Documento sin título

ARTÍCULO ORIGINAL / ORIGINAL ARTICLE/ ARTIGO ORIGINAL

 

Job satisfaction of nursing professionals in adult hospitalization wards. An ambivalent feeling

Satisfacción laboral de las enfermeras en salas de hospitalización de adultos. Un sentimiento ambivalente

Satisfação trabalhista das enfermeiras em salas de hospitalização de adultos. Um sentimento ambivalente

 

 

Marleny Zapata Herrera1

Gloria Margarita Alcaraz López2

 

1 RN, M.Sc. Professor, Nursing Faculty, Universidad de Antioquia, Colombia. email: zapatah@udea.edu.co.

2 Dietitian-Nutricionist, Ph.D. Professor, Nursing Faculty, Universidad de Antioquia, Colombia. email: glory@udea.edu.co.

 

Subventions: Comité para el Desarrollo de la Investigación -CODI- de la Universidad de Antioquia en 2007.

Conflicts of interest: none.

How to cite this article: Zapata M, Alcaraz GM. Job satisfaction of nursing professionals in adult hospitalization wards. An ambivalent feeling. Invest Educ Enferm. 2012;30(2): 178-187.

 


 

ABSTRACT

Objective. To know and understand job satisfaction of nursing professionals in adult hospitalization wards in institutions of the Metropolitan Area of Valle de Aburrá (Colombia). Methodology. This was a qualitative study, frame-worked within the ethnographic paradigm. During 2008, semi-structured interviews were made to 15 female nursing professionals and two male nursing professionals, in addition to 30 hours of observation in their work places, with prior signed consent and authorization from the institutions. Results. The following categories emerged: satisfaction, dissatisfaction, and ambivalence between job satisfaction and dissatisfaction of the nursing professionals; with dissatisfaction being the primordial feeling among them. Nursing professionals feel satisfaction when patients leave recovered, when they provide direct care, or when there are positive results through their work. Dissatisfaction appears when they cannot provide direct care, lose autonomy, are overloaded with work, or because job demand diminishes. Conclusion. Job satisfaction is an ambivalent feeling, dissatisfaction prevailing in the study group.

Key words: job satisfaction; nurse-patient relations; nursing care; nursing.

 


 

RESUMEN

Objetivo. Conocer y comprender la satisfacción laboral de las enfermeras en salas de hospitalización de adultos en instituciones del Área Metropolitana del valle de Aburrá (Colombia). Metodología. Estudio cualitativo, enmarcado en el paradigma etnográfico. Durante 2008 se realizaron entrevistas semiestructuradas a 15 enfermeras y 2 enfermeros, además de 30 horas de observación en los lugares de trabajo, previo consentimiento informado y autorización de las instituciones. Resultados. Surgieron las categorías: satisfacción, insatisfacción y ambivalencia entre la satisfacción e insatisfacción laboral de las enfermeras; siendo la insatisfacción, el sentimiento que primó entre ellas. Las enfermeras sienten satisfacción cuando el paciente sale recuperado, dan cuidado directo o hay resultados positivos con su gestión. La insatisfacción aparece cuando no pueden dar cuidado directo, pierden autonomía, tienen exceso de trabajo o porque se disminuye la demanda laboral. Conclusión. La satisfacción laboral es un sentimiento ambivalente, primando la insatisfacción en el grupo estudiado.

Palabras clave: satisfacción en el trabajo; relaciones enfermero-paciente; atención de enfermería; enfermería.

 


 

RESUMO

Objetivo. Conhecer e compreender a satisfação trabalhista das enfermeiras em salas de hospitalização de adultos em instituições da Área Metropolitana do Vale de Aburrá (Colômbia). Metodologia. Estudo qualitativo, emoldurado no paradigma etnográfico. Durante 2008 se realizaram entrevistas semiestruturadas a 15 enfermeiras e 2 enfermeiros, além de 30 horas de observação nos lugares de trabalho, prévio consentimento informado e autorização das instituições. Resultados. Surgiram as categorias: satisfação, insatisfação e ambivalência entre a satisfação e insatisfação trabalhista das enfermeiras; sendo a insatisfação, o sentimento que primou entre elas. As enfermeiras sentem satisfação quando o paciente sai recuperado, dão cuidado direto ou há resultados positivos com sua gestão. A insatisfação aparece quando não podem dar cuidado direto, perdem autonomia, têm excesso de trabalho ou porque se diminui a demanda trabalhista. Conclusão. A satisfação trabalhista é um sentimento ambivalente, primando a insatisfação no grupo estudado.

