WORK INTENSIFICATION FROM NURSING WORKERS’ PERSPECTIVE

LA INTENSIFICACIÓN DEL TRABAJO DESDE LA PERSPECTIVA DE LOS TRABAJADORES DE ENFERMERÍA

ABSTRACT

Objective:

to understand the factors that intensify work from the perspective of nursing professionals working in medical and surgical clinical units.

Method:

this is a descriptive, exploratory study, with a qualitative approach, carried out with 18 nursing professionals working at a university hospital in southern Brazil. Data production took place between April and June 2021 through semi-structured interviews. Data processing occurred through textual analysis, with the aid of IRaMuTeQ software, with the results being subjected to content analysis. The project followed the recommendations for research involving human beings, approved by the Research Ethics Committee.

Results:

based on similarity analysis and Descending Hierarchical Classification, data were organized into seven classes: I - Weaknesses in physical structure and lack of materials and/or equipment; II - Complexity of patients’ clinical condition; III - Weaknesses in training, qualification and number of professionals; IV - Work rhythms and demands; V - Work process organization; VI - Weaknesses in management; and VII - Lack of interprofessional collaboration.

Conclusion:

work intensification is present in study participants’ daily lives, being related to the lack of materials and equipment, severity of patients’ clinical condition, weaknesses in professional training and qualification, intensified pace and increase in work demands, weaknesses in management, and lack of interprofessional collaboration.

DESCRIPTORS:
Nursing; Professional practice; Working conditions; Workload; Occupational health

RESUMEN

Objetivo:

comprender los factores que intensifican el trabajo desde la perspectiva de los profesionales de enfermería que actúan en unidades clínicas médico-quirúrgicas.

Método:

Estudio descriptivo, exploratorio, con enfoque cualitativo, realizado con 18 profesionales de enfermería que actúan en un hospital universitario del sur de Brasil. La producción de datos se realizó entre abril y junio de 2021, a través de entrevistas semiestructuradas. El procesamiento de los datos ocurrió a través del análisis textual, con la ayuda del software IRaMuTeQ, siendo los resultados sometidos al análisis de contenido. El proyecto siguió las recomendaciones para la investigación con seres humanos, siendo aprobado por el Comité de Ética en Investigación.

Resultados:

con base en análisis de similitud y Clasificación Jerárquica Descendente, los datos fueron organizados en siete clases: I - Debilidades en la estructura física y falta de materiales y/o equipos; II - Complejidad del cuadro clínico del paciente; III - Debilidades en la formación, calificación y número de profesionales; IV - Ritmos y exigencias de trabajo; V - La organización del proceso de trabajo; VI - Debilidades en la gestión; y VII - Falta de colaboración interprofesional.

Conclusión:

la intensificación del trabajo está presente en la vida cotidiana de los participantes del estudio, estando relacionada con la falta de materiales y equipos, la gravedad del cuadro clínico del paciente, las debilidades en la formación y calificación profesional, el ritmo intensificado y aumento de las exigencias laborales, las debilidades en gestión y la falta de colaboración interprofesional.

DESCRIPTORES:
Enfermería; Práctica profesional; Condiciones de trabajo; Carga de trabajo; Salud laboral

RESUMO

Objetivo:

compreender os fatores que intensificam o trabalho na perspectiva de profissionais de enfermagem atuantes em unidades de clínica médica e cirúrgica.

Método:

estudo descritivo, exploratório, de abordagem qualitativa, realizado com 18 profissionais de enfermagem atuantes em um hospital universitário do sul do Brasil. A produção dos dados ocorreu entre abril e junho de 2021, por meio de entrevista semiestruturada. O processamento dos dados ocorreu pela análise textual, com auxílio do software IRaMuTeQ, sendo os resultados submetidos à análise de conteúdo. O projeto seguiu as recomendações da pesquisa envolvendo seres humanos, sendo aprovado por Comitê de Ética em Pesquisa.

