Double working hours in nursing: difficulties faced in the labor market and daily work^a

Abstract

Objective  To understand, through basic lexicography, the most frequent words expressed by nurses on the experience of working double shifts.

Method  A qualitative research study carried out with 30 nurses working double shifts, captured by the snowball technique, between January and March 2019, in the city of Eunápolis, state of Bahia, Brazil. Data was obtained through a semi-structured interview and processed with the aid of the Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires (IRAMUTEQ®) software. From the word cloud, lexical analysis took place.

Result  The most frequent words identified in the corpus were “no” and “we”.

Conclusion and implications for practice  The many “nos” evoked by the participants point out that the experience is marked by negativity, restrictions and suffering, a fact that puts the health of the “we” at risk, that is, of this professional group, their social relationships, and even the quality of the assistance provided to the customer. Understanding this context is essential to produce reflections that contribute to the creation of public policies aimed at valuing and protecting nurses, as well as to reinforce the indispensable need for Nursing to strengthen as a working class.

Keywords:  Nursing; Work Hours; Job Market; Occupational Health; Qualitative research; Software

Resumo

Objetivo  compreender por meio da lexicografia básica os vocabulários mais frequentes expressos por trabalhadores de enfermagem sobre a experiência de ter uma dupla jornada de trabalho.

Método  pesquisa qualitativa, realizada com 30 trabalhadores de enfermagem com dupla jornada de trabalho captados pela técnica snowball, entre janeiro e março de 2019, na cidade de Eunápolis, Bahia, Brasil. Os dados foram obtidos por meio de uma entrevista semiestruturada, processados com o auxílio do software Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires (IRAMUTEQ^®). A partir da nuvem de palavras deu-se a análise lexical.

Resultado  os léxicos mais frequentes identificados no corpus foram “não” e “gente”.

Conclusão e implicações para a prática  os vários “nãos” evocados pelos participantes apontam que a experiência de trabalho é marcada por negatividade, restrições e sofrimento, fato que coloca em risco a saúde dessa “gente”, ou seja, desse coletivo profissional, suas relações sociais e até mesmo a qualidade da assistência prestada ao cliente. A compreensão desse contexto é fundamental para produzir reflexões que contribuam para a construção de políticas públicas voltadas à valorização e proteção dos trabalhadores de enfermagem bem como para reforçar a indispensável necessidade da enfermagem se fortalecer como classe trabalhadora.

Palavras-chave:  Enfermagem; Jornada de Trabalho; Mercado de Trabalho; Saúde do Trabalhador; Pesquisa qualitativa

Resumen

Objetivo  Comprender, a través de la lexicografía básica, los vocabularios más frecuentes expresados por los trabajadores de enfermería sobre la experiencia de tener una doble jornada laboral.

Método  Investigación cualitativa, realizada con 30 trabajadores de enfermería con doble jornada capturada por la técnica de bola de nieve, entre enero y marzo de 2019, en la ciudad de Eunápolis, Bahía, Brasil. Los datos se obtuvieron a través de una entrevista semiestructurada, procesada con la ayuda del software Interface de pour pour Analyzes Multidimensionnelles de Textes et de Questionnaires (IRAMUTEQ®). A partir de la nube de palabras, se realizó el análisis léxico.

Resultado  Los léxicos más frecuentes identificados en el corpus fueron “no” y “personas”.

Conclusión e implicaciones para la práctica  los distintos “no” evocados por los participantes señalan que la experiencia laboral está marcada por la negatividad, las restricciones y el sufrimiento, hecho que pone en riesgo la salud de estas “personas”, es decir, de este grupo professional, su relaciones sociales e incluso la calidad de la asistencia prestada al cliente. Comprender este contexto es fundamental para producir reflexiones que contribuyan a la construcción de políticas públicas orientadas a la valoración y protección de los trabajadores de enfermeira, así como a reforzar la indispensable necesidad de que la enfermería se fortalezca como clase trabajadora.

Palabras-clave:  Enfermería; Horas de Trabajo; Mercado de Trabajo; Salud laboral; investigación cualitativa

INTRODUCTION

The working day is defined as the daily time lapse in which workers make themselves available to the employer and sell their workforce by virtue of a specific employment contract.^1,2 Within the scope of Nursing, due to the low wages that are historically received by the category, it is common for their workers to work double shifts,³ a condition experienced by those who have more than one job, generally, in the expectation of better financial return for the work performed.