Palavras chaves: satisfação no emprego; relações enfermeiro-paciente; cuidados de enfermagem; enfermagem.

 


 

INTRODUCTION

Nursing care is a practice of humanized care of individuals and groups that implies academic formation with ethical, scientific, human, and social criteria1-3 and must generate satisfaction in the nursing professional providing the care, as well as in the individuals receiving it. Zas4 defined satisfaction as: "an essentially human and inter-subjective phenomenon that starts and culminates with the subject"; while Berger and Luckmann5 state that it is an experience related to something or someone and permits providing an image of the subjective and inter-subjective world of humans within their daily context.

Patient satisfaction is the result of their interaction with healthcare professionals and a measurement of efficiency and objective control of the quality of care.6 However, our healthcare institutions, as in the international context, measure satisfaction and quality of attention based, especially, on the patient's perception7 without much consideration for nursing care.7,8 On the contrary, Legislation 266 of 1996,9 which regulates the nursing profession in Colombia, states that "Quality is reflected on the satisfaction of the individual using the nursing and healthcare services, as well as on the satisfaction of the nursing personnel who provide said service", including the nurse's perception. Upon evaluating job satisfaction in nursing personnel, Parada et al.,10 found that 46% manifest dissatisfaction due, mainly, to lack of recognition and autonomy and to the multiple tasks that must be carried out. Likewise, at the international level,11-13 increased dissatisfaction is noted in nursing professionals because of deteriorated work conditions and increased work load.

The International Nursing Council (INC)14,15 has alerted of the scarcity of nursing professionals throughout the world and relates it, among other causes, to unfavorable working conditions that trigger these professionals to seek mobility and abandon their posts, while it produces lack of motivation and dissatisfaction, with the consequent decrease in the quality of care and of the safety standards.16 The healthcare system and the nursing human resource have not been strangers to neoliberal policies in Colombia and Latin America; the crisis caused by healthcare reforms, globalization, and lack of planning of the human resource locate the nursing praxis on the wellbeing perspective, and healthcare services are turned into simple mechanisms of assurance and economic profit, often forgetting the responsibility of protecting life.17

Studies conducted in Colombia18-22 between 1992 and 2008 reveal increased dissatisfaction of nursing professionals because of deteriorated working conditions and the delegation of care to nursing aides. These studies have been conducted with a quantitative approach, centered on observable and measurable objective phenomena like the evaluation of administrative policies and structures of the labor scenario. Job satisfaction has not been widely studied from the qualitative perspective, regarding the personal, emotional, and behavioral factors of the nursing professionals. Hence, another view is required of this essentially human phenomenon and in relation to the other; thereby, emerging the question addressed in the research presented in this article: Are nursing professionals who work in adult hospitalization wards of Medellín and its Metropolitan Area satisfied?

 

METODOLOGY

This work was carried out in the Metropolitan Area of Valle de Aburrá (Colombia), between 2007 and 2008, with a qualitative approach frame-worked on the ethnographic perspective.

Field access. To have access to the hospitals where the nursing professionals work, letters were sent to 13 managers of healthcare institutions, requesting their authorization to perform the observations and the interviews with the nursing professionals working in adult hospitalization wards; affirmative response was received from only six of these. In the institutions, contact was made with the ushers, who in this study were the coordinating nursing professionals, to obtain authorization to approach the participants and make the necessary observations.

Ethical considerations. The ethical principles were guaranteed according to Resolution 008430 of 199323 and the criteria of respect to dignity and protection to rights prevailed, along with the wellbeing of the participants and institutions. Informed oral and written consent was obtained prior to holding the interviews, data confidentiality and participant anonymity was assured, and approval was received from the Ethics Committee of the Faculty of Nursing at Universidad de Antioquia.

Participants. To select the participants, the snowball technique was used; the coordinator remitted the first nurse, then this one remitted another and so forth. The diversity of the sample was considered to comply with the criterion of heterogeneity regarding: gender, seniority, type of contract (fixed term, indefinite, and through cooperative labor) and type of institution (public or private). The selection of the participants and of the episodes and interactions were carried out through a conceptual approach, and not because of their numerical representation. The inclusion criteria were: nursing professionals, with current labor contract in the institution and job experience of over six months in adult hospitalization wards.

Observation. The observation was not totally participative or covert; given that due to the restrictive context of hospitals, we had to perform it mainly in the nursing stations because this is where the nursing professionals spend most of their time. Participant behavior was observed during their interaction with medical personnel, nursing aides, colleagues, patients and their families, and with the administrative personnel. Other observations were made in patients' rooms and in common areas of the hospitalization wards.

