ORIGINAL ARTICLE

 

Coping strategies to workloads of nurses from the emergency unit

 

Estrategias de enfrentamiento a las cargas de trabajo de enfermeros de unidad de emergencia

 

 

Júlia Trevisan Martins^I; Maria Cristina Cescatto Bobroff^I; Renata Perfeito Ribeiro^II; Vanessa Monique Luiz Costa^III; Alexandrina Aparecida Maciel Cardelli^IV; Mara Lúcia Garanhani^IV

^IPhD, Adjunct Professor, Departamento de Enfermagem, Universidade Estadual de Londrina, Londrina, PR, Brazil
^IIPhD, Professor, Universidade Estadual de Londrina, Londrina, PR, Brazil
^IIIRN
^IVPhD, Associate Professor, Universidade Estadual de Londrina, Londrina, PR, Brazil

Correspondence

 

 

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ABSTRACT

Descriptive, exploratory and qualitative research in order to identify the coping strategies to workloads of nurses from one emergency unit. The data collection was conducted through a semi-structured interview with 12 nurses from a teaching hospital in northern Paraná, in November 2010. The data were analyzed according to the technique of content analysis. The results revealed three analytical categories with thematic subcategories. It was concluded that nurses use individual defensive strategies and the same are related to direct confrontation actions, indirect confrontation and those related to emotional state.

Descriptors: Occupational Health; Work; Nurses; Workload.

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RESUMEN

Investigación descriptiva, exploratoria y cualitativa con el objetivo de identificar las estrategias de enfrentamiento, a las cargas del trabajo, de enfermeros de una unidad de emergencia. La recogida de datos fue realizada por medio de entrevista semi-estructurada con 12 enfermeros de un hospital de enseñanza del norte de Paraná, en noviembre de 2010.  Los datos fueron analizados conforme la técnica de Análisis de Contenido. Como resultados se identificaron tres categorías analíticas con subcategorías temáticas. Se concluyó que los enfermeros utilizan estrategias defensivas individuales y las mismas están relacionadas con acciones de confrontación directa, confrontación indirecta y aquellas referentes al estado emocional.

Descriptores: Salud Laboral; Trabajo; Enfermeras; Carga de Trabajo.

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Introduction

The working process of the hospital nursing staff is influenced by the organization and development of multi-professional and multidisciplinary activities and certain peculiarities that contribute to workloads bringing consequences to physical and mental health of these professionals⁽¹⁾.

It is known that Emergency and ER units (UEPS) are environments with unpredictable and urgent situations aiming to save lives. These and other aspects require quick thinking and decision-making of health professionals. In these units are attended patients with different ages and conditions.

Thus, understanding the process of working of health professionals of UEPS and their suffering / illness as a result of this context as well as recognizing the defense strategies used are fundamental to implement prevention and health promotion actions of these workers. Furthermore, it is important to know how is the self care and their own health to provide subsidies for the care of another.

The work, generally and in this particular case in the UEPS, must be understood in its full scope, considering its economic, cultural and social aspects. It is essential the understanding of issues involving the social production of subjectivity and physical and mental health of people, realizing that these issues are directly and indirectly connected to each other and there is no way to separate them⁽²⁾.

Thus, it is necessary to understand that workers are exposed to workloads and  they are related with the organizational process of labor. In this perspective, the elements of the work process interact with each other and with the worker’s body featuring a differentiated analysis of the risks to workers’ health⁽³⁾.

This understanding subsidizes the overcoming of a single cause model in which risks alone cause the disease⁽³⁾ to the paradigm of social determination of disease that represents a resumption of social approaches of Epidemiology - understanding of disease socially produced and dependent on the interaction of various factors .

Workloads that can generate work or professional diseases are classified into external materiality to the worker’s body (physical, chemical, biological and mechanical) and  internal materiality (physiological and psychic), by establish and interact with the body of worker⁽³⁾.

It is assumed that nurses of UEPS perform a fragmented work, socially devalued and that due to the specificity of the environment are subject to various workloads. Therefore, they seek ways to preserve the psychic, emotional and physical balance to minimize them using coping strategies.