This fact, however, characterizes a process of intensification of work and that needs to be rethought, considering that long working hours are associated with the increase of adverse health events and that can culminate in physical, mental, and social illness in the workers and even affect the safety of their patients.⁴

Christophe Dejours, and occupational physician, psychiatrist and psychoanalyst and the greatest representative of the field of Psychodynamics at Work, asserts that work is never neutral with respect to health⁵ and can promote it or lead to illness, hence the importance of understanding how the worker deals with work and how it becomes a determining and conditioning factor in the health/disease process.

Thus, aware that until now there is no legal device that regulates the national working hours in the context of Nursing,⁶ and considering that these professionals are inserted in a capitalist economic system, which is based on political and economic doctrines guided by neoliberalism and make them even more vulnerable to the processes of distress and illness,^7-9 it is fundamental to investigate this issue.

In addition, studies on the perception of the Nursing professionals working a double (professional) shift about their daily work and the job market are scarce, therefore requiring more research to elucidate this phenomenon. In this way, this research offers a brief reflection on this theme and on the job market where the Nursing professionals are inserted. And, by using the IRAMUTEQ^® software, the study contributes to disclosing this possibility of application in the context of qualitative research.

Given the above, this study aimed at understanding through basic lexicography the most frequent words expressed by Nursing professionals on the experience of working double shifts.

METHOD

An exploratory-descriptive study, structured on a research qualitative approach. It was conducted with 30 Nursing professionals working double shifts, who were recruited by means of the snowball sampling technique, in the city of Eunápolis, state of Bahia, Brazil, from January to March 2019. The application of this technique started with two nurses who work in the city of Eunápolis/BA. Subsequently, they indicated new participants for the research, who recommended others and, thus, a “snowball” was created until the researcher obtained enough individuals for the constitution of the sample.

The following were established as inclusion criteria to participate in the study: Nursing professionals (nurses, nursing technicians) working double shifts as a result of having two employment contracts in the field of Nursing in public and/or private institutions in Nursing care and/or managerial activities; in addition to living in the city of Eunápolis/BA or in cities that belong to the same health region.

And the exclusion criterion included Nursing professionals (nurses, nursing technicians) working double shifts for less than a consecutive year. This criterion was based on the belief that the period of one year is minimally necessary for the Nursing professionals working double shifts to become familiar with the routines required to carry out these two shifts in different institutions, consider the advantages and disadvantages of this practice, assess the financial return and the impacts on the work and on their personal life.

Before actual data collection, contact was made with the potential participant over the phone, with a brief explanation of the research and checking availability for a face-to-face meeting. It is also important to comment that there were ten refusals to participate in the research and the alleged reason was unavailability of time due to the extensive workday.

Data was collected through a questionnaire to characterize the participants and semi-structured interviews. The interviews were carried out according to the professionals' availability and outside their workplaces, after signing the Free and Informed Consent Form (FICF). The interviews were recorded with the interviewees' agreement and, after being transcribed, the texts that came out were reviewed regarding spelling, without the essence being changed, and were returned to the participants for reading and approval of the content described. As for the duration of the interviews, it is noteworthy that the shortest occurred in a period of 25 minutes and the longest lasted 90 minutes.

It should be noted that data collection was interrupted upon theoretical and empirical saturation and, therefore, the data produced were satisfactory and already answered the guiding questions and the proposed objective. Thus, from the sixth interview with nurses and the fourteenth interview with nursing technicians, data repetition was observed and it was considered that no new information would emerge; thus, the collection of new data would add little information to the discussion.

The lexical analysis of the data occurred using the Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires (IRAMUTEQ^®) software, version 0.7 alpha 2. IRAMUTEQ^® allows five types of analysis: classic textual statistics; research on specificities of groups; descending hierarchical classification; similarity analysis; and word cloud. For the purposes of this study, the lexical analysis was based on the word cloud.

The following stages were conducted so that the data could be submitted to IRAMUTEQ^®:

1. ¹

   Data organization and preparation, with transcription of the interviews in full, coding and arrangement of data in textual corpus format. Corpus means all material that is intended to be analyzed with the aid of the software; and in the study in question, the set of interviews. In turn, each interview becomes a text. And the text segments are the environments of the words, the main units of textual analysis of this type of software.¹⁰

2. ²

   Reading of all data to obtain the general perception of the ideas expressed by the interviewees.

