WORKING CONDITIONS AMONG DIFFERENT PROFESSIONAL CATEGORIES OF THE HOSPITAL AREA

ABSTRACT

Objective

to compare the working conditions in relation to demand, control and social support among Nursing, Nutrition, and Hygiene and cleaning professionals.

Method

a quantitative study conducted with 227 professionals from a general hospital in the state of São Paulo, Brazil, by applying the Job Content Questionnaire. The SPSS software and statistical tests were used for the analyses.

Results

the cleaning professionals presented lower social living conditions, with incomes up to two minimum wages (88.5%); no higher education (98.7%); social classes C/D/E (78.2%); and black or brown skin color (55.2%). There were no significant differences between the teams in relation to the demand. Regarding control, Nursing and Cleaning presented the best and worst working conditions, respectively. Nursing and Nutrition presented the best and worst social support indices, respectively.

Conclusion

it was emphasized that it is necessary to implement strategies aimed at improving the working conditions in order to minimize stress and illness.

DESCRIPTORS
Workers’ Health; Work-related Stress; Work Environment; Professional Strain; Social Support

RESUMO

Objetivo

comparar as condições de trabalho em relação à demanda, controle e suporte social entre profissionais da enfermagem, nutrição e higiene e limpeza.

Método

estudo quantitativo com 227 profissionais de um hospital geral do estado de São Paulo, Brasil, por meio da aplicação do Job Content Questionnaire. Para as análises, foi utilizado o software SPSS e testes estatísticos.

Resultados

os profissionais da limpeza exibiram condições sociais de vida inferiores, com renda até dois salários-mínimos (88,5%); sem ensino superior (98,7%); classe social CDE (78,2%); cor negra ou parda (55,2%). Em relação à demanda, não houve diferenças significativas entre as equipes. Quanto ao controle, a enfermagem apresentou melhores condições e a limpeza as piores. A enfermagem apresentou melhores índices de suporte social e a nutrição os piores.

Conclusão

salientou-se que é necessária a implementação de estratégias de melhoria das condições de trabalho para minimizar o estresse e o adoecimento.

DESCRITORES
Saúde do Trabalhador; Estresse Laboral; Ambiente de Trabalho; Desgaste Profissional; Apoio Social

RESUMEN

Objetivo

comparar las condiciones de trabajo en relación con la demanda, el control y el apoyo social entre profesionales de Enfermería, Nutrición e higiene y limpieza.

Método

estudio cuantitativo realizado con 227 profesionales de un hospital general del estado de San Pablo, Brasil, con aplicación del Job Content Questionnaire. Para los análisis se utilizó el software SPSS, además de pruebas estadísticas.

Resultados

los profesionales del área de Limpieza presentaron condiciones sociales de vida inferiores, con ingresos de hasta dos salarios mínimos (88,5%); sin educación superior (98,7%); clases sociales C/D/E (78,2%); y color de piel negro o pardo (55,2%). En relación con la demanda, no se registraron diferencias significativas entre los equipos. Con respecto al control, las áreas de Enfermería y Limpieza presentaron las mejores y peores condiciones, respectivamente. Los sectores de Enfermería y de Nutrición presentaron los mejores y peores índices de apoyo social, respectivamente.

Conclusión

se destacó que es necesario implementar estrategias para mejorar las condiciones de trabajo a fin de minimizar el estrés y las enfermedades.

DESCRIPTORES
Salud Laboral; Estrés Laboral; Ambiente de Trabajo; Desgaste Profesional; Apoyo Social

INTRODUCTION

The profound social changes that have led to the so-called post-modernity bring about implications to people’s lives, especially in the work context, where globalization, increased competition, competitiveness, and unemployment exert pressure on people to work more, with fewer benefits and in a context of insecurity. This condition leads to work-related stress, which represents a significantly relevant problem worldwide⁽¹⁾.

