ORIGINAL ARTICLES

Nursing work in hospital emergency units – psychosocial risks: a descriptive study

Elias Barbosa Oliveira¹, Jacqueline Silveira Pinel², Juliana Botelho de Andrade Gonçalves³, Dayana Barbosa Diniz⁴

¹Rio de Janeiro State University
²Nurse
³Health Department of Rio de Janeiro Municipality
⁴Militar Firefighters Brigade of Rio de Janeiro State

ABSTRACT
Aims: To identify, from the nurses’ point-of-view, the psychosocial risks present in hospital emergency units and to analyze how these risks affect the nursing team in general. Method: This is a qualitative, exploratory and descriptive study. For data collection, we used semi-structured interviews based on a guide. The informational content was then analyzed. Twelve nurses from a public hospital located in the city of Rio de Janeiro participated in this study, in 2010. Results: The psychosocial risks identified derived from occupational stress, such as lack of human resources and equipment, ambiguity in paperwork and violence. Conclusion: The employer must take preventative action to reduce the psychosocial risks identified, to promote the physical and mental health of the nursing team and to motivate nurses to participate in the decision-making processes that can lead to improving existing working conditions.
Keywords: Nursing; Occupational Risks; Labor Health; Mental Health.

INTRODUCTION

In spite of the expansion of health services to the general population after the implementation of the Family Health Program (PSF, in Portuguese) and the creation of Emergency Care Units (UPA, in Portuguese) in some cities, we still observe an unnecessary demand for emergency care services⁽¹⁾ due to problems such as insufficient ambulatory care, lack of screening procedures, too few specialists, reservation of beds in intensive units and the failure of the hospital to respond to the needs of the emergency unit. Adding to these problems is the belief of users that these services, which have specialized technological and human resources, will ensure effective treatment for their health problems.

Another factor contributing to overcrowding in emergency units is the rise of violence in the country, especially in urban areas⁽²⁾, where more than 75% of all deaths are due to physical injuries, poisoning, fractures, burns and intoxication. Violence also affects health service equipment, in terms of both cost and organization, and it involves the professionals, both as victims and as actors who cooperate to overcome violence in their working environment or who demonstrate abusive language, mistreatment and other forms of violence themselves.

The nursing team is the one the most affected during emergency work, regarding the pressure for productivity and the necessity to adapt to the demands imposed by the organization and its users, because it gives direct assistance to patients and relatives⁽³⁾. The decay of working conditions due to the deficit of labor and material resources generates dissatisfaction, demotivation and occupational stress, either by the excessive work load or by the specificity of the activity related to assisting critically ill patients, who demand quick and decisive assistance.

Thus, the urgent need for greater productivity, associated with the continuous reduction of the workforce, time pressures, the increasing complexity of the tasks and the rise in tension, fatigue and professional exhaustion, are all psychosocial risk factors⁽⁴⁾, arising as a result of greater demand combined with a lack of proper resources to deal with the situation. In the area of healthcare, the stress-generating situations present in the workplace, despite being fully recognized, have had little attention in investigative studies. It is known that hospitals, in particular⁽⁵⁾, provide poor working conditions for their employees, exposing a greater number of workers to occupational risks and contributing not only to a rise in workplace accidents but also frequently to the development of stress situations and physical and mental fatigue.

Besides the development and implementation of public policies and programs, there are many other potential problems in the area of health⁽⁶⁾, for example: management failures in human resources arising from the State development process, the low priority of  management meetings, third-party services, the low staff retention rate, low wages, the lack of career plans at all three levels of government and weak links between services and the university and between services and educational practices.

Therefore, the need for change regarding the flexibility of labor practices⁽⁷⁾ is spread across all activities and adding to this problem is the low quality of contracts, the reduction in the number of workers and the intensification of working rhythms, which will result in a higher number of people infected by stress-related diseases, which can develop into serious mental and physical health conditions in the workers.

It is highly important to analyze the influence of psychosocial risks on the lives of workers in the area of healthcare, especially because there are not many studies that investigate this problem in emergency care units, which means that it is difficult to better understand the inconveniences and their consequences on the health of the professionals involved. With the intention of contributing to those studies that deal with the influence of psychosocial factors in the work environment, this article aims to identify, from the nurse’s point-of-view, the psychosocial risks present in emergency care and analyze how such risks affect the team’s health. These aims intend to improve the comprehension of these inconveniences and their consequences to the health of nursing professionals.

