Psychic suffering and psychodynamics in the nurse's work environment: an integrative review

Alessandro Fabio de Carvalho Oliveira1, Enéas Rangel Teixeira2, Alcinéia Rodrigues Athanázio2, Rafael da Silva Soares2

1 National Cancer Institute, RJ, Brazil

2 Fluminense Federal University, RJ, Brazil

ABSTRACT

Objective: To analyze scientific productions in order to identify the existence of pleasure and psychic suffering in the work environment of nurses and the relation with their emotional state. Method: An integrative literature review based on the search with the following keywords: Nurses, Work Psychodynamics and Psychic Suffering, in the LILACS, IBECS, BDENF, MEDLINE and SCIELO databases, including articles published between 2015 and 2019. Results: The 20 analyzed articles were positioned as favorable to the existence of pleasure and suffering in the Nursing work. Conclusion: The nurse's psychic suffering is a factor that interferes in their personal and professional life, and the debate about the mechanisms to confront the feeling of suffering in the work environment should become popular.

Descriptors: Work Psychodynamics; Nursing; Worker's Health; Psychological Stress; Oncology Nursing.

INTRODUCTION

Nursing is a profession that takes care of individuals and human groups, promotes health and prevents diseases, so it presents different requirements in its development. Thus, nursing professionals demand a set of knowledge and skills, such as scientific knowledge, psychomotor capacity, and sensitivity to deal with the patients and their families. Skills that enable the professional to assist the patient in an integral and humanistic way, interacting with pain and suffering, and sometimes with death(1).

Thus, nursing professionals, especially those who work in emergency services or with seriously ill patients, undergo great mental and physical stress. In assisting the patient's health, the professional deals with various emotions, such as affection, joy, gratitude, suffering, anguish, pain, agony, sorrow, anxiety, anger, and sadness. The patient facing a disease condition is weakened, needing not only physical but also psychological support, a situation that reflects in the nursing professional, who experiences this dense environment of emotions. However, at other times, the nurses face a load of invigorating emotions, like happiness and success in the care process, impacting them pleasantly. Thus, within the psychodynamics of the Nursing work, in a situation of the patient’s fragility, there are moments of suffering and pleasure for the field professional(2).

However, what causes emotional distress to nurses is the object of concern in this study, that is, their psychic suffering. This is because the emotional imbalance of nurses may negatively impact their personal and professional lives. In turn, psychic suffering in the daily life of Nursing professionals may trigger diseases in the nurses and the staff, or negatively interfere with their performance at work. Therefore, the relationship between the professional and the patient, in the context of health-disease assistance, can influence the nurse's well-being and performance(2).

Thus, in the context of the work psychodynamics, since Nursing is a profession that impresses on the worker the feelings of pleasure and suffering, the study aims to analyze scientific productions in order to identify the existence of pleasure and psychic suffering in the nurses' work environment and the relation with their emotional state.

METHOD

The Integrative Literature Review (ILR) was adopted as the investigative method; it is a research method used in the Health field synthesizing research studies related to the practice of health-disease care, offering academic substantiality to the current theme(3).  

To carry out the ILR about the psychodynamics of the Nursing work, some databases were used from August to September 2019. The chosen databases were the following: Scientific Electronic Library Online (SCIELO) and Virtual Health Library (Biblioteca Virtual de Saúde, BVL), its databases being the Spanish Bibliographic Index of Health Sciences (Índice Bibliográfico Español de Ciencias de la Salud, BECS), the Latin American and Caribbean Health Sciences Literature (Literatura Latino Americana e do Caribe em Ciências da Saúde, LILACS), the Nursing Database (Base de Dados de Enfermagem, BDENF), and the Online System for Searching and Analyzing Medical Literature (MEDLINE).

The descriptors were determined using the Health Sciences Descriptors (Descritores em Ciências da Saúde, DeCS) and MESH (Medical Subject Headings) tools, using the PICO strategy (P = Patient, Population or Problem; I = Intervention or Indicator; C = Comparison or Control; O = Result or Outcome)(4).

