of the patients under the care of the nursing professionals, they stated that these relationships werecomplex, with an increase in the demands and those that hinder the development of engagement in the work environment, a fact that is seen also hindered by the increase in aggressions and verbal violence towards health professionals. Other authors arrive atthese same conclusions, which relate the existence of aggresion with the appearance of burnout syndrome (31) ,exposure to verbal abuse with high levels of emotional fatigue, depersonalization, and intention to leave work (32) .
Improving and implementing job engagement in nursing professionals prevents the risk of suffering job stress and burnout, and consequently leads toa higher quality of care for users of their services. Knowing the engagement situation among professionals, and the issues that, in the opinion of those involved, encourage or hinder their appearance, isessential to establish measures that contribute to their development.
The use of qualitative techniques has allowed the discovery of situations that would have gone unnoticed otherwise, identifying a series of risk factors that were not easily identifiable through quantitative techniques.
The main limitation of the study is that it was developed in a specific area of northeastern Spain, so the results may not be representative of nursing professionals in other territories. Despite this, the study was conducted in health centers with a capacity of less than 500 beds, and these centers represent 90% of Spanish health centers (33) . On the other hand, there is the possibility that some of the participants have modified their responses based on what they thought was expected of them (social desirability bias).

Conclusion
After analyzing the interviews and the discussion • promote gender equality in the organizational representation of nursing professionals, breaking the "glass ceiling" currently in existence, • favor healthy and egalitarian interprofessional relationships, • control and reduce verbal and physical violence in the healthcare environment.
The use of the communicative methodology will allow the design of prevention strategies that work to transform areas that favor the appearance of engagement.One of the preventive strategies may be to hold meetings similar to the discussion groups, and convert the dialogic methodology into a prevention proposal.