METHOD

We decided to use a qualitative research method⁽⁸⁾, as this is based on a variety of methods and techniques that, when applied to nursing, permit us to understand the problems emerging daily out of ordinary practice. This method gathers information about these natural and rich situations and is full of descriptive data, which focuses on reality in a contextualized manner.

Twelve nurses participated in this study, who all worked in the emergency care unit of a public hospital located in the municipality of Rio de Janeiro. The inclusion criteria were that each participant should be a full-time professional who had worked in the hospital for at least one year in emergency care, because we believe that this length of experience allows them to have witnessed and experienced situations that will enable them to familiarize us with the work processes and the resulting psychosocial risks.

The data collection, done in the second semester of 2010, used interviews based on a script, with questions that helped the nurses to assess their work in the emergency care service, the problems faced in institutional life and the repercussions to their health. The declarations were recorded on mp3 equipment and transcribed in full for further analysis.

The interviews were performed in a private location after proper invitation, in full awareness of the report issued by the Ethics in Research Committee (CEP/HUPE/UERJ - 0169.0.228.000-10) and with signatures to the Free and Clear Consent Agreement, in accordance with Brazilian National Health Council Resolution 196/96. We guaranteed the participants’ anonymity and confirmed that they could withdraw from this study at any point, if they wished. It was also drawn to their attention that the results of this study would be presented at events and published in scientific publications. When producing the corpus of the article, some conventions were adopted such as using the letter E for an interviewed person, followed by a number according to their order of participation in the study. 

The categories in the study suggested the application of an analysis technique by themes⁽⁹⁾, where the objective is to find and identify, after an exhaustive reading of the material produced, the frequency or homogeneity of certain items. From the interviews analyzed, the words or registry units identified were grouped to generate theme units, which reflect the experiences of the nurses regarding their work, the psychosocial risks and the impact on their health status. The results are presented in the following order: emergency overcrowding and work overload; deteriorations and adaptations; ambiguity of roles - mediating conflict; violence at work - another cause of suffering and repercussions on the health of the nurse.

RESULTS

Emergency overcrowding and work overload
The first question presented to the nurses regarding the influx of work in the emergency care unit produced an observation towards finding a solution to the overcrowding problem, using the patient risk classification system based on the steps established by QualiSUS. It is an essential strategy and it reflects the relationship between the emergency service, the rest of the hospital and other external services. With regards to the screening (reception) carried out by the nurse at the entrance of the emergency care area, professionals reported that patients consistently arrive with clinical conditions that could have been responded to by an ambulatory service or even by primary care units, where the majority of the patients report that they cannot find proper medical care.  

We classify the patient risk, and according to the level he will have some priority in service. If the risk achieves the red level, we send the patient directly to the trauma room. Our risk is not being able to deal with the demand the population has. Someone has a chronic disease and our risk is that we think we have to deal with everything, but we can’t. (E1)

The emergency gets too crowded! As in every health system, the demand is higher than the offering! Then, we have too many patients and this generates a conflict, a discomforting situation. For example, today we have forty-eight patients. We can’t handle it; it’s impossible. (E2)

Well, here we are an open-door emergency, from high complexity patients to basic patients. However, we always work here with an overcrowded service, a overload of patients. So we work in the chaos, and we do the best we can as much as possible. (E7)

Deteriorations and adaptations
As seen, the overcrowding of emergency units is observed through the nursing process, and this generates a work overload and deterioration in conditions. Nurses have an essential role to play in planning and managing human resources and in supporting the nursing teams in solving the technical and organizational problems that arise. Additionally, they have a huge responsibility towards critical patients, who could have some sort of complication, and in the support and guidance they give to the families, and with follow-up patients. As demand on the emergency service exceeds its capacity, nurses have less control over their workload, which is seen in the limitation to their autonomy and decision-making skills because of the pressure for higher productivity. Aiming to overcome such problems, the nurses need to improvise and adapt.

In emergency, we have that thing: if there is something missing, we have to deal with it, improvises and in the end it works. We hope that in the end everything will be ok! Because there are many difficulties: absences, lack of material, lack of human material. In the end these things we know we have to manage and we try to do the best we can. (E4)

We face some difficulties regarding the material resources and the overload of work; a great number of patients for little human resources, too. But we try to do our best to provide an adequate service. (E8)

The material resources vary a lot. Every once in a while, there is something missing. Everything regarding nursing is like that! You must improvise! Adapt! We just carry on. (EF12)

The physical environment, which has not been modified to adapt to the developing demand for care, forces the workers to continuously adapt and improvise with the furniture. The exiguous work space compromises the working process and results in a lack  of comfort for both nurses and patients; for example, nurses have to carry out observations on patients with critical clinic conditions, exposing these professionals to biological hazards and problems due to poor posture.

