versión impresa ISSN 0080-6234
Rev. esc. enferm. USP vol.46 no.2 São Paulo abr. 2012
The effects of professional factors on the quality of life of family health team nurses*
La relación de los aspectos profesionales en la calidad de vida de los enfermeros de los equipos de salud de la familia
Janielle Silva FernandesI; Sybelle de Souza Castro MiranziII; Helena Hemiko IwamotoIII; Darlene Mara dos Santos TavaresIV; Claudia Benedita dos SantosV
IMaster in Health Care by the Graduate Program in Health Care, Federal University of Triângulo Mineiro. Uberaba, MG, Brazil. firstname.lastname@example.org
IIPh.D. in Public Health Nursing. Adjunct Professor of the Department of Social Medicine, Federal University of Triângulo Mineiro. Uberaba, MG, Brazil. email@example.com
IIIPh.D. in Fundamental Nursing. Adjunct Professor of the Department of Hospital Care Nursing, Federal University of Triângulo Mineiro. Uberaba, MG, Brazil. firstname.lastname@example.org
IVPh.D. in Nursing. Adjunct Professor of the Department of Nursing in Community Health and Education, Federal University of Triângulo Mineiro. Uberaba, MG, Brazil. email@example.com
VPh.D. in Statistics. Adjunct Professor of the Maternal-Child and Public Health Nursing, University of São Paulo at Ribeirão Preto College of Nursing. Ribeirão Preto, SP, Brazil. firstname.lastname@example.org
The objective of this study was to identify the professional factors affecting the quality of life of nurses working in the family health teams in the Macro Health Region, referred to as the South Triangle, in the State of Minas Gerais. This is a descriptive, cross-sectional study. The participants were 90 nurses, who answered a questionnaire containing the professional variables and the Quality of Life assessment instrument - WHOQOL-100. The results showed a negative impact regarding the number of jobs, unstable jobs, excessive workload and job dissatisfaction in the nurses' Quality of Life domains. There is a need to (re)define the public policies that control the working conditions of these professionals. Actions that contribute towards improving nurses' Quality of Life are important, considering their strong influence on the quality of the healthcare that is delivered.
Descriptors: Quality of life; Nursing, team; Family health; Occupational health
Ese estudio objetivó conocer los aspectos profesionales relacionados a la Calidad de Vida de los enfermeros de equipos de salud de la familia de la Macro-región de Salud del Triángulo Sur. Se trata de un estudio descriptivo y transversal. Los 90 enfermeros sujetos de la investigación respondieron un cuestionario conteniendo las variables profesionales y el instrumento para evaluación de Calidad de Vida WHOQOL-100. Los resultados muestran impacto negativo del número de vínculos, del vínculo laboral inseguro, de la excesiva carga horaria de trabajo en los dominios de Calidad de Vida del enfermero. Se considera necesaria la (re)definición de políticas públicas orientadas a las condiciones de trabajo de tales profesionales. Son importantes aquellas acciones que contribuyan al desarrollo de la Calidad de Vida del enfermero, considerando su fuerte influencia en la calidad de la atención brindada.
Descriptores: Calidad de vida; Grupo de enfermería; Salud de la familia; Salud laboral
The Family Health Strategy (FHS) is a national public policy and has gained recognition as a strategy for reorganizing primary health care based on the logic of health surveillance. The FHS was implemented in Brazil as the major means to reorient health care according to the principles and guidelines of the national health system (Sistema Único de Saúde SUS). The actions of the FHS represent a health concept centered on promoting quality of life (QL) through its main objectives: the prevention, promotion and recovery of health(1).
For health care professionals, the implementation of the FHS means to review their own practices, values and knowledge, because it increases the complexity of the actions being developed as well as the limits and possibilities of practice, which requires new skills.
In order to work with quality, and encourage the community towards seeking better health conditions, it is understood that health professionals need good QL, because the factors that interfere in their QL can compromise the quality of the care they provide. The quality of life of health care professionals is a theme drawing increasing interest over the last years, considering the importance of the factors involved in the work context and its relationship with the quality of the care that is provided(2).
Knowing the QL of these workers permits to identify the changes that must be made to promote their well-being and the appropriate condition for their rehabilitation. Depending which domains of the workers' QL are affected, they may face different disorders that could, inclusively, compromise their roles and attributions at work(3).
