Nurses’ job satisfaction assessment by areas of care*

Objective: To analyze the level of nurses’ job satisfaction according to the area of care provided in a Local Health Unit, in Portugal. Method: This is a quantitative, descriptive, analytical study, with observational and cross-sectional design. The Job Satisfaction Assessment Instrument was used for data collection. Results: Sample (n = 218), predominantly female (84.6%), with a mean age of 33 years. The area of care delivery influences total job satisfaction (p < 0.05) and some of the dimensions studied (p < 0.05). Nurses from Community Care Units show greater job satisfaction, followed by nurses from Indirect Care. Critical Care nurses show lower job satisfaction, followed by those who work in outpatient’s units. Most nurses show lower satisfaction level in the aspect Management Bodies and in the dimension Quality of Care Delivery. Conclusion: The most satisfied nurses are those from the Community Care Units and the nurses with the lowest level of job satisfaction are those from Critical Care.


INTRODUCTION
Job satisfaction ( JS) is a critical organizational behavior variable that improves the functioning of organizations, and is a powerful management indicator, due to the impact it may have on performance. Thus, to define support structures and organizational policies that promote this variable, it is imperative that we know it (1) . Professionals who feel valued in their profession are less likely to quit work; engage in more organizational citizenship behaviors; show higher level of satisfaction, better performance, more confidence; develop feelings of loyalty to the organization; and have less voluntary absenteeism. Job satisfaction is directly related to mental health, and greater satisfaction reduces the incidence of burnout and, consequently, increases the quality of care (2)(3) .
The retention of satisfied nurses is essential to ensure high-quality care and, in this area, authentic leaders play an important role in creating environments with an effective support for professional practices, resulting in a perception of high Quality of Care Delivery (QCD) and higher level of job satisfaction (4) . The increasing quality needs of the population require innovation in the provision of care, which shall be supported by research. Although talent management can be a challenge for human resources management, it shall not be seen as a difficulty, but rather as an opportunity to respond to these needs, raising quality standards and adding value to organizations.
Local health units are organizational models aiming to improve the capacity and optimization of care provided to the population, through an integrated management of units from different areas, perhaps depicting the maximum exponent of integration and continuity of care. This type of organization seeks to "improve the responsiveness of the healthcare system and optimize services response through integrated management of the various healthcare units in a region" (5) . It represents a vertical integration of healthcare, as it is the only management entity that controls two (or more) organizations, with at least one of them using the other's output as input (6) . Thus, in the same organization there are different areas of care: primary health care (PHC), hospital care (HC) and continuing care (CC).
A Local Health Unit (LHU) in the south of Portugal integrates the following units, distributed over the three areas of care: a) Primary Health Care: community care units (CCU), personalized health care units (PHCU), and public health units (PHU); b) Hospital Care: Inpatient Department (Internal Medicine, Surgery, and Orthopedics); Outpatient Department (Day Hospital, Outpatient Consultation, Outpatient Surgery, Gastroenterology Techniques); Critical Care (Intensive Care Unit, Surgical Unit, and Urgency Services); Indirect Care (Sterilization, Technical Commissions and Training); and Continuing Care (recovery unit and discharge management team).
Based on the diversity of care settings, it was considered that the nurses' JS in a LHU could vary according to the areas of care. Thus, as stated, the research question established initially, and which guided the entire investigation process was: is nurses' job satisfaction affected by the area of care?
The present study aimed to analyze the nurses' job satisfaction level according to the area of care in a LHU, in Portugal. In terms of specific objectives, the aim is to: a) compare the level of total job satisfaction among the different areas of care; b) compare the level of dimension-based job satisfaction among the different areas of care; c) know the level of satisfaction by area of care.

Study deSign
This is a quantitative, descriptive study, with observational and cross-sectional design.

