versão impressa ISSN 1516-4446
Rev. Bras. Psiquiatr. v.30 n.1 São Paulo mar. 2008 Epub 20-Dez-2007
Equipes de serviços psiquiátricos públicos: avaliação da satisfação
Sergio IsharaI; Marina BandeiraII; Antonio Waldo ZuardiI
IDepartment of Neurology, Psychiatry and Medical Psychology, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (USP), São Paulo (SP), Brazil
IIResearch Laboratory in Mental Health (LAPSAM), Department of Psychology, Universidade Federal de São João del Rei (UFSJ), São João del Rei (MG), Brazil
OBJECTIVE: To investigate the satisfaction of health-care professionals in inpatient and outpatient psychiatric hospitals of a Brazilian medium-sized city.
METHOD: The study evaluated 136 health-care professionals from six hospitals; of which two were outpatient hospitals, two general hospitals, and two psychiatric hospitals. All professionals answered the Brazilian Mental Health Services' Staff Satisfaction Scale.
RESULTS: An average satisfaction score of 3.26 was observed, which is situated between indifference (level 3) and satisfaction (level 4). Factors "service quality" (3.48) and "relationships at work" (3.48) showed higher scores compared to "service participation" (3.20) and "work conditions" (2.97) (p < 0.001). The female patient unit in the psychiatric hospital presented lower satisfaction scores (p < 0.001). Satisfaction was higher in the category "technicians" compared to "physicians" and "nurses" (p = 0.004). Moreover, day workers reported higher satisfaction compared to night workers regarding "service quality" and "service participation" (Student's t, p = 0.01 and p = 0.007).
DISCUSSION AND CONCLUSION: Results show an intermediate level between indifference and satisfaction with services, with higher scores regarding care provided to the patients. Comparisons among the studied facilities revealed the numerous factors involved in determining one's satisfaction. They suggest advancements and reform measures likely to occur in the region's psychiatric health-care services. Monitoring satisfaction proved useful in predicting service quality improvements.
Descriptors: Job satisfaction; Mental health; Deinstitutionalization; Program evaluation; Occupational health
OBJETIVO: Investigar a satisfação de profissionais pertencentes às instituições psiquiátricas de internação integral e parcial em uma cidade de porte médio.
MÉTODO: Foram avaliados 136 profissionais de seis serviços, sendo dois de hospitalização parcial, duas enfermarias em hospital geral e duas unidades em hospital psiquiátrico. Os profissionais responderam à Escala de Avaliação da Satisfação da Equipe.
RESULTADOS: Observou-se um escore global médio de satisfação de 3,26, que se situa entre indiferença (nível 3) e satisfação (nível 4), sendo maior nos fatores "Qualidade do Serviço" (3,48) e "Relacionamentos no Trabalho" (3,48) em relação à "Participação no Serviço" (3,20) e "Condições de Trabalho" (2,97) (p < 0,001). Observou-se satisfação inferior na unidade feminina do hospital psiquiátrico (p < 0,001). A satisfação foi maior na categoria "técnicos" em relação a médicos e enfermeiros (p = 0,004) e maior entre profissionais do período diurno do que noturno, nos fatores "Qualidade do Serviço" e "Participação no Serviço" (t de Student, p = 0,01 e p = 0,007).
DISCUSSÃO E CONCLUSÃO: Os resultados mostraram níveis intermediários de satisfação com os serviços, com maiores escores de satisfação relacionados à assistência aos pacientes. A comparação dos serviços aponta a diversidade de fatores envolvidos na determinação da satisfação e sugere avanços no processo de reforma da assistência psiquiátrica na região. O monitoramento da satisfação mostra utilidade na perspectiva de desenvolvimento da qualidade dos serviços.
