Nurses' perceptions about the influence of the labor environment in the use of psychoactive substances.

Background
The work environment of nurses is characterized by physical and mental hazards liable to cause exhaustion and lead them to take psychoactive substances as coping strategy.


Objective
To investigate nurses' perception of the work environment influence on psychoactive substance intake.


Methods
Exploratory, descriptive and qualitative study with 14 nurses in two public hospitals. Data were collected through semi-structured interviews and subjected to content analysis.


Results
Staff and material shortages, submission, lack of autonomy, conflict in interpersonal relationships and power struggles were the main reasons for nurses to take psychoactive substances.


Conclusion
Nurses are exposed to stressors in the workplace, including understaffing, power struggles, interpersonal conflict and lack of autonomy, which may lead them to take legal or illegal drugs.


INTRODUCTION
Hospitals provide care all along the entire lifecycle of people, i.e. from birth to death. Within this context nurses play a crucial role inasmuch as they continuously intermediate between staff and patients and their relatives 24 hours a day 1 . However, hospital nurses are exposed to countless risk factors, such as long working hours, staff and material shortages, work overload, too large numbers of patients, low autonomy, and body fluids and secretions 2 , which may contribute to the occurrence of physical or mental disorders among this population of workers. In addition, the working conditions of nurses include exposure to pain, suffering, death, occupational stress, lack of recognition, shift work, accelerated pace of work, low salary or unequal pay, indefinite roles and fragmentary tasks, while interpersonal relationships with other staff members may be conflicting 3,4 . All these factors may have negative influence on the mental health of nurses and eventually lead them to take psychoactive substances.
According to some authors 5 , the more negative the work environment, the higher the odds of job dissatisfaction, and consequently also of psychoactive substance intake as coping strategy.
The prevalence of psychoactive substance use or abuse among nurses is similar to that of the general population. This behavior represents a global challenge that requires prevention measures, early detection, support and rehabilitation to overcome it 6 . In a study, 44.6% of nursing professionals, mainly male, reported binge drinking, 16.2% exhibited symptoms of depression, 15.2% of stress and 23.2% of anxiety 7 .
The aim of the present study was to investigate the self-perception of nurses about the work environment influence on psychoactive substance use. For this purpose, the research question was formulated as: what is the nurses' perception of the work environment influence on psychoactive substance use?
Achieving sustainable development is one of the goals of the World Health Organization 2030 Agenda, which demands protecting workers and promoting safe workplaces 8 . Therefore the present study contributes to joint efforts of managers and employees to promote a healthier environment at hospitals to meet the goals of high-quality, equity, freedom and safety for all workers.

METHODS
The present qualitative study was performed at two public medium-complexity hospitals in a city in the interior of the state of Paraná, Brazil. Participants were nurses who provided direct patient care or were supervisors in adult clinical and surgical departments.
We included a total of 94 nurses, 47 from hospital A and 47 from hospital B. These hospitals are very similar: nurses work 12-hour shifts followed by 36 hours off duty, only patients cared within the national health system are admitted, and both are municipal referral hospitals for medium-complexity patients.
Participants were recruited by means of intentional sampling. The principal investigator invited eligible subjects to participate, at which time they received information on the study aims and procedures and were inquired as to whether they had ever taken any psychoactive substance. Those who answered affirmatively were selected; additional inclusion criteria were: working in direct patient care or as supervisor for one year at least at the current hospital and not being on vacation, sick or any other type of leave.
Interviews were performed according to the participants' availability in secluded rooms at both hospitals. This stage of the study ended when the saturation point was reached, i.e. when narratives became repetitive, to avoid redundancy in information 9 . As a result, the sample comprised seven nurses from each hospital to a total of 14.
Data collection took place from October 2015 through April 2016 by means of semi-structured interviews which lasted 30 minutes, on average, were taped and fully transcribed. The point of departure was the question: what do you think about the workplace influence on psychoactive substance use by nurses?
The resulting narratives were subjected to content analysis, which comprises the following steps: We began by a non-focused, thorough reading of transcripts to understand what the interviewees sought to convey. We then looked for meaning units in the narratives, i.e. semantically similar elements, as basis for categorization and further analysis 10 . The result was one single category: factors which led the participants to take psychoactive substances. To safeguard their anonymity, the participants are represented by letter I (interviewee) followed by a random number from 1 to 14.
The present study complies with national and international standards for research involving human beings and had ethical clearance, Certificate of Presentation for Ethical Appraisal no. 49062415.5.0000.5231. All the participants signed an informed consent form.

