Professional satisfaction in nursing during the COVID-19 pandemic

Objective: to assess the job satisfaction of nursing professionals who worked in care and management during the COVID-19 pandemic. Method: cross-sectional epidemiological study, with the participation of 334 nursing professionals of a teaching hospital. Absolute and relative frequencies of qualitative variables and means of numerical variables were calculated. The mean scores of the domains of the Job Satisfaction Survey were compared with sociodemographic-labor variables. Student’s t-test, Mann-Whitney test, and ANOVA test were applied and followed by Tukey, Kruskal-Wallis, or Dunn’s post-test to verify the statistical significance of the results with a critical level of 0.05. Results: 90 professionals were satisfied with their work, three professionals were dissatisfied and 241 professionals were ambivalent. Conclusion: ambivalence was evidenced among nursing workers regarding their job satisfaction during the period of the COVID-19 pandemic. The findings indicate a path for managers and health policymakers to invest in career plans and work environments that improve the working conditions of nursing workers.


Introduction
Healthcare systems worldwide are able to operate at full capacity for a few months, but healthcare workers do not have this power. People simply cannot be compared to fans or production machines, because they cannot be manufactured or run on an emergency basis and remain in that position for long periods. Health managers must consider health professionals as the most valuable resource when it comes to fighting the COVID-19 pandemic (1) .
Nursing professionals remain in hospitals experiencing precarious personal protection equipment, prolonged exposure to a large number of infected patients (increased viral load), and sudden increases in the pace of work, which added to an insufficient number of nursing workers.
All these related factors increase health professionals' risk of infection and, consequently, anxiety (2) .
In an analysis of the COVID-19 pandemic period, health professionals experienced a completely new situation, with difficult decisions to be made under pressure (3) . These decisions included: allocating scarce or limited resources to equally high-need patients, balancing personal and professional demands, coping with sudden increases in workload, and dealing with absenteeism.
These factors were generators of moral damage or mental health problems, such as psychological suffering resulting from the lack of actions and which violates their moral or ethical code (3) .
In addition, the essentiality of nursing activities stood out in such a way that, during the pandemic and situations of restricted activities and mobility, nursing professionals kept working without neglecting the responsibilities of caring for family members such as children or elderly parents.
Nursing is considered a stressful profession, i.e., subject to the set of reactions that occur in an organism when subjected to the effort of adaptation, generating physical and psychological health problems (4) .
Thus, the illness process of nursing professionals can be caused by the routine occurrence of situations such as fragmentation of tasks and relationships, inflexible hierarchical structure, inadequate staff sizing, high absenteeism, inadequate working conditions, overload of tasks, poor remuneration, professional dissatisfaction, and exposure to losses, suffering, and death (4) .
Preliminary data from a study with a total sample of 1,379 health professionals who worked in health care during the COVID-19 pandemic pointed out that the professionals reported experiencing symptoms of post-traumatic stress, depression, anxiety, insomnia, and stress (5) .
Although there is no single model of the composition of the determinants of job satisfaction, there have been discussions and studies on the subject since 1969. Some models consider the worker's evaluation of his/ her function, which should be translated into a positive feeling of well-being if there is satisfaction (6) . However, some models delve into the factors that would lead to dissatisfaction, such as increased workload, private life impaired by work, remuneration, and repetitive or monotonous activities in the daily work routine (7)(8) .
Job satisfaction is not static. It is influenced by internal and external factors in the work environment and can be understood as a feeling of well-being with what one does, satisfaction of needs, and self-fulfillment in the work environment. Considering that job satisfaction generates pleasure and motivation, specifically in nursing, it can positively impact patient care through greater involvement of these workers, with professional and institutional commitment (9) .

Data collection
Data collection was conducted between June and August 2021, by means of an electronic form using Google Forms. Fifteen minutes were estimated for the participants to answer the survey.