Resultados:

a partir da análise de similitude e da Classificação Hierárquica Descendente, os dados foram organizados em sete classes: I - Fragilidades na estrutura física e falta de materiais e/ou equipamentos; II - Complexidade da condição clínica do paciente; III - Fragilidades na formação, qualificação e quantitativo de profissional; IV - Ritmos e exigências do trabalho; V - A organização do processo de trabalho; VI - Fragilidades no gerenciamento; e VII - Falta da colaboração interprofissinal.

Conclusão:

a intensificação do trabalho se mostra presente no cotidiano dos participantes do estudo, sendo relacionada à falta de materiais e equipamentos, à gravidade da condição clínica do paciente, às fragilidades na formação e qualificação profissional, ao ritmo intensificado e aumento das exigências laborais, às fragilidades no gerenciamento, e à falta de colaboração interprofissional.

DESCRITORES:
Enfermagem; Prática Profissional; Condições de Trabalho; Carga de Trabalho; Saúde do Trabalhador

INTRODUCTION

Transformations in the world of work, which have occurred over the last 50 years, originate from the structural crisis of capital and the process of productive restructuring, which began in the 1970s. This restructuring is characterized by proliferation of managerial policies, which aim to make more flexible and precarious conditions for hiring workers, in addition to working hour intensification.

These transformations in the world of work constitute a process of work intensification that is based on the neoliberal model. It is a multifaceted construct, characterized by an increase in the number of tasks and/or complexity of a task1 and/or the performance of several tasks simultaneously2 (with the same technological standard)3 without due compensation.

Furthermore, it is understood that work pace acceleration, work precariousness, the lack of human resources, staf undersizing, workload and/or work overload increase, the weaknesses in working conditions and relationships and working hour length and/or duplication are also factors that are related to the construct.

From the point of view of contractual relations, the labor market is increasingly demanding a qualified and versatile worker who can work on several front lines and in accordance with employers’ needs, a fact fact nullifies workers’ subjectivity4. This intensification also requires a greater expenditure of physical, cognitive and emotional capacities by workers5, promoting a plurality of health problems and resulting in a decrease in job satisfaction, an increase in absenteeism and a poor balance between work and personal life. In the health area, it can have important repercussions, including reducing the quality of care provided to patients/users.

In the nursing area, the existence of many factors related to work intensification is well known, such as precariousness of working conditions, increase in activities to be carried out during work shift, in addition to issues related to work relationships among teams, often weakened. The hospital environment is complex, marked by the need to improve professional skills in addition to technical interventions, which aim to prevent damage and treat injuries.

In nursing professionals’ daily work, there are unfavorable environments, poor working conditions, overload, intense work pace, long working hours, physical and mental exhaustion, occupational stress, interpersonal conflicts, low pay and professional devaluation6.

A recent study highlights that the most common problems in nursing managers’ practice are related to resource allocation, high-quality care provision and development7, in addition to professional turnover in direct patient care. In this context, a study carried out in Jordan reveals that nurses who rotated units and work shifts had a higher level of satisfaction and lower levels of conflict8, which, in turn, may also be related to work intensification.

A Finnish study reveals that health professionals at a hospital complex continually experienced intensified job demands (IJDs), which are more related to work pressure, increased work pace and multitasking, which resulted in greater exhaustion of workers and less satisfaction of patients in relation to the assistance offered to them. It was also evident that nurses who cared for critically ill patients experienced these IJDs more, when compared to other health professionals9.

This is justified by the high intensity of work, infrequent breaks, highly demanding patients from a clinical point of view, in addition to the increasing increase in these demands at a fast pace. In another study, work intensification and personal concern about organizational change were associated with more severe conscience stress among nurses10.

Given this, the research question was elaborated: what are the factors that intensify work from the perspective of nursing professionals working in medical and surgical clinical units? This study aimed to understand the factors that intensify work from the perspective of nursing professionals in medical and surgical clinical units.

METHOD

This is a descriptive, exploratory and qualitative study, carried out with nursing team workers from two medical clinic units and a surgical unit of a university hospital in southern Brazil. The institution is 100% accredited by the Brazilian Health System (Sistema Único de Saúde), and has 403 beds, being a health reference for 43 municipalities. Medical clinic units I and II assist patients and have different specialties, such as hemato-oncology, cardiology, infectious diseases, gastrology, pulmonology, with a total of 58 beds and 76 nursing professionals. The surgical clinic unit has several surgical specialties, such as general surgery, urology, traumatology, head and neck, digestive, thoracic, vascular and proctology, differing from those previously mentioned, as it provides assistance in the pre-operative and post-operative period. It has 52 beds and 62 nursing workers.