Coping strategies can be individual and collective, depending on the organizational context and psychological resources mobilized in work situations and take on different forms of behavioral manifestations, and may vary between groups of employees within the same organization⁽⁴⁾. The difference between the individual and collective mechanism of defense is the fact that the first remains without the physical presence of the object, since it is internalized, the second depends on the presence of external conditions and remains the consensus of a group of workers⁽⁵⁾.

The individual defenses are essential for the individual to adapt to suffering, but have little or no influence on the social violence of the work, due to its characteristic of isolation. On the other hand, the collective strategies contribute to the cohesion of the work, because work does not just mean having a task to be undertaken, but also to experience the pressure in  collectivity, meet the resistance of the real work, construct the meaning of work, of the situation, of suffering, of pleasure and others⁽⁶⁾.

Considering that the identification of defensive strategies provides nursing workers from health institutions a planning to intervene in the organization of work and the collective construction of solutions and compromises, the question about the coping strategies to workloads of nurses working in UEPS of a quaternary public hospital emerged.

In this context this study aimed to identify the coping strategies to the loads stemming from the work of nurses of a UEPS working in a teaching, public and quaternary hospital inner in the state of Paraná.

 

Method

A descriptive, exploratory and qualitative research developed with nurses of a UEPS of a teaching, public and quaternary hospital of the city of Londrina – PR.

It was used as a theoretical referential the Dejourian Psychodynamic that considers the work process and the man in continuous movement, in dynamic equilibrium, free and open to the evolution and transformation. In this approach, if this balance is broken, blocked or permanent, can occur to the inefficiency of production and in any instant initiate its rupture. To maintain this balance in the workplace the worker uses coping strategies⁽⁷⁾.

The work of this UEPS is organized according to the clinical model centered on the  opinion/diagnosis of the physician and the nurses subjects in this study are responsible for the organization of the work of the nursing staff (nursing assistants and technicians), as well as oversee the activities developed by this team. Note also that there is the constant presence of teachers and students of undergraduate and postgraduate of medicine, nursing, physiotherapy among others.

The patients attended in UEPS are referenced by other hospitals in the city and region by the Service of Medical Assistance and Emergency and through the central of beds. Are attended, daily, patients in critically state of medium and high complexity. There are also care of patients of spontaneous demand resulting on a attended superior to the capabilities of human and materials resources.

Data collection was carried out in November 2010 through a semi-structured interview with the guiding question: "Tell me what strategies do you use to cope with the workload." The interviews were conducted in own unit during the work shift and fully transcribed. To preserve the anonymity of the respondents they were identified with the letter E and the number of subsequent interview (E1, E2, E3).

A priori, the number of respondents was not defined. The speeches were kept until the time was repetition in speech, occurring convergence sufficient for the establishment of such phenomenon when the sample reached 12 nurses from morning, afternoon and evening shifts. Inclusion criteria were being a nurse and have at least one year of work in the unit.

Data were analyzed using the technique of Content Analysis⁽⁸⁾ that comprised three distinct periods: pre analysis which consists of the floating reading of the transcribed data, the material exploration with selection of participants’ speech and organization of categories and, finally, the treatment of results by inference and interpretation of them⁽⁸⁾.

The study was approved by the Ethics Committee of the State University of Londrina  (UEL) under No. 002.0.268.00.09 and all participants, after informed about the objectives and methodology of the study, signed a Statement of Consent.

 

Results and Discussion

Most participants in this study were female, aged above 30 years, married, with  predominance of the Catholic religion. The workload of the respondents is 36 hours per week and all with more than four years of experience in the field of study and formation time over six years.

Data on coping strategies resulted in three analytical categories with its thematics subcategories and are presented in Figure 1.

Category 1: Coping centered in actions of direct confrontation

Regarding the subcategory share information with the team the following statements were reported:

[…] talking, trying to improve this communication we try to slightly decrease the workload [...] some things you will have to talk about, hear the other. Sometimes the dissatisfactions are things of the whole team, but we need to hear, so we hear. This is a way we help ourselves (E1).

you share with colleagues to see if they are feeling the same thing you in that  particular problem that is grieving you. You need to develop strategies with the team, [...], you have to seek concrete ways in team otherwise it will not work (E6).

Discuss with the multidisciplinary team so that the load is not too heavy for one person to not generate so much stress and not generate distractors, we need to divide the team with our anxieties, our problems and also the steps we take in a given situation pair to see if we act right or not (E12).