Data collection instrument
The Job Satisfaction Survey (JSS) -Brazilian version (10) was used. This is a public domain instrument developed in the United States in 1985 (11)

Participants
Given the limitations imposed by the pandemic for face-to-face data collection, all 1,407 nursing professionals working at the study hospital were invited to participate by e-mail. The sample was made up by convenience, considering that any nurse or nursing technician working at the institution during the data collection period could participate in the study. A total of 367 answers were obtained, but 26 participants sent duplicate answers, and only the second one was considered. Of the 341 respondents, seven did not answer the instrument completely, thus 334 participants were considered for the study, namely 196 nursing technicians and 138 nurses.

Ethical aspects
The research project was reviewed by the research ethics committee of the university where the researchers are affiliated and, after approval through opinion number 4.421.122 9/2021, the professionals were invited to participate in the study. The professionals were informed about the study's purpose and anonymity in data collection to become study participants, and they could only answer the JSS after reading and signing an informed consent form.

Data processing and analysis
The data was stored in spreadsheets created in t-test or Mann-Whitney test were applied, according to data distribution (12) . For comparisons involving more than two groups and the results of a quantitative variable, the Anova model was applied followed by Tukey's posttest, or the non-parametric Kruskal-Wallis test followed by Dunn's post-test, according to data distribution (12) .
The data distribution was evaluated by the Shapiro-Wilk test and a 0.05 significance level was adopted (12) .  Regarding total score and indication of job satisfaction, 3 professionals were dissatisfied (score between 96-108), 241 were ambivalent about job satisfaction (score between 109-143) and 90 professionals were satisfied with their jobs (score between 144-172).