Ten nurses and eight nursing technicians participated in the study. Nurses or nursing technicians, working in one of the medical and/or surgical clinical units for at least one year were included. Workers absent from work during the period established for data production were excluded.

The number of interviewees was defined based on participants’ adherence to the research, following the data saturation criterion. Participant selection was carried out by draw among nurses and nursing technicians, work shifts (day and night) and units (medical and surgical clinic).

Data production took place from April to June 2021, through semi-structured interviews, based on a script prepared by the authors themselves. Among the questions asked to participants, the following stand out: 1) What is your daily work like?; 2) What does your job require of you?; 3) What do you have to say about your job demands in this unit/institution?; 4) How do you feel about this demand?; 5) Does your work have any repercussions on the other activities you carry out during the rest of the day? Which?; 6) What can you tell me about the working conditions in your work unit?; 7) How do you perceive the relationship between your work and your health?; 8) How do you feel about your work in your unit/institution?; 9) Could you tell me about the activities carried out simultaneously?; 10) Were you invited to remain working even after your work shift? What activities did you carry out?; 11) How do you perceive the relationship between goals (planning) in your health?; 12) How do you perceive the impact of your work productivity on your health? and 13) After this conversation, would you have any further thoughts on the topic?

Participants were informed, using accessible language, about the justification, objectives and procedures used in the research, in addition to the information destination. Only upon agreement and signing of the Informed Consent Form (ICF) did the interviews begin.

Considering that the data production period took place during the COVID-19 pandemic, the interviews were carried out via Google Meeting, with a view to respecting personal distancing rules. It is noteworthy that the units did not treat patients with COVID-19 during the data collection period. Data were collected by the main researcher outside participants’ working hours, and lasted about 50 minutes each. Participants’ statements were transcribed in full, and the text corpus resulting from the dialogues was subjected to lexicographic analysis, with the aid of the Interface de R pour Analyzes Multidimensionnelles de Textes et de Questionnaires (IRaMuTeQ) software11. It is free software, used for processing qualitative data, which provides different types of textual data analysis, organizing the arrangement of vocabulary in an understandable and visually clear way11.

The categories of words included for analysis were adjectives, nouns, verbs and unrecognized forms, as these included frequent terms in the corpus, such as acronyms and unified terms so that 91.3% of the text segments (TS) were used for analysis. For this study, similarity analysis and Descending Hierarchical Classification (DHC) were carried out. The occurrences presented in each of the classes in DHC were arranged in descending order, according to the value obtained in the chi-square test (X2), and all presented statistically significant values (p<0.0001).

When processing participants’ statements, IRaMuTeQ recognized 74 texts, 181 TS, 1,200 forms, 5,839 records of word occurrences, 861 of which were distinct and 430 had a single occurrence (hapax). Based on similarity analysis and DHC, the results were organized into seven classes.

Participants were identified by the letters “N” (nurse) and “NT” (nursing technician), followed by the Arabic number corresponding to the interviews in a random sequence (N1, NT2 and so on). For interpretation and analysis, the content analysis technique12 was used. The project followed the recommendations for research involving human beings, and was approved by the Research Ethics Committee.

RESULTS

Ten nurses and eight nursing technicians from medical and surgical clinical units participated in the study. The majority (15) are women aged 27 to 52 years old, with an average age of 39 years old. Training time ranged from five to 28 years, with an average of 13 years, and job tenure ranged from two to 19 years, with an average of 12 years. Regarding education, two workers have a doctoral degree in nursing, and two are studying for a doctoral degree and two a master’s degree. Furthermore, 11 have nursing degrees, and seven have high school (nursing technician). It is noteworthy that, although they have a degree, they were currently working as a nursing technician. Regarding shifts, 10 work morning and afternoon shifts, and eight work night shifts. Regarding the work regime, eight were hired by the Single Legal System (RJU), and 10 by the Brazilian Hospital Services Company (EBSERH - Empresa Brasileira de Serviços Hospitalares).

