Introduction

In the world of work, constant changes force workers to make a greater effort to get used to new circumstances. Work is a way for human beings to feel satisfaction when they see themselves useful within society and experience the pleasure of personal fulfillment, as well as being an important influencer in maintaining relationships. However, the presence of stress in a context that demands greater dedication and professional adaptation contributes to a deterioration in workers’ health, leads to a reduction in quality of life and interferes with work performance.(¹,²)

Work-related stress can be understood as a negative subjective and psychological experience with physiological repercussions caused by work-related stimuli.(¹-³) It is addressed in many studies because it negatively affects professional health, job satisfaction, productivity and quality of care, and can lead to risks for patient safety.(⁴,⁵) Job satisfaction is considered one of the indicators of quality of life and its measurement has been used in studies in Brazil and abroad.(¹)

The causes of stress in the operating room environment lead to tensions and an unfavorable organizational climate, affecting communication and patient safety, as well as work-related quality of life.(¹,⁶) Overload, worn-out or dysfunctional interpersonal relationships, a surgeon-centered model and the invisibility of nursing all contribute to the fact that Surgical Center (SC) nursing workers, although they find satisfaction in the area, also experience suffering, contributing to stress, culminating in exhaustion, psychological and physical repercussions and lack of motivation to work.(⁶-⁷) It is important to consider how variables such as the age and gender of the professional, time in the same job, work shift (day or night) and weekly workload can influence the perception of stress or have repercussions on job satisfaction.

The performance of nursing activities in the operating room has a direct impact on the sector’s productive capacity and there is a major challenge in balancing the demands and demands on the profession with the physical strain, mental health and quality of life of these professionals. Job satisfaction and work stress for operating room nurses has been studied over the years in national and international research, however, the motivation variable is generally not considered.(¹,³,⁷) In other studies, the question of motivation is assessed indirectly by evaluating the intention to leave the job.(³) Considering the motivation variable is a direct look at a factor that can be important and even decisive in dealing with stress in the operating room.

The aim of this study was to assess the job stress, job satisfaction and job motivation of operating room nurses in Brazil.

Methods

This was an open survey observational study guided by the CHERRIES (Checklist for Reporting Results of Internet E-Surveys) tool.(⁸) Data collection took place between August and December 2023, with the support of the Brazilian Association of Surgical Center, Anesthetic Recovery and Material and Sterilization Center Nurses - SOBECC. The research project was registered on the OSF platform (https://osf.io/t8a4v/).

A pilot study was carried out with nurses and nursing technicians from the Surgical Blocks unit of a large university hospital in the Northeast of Brazil. With the results of the pilot, the collection instrument was validated with good usability and functionality for the national survey, presenting no significant difficulties that would motivate major corrections or hinder collection.

There was non-probabilistic sampling for convenience.(⁸) The main sources of respondents for the survey were nurses and technicians associated with SOBECC or registered in the association’s database, and professionals invited via a public call on social networks and mobile messaging applications. Initially, the idea was to carry out a closed survey only among SOBECC members; however, considering the low proportion of technicians among members and the possibility of expanding the expected sample, it was decided to carry out an open survey in order to expand the number of respondents. It wasn’t possible to advertise on banners on the institution’s website, only the e-mail list was used.

Nurses, technicians and assistants with at least six months’ experience in operating rooms were included. Incomplete answers or retired professionals were excluded.

After approval by the Research Ethics Committee, an e-mail was sent to SOBECC for access to the membership register and continuation of the research. SOBECC has a system for conducting research among its members. The association has approximately 500 professionals associated with it. Of these, around 70% are operating room professionals. Considering a return rate of 30%, the estimated sample for this source was 100 respondents. The sample was made up of respondents who spontaneously returned our invitation via social networks and mobile messaging applications.

Artwork was created for dissemination on social networks and at events in the field of perioperative nursing. These invitations remained publicized during the collection period. Data was collected digitally using the online platform Research Electronic Data Capture - REDCAp.

Participants were invited to take part in the research by sending invitations by e-mail, by cell phone messages via Whatsapp and by public invitations on social networks. The e-mail invitations were repeated only once after 30 days, and the absence of responses 30 days after the second attempt was considered to have excluded them from the survey. For participants who agreed to take part, when they clicked on the link sent to them, the form initially opened with an invitation explaining the research, objectives and methods and asking them to agree to take part, requiring them to sign the Informed Consent Form. The form then continued with the collection instrument itself. The REDCAp platform stored the data collected.

The same collection instrument was used as in the pilot test. The form consisted of an initial part with the participant’s identification, the Work Stress Scale (WSS), the Work Satisfaction Scale (WSS) and the Work Motivation and Organizational Commitment questionnaire.(⁹-¹⁴) The items on the scales were presented to each participant randomly, with randomization of the items (changing the order of presentation) proposed automatically by the platform, in order to reduce filling bias.

The form’s link allowed completion via cell phone or computer and respondents were only allowed to fill in one item for each registered e-mail address. The form had five screens, the first for the Informed Consent Form, the second for sociodemographic data and the following three for the validated instruments. The screen for professional characterization questions allowed you to move forward with items that had not been filled in; however, the instrument screens only allowed you to complete the form once all the items had been filled in. At the end, you were given the option of reviewing your answers and receiving them by e-mail.