Such situation emerges when a persistent imbalance is perceived between the demands and the personal resources to deal with them. High psychological demand and low control (autonomy) over work are among the factors associated with Common Mental Disorders (CMDs), characterized by insomnia, anxiety, fatigue, irritability, difficulty concentrating and forgetfulness, among other somatic symptoms⁽²⁾.

The prevalence of CMDs in the world population ranges from 14.7% to 21.8%. At the Brazilian level, it varies between 17% and 35%. These disorders can be related to factors such as low income, low schooling, not having a partner, brown or black skin color, having children, menopause, lack of leisure activities, and having suffered physical aggressions⁽³⁾. CMDs lead to important individual and social consequences⁽⁴⁾.

From this perspective, the demand-control model, created by Robert Karasek⁽⁵⁾, has been used to study stress in the workplace in many countries, and is considered capable of evaluating the association between the psychological and social aspects of work and their effects on workers’ health. This model characterizes work as passive or active, with high or low requirements, depending on the level of demand (physical or psychological) and control (decision-making authority) of the job. A job that produces high strain (high demand and high requirements) imposes a higher risk of producing stress and CMDs⁽⁶⁾.

Some work environments present even greater risks to workers’ health, as is the case in hospitals, which have a complex organization, in view of the need to work in different shifts, in addition to relationship problems among the team members and lack of human and material resources^(7-8).

Considering the importance and the complexity of the work performed surrounding the patient in the hospital area, involving different professionals and backgrounds, such as the Nursing, Nutrition and Hygiene and Cleaning Service (HCS) teams, who need to live with other people’s suffering, teamwork, and requirements for tasks to be performed with quality and on time, the question is how the work of these professionals is characterized in relation to demand, control and social support. Given the above, the objective was to compare the working conditions in relation to demand, control and social support among Nursing, Nutrition, and Hygiene and cleaning professionals.

METHOD

This is a cross-sectional and observational study. It was conducted in a general hospital linked to the Unified Health System (Sistema Único de Saúde, SUS) and located in a city in inland São Paulo, being a high-complexity reference for 68 municipalities. It has 318 beds, divided into the clinical, surgical and Intensive Care Unit areas, and 1,515 workers, divided into the technical, administrative and support sectors.

The Nursing area has 582 workers: 162 nurses and 420 nursing technicians. The Nutrition Service has 78 employees: 10 nutritionists, 10 breastfeeding consultants, nine cooks, four nutrition technicians, and 45 kitchen assistants. The HCS consists of a manager hired by the hospital and the outsourced company, whose staff consists of five supervisors, one for each shift, 87 cleaning assistants, and two window cleaners (n=94). Consequently, there was a total of 754 workers in the three professional categories selected for the study.

The sample consisted of all the professionals in the Nutrition (n=78) and HCS (n=94) services, due to the reduced number of workers and heterogeneity of the categories. As for the Nursing team professionals, a prevalence of 50% was used, with an error margin of 5% and 95% confidence, being corrected for the finite population and stratified by professional categories, obtaining n=96 professionals: 35 nurses and 61 nursing technicians. Those with at least six months of activity in the institution were included in this study; whereas temporary professionals, those who performed only administrative functions and those who were on medical or maternity leaves were excluded.

Data collection was conducted from August 2016 to December 2017, in the different work shifts. The self-administered instrument was handed in to the participants, with the researchers remaining in the locus to assist them if necessary. The Nursing team professionals were selected for convenience. As for the other categories, despite the attempt to approach the totality, there were refusals and leaves. The research instrument was applied by a single evaluator.

The collection instrument consisted of sociodemographic data, including age group, gender, marital status, skin color, schooling, individual and family income and socioeconomic class, according to the 2015 Brazilian Criterion of Economic Classification (Critério de Classificação Econômica Brasil, CCEB), which defines the following classification: Class A = 45-100 points; Class B1 = 38-44 points; Class B2 = 29-37 points; Class C1 = 23-28 points; Class C2 = 17-22 points; and Classes D-E = 0-16 points⁽⁹⁾.