RESULTS
About 57.1% (n=8) of the participants were female, 64.3% (n=9) married, aged 38.4 on average (range: 28 to 56), earned an average monthly salary of BRL 4,699.79 (USD 1,206.42) and 64.3% (n=9) reported to practice physical activity. About 78.6% (n=11) of the sample had one single job, 64.3% (n=9) provided direct patient care and 64.3% (n=9) were allocated to the night shift. The participants had worked 5.3 years in the current job, on average (range: 3 to 11).
Analysis of narratives led to one single category, to wit, factors which motivated the participants to use psychoactive substances.
In the participants' view, staff and material shortages increase their workload, which causes exhaustion and leads them to take psychoactive substances, as shown in the following excerpts: Staff shortage, both in number and quality, increases our workload and indeed contributes to taking legal or illegal drugs. (I10) Staff shortage is the main factor that interferes with the work process and causes work overload, stress and dissatisfaction, which therefore become factors likely to favor the use of legal or illegal drugs. (I12) The narratives also revealed conflict in interpersonal relationships as direct or indirect reason to take psychoactive substances: There's much conflict in the interpersonal relationships between the nursing staff and other professionals. In my opinion, this is one of the factors that cause a desire to take psychoactive drugs and make me take them. (I1) This place is extremely tense, there's much conflict in the interpersonal relationships between the nursing staff and other professionals, which leads us to take psychoactive drugs. (I3) Very difficult relationships among all the professionals, which in the end cause a wish for legal, and even illegal drugs. (I13) Submission and poor or no autonomy were described as aggravating factors, since they demotivate nurses and thus contribute to make them take psychoactive substances: Lack of autonomy in almost everything makes me feel exhausted. I get so down that I need to take hold of myself not to take too much tranquilizers, but I admit I take them. (I2) The nurses' submission to doctors, which comes from the time of Florence Nightingale, 'we are to serve' this people who treat us badly, and worse, have to swallow back our tears and keep on working. Then we need drugs to stay calm and not 'explode' . (I3) Nothing worst at work than the nurses' submission to doctors. (I9) Tremendous exhaustion and distress, because of our submission to doctors, and even also to other professionals, in my opinion are more than fair reasons to take drugs. (I12) Lack of cooperation and cronyism emerged as a cause of stress and a reason to take psychoactive drugs: In my opinion, lack of cooperation, help and team spirit are things sometimes I have to deal with, I need to take something to overcome them; I've done it in the past and I do it also now. (I2) When there's no team spirit, or colleagues or other professionals don't cooperate, I get to think: I need to take something to calm down and cope with this. (I6) Power relations in the workplace were also evidenced as influencing the participants' feelings and as a reason to take psychoactive substances: The struggle for power upsets me too much, and at times I even need to take a pill to control myself and do my work. (I4) The struggle for power is a cause of too much stress, and I find myself thinking about taking some pill to overcome my anger and keep moving on. Actually, I do take them. (I11)

DISCUSSION
The participants' narratives evidenced that staff and material shortages are factors which contribute to psychoactive substance intake. Such shortages are ubiquitous in Brazilian health services because the government does not invest in infrastructure and human and material resources as is needed. This situation makes health care providers vulnerable to occupational diseases 11,12 . In addition, Brazilian civil servants are not given their due value, as shown by salary delays, lack of career plans and of permanent education policies 10 . These workers are demanded high-quality work by the health system users, while lack of management and governability of intrinsic problems -such as staff and material shortages and user dissatisfaction -increase the pressure on them 12 .
"Hospital Nursing Staff Sizing: A Study Based on Official Brazilian Parameters, 2004 -2017" evidenced that when staff or materials are below the minimum necessary to ensure adequate care delivery, workers become prone to exhaustion and illness, and patients more exposed to adverse events, including death 13 .
Nurses with high levels of stress derived from work overload exhibit high odds of developing high-risk behaviors, such as smoking, overeating, drinking or taking other psychoactive substances 14 . Unfavorable working conditions in health services have negative impact on the physical and mental health of care providers and their patients.
According to the participants' narratives, conflict in relationships, lack of autonomy and power struggles were reasons which lead them to take psychoactive substances. As the literature shows, workplaces with negative traits -such as understaffing, conflict in interpersonal relationships, lack of autonomy and power struggles -lead to job dissatisfaction 15 and contribute to cause mental disorders, with consequent impact on care delivery and patient safety 14 .
Conflict within the nursing work process may derive from inefficient communication, excessive stress or differences in priorities among staff members 16 . All these aspects have direct influence on care delivery and job satisfaction, which may be reasons for nurses to take legal or illegal psychoactive substances as coping strategy.
Our findings point to the relevance of management investment in actions to improve interactions among multiprofessional staffs members