Descritores: Satisfação no trabalho; Saúde mental; Desinstitucionalização; Avaliação de programas; Saúde do trabalhador
Psychiatric service evaluation allows for the verification of the effectiveness of different treatments. It provides information needed to establish realistic plans and to target adequate interventions.1 In Brazil, mental health service evaluation is a rather new field with no consensus regarding the choice of indicators or the best form of evaluation.2
Evaluation of patient, family, and health-care professionals' satisfaction should be an indicator for service quality.2-4 Satisfaction among healthcare professionals should have strong and lasting effects throughout treatment. Such feelings directly interfere with the bonds built between patients and professionals.Effective workers presenting altruism, creativity, initiative and the capability of giving additional assistance, promote the institution's ultimate goals.5
In a research with the purpose of identifying the best criteria to evaluate mental health services, the parameter "technician's satisfaction toward the service" received the highest score among the 25 criteria listed.Although it is acknowledged that a satisfied professional does not always deliver the best service.2
A study by Aronson,6 performed with psychiatric hospital workers, highlighted an association between job satisfaction and the well-being of patients and employees. Other study indicates that job satisfaction was greater in smaller units, with higher functioning patients and lower illness severity.7 Different studies evaluated different aspects regarding satisfaction, including: workers' relationship with the organization;8 nature and volume of service;9 ward cleanliness;10 level of responsibility and autonomy;11 characteristics of patients;6,7 relationship with patients;10,12 peer support;12 age and education;9 level of personal fulfillment and interest in job.9,11
In Brazil, several changes in the model of psychiatric care are in progress. One example is the shift in resources from psychiatric hospitals to other services such as day hospitals, centers for psychosocial care, and specific wards in general hospitals. Therefore, we attempted to perform an extensive evaluation of mental health services involving the various modalities of intensive psychiatric treatments, as well as including different professional categories. Systematic evaluations using validated instruments are relevant. In this sense, the objective of this study was to investigate the satisfaction levels of health-care professionals in all psychiatric hospitals offering inpatient and outpatient care in a medium-sized city of Brazil.
Data were collected at six psychiatric hospitals in the city of Ribeirão Preto, in the State of São Paulo, Brazil. Characteristics regarding these facilities are listed on Table 1.
The subjects were evaluated with the Satisfaction Inventory (SATIS-BR),13 adapted and validated to Brazil.3,4 SATIS-BR is a self-administered instrument with 69 questions, of which 32 are quantitative items used to calculate the team's satisfaction level. All items are distributed on a 5-point Lickert scale, ranging from very unsatisfied (1) to very satisfied (5). The scale is divided into four subscales that assess the following aspects: quality of service offered, relationships at work, service participation, and work conditions. Other questions provide information regarding: time on the job, team meetings, promotions, relationships with supervisors, overload, safety measures, and the involvement of families in treatment.
All participants received detailed information about the research prior to signing the informed consent form. The study was approved by the Ethics Committees of the institutions. Since the instrument is self-administered, participants completed the questionnaires individually at their own workplace. Data were collected by the first author, who was always present and available to clarify occasional doubts.
The overall mean satisfaction score and the values concerning the subscales were calculated. The analysis of variances (ANOVA) was used to compare satisfaction scores obtained in different services, employees' categories and the variables "marital status" and "time working in mental health". Student's t test was used to compare satisfaction results among day workers and night workers and to compare satisfaction scores with gender. Pearson's correlation was used to verify the association between satisfaction scores and the variables "age" and "educational level". The analysis was performed using the Statistic Package for Social Sciences (SPSS) 10.0. The level of significance was set at 0.05.
A total of 136 healthcare professionals participated in this study, which corresponds to 92% of all employees from the studied facilities. The exclusions were due to: vacations (10) and incomplete inventories (2). Table 1 shows the distribution of these professionals according to their workplace. Participants' ages ranged between 18 and 64, with an average age of 40. Most were women (65%) and married (52%). Almost half had completed university studies (48%) and had been on the job for over ten years (47%).
The overall satisfaction score on SATIS-BR showed mean satisfaction of 3.26, which represents an intermediate level, situated between indifference (level 3) and satisfaction (level 4). Considering the subscales, it was observed that employees reported significantly greater satisfaction for the work dimensions "service quality" (3.48) and "relationships at work" (3.48) compared to "service participation" (3.20) and "work conditions" (2.97). This information was obtained using ANOVA (F(3, 135) = 35.76, p < 0.001) and Tukey's post-hoc test. Highest and lowest mean scores were found for items regarding the intention of recommending services to other people and salary satisfaction, respectively.