Scenario
The study was carried out in a Local Health Unit in the south of Portugal. The study population corresponded to all LHU's nurses working from January 9 to 12, 2017, 311 nurses, to whom a questionnaire was delivered. The inclusion criteria were nurses in effective exercise of their functions with a completed questionnaire, and the final sample consisted of 218 nurses.

data collection
The Job Satisfaction Assessment Instrument (Instrumento de Avaliação da Satisfação Profissional -IASP) questionnaire, developed by the Center for Studies and Research in Healthcare of the University of Coimbra (Centro de Estudos e Investigação em Saúde da Universidade de Coimbra -Ceisuc), Portugal, was applied, since it fits the specificities of healthcare professionals, and contains quality dimensions directed to the workplace, care, and continuous improvement questions. It is divided into 6 groups. In the first group, the unit is identified. The second, third and fourth groups of the instrument include the "Workplace Quality" (WPQ), "Quality of Care Delivery" (QCD) and "Continuous Quality Improvement" (CQI) scales. The WPQ scale aims at assessing nurses' satisfaction with human resources policies, namely, with regard to human resources themselves and management bodies. Satisfaction with safety and organization where they work and with the salary earned is also assessed, with their performance, experience, and responsibility being considered. WPQ also includes an aspect related to morals, in which satisfaction with the immediate superior (coordinator), as well as with their state of mind, is assessed. QCD scale assesses satisfaction with direct care, the capacity and sensitivity of professionals, the organization of care, the information provided to customers, as well as the services facilities, and the cost of care. Finally, CQI refers to investment in the quality of care, assessing satisfaction with the work environment, sharing of ideas, knowledge and expectations of quality of professionals, as well as concern about how to invest to do well the first time, and with measures implemented to reduce waste.
The answers were given on a 5-point Likert scale, in which: 1 means "Poor"; 2 "Fair"; 3 "Good"; 4 "Very Good"; 5 "Excellent", with the option "not applicable" also provided. Each item on the Likert scale (1 to 5 points) corresponds to a percentage scale from 0% to 100%, according to the following criteria: poor -0%; fair -50%; good -70%; very good -90%; excellent -100%. In an attempt to better understand the phenomenon, a question (group five) was included that asked participants to rate their level of total satisfaction with the institution, using a Likert-type scale, from 1 to 4, with an inversion in the assigned score (1 representing the most satisfactory situation, and 4 the least satisfactory). Finally, group six included questions for the characterization of the sample (sex; age; family situation; family households; number of children; family income; academic background; professional category; and emigration), whose answers were optional.
IASP showed excellent reliability in previous studies, as in the Cronbach's Alpha analysis the results obtained are above 0.706 and, in most situations, above 0.9. Internal consistency in this study was calculated, and Cronbach's Alpha values higher than 0.889 and 0.9 in all scales, subscales and aspects were obtained. Therefore, internal consistency is classified as "good" and "very good".

data analySiS and treatment
Data organization, systematization, and statistical processing were carried out using the SPSS 24.0 (Statistical Package for the Social Sciences) software, allowing their descriptive analysis, verification of the existence of relationships among the variables, and comparison among groups, to determine if the differences among them are statistically significant (7) . Descriptive and comparative statistical measures were used to analyze the nurses' JS at the LHU. The mean, standard deviation, absolute and relative frequencies were used as descriptive statistics. To determine the mean difference in the dimensions of job satisfaction according to (sociodemographic and organizational) factors, parametric t-Student and One-Way ANOVA tests were used as, according to some experts (8) , they are quite robust for large samples (n = 218), even when the distribution of the variable under study is not of the normal type. The Post Hoc Sheffe test was used to determine in which groups the statistically significant differences occur. The significance level p = 0.05 was considered, with a 95% confidence interval. That is, for < 0.05, the existence of difference or association between groups is admitted. If > 0.05, the existence of difference or association between groups is not admitted.

ethical aSpectS
Ethical procedures (informed consent, confidentiality, data privacy, and instructions), with regard to the study organization and participants, were considered during the elaboration of the questionnaire, in the procedures for its application and data processing. IASP application was authorized by the author of the data collection instrument. After the approval by the Ethics Committee, the application of the questionnaires was authorized by the LHU's Board of Directors. Participation in the study was voluntary. All questionnaires were accompanied by a cover letter from the researchers explaining the objectives of the study. To keep the confidentiality of the answers, the questionnaires were also distributed with an envelope that allowed its closing. The nurses themselves placed the envelope in a box, which was also closed.

