Factors related to the risk of illness of nursing staff at work in a psychiatric institution*

Objective: identify the associations between the sociodemographic, and work variables, health conditions and lifestyles, and the risks of illness of nursing workers in a psychiatric hospital. Method: analytical cross-sectional study. The sample of 74 workers answered a questionnaire for sociodemographic, work, health conditions and lifestyles survey characterization. The Work Context Assessment Scale and the Human Cost at Work Scale were used to evaluate the perception of the risks of illness in the interviewee’s opinion. A descriptive and bivariate analysis was performed, with significance of 5%. Results: the factors associated with the risk of illness were: insomnia complaints, night work and workday. Conclusion: the associations between the work variables, health conditions and life habits can harm the health of the nursing staff of a psychiatric hospital.


Introduction
The Psychiatric Reform was a milestone in mental health care in Brazil. Since then, many advances can be observed in the care and management of these services, considering the processes of deinstitutionalization and dehospitalization of users, with reorientation of the psychiatric care model (1) . However, areas of care gaps and the need of "replacement of the mental hospitals still operating in Brazil" (2) , in line with the principle of universal coverage of mental health in the country, with emphasis on regions with low economic development.
In this context, mental health services produce situations that affect health conditions, in particular, of nursing professionals. These situations increase the risks of illness associated with the feeling of physical fatigue at the end of the work day, caused by the fear of suffering some kind of aggression by users (3) , exposure to physical and psychic loads, inadequate working conditions, limitation of autonomy, stress complaints, body aches, anxiety and fatigue, leading to suffering at work (4) .
A research (5) reinforces the occurrence of violence in the context of psychiatry, by identifying a higher prevalence of aggressions by patients to nurses working in psychiatric settings, in addition to presenting a worse subjective state of health and reduced working capacity in relation to those who worked in clinical and surgical units.
Inadequate working conditions and care for people with mental disorders with considerable cognitive demand represent critical risks for the illness of nursing workers (6)(7) . Night work, a common situation among these workers, is a strong factor of occupational exposure, generating important consequences for the work activity and health conditions of the worker (8)(9) .
In addition, the results of care -sometimes out of reality -, the state of continuous surveillance and professional dissatisfaction related to environmental structure, comfort, safety and wages should potentiate the possibilities of illness (7,10) .
The work context requires workers to make use of personal characteristics and physical and mental balance to face the stressful place of work, pressure and responsibilities (11) . Added to this scenario is the exposure to the long working days -commonly observed in nursing teams -, associated with Burnout syndrome, dissatisfaction at work, intention to leave the profession and increased patient dissatisfaction (12) . Thus, the work carried out in a psychiatric institution exposes health professionals to physical and psychological stress, contributing to the development of several diseases and occupational stress.
It is observed, then, that some characteristics of nursing work expose this professional category to different occupational risks and, particularly, worrisome when considering psychiatric institutions. In view of the context of the Brazilian Psychiatric Reform, the problem of professional insecurity regarding its future is still be seen in the hospital care scenario. The  (13) and the Escala de Custo Humano no Trabalho (ECHT) -Human Cost at Work Scale -which has 32 items divided into the dimensions -emotional cost, cognitive cost and physical cost (13) .  (13) .
These scales evaluate the risk of illness in the employee's opinion. To each question is assigned a score ranging from 1 to 5, depending on the intensity of the risk. In other words, the higher the score, the more noticeable the risk, and the final score is obtained by the arithmetic mean of each question, subsequently grouped to form the dimensions of risk of illness. According to the authors of the scales mentioned above, when the score is lower than 2.29, the work environment does not offer risk to the worker; between 2.3 and 3.69, the work environment offers moderate risk; and higher than 3.7, serious risk for worker illness (13) . In this study, in order to maximize the differences between the groups, the classifications were reduced from three to two groups -with risk of illness (score ≥ 2.3) and without risk of illness (score < 2.3).
The data were analyzed with the help of the  According to the results presented in Table 1, it was possible to observe that insomnia complaints were more frequent among workers at risk of illness for socio-professional relationships. Workers at risk of illness for personal relationships are 4.22 (CI: 1.43-12.41) times more likely to report insomnia complaints. In relation to working hours, we noted its association with both the risk of illness for work organization and working conditions. Although no significant associations were observed with regard to the analysis of the odds ratio, a greater proportion of the risks of illness was observed among workers who work longer than 30 hours per week.