• P – enfermeiros, nurses, enfermeras; enfermagem, nursing, enfermería;

• I – psicodinâmica do trabalho, work psychodynamics, psicodinámica laboral;

• C – inexistent;

• O – sofrimento psíquico, psychic suffering, sufrimiento psíquico.

The use of the Boolean operators AND and OR favored the use of a combination of the chosen descriptors, with AND being a more restricted combination and OR a more additive one. In this way, the following approach was used: a) Nurses AND nursing AND work psychodynamics; and b) Nurses AND nursing AND psychic suffering.

The inclusion criteria adopted were primary studies that addressed the theme of psychic suffering in nurses in the hospital and pre-hospital environment; in Portuguese, English and Spanish; full text available; published between 2015 and 2019.

The exclusion criteria were revisions; publications without a clear and reproducible methodology; duplicate studies or only with abstracts.

RESULTS

An initial screening based on the inclusion and exclusion criteria followed the use of descriptors, reaching a volume of 359 articles, covering the three selected languages (Portuguese, English, and Spanish). Such quantity of articles obtained in the databases had the disposition listed in Figure 1.

Figure 1 - Disposition in the databases. Niterói, RJ, Brazil, 2019

Source: Elaborated by the authors, 2019.

Of the volume found, 326 studies were excluded after reading their titles and abstracts, where 139 referred to nursing students, 53 dealt with issues related to primary care, 33 had psychiatric nursing care as theme, 29 were secondary reviews, 13 studies were repeated in the databases, and another 59 studies did not fit the theme addressed. Thus, 20 articles were selected as indicated in the PRISMA (Main Items for Reporting Systematic Reviews and Meta-analyses) guidelines(5) highlighting the stages through Figure 2:

Figure 2 - Strategy for searching and selecting articles in the BVS and SCIELO databases. Niterói, RJ, Brazil, 2019

Source: Elaborated by the authors, 2019.

The summary of the 20 selected articles, as well as the levels of evidence(6) of each publication, is presented in Figure 3:

Figure 3 - Summary of the selected studies. Niterói, RJ, Brazil, 2019

Source: Elaborated by the authors, 2019.

DISCUSSION

The articles point out that, in the psychodynamics of the Nursing work, there is concomitance of different types of feelings, both positive and negative. Thus, the positive feelings are related to pleasure and the negative ones, to suffering(7,8). A result based on the theory of the work psychodynamics, which in the Nursing field studies the relationship of nurses with their work environment, which in this case involves both the medical-hospital infrastructure and relationships with other professionals, and with patients and their relatives. The work psychodynamics was based on the knowledge of Christophe Dejours(9).

The psychodynamics of the Nursing work studies the psychic processes linked to nurses' everyday situations, involving different feelings. And, as in any life scenario for all human beings, whether in a personal or professional environment, there are moments of pleasure and suffering, positively or negatively influencing their relationship with the world around them. A context in which feelings related to pleasure are easy and better to assimilate, while the ones related to suffering are not. It is in this critical point of the human being, dealing with suffering, that the emotional imbalance occurs, interfering in the quality of life and setting a precedent for somatic diseases. Therefore, due to having an intense daily life in the professional environment, the nurse tends to absorb a greater load of feelings related to suffering, even if unconsciously sometimes(7,8). This is because there is a conflict between the nurse and the reality of work, a moment that encompasses a dynamic of susceptible absorption of suffering, arising from conflicts or emotionally destabilizing situations(7,8,10,11).

