Professional satisfaction of nurses working with home care

Abstracts

Estudo realizado com 34 enfermeiros para conhecer o nível de satisfação desta classe profissional em relação ao trabalho. Utilizou-se o questionário do Índice de Satisfação Profissional (ISP), traduzido, validado para a língua portuguesa e adaptado para a assistência domiciliar analisando seis componentes: Interação, Autonomia, Remuneração, Status Profissional, Normas Organizacionais e Requisitos do Trabalho. Os resultados mostraram os enfermeiros mais satisfeitos nos aspectos Autonomia, Interação e Requisitos do Trabalho. O ISP encontrado no estudo foi de 13,19. Esse valor foi baixo, considerando a possível variação de 0,9 a 37,1, embora tenha sido superior aos índices de satisfação encontrados em outras pesquisas envolvendo enfermeiros.

Enfermagem; Satisfação no trabalho; Serviços de Assistência Domiciliar

ORIGINAL ARTICLE

Professional satisfaction of nurses working with home care

Satisfacción profesional entre enfermeros que actúan en atención domiciliaria

Flávia Feliciana Silva Paiva^I; Adelaide de Mattia Rocha^II; Luciana Dalva Ferreira Cardoso^III

^INurse. Specialist in Hospital Infection Control. Professor of the Nursing Course, Universidade José do Rosário Vellano. Nurse of the Home Care Program of a Private Company in the city of Belo Horizonte. Belo Horizonte, MG, Brazil. [e-mail]

^IIPh.D. in Nursing. Full Professor of Basic Nursing, School of Nursing, Federal University of Minas Gerais. Belo Horizonte, MG, Brazil. [e-mail]

^IIINurse. Specialist in Hospital Infection Control. Nurse of the Home Care Program of a Private Company in the city of Belo Horizonte and at the Minas Gerais Military Police Hospital. Belo Horizonte, MG, Brazil. [e-mail]

ABSTRACT

The objective of this study was to learn the level of satisfaction that nurses have about their work. Participants were 34 nurses, who answered the Professional Satisfaction Index (PSI), translated and validated for the Portuguese language and adapted to home care. The following six components were analyzed: Interaction, Autonomy, Remuneration, Professional Status, Organizational Norms, and Working Requirements. The PSI found in the study was 13.19. This was a low value, considering the possible variation from 0.9 to 37.1, though it was greater than the satisfaction indexes found in other nurse studies.

DESCRIPTORS: Nursing; Job satisfaction; Home Care Services.

RESUMEN

Estudio realizado con 34 enfermeros para conocer el nivel de satisfacción de esta modalidad profesional en relación al trabajo. Se usó cuestionario de Índice de Satisfacción Profesional (ISP) traducido, validado para lengua portuguesa y adaptado para la atención domiciliaria, analizando seis componentes: Interacción, Autonomía, Remuneración, Status Profesional, Normas Organizacionales y Requisitos Laborales. Los resultados mostraron a los enfermeros más satisfechos en los aspectos Autonomía, Interacción y Requisitos Laborales. El ISP resultante del estudio fue de 13,19. Ese valor resultó bajo considerando la posible variación de 0,9 a 37,1, a pesar de haber sido superior a los índices de satisfacción encontrados en otras investigaciones involucrando personal de enfermería.

DESCRIPTORES: Enfermería; Satisfacción en el trabajo; Servicios de Atención de Salud a Domicilio.

INTRODUCTION

The changes made in the working process have increased the demands imposed on workers, who must be more and more qualified in order to produce work with better quality and greater productivity. In the health area, new health care technologies and population aging have contributed to increasing the demand for highly complex services, with a consequent rise in the costs of those services.

Home care emerged as an alternative to hospital interventions, aiming at reducing the demands of hospital admissions or shortening the length of stay. The incorporation of new technologies and methods of treatment permitted to offer, at home, many of treatments that were once only available at hospitals.

The home care model represents a great challenge for nurses, as some features of its working process are very different from the hospital model, which was the main focus of the nurses' education.

Some characteristics specific to the home care model, e.g. a greater participation in family conflicts, the risk of being exposed to violence on their way to the visit, a smaller infrastructure for emergency situations at home, or the therapy limitations of patients receiving palliative care could be considered as factors that contribute to dissatisfaction at work. However, it is assumed that because the care occurs outside an institution, nurses would have more freedom in their work and have greater autonomy, which would result in professional satisfaction.

