Perception of nurses on working conditions in the emergency area of a hospital

Abstracts

OBJETIVO: Conhecer as condições de trabalho na emergência do Hospital da Restauração, a partir da percepção de enfermeiros que trabalham nesse setor. MÉTODOS: Estudo de caso, que utilizou a abordagem qualitativa e quantitativa, com triangulação de métodos. A coleta de dados foi feita por meio de entrevista aberta, questionários fechados e observação. Foram entrevistados 23 enfermeiros. Empregou-se, na análise dos dados, a Condensação de Significados e o programa Excel versão 2003. RESULTADOS: A quantidade excessiva de pacientes e a falta de segurança para o desenvolvimento do trabalho foram os itens mais criticados pelos entrevistados, e confirmados pela observação. Do grupo pesquisado, 47,8% trabalhavam na emergência há mais de 16 anos consecutivos, sendo a maioria na faixa etária de 41 a 50 anos e do sexo feminino. CONCLUSÃO: Predominou uma percepção de condições precárias de trabalho, salários insatisfatórios, ambiente insalubre e inseguro, levando a um sentimento de desmotivação que influi na qualidade da assistência.

Hospitais de emergência; Enfermagem em emergência; Condições de trabalho

ORIGINAL ARTICLE

Perception of nurses on working conditions in the emergency area of a hospital^*

Percepción de enfermeros sobre condiciones de trabajo en el sector de emergencia de un hospital

Betise Mery Alencar Sousa Macau Furtado^I; José Luiz Correia de Araújo Júnior^II

^IGraduate student (PhD) in Public Health at the Núcleo de Estudos em Saúde Coletiva - NESC/CPqAm/FIOCRUZ, city of Recife, Brazil. Assistant Professor at the Faculdade de Enfermagem da Universidade de Pernambuco UPE - Recife (PE), Brazil and Nurse in the emergency unit of the Hospital da Restauração - Recife (PE), Brazil

^IIPhD in Public Health. Professor at the Núcleo de Estudos em Saúde Coletiva - NESC/CPqAm/FIOCRUZ and at the Faculdade de Ciências Médicas da Universidade de Pernambuco - UPE - Recife (PE), Brazil

Corresponding Author

ABSTRACT

OBJECTIVE: To determine the working conditions in the emergency sector in the Hospital da Restauracao, from the perception of nurses working in that sector.

METHODS: A case study, which used a qualitative and quantitative approach, with triangulation of methods. Data collection was done through open interviews, closed questionnaires and observation. 23 nurses were interviewed. To analyze the data was used the condensation of meanings and the program Excel-version 2003.

RESULTS: High number of patients and lack of security for the development of the work were the items most criticized by those interviewed, and confirmed by observation. From the studied group, 47.8% worked in emergency for more than 16 consecutive years, most of them female in the age range of 41 to 50 years.

CONCLUSION: The prevailing perceptions were: poor working conditions, unsatisfactory wages, unhealthy and insecure environment, leading to a feeling of discouragement that influences the quality of care.

Keywords: Emergency hospitals; Emergency service nursing; Working conditions

RESUMEN

OBJETIVO: Conocer las condiciones de trabajo en el sector de emergencia del Hospital de la Restauración, a partir de la percepción de enfermeros que trabajan en ese sector.

MÉTODOS: Estudio de caso, que utilizó el abordaje cualitativo y cuantitativo, con triangulación de métodos. La recolección de datos fue hecha por medio de entrevista abierta, preguntas cerrados y observación. Fueron entrevistados 23 enfermeros. Se empleó, en el análisis de los datos, la Condensación de Significados y el programa Excel versión 2003.

RESULTADOS: La cantidad excesiva de pacientes y la falta de seguridad para el desarrollo del trabajo fueron los ítems más criticados por los entrevistados, y confirmados por la observación. Del grupo investigado, 47,8% trabajaban en el sector de emergencia hace más de 16 años consecutivos, estando la mayoría en el intervalo de edad de 41 a 50 años y del sexo femenino.

CONCLUSIÓN: Predominó una percepción de condiciones precarias de trabajo, salarios insatisfactorios, ambiente insalubre e inseguro, llevando a un sentimiento de desmotivación que influye en la calidad de la asistencia.

Descriptores: Hospitales de emergencia; Enfermería en emergencia; Condiciones de trabajo

INTRODUCTION

The work process of a hospital emergency room is defined⁽¹⁾ as a daily and continuous possibility of having as object of work a person seriously ill, who needs immediate care and whose life's been threaten. The service operates 24 hours a day, and being public is for free⁽²⁾, and applies an universal and integral mode to serve those seeking for care.