One thing is to have the patient coming from hemodialysis and sending him back to bed! The other is this patient returning from the hemodialysis and then waiting seating someplace! Do you see? He can fall face on the ground and then having some trauma! Do you understand? I can’t stand this! The number of nurses and technicians is not enough and we can’t continue like this. (E1)

The physical space is horrible. During the intercurrences of heart failure we don’t have enough room. We have to adapt! And I think this is not right. [...] the situations of contact precaution! Sometimes you have one patient sleeping almost on top of the other. In order to interfere, to continue in a proceeding, it is terribly bad for a patient and for the professional too. (E5)

Our nursing post is too small, and we can’t have a seat. It is as if we played with the chairs coming and going! While one is standing up, the other one sits down! The whole day we take turns to sit and rest a little! The conditions to stay in the emergency are bad both for the patient and for the professional! But […] that’s what it is. (E6)

Ambiguity of roles - mediating conflict
An ambiguity of roles was identified in situations where the nurses try to solve problems of a technical nature, which are not usually the responsibility of these professionals. This situation arises because of an inadequate job description, with a lack of description of the roles of the nurse. Taking into consideration the innumerable difficulties that come from the natural dynamics of the emergency care service and the lack of specialists, the nurse is “pressured” to mediate any conflict and to meet the expectations of relatives dissatisfied with delays and the quality of the service provided. There is also the idea of responsibility towards the members of the team: where situations arise that contribute to the discordant role of the professional, this leads to the physical and emotional stress of the professional, with time used to resolve problems that could have been used to rest or to carry out another specific activity required of that person.

Sometimes it is a patient without a deep access, to we have to look for the general surgeon to evaluate this patient! Just to see if it is possible to dissection the patient, so he is not without medication. (EF1)

I also think it is a nursing characteristic to call the responsibility for contextualized caretaking! The whole context. (EM4) 

Violence at work - another cause of suffering
As a result of the many organizational and structural problems pointed out by the nurses in their work routine in the emergency unit, the quality of service is compromised and consequently the nurse becomes the target of patients and relatives. Anxiety is high because there are lives at risk; the demands faced by nurses to meet the needs of the users and the precarious working conditions the team has to deal with everyday provide fertile soil for conflicts to arise and for hostile attitudes from the relatives and patients.

Both the team and the patients are revolted with the conditions of this place! Have you thought to bring your mother and the doctor says she needs to be hospitalized? Then she is hospitalized and sits in a hard seat. Then the patients are too aggressive, especially when they arrive. (EF1)

We can’t handle it! It is a huge demand! It is as I told you: patients demanding, cussing, and complaining, because they want a quick service! And it is not your problem as a nurse. (EF9)

The emergency is very tiring because it is the front door of the hospital! Sometimes you have to deal with situations that are dangerous. One or two months ago we had a situation when a colleague of ours was assaulted. (EM11)

Repercussions on the health of the nurse
Work in the hospital emergency unit is highly-demanding and the nurses have little control, due to technical, organizational and relational demands, especially regarding problems relating to human and material resources and control over the influx of patients. This work pattern damages the dignity of the professional because of limitations imposed by the organization itself, regarding the decision-making process and autonomy. The professional experiences feelings such as dissatisfaction, desperation and demotivation as problems are repeated day after day without any prospect of change, with repercussions to the health of the worker identified through the following statements, such as tiredness, exhaustion and depression.

I feel very sad, tired, exhausted working in this unit, because we have to work our best for the patient, but we can’t. (EF1)

After a day of work I feel very tired! Working 12 hours in the emergency is a burden! The work in the emergency does not decrease at all! You have to be always ready. (EF2)

A problem there (regarding the work) is one employee! There is the humanization for the patient, but there is no humanization for employees. I’ve been through this once and got into depression. (EF9)

DISCUSSION

Because of the countless risks faced by nurses working in the emergency unit, we decided to analyze the psychosocial risks and the repercussions to the health of these professionals, as it is an objective with great social relevance nowadays. Such risks are linked to the employees’ perceptions and the resources available to respond to these situations, as individuals, collectively and/or at an organizational level. Therefore, technical and/or structural problems, when not properly dealt with by the organization, have an impact on the satisfaction, well-being and health of the workers, which become the main reasons for absences and sick leave. Thus, the hospital organization has a major responsibility to solve the problems pointed out by the nurses, which include overcrowding, work precariousness and workplace violence.