After analyzing the responses, 42 forms were excluded because they were incomplete and there were no exclusions because professionals did not meet the criteria. The recruitment or participation rate was 73.62%, with 427 forms answered out of a total of 580 visits to the link. There was no time limit for responses after consent to participate was given on the first screen.

The Work Stress Scale, in the version used with 23 items, presents the average scores considered to be low levels of occupational stress with values from 1 to 2, medium occupational stress with values from 2.01 to 2.99 and high occupational stress with values from 2.01 to 2.99 and high occupational stress values of 3 to 5.(¹⁰,¹³)

The Job Satisfaction Scale scores each item between 1 and 7 points, and the average score for each factor is obtained by adding up the values indicated by the respondents and dividing the result by the number of items. Thus, the score for each factor can vary from 1 to 7, with values between 1 and 3.9 indicating dissatisfaction with the dimension in question, values between 4 and 4.9 indicating indifference and values between 5 and 7 indicating satisfaction.(¹⁰-²⁰)

The Work Motivation Scale ranges from 30 to 210 points, in a positive direction. Each domain of this scale ranges from 15 to 105 points or can be presented as the average of the items, ranging from 1 to 7 points.(⁹) The Motivation domains comprise the motivational index (achievement, recognition, responsibility and progress - factors relating to the content of the job and the rewards for professional performance) and the hygienic index (relating to salary, working conditions and the institution’s policy).(⁹)

The data collected was analyzed using the Statistical Package for the Social Science (SPSS) version 20.0 for Windows. The normal distribution of the variables was confirmed by the QQ matrix and the Kolmogorov-Smirnov test. Student’s t-test was used to assess occupational stress, motivation and satisfaction if the variables adhered to normal distribution and Pearson’s correlation coefficient if they did not. A significance level of 5% and a 95% confidence interval were adopted for all tests.

The research follows the normative precepts of Resolution 466/12 of the National Health Council. Data collection for the pilot test only began after it had been assessed and approved by the Human Research Ethics Committee of the Hospital das Clínicas of the Federal University of Pernambuco (Opinion 5.739.463/ Certificate of Submission for Ethical Assessment: 63462222.2.0000.8807). Considering that the research took place in a virtual environment, the research protocol was drawn up in accordance with the guidelines of the National Research Ethics Commission - CONEP for procedures in research with any stage in a virtual environment (SEI Process No. 25000.026908/2021-15 of February 24, 2021).

Results

There were a total of 385 responses, between SOBECC members and spontaneous demand. Of these, 160 professionals (41.6%) were nursing technicians or assistants and 225 (58.4%) were nurses. Among nurses, 164 (72.9%) claimed to be in care positions and 61 in management positions (27.1%), such as supervisors, coordinators or bosses. In total, most professionals were female (327; 84.9%), with a partner (married or in a stable relationship) (224; 58.2%). Age varied between 19 and 69 years, with an average of 42.4±8.7 years. The sample had between 1 and 43 years of training, with an average of 17.5±8.3 years. The majority had the lato sensu specialization as their highest degree (201; 52.2%) and 81 (21.1%) had stricto sensu titles (master’s or doctorate). Among the specialties, 69 (34.3%) stated that they had training in perioperative, surgical or operating room/surgical center nursing. Regarding the work shift, only 79 (20.4%) of the respondents worked the night shift. 197 (50.9%) participants stated that they only had one job, with an average weekly workload of 34.4±7.6 hours. Regarding the type of institution in which they worked, 295 (79.6%) stated that they only had public ties, 77 (20.0%) stated that they also worked in private institutions and 16 (4.2%) in philanthropic institutions. The respondents mostly lived and worked in the Northeast region of the country (223; 57.9%), followed by the Southeast (102; 26.5%), South (35; 9.1%), Central-West (15; 3.9%) and North (10; 2.6%). Stress was considered moderate for both technicians and nurses. In the total sample, total satisfaction had a mean of 4.4±1.0 (indifferent satisfaction). Motivation had hygienic index averages (4.7±1.2) slightly lower than the motivational index (4.9±1.2) and work-related stress was 2.4±0.7 (considered average). Among technicians and nurses, only satisfaction with promotions had significantly higher results among nurses (p=0.04). Table 1 presents the comparison of these results depending on the professional category (Table 1).

Table 2 shows that the perception of work-related stress was slightly higher among respondents with two jobs (p=0.02), while there was no significant difference in the overall satisfaction (p=0.57) and work motivation (p=0.09) scores.

Table 3 shows the comparison between types of employment, showing that no significant difference was identified between professionals in public and private or philanthropic services.

Table 4 shows the distribution of stress levels according to a number of variables, with a significant result of greater moderate to high stress among day shift workers (p=0.01) and no difference by gender or age group. Overall, 72.98% of those interviewed had moderate to high work stress scores (Table 4).