For the work process to happen, proper conditions are necessary which include the environment, staff, and adequate material for developing such activities^(3-4). The process of nursing work follows the division of work based on the operating mode in which nurses will use their knowledge as ideological tool of power. This technical division is moving in the same sense of social division of labor^(4-5) is therefore a discontinuous and fragmented work

Functions of the emergency nurse range from listening to a patient's story, physical examination, therapy execution, patient's guidance, to the coordination of the nursing team⁽⁶⁾, combining scientific knowledge and leadership skills, agility and quick thinking and the need to keep the serenity⁽⁷⁾.

The Emergency Room of the Hospital da Restauração counts with 71 nurses. For each 12 hour shift, eight nurses are allocated in average, including 46 nursing assistants/technicians and 30 to 40 physicians from several specialties.

For being part of this reality and given the necessity for nurses' constant presence with patients in overall health services, for the indisputable essence of their work, the costs of their professional education, the emergency room work process, and moreover, considering the conditions in which such professionals perform their functions; as well as that in Brazil there are studies focusing on nurse's work in the emergency room, which emphasize profile, management^(6-9) and stress^(10-11) in the sense of psychological pressure, and that few studies relate to specifically nurse's work conditions in emergencies⁽¹²⁾, the author felt the need to develop the present study, with the objective of understanding the conditions of work in the Emergency Room of the Hospital da Restauração, from the perception of the nurses working in the sector.

METHODS

The study was conducted in the emergency room of the Hospital da Restauração (HR), of the Secretary of the State of Pernambuco, considered as the primary unit of reference in public care of patients with multiple trauma. Counting with 480 beds attends daily approximately 400 patients. Qualitative and quantitative approach was applied across a case study^(13-14). The qualitative approach through such study is well suited for such research, as the method's object is a unit that assesses in depth, develops within a natural environment, is rich in descriptive data, has an open and flexible plan, forecasts how the studied problem is manifested in daily interactions, and seeks to portray the perspective of the participants⁽¹⁵⁾.

Data gathering was made through structured interviews, thinking it would allow an in-depth understanding of the theme(13); a questionnaire consisting of open and closed questions, to capture timely basis results and direct observation, with the intention of having another dimension to the problem studied^(13-16), for a methodological triangulation^(14,17-18), with a view to greater validity of findings. A script⁽¹³⁾ was used in the open interview and issues approached are: nurse moments of nursing work within the emergency sector, the activities undertaken during working hours, the conditions in which these activities were developed, the factors responsible for job dissatisfaction. Each interview lasted about an hour.

The intention was to systematically observe the work of one of the professionals in each shift, selected from the ones that participated in the interviews, chosen randomly, totaling seven nurses from day and night shifts. It is observed how the nurse organizes and conducts the shift, the work environment, the activities performed and the relationship with other clients (patients, families, other professionals), being all the observations recorded in a diary, having used a predetermined script, lasting on average each session from four to five hours. The questionnaire consisted of socio-demographic variables (sex, marital status, age, year of graduation, title, number and type of other work affiliations, job arrangements and perceived total income) in order to describe the profile of nurses and issues relating to working conditions in emergency: the quality of the environment for performing the role; the quantity and quality of equipments and supplies; number of professionals; the diagnosis and therapeutic areas support to services; management and organization of the work.

For the selection of interviewees, it was initially provided with the people management of the institution the listing of all 71 nurses allocated to the emergency room. Professionals with more than five years of experience in the sector were selected, considering a sufficient period of time to better know the service, coming up to a total of 28. From that group, were excluded who were on vacation (2) license (1) and those occupying leading positions (2); remaining 23 nurses, all being interviewed. Both the interviews and observation sessions were made by the researcher in the period from September to December 2007, with the concent of the interviewees. The open interviews were recorded electronically and transcribed afterwards.

For the systematization and analysis of data from the open interviews, the Condensation Meanings of Kvale⁽¹⁹⁾ was taken as reference. In this type of analysis, the passages of the interview that relate to a specific question of the study are quoted and condensed into a framework provided by the natural units of the meanings of the responses of individuals in the left column, and the central themes related to those that are conceptual categories, in the right column; it follows, below both, the description of the essential question related to the study, as shown in Boxes 1 and 2. To ensure the anonymity of the individuals interviewed and quoted, identification codes were used. The data obtained from the questionnaires on working conditions in the emergency room were processed and analyzed using the Excel application, version 2003 and presented as tables. The observation results were consolidated and described following the categories defined in the roadmap for this purpose. It was decided to interview all the nurses in the sample, although saturation of some questions, hoping to find different responses, even in the last interviews. Data analysis allowed to recombine the quantitative and qualitative evidences, confronting them with the theory, in order to seek results convergence more consistently^(14,17-18).