QL information has been used to assess the efficacy of certain treatments for diseases and illnesses and their physical and psychosocial impact. Furthermore, QL information also have an appropriate use in epidemiological studies and in planning and evaluating the health system(3). The World Health Organization defines QL as: individual's perception of their position in life, in the context of culture and the value system in which they live and in relation to their goals, expectations, standards, and concerns(4).
Among the family health team components, nurses stand out due to their relevance in the development of health systems. As professionals participating in the reform of the health care model, nurses stand out due to their significant responsibility in the many actions developed within the community and in the health team. They are participative agents in charge of operating primary FHS activities and their actions have a direct effect on the implementation of the strategy and its outcomes(5,6).
The QL studies centered on this professional category in Brazil are scarce and lack methodological consistency, which impeded the construction of a specific body of knowledge. No studies centered on primary care nurses were in the Brazilian scientific literature(5).
The assessment of nurses' QL offers subsidiary information to improve the working process in health, clinical practice, professional-user relationship, and to guide the (re)definition of specific public policies for these professionals in their performance. Promoting better life and working conditions for these workers could have a positive impact on the health of both nurses and the population they care for.
To evaluate the professional aspects related to the QL of family health team nurses.
This is a descriptive, cross-sectional study. The population consisted of family health team nurses from the 27 cities comprising the South Triângulo Mineiro region, who agreed to participate in the study. Twenty-three nurses were on a temporary leave from work or on vacation, and, therefore, were excluded from the study. None of the nurses refused to participate. Of the total 113 nurses who were working regularly during the data collection period, i.e. between May and July 2007, 90 (79.7%) participated in the study.
Data were collected using two self-administered instruments: one for the overall QL assessment; and the other containing the professional variables. We came in touch with the participants at their respective Family Health Units, and explained the study objectives, how to complete the questionnaire, sign the Free and Informed Consent Form, they were guaranteed the anonymity of their answers, and any doubts they had were solved. Only after their agreement and signature of the referred form, the instruments were administered.
The QL assessment was performed using the validated Brazilian version of the World Health Organization Quality of Life (WHOQOL-100), comprised of 100 questions distributed across six domains: physical, psychological, level of independence, social relationships, environment, and spirituality/personal beliefs. Each domain is comprised of specific facets, with a total of 24. Each facet consists of four questions. In addition to the 24 specific facers, the instrument has a twenty-fifth facet comprising general QL questions. The instrument was answered in one single meeting and based on the two weeks in their lives before answering the questionnaire. This questionnaire was chosen because it is generic, i.e., broad in terms of QL aspects and has shown satisfactory psychometric characteristics in the Brazilian population(4).
In relation to the professional aspects, the following variables are addressed: number of jobs, nature of the job contract, daily workload, monthly income with the FMS, accumulated monthly income from all jobs, and satisfaction towards work.
The data were managed and analyzed using SPSS software 16.0. The categorical variables were subjected to descriptive analysis abased on the frequencies, in absolute numbers as well as percentages. Regarding the numerical variables, the descriptive measures of centrality (mean, median and mode) and of dispersion (standard deviation, coefficient of variation, maximum and minimum values). In addition, the WHOQOL-100 syntax was applied in the SPSS to evaluate the QL scores. The scores obtained in relation to the domains are determined in a scale from 4 to 20, in which the higher the value, the higher the QL in that domain. The scores obtained in each domain and regarding the overall QL were ranked into four intervals for a better understanding of the results (Chart 1).
The association between variables and the scores of the QL domains were verified by comparing QL scores across the different categories of professional variables, in which the Student's t-test was used for variables with two categories and ANOVA-F followed by the Tukey multiple comparison for variables with more than two categories. In cases with no normality, the Mann-Whitney and Kruskal-Wallis non-parametric tests were used followed by Dunn's multiple comparisons, respectively. A 5% level of significance was considered (p<0.05).
The p values are interpreted considering the hypothesis that the cases consist of a convenience sample of a hypothetical population with similar characteristics.
This study was performed in accordance with Resolution 196/96 of the National Research Ethics Committee, and was approved by the Research Ethics Committee at Federal University of Triângulo Mineiro (protocol 791/2006). Furthermore, the study was approved by the Municipal Health Administrators, and all participants provided written consent.