RESULTS
The 218 participants of the sample represent a response rate of 70.1%. The sample is mostly consisted of females (84.7%), with a mean age of 33 years, with a standard deviation of 13 years. Most of them (64.0%) are married or have a common-law marriage, with a household of 3 to 4 members (56.0%), and have 1 to 2 children (59.0%).
Regarding organizational aspects, about half of them work as nurses, are graduate nurses, and work for an average of 35 hours per week (58.0%, 54.0% and 50.0%, respectively). The other half is distributed among the remaining categories and degrees, with the most representative being the category of specialist, the degree of post-graduation, and a workload between 36 and 40 hours of care per week (22.0%, 23.0% and 40.0%). The great majority (81.3%) works with accumulation of tasks. Finally, regarding length of service, the sample has a larger portion (46.7%) in the interval of 0-10 years, with the remaining ones within 11 to 20 years (29%) and 21 to 30 years (19.3%). Most participants work in Hospital Care (HC) (57.8%), followed by Primary Health Care (PHC) (39.9%) and Continuing Care (CC) (2.3%). Given the diversity of settings integrating the HC area, 4 groups were created taking the similarities in the provision of care into account: Critical Care (Surgical Unit, Intensive Care, Urgency), in which the client needs 24-hour/day care and is in a situation of hemodynamic instability; Inpatient Department (Internal Medicine, Orthopedics, Surgery), where the client needs 24hour/day care and, a priori, shows greater stability, being in a compensation phase; Outpatient Department (Day Hospital, Outpatient Consultation, Outpatient Surgery, Gastroenterology Techniques) where, as a rule, care is provided on a scheduled basis and does not require the 24-hour presence of nurses; and Indirect care (Commissions, Sterilization, and Training), which is provided only during the day and on a scheduled basis, with no direct contact with the client. PHC include five Personalized Health Care Units and five Community Care Units. Continuing Care includes one Convalescence Unit and one Discharge Management Team.
In the analysis of the total average of JS by area of care, it was found that the majority of nurses in the various areas of care (five) had satisfaction classified as "Fair" (58.4% to 67.8%), with a setting being classified as "Good" (CCU) and another as "Very Good" (Indirect care) ( Table 1). There were statistically significant differences (p < 0.05) in the analysis by area of care in all dimensions of job satisfaction: "WPQ" (p = 0.000); "human resources policy" (p = 0.001); "management bodies" (p = 0.000); "human resources" (p = 0.035); "morals" (p = 0.000); "coordinator" (p = 0.000); "state of mind" (p = 0.001); "QCD" (p = 0.000); and "CQI" (p = 0.000). Statistically significant differences were not identified only when related to "technological financial resources" ("salary" and "workplace and equipment") ( Table 2). On the "WPQ" scale and the "human resources policy" subscale, the level of job satisfaction of nurses at CCU is higher (71.69% and 66,16%) than that of the Critical Care group (56.74% and 51.85%). Regarding the "management bodies", the nurses working in the CCU are more satisfied (68.41%) than the ones in the PHCU/PHU (51.77%), Inpatient Department (48.21%), Outpatient Department (48.08%), and Critical Care (41.95%) groups.
Regarding the aspect "human resources" and "coordinator", despite the statistically significant difference between the groups, the use of the Post-Hoc Sheffe test did not allow the identification the one with the highest level of satisfaction. However, there is a tendency to follow the pattern identified in the other aspects/dimensions, in which nurses in the Indirect Care group tend to show higher level of satisfaction (80.67% and 91.14%) than those working at Critical Care (55.9% and 62.91%). Regarding the "morals" and "state of mind" subscale, nurses at CCU show greater satisfaction (86.15% and 77.27%) than the group in the Critical Care area (62.83% and 62.37%). Another group that emerges as showing higher level of satisfaction regarding the aspect state of mind is the Inpatient Department group (Table 2).
Regarding "WPQ", nurses in Indirect Care have a higher level of job satisfaction, with 96.79%, compared to nurses in the Inpatient (69.52%) and Outpatient Department (63.33%), Critical Care (64.19%), PHCU/PHU (65.45%), and CU/DMT (67.71%) groups. Also in this dimension, a statistically significant difference was identified between the CCU group and the Critical Care group, with the former presenting higher level of satisfaction (76.88%) than the latter (64.19%).
With regard to "CQI", both nurses in the CCU and Indirect Care groups have a higher level of satisfaction (81.59% and 94.06%, respectively) than the Outpatient (61.54%) and Critical Care (63.64%) groups.
The participants defined the level of satisfaction in their institution (what is your level of satisfaction in this institution?) taking the following hypotheses into account: 1 -"very dissatisfied", 2 -"dissatisfied", 3 -"neither satisfied nor dissatisfied", 4 -"satisfied", and 5 -"very satisfied". There were statistically significant differences (p = 0.000) in the level of global satisfaction according to the area of care.
Nurses in the CCU area perceive themselves in a higher level of satisfaction, compared to nurses in the Outpatient Department and in Critical Care. Most professionals position themselves in a point of neutrality ("neither satisfied/nor dissatisfied"). The group of professionals belonging to the CCU stands out with the level of satisfaction that is closest to "satisfied". The groups with the lowest classification are those in Outpatient Care and Critical Care, who consider themselves, respectively, "dissatisfied" and "neither satisfied/nor dissatisfied" (Figure 1).