To verify the social and psychological characteristics of the job, the Job Content Questionnaire (JCQ) in its short version was used, derived from Karasek’s demand-control model (1979). This version consists of 17 items, six to assess control, five to assess demand and six for social support, and it was validated in Brazil^(5,10).

The JCQ consists of items on a Lykert-type scale, whose scores vary from one (I strongly disagree) to four (I strongly agree). To calculate the indicators for demand, control and other items, the JCQ⁽⁵⁾ formula was used; subsequently, the median, first and third quartiles were calculated for each professional category, in order to later compare them.

The qualitative variables are described by absolute (f) and relative (%) frequency distribution. In the case of missing data, relative frequency distribution was adjusted for the total of answers. To analyze distribution of frequencies and the association between each other, the Chi-square or Fisher’s Exact tests were performed when necessary.

Normality distribution was verified by means of the Kolmogorov-Smirnov test. The quantitative variables were described by the mean and quartile distribution in tables or Box Plot graphs. For comparisons between the professional categories, the Kruskal-Wallis non-parametric test was performed

The Post-Hoc comparisons were conducted by means of the Mann-Whitney test, with a critical p-value adjusted for multiple comparisons by the Holm-Sidak procedure. The SPSS software, version 19.0 for Windows, was used for all the analyses, adopting a 5% significance level.

The research was approved by the Research Ethics Committee under opinion No.1,140,406.

RESULTS

Among the workers, 85.3% were female, 66% were less than 35 years old and 67.5% lived with a partner. Among the cleaning professionals, 98.7% have no higher education, 88.5% earn up to two minimum wages, 78.2% belong to economic classes C/D/E and 55.2% are black- or brown-skinned, making it possible to infer that, in these aspects, they present the worst conditions (p-value=0.001) (Table 1).

Table 1
Analysis of the association between professional categories and the qualitative variables that characterize the sample (n=227). Marília, SP, Brazil, 2019

		Professional Category						X2
		Nursing (n=96)		Nutrition (n=53)		HCS (n=78)
		F	%	F	%	F	%	p-value
Age Group	18-35 years old	41	42,7	16	30,2	23	29,5	0,064
	> 35 years old	55	57,3	37	69,8	55	70,5
Gender	Female	79	82,3	50	94,3	62	79,5	0,7
	Male	17	17,7	3	5,7	16	20,5
Marital Status	With a partner	68	70,8	34	64,2	53	67,9	0,658
	Without a partner	28	29,2	19	35,8	25	32,1
Skin Color	White	79	82,3	40	75,5	35	44,9	0,001**
	Asian	1	1	0	0	0	0
	Black	6	6,3	2	3,8	8	10,3
	Brown	10	10,4	11	20,8	35	44,9
Schooling	Without SC	53	55,2	41	77,4	77	98,7	0,001*
	With SC	43	44,8	12	22,6	1	1,3
Income	Up to 2 MWs	25	26	42	79,2	69	88,5	0,001*
	> 2 MWs	71	74	11	20,8	9	11,5
Family Income	Up to 2 MWs	6	6,3	8	15,1	37	47,4	0,001*
	> 2 MWs	90	93,8	45	84,9	41	52,6
Economic Class	C/D/E	15	15,6	16	30,2	61	78,2	0,001**
	B	65	67,7	33	62,3	17	21,8
	A	16	16,7	4	7,5	0	0

• Note:
• ^*
  p=0.05: Significant association between the variables by Fisher’s Exact test;
• ^**
  p=0.05: Significant association between the variables by the Chi-square test.
• Source: The authors (2019)

In Table 2 and regarding the control variable, it can be seen that 89.59% of the Nursing professionals, 69.81% of the Nutrition professionals, and 58.98% of the HCS professionals agree that work makes it possible to learn new things, but they consider it repetitive, although the participants from Nursing and HCS agree that it requires a high level of qualification, whereas those from Nutrition disagree.

