Workloads , strain processes and sickness absenteeism in nursing 1

Copyright © 2013 Revista Latino-Americana de Enfermagem This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (CC BY-NC). This license lets others distribute, remix, tweak, and build upon your work non-commercially, and although their new works must also acknowledge you and be non-commercial, they don’t have to license their derivative works on the same terms. Corresponding Author: Vanda Elisa Andres Felli Universidade de São Paulo. Escola de Enfermagem Av. Dr. Enéas de Carvalho Aguiar, 419 Bairro: Cerqueira César CEP: 05403-000, São Paulo, SP, Brasil. E-mail: vandaeli@usp.br Vivian Aline Mininel2 Vanda Elisa Andres Felli3 Everaldo José da Silva4 Zelinda Torri5 Ana Paula Abreu5 Maria Tereza Afonso Branco6


Introduction
The human body's different reactions to work, manifested through pleasure and satisfaction, but also through pain, disease, strain, psychic and physical suffering, which trigger disabilities, absenteeism, early retirement and even death among nursing workers, have been focused on in different Brazilian studies (1)(2)(3)(4)(5) .
Based on the theoretical reference framework of the social determination of the health disease process (6)(7) , the relation between factors of exposure (workloads) and the consequent potential or manifested processes of physical and/or psychic strain, a disease profile characteristic of these workers can be drawn (7) .
The workloads that nursing workers are exposed to during their workday are classified as biological, physical, chemical, mechanic, physiological and psychic (8) , even if they are unaware of the risks inherent in this exposure.
Brazilian studies characterize the workloads and the effects of this exposure, such as absenteeism, strain processes, occupational illnesses and accidents caused in the nursing team, in different environments, conditions, organizations and professional contexts (9)(10)(11)(12) .
Despite the doubtless relevance of the theme, not all employers are willing to invest in resources to interrupt or minimize the occupational exposure and illness process, nor in actions to promote quality of life at work.
Therefore, the impacts of this reality need to be evidenced, not only on workers' health, but also for the employers, including financial losses and a drop in service quality resulting from absences, medical leaves, leaves of absence and presenteeism, in the attempt to trigger a change of attitude to enhance occupational health surveillance.
In that sense, the Monitoring System of Nursing Workers' Health (SIMOSTE) (13) , a software developed

Method
A descriptive and cross-sectional study with a quantitative approach was conceived within the theoretical framework of the social determination of the health and disease process (6)(7) .The quantitative approach, as a dimension of quality, sustained by the dialectical law of the "transition from quantity to quality" (14) , permits establishing the relation between work as a social category and occupational health.The stored data were extracted from SIMOSTE and inserted in an Excel worksheet.For the analysis, relative and absolute frequencies and the Risk Coefficient (RC) were used, which is calculated by dividing the number of events that occurred at the same place and time by the total number of people exposed to the events (15) .

This project received approval from the Research
Ethics Committee at the University of São Paulo School of Nursing, process 718/2008/CEP-EEUSP.

Results
In 2009, 144 workload-related notifications were registered, 129 (89.58%) of which involved female and 15 (10.42%) male workers.These notifications were distributed as described in Table 1.As regards the professional category, the auxiliary nurses are the most frequent victims, with 89% of the notifications.On the other hand, the nursing technicians show the highest risk coefficient, followed by the auxiliary nurses.
The age range between 31 and 40 years is the most representative among the professionals, with 37.5% of Approximately 56% of the workers with notification in SIMOSTE indicated a monthly income between R$ 1,501.00 and R$ 2,000.00,25% between R$ 500.00 and R$ 1,500.00 and 17% over R$ 2,001.00.
The results demonstrate that 99.3% (143) of the notifications involved workers with a weekly work journey between 10h and 36h and that 82% were statutory public servants.
In general, all hospital services were represented in the notifications made during the study period.The outpatient clinic was responsible for 38.9% of the notifications, followed by the surgery room (obstetric center, surgical center and sterilization center) with 26.4% and the gynecology and obstetrics services with 10.4%.The intensive care unit corresponded to 6.9% of the notifications, the medical clinic to 6.2%, pediatrics and maternity to 5.6% and the other services 5.6%.
The results related to the notified workloads have been described in Table 2.The number of referred workloads (160) is higher than the number of notifications made (144), showing interaction between two or more workloads, like psychic workloads with other types.Convalescence, which figures in the ICD10 group related to the health recovery periods after surgery or treatment, also stood out in terms of the days of absence it caused (294).