Interviews. The strategy of semi-structured interview was used, which asked: Do you feel satisfied or dissatisfied with your job performance in this institution? What gives you the greatest job satisfaction? What causes you to be dissatisfied with your job? How does satisfaction or dissatisfaction affect you as a nurse? For the interview, the participants were suggested a comfortable and relaxed place, inside or outside the hospital centers; however, most preferred the interview be done before or after the work shift, including in the middle of the shift; only one preferred for it to be carried out during non-working hours.

The interview guide was flexible, open, and subjected to changes during the conversation. By following the guidelines by Hammersley and Atkinson,24 we began with three interviews, which were part of the exploratory study to test and fine tune the questions and approach the participants. When reaching the saturation of the categories, the information collection process was terminated.

The last interviews served to refine, develop, and verify the categories found. The interviews were recorded and transcribed with participant consent. In order to guarantee anonymity, the individuals were identified with a letter and number code, e.g., (E5) where "E" corresponds to the interview and the number corresponds to the participant.

Field diary. The individual and immediate context of the interviewees was registered and described in the field diary. Once the notations were made, these were transcribed to keep from losing valuable details of the phenomenon being studied.

Analysis. This was performed while the information was being collected based on guidelines for ethnographic analysis: a) carefully read the information gathered, pose questions, and establish relationships; b) document the meanings of the concepts spontaneously arising and trace them; c) identify concepts and classify them until adopting concrete and analytical categories for data organization, and d) work with the fundamental categories for analysis, seek relationships with other categories and subcategories, until reaching the study goal. The whole process was performed manually, carefully, and meticulously upon examining, interpreting, and organizing the interview data (emic), field notes and observations (etic). We started from the particular to go to the general in small steps; we began with data from an interview that we then compared to other similar interviews, and henceforth until obtaining valuable information that permitted us conceptual ordering until debugging the codes, reaching the main categories, and saturating the categories.

Once the data were analyzed, these were presented to academic peers and the results were returned during a meeting with the six female nurses and a male nurse who participated, who manifested that they identified with the study results. After the meeting, the recording tapes were destroyed in front of a member from the Ethics Committee and a report was drafted. The results were also socialized with the Committee of Nursing Coordinators (COINDE) from different healthcare institutions in the Metropolitan Area of Valle de Aburrá and with four nursing professionals representing the Nursing Faculties of Antioquia.

 

RESULTS

This research had the participation of 15 female nursing professionals and two male nursing professionals from three public institutions and three private institutions from the Metropolitan Area of Valle de Aburrá (Colombia). Age ranged between 25 and 52 years and seniority was between six months and 26 years, with most (41%) between six months and two years. A total of 41% of the employing entities were state-run and 59% were private; 53% of the participants had fixed-term contracts and the rest had indefinite contracts. Some 76% of the participants were hired by the hospital institution and the remaining 24% by the labor cooperative. Two main categories emerged from this study: job satisfaction and job dissatisfaction.

Job satisfaction. Job satisfaction of the participating nursing professionals is evidenced by having the following three subcategories:

Autonomous role and professional identity. It is also subdivided into three codes: a) 'seeing people recovered and discharged from the institutions': What gives me the most satisfaction is to watch patients discharged from a service with their problems solved, seeing people leave content with the attention one provided (E10); b) 'providing direct care to sick people: Satisfaction yes, because even if there is little contact with the patient, that contact is important, it is how I feel with what I am doing (E16); and c) 'Showing results in managing care and service': What brings me the most satisfaction is to be told that in this service things are being done well, patients are not complicated, they are being discharged increasingly better; morbidity was diminished and mortality is being decreased (E6) and, It is very gratifying because with all the planning we have done, with the work, and the plans for improvement and compliance with goals, we are guaranteeing patient satisfaction (E1).

Although direct care and nurse-patient interaction have diminished over time, as expressed by the participants, it is the experience of providing direct care and seeing people discharged and recovered what produces the greatest satisfaction in the group of participants; in fact, 16 of the 17 participants expressed it so and only one stated that the greatest satisfaction was obtained from participating in management of nursing services and belonging to the different institutional committees like the accreditation, certification, and epidemiological surveillance committees.

For nursing professionals, most of the time is spent in managing nursing services and it is a satisfactory activity when positive results are shown to the institution. Healthcare institutions prioritize administrative work to showing quality and productivity results in the services offered, and part of that responsibility falls upon the nursing professionals.