Therefore, we question if the model adopted in Home Care provides the satisfaction or dissatisfaction of nurses towards work and what are the variables involved in the satisfaction/dissatisfaction binomial in this model of care.

Although controversies exist regarding the concept of Work Satisfaction and its associated variables, systematically, it can be defined as a pleasant or positive emotional state resulting from the evaluation of a work situation, or any experience lived in it. That evaluation is subject to one's values and beliefs, and, if the outcome is an unpleasant emotional state, it will cause dissatisfaction and may affect the worker's physical and mental health, interfering in his/her professional or social behavior^(1-2).

Considering the growing dissemination of home care services in Brazil, and in view of the relevance that the theme professional satisfaction has for nurses and the scarcity in our environment of studies surrounding this theme, it became timely to develop a study that would fill in the existing gap.

The present study was designed with the objective to evaluate the work satisfaction of nurses working with home care.

LITERATURE REVIEW

Home Care as we know it appeared in the United States, in 1947, as an institutionalized practice motivated by the need to relieve the hospitals and create an environment more suitable for the patient's recuperation⁽³⁾.

The Norm Resolução da Diretoria colegiada (RDC) number 11 was established in 2006, and disposes about the technical regulation for the delivery of home care services, which involves a variety of modalities: from visiting chronic patients at home, through providing palliative care to terminally ill patients, to establishing medical-hospital devices for intensive home care, similar to that offered in hospital care⁽⁴⁾. Therefore, the health care needs of a patient receiving home care are very different from those of a patient in hospital, and thus may involve different types and intensities of physical and emotional efforts form the professionals assisting them.

The managerial processes adopted at the hospital level affect the nurses' health conditions, and can become determinants of health hazards if authoritarian or improve health if more flexible and democratic. The activities performed by the nursing team working in hospitals are permeated with physical and psychological burdens that harm their quality of life⁽⁵⁾. Therefore, it is important to investigate if that physical and emotional burden persists in other contexts of care, such as Home Care.

It has been suggested that organizations should evaluate the factors of work dissatisfaction among nurses so they can be treated with the due importance. That would allow for nurses to be acknowledged through their competence, politicization, organization of the category, the positioning of the team in the institution, and performing quality work⁽⁶⁾.

Regardless of the location and methodology used, professional satisfaction in nursing is a theme that should be investigated so that the difficulties that nurses experience in their practice can be detected and minimized⁽⁷⁾.

METHOD

This exploratory, descriptive study was performed with a quantitative approach and using prospective data⁽⁸⁾.

The study was performed at a private company, in the city of Belo Horizonte, that assists home care as defined by RDC 11/2006⁽⁴⁾. The profile of the clientele is characterized by having at least one impaired Activity of Daily Living (ADL), with most patients being individuals with dementias and stroke complications, and other chronic-degenerative diseases such as Parkinson's disease.

The study population consisted of 44 nurses working at the service. The following were excluded: one nurse whose activities were exclusively administrative; three nurses who were on sickness leave by the National Social Security Institute (INSS), with no expected date of return; two, for being the researchers; and four who did not wish to participate. The sample was, hence, composed of 34 subjects, referring to 77% of the total.

The independent variables of the study were the professional data, and professional satisfaction was the dependent variable, defined as that which the researcher wishes to explain, understand, or predict, which is influenced, determined, or affected by the independent variables⁽⁸⁾.

The Professional Satisfaction Rate (PSR) was measured using an instrument translated and validated to Portuguese, which has the objective to evaluate work satisfaction according to six components: Autonomy, Interaction, "Professional Status", Work Requisitions, Organization Norms, and Remuneration⁽⁹⁾. Because the original instrument was created specifically to collect data among nurses working in the Intensive Care Unit (ICU), it was adapted for home care, thus meeting the object of study. The only change made to the original instrument was replacing ICU by Home Care. A pre-test was made with 10% of the study population, and the instrument was considered appropriate, preserving the original standard.

The instrument has the form of a questionnaire consisting of three parts: the first (Part A) consists of items for socio-demographic and professional characterization of nurses; the second (Part B) contains one method of Paired Comparisons that combines six components related to Professional Satisfaction in terms of the degree of importance that nurses assign to each component; the third (Part C) relates the measurement of the current work situation with the measurement of the expectations towards work using a Likert scale. The scale has a positive direction and the highest score (7) should be assigned to the answer that indicated the highest level of satisfaction⁽⁹⁾.