3. ³

   Data processing using the IRAMUTEQ^® software, using the Word Cloud option.

The word cloud is a simple lexical analysis but graphically interesting since, based on the cloud, words are grouped and organized according to their frequency in the textual corpus. Thus, after the processing stage performed in the software, the analysis and interpretation of the meaning of words in the participants' testimonies took place; and when retrieving the text segments where such words appeared, the most frequent lexicon started to make sense in the context of the discussion and, thus, it was possible for the researcher to interpret the data, comparing the findings with the scientific literature that deals with the Nursing labor market and the precarization process of the Nursing work.

In the presentation of the results, to maintain the anonymity of the participants, at the end of the text segments (TS) the coding “T” for nursing technicians or “E” for nurses (“enfermeiros” in Portuguese) was used to represent them, followed by an Arabic number which indicates the chronological sequence of the interlocution performed.

The study was submitted to Plataforma Brasil and was approved by the Research Ethics Committee of the Anna Nery Nursing School under CAAE 03857318.9.0000.5238 and opinion No. 3,085,492 on December 14^th, 2018. The study observed the ethical precepts of voluntary, informed and consented participation in such a way that the recruited participants were protected by signing the Free and Informed Consent Form, respecting their autonomy, dignity and anonymity as determined by Resolution No. 466/2012 of the National Commission on Research Ethics of the National Health Council.

RESULTS

The results are presented in two sections: characterization of the participating professionals and lexical analysis, by means of the word cloud.

As for the characterization of the participants, of the 30 professionals interviewed, ten were nurses and 20 were nursing technicians. Most of the participants were female: 23 individuals (76.7%). The participants' age varied from 26 to 67 years old, with a mean of 38. Regarding self-declared skin color/race, according to the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística, IBGE) nomenclature, the majority (22 interviewees – 73.3%) considered themselves black- or brown-skinned.

All the participants had two employment contracts in Nursing (17 had passed the public sector recruitment examination in the city in at least one the jobs, 11 had both jobs through temporary contracts, and two had contracts for an indefinite time). When considering the length of service in the Nursing field, 23 participants (76.7%) worked in the field for more than 5 years and 20 (66.7%) also worked double shifts for an equivalent period. The net income declared by the research participants, when considering the sum of the wages received as a result of both of their jobs, indicates that 17 nursing technicians working double shifts, that is, 85% of the participants in this category, earn between two and four minimum wages and eight nurses (80% of the interviewees) earn between four and ten minimum wages.

Through the word cloud method, it was possible to identify that the word “no” was the most frequent in the corpus, being evoked 1,610 times. Next, the word “we” was identified with 743 evocations. Figure 1, which presents the word cloud displayed by IRAMUTEQ^®, places words at random, so that the most frequent words appear larger than the others to emphasize their prominence in the corpus. That is the case of words “no” and “we”, which are highlighted in the center of the image.

Figure 1
Word Cloud

Upon retrieving the text segments where the word “no” appears, it is evident that the discussions on double shifts refer to two dimensions that are explained below.

The first dimension indicates the reasons reported by these workers that make them adopt a double workday. These reasons establish a relationship with the Nursing labor market. There are reports about the devaluation of the category, low wages, the absence of a decent minimum wage, and the fragility of the employment contracts as factors that contribute to the perpetuation of working double shifts among the professionals in the category, who: “wouldn't be in two jobs, if they had a decent salary”, “don't quit one job for fear of losing the other”, “don't feel recognized and valued in the profession”, “don't want to keep two jobs for a long time”, “can't stop for now”, “don't want to pursue the Nursing career”.

If we had a minimum wage and were valued as professionals,wewouldn’t be working double shifts (E10)

I tried once to quit one of the jobs, but Ididn'tleave because of fear, because wedon'tknow when we might lose the other, we're at their mercy, if we quit one and lose the other, what will we do if we end up with nothing? We feel threatened all the time (T7)

I always think about quitting, but Ican't. Ican'thave just one job, Ican’tprovide for me and my family (T11)

I want to study. Nursing,no! Because it's not really valued, it pays little, so I prefernotto go to that field because I know that if I go, to have a better condition, I will end up having two jobs again. So, I would continue in the same way (T2)

The second refers to the repercussions of double shifts, indicating the negative aspects to the physical, mental and social health of the professionals, who: “don't sleep well”, “don't eat well”, “don't do physical activities”, “don't have time”, “don't have a social life”, “don't have a healthy lifestyle”, and “don't want to show weakness”.