To better explore the collected data, similarity analysis was carried out. Thus, through an assessment based on graph theory, it was possible to identify textual occurrences between words, which helped to identify the content structure and the text corpus.

It is noteworthy that the word “patient” presented the greatest number of connectivities, constituting the main nucleus of meaning in participants’ statement. From the central element “patient”, other terms emerged that led to reflections on care routines, patients’ severity level, unit physical structure and care technologies. The terms “nursing” and “lack” also stood out in the statements, which gave rise to new webs and developments. From them, other words suggestive of more detailed meanings branched out, which can be seen in the Figure 1 below.

Figure 1 -
Similarity analysis. Santa Maria, RS, Brazil, 2023.

As seen in the diagram above, the word “nursing” gives rise to other terms related to nursing team structuring, training processes, and technologies necessary to provide patient care. On the other hand, it is clear that the word “lack” has a strong relationship with important elements for nursing assistance/care. Among them, the lack of materials, equipment, staff, communication and management can be highlighted.

In this study, DHC analysis was also used, which presented 172 segments with 95.03% of use, resulting in seven semantic classes. Class interpretation was carried out by the researchers based on occurrences/words that presented statistically significant values (p<0.05) and the TS assigned by the software in each class.

From the dendrogram analysis, it was possible to identify the classes’ lexical content and the most frequent words in each of them. Participants’ statements were initially organized into two subgroups. In subgroup “A”, there are classes I and II, which are related to each other. In subgroup “B”, classes III and IV are identified, and from the cluster generated by these classes, subgroup “C” emerged, which is composed of classes V, VI and VII. The following Figure 2presents the dendrogram with semantic classes and their relationships.

Figure 2 -
Dendrogram showing semantic classes and their relationships. RS, Brazil, 2023.

Chart 1 presents the TS for each of the classes.

Chart 1 -
Structural aspects of the unit and clinical dimension of care. Santa Maria, RS, Brazil, 2022.