Table 2
Distribution of the answers about work control, demand and support in relation to the professional categories (n=227). Marília, SP, Brazil, 2019

Variables		Nursing (n=96)		Nutrition (n=53)		HCS (n=78)
		Agrees (%)	Disagrees (%)	Agrees (%)	Disagrees (%)	Agrees (%)	Disagrees (%)
Control
	Learning new things	89,59	10,41	69,81	30,19	58,98	41,02
	Repetitive work	77,08	22,92	84,91	15,09	88,46	11,54
	Requires high qualification level	82,3	17,7	39,62	60,38	78,2	21,8
	Requires creativity	81,25	18,75	62,27	37,73	28,2	71,8
	Allows making autonomous decisions	40,63	59,37	37,74	62,26	11,54	88,46
	Limited decision-making freedom	36,46	63,54	39,62	60,38	60,26	39,74
Demand
	Sufficient time	67,71	32,29	47,17	52,83	67,95	32,05
	Conflict-free	33,33	66,67	11,32	88,68	28,2	71,79
	Too much physical effort	63,54	36,46	64,15	35,85	73,08	26,92
	Lifting heavy weights	60,41	39,59	35,85	64,15	35,9	64,1
	Fast and continuous activity	60,41	39,59	73,59	26,41	66,67	33,33
Support
	They care about their subordinates	59,37	40,63	41,51	58,49	53,85	46,15
	They promote teamwork	63,54	36,46	33,97	66,03	71,79	28,21
	They are interested in what happens	64,59	35,41	56,61	43,39	52,57	47,43
to others
	They expose the other coworker to	58,34	41,66	58,49	41,51	26,92	73,08
conflict or hostility
	They are friendly	83,33	16,67	60,38	39,62	58,97	41,03
	Satisfaction in working with the	64,6	35,4	71,7	28,3	78,2	21,8
colleagues

• Note: *Agrees=Agrees or Strongly agrees; **Disagrees=Disagrees or Strongly Disagrees.
• Source: The authors (2019)

In the “requires creativity” variable, the Nursing and Nutrition professionals agree, but the HCS workers disagree. As for the “allows making autonomous decisions” variable, 40.63%, 37.74%, and 11.54% of the professionals from the Nursing, Nutrition, and HCS services disagree, respectively. In the “limited decision-making freedom” variable, 60.26% of the HCS professionals agree.

When analyzing demand, 60.41%, 73.59% and 66.67% of the participants from the Nursing, Nutrition and HCS services, in this order, consider that work happens at a fast pace. On the other hand, 67.71% of the Nursing team professionals and 67.95% from the HCS service consider that the time to perform the tasks is sufficient. Of the Nutrition professionals, 52.83% disagree that the time is sufficient.

63.54% of the Nursing professionals, 64.15% from the Nutrition area and 73.08% from the HCS service state that work requires too much physical effort. In addition to that, 60.41% of the Nursing professionals agree in that they lift heavy weights. 60.41% of the Nursing team professionals, 73.59% from the Nutrition area and 66.67% from the HCS service also mention that the activities are fast and continuous. As for being conflict-free, 66.67%, 88.68% and 71.79% of the Nursing, Nutrition and HCS professionals disagree, respectively.

As for the variables referring to support, 58.49% of the Nutrition team professionals disagree that they can count on the support of their superiors and 66.03% that they promote teamwork. The interviewees believe that their coworkers are interested in what happens to the others, as follows: 64.59%, 56.61% and 52.57% of the Nursing, Nutrition and HCS professionals; in addition, 83.33%, 60.38%, and 58.97% of the participants from the Nursing, Nutrition and HCS services, respectively, consider that they are friendly and collaborative. In the Nursing team, 58.34% agree that the colleagues expose the other coworkers to conflict or hostility. In the Nutrition area, this percentage was 58.49%. In the HCS service,73.08% disagree regarding this variable.

Table 3 shows statistical differences between the categories studied, in the “opportunity to develop special skills”, “decision-making authority”, “support from supervisors and coworkers”, “job insecurity”, “social support”, and “control over work” items (p=0.05), with the Nursing team presenting the best context. The “psychological demand”, “physical demand” and “demand” (sum of physical demand and psychological demand) topics did not present statistical differences between the professional categories.