The overcrowded emergency unit, as described by the nurses, is an organizational problem that reflects directly on the quality of the service provided and on the work of the nursing teams, due to improper use by the population, as a consequence of excessive demand and inadequate provision. These factors, taken together, interfere with communication and the comfort and well-being of both patients and workers. The nurse, as the professional responsible for the management and performance of complex procedures, is directly affected by a work environment in which there is a high degree of stress due to the difficulty of accommodating patients and relatives.

The indiscriminate use of emergency units⁽¹⁰⁾ results from the incapacity of local health units to provide an efficient response to the treatment needs of the population, who look for emergency services in less-complex clinical surroundings and who could be assisted in an ambulatory clinic, or even in a primary care level unit. On the other hand, there are users who require emergency assistance in extremely serious situations, where death may be imminent. Then, it is necessary to implement screening⁽¹¹⁾ with the help of extremely qualified professionals and supported by specialists, so that decisions taken by the team do not generate a situation of neglect, with all its legal implications.

Nurses working in the emergency unit⁽¹²⁾ assume a fundamental role, full of responsibility, because they are responsible for the quality of the service provided; they must show technical and organizational knowledge, as well as being able to take quick decisions to cope with the clinical unpredictability of patients. From a managerial point-of-view, these professionals must handle the human and material resources and provide the necessary infrastructure that facilitates all the teams working in the emergency service. These responsibilities, despite the fact they allow the professional some autonomy, can be a burden with many points of tension, conflict and friction, which reflects the power relationships that are present in the work process.

Nurses are the professionals in receipt of all sorts of information and, as a result, their role is sometimes subject to ambiguity due to the excessive demands made of them. Therefore, it is important that these employees have a defined role to perform, but the centralization of information and decision-making in order to maintain control⁽¹³⁾ can adversely impact on other privileges such as a certain degree of creativity and autonomy.

Because of the technological evolution and advances in scientific understanding, since the beginning of the twentieth century, the nurse has accumulated a diversity of roles⁽¹⁴⁾, in addition to the management of the care unit and the support of patients and their relatives. However, it is understood that the professional is constantly overwhelmed by a sensation of ambivalence while performing tasks not listed in his job description; he has an enormous list of obligatory tasks and all duties must be performed within the time permitted. When the nurse feels the impact of this reality, it provokes irritation and frustration; he feels conditioned by factors connected to the context of his work which limit his professional and personal ideas.

The nurse is also responsible for many lives and, suffering the pressure of having to work in precarious conditions, he has to adapt and improvise with regards to his use of time, in addition to making a psychophysical effort to select and use the necessary materials to perform the job. This adaptation⁽¹⁵⁾, which enables the process of work, proves to be dialectic: at the same time as it gratifies and satisfies, it also physically and psychologically harms the worker. We also have to take into consideration the risks involved in this practice, regarding the increased possibility of errors and iatrogenic complications. This should force the hospital organization to take action to improve both the quantity and quality of care, aiming for better safety at work and employee satisfaction.  

The intensification of the rhythm of work in the emergency unit, ruled by factors such as overcrowding, patients with life-threating conditions and the precariousness of the working conditions, exposes workers to a diverse range of physical and/or emotional loads that contribute to occupational stress. An aggravating factor in this situation is the subjective mobilization of the workers due to the importance of patient care⁽¹⁰⁾, where even a few minutes wait to be attended to, can lead to death. In this way, the social environment of the work generates feelings of insecurity, irritation, low tolerance and even rejection, because the individual will lose his sense of ‘self’ in the tasks he has to perform and his performance can therefore be damaged.

Based on the dynamics of the sector and the many stress factors present, there is a possibility that the professional may become involved in violent situations, which implies the risk of suffering verbal and/or physical aggression that will further harm the performance, safety and  well-being of the worker, as well as his physical and psychological integrity. The main consequence of workplace violence on the health of the worker⁽¹⁶⁾ is emotional symptoms, such as anger, sadness, irritation, anxiety and humiliation. On the other hand, violent acts can be performed unintentionally by the worker, when accepting these situations as part of the “normal” (emphasis added by the author) dynamics of the emergency unit and clinic urgency.

