Work process and its impact on mental health nursing professionals

Abstract

Objective

To analyze the work process and its impact on nursing professionals in a mental health service for the care of drug users.

Methods

Cross-sectional study including nursing professionals in a community mental health service. The research instrument was the SATIS-BR and a questionnaire with analysis categories of the work performed. Dialectic hermeneutics was used for the qualitative data. Data were processed and analyzed using the Statistical Package for the Social Sciences.

Results

The work overloads identified have interfered with the satisfaction experienced by workers and reflected in their physical and mental health.

Conclusion

In their work process, nursing professionals were exposed to all work overloads, with mental burnout more intense than the physical, reflecting in dissatisfaction with the work activity and in workers’ physical health.

Nursing/psychology staff; Burnout professional; Occupational health; Mental health; Mental health services

Resumo

Objetivo

Analisar o processo de trabalho e seu impacto nos profissionais de Enfermagem em serviço de saúde mental destinado à atenção aos usuários de substâncias psicoativas.

Métodos

Estudo transversal que incluiu os profissionais de enfermagem em um serviço de saúde mental comunitário. O instrumento de pesquisa foi o SATIS-BR e um questionário com as categorias de análise do trabalho realizado. Para os dados qualitativos, empregou-se a hermenêutica dialética. Os dados foram processados e analisados no programa Statistical Package for Social Sciences.

Resultados

Foram identificadas sobrecargas de trabalho que interferiram na satisfação percebida pelos trabalhadores e refletiram em sua saúde física e psíquica.

Conclusão

Os profissionais de Enfermagem, em seu processo de trabalho, estiveram expostos a todas as cargas de desgaste, sendo o desgaste psíquico mais intenso que o físico, o qual refletiu na insatisfação com a atividade laboral e na saúde física dos trabalhadores.

Recursos humanos de enfermagem/psicologia; Esgotamento profissional; Saúde do trabalhador; Saúde mental; Serviços de saúde mental

Introduction

The working process is a social practice directed to a particular object that should be transformed into a product by making use of tools to achieve a particular purpose. Its basic elements are the agents, objects, instruments, activity and purpose. In nursing, the organization and division of labor refers to the work object, the means and instruments. In this sense, nurses should be able to set priorities and goals, subsequently assessing the results achieved.

Despite the growing interest in studying the workers’ health, there is little discussion about the impact of work for nursing professionals at national and international levels, and even less in the context of mental health.(¹,²) A bibliographic search in the Virtual Health Library from the year 2011 resulted in 15 articles related to the work impact for nursing professionals. However, only five of them dealt with the phenomenon experienced in mental health services.(³,⁴-⁸)

Thus, the guiding question in this study was about the overload to which nursing professionals are exposed in a community mental health service, in order to reflect on the work process and its impacts, and the individual and institutional strategies that can minimize these impacts.

The aim of the study was to analyze the work process and its impact on nursing professionals of a mental health service for the care of users of alcohol and other drugs. The initial hypothesis was the prevalence of mental burnout in relation to physical burnout in nursing workers.

Methods

This is a cross-sectional study conducted in a mental health service specialized in the provision of comprehensive care for users of alcohol and other drugs, part of the Psychosocial Care Network of the Secretariat of the State of São Paulo, in southeastern Brazil. Data were collected between August and November 2013.

The unintentional sample comprised eight nursing professionals formally employed in the institution for over a year, who were not away from their professional activities. These were the eligibility criteria for participation in the study.

For analysis of the work impact referred by participants was used the semistructured instrument called the Scale of Patients’ Satisfaction with Mental Health Services, known as SATIS-BR in Brazil (Evaluation of the Users Satisfaction Scale Brief in English).

A self-administered script with issues relating to the theme was elaborated to obtain data about the work process. Data were organized into the following analysis categories: work object; work purpose; means and instruments of work; and organization and division of work.

Quantitative data were transcribed and submitted to participants to confirm the information obtained by using the Statistical Package for the Social Sciences® (SPSS), version 19. For qualitative data was used the dialectic hermeneutics because it allows the articulation between data collected and the theoretical framework of the study, in order to find the fundamentals related with the issues and formulated goals.

The development of the study met national and international standards of ethics in research involving human subjects.

Results

Among nursing professionals, 62.5% were men, and the age ranged between 26-54 years, with 37.5% aged 25-30 years. Regarding education, only 25% of nurses had postgraduate education in the area of mental health.

Concerning the sub-theme ‘work object’, the workers considered the users as people with cognitive changes reflected in their behavior, impacting negatively on their daily, social and family lives. For them, users needed support and understanding from the service workers and family. The treatment should be systematized in co-responsibility with users and the family, in a unique treatment plan to meet the individual needs of each user.

Similarly, nursing professionals pointed the methods as ‘work purpose’, indicating humanization, and individual and group care as tools. From the perspective of participants, the work aimed to stimulate self-esteem and autonomy, promote coping mechanisms, the ability to build social relationships and improve cognitive ability, contributing to the psychosocial rehabilitation of users.