Most of the family health team nurses of the South Triângulo Mineiro region were female (92.2%). Their mean age was 28.6 years (± 5.9), with most in the age group of 20├ 30 years (72.1%).
Regarding the number of jobs, 64.8% had only one job, and 33% held two different jobs. Regarding the nature of their job contract with the FHS, 62.9% has a temporary work contract and 19.1% had passed a competition exam. Regarding their daily workload with the FHS, 92.1% worked an eight-hour shift. The monthly income with the FHS was between R$1,400.00 and R$2,799.00 (between four and eight minimum salaries at the time of data collection) for 83.3% of the nurses. Regarding the gross value they received from their jobs combined, 72.7% reported the referred income, and 14.8% reported receiving more than R$2,800.00. When the nurses were asked about their satisfaction towards work, 61.8% answered they were satisfied or extremely satisfied with their work, and 37.7% were more or less, very little, or not satisfied.
The overall quality of life, comprised of the facets satisfaction towards life, satisfaction towards health, satisfaction towards their own QL, and QL assessment, received a mean score of 16.7, which means there is no negative impact of the facets.
The scores found for the domains evidenced higher mean scores for the level of independence, aspects of spirituality/religion/personal beliefs, and social relationships. The smaller means were obtained for the psychological, environment and physical domains (Table 1).
The variation obtained, from 14.1 to 17.0 shows that these values are above the levels of neutrality, with tendency towards a positive valorization, which means satisfactory QL, i.e., small or no negative impact from the QL domains. The internal consistency of the WHOQOL-100 for the facets (0.78), domains (0.88), domains+facets (0.91) and 100 questions (0.94) was assessed using the Cronbach's reliability coefficient and found good internal consistency in the present study population, with values above 0.70.
No statistically significant differences were found between the mean scores of the QL domains between the FHS salary levels and accumulated monthly incomes (p>0.05).
The group that reported having only one job presented a lower mean QL score in the environment domain, compared to the group of nurses holding two or more jobs (p=0.033) (Table 2).
Regarding the types of jobs, in the spirituality domain (p=0.009), the Others group (temporary work contract or commissioned position) achieved a worse mean QL score compared to the Competition exam and Work contract group (Table 2).
The group working eight hours a day in the FHS presented a higher mean QL score n the psychological domain (p=0.025), compared to the group working twelve hours or more (Table 3).
Regarding their satisfaction towards work, the More or less, very little, or not satisfied group presented smaller mean scores in the physical (p=0.005), psychological (p=0.000), level of independence (p=0.020), and environment (p=0.003) domains, compated to the Extremely, or very satisfied group (Table 2).
The present study results, regarding the nurses' profile, confirm the finding of previous studies(6-7) that show that nursing is mainly a female professional. In nursing, this historical characteristic appears to be connected to the essence of the profession: care. The act of caring has always been associated with the feminine image.
The age group found for FHS nurses in the South Triângulo Mineiro region confirm studies performed in ten large urban centers when FHS nurses are usually younger than 30 years of age(8). On the other hand, a nation study found that most nurses were above 30 years of age, with a mean age of 34 years, i.e., above the values found in the present study(7).
The data demonstrate that in the case of the South Triângulo Mineiro refion, the FHS appears to comprise a more effective work alternative for young professionals, with little experience or newly graduated. This statement can be related to the greater knowledge that these professionals have about the FHS foundations and principles due to the relatively recent inclusion of this content in the nursing curriculum. A national study(7) pointed out that the nurses had less than 15 years since their graduation.
Regarding their working conditions, it is observed that the nurses were incorporated in the FHS through a temporary contract complying with the current legislation (67.8%), working an average of eight hours per day (92.2%), and receiving between R$1,400.00 to R$2,799.00, between four and eight minimum salaries at the time (83.3%), and the other nurse subjects received salaried below the referred value. Some participants held other jobs besides the FHS (35.5%). Data of the Ministry of Health demonstrate that this is the predominant reality of Brazil, because only 15.2% of family health nurses are employed under the statute, as most are hired under a temporary and service contract(8). There are about 200,000 health care professionals working in the FHS with no contract under the legislation or statute, or any other formal form of employment(9).
In Brazil(7) it was observed that 43.67% of nurses work with the FHS under a temporary contract, 61% have no legal guarantee of their occupational rights, work 31 and 40 hours per week (68.22%), and report receiving a mean salary of R$1,750.00, ranging between R$550.00 and R$3,500.00. Other studies also show nurses close to this occupational profile(7,11-12).