Institucional recognition. The participants expressed that when feeling backed and supported by management at the institution, being taken into account for decision making, having communication channels in the healthcare team, and feeling that their work is valued, it is indispensable to feel job satisfaction. This subcategory has the code 'having institutional support': Here at the clinic, we have people who support us and respect us a lot, who believe in the nursing work and support it, the manager, the medical director, and many of the partners [.], that brings me much satisfaction (E5).

Working conditions. Besides the previous aspects, having decent employment conditions, which guarantee a salary and work stability, is a privilege that brings satisfaction. This sub-category had the code 'having a job': You have to love this job, because this is scarce (E5).

Job dissatisfaction. The opposite face of satisfaction is dissatisfaction, from which three sub-categories also emerged:

Autonomous role. Most of the participants coincided in stating that the main causes of dissatisfaction are loss of direct care and of the autonomous role. They see direct care as something that is being lost, given that during other times they could provide it and enjoyed their autonomy, a situation that gives them a sense of frustration and dissatisfaction. Said loss leads patients and their families to no longer identify the nursing professional as the person leading in the care. Likewise, some nursing professionals expressed sadness and feelings of guilt for not knowing well the people hospitalized in their wards; they consider they are not doing their work well by concentrating on complying with administrative functions.

With the code 'dissatisfaction because of the loss of direct care and of autonomy' we find statements like: Direct care with the patient is lost, which is why there is dissatisfaction; direct contact with the patient is scant (EP1), When one attends the university wishing to study nursing, one thinks that 90% involves care, thinking that only 10% is administrative, but the percentage is inverted; therefore, one often is not satisfied (E15). Another thing that does not satisfy me much is that patients do not recognize the nurse's work. They do not recognize or value it (E5). When the treating physician arrives, we have so many activities and so many things to do that we cannot accompany them in the rounds, often wanting to do a process properly, that is sad because it is not organized work (E5), and Within the profession we use to have a lot of initiative and autonomy, now we are a bit restricted; before, I would do the curing, took care of diet matters, but here I cannot do that without prior authorization from the physician (E6).

Institutional support. Without support from their peers or from management, nursing professionals feel alone. However, they carry much of the responsibility for the service: they must be aware of what the interdisciplinary team is doing and guarantee harmony of the wards where they work. Some statements that belong to the code 'little support from the institution to perform the autonomous role, are: We are not supported at any time; rather, we are the ones who have to stand up for everything and that is quite stressful" (E7). The institution should give nurses the participation they deserve, even the hospital director says the nursing professionals are the backbone of the institution, but we have no participation; we participate little in decision making, in planning (E7).

Working conditions. During the study, the nursing professionals were performing duties of the delegated medical role and administrative procedures, which are the responsibility of a ward secretary or of other support personnel (invoicing, auditing, authorizations, supply procedures, and maintenance procedures). These functions take away time from nursing care and produces much dissatisfaction. We are beginning to note the new forms of employment with cooperative labor intermediation in 24% of the participants and decreased indefinite-term contracts through the healthcare institution; this creates a sense of work instability and precarious working conditions, which generate dissatisfaction and lead nursing professionals to refrain from complaining about the work and professional situation for fear of losing their jobs.

This subcategory has two codes: a) 'the workload with activities that are not incumbent': Here, there is a lot of secretarial work. It is horrible when I leave caretaking aside to get on the phone to schedule appointments or remit patients" (E2) and, Physicians discharge patients and nurses must return all those medications and that requires extensive paperwork, along with placing the medications in a bag and return it to stock, which takes up a lot of time. So first you take care of the discharges to notify the invoicing of the discharges because people start rushing you and making you run around crazy, thinking you will run out of time (E3); and b) 'poor labor demand: Given that there is so little opportunity for work, many people stay at an institution because. where will they go?" (E12) and, No body balks for fear of not being hired again. That is the truth; we are tied hands and feet! And those of us who do speak up cannot be easily fired" (E7).

 

DISCUSSION

In this study, we perceive, on one side, the nurse's satisfaction when contributing to the recovery of patients, providing direct care, showing results in managing care and service, being supported by the institution, and having decent employment and, on the other, we perceive dissatisfaction due to the decrease of direct care and autonomy, poor institutional support to perform their autonomous role, the work load with activities that are not incumbent, and few employment opportunities.