The study began after being approved by the Research Ethics Committee on 03/03/2009 under document number 565/08, and complied with all the parameters of Resolution 196/96, the National Health Council (Ministry of Health), regarding research involving human beings in Brazil, including the consent form⁽¹⁰⁾.

The researchers collected the data between April and August 2009, in the mornings and afternoons, at the Home Care Program center.

The obtained data were organized on an electronic spreadsheet as a databank for statistical analysis. To do this, we used Statistica 6.0 and Microsoft Excel 2007.

The socio-demographic and professional data of the home care nurses were analyzed using descriptive analysis.

The questions that addressed the PSR were recoded following the steps that the author recommended for scoring⁽⁹⁾. We used the Weighting Coefficient of the components of work satisfaction (Part B), The Mean and Total Scores of the Component on the Scale (Part C) and the Adjusted Component Scale to obtain the nurses' professional satisfaction rates.

To evaluate data reliability we used the Cronbach's Alfa Coefficient ranging from 0 to 01. An appropriate alpha for the developed instruments should b greater than 0.8⁽⁹⁾. The total alpha coefficient of the scale for this study was 0.92, which shows that the instrument has a small measurement error.

The Tau Kendall test was also used to evaluate reliability, and the values found were between 0.84 and 0.86. Considering that its value must be between 0.80 and 0.90⁽⁹⁾, the obtained results indicated high reliability for the instrument.

RESULTS AND DISCUSSION

Historically, nursing is known as a predominantly female profession, as stated by several authors^(7,11-12). By analyzing the data of home care nurses according to the gender, we found there were more women (31, 91.17%) than men (3, 8.82%).

It was found that most professionals were young (32, 94.12%), with less than 37 years, and, consequently, with a maximum 10 years since their graduation (33, 97.06%). These findings are in agreement with those of previous studies that identified that most nursing professionals were at their most productive age^(12-13).

Regarding education, 20 nurses (58.82%) had a specialization degree in other areas; only two (5.88%) had a specific education in Gerontology, although this is the greatest demand of care in the studied service. However, 14 nurses (41.18%) informed they were attending a specialization course in that area. There are no career or salary plans in the studied company, and the mean monthly remuneration was five minimum salaries. We did not find any nurses with a title higher than a specialization degree.

The relevance of the nurses' preparation for home care can be attributed to the growing dissemination of this type of service and the escalating demand for professionals with specific skills that would allow them to achieve the goals of the increasingly complex home care service⁽³⁾.

None of the interviewed nurses had any previous work experience with home care, 30 (88.23%) had worked at the service for less than three years, which is in agreement with the institution that has provided home care services for less than six years and expanded its service over the last four years. The weekly workload is 36 hours, and is performed exclusively in the day: 20 (58.82%) work in the morning, and 14 (41.18%) work in the afternoon.

All the interviewed nurses reported enjoying working with home care, and are satisfied with the work, and the most common activity they performed was direct patient care. Of these nurses, only one (2.94%) was transferred to home care on the account that the service needed this change, while all the other 33 (97.06%) nurses had chosen to work with home care.

Among the above factors, working during the day and the predominance of health care services could be directly related to a higher level of work satisfaction, as the literature has referred to having to work nights and the excessive bureaucratic activities as reasons for nurses' dissatisfaction towards work^(3,5-7). Choosing the place of work has a positive effect on work satisfaction and productivity⁽⁵⁾.

Regarding the nurses' marital status, different from previous studies^(7,12-14) that reported a higher percentage of married nurses, the present study found that most participants (20, 58.82%) were single and without children. Among the 14 (41.18%) married nurses, two (5.88%) had more than one child, 10 (29.41%) had only one child, and two (5.88%) had none.

It is understood that the innovations in the working market and the demand for improving the preparation and professional development imply that women will get married and have children at an older age. Similar results were found in a study with nurses of an ICU, which also found that most nurses were single and had no children⁽¹¹⁾.

The Weighting Coefficient of the work satisfaction components (Part B) was obtained using the frequency matrix of the choice of each of the paired component, followed by the conversion of the proportions into standard deviations (matrix Z) using the correction factor + 2.5. The Weighting Coefficient is directly proportional to its degree of importance, ranging from 0.9 to 5.3⁽⁹⁾.