For some authors⁽⁴⁾ the healthy personal interactions may demonstrate different thoughts, promote understanding, affection, harmony, cooperation and strengthen teamwork. Thus, listening is an important defense strategy. Sharing the difficulties gives opportunity to free exercise to opine and develop mutual aid, making the difficulties encountered in daily worker less "heavy".

In a study of workers of a team of Family Health in Ribeirão Preto identified that they used collective strategies to relieve tension in the workplace and improve relationships between team members through weekly meetings for discussions of cases⁽⁹⁾.

In this context, it emphasizes the fundamental role of worker participation and health institutions to provide the development of collective strategies for coping with workloads.

Good interpersonal relations favoring trust, solidarity and friendship and thereby relieve the stresses of working through a mutual aid support⁽⁴⁾.

When problems are shared establishes a communication channel and increase the chances of collective growth through reflection and critical stance, the development of creativity from the freedom and responsibility. Moreover, listening creates emotional bonds. These are strategies that result in more harmony among the team, strengthening the responsibilities of each and, consequently, improving the care provided to patients and families.

As regards the subcategory information search and understand the situation the following speech is presented:

I try to see the situation that is bothering me at the time, I try to solve it the best way possible, with patience, respecting everyone and everything, I try to see the work as a whole, but especially the individual situation of that problem that I am facing in the moment, is one thing at a time (E2).

The man is unique and has different views of the world, so there is no way to standardize the conduct, actions and thoughts. It is essential to respect the individuality without disregarding the objectives common to all ⁽¹⁰⁾. It is essential to work being guided by strategies that enhance cooperation, respect, trust, union, among other things, to occur the exchange of experience and collective discussions about the problems experienced⁽¹⁰⁾.

The following discourses demonstrate the subcategory seek alternatives that help to circumvent the situation.

I always go to church, pray for a long time, even in the hours I’m in overload here at work I ask God’s direction, I always try to be with God all the time he is my breath in  difficult hours (E10).

I go to church every Sunday to pray for God to help me, but I pray when I’m at work too, it has situations that sometimes I think I can´t overcome and only God can really help me and I always find a way out when I ask He to help me (E12).

In a study accomplished with nurses on ways of coping with problems related to work, the most frequently used strategy was clinging to religion and to seek support for a superior "entity". This belief helps to cope with the feelings arising from the difficult situations that these professionals experience ⁽¹¹⁾. In another study with nursing assistants and community agents of team of Family Health the support in religion was cited as a strategy to alleviate the stresses of work by providing inner peace and spiritual support⁽⁹⁾.

The beliefs, faith and hope attributed to religion were also mentioned by other authors such as coping strategies for representing daily balance face of suffering from work⁽¹²⁾. Therefore, it is evident the importance of religiosity and beliefs in coping with workloads even individually.

The subcategory plan and prioritize work activities was identified in the following statements:

I use my sense of experience [...] I prioritize assistance, I have ten years of work experience, for example, a patient that I see that is not right, his evolution, and that already has a history, depending on the disease, depending on his record, what do I do? I monitor him(E9).

[...] As far as possible use planning work, you have to plan, but still within the ER you have multiple units, there are units that you can plan better and there are units that the flow is quite large and has a very large turnover of patients (E4).

Particularly I always try to use a strategy that I believe to be a priority in this sector that is assessing who is more serious first, then the age, because older people are more likely to have problems [...] (E8).

There are researchers who claim to be a function of the nurse articulate, monitor and control the actions performed by the nursing staff. The managerial role of the nurse includes numerous activities necessary and essential to ensure the development of collective work. It is also for this professional use management techniques to motivate staff in the provision of quality services ⁽¹³⁾.

It is noticed in the speeches of the nurses that they use their professional experience and management techniques as to plan and prioritize the nursing care to circumvent the daily conflicting situations in this sector of constant emergencies and large flow of patients and health professionals.

Category 2: Coping centered in actions of indirect confrontation

The following are reports subcategorized as not to take problems home.

I arrive at my home, I shower, lay and "faint", I live with my family and try to forget what I experienced at work, we chat about happier things, everything I do is to forget about what happened at work, otherwise it is bad, right? (E3).

I always try not to take things for personal life if not you can not take it,  it’s enough what we experience at work and our family can not tolerate, it is not fair that they are aware of what happened in the workplace, for what ? (E5).