Class I - Weaknesses in physical structure and lack of materials and/or equipment
I also see it as precariousness [referring to the rooms/wards]; We don’t have screens on the windows. There is a lack of HGT equipment, shower chairs, electrocardiogram equipment, IV poles, screens, and the structure of the unit itself, which is very long (N6). The rooms are cramped. It is not possible to reach patients, to assess, perform a puncture, aspirate. It’s the companion’s backpacks, the armchair, the companion, the infusion pumps, the monitor that doesn’t work, the window that’s stuck (N5). The patient doesn’t have things on edge. The beds are very close together. The bathrooms do not have hot water. We only have two shower chairs. Monitors, we also have few on the floor! So, it’s quite difficult like that. This lack intensifies our work (NT7). The wards have five patients and five companions, and then you go to give a bath to an elderly woman, who has protected herself all her life and doesn’t have a screen. We don’t have air conditioning or fans in the rooms, and this also impacts (NT13). The physical space is precarious! The headboard is small, the drawer is falling out! (NT2). Sometimes we need infusion pumps, and having to borrow them takes time. At night, we don’t have access to mechanical ventilators, so when the patient gets worse, it’s difficult (N05). In two-bed wards, there is only one headboard with an oxygen network and a compressed air outlet, so you have to change the patient’s room. The patient doesn’t have things at the bedside, you have to run from one side to another (N10). The bells don’t work, or the sensor beeps but doesn’t show which room, so you have to go out looking [...] in this regard, it increases our workload (N1). You go to pick up the patient, there is no wheelchair, so you need to go downstairs to get the chair and take the patient there for the exam. It’s too late, it’s wasted time! (NT15).
Class II - Complexity of patients’ clinical condition
It is not uncommon for us to have patients on mechanical ventilation on the floor. So, our patients end up being [admitted to the unit] (NT2). We receive patients coming from the ICU, the recovery room, the emergency room, the cardiology unit, so these are patients who require a lot of care (N9). Patients are increasingly unstable. We see fewer patients, but with very different levels of complexity. So, it is pulled towards the nursing team. So, this factor of patients’ severity is an immutable factor (N10). We have many semi-critical or some chronic patients who come from the ICU, tracheostomized, with skin lesions, using a probe, central venous catheter, bladder catheter (N4). Patients are increasingly serious, increasingly unstable, especially the surgical patients we have. The unit, despite being open, has many seriously ill patients, even patients who would be in intensive units. Today, I had two patients on mechanical ventilation, two with tracheostomy (N10).
Class III - Weaknesses in professional training, qualification and number
Now, in this time of pandemic, the lack of staff and absenteeism are very visible, and this greatly interferes with our daily lives (N16). During the pandemic, we were the ones who covered the certificates, who were working, and then, the days we would have had off, we ended up having to work (NT2). In general, we work with four co-workers (nursing technicians) and one or two nurses; There are days when we take on up to 10 or 11 patients. We still have nursing assistants, and it puts a lot of burden on them, because they don’t have support to carry out some activities. Therefore, the nurse must be careful to organize the schedule (NT3). One of the factors that influences nurses’ work is the team itself. We know our co-workers, and we know, today is going to be tough! (N14). The teams of nursing technicians are not fixed, and if you ‘get’ a weak team, you already know that you will have to keep an eye on them all the time, so it’s very difficult! (N17). Training is fragile, not only for the nursing technician, but for other professionals on the team. If the doctor or physiotherapist has more control over the situation, the actions are more correct and you don’t have to worry about other things (N18). It is visible that schools, that teaching, is fragile. There are a lot of people who were hired and who don’t understand the process, some things that are considered basic (N13). The lack of qualifications is glaring and, with the pandemic, it became much more evident (N17).
Class IV - Work rhythms and demands
You have to have attention and vision. There are a lot of details, there are a lot of chances to make mistakes, a lot of chances! So, you have to read, re-read, interpret a medical prescription (NT3). The time when the patient receives the most medications is at night. So, there are several trays throughout the night, so it ends up that at night the use of medication intensifies more (NT3). I think the work is boring. There are things that are not the responsibility of [nursing] technicians, such as vacuuming and here we still do that (NT7). It requires organization, understanding priorities, and knowledge to assess patients. It requires skill, competence, leadership, knowledge about the clinic itself (N1). This diversification of patients’ clinic, you are studying all the time, ends up intensifying, because, in addition to your work shift, when you get home, whether you like it or not, you have to study to be able to handle your work the next day (N11). These situations happen every day, where you have to improvise, where you have to go back. So, all of this ends up tiring and, at times, demotivating you a lot (N6). There are times when there is a shortage of material, you end up spending more time looking for the material or going to other sectors to borrow it. Not long ago, for example, we ran out of 20 (ml) syringes and so we ended up using two 10 ml syringes, we had to improvise (NT12). We have to be creative and look for other resources. This also ends up influencing work intensification there on a daily basis (NT9).
Class V - Work process organization
Computerization makes it easier, but it also creates more work; It requires you to write more, to speak in more detail, to assess the patient better, and this takes time, mainly because, sometimes, the system is very slow (NT2). We make an effort to leave as few issues as possible, but sometimes there is something left, but it is not within your power (N4). What also interferes are the double shifts. You have an employee who is tired, stressed, due to the number of hours worked, and here, in the hospital, many co-workers work double or triple shifts, and this influences the occurrence of some errors (N17). The lack of routine, conversation, and standardization creates overload. There is no implementation of a routine aimed at improving flow for teams (N14). In addition to our service, we have to check everything the technicians do. So, there are some teams that we can trust and there are other teams that this is more complicated, that we need to go after, that we need to check everything (N7).
Class VI - Weaknesses in management
Next, we need to give an “opinion” on some materials, but even so, after a while, we notice that, even so, the material was purchased (N18). Another aspect that could be seen is the issue of lack of management, of routines, of small things that can be done daily, both by those who manage (NT3). The lack of material influences a lot, sometimes equipment needs to be repaired and it takes a while to return, so you have to borrow it from other units (N9). The lack of equipment is certainly an obstacle, because, often, we have to organize things from here to there so we can provide better assistance (N6). So, from providing the minimum materials needed for the shift, to training the secretary, this takes time and a certain amount of care (N6).
It depends on the team you’re on; if the team is good, the work flows. Of course, everyone has their own particularities, but I see the lack of teamwork intensifies this! (NT12). If all teams focused on the patient, converging their thoughts, it would greatly improve quality of care, reducing stress and rework (N18). Sometimes, we don’t even know that the patient has an exam. This could have already been seen. And, look, it happens a lot [changed the intensity of his voice], it’s very complicated! (N14). Sometimes, a department wants you to rush the patient, but they don’t know the conditions; need a stretcher bearer, elevator; There is the issue of patients’ condition. This lack of communication is very disruptive, and there is also a lack of empathy among co-workers (N06). I see that the lack of teamwork intensifies this! When you work as a team, work intensification becomes less. There are days when I leave work exhausted and I can’t stand the pain in my legs from walking so much (N5).