My family says that Iwon'tmake it, after all sometimes wedon'tsleep, we eat unhealthy foods, wedon'thave time to do physical activities. But, I'm strong! (T1)

Some co-workers started with a double shift andcouldn’thandle it, they said they were tired; othersdon'teven consider because they say theycan'tdo it (E1)

Idon'thave time to do the things I like, to be with the people I like, I think we stop our lives in a way (T20)

Wedon'thave time, wedon'thave a social life, we're always tired and this fatigue causes irritability, psychological problems, Idon'tsee the advantage (T14)

I trynotto show, but double shifts affect me directly, I get tired, it wears me out (E2)

Most people I know who have two jobsdon’tlive healthy and those who live healthy make big efforts to go to the doctor, for example, only if it is an urgent issue because in their daily life,no,theydon't go (T4)

Regarding the word “we”, it means collectivity (Nursing professionals), who share the “difficulties” that result from working double shifts, for example:

Westart hearing from co-workers: it's difficult; it's hard; I can't do it anymore; there comes a time whenwecrash, then we will have to stop anyway (E1)

Ourincome is very low. That is whyweneed to have two jobs, there is no way to have just one.Weearn little money,wework a lot and dedicate a lot, so should the money be so little? Forusto survive only on Nursing, we need to have two jobs (T8)

Wehave limits, especially those who work night shifts, becausewewho do night shifts are very different (E2)

DISCUSSION

The profile analysis of the professionals participating in the research with respect to sex, gender and self-declared skin color/race corroborates what was identified in other surveys and is related to the historical trajectory of the profession: predominantly female and self-declared as black- or brown-skinned with respect to skin color/race.¹¹

As they are relatively young professionals, their insertion takes places in a context marked by the deregulation of employment relationships and job insecurity, since there is, more and more, an army of professionals eager to enter the labor market due to lack of jobs, even if they are unworthy. IN this way, although this job requires a high weekly workload, with extremely low wages, under precarious conditions, it is still better than being unemployed.^11-13

It is possible to note that the Nursing professionals did not choose to work double shifts for pleasure, but rather feel forced to do it, given the low wages they earn, the devaluation of the professional category and the precarious and temporary employment contracts. This context of precarious work meets the needs of capitalism and reflects the influence of the neoliberal model on the Nursing work process.^3,4,7-9

Precarization of work is a process resulting from the evolution of modern capitalism, which, in the face of the new technological and economic requirements, is characterized by the destabilization of stable workers, installation of precariousness of different workers, and increase in unemployment, in addition to lack of protection for workers and low remuneration.^13-14

It is also necessary to consider that the uncertainty as to whether they will keep their work; the current unemployment situation, especially among nurses; the informal and unstable employment contracts, which lead workers to remain in more than one job to guarantee their material subsistence and a more economically stable future, reinforce the psychophysical wear out and distress of the workers, thus having even greater potential for illness in the professional group.⁸

Unfortunately, this context of disenchantment with market opportunities and with the world of work, which is perverse and excluding, can culminate in evasion of professionals in their field of activity, which is very negative and affects the subjectivity of workers as they made all their efforts in favor of Nursing, but they do not obtain the material and symbolic retribution expected.^15,16

Without material retribution, which comes from wages and bonuses, and without symbolic retribution, recognition and pleasure at work can be transformed into suffering, to the extent that the dynamics of self-realization in the context of work is not established.⁵

In addition, it is necessary to consider that, in this context, where devaluation and lack of recognition of the professionals prevails, their work performance can be negatively affected. Because, if the processes of recognition and appreciation are mobilizing sources, capable of increasing the commitment and satisfaction of the worker with the service, even capable of providing better quality of care, the opposite can generate negative impacts.¹⁷

Working double shifts reduces the worker's free time, which can affect their personal, family and social life. This situation tends to be worse among women. After all, the conception that female individuals are protagonists of domestic work, home/family care and child rearing is still very present in contemporary Western society, even though some men have been changing their attitude and taking a proactive and participatory position in family life and day-to-day activities.¹⁸

Lack of time and overload of domestic and professional duties are the most common factors causing health neglect and restraining the adoption of preventive and health promotion behaviors, especially sedentary lifestyle, poor diet, insufficient sleep/rest pattern, and no medical examinations, with negative consequences for health and well-being.⁴

The change in the sleep pattern can produce distraction, automatic behavior, involuntary lapses of sleep and amnesia and, thus, Nursing professionals can compromise the care provided to the patients under their responsibility.¹⁹ This situation demonstrates that the workload of these professionals is one of the factors that can compromise patient safety because, even considering the professionals' surveillance and concern with the care provided, the risks resulting from human error can overlap.