Comparing satisfaction levels by services,differences were observed only in relation to PH-B, which showed less satisfaction compared to DH-A, GH-A, and PH-A [ANOVA (F(5, 135) = 6.175, p < 0.001) and Tukey's post-hoc test]. Regarding the professional categories, technicians presented greater satisfaction compared to physicians, nurses, and nursing auxiliaries [ANOVA (F(4,135) = 4.037; p = .004)]. Compared to night workers, day workers reported greater satisfaction on the subscales "quality of service offered" and "service participation" [Student's t test (t = 2.63, p = 0.01 and t = 2.75, p = 0.007)].
Service time contributed to increased satisfaction levels, with greater satisfaction levels among employees who had been on the job for over ten years compared to those on the job for six to ten years [ANOVA (F(2,135) = 5.687, p = 0.004)]. Mild, but significant, correlations were observed between satisfaction and age, with levels of satisfaction increasing with age (r = 0.275; p = 0.001); and between satisfaction and educational level (r = -0.264, p = 0.05), with greater satisfaction levels among those who have attended only elementary school compared to those having attended high school and university. No differences were observed concerning gender and marital status (Student's t test, p = 0.33 and ANOVA, p = 0.93).
Although statistical and clinical significance may refer to distinct aspects of an evaluation, study results indicate statistically significant differences in satisfaction levels for the work dimensions evaluated. The highest SATIS-BR scores were related to the work dimensions "service quality" and "relationships at work". The subscale "service quality" was related to employees' satisfaction concerning the care offered to patients. It may be presumed that this clinical feeling of accomplishment serves as a differentiating element contributing to overall satisfaction and motivation.
Literature contains references regarding the importance of employees satisfaction with service treatment.10,12 This is considered the second most important source of satisfaction, aside from contact with colleagues. However, it must be considered that employee-patient relationships vary considerably, depending on the patients' health condition and their level of hostility.7
Concerning the other highest scores subscale ("relationships at work"), the literature contains similar references, with special emphasis on the role that satisfaction with colleagues plays in work motivation and in reducing the effects of overload and stress. Peer support offered through informal contact has been more valued than when offered in formal work groups.12
On the other hand, aspects associated with working conditions seemed more troublesome in the present study, especially regarding low salary dissatisfaction. Literature shows that dissatisfaction with income weighs interferes objectively, as in bill paying, as well as subjectively, as in fulfilling dreams and personal projects.14
Similarly, the subscale "service participation" also had lower satisfaction scores. The perspective of participation was influenced by characteristics like professional category and educational level. Participation in team meetings was higher among physicians, psychologists, occupational therapists, and social workers, compared to the group of nursing auxiliaries.
In this study, comparisons of satisfaction levels among services revealed there are higher satisfaction scores at two university services (one general hospital and one day hospital) and in one of the units at the non-university psychiatric hospital. These results disagree with beliefs and expectations of greater satisfaction being concentrated only in university and replacement services.
Results of other studies show that employees working at hospitals have lower satisfaction levels compared to those working at outpatient clinics or with home care.9 Moreover, satisfaction was greater in small hospitalization units and in assisting patients in less critical and more functional conditions.7
The similarities among different satisfaction levels throughout various services, observed in the present study, suggest the influence of the improvements resulting from the changes in psychiatric care on a regional level. These improvements are associated with the reduction in the number of beds in psychiatric hospitals15 and renovation on service organization, which reduces the difference between university and public services. Nonetheless, differences were found between two units of the same psychiatric hospital. This fact reveals the variety and complexity of factors that determine satisfaction. With regard to the present study, patients' genders should be taken into consideration, since employees working in the women's ward reported lower satisfaction.
In general, satisfaction was similar among the various professional categories, but greater satisfaction was observed among "technicians", which could be associated with their lower level of responsibility in the decision taking in the service. In this sense, Aronson6 observed that nurses with supervisory responsibilities were particularly dissatisfied.