I try to shut down completely when I go home so I did not take this to my family, [...] I disconnect here, I’ don´t see the news, who came here, I do not like, understand? This is a way that I use to reduce the psychological load [...] I also seek recreational activities (E7).

In a study with the nursing staff of an Emergency Care other forms of coping classified as indirect confrontation were cited as, for example, recreation, leisure, chat and socio-cultural activities. However, these strategies have been employed to alleviate the degree of tension and not to avoid it ⁽¹²⁾.

It is known that the interaction and support of family and friends are ways to overcome the stress experienced at work and was also evidenced in the study.

Category 3: Coping actions linked to the emotional state

The subcategory deny the situation was revealed in the following statement:

[...] as a strategy to compensate for the emotional loads I have none, because I finished my masters, I finished my marriage and I have a child to care, so we end up thinking that the difficulties of the work are few because the difficulties of the house are larger (E11 .)

The worker claims not to have strategies to deal with the mental loads of the work. However, his speech reveals that it seeks a way to avoid suffering at work denying the loads present in this environment due to personal problems, and you can not separate the professional human being of social and familiar human being.

In a study performed with nurses of the emergency unit of the city of São Paulo ⁽¹⁴⁾ such professionals were qualified as stressed, although the authors inform no scientific evidence on this aspect. What is conclusive is that the nursing profession regardless of the focus of activity is a stressful activity.

In a recent literature review on the stress of nurse of Intensive Care Units with some job characteristics similar to work sector of this research it is reported that the stress of the nurse and the wear caused by the same are troubling because situations of continued dissatisfaction can lead to Burnout syndrome (15).

In this context, when the defense strategies are not used properly it can produce a kind of insensitivity no longer consciously perceived by workers, contributing to the stabilization of the situation and the onset of diseases and ailments to physical and mental health of these individuals (16-17 .)

It is necessary the awareness of health professionals about the loads they face in the workplace, particularly those considered invisible, as the psychic, to seek ways to address them and not mask them, because they are pathogenic as well as chemical, physical, physiological, among others loads⁽¹⁸⁾.

Some researchers claim to be of fundamental importance the presence of the psychologist to develop activities with a focus on work organization to ensure the health of the worker with actions not only palliative but also to prevent the onset of mental health problems. Cited were also complications and / or diseases that may arise from occupation, for example, depression, affective disorders, changes in the sleep-wake cycle, neurasthenia and Burnout syndrome among others ⁽¹⁹⁾.

The subjective questions that permeate the work process are complex and therefore it is a challenge facing them. However, seek balance through collective or individual strategic defense is consider that the work can be constructive for the individual since it considers everything and everyone, and in particular, the individual characteristics of each employee, their beliefs, their culture and their spirituality.

 

Conclusion

After the analysis of the narratives of the participants, it is concluded that nurses use defensive strategies in the workplace to protect themselves from loads that routinely experience in focus UEPS of this research.

It was found that the strategies used were related to actions of direct confrontation, indirect confrontation and linked to the emotional state.

Stands out the importance of these professionals seek alternatives to prevent injuries and illnesses, as well as promoting health, improving the quality of life in the workplace and personal life. However, the study revealed that most of the strategies was individual. Thus, it appears that the charges arising from work are not being discussed collectively. In this context, the actions and possible individual solutions do not reach for the collective improvement of the work process and the quality of life and work of these professionals.

Thus, it is understood to be necessary for the institution and nurses seek collective alternatives for coping effectively the loads that are present in this unit, as it is known that individual alternatives do not encourage cooperation, mutual aid and solidarity. It is essential that not trivialize the suffering at work, because it can become habitual and understood as unsolved by the workers.

It is believed that this study elucidated the importance of nurses be aware mainly on subjective problems experienced. Solutions should be planned jointly for everyone to have the opportunity to participate and take responsibility for decisions contributing substantially to improving the quality of life of these professionals themselves.

 

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Correspondence
Maria Cristina Cescatto Bobroff
Universidade Estadual de Londrinha. Departamento de Enfermagem
Rodovia Celso Garcia Cid, Pr 445 Km 380, Cx. Postal 10.011
Campus Universitário
CEP: 86057-970, Londrina, PR, Brasil
E-mail: crisbob@uel.br

Received: May 14^th 2011
Accepted: Mar. 5^th 2013