Added to this situation is the fact that the Nursing professionals working double shifts, despite feeling physically tired and experiencing other repercussions of this practice on health, deny suffering, neglect the signals of their tired body, and adopt a posture of resilience, even showing presenteeism.

Presenteeism is characterized by the physical presence of the professional in the work environment under inoperative biological and psychological conditions for the effective exercise of their activity.²⁰ It is an emerging and disturbing problem because, in addition to decreasing productivity, is difficult to be detected. Thus, if the workers' health problems are not detected early, they can become chronic and disabling, which interferes with their quality of life.²¹

This behavior among the Nursing professionals working double shifts can be related to empathy, cordiality, solidarity and identification among the professionals, indicating that they know they belong to the same group, “we”, who suffer as a result of work and the precariousness of the Nursing work.

However, it must be considered that presenteeism negatively affects the work environment, and this situation is not always perceived by professionals, managers and the work team but interferes with the worker's well-being and quality of life, as well as disqualifying assistance.^20,21

Thus, there is a need for changes in the Nursing work contexts and with regard to the practice of working double shifts due to its potential to cause illness in the professionals and, consequently, harm the assistance provided. It is necessary that this category breaks free from the bonds of the past²² that made it subservient and resigned and that it assumes the role of owner of its destiny, risking to see such a noble profession degraded, a field that makes a difference in the life of those who are born, develop, reproduce and die.

CONCLUSION AND IMPLICATIONS FOR THE PRACTICE

The study made it possible to learn, through basic lexicography, the most frequent words in the report of the daily work of Nursing professionals working double shifts. The word no was the most frequent, highlighting the negativity, restrictions and suffering experienced by the participants due to their work dynamics. This fact puts the health and subjectivity of this collective of workers at risk, as well as their social relationships and quality of care.

And, since the Nursing work is so essential to the health services and the population, it is fundamental, indispensable and urgent to rethink the practice of working double shifts, so that these professionals can re-elaborate their relationship with work and, through a positive relationship, expand their experiences of pleasure at work. In addition, it is also important that these we (Nursing professionals) can recognize and strengthen themselves as a working class and, thus, contribute to the creation of public policies aimed at valuing and protecting the Nursing professionals.

As a limitation of this study, the fact that it discusses only the main words reported by the Nursing professionals working double shifts and that the word cloud allows for a simple lexical analysis is to be mentioned. However, it is emphasized that this type of analysis can be complemented by means of the other resources available in IRAMUTEQ^®, that is, data can be analyzed, for example, through multivariate analyses, thus suggesting its development in order to confirm the results herein presented and to expand the discussions on the theme. The replication of this study in other contexts is also important in order to validate the findings.

It should be noted that the IRAMUTEQ^® software proved to be an important tool for carrying out this study. And, considering that there are still few articles in Brazil that use this software and the analysis method produced by the word cloud, this study contributes by disclosing this possibility of analyzing qualitative data.

• FINANCIAL SUPPORT
  This work was carried out with the support of the Coordination for the Improvement of Higher Level Personnel (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior, CAPES) – Brazil – Funding Code 001, master's scholarship granted to Samira Silva Santos Soares (process No. 88887.200750/2018-00).
• a
  Extracted from the master's thesis entitled “Double Workday: Repercussion for the health of the Nursing Worker”, authored by Samira Silva Santos Soares, with the guidance of Marcia Tereza Luz Lisboa, presented in 2020 to the Graduate Program in Nursing, of the Anna Nery Nursing School.

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Edited by

• ASSOCIATED EDITOR
  Aline Aparecida Monroe

Publication Dates

• Publication in this collection
  08 Feb 2021
• Date of issue
  2021

History

• Received
  09 Oct 2020
• Accepted
  23 Dec 2020