In conclusion, continuous service evaluations and monitoring of job satisfaction can be useful to determine aspects of the services that need improvement.
1. Vasconcelos EM. Avaliação de serviços no contexto da desinstitucionalização psiquiátrica: revisão de metodologias e estratégias de pesquisa. J Bras Psiquiatr. 1995;44(4):189-97. [ Links ]
2. Almeida PF. O desafio da produção de indicadores para avaliação de serviços de saúde mental: um estudo de caso do Centro de Atenção Psicossocial Rubens Corrêa, RJ. [Dissertação]. Rio de Janeiro: Escola Nacional de Saúde Pública; 2002. [ Links ]
3. Bandeira M, Pitta AM, Mercier C. Escalas brasileiras de avaliação da satisfação (SATIS-BR) e da sobrecarga (IMPACTO-BR) da equipes técnica em serviços de saúde mental. J Bras Psiquiatr. 2000;49(4):105-15. [ Links ]
4. Bandeira M, Pitta AM, Mercier C. Escalas da OMS de avaliação da satisfação e da sobrecarga em serviços de saúde mental: qualidades psicométricas da versão brasileira. J Bras Psiquiatr. 1999;48(6):233-44. [ Links ]
5. Jex SM, Cunningham CJ, Rosa G, Broadfoot A. Stress e eficácia dos funcionários. In. Rossi AM, Perrewé PL, Sauter SL. Stress e qualidade de vida no trabalho. São Paulo: Atlas; 2005. p. 104-22. [ Links ]
6. Aronson KR. Job satisfaction of nurses who work in private psychiatric hospitals. Psychiatr Serv. 2005;56(1):102-4. [ Links ]
7. Bingham CR, Valenstein M, Blow FC, Alexander JA. The mental health care context and patient characteristics: implications for provider job satisfaction. J Behav Health Serv Res. 2002;29(3):335-44. [ Links ]
8. Gulliver P, Towell D, Peck E. Staff morale in the merger of mental health and social care organizations in England. J Psychiatr Ment Health Nurs. 2003;10(1):101-7. [ Links ]
9. Gigantesco A, Picardi A, Chiaia E, Balbi A, Morosini P. Job satisfaction among mental health professionals in Rome, Italy. Community Ment Health J. 2003;39(4):349-55. [ Links ]
10. Olusina AK, Ohaeri JU, Olatawura MO. Patient and staff satisfaction with the quality of in-patient psychiatric care in a Nigerian general hospital. Soc Psychiatry Psychiatr Epidemiol. 2002;37(6):283-8. [ Links ]
11. Farrell GA, Dares G. Nursing staff satisfaction on a mental health unit. Aust N Z J Ment Health Nurs. 1999;8(2):51-7. [ Links ]
12. Reid Y, Johnson S, Morant N, Kuipers E, Szmukler G, Thornicroft G, Bebbington P, Prosser D. Explanations for stress and satisfaction in mental health professionals: a qualitative study. Soc Psychiatry Psychiatr Epidemiol. 1999;34(6):301-8. [ Links ]
13. Word Health Organization. WHO-SATIS Consumer's and Caregivers'satisfaction with Mental Health Services - A Multisite Study. Geneva: Division of Mental Health. WHO; 1996. [ Links ]
14. Dejours C. A loucura do trabalho. 5ª. ed. São Paulo: Cortez Oboré; 1992. 168 p. [ Links ]
15. Del-Ben CM. Marques JM, Sponholz A Jr, Zuardi AW. Mental health policies and changes in emergency service demand. Rev Saude Publica. 1999;33(5):470-6. [ Links ]
Rua Catão Roxo, 2650
14051-140 Ribeirão Preto, SP, Brazil
Financing: AWZ is recipient of a CNPq Productivity fellowship (nº 300775/2004-0) and of a FAPESP grant (nº 2002/13197-2). MB is recipient of a CNPq Productivity fellowship (300265/2004-2)
Conflict of interests: None
Submitted: February 22, 2007
Accepted: June 18, 2007
Department of Neurology, Psychiatry and Medical Psychology, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (USP), São Paulo (SP), Brazil