DISCUSSION

As presented in the previous session, the lexical content and the most frequent words in participants’ statements are presented in seven classes. The findings from class 1, which deals with weaknesses in the physical structure and lack of materials and/or equipment, are corroborated by another study that investigated the nursing team’s working conditions in 15 public hospitals in southern Bahia, Brazil. The authors highlighted that lack of inputs, inadequate place to rest, impossibility of taking time off resulting from overtime worked and low wages are factors that allow working conditions to be classified as precarious13.

It is understood that the absence of adequate working conditions in health institutions constitutes a factor in work intensification. In the scenario investigated, this is characterized, especially, by the lack of materials, equipment and weaknesses in unit structure. These questions are related to the findings of class II, when participants pointed out as an important point the complexity of the clinical condition of patients treated in medical and surgical clinical units, which results in work activity intensification.

Research carried out in adult hospitalization units of a public hospital of a teaching institution revealed that the main reasons attributed to omission of care wereinadequate staffing, emergency situations with patients during the work shift and the non-availability of medications, materials or equipment when necessary14.

In relation to the findings of class III, it was evident that the deficit in human resources, combined with weaknesses in the training processes, substantially influenced the quality of assistance provided and, consequently, work intensification. This intensification comes from the reduced number of nursing staff, absenteeism resulting from the pandemic context, the alternation of work schedules and the lack of qualifications of workers. Although some participants in the present study have graduate qualifications, it appears that reports of fragility in the training process are related to professionals’ basic training, in addition to the need for ongoing in-service education, especially considering the accelerated technical-scientific advancement in the area, which requires constant updating.

In this context, staff sizing (SS) is an important strategy for allocating the quantitative (number) and qualitative (category) of professionals needed for nursing care in health institutions. To calculate SS, the health service characteristics, nursing and patients must be considered, including, as a minimum reference, the Risk Stratification System (RSS), according to patients’ degree of dependence, hours of nursing care and the professional/patient ratio15.

A recent study, carried out in a university hospital in southern Brazil, revealed that the majority of patients admitted to a surgical unit were classified as receiving minimum care (16.81%), followed by intermediate care (6.81%), recommending 8.38 % to 10.06% of nurses and 17.01% to 20.43% of nursing technicians or assistants. The study pointed out as evidence the direct relationship between SS for management, teaching and care, showing that an adequate SS contributes to the quality of service and patient safety16.

International research carried out in six countries (Belgium, England, Finland, Ireland, Spain and Switzerland) revealed that an increase in the number of nursing professionals is associated with lower mortality, less chance of inappropriate patient classifications, less chance of poor quality reports and greater patient safety. Every 10 percentage point reduction in the proportion of professional nurses is associated with an 11% increase in the chances of death17.

A study carried out in Saudi Arabia revealed that, in the near future (2030s), many countries will likely experience a shortage of human resources in health, a situation that requires managers to make an effort to recruit, train and retain these professionals. The authors also highlighted the need for public policies to enable better working conditions, professional training and remuneration for nurses so that there is no collapse in health services18.