Workloads
Table 4 shows the recurrence of notifications among the nursing workers during the study period.Diseases of the musculoskeletal system and connective tissue 1

Discussion
The results reveal a large number of occupational health related notifications during the study period, with a mean 12 notifications per month.The risk coefficient (RC) for nursing at the institution corresponded to 25.2 during the period and was higher for nursing technicians and auxiliaries.This may be due to the characteristics of these professional categories' activities, responsible for most direct care to patients (10,16) .
In a study about accidents that involved piercingcutting materials at a public hospital in the interior of Sao Paulo State, the RC=15.13 for accidents that involved this equipment among auxiliary nurses (8) .In another study, undertaken at six public hospitals in the Federal District, found an RC=39.1 for accidents involving biological material among health professionals (17) .A result very similar to the present found an RC=26.47 for occupational accidents among auxiliary nurses at a teaching hospital in the Federal District (18) .
The present study data are in accordance with earlier studies when considering the high occupational risk exposure level nursing workers are exposed to in the hospital context.
Concerning the age ranges of the workers that filed notifications in SIMOSTE, in a study of nursing workers at a teaching hospital in the Federal District, similar results were found.The highest frequency of occupational accidents was found among professionals between 31 and 50 years of age.The authors attributed these results to the associated population's long experience, associated with non-compliance with the rigor needed to prevent occupational accidents, deriving from the non-surveillance of their application (17) .
Studies involving hospital nursing professionals demonstrated that most of these professionals work double or triple shifts, reflecting in few hours for leisure, rest, physical exercise, quality of sleep, besides increased exposure to the workloads and risks present in their work environments (12,(19)(20) .That was not observed in the present study, possibly because the population has a sole job contract (up to 36 hours per week), something rare among Brazilian nursing professionals.
The physiological workloads prevailed in the notifications in SIMOSTE.In a study to investigate exposure to these workloads among outpatient nursing workers indicated exposure to excessive weight handling during their activities, as well as the predominance of standing, uncomfortable or inappropriate positions during the work day (11) .
The psychic workloads were also relevant in the study context.As a result of the precarious work organization, in combination with the institutionally established vertical relations, nursing becomes increasingly exposed to these workloads, through moral harassment, organizational pressure, restricted supervision, lack of autonomy, power abuse and lack of collective defense.Some forms of strain deriving from this type of exposure were also indicated in a specific study about psychic workloads, including sleep and insomnia, gastritis, increased blood pressure, anxiety, insecurity, depression and stress (12) .
The biological workloads, which rank third in the notifications, generally derive from accidents that involve piercing and cutting material and from contact with body fluids and secretions (16)(17)(18) .The physical and chemical workloads corresponded to the smallest notification percentages during the analysis period.
It is interesting to note that the hospital environment offers a range of situations that expose the workers to the different workloads -a process that can take form abruptly (as workplace accidents or accident to and from work) or in a gradual exponential form, through strain and illnesses.Similar studies involving nursing workers in Brazil converge towards the same conclusion (7)(8)21) .
Diseases of the musculoskeletal system and connective tissue and mental disorders were the most representative in the referred groups of diseases.
Work-related Musculoskeletal Disorders (WMSD) show the highest incidence levels among nursing workers and are the main causes of leaves in this category (22) .This is due to the nursing professionals' tasks, which demand constant and intense physical efforts, mostly in inappropriate positions and conditions.
Mental and behavioral disorders, equally relevant, end up triggering strain processes that cannot always be easily related to work and often are attributed to the individual's general lifestyle.
In this study, depressive episodes were the most representative in this disease group, in accordance with the literature (23) .
The group of diseases of the respiratory system is associated with cases of sinusitis, tonsillitis and pharyngitis; only three cases were directly related with the flue H1n1, which affected the world population and caused different leaves in that period, also for suspected and unconfirmed cases of the disease.
Convalescence is related with health recovery associated to some kind of treatment, procedures or specific care.As the convalescence diagnosis was attributed without the sub-classification of the ICD10, the actual cause of the notification and its relation with work remained unknown.
One unexpected finding refers to the group of diseases related to the pregnancy period, which were included in SIMOSTE as work-related.In the present study, the relation between these conditions and the work environment could not be identified.This fact should be looked at in further depth, especially considering that nursing is a predominantly female profession, involving women of fertile age, making pregnancy a constant event in this public.
Another relevant research result is the number of recurrent notifications among the nursing workers.
Among the 144 notifications, 52 related to workers who had filed a notification.This arouses reflections on the health profile of nursing, which increasingly indicates the chronic nature of work-related conditions and illnesses.
The notifications in SIMOSTE triggered 1567 days of absence from work due to diseases related to occupational exposure during the 12-month period.
These lost workdays, if considered for a single worker, in consecutive days, would be equivalent to approximately four years and three months.It should be emphasized, however, that the absenteeism mentioned relates to different workers, at distinct or simultaneous times, and that not all cases related to periods of more than 15 days, which characterizes the severity of the health problems.
In line with the research findings, other studies demonstrate that the rates of diseaserelated absenteeism in nursing are very high, mainly due to the presence of risk factors in the work environment (24)(25) .
For the institution, this information is extremely important, as it permits recognizing individuals with