DISCUSSION
The area of care influences nurses' job satisfaction, both general satisfaction and satisfaction by dimension (WPQ, QCD, and CQI), as well as their perception of the level of satisfaction, being consistent with previous studies (9)(10) that concluded on the existence of a relationship between satisfaction and the context of the performance of tasks.

Job SatiSfaction
Nurses with the highest total JS work in the Indirect Care units and in the CCU. The functions inherent to Indirect care are related to an autonomous intervention in care planning and implementation, a characteristic that is also inherent in the organizational model of the CCU. This leads to the hypothesis that this is one of the reasons for the greater satisfaction identified in both settings, given that autonomy and participation in decision-making are the factors that most contribute to the promotion of this dimension of organizational behavior (11)(12) . Support that promotes autonomy and independence in the organization of care is a factor that promotes job satisfaction for nurses in this area of care, helping them to be more satisfied in view of the intrinsic rewards such as the nature of work, achievement of goals and personal development (13)(14) .

Job SatiSfaction by dimenSion
Job satisfaction analysis by dimension also led to the finding that the least satisfied nurses are those who work in Critical Care environments. Critical Care nurses are the group presenting the lowest level of satisfaction regarding workplace quality, that is, regarding the human resources policies (management bodies and human resources) and morals (coordination and state of mind), and the quality of care delivery and continuous quality improvement.
The relationship established with the management bodies is decisive for the nurses' job satisfaction. These bodies are responsible for the organizational policies that will form the support strategies for all professionals, namely with regard to human resources (proportion, number, continuity). The way management bodies communicate with, treat, support, and recognize the professionals are factors identified as sources of satisfaction for primary care nurses.
Specifically in this study, a group was identified that incorporates this area of care, the nurses from the CCU, whose organizational model allows a direct communication channel with the management bodies considering it is the only unit coordinated by nurses (13)(14) . Another study (15) corroborates this result, having identified the CCU as corresponding to the primary health care unit with more satisfied nurses regarding the management bodies. Leadership based on motivation, support, and effective (transformational) communication, to the detriment of the cult of control and punishment (transactional), promotes job satisfaction. Nurses feel more satisfied when dealing with a leadership based on a bottom-up management model rather than a top-down one (16)(17) .
The present study also identified Critical Care nurses as the least satisfied group regarding workplace quality. Regarding management bodies, critical care nurses appear to seek leadership that promotes bidirectional communication, recognition, and transparency of processes, and in this area of care, transactional leadership is a source of job dissatisfaction (14,16) . It was also found that the lowest level of satisfaction with the management bodies is cross-sectional to most nurses (Inpatient Department, Outpatient Department, and PHCU/PHU), who need closest proximity to the upper management, since the forms of leadership supporting the development of trust, such as communication and respect for the employees' opinions, are promoters of job satisfaction (18) . In the same line of thought, there is satisfaction with the leadership of the middle managers, in this study named coordination.
It was not possible to statistically identify which groups had the greatest differences in satisfaction; however, the results point to the tendency that nurses with the greatest   www.scielo.br/reeusp Rev Esc Enferm USP · 2021;55:e03730 satisfaction will be those in the CCU, and the ones with the lowest level those in Critical Care. It is hypothesized that the fact that the CCU's direct nursing coordinator is the same as the unit coordinator can contribute to the greater satisfaction of this group compared to the others. This position is a factor that promotes effective communication and the strengthening of interpersonal relationships with the team, since decision-making is based on real knowledge and contextualized in the difficulties and opportunities of the nurses' practice settings. Still with regard to the Workplace Quality, although Inpatient Department nurses are less satisfied with the management bodies, they fall into the category of greatest satisfaction in terms of state of mind. That is, although they are less satisfied with the communication, with the way they feel recognized, and how their complaints and objections are dealt with by the management bodies, they are satisfied with the work in their clinical practice settings and with how they think others perceive them for that fact.
The characteristics of the work environment, either of an intrinsic (resulting from direct care) or extrinsic nature (including issues related to organizational policies, leadership and interpersonal relations, to which WPQ refers), are mediators of job satisfaction and this, in its turn, of the quality of care (14,19) . Similar to what was observed with the satisfaction with the management bodies, most nurses are less satisfied with QCD. All nurses interviewed in Critical Care, Inpatient Department, Outpatient Department, PHCU/PHU, and Continuing Care are less satisfied with the way care is provided and how information is delivered to users, with the sensitivity and the way professionals perform their tasks. The perception of not providing high-quality care promotes job dissatisfaction, and may alone lead and/ or aggravate the decrease in that same quality (20)(21) . Nurses have very defined and structured conceptions of quality standards, which can contribute to an increased level of their demand; this helps to understand the lower level of satisfaction observed among these nurses (22) . Even so, two groups of nurses stood out with greater satisfaction in relation to this dimension: those from the CCU and Indirect Care. This result may be related to the justification regarding the organizational model, in which autonomy and independence may have contributed to highlight nurses' job satisfaction at CCU regarding this dimension, as it is a characteristic of work organization similar to that developed in Indirect Care (23) . The nurses with the highest level of satisfaction regarding CQI are those working in Indirect Care and CCU, and the ones with the lowest are those from Critical Care and Outpatient Department. Despite the identification of less satisfaction with QCD by five of the participating nurse groups, this was not observed in relation to the effort made by the units to invest in the quality of care on an ongoing basis.