Discussion

The research achieved its objective by understanding the status of stress, satisfaction and motivation of operating room nursing professionals in the country. The diversity of regions and employment relationships may reflect different salary ranges and working conditions and perhaps, with a larger sample, these variations could be tested and their repercussions on the variables estimated with greater certainty. It is believed that a publicity campaign to increase the number of respondents would perhaps provide even better evidence of other relationships with greater statistical significance. One of the limitations was the time frame for the survey, which made it difficult to disseminate it beyond SOBECC members.

Still on the subject of the study’s limitations, it was not checked whether the average salary made a difference between the types of employment relationship to allow greater inferences to be made about the results. Considering that there is still no fully implemented salary floor for the category, regional differences and differences between jobs may have repercussions on the satisfaction and motivation of professionals.

Looking from the perspective of health service management, little has been studied about aspects related to the mental health of nursing professionals in the operating room that can have an impact on their performance and directly or indirectly on patient safety, although in the last two decades important emphasis has been placed on burnout among health professionals in general.(⁵,¹⁴-¹⁷)

The proportion of professionals with moderate to high stress was high. Although in other areas stress may be higher during the night, for the operating room, as elective surgeries are carried out during the day shift, the demand to reconcile productivity in elective surgeries with urgencies and emergencies for some services may explain the higher stress among those who work during the day. Studies of perioperative nurses show that up to 70.3% of them experience a constant state of stress mediated by emotional exhaustion.(²)

For operating room nursing professionals, the operating room is a place of high demands of responsibility, with many tasks, handling of technologies, where long hours are spent in tension between surgeries, requiring high concentration.(²,¹⁴,¹⁹) In the operating room, professionals have direct contact with blood and body fluids, sharps, surgical smoke, volatile anesthetics and radiation, which requires even more attention to ensure not only patient safety but also their own.(²,¹⁴,¹⁹)

Stress has a multifactorial genesis and can arise from work overload, high demands with few resources, training or benefits, lack of organizational support and conflicts with colleagues and professionals from other categories, making the job unattractive.(²,¹⁴,¹⁹,²⁰)

Satisfaction was rated at the indifference level and close to the lower limit to be considered satisfied. This indicator goes beyond the sum of the scale’s domains, representing the totalization of the pleasurable experience related to work, despite the factors that could diminish satisfaction.(¹⁰-²⁰)

There was no significant difference between the stress levels of nurses and technicians. Although there was no qualitative approach to understanding the genesis of stress in each category, it is known that other authors also point to similar levels between them, even if the causes are different.(²⁰) The causes of stress in the operating room environment lead to tensions and an unfavorable organizational climate, affecting communication and patient safety, as well as work-related quality of life.(²,³,⁵-⁶,¹⁷) Overload, frayed or dysfunctional interpersonal relationships, a surgeon-centered model and the invisibility of nursing all contribute to the fact that SC nursing workers, while finding satisfaction in the area, also experience suffering, which can contribute to occupational stress, culminating in exhaustion, psychological and physical repercussions.(⁶,⁷,²¹-²²)

Still on the subject of stress, the perception of this variable in the sample may be influenced by the correct sizing of staff. In this study, due to the design adopted, it was not possible to consider this variable, however, there are studies that indicate that better sizing favors the presence of the nurse at the patient’s side and the presence of the nurse in the operating room improves adherence to protocols, increases patient safety, reduces the overload of the room circulator, improves the interpersonal relationship of the team and increases the professional recognition of the nurse.(²³-²⁵)

The sample was largely made up of civil servants who do not find it easy to change jobs in search of better salary recognition and who depend on pay rises and promotions to increase their remuneration and improve their satisfaction with their salary.(²⁶,²⁷)

Another study found that emotional exhaustion was inversely related to perceived satisfaction and the desire to change jobs.(³) Other authors point out that job satisfaction and teamwork have a direct influence on the performance of nursing activities in the operating room.(³,²²)

The higher perception of stress among professionals with two jobs is directly related to the increase in weekly working hours and work overload. International studies have identified that among the most frequent stress factors for operating room nurses, work overload was the most frequent stressor, which is different from the findings presented here.(¹⁴,²⁹) Overload is often the result of management for results that creates demands without taking people into account, resulting in exhausting and mechanized processes.(¹⁷,³⁰) Process management for the operating room focused on patient safety can streamline flows by putting nurses in the lead, resulting in greater productivity and job satisfaction.(³⁰) However, current management models focusing on results fall on the shoulders of nurses in the form of demands for agility, time reduction, room turnover and other indicators.

With regard to the excessive workload, the overload had a negative impact on job satisfaction and increased the desire to leave the job.(²⁰) The perception of work stress for professionals with two or more jobs corroborates the national movement in defense of reducing the working hours of nursing professionals to 30 hours a week.

Conclusion

The high proportion of professionals with moderate and high stress deserves to be highlighted among the research findings. There was no difference between the variables for technicians and nurses, nor in terms of the type of employment. Having two or more jobs and working daytime hours is associated with a higher perception of work-related stress.

Acknowledgements

To the Brazilian Association of Surgical Center, CME and Anesthetic Recovery Nurses - SOBECC. To NASCECEM.

References

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Publication Dates

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