Another type of violence felt intensely by the worker is that of structural or institutional violence, which is due not so much to the attributes of the worker, for example, his capacity to take decisions, leadership skills, tacit knowledge, formation and information, but to the precariousness of the working conditions. The infrastructure conditions in the workplace⁽¹⁷⁾, such as the inadequate physical space to perform routine care activities and the insufficient powers of the nursing professional board, generate tensions and conflicts that are manifested in increased stress among the emergency professionals, especially the nurses.

An aggravating factor of the occupational stress that is faced by nursing professionals in hospital emergency units is the lack of autonomy and decision-making power when faced by problems that are repeated day after day. Such situations, besides exposing the nurses to risks⁽¹⁸⁾, mask the emotional loss, the strain and the work overload, enabling the workers to experience feelings of alienation, preoccupation and indecision and to abdicate self-care in order to dedicate themselves to the demands of the organization. Thus, living daily with work activities that cause displeasure and/or tension can impact on the life of the workers, resulting in physical and psychological disturbances, leading to psychosomatic diseases.

Workers who are stressed and dissatisfied with their working conditions⁽¹⁹⁾ tend to carry out activities with less efficiency, leading to a consequent reduction in productivity, and they become susceptible to accidents and occupational diseases. The irritability caused by stress tends to be extended to the family, generating tense and conflicted relationships, therefore affecting the health of both the workers and those they encounter socially.

Knowing that they are exposed to a stressful work process, characterized by the high demand and the intensity of the conflicts they have to manage⁽¹²⁾, it is necessary for the emergency nursing professionals to rethink their professional practices and the unhealthy working conditions they operate in. On the other hand, it is the responsibility of the Occupational Health Service in the health institutions to create a more effective workplace and to institute policies towards the prevention and monitoring of risk in the work environment.

The creation and maintenance of a space destined to give psychological support to the workers has an undeniable relevance, which may create the opportunity for discussing and developing coping strategies for the problems already referred to. The work of health professionals in critical units⁽¹⁰⁾ should not only involve the management of suffering, but should also give the possibility to alleviate pain, save lives and perform all aspects of their profession to the full, which can be a source of comfort and satisfaction that will contribute to the psychological well-being of the workers, allowing them to feel pleasure in their work.

CONCLUSION

It has been shown that, despite the implementation of patient risk classification at the emergency unit, using the QualiSUS norms, and the work led by the nurses who perform that screening, there are still problems regarding the excessive demand for services, which leads to overcrowding and work overload, especially for the nursing team. The psychosocial risks mentioned by the nurses originate at an organizational level and are triggered by intrinsic factors, such as work overload, intensification of work rhythms, precariousness of the working conditions, ambiguity over the nurse’s role, the need for improvisation and violence at work.

The physical and mental overload was evident in the complaints of the workers; for example, in the excessive demands experienced when patients require continuous care, necessitating a great effort by the team to respond to all the patients’ needs. In addition to the specific activities of the nurse with respect to management and the assistance of severely ill patients, the professional faces problems regarding the precariousness of the workplace, due to the lack of personnel and materials and the inadequate physical environment.

In order to confront the precariousness of the working conditions, nurses have to improvise in order to attend to the needs of patients, exposing themselves to the possibility of professional errors and iatrogenic complications. The ambiguity of roles is observed when the nurses, feeling under pressure from the users, take on the responsibility for solving problems that are not related to their position, which results in more work overload and stress.

As nursing professionals are in daily contact with the population and its health problems, and they are also responsible for mediating any conflicts arising, they can become the victims of verbal violence from patients and their relatives, as a result of dissatisfaction with delays and the poor quality of service. This is a serious problem, generating dissatisfaction and demotivation and further affecting the quality of the service offered.

The understanding that the hospital, and more specifically the emergency unit, is a working environment that exposes nurses to many risks that can affect their general health, is evidenced by their complaints, such as tiredness, exhaustion and stress. It is essential that the employer, and particularly the Occupational Health Service, understands these problems and sees the necessity of putting in place policies aimed at reducing these risks. However, it is also essential to mobilize the nursing staff to identify problems in their work environment and to raise suggestions as to how they might perform their tasks safely and without putting their own health at risk through the demands generated at work.

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Received: 12/09/2012
Approved: 03/12/2012