This balance that permeates pleasure and suffering in the Nursing work is debated by a number of studies, which try to identify the factors that generate both feelings. A study conducted with 184 professionals, which pointed out the existence of pleasure and suffering in Nursing, reported that, for nurses, there was both pleasure and suffering at work. For the study, pleasure was related to gratification, freedom (thinking, speaking), pride of accomplishment and identification with work, while suffering was linked to emotional exhaustion, discouragement, overload, and job insecurity(11). In another study conducted with 11 nurses, pleasure also narrowed with the feeling of accomplishment, but it still covered comfort and relief due to the efficiency in patient care. While the suffering indicated by the study involved sadness, frustration, difficulty with grief, inability, and incapacity(9).

Following the line of identification of factors that generate pleasure and suffering, another two studies stand out. The first, carried out with 130 nursing professionals, highlighted social support at work as a pleasure factor and pointed out work in high demand and high control as factors for suffering(12). The second, carried out with 27 nurses from hospices, identified the relation between pleasure and the good coexistence of the team with the freedom to modify the work organization and with the creation of bonds with the elderly. However, the study draws the attention to the factors related to suffering because there are particularities in the intense and sometimes prolonged interaction with the elderly. These suffering factors were identified as follows: the physical effort of the accelerated and repetitive routine; scarce human resources; the accumulation of responsibilities; and the absence of on-site medical service at the institution. Certainly, among the factors of pleasure and suffering, those of suffering are responsible for negatively affecting the nurse's psyche, differentiating from positive emotions like pleasure(13).

By itself, the care work in the health-disease process generates intense feelings in the nurse's work environment, especially when related to factors of suffering. However, when there is greater proximity to death situations, the nurse becomes even more touched by the factors that generate suffering. These situations tend to occur in the urgency and emergency rooms and in the Intensive Care Unit (ICU), as well as in the care for individuals with terminal or severe diseases, with the elderly and children. These are work environments that induce nurses to have conflicting emotions, related to the practice of their profession and to their perception of death(14,15).

The proximity to death makes the nurse reflect about life, creating perceptions about personal and ethical values, but especially about the death process. Such internal questions were assessed in a study with 18 nurses who worked in the care of patients under palliative care(16). Another example is the Nursing work in a pediatric ICU, which can generate intense feelings, since the child's death has repercussions of suffering for the nurse. In addition to witnessing infant death, the nurse also suffers when witnessing the pain of the family members, encompassing negative feelings such as sadness, inability, and frustration(8). Another study accompanies this situation: in the exercise of pediatric oncology Nursing, it pointed out emotional overload in 17 nurses, caused by the interaction of the professionals with sick children and their relatives(17).

In addition to the pediatric environment, there are studies on the nurses' suffering in an environment that deals with the imminence of death. As in the case of a research study conducted with 18 nurses in the emergency department of a university hospital, which assessed emotional destabilization in the entire group investigated, generated by the following reasons: overcrowding, work overload, and frustration. In this group, there was not only emotional but also physical distress(14).

Another study, carried out with 70 oncology nurses, concluded that the work with cancer patients distresses nurses, reaching their emotional balance(15). It also corroborates a study with 26 ICU nurses that found the relation between work distress and the existence of psychic suffering(18). Likewise, a study carried out with 94 professionals observed suffering in the Nursing work environment in the emergency room, covering both the work scenario (overload, imminent possibility of unexpected circumstances, dissatisfaction with the result of work and lack of recognition), as well as internal and personal conflicts (diagnosis and history of the patient, influence of personal life at work, and influence of work in the personal life)(19).

Certainly, as in any human life scenario, whether in a personal or professional environment, moments of pleasure and suffering occur, positively or negatively influencing quality of life. In this way, the work environment interferes with quality of life. In a coadjuvant way, factors that generate a better quality of life are identified, such as better social interaction, good interpersonal communication, and the existence of motivational factors. However, in contrast, there are factors that worsen quality of life, which were identified as suffering, overload, and working conditions(20).