Participants expressed mixed feelings of job satisfaction and dissatisfaction, which Bauman25 denominates as ambivalence: when the subject debates amid contradictory impulses and emotions toward the same object. Mixed feelings in being a nurse and in the professional praxis reflect an internal struggle; something is missing, to the point that some expressed they felt they had lost the reason for being nurses, by not providing direct care to patients.

Providing direct care is a function of the nursing task. For this purpose they were trained professionally, as stated by Kérouac et al.:2 the center of interest of the nursing discipline is caretaking; it is the essence, the heart and soul.

Some studies 26-29 show that caring for the patient is what brings the most satisfaction, as we have observed in this study.

Morgan and Lynn,30 as well as Castle31 identified key factors of satisfaction and in retention of nursing professionals: autonomy, organization of nursing care, education, professional development, incentives, and administrative support, which coincide with the findings by Kramer and Schmalenberg32 and Lake,33 when pointing to the existence of the so-called "Magnetic Hospital" understood as an institutional culture that influences positively on the retention of nursing professionals, on personal and professional satisfaction, given that it provides autonomy to act in their professional environment, seeking recognition of their status and promoting quality of care.

Nursing professionals with more years of experience perceived that before the Healthcare Reform, the nursing professionals had more recognition, autonomy, and satisfaction in their professional performance. Now, on the contrary, it was noted that institutions tried to lower costs by hiring less nursing professionals; thus, diminishing the quality of care. This can be explained by the increased university quotas and the decreased demand for healthcare institutions.34

Current unemployment conditions and labor intermediation seen in Colombia,35 leads nursing professionals, mainly the youngest, to prioritize the management function over direct care to keep their jobs. Most of the participants in this study coincided in stating that their motivation to study nursing was to provide direct care, but upon entering the job market, this went on to a second level, which brings them, as reported in other studies,36-40 much dissatisfaction: they feel that direct care is being lost and that, as corroborated by Fletcher,41 it gives them a sense of guilt and dissatisfaction. The delicate part of this situation is that, nor patients or their families distinguish nurses as the leaders of the care they receive, given the lack of clarity of the roles and tasks they think should be performed.

Nurses feel alone, without peer support or from the hospital administration. Also, diminishing employment opportunities made many of the participants report that they adapt to and put up with the high load of administrative functions imposed on them; a situation that has also been indicated by Melo et al.42 Nursing professionals do not find alternatives or do nothing to change the situation and fall into routines, silence, and resignation, which affects their job satisfaction, as also pointed out in another study.8

Expression of job dissatisfaction could be positive if it motivated nursing professionals to question themselves and struggle to defend their professional autonomy or to make the decision to leave their jobs for better ones, where they find respect for their autonomy, work conditions, and decent pay.43 Unlike Europe and North America,14,15 where, due to dissatisfaction, nursing professionals abandon their jobs to look for other jobs that offer them better conditions.

Job dissatisfaction also reflects the voids of quality policies at institutions,43,44 when almost exclusively considering patient satisfaction, ignoring that the nurse-patient interaction is an important indicator for satisfaction and quality of service.45,46 Underestimating the job satisfaction of nursing professionals may even affect the institutional quality. Nursing professionals and their support personnel are the most numerous human resource at institutions and to a great extent the success of the attention processes depends on them. Likewise, Hung et al.47 revealed the importance of promoting professional development in new nursing professionals through work with mentors, which has proven to have positive effects on job satisfaction.

Satisfaction is an inter-subjective phenomenon that is started with the subject and culminates with the subject.4 The profession starts with the nursing praxis that promotes its relationship with the patients, with the healthcare team, and with the hospital administration. In this sense, most of the interviewees stated not being satisfied with the scant direct relation they have with their patients, or with the professional communication with the treating physician, given the volume of administrative functions they have in the services. In addition to the aforementioned, they perceive tense relationships with institutional directors due to pressure to comply with goals and indicators.

Further, job dissatisfaction generates questions regarding the nurse's reason for being. For some, it may be seen as progress in that nursing professionals dedicate time to management processes at institutions, but the vast majority thinks that direct care is the core of their praxis and the base of the profession's social recognition.

The conclusion of this study is that the participants have mixed perceptions of job satisfaction and dissatisfaction, with the latter prevailing. Nursing must guide its glance at enhancing its autonomous role and its professional identity, with support from institutions in charge of training healthcare human resources. We must seek to retake the leadership lost and rescue the cultural and historical legacy in which nurses are dedicated to caring for human beings and promoting health and life. If this were done, we could, then, speak of job and professional satisfaction.

 

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Receipt date: February 22nd 2011. Approval date:: December 13rd 2011.

Abstract : 259

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