In relation to class IV, it was noticed that an increase in the pace and demands in the work context are also related to class III, since, when there is a smaller number of workers, there is also an increase in quantity and complexity of the task(s). According to participants’ reports, work-related demands are also characterized as sources of intensification, while workers need to have greater attention, concentration, organization, understanding of priorities and knowledge. The work also requires skill, competence, leadership, interpretation and critical sense, since, in many moments, it is necessary to know how to improvise to meet some of the patients’ demands.

In the context of Brazilian nursing, historically, there has been a devaluation of wages and, due to this, it is common for workers to have two or more employment contracts (some even without official registration), generally in the expectation of a better financial return for the work performed19. A recent study, which analyzed the nurse-population relationship in 58 countries, revealed that there is subnational inequality in the distribution of nursing staff. This disparity is correlated with the Human Development Index (HDI), maternal mortality and lower life expectancy20.

A Brazilian study, carried out in the southwest of Bahia, revealed that the organization of work is predominantly based on a neoliberal logic, which intensifies work pace, making workers versatile and multifunctional. Furthermore, it puts strong pressure on workers to produce more and better; therefore, it makes interpersonal relationships tense, due to demands from management21.

One of the aspects mentioned by participants is related to weaknesses in training processes, both at secondary and higher education levels. For nursing schools, the great challenge is to bring the training process closer to innovations resulting from curricular and professional guidelines, in order to qualify nurses to perform competently in the current political-economic, cultural and health context of the country. This needs to function as a starting point for a larger project, which brings this debate to light, as education is a dynamic area of knowledge that gives rise to multiple perspectives and different understandings and interpretations.

The training of nurse leaders, in addition to being supported by the pedagogical project of the undergraduate nursing course, needs to articulate theoretical teaching, its application in practice and promotion of transformations in nursing students’ social reality. It is understood that nursing professors are examples of leadership for students. Therefore, knowledge about leadership models and strategies for their implementation is beneficial, with a view to promoting changes in the scenario of nursing and health training22.

Regarding the teaching-learning process, it is necessary to recognize leadership as a managerial competence by students, because, when exercising it during academic training, students will gradually understand the dimension of the complexity of health services, the shortage of employees, the risks to patient safety, among other problems experienced23.

Therefore, health institutions will need to readapt their workforce. A study carried out with 25 nurses from five public hospitals revealed that the decrease in the nurse-patient ratio and the increase in patient-focused care negatively affected evidence-based practice. The authors also highlighted that the gap between theory and practice in providing quality care is increasing due to existing communication barriers between healthcare professionals and an inadequate work environment24.

It is evident that workers perceive computerization as a factor that intensifies work. However, recent research has revealed that the use of information technology products can significantly influence the management of materials used in daily nursing care, having beneficial implications in clinical practice, reducing workload, work stress, level of concern and improving nurses’ satisfaction25.

This situation is evidenced in the reports contained in class V, when they point out that, due to computerization, work becomes more intensified, as it demands more from workers. Furthermore, work intensification is also related to the lack of routine and double working hours.

In relation to class VI, which deals with weaknesses in management, one can see, from participants’ reports, a well-defined issue, which is the lack of resources and, in particular, materials and equipment. In this context, there is a need for better institutional organization regarding equipment management, since the lack of these implies a decrease in quality of care which, consequently, intensifies work, as workers need to reorganize their practice.

Hospital equipment management plays a vital role in improving patient care conditions, especially in environments with high technological density, which results in considerable work demand for the nursing team. That said, and given the reports of the participants in this study, research carried out in Sri Lanka highlighted that the lack of maintenance and repairs of hospital equipment, improper procurement plan, improper calibration and poor validation of equipment is a common problem in hospital equipment management26.

Another aspect that is present in participants’ statements concerns the daily work demands of medical and surgical clinical units, and the lack of communication and collaboration between different professionals/teams. Thus, class VII is titled as lack of interprofessional collaboration.

Interprofessionality requires professionals to communicate effectively and respectfully. Effective communication and understanding professional responsibilities are core competences of patient-centered collaborative practice. Therefore, it is necessary for health professionals to understand the singularities of the process and clarity regarding the tasks in which they work27.