Table 3
Distribution of the answers about work control, demand and support in relation to the professional categories (n=227). Marília, SP, Brazil, 2019

	Professional Category									p-value
	Nursing (n=96)			Nutrition (n=53)			HCS (n=78)
	M	25th	75th	M	25th	75th	M	25th	75th
Skill	9	17	20	17,0†	15	19	16,0†‡	14	17	0,001*
Decision-making authority	16	12	17,8	15	12	16,5	11,5†‡	10	15	0,001*
Psychological Demand	17	16	19	19	16	20,5	19	16	20	0,114
Physical Demand	13	11	15	13	11,5	15	14	12	15	0,618
Support from Supervisor	11	9	12	9,0†	8	10	10,0‡	9	11,3	0,001 *
Support from Coworkers	12	10	12	11,0†	9	12	11,0†	0	12	0,001 *
Social Support	22	20	24	19,0†	18	21	21,0†	12	23	0,001 *
Insecurity	7	6	7	7	6	7	7,0†	6	8	0,001 *
Social Support	22	20	24	19,0†	18	21	21,0†	12	23	0,001 *
Demand	31	27,3	34	32	28	34,5	32	27	35	0,259
Control	34	31	37	32,0†	28	34	28,0†‡	26	31,3	0,001 *

• Note: Median (M);
• ^*
  p=0.05 significant difference between the professional categories by Kruskal-Wallis non-parametric test;
• ^†
  p=0.05 significant difference in relation to the Nursing professional category by Mann-Whitney’s non-parametric test adjusted for multiple comparisons by the Holm-Sidak procedure;
• ^‡
  p=0.05 significant difference in relation to the Nutrition professional category by Mann-Whitney’s non-parametric test adjusted for multiple comparisons by the Holm-Sidak procedure.
• Source: The authors (2019)

Figure 1 shows that, when comparing the median, first quartile (25^th) and third quartile (75^th) of the variables in relation to demand, there were no significant differences between the three teams under study. When it comes to control over work, there was a significant difference in Nutrition with respect to Nursing, and in HCS with respect to Nursing and Nutrition, with Nursing presenting the best conditions. In relation to social support, the Nursing team and the Nutrition service presented the best and worst indices, respectively. HCS was the category that presented an indication of the second highest social support among the categories.

Figure 1
Comparison of the median, first quartile (25^th) and third quartile (75^th) of the quantitative variables (demand, control and social support) in relation to the professional categories. Marília, SP, Brazil, 2019

DISCUSSION

In this study, which aimed at comparing the working conditions in relation to demand, control and social support among Nursing, Nutrition and HCS professionals who develop activities in the hospital, there was prevalence of women. To explain this phenomenon, it is necessary to consider that the insertion of women in the labor market, which began at the end of the 19^th century, was linked to education, care and service activities, understood as a female vocation or gift⁽¹¹⁾.

However, stereotypes regarding patriarchy remain, as women lead in the professions related to education, health and nutrition, while men work mainly in the areas of administration, technology and finance. Women also stay in home and family care, a socially undervalued job⁽¹²⁾.

Gender discrimination is amplified when associated with black skin color, as is the case of most HCS workers, since the unemployment rate among black-skinned people is 13.8%, while among white-skinned individuals it is 10.2%, in addition to the tendency for black-skinned people to hold positions with lower remunerations and heavier work, which shows a society marked by differentiated opportunities for ethnic and racial groups⁽¹³⁾.

The HCS workers are a group of professionals who have less schooling, earn less money and belong to lower social classes than the rest, in addition to having early insertion in the labor market as a distinctive characteristic⁽¹⁴⁾. In the hospital environment, this category usually works in the outsourced modality, subjected to a high demand of tasks with repetitive movements, which can generate physical and mental disorders and work accidents, among other negative repercussions⁽¹⁵⁾. In addition to that, outsourcing favors labor precariousness, given the greater flexibility in the contracts and the lesser guarantee of fulfillment of the workers’ rights, reinforcing the capitalist logic and competitiveness and generating psychological distress⁽¹⁶⁾.