This study was conducted in accordance to the guidelines and rules for research involving human beings, approved by the National Health Council, through Resolution No. 196/96. It is part of the PhD thesis developed by the researcher, entitled The work of nurses in emergency: the social representation, commitment, satisfaction and working conditions. In the case of the Hospital da Restauração, it was approved by the Research Ethics Committee, of the Centro de Pesquisa Aggeu Magalhães/ Fundação Oswaldo Cruz and received a Certificado de Apresentação para Apreciação Ética (CAEE) at No. 0045.0.095.000-07. All participants of this study signed a consent form Term of Free and Cleared Consent.

RESULTS

Results presented on Table 1, referring to the profile characteristics of the nurses studied, show the majority of the 23 professionals interviewed being women (91.3%); age 46 to 50 year registered the highest frequency (26.1%), with age of 41 years in average. The predominant marital status (60.9%) was married. It was found that 47.87% of respondents had received under-graduation degree from 11 to 20 years ago and 87% of these with expertise or residence programs. Working in Emergency as personal choice was 65.2% in the group. 47.8% had been working in the ER for more than 16 consecutive years, being professionals with a period exceeding 26 years. All respondents worked in two shifts of 12 hours each day or night per week. 73.9% reported having a secondary job, 52.2% other public hospitals and 13% in other emergency rooms. The salary ranged from $ 2,000.00 to $ 10,000.00, with an average of R $ 3,739.00.

The results obtained from the closed questionnaire (Table 2) show that the quality of the environment for doing the work, 39.1% and 34.8% indicated Bad rate for comfort and cleanliness, respectively. In the variable equipment and supplies the prevailing rate was regular in all items, except the amount of material, which has good rating (56.5%). Regarding the number of professionals in emergency, physicians found 50% Good, nurses 36.4% regular and 27.3% for Bad rates. The team of nursing assistants took a balanced position between Good, Fair and Poor. In relation to diagnostic and therapeutic services the worst rate was for the imaging service, with 40.9% for Bad. As for the management and organization of work, the worst rate was for safety, with 56.5% Poor, followed by the number of calls per shift (43.5%).

Regarding the results of open interviews, the team of nursing assistants was considered insufficient for the degree of complexity and frequency of care demand. Remarkable findings related to the lack of equipment, poor quality of materials purchased by the department and the lack of trained nurses for the proper handling of equipment, as it can be seen in the passages below:

[...] it's a total chaos, because no one sees you entering at work and facing an overcrowded emergency, with the lack of professionals in all categories and specialty category, [..] no training for nursing assistants, for nurses, there is no psychological support for nurses to understand that it is not their own self being attacked (Nurse IV)

One of the topics that was most criticized was the safety group of the hospital, considered by virtually all nurses as total failure.

Safety at work is something that is completely extinguished in here, do not know if it's like a routine in public hospitals, in general, but here we know we're very susceptible to a marginal patient at any time. I've been a victim, some years ago, the marginal came here to finish killing a policeman and took me nearly as a hostage [...], apart of that, the aggressiveness of patients' own companions in the context of the situation that you can not serve everyone at the same time [...] (Nurse II)

Regarding the material used for carrying out the procedures, some interviewees considered that not planning activities generates a complete disorder in the flow of service, which leads to waste of time and resources. This fact can be observed in the following speech:

[...] sometimes it lacks material in a sector because someone failed to get it at the pharmacy, the pharmacy failed to pick it up at the deposit and so on and you'll get tired of that, we've been too much looking for things that should already be there, and this is stressful [ ...] (Nurse IV).

As for the demand of patients in the emergency room, respondents complained about the uncontrollable number of patients using the service

There is a sizing of patients greater than the structure is capable of supporting both the physical structure and the personnel structure [...] It is a mistake to increase the number of health professionals, it resolves through organizing the issue of number of patients. We do not have a healthy environment for professionals, much less for the patients. It is unacceptable that you have to make a catheter insertion in a patient in the hallway in front of men and women, or whoever passes by [...] (Nurse IV)

The nurses emphasized also that they are suffering discrimination in recent years, related to different increases in salaries between health professionals in the institution. This can be seen through the statement:

It has not always been this way, we already experienced moments in which there really was a kind of treatment differential, but you could win a space, in seeing that thing the team wants you to win [...]. There was a possibility to fight together, to respect and want also the same for you (Nurse IV).

[...] Salary, it is not a fair wage for the work that is developed here, since you have to have two or three jobs to survive and the Emergency of HR does not give you the chance to have more jobs because it consumes much [...] (Nurse XVII).

Another important point to draw attention was the issue of the difficulty of nurses working with education, once the hospital is classified as educational and the practice will always exist:

[...] We are even ashamed to pass on to academic students, this is our reality. [...] Because we are teaching here something which is totally wrong, it is obvious that that is no healthcare, there are days here that we do not have any conditions to develop decent work [...], everything is wrong (Nurse XVI).