Results
The results of the comparison between the means of the JSS domains by sex and marital status did not show statistically significant differences (p>0.05). Table 2 shows the comparison between the mean scores of the domains and the total JSS by education.     Considering the JSS total score, there was a predominance of ambivalent professionals regarding their job satisfaction in the sample studied, which was similar to the results of another national study (13) .
Most participants were female and married, evidencing that in the sample, Nursing is essentially female, and culturally considered a woman's attribution in relation to health care (14)(15)(16)(17) . Among frontline health professionals, women are a risk group for mental suffering because they perform tasks that require a high level of contact with patients, which increases the fear of contagion (14)(15) . In addition, women are culturally expected to make sacrifices for the benefit of others, carrying out household chores and caring for children, the elderly, or sick people, which contributes to their work overload (14)(15)(16)(17) .
However, in the present study, job satisfaction did not differ between sexes, nor even between professionals with or without a partner.  (Table 3) and remain in mid-level positions while awaiting the opportunity of a public exam to be hired as nurses, it can be considered a risk or a triggering condition for conflicts in power relations and, consequently, promote mental health problems among these professionals (18)(19)(20)(21) .
This culture may justify the results of this study, with the ambivalence of managers and nursing technicians and the dissatisfaction of nurses working in care, especially in the field of operational working conditions.
Nursing work is focused on care management and nursing service management, which is characterized by involving people and material management activities to reach organizational goals. Care management is an inherent attribution of the nurse's professional practice. The management of nursing services is the responsibility of nurse managers or heads of units (17)(18)(21)(22)(23) .
The two spheres of nursing work are interconnected in the search for excellence in patient care, and the perseverance of professionals has been associated with job satisfaction (17,22,24) .
Although no studies were found aiming to assess job satisfaction in times of pandemics, a national study indicated that nursing technicians and aides showed a significant association with suffering at work, in addition to low pleasure, which was attributed to the demands of the nature of their work, as well as low social support (15) .
In this sense, it is important to emphasize that not only the physical and organizational conditions of the nursing work environment influence the best practice of nursing professionals. Factors such as the size of the institution or health service, management model, professional hierarchies, organizational culture, infrastructure, and human and financial resources for the performance of care can enhance or limit nursing practice (17)(18)22) . Thus, work environments that have these aspects strengthened bring greater professional satisfaction to nursing, and consequently, improve the quality of nursing care in the hospital environment (20,(22)(23) .
The Colleagues and Supervision domains, considered positive in the study, involve the relationship among team members and have relevant representativeness regarding pleasure at work and quality of life of workers and may impact quality of care and patient safety (14)(15)21,24,(26)(27)(28) .
Given the positive evaluation in these domains that involve the relationship among nursing team members and the relationship with the immediate superiors, the findings may represent the sense of belonging of professionals in the work team, with constructive experiences and www.eerp.usp.br/rlae 7 Pirino MVB, Nascimento CL Sobrinho, Dini AP the possibility of mutual support in facing the difficulties inherent to the pandemic period (14,(24)(25)(26)(27)(28) .
Operational Conditions, a domain that presented averages consistent with job dissatisfaction, should be compared longitudinally because they may have been worsened in the waves of the COVID-19 pandemic. Due to the abrupt increase in work demand, the domain may have captured workers' perceptions of task fragmentation, insufficient staffing, absenteeism, turnover, and exposure to suffering and death (1,7,(15)(16) .
A survey of healthcare professionals in Portugal revealed satisfaction, more specifically the relationship between job characteristics and job satisfaction on turnover, which reflects directly on organizational commitment. It concluded that the higher the satisfaction, the higher the commitment, the lower the impact on turnover and absenteeism, and the better the perception of customer satisfaction specifically in healthcare organizations (23) .
The leadership practice and organizational commitment evaluated in the Supervision and Operational Conditions domains are indicators of potential or achieved improvements in the work process and consequently drivers of job satisfaction among nursing workers (7,16,19,21,(26)(27)(28) .
In this direction, the analysis of the Remuneration, organizational support with the creation of physical spaces for workers to rest (7,16,19,(26)(27)(28) .
From this perspective, the JSS author (11) highlights that job satisfaction is a feeling experienced by professionals about their work and reflects how much people like or dislike their work, denoting a constellation of attitudes related to various aspects of the occupational environment (11) . In this sense, the experience of pleasure may result from the relationship between professional achievement and freedom of expression, involving aspects such as well-being, satisfaction, motivation, recognition and pride for the activities performed and opportunities to express opinions to colleagues and supervisors (15)(16)19,(27)(28) .
During the work in the pandemic period, the impossibility of holding conversation circles associated with the negative experiences of nursing workers, such as emotional exhaustion, stress, dissatisfaction, overload, frustration, insecurity, feelings of devaluation, indignation, uselessness, disqualification, injustice, discrimination, and lack of recognition (7,15,19,(25)(26)(27) , may have interfered in the completion of the instrument, including discouraging professionals to participate.
The limitations of this study are the lack of randomization of the sample and its cross-sectional design, which does not allow for establishing a causal link, but rather indicates an association between variables.
In addition, no studies that used the JSS during the COVID-19 pandemic were found, which would allow comparability with the findings of this study.
This study indicated the importance of recognizing and rewarding the nursing professionals who worked uninterruptedly during the COVID-19 pandemic with actions, policies, and strategies that go beyond the transience of clapping hands and contemplate reviews of work processes, career plans, possibilities of rewards, and a careful look at working conditions with the acceptance of fears and possibilities of continued reflections.
The study also revealed the professionals' recognition in relation to their supervision and coexistence with co-workers, in such a way that these two were the only dimensions of job satisfaction considered positive among all the actors of care in the study institution: nurse managers, nurses involved in care, and nursing technicians.

Conclusion
In the present study, ambivalence among the nursing workers was evidenced regarding their job satisfaction during the period of the COVID-19 pandemic. Nurse managers showed better job satisfaction regarding remuneration, promotion, and operational conditions than nurses involved in care and nursing technicians.
The findings indicate a path for managers and health policymakers to invest in career plans and the work environment to improve the conditions for nursing workers to act with safety and dignity in patient care.