When it comes to health risk factors and control over them, Karasek (1979) includes the organization’s resources to involve workers in decision-making and in work planning and execution, these being important aspects to be considered since they reinforce the ability to intervene and solve work demands⁽¹⁶⁾. According to this model, greater control (greater autonomy) contributes to mitigating the high psychological demand. This greater autonomy occurs when workers can make choices about their daily routine⁽⁵⁾.

When compared to the other workers in this research, the Nursing team presented more control, although a large part of the team does not consider having such control. This fact can be understood by the higher number of nursing technicians interviewed, since they must follow the nurses’ prescriptions in the care they provide.

In the hospital context, the HCS professionals, although working under highly complex conditions, generally lack the technical and theoretical preparation to deal with this reality since, among the teams, they show less agreement in relation to learning new things, in addition to limited use of creativity, which involves autonomy and/or self-learning^(17-18). It is therefore recognized that greater visibility, investment and recognition of the potential of this professional category is necessary, in addition to valuing the function and directing attention to all the roles because, even if not acting in direct assistance, these workers represent an integral part of the care management process^(17-18).

Regarding the demand issue, although no significant differences were found among the three categories, it is observed that the professionals under study mainly state the presence of conflicts at work and excessive physical effort. These situations are closely related to the psychosocial aspects of work, that is, the interactions between the working conditions and the environment which, when associated with low control over the work activities, cause absenteeism and turnover, in addition to emergence of CMDs⁽¹⁹⁾.

It was observed that active work (high demand and high control) is associated with greater emotional exhaustion if compared to passive work (low demand and low control). The same authors indicate that high-demand work could block the efforts coming from high control, since high demands increase the response effort. Low control and high demand (high-requirement work), identified mainly among the HCS workers, are health risk factors that can lead to lack of interest, loss of skills and gradual reduction of capabilities^(20-21).

As for social support⁽⁵⁾, when it is low, the risk of stressful situations is higher, because its function is to increase the ability to cope with stressors. Among the three categories studied, the team that presented the second highest social support index was HCS. Therefore, although HCS work is characterized as high-strain (or high-requirement), social support can be a protection against psychological illness.

The limitation of this study is that it was conducted in only one institution. In addition to that, given the differences in the living and health conditions of the HCS workers in relation to the other categories analyzed, and that these professionals also count on differentiated work contracts (outsourcing), new studies become necessary to deepen the knowledge about the reality of these individuals.

CONCLUSION

This research made it possible to identify that, among the three categories, the HCS professionals are those who present the worst social living conditions in relation to schooling, income and socioeconomic class, and are predominantly black- or brown-skinned. In addition to that, they are at a greater risk of developing worse health conditions due to the greater psychological and physical burdens of the work environment, although they are better protected in terms of social support when compared to the Nutrition service professionals. However, it is necessary to consider that, among all the categories, there are important characteristics of the working conditions that can interfere with their health and well-being.

Consequently, this research reveals the precarious working conditions, especially present among the HCS professionals, and contributes to warning the health institutions about the work environment to which the employees are exposed, so that they can create strategies to minimize stress and illness, propitiating improvements in the general working conditions.

HOW TO REFERENCE THIS ARTICLE

• Gimenez FV, Rocha MRA, Chagas EFB, Marin MJS. Working conditions among different professional categories of the hospital area. Cogit. Enferm. [Internet]. 2021 [accesse “insert day, monh and year”]; 26. Available from: http://dx.doi.org/10.5380/ce.v26i0.73160.

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Edited by

Associate editor: Susanne Elero Betiolli

Publication Dates

• Publication in this collection
  22 Nov 2021
• Date of issue
  2021

History

• Received
  25 Apr 2020
• Accepted
  27 May 2021