From the perspective of ‘means and instruments’ of the production process of health services, the professionals mentioned the following workers and services provided to users: reception centers, medicines, referrals and therapeutic workshops.

Regarding the “organization and division of work” in service, the tasks were divided according to the functions of each professional, namely: coordination, administrative staff, technical staff and support staff (general services), and, finally, the community.

When asked about the overload resulting from care to users, 75% of nursing professionals stated they were moderately overloaded. In the same context, 62.5% considered that their work partially affected their general physical health. An indication of this was the increase in problems or physical complaints that appeared after beginning the professional activity in the mental health area.

Regarding the emotional stability of nursing professionals, 50% of them said that working with users has not affected much, while for 37.5% it has affected in part. In general, participants claimed they would feel less emotionally exhausted if they worked in another area.

Dissatisfaction with the job was more evident for 50% of nursing professionals, who stated they often considered changing their work field. However, for 62.5% of the nursing professionals participating in the study, the impact of mental health work did not interfere in family relationships. For the majority, their social life was not affected by their type of work.

Participants have mentioned the following factors as causes of overload: disorganization of the work process, emotional burnout, relationship between professionals and insufficient amount of professionals.

Table 1 shows the work overloads to which nursing professionals were exposed in the workplace.

Table 1
Work overloads in the workplace

Work overloads	n(%)
Inadequate lighting	4(11.1)
Exposure to moisture	3(8.3)
Multiple functions	3(8.3)
Heavy working hours	2(5.6)
Physical burnout	1(2.8)
Distance traveled within the institution	1(2.8)
Weight manipulation	1(2.8)
Standing for long periods	1(2.8)
Mental overloads	n(%)
Mental burnout	5(13.8)
Verbal abuse	4(11.1)
Fear of physical aggression	4(11.1)
Sexual harassment	2(5.6)
Devaluation by the other team members	1(2.8)
Lack of immediate supervision	1(2.8)
Biological overloads	n(%)
Exposure to cigarette smoke	3(8.3)

Some work overloads have prevailed among others, namely those related to the physical structure (19.4%), the working hours and dynamic of work (13.9%), mental burnout (13.8%), fear of physical aggression (11.1%) and verbal abuse (11.1%).

The work aspects that resulted in lower burden for nursing professionals were the performance of their role, flexibility of shifts, decision-making in team, and participation in internal and external activities to the unit.

Despite the evident overload to which nursing professionals were exposed, the institution participating of this study did not offer alternatives for relieving the stress suffered by them. In this sense, they sought coping strategies individually outside the work environment, such as physical activity practice and family life, among others.

Participants have mentioned the reduction of weekly working hours and the increase in number of workers in the nursing team as strategies to minimize the work overloads.

Discussion

The limitations of the study results are related to its design and realization in a single mental health service, not allowing the generalization of results.

By analyzing the work process of the nursing team of a service specialized in the care for psychoactive substances users, the results of this study have added knowledge about the conceptions of these workers on the overloads to which they perceived to be exposed. This enabled a qualitative leap in the work process and, consequently, in the health of nursing professionals and the care for mental health users. The study signaled to managers and mental health workers the work overloads generated in the work process, as well as strategies to minimize them, which therefore must reflect on the degree of satisfaction and retention of nursing workers in their labor fronts.

Among the sociodemographic results, the prevalence of male professionals in the nursing staff of the unit drew attention, since this is uncommon in the profession.

The training in postgraduate courses (Lato Sensu type, equivalent to specialization) stood out in the sociodemographic findings, accounting for one-third of the participating nurses. This data is observed in most services that serve drug users.

The prevailing physical loads in the present study were the exposure to moisture and inadequate lighting. These were also related to infrastructure deficiencies. The physical plant was considered unsuitable to host a mental health service because of inadequate natural lighting; inadequate ventilation, without windows in most rooms; the existence of moisture on the walls; and no emergency exit. The physical resources offered by infrastructure, combined with the emotional resources provided by workers acted as important generators of work stress. Thus, mental health services must combine physical resources with the work demands in order to decrease the work overloads to the health of nursing staff,(⁴) since organizational aspects may play a more significant role for the professional burnout than individual aspects.(¹,⁹)

The heavy working hours and multiple functions have also been mentioned as physical loads to which nursing professionals were exposed, consisting work overload and generating negative impacts on the workers’ health.

A study with health professionals had the objective to identify the organizational and personal factors predictive of professional engagement and occupational stress of the nursing staff and other health professionals. It showed that the workload, mental health, and job satisfaction were correlated with the energy for work. Professional effectiveness was the best predictor of job satisfaction. Therefore, if the workload is not excessive, and professionals feel emotionally balanced and resolute in their professional activity, there should be greater satisfaction in their daily labor routine.(¹⁰)

With respect to biological loads, the interviewed nursing professionals reported exposure to cigarette smoke due to lack of an appropriate area where smokers could use tobacco, a situation caused by infrastructure deficiency.

As the prevalence of tobacco use among people with mental disorders is high comparing to other diseases, conflicts between patients/users in disputes for a cigarette are very common in the daily life of all types of mental health services, in addition to the health risks caused by the smoke resultant of burning its components.