The frequencies of the answers obtained for the different levels of agreement, neutrality, or disagreement related to the attitude scale (Part C) were grouped into categories for a better understanding of the results. We used the answer frequency to obtain the Mean Score of the Scale Components that show the nurses' current professional satisfaction regarding each of the six components of the PSR.

The Scale Weighting Scores (Column I) and the Mean Scores of the Scale Components (Column II) are seen in Table 1.

The studied nurses considered that the most important component to obtain work satisfaction was Autonomy. Previous studies performed with the nursing teams of Intensive Care Units (ICU), Emergency Medical Services (SAMU) and Surgery Departments have found similar results^{(7,9,11-12,14)}.

Autonomy offers better professionalization and reputation to an occupation, meeting the individual need of social integration. The lack of autonomy is seen as a negative factor for work⁽¹¹⁾. In the attitude scale (Part B), we found that 85.29% of the nurses marked they disagreed with the statement Sometimes I feel frustrated because all my activities appear to have been programmed for me, 88.23% agreed with the item I feel I participate enough in planning the health care for each patient, but 55.88% disagree with the statement I have too many responsibilities and not much authority.

Therefore, an unbalance is observed between the importance assigned to autonomy and the third position this component occupies in the nurses' current satisfaction, as seen in Table 1.

Today, there are many challenges in the world regarding the fragmented thought created by the rationalism of modern age⁽¹⁵⁾. It is considered that the alternative health care models, including home care, need to overcome biological myths in order to develop interdisciplinary knowledge founded on the theory of social production. This new paradigm in health implies a greater interaction of all the subjects involved in the service, which in home care surpasses the limitations of the professional team, as patients, relatives and caregivers are active subjects of care.

Regarding the Integration, which is the second most important item to achieve work satisfaction according to the participants, and the component they currently show the highest satisfaction, there was greater agreement in the answers In my unit there is a lot of teamwork among nurses and physicians (91.18%), At my service, nurses make themselves available and help each other when things get busy (85.29%), and disagreement in The physicians at this service underestimate the nursing team too much (79.41%). In the sub-component I would like physicians working here to show more respect for the nurses' skills and knowledge, most answers were neutral (55.88%).

The relationship issue between physicians and nurses, due to the hegemony of the physicians implied by the Biomedical Health Model, persists until today, and has also been confirmed in other studies^(12,14). In home care we find there is more interaction in the team, but we observe that nurses do not see much appreciation of their skills and knowledge from the physicians.

The hierarchy of nursing work and the power relationship often instituted between nurses and the other team members are the cause of many conflicts in the relationships between these professionals^{(7,9,11-12,14)}. At the studied service, there is no routine inclusion of nursing auxiliaries and technicians at work, except in cases of intensive home care, which is not the highest demand of service. The inexistence of this hierarchy is a possible explanation for the better interaction in the nursing team.

By comparing the nurses' current level of satisfaction in terms of the components of professional satisfaction (Part III of the scale) with the level of importance attributed to each (Part I of the scale), it is observed in Table 1, that Remuneration was the only component whose perceived level of satisfaction was lower than the level of importance. This was an expressive finding, although it was not surprising because it had already been described in previous studies about the dissatisfaction of the nursing team regarding the low remuneration of this professional category^(9,11,14).

Several studies point at the association of economical aspects with work satisfaction and found that low remuneration was one of the motivators for dissatisfaction in the nursing team^(7,9,11,14). In the present study, 73.53% of the nurses disagree with the statement "I am satisfied with my current salary", but 82.35% of them agreed with the statement "From what I have heard about the nursing staff from other institutions, we receive a fair remuneration". It is understood that the nurses are aware about and dissatisfied with the low salary their category receives.

It is observed there is a disagreement regarding the evaluation of the performance of the Work Requirements and Organizational Norms components.

In this study, the Work Requirements component was considered to be one of the least important, but second in terms of satisfaction among nurses. As described before, we could attribute a greater satisfaction in relation to this component in this study because of the predominance of health care activities in the nurses everyday routine instead of bureaucratic and administrative activities, which have been proven to contribute to the professional dissatisfaction of nurses in other studies^(9,11-12).

The work bureaucratization, inflexibility, routinization, and overload are considered to be the Work Requirements that cause dissatisfaction in the nursing team ^(7,9,11-12).