The percentages found in the present study and in the literature regarding the precarious jobs or under temporary contracts are expressive, considering that the family health model proposal requires workers to be stable in their job positions, because the legal aspect of work contracts and safe employment promote more security and decent work conditions for nurses to accomplish their roles completely.
Regarding their remuneration, we observe that the nurses' salaries found in the present study are outdated, because they are actually lower compared to those reported by the national research professionals(7), and that is without considering the losses due to inflation in the period. Furthermore, these salaries are lower compared to those of most nurses in the State of Minas Gerais according to a study performed by the Health Human Resources Observatory, who stated that salaries range between R$2,000.01 and R$3,000.00, currently corresponding to approximately U$1,750(12).
It is observed that the remuneration found in the Family Health Strategy is not consistent with the nursing profession, because the position requires great responsibility due to the growing attachment established with society, and the many specific attributions determined by the Ministry of Health, which, in practice, assume additional unpredicted demands related to the local reality, making the work heavier than the expected.
The FHS nurses from Ipatinga - MG defined their remuneration as dissatisfactory, particularly related to the workload and the responsibility that nurses assume in a family health team. Furthermore, their dissatisfaction increased when they compared their salaries to those of physicians. The study demonstrated that FHS nurses consider their remuneration compatible with the reality of the labor market of the category, but this has not been sufficient to keep the nurses in the team(10).
The present study data corroborate with the thesis that the FHS, as a policy for the expansion of health care, consequently expand work posts with limited financial resources, hence the existence of workers with different contracts and salaries for the same role, as well as flexible to precarious forms of employment. However, these strategies adopted to dribble legal obstacles increase the human resource problems in health.
Therefore, it is realized that the precarious jobs and low salaries cause insecurity and professional dissatisfaction, which in the present study was 37.8%, creating difficulties to implement and establish the FHS. In these conditions, nurses tend not to consider the FHS to be their main activity, or they eventually leave the FHS and choose another job that offers better salary and employment conditions.
Regarding the analysis of the professional aspects, it was observed the number of jobs affected the environment domain, in that nurses who had one job presented a lower QL score compared to those with two or more jobs.
The lower mean score of the environment domain was represented by the following facets: physical security, financial resources, and participation in/opportunities for recreation and leisure.
This domain may have had an effect on professionals whose only job was with the FHS because the atmosphere of insecurity that is established by their daily experience of social and family conflicts, as well as with urban violence when working in the city's outskirts. In addition, it is also observed that the intense demand of the clientele regarding nursing care in view of the poor quality of the care provided due to the current difficulties of the health sector, they favor the occurrence of violent acts at work, particularly of users towards workers(13).
FHS nurses from the city of Teresina - PI reported difficulties to organize the demand found in the daily life of the community, because, besides the diseases, they face violence, drugs, and prostitution, and did not feel safe to intervene(14).
Another factor that could effect the assessment of this domain is the reality of the precarious working conditions in the primary health network, including in the Family Health environment. In these places, nursing professionals work in conditions that are clearly insalubrious, with a constant lack of human and material resources(15). Literature shows that, in order to establish satisfactory health care, these professionals need to have the basic material and human conditions to develop their activities in a correct and just way(16).
Regarding the financial resources issue on the lowest score of the environment domain, as mentioned before, the low salary levels are a source of dissatisfaction among the professionals of the category, particularly if considering the workload and responsibility that nurses assume in a family health team(10).
The attitude of holding two nursing jobs is usually associated to the low salaries of either jobs assumed by the nurses, because, despite receiving a relatively more attractive salary compared to the FHS, nurses usually have to add up the salaries to be able to provide for their economical and social needs(11).
It is possible that the opportunity to participate in recreation and leisure activities is being harmed by the percentage of professionals working with the FHS for over eight hours a day (7.8%). Maintaining a long workday occurs as a result of the nurses salaries being, in most cases, below their needs. Among the women, in addition to the extensive workload, most also assume domestic responsibilities(15). In another study(17), nurses highlighted in their statements that they perceived they had insufficient time for leisure and rest. But the need for surviving makes them submit themselves to life and work conditions that lead to suffering.