Fluid communication is recognized as an essential element for safe, high-quality care that guarantees more integrated approaches and clarity of health needs and behaviors. This logic ensures greater capacity to face complex problems, adopting interventions that aim at the process and relational aspects of comprehensive health care28.

A Brazilian study reveals that institutions that reorganized themselves from an interprofessional perspective were able to act with greater agility and clinical response capacity, developing more qualified assistance and offering training to health professionals working on the front line of COVID-19, ensuring harm-free and safe care for others and for themselves29.

A study carried out in Spain with nurses, surgeons and anesthesiologists working in a surgical center unit reveals that different team perspectives can facilitate genuine reflection, discussion and implementation of interventions to improve interprofessional collaboration in the operating room and overcome barriers and their consequences30. The authors also highlighted that an interprofessional practice involves learning to dialogue, in a more effective and assertive way, with co-workers, which contributes to improving the care provided.

Based on the results of this study, an important reflection is highlighted regarding the process of intensification of nursing work, a contemporary phenomenon that has been increasingly present in daily work, with implications for worker health and quality of care. The development of investigations into this construct constitutes the possibility of supporting strategies and policies aimed at worker health, resource management (human, materials, equipment), especially in hospital institutions, in addition to improving the quality of care offered to patients/users.

Among the strategies, those aimed at SS can be highlighted, especially in sectors that serve patients with a higher level of complexity and that require greater technological density for the care process. The need for a continuing education process aimed at the demands of constant updating by professionals is also reiterated as well as a management process attentive to the demands for better working conditions and the construction of a perspective of interprofessional work among health workers.

Another important development of this study refers to the advancement in the scope of publications produced on the topic both nationally and internationally. Thus, the present study presents potential advancement in the construction of new debates on the topic, both at a theoretical and empirical and methodological level, making it possible to visualize new horizons on the topic to improve nursing working conditions. Furthermore, The results of this study can support the construction of a measurement instrument designed to measure the construct of nursing work intensification.

Regarding the limitations of this study, it is considered that the remote interview modality may have hindered the possibility of a broader dialogue with participants. Furthermore, it is believed that the association of other data collection techniques could have offered greater robustness to the study. As this is qualitative research, the results cannot be generalized, with limitations of the method, as participants may not represent the opinion of all nursing professionals who work in medical and surgical clinical units.

Also noteworthy is the interference of the pandemic in workers’ perception of work intensification. Although it was not an objective of this study, the implications of the pandemic on the work process may have interfered with workers’ perception of nursing work intensification.

CONCLUSION

From this study, it is concluded that work intensification is present in the investigated scenario, being related to the progressive demand demanded by patients and organizational aspects. Lack of materials and equipment, severity of patients’ clinical condition, weaknesses in professional training and qualification, intensified pace, increased work demands, weaknesses in management and lack of interprofessional collaboration stand out as factors related to nursing work intensification.

Considering that this is a topic recently addressed in scientific literature, as it is related to contemporary phenomena, it is suggested to develop new studies on the topic as a way of obtaining plausible theoretical subsidies that enable formulating strategies and policies aimed at improving nursing working conditions and quality of care.

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NOTES

• ORIGIN OF THE ARTICLE

  Article extracted from the thesis - Elaboração e validação de conteúdo do instrumento para mensurar a intensificação do trabalho da enfermagem: estudo metodológico, presented to the Graduate Program in Nursing, Universidade Federal de Santa Maria, in 2022.

• APPROVAL OF ETHICS COMMITTEE IN RESEARCH

  This study was approved by the Research Ethics Committee of the Universidade Federal de Santa Maria (UFSM), Opinion 4.104.436, Certificate of Presentation for Ethical Consideration (Certificado de Apresentação para Apreciação Ética) 30816020.5.0000.5346.

Edited by

EDITORS

Associated Editors: Bruno Miguel Borges de Sousa Magalhães, Maria Lígia dos Reis Bellaguarda. Editor-in-chief: Elisiane Lorenzini

Publication Dates

• Publication in this collection
  11 Dec 2023
• Date of issue
  2023

History

• Received
  10 July 2023
• Accepted
  18 Sept 2023