Conclusion
This study provided knowledge on the workloads, processes of illness or strain and sickness absenteeism among nursing workers from different hospital services, in a systematic manner, through SIMOSTE.
The physiological workloads prevailed, followed by the psychic workloads.The causes of absence from work were related to the illnesses grouped according to the ICD10, particularly diseases of the musculoskeletal system and connective tissue and mental and behavioral disorders.
It could be identified that the nursing workers are absent for less than 15 days, recurrently, frequently due to the same reasons, and that these short-term absences, when analyzed over a one-year period, represent a relevant number of workdays lost.
This study contributes to the advancement of nursing knowledge through the use of a technological tool for the collection and systematic analysis of data and patented by the Research Group "Health Studies of Nursing Workers" at the University of Sao Paulo School of Nursing, was implemented at seven hospitals in different Brazilian regions to register nursing workers' occupational exposure and its consequences, permitting the monitoring of these conditions through indicators.Thus, the aim in this study is to describe the workloads, the respective strain and the sickness absenteeism among nursing workers in one of the setting of the SIMOSTE Project, located in the Brazilian Central-West.
the notifications, followed by the range between 41 and 50 years with 36.8%.The groups between 21 and 30 years and between 51 and 60 years correspond to 10.4% and 11.1%, respectively, and the least representative range relates to professionals over 60 years of age (4.2%).
recurrent complaints and absences, enhancing the individual assessment of cases and the proposal of the collective interventions needed.Also, additional studies on the costs of the workdays lost are needed to demonstrate the financial losses the institution is incurring due to absenteeism, indicating the advantages of investing in actions aimed at health surveillance and the promotion of quality of life at work.
while the 30 notifications due to diseases of the musculoskeletal system and connective tissue lead to www.eerp.usp.br/rlae

Table 3 -
Distribution of notified processes of exhaustion according to ICD10 groups and days of absence counted.

Table 4 -
Recurrent notifications across analysis period.