Among the studied group, there were few people expressing the desire to leave the ER. Maybe, in fact, they will never leave; beyond personal attachment, they feel that the time to make a decision has passed. Most of the group believes that, despite of everything, there is still hope that one day the emergency department can improve. This can be the likely reason for staying in the industry for so many years.

From the direct observation of nurse's work, it was noted that this professional can not develop a smooth work sequence due to excessive demand and the constant requests from the nursing assistants, patients, as well as from other professionals, which demonstrates, clearly the insufficient number of such professional and the lack of planning in performing their role. The workplace is unhealthy, there is no adequate space for carrying out the procedures in privacy, nor for professionals or for patients, who occupy all the areas designed for circulation, regardless of specialty or diagnostic and often independently of the severity of the case.

DISCUSSION

Some characteristics of the interviewed nurses matched with findings in other studies, such as sex⁽²⁰⁾ and age⁽²¹⁾, although the results of these studies do not always refer to the emergency room.

One of the topics discussed by the interviewees that cause most dissatisfaction with working conditions is the issue of excessive demand of patients, which leads to physical and emotional burden on the professionals. The staff increase is not considered as ideal solution to the problem, but probably the re-ordering of demand. The results of this study, quantitative (questionnaires) and qualitative (interviews and observation), lean towards the same direction, i.e., the dissatisfaction of nurses on the high patients demand, which also is confirmed by other studies^(21-23).

Another problem that causes serious consequences at healthcare to the population, and also corroborates to nurses' high level of tension, is the lack of training on a regular basis for these professionals, affecting the efficiency and speed of nursing care to the victims of trauma and clinical emergencies that comes to the unit. On that respect, a major concern is that not being a problem uniquely to that hospital, but appears more to be like a general problem, according to study investigated⁽⁷⁾, which considers the training in the emergency area in Brazil incipient

Work conditions related to environment, in the studied emergency room, were considered from regular to bad as questionnaires' results point out, which was shown during the observation of the work of these professionals and confirmed by their statements during the interviews. The workplace is considered inadequate to offering dignified care, with respect to the human being, and allowing the stabilization and treatment of patients seen, from the availability of materials, the unhealthiness of the place, to the accumulation of patients in all areas, which affect the execution of procedures and patients' privacy. This scenario contributes to the physical and emotional exhaustion of professionals, a situation resulting from the work environment and not caused by problems from health professionals. This fact is also highlighted by other authors^{(10-11,21-23)}.

It's worth noting that besides the unsuitable environment for provisioning of care, nurses are still submitted to physical and verbal aggressions. The hostility that the individual finds in the ER environment can be understood as the intensification of events related to changing hospital culture classic isolation, the impersonal attitude, based on the technique or medical positivist scientism, the defense mechanisms, given the outrageous work conditions; as well as the reaction to the condition of misery and social violence^(21-23).

Virtually all professionals interviewed had a secondary job, which obviously creates greater burden of fatigue and stress. One author⁽²⁴⁾ considers that having multiple jobs, by choice or by necessity, evolves into various working conditions, physical tiredness, emotional stress and lack of leisure time.

The poor working conditions in nursing are a longstanding problem and it has been acknowledged since the 1980s, by the Brazilian Association of Nursing⁽⁸⁾, when there was a significant dropout of students from universities and the abandonment of the profession. In countries like the USA, Canada, Germany, England and Scotland, the nurses show concern about working conditions⁽²⁰⁾ and indicate the physical tiredness, low pay, the discredit and social factors associated to these conditions, which have impacted negatively the quality of care provided to customers, which fact is also demonstrated in this study.

The results of this study differ from other studies^(8,23) referring to the desire of professionals to leave the profession. It was not observed on the interviewees a firm determination to leave the profession or the hospital. There were outbursts of disappointment about the situation which the hospital has experienced, with only one professional proving clearly eager to leave the set. Instead, what calls attention is the long stay of nurses in the Emergency Room, even considering the working conditions offered. This attachment can be a way to minimize the suffering⁽³⁾.

CONCLUSION

From the reality described in this study, it becomes clear how the nurses of the emergency room of the Hospital da Restauração see the working conditions they are submitted, which has led to discouragement, insecurity and low performance. It is expected that the dissemination of these results may encourage managers to define a development plan for the ER of the selected Hospital, considering its importance, and essentiality of the work of nurses within this context.

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*

Trabalho realizado no Hospital da Restauração da Secretaria de Estado da Saúde de Pernambuco, Recife, (PE), Brasil.

Publication Dates

• Publication in this collection
  26 May 2010
• Date of issue
  Apr 2010