Discussion
The sociodemographic characteristics of the sample are similar to those found in other studies (14)(15) , with risk of exposure to contaminated fluids, wage dissatisfaction and non-recognition by peers (14) .
In this study, referrals to insomnia are associated with the risk of illness both for socio-professional relationships and for physical costs. In this regard, a study proved that the nursing staff of psychiatric hospitals recognizes more the risks to their physical health than to the psychic, denoting an arduous and dangerous work. It also reinforced the need to expand the scope of knowledge of workers about what constitutes risk to their health, considering that less than half of the study sample communicated its last exposure to some occupational risk to the management bodies of hospitals (16) .
Previous studies demonstrated that sleep disorders were reported by workers with Burnout (17) , even though there was an association between insomnia and musculoskeletal disorders -such as headaches, back and neck pain (18) -and that the number of nursing professionals who attend work complaining of some musculoskeletal symptom is considerable (19) . Some studies (14,(18)(19)(20) have indicated that the main body sites of musculoskeletal disorders are the regions of the head and cervical, lumbar and thoracic spine.
Thus, insomnia associated with the risk of illness for physical cost represents an occupational health problem that usually has multifactorial causality, including the physical, psychosocial and ergonomic dimensions.
In addition, it is noteworthy that sleep dissatisfaction was associated with patterns of negative and sometimes "cynical" attitudes and feelings, reinforcing the findings of this research (21) . In this line, it is important to point out that social support, professional recognition by patients, superiors and other team members, optimism, pleasure and job satisfaction are protective factors for not getting sick and cordiality and respect relationships should be strengthened (22) .
The study also measured the association between night work and the dimensions of risk of illness, and it was found that it is approximately three times more likely to present risk of illness for physical cost among night shift workers than those who works during the day. Literature data corroborate the findings of this investigation, identifying that working at night increases the risk of depersonalization (22) , with higher prevalence of mood swings and headaches among night workers (23) .
After night work, the risk of headaches and upper limbs increased; when associated with a few hours of sleep, it also increases the risk of abdominal and back pain. (24) .
Despite having lower labor demands and higher financial gains -considering the additional wages in relation to daytime workers -, nursing professionals in the night shift have a fragmented work process with interpersonal relationships often conflicting and/or absent, due to low supervision and lower staff numbers, which can cause social isolation and physical and mental illness (21) .
Thus, the importance of the balance between private and professional life is outlined and also the importance of avoiding dissonances between the chronotype and the work shift, thus minimizing biological disorders, the commitment of professional performance and social and family relationships (25) .
Given the findings presented here -greater chances of risk of illness related to physical cost among those workers who work at night and reported complaints of insomnia -, it is pointed out the possibility of the amount of hours of sleep act as a mediator between the work shift and the risk of illness, corroborating a previous study (24) .
Although this investigation did not find a significant difference in the odds ratio between the different working days, the study showed higher prevalence of illness among workers with long working hours (26) . The illness resulting from long working days can be explained by the reduction of free time -for sleep and recovery, family and social experience in addition to the longer exposure time to the risks of illness limited to the work environment (27) . This aspect was reported by nurses in qualitative research, when they attributed the illness to work overload and lack of time for self-care (28) .
Nursing still appears as the professional category that performs the longest working day among health care professionals (29) . A study revealed that, despite positively understanding their work as a care relationship, nursing workers recognize the deficiencies and deficits associated with the organization and working conditions -such as work overload, lack of autonomy and deficit of staff and material -, thus pointing to an ambivalent work (30) . It is important to highlight that long working days were associated with inadequate working conditions, work overload and stress (31) .
A study pointed out that the reduction of the workday makes the work more pleasant, with improved recovery, lower energy requirements, improvements in the quality of care and promotion of balance between personal and professional life (32)  nursing workers about what may constitute a real risk to their health, using in-service education actions, should also be considered. Once clarified about the different kinds of risks to which they are exposed in their work environment, this nursing worker can create strategies to minimize the different risks to their health, not only physically, but also emotionally.
The results of this study, however, alert us to think about solutions for night shift workers that are usually outside the scope of in-service education initiatives.
In other words, educational actions are generally designed and implemented for day shift workers. This "isolation/distancing" from the other members of the nursing team can lead to a feeling of "not being part" of the group, further removing the night shift worker from the feeling of being part of a team that works collaboratively aimed at the recovery of the individual with mental health problems.
The limitations of the study are due to the size of the sample and its design, because, despite meeting the proposed objectives, 74 nursing professionals in the hospital area do not standardize the nursing context in psychiatry existing in Brazil, and make it impossible to perform more elaborate statistical analyses, besides not being possible to make causal inferences.

Conclusion
The results confirmed associations between insomnia complaints, night work and working days of more than 30 hours per week and the risks of illness, mainly associated with the work context. Thus, we concluded that there is evidence that the associations between the work variables, health conditions and life habits and the risks of illness related to the dimensions of the context and human cost at work can harm the health of the nursing staff working in a psychiatric hospital.
Thus, this study will greatly contribute to the knowledge of the risk factors that generate illness of professionals and more specifically the intensity and perception of these factors by professionals, in the context of work in the psychiatric nursing area.