level of SatiSfaction by area of care
The quantitative results of job satisfaction analysis are corroborated by the level of satisfaction, with nurses working in the CCU being the most satisfied and, on the other hand, the least satisfied being those who work in the Outpatient Department and Critical Care units. The lowest level of satisfaction of critical care nurses is supported by the literature (24) , with this group of nurses being the one presenting lower level of satisfaction when compared to the other areas. This may be due to the difficulty in accessing flexible working hours, which contributes to the imbalance of the work-family binomial, as a higher quality of professional life rather than family life (14) is reported. In addition, the literature also identifies the highest prevalence of high levels of burnout and the likelihood of leaving the profession among critical care nurses due to exposure to overly stressful work environments (25) .

Study limitationS
A low response rate of participants from Continuing Care area was identified, which may have limited the understanding of the variable job satisfaction in this specific context. Thus, the existence of some samples of reduced size may limit part of the generalization of the results.

CONCLUSION
The results of the study lead to the finding that the area of care influences nurses' job satisfaction. It was identified that nurses from Community Care and Indirect Care Units show higher total satisfaction level compared to the remaining nurses from the LHU. The analysis by dimension showed that the level of job satisfaction of nurses from Community Care Units is globally higher, except for the dimensions quality of care and continuous quality improvement. In these latter dimensions, the nurses with the highest level of satisfaction are those from indirect care. Regarding workplace quality, the lowest level of satisfaction regarding Management Bodies of the majority of nurses was highlighted.
It was also highlighted that Critical Care nurses are the least satisfied in all dimensions of job satisfaction, which deserves particular attention on the part of the heads of the LHU.
Consistent with previous results, the study showed that the nurses in the Community Care and Indirect Care Units recognize that they are the most satisfied, those in Critical Care the least satisfied, and those in the Outpatient units tend to a neutral point.
Although the areas of Primary Health Care, Hospital Care, and Continuing Care of a LHU should be seen as a single organization, in a holistic perspective of care and its joint mission, in which the whole is more than the sum of parties, from the point of view of human resources management the approach should take into account the specificities of the contexts and the promotion of job satisfaction strategies appropriate to the assessment carried out by its professionals.
One suggests the conduction of an independent analysis of job satisfaction in each area for a more refined identification of nurses' perception, using the potential provided by the data collection already carried out.