Since 2009, the Brazilian tobacco public policies at state and federal levels have focused on the promotion of smoke free environments.(¹¹) In this sense, the managements of mental health services should develop strategies locally, so users can exercise their citizenship regarding the freedom to smoke and the respect to non-smokers. Frequently, in these spaces there are no areas reserved for smokers, turning non-smokers into passive smokers.

The perceived mental loads were fear of physical aggression, mental burnout, verbal abuse and sexual harassment. The constant attention to threats and fear experienced in the workplace caused emotional exhaustion and made workers feel a greater mental overload.

The experience of psychiatric comorbidity with psychotic clinical picture may result in physical aggression, which led many participants to think that by working in another sector they would be less exposed to overloads. Consequently, they often considered changing their work field in order to decrease the impacts resultant of mental health work.

A study with 69 psychiatric nurses working at a hospital and in an Irish community service revealed that professionals remained in a moderately stressful environment. The work overloads were centered on organizational issues and not on those related to patients or users. The main triggers of professional burnout were lack of resources, workload and organizational/process structures. Both groups showed average levels of emotional burnout, low levels of depersonalization, and average levels of personal fulfillment.(⁵)

The work overload generates dissatisfaction with work and the profession, and may lead nursing professionals to think of changing jobs or even professional activity.(⁴) There is evidence that this occurs more frequently with nurses working in hospital environments. A study showed that professionals working in hospitals had higher scores of depersonalization and nurses working in community services had a greater sense of personal fulfillment.(⁵-¹²)

The exposure to conflict situations and living with violence in the workplace can contribute to the psychological burden on nursing professionals. A protective measure against the violence of patients can be implemented by the service management with appropriate therapeutic support.(¹³,¹⁴) Moreover, the construction of a pleasant atmosphere in the workplace contributes to the prevention of professionals’ emotional exhaustion.(¹)

Many nursing workers identify themselves with the professional activity they develop, but feel with few internal resources to cope better with unexpected situations that arise in the daily service, such as a discussion between users starting unexpectedly or aggressive actions of users with other professionals or themselves. For not knowing how to handle these demands, the physical and/or mental loads are more perceived. In this sense, organizations and administrations should invest in training for mental health professionals to work skills related to emotional intelligence and make them more resilient in face of the demands, accepting them better without generating loads of mental burnout.(⁷,¹⁵)

The lack of coping strategies offered to professionals by the institution made it more difficult to implement other strategies capable to provide support and ways to minimize the overloads experienced in the work routine. The implementation of actions aimed at the supervision and involving the emotional aspect of professionals, discussions of cases attended and about the work itself are strategies to teach nursing professionals to handle overload situations in the workplace and share experiences with other members of the interdisciplinary team.(⁴,¹⁶,¹⁷)

Organizational solutions such as increasing the number of nurses, better training these professionals, as well as reducing the number of hours worked and process automation positively impact the perception of work overload.(¹⁵)

A study carried out in Wales (UK) with 817 nurses in community mental health services aimed at correlating clinical supervision and emotional burnout found that among participants who responded to the questionnaire (n = 260), 73% had clinical supervision in their workplace and 40% had it in a previous job. The results showed that 36% suffered strong emotional exhaustion, 12% showed depersonalization and 10% experienced low levels of personal fulfillment. In the study, 66% of professionals received six or more sessions of clinical supervision. After application of the Manchester Clinical Scale instrument, there were higher scores, indicating lower levels of emotional exhaustion and depersonalization. Thus, the results showed that prolonged clinical supervision can positively impact on emotional burnout levels of nurses.(¹⁸)

The profile of the unit manager tends to influence the perception of work overload and emotional burnout of workers.(³,⁶,¹⁶) There is evidence that when the professional manages the unit jointly with the health team, other workers, patients and families, through meetings of the technical team, management board and assemblies with predetermined frequency, empowering all actors in the service, there is greater individual satisfaction of the nursing professionals with work, and lower perception of physical and mental burden of everyday labor. Hence the relevance of the unit manager having a good profile for the role. An autocratic profile certainly reflects on interpersonal relationships, in the perception of satisfaction and work overload and, consequently, on the quality of care to users.

Finally, the results of this study suggested that interdisciplinary work; the expansion of the workforce and training of nurses; the bonding between professionals and users that contributes to greater emotional exchanges; and the characteristics of intrasectoral and intersectoral mental health work in community services may constitute factors that minimize the perception of work overload. Moreover, the level of job satisfaction is associated with higher or lower perception of overloads generated by work activities.(⁴,¹⁵,¹⁶)

Conclusion

In their work process, nursing professionals were exposed to all work overloads, with mental burnout more intense than the physical, reflecting in dissatisfaction with the work activity and in the physical health of workers.

Acknowledgements

Thanks to the Conselho Nacional de Ciência e Tecnologia for granting the scientific initiation scholarship and to the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior for granting the Postdoctoral scholarship.

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Publication Dates

• Publication in this collection
  Sep-Oct 2015

History

• Received
  17 Mar 2015
• Accepted
  28 Apr 2015