The type of work contract affected the spirituality domain; nurses who had a commissioned position or temporary work contract has a lower QL score compared to those with a formal work contract or who had passed a competition exam. This result suggests that the nurses' personal beliefs involved in the meaning they assign to life may be weakened by the insecurity and breaking the feeling of belonging, caused by the employment that does not offer any professional stability. The fact that nurses have an unstable job keeps them from making investments that involve making any long-term life plans or organization. FHS nurses from Teresina PI referred to the inexistence of formal employment as being determinant factors of feelings of suffering and uncertainty(14). The FHS professionals from Ipatinga MG reported that the dissatisfactory job contract and the constant threats of staff changes due to political-party issues were factors that discouraged them to continue working in the FHS(10).
It was observed that the daily workload affected the psychological domain, as nurses who worked 12 hours a day presented a lower QL score compared to those working eight hours a day.
In the psychological domain, it is evident that a greater daily workload has a negative effect on the workers' possibility of enjoying life, such as spending time with family and friends, and with personal development and leisure. A study with nursing professionals suggests that individuals with a smaller workload appear to experience more positive feelings in life(18).
It was found that the workers' reported satisfaction towards work affected the domains: physical, psychological, level of independence, and environment. Subjects who reported being dissatisfied presented lower QL levels compared to those who reported being more satisfied.
The fact that job satisfaction is a variable that affects a number of QL domains can be assigned to the important that work has in people's lives. In today's society, among other aspects, work is used as a parameter to determine a person's value. Literature(19) states that work activities, just as eating, housing, education, equity, the environment, and other social factors are human necessities, and supplying them is key to constructing a life with quality.
It is through work that man interacts with the productive society, i.e., it is considered an essential part of human life. This way, it is observed that work holds a central role in human life, and, depending on how it is performed, it can generate distressing and potentiating factors of the health-disease processes (20).
In spite of most nurses in the present study having reported being satisfied with their work, the almost 40% rate of dissatisfaction and/or neutrality towards this aspect appears to be quite relevant, because it can have negative effects on their work performance in the FHS, such as absenteeism, harms to work activities, more occupational accidents, workers' lack of interest and apathy, which has a direct effect on the quality of nursing care. Other studies have found poor job satisfaction among nurses(21-22).
The issues addressed in the literature that would most likely be related to dissatisfaction towards work, and, consequently, establish lower OL rates in most domains among FHS nurses, involve he predominance of insecure job contracts, low salaries, inappropriate environmental and organizational working conditions, increased exposure to risks in the workplace, and a compromised social life due to the accumulation of jobs and the extensive workload, as well as the burden to maintain the workers' physical and mental health due to all these factors combined.
Regarding the characterization of the present study participants, it is observed that most are young females. Most participants had one single job (64.8%) under a temporary work contract in compliance with the labor legislation (62.9%), worked eight hours per day (92.1%), an income between four and eight minimum salaries (83.3%), and reported being satisfied with their job (61.8%).
The results show that the domain components had little or no negative impact on the nurses' QL assessment.
It is perceived that although the nurses from the Triângulo Sul Macro Health Region present mean scores consistent with a satisfactory QL, it is observed that certain conditioning factors of the professional variables, type and number of jobs, workload, and job satisfaction, harm FHS nurses' QL, affecting the psychological and environment domains, followed by the domains: physical, level of independence, and spirituality aspects.
These data demonstrate the need to define public policies aimed at taking care of the nurses' working conditions, considering that almost all the factors involved in the work context, including the reports of dissatisfaction, had a negative effect on QL.
It must be considered that QL is a complex theme, because it reflects individual conditions and values, which can change according to the characteristics of a certain moment in people's lives. However, the analysis of the professional aspects associated to QL direct the implementation of change in the working conditions, reducing the distance between personal expectations and these professionals' reality of work. Actions that contribute to improving the QL of family health team nurses are necessary, considering the fact that the QL of these professionals can strongly affect the care that is provided.
Apoio Fundação de Amparo à Pesquisa do Estado de Minas Gerais FAPEMIG
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from the dissertation "Qualidade de vida dos enfermeiros das equipes saúde
da família", Federal University of Triângulo Mineiro, 2009.
* Extracted from the dissertation "Qualidade de vida dos enfermeiros das equipes saúde da família", Federal University of Triângulo Mineiro, 2009.