Although 94.12% of nurses reported being satisfied with the types of activities they perform at work, and 82.35% agreeing with the sub-component I have enough time for direct patient care, 73.53% of the population agreed with the statement In this service, nurses have a lot of bureaucratic and administrative work, possibly characterizing work overload.

Based on the findings regarding the Organization Norms component, 76.47% of the studied nurses agreed with the statement In my service, nurses have enough control over their own work shift planing. Considering that in home care, the service is delivered during scheduled visits, we found that the team has more flexible working hours, which could have a positive effect on their satisfaction towards work.

Another aspect revealed in the study was a greater percentage of nurses (61.76%) that disagreed with the statement There is a large gap between the administration of this service and the daily problems of the nursing team. We found disagreement between this finding and the fact that 58.82% of nurses agreed with another statement: In this service, the administrative decisions have a strong influence on patient care. This contradiction was also found in the study with nurses of the emergency medical service⁽¹⁴⁾.

The lack of promotion opportunities for nurses appeared to be associated with their demotivation and dissatisfaction at work, as this study found that 91.18% of the population agreed with the statement: This job does not offer sufficient opportunities for nurses to be promoted. Therefore, the Organization Norms was the component that received the lowest degree of importance and satisfaction by the studied population.

The Professional Status component, which was assigned the least importance, is described in the nurses' practice as devaluation and lack of acknowledgement of their work, verified by the low remuneration, work overload and few expectations of rising in the career^(7,9,12-13).

Regarding the nurses' perception of their Professional Status, as in previous studies^(7,12,14) that reported the lack of acknowledgement and respect for nursing work, 79.41% of nurses agree that Nursing is not broadly recognized as being an important profession and 55.88% disagree that Most people recognize the importance of nursing in home care. Nevertheless, 97.06% of the home care nurses agreed with the statement I have no doubts in my mind: what I do in my job is truly important.

A study performed in a surgery department evidenced that the nursing team recognized the importance of their profession, but still felt it was necessary to prove their essencial role in order to be respected as other professions in the health area⁽¹²⁾.

The Total Scale Score provides an estimate of the total satisfaction levels and is calculated by summing the Total Score of the Components, ranging from 44 to 308, in which higher values represent greater work satisfaction. As for the Mean Scale Score, obtained by summing the mean Score of the Scale Component and dividing it by the number of components (6), ranges from 01 to 07. The present study presented a Total Scale Score of 207.98 and Mean Scale Score of 4.69. The Total and Mean Scale Scores found in other studies were, respectively: 164.86 and 3.74⁽⁷⁾; 137.91 and 3.8⁽⁹⁾; 141.89 and 3.81⁽¹¹⁾; 170 and 3.85⁽¹²⁾; 133.47 and 3.5⁽¹⁴⁾.

The PSR of the home care nurses was obtained by summing the Adjusted Scores of each professional satisfaction component and dividing it by the number of components (6). The PSR found in this study was 13.19. Although it indicates low professional satisfaction considering that this rate is between 12 and a maximum of 37, it was higher than the satisfaction found in other nurse studied^{(7,9,11-12,14)}.

Figure 1 shows the true level of professional satisfaction among home care nurses, which is a weighted measure between the importance they assign to the components and their perceived satisfaction in that regard⁽⁹⁾.

Nurses show more satisfaction regarding Interaction, Autonomy, Remuneration, Work Requirements, Professional Status, and, finally, the Organization Norms component.

CONCLUSION

Considering the proposed objectives of the present study, we conclude that most of the studied nurses were women, young, single, and without children. Most participants were attending a gerontology specialization course, and had thus chosen deliberately to work with home care, and have been working in this field for less than three years, with no previous experience.

Regarding the level of importance assigned to the professional satisfaction components and the real level of satisfaction, home care nurses considered that Autonomy was the most important and Professional Status the least important component, and were more satisfied with Interaction and Autonomy and least satisfied with the Organization Norms component.

The low work satisfaction rate among home care nurses, despite being greater than the satisfaction found among nurses from other sectors, is evidence of the need to improve the working process of these professionals with a view to provide better life conditions and health care quality.

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Correspondence addressed to:

Publication Dates

• Publication in this collection
  12 Jan 2012
• Date of issue
  Dec 2011

History

• Received
  29 Oct 2009
• Accepted
  07 Apr 2011