When the individual's well-being and quality of life is weakened, there is a favorable environment for emotional destabilization. Consequently, emotional instability provides an environment for the emergence of diseases. When there is suffering arising from the nurse's work, there is a tendency to develop psychic imbalance, leading to the emergence of diseases. A study conducted with 12 nurses identified the presence of depression in these investigated professionals and related the influence of the Nursing work on mental illness(21). Another study conducted with 70 nurses found a high level of stress and exhaustion in all nurses in the sample, indicating that such a condition would be a stimulus for the development of the Burnout Syndrome(15). A high stress level was also found in another study, carried out with 17 oncology pediatric nurses, who also had a high level of uncertainty regarding their professional life(17). Stress in nurses is recognized as a result of the conditions and of the social environment of their work(22).

Complementing the subject matter in question, there is the understanding that, in addition to stress, the emotional instability of nurses may cause depression, which also triggers the Burnout Syndrome and, in more severe cases, may lead to suicide(23). In a correlated way, a study conducted with 23 nurses pointed out that 91.3% of them had depression, and did not perceive themselves as sick(24).

In summary, it can be said that the nurse's suffering generates intense feelings such as pain, frustration, anguish, fear, inferiority, and sadness, causing psychic imbalance. Suffering can cause somatic diseases to the nurses, such as depression and Burnout Syndrome(7). It is also added that it can cause lack of professional dynamics and not only illness due to emotional imbalance. Therefore, it is extremely important to pay attention to the comprehensive view of the nurse's health, which may include defensive strategies against suffering(10).

In order to confront the nurses' feeling of suffering, a study carried out with 68 professionals showed that there may be a collective and individual adaptation in coping. In the collective mechanism, the study indicated the adoption of meetings for debates and discussion of the team, with sharing of dissatisfactions and feelings. In the individual mechanism, it pointed to the use of rationalization in negative situations, promoting distance from the nurse(25). In another study, carried out with 11 nurses, the following were used as mechanisms against suffering: not thinking about suffering and death, and taking refuge at work(9).

It was found that there is a favorable scenario for the generation of suffering in the Nursing work. A situation that influences the development of the psychic imbalance of the nurse and may cause the development of related diseases, such as depression and Burnout. In this way, the science of the existence of such a possibility of emotional fragility in the work environment makes it necessary to debate the psychosocial nature of the Nursing work. Precisely, so that public policies are created for safety and health at work, covering mechanisms for coping with the suffering of nurses, seeking the health of the professional(12).

CONCLUSION

The study herein undertaken, based on the work psychodynamics, verified the universe of intense emotions in the nurse's work environment. Feelings of pleasure and suffering are present in the Nursing work. However, there is a subtle emotional path when the feeling is related to psychic suffering. The investigated articles report the existence of both pleasure and psychic distress in the nurse's work environment.

The causes of suffering that drew most of the attention were related to work environments surrounded by dense emotions such as urgency, emergency, and ICU, and also with cancer patients, the elderly, and children. Above all, because they are environments with greater potential for the emotional distress of nurses, since there is a greater proximity to the patient's death. An emotional distress that causes suffering to nurses, making them reflect on life, questioning their personal and ethical values, and leading them to think about their potential and professional dedication. In addition to emotional exhaustion, the following also emerge as causes for suffering: work overload, frustration, dissatisfaction with the result of work, lack of recognition at work, and conflicts. Therefore, when showing the causes of the nurses' suffering in the work environment, the investigated literary compendium found the predominance of psychic suffering in the Nursing work.

It is important to note that the psychic suffering of nurses makes them prone to the development of somatic diseases, such as depression and Burnout Syndrome. Still, psychic suffering in nurses causes their quality of work to decrease. Therefore, the public and/or private Health Management must adopt a new perspective on the coordination of nurses, promoting mechanisms to deal with psychic suffering in the work environment, either individually or collectively.

Thus, it becomes feasible to deepen on the theme herein proposed, perhaps promoting new studies about the gap found, that is, investigating the mechanisms of confrontation to the psychic suffering of nursing in the work environment, as well as creating environments that promote health and well-being.

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Received: 01/17/2020

Revised: 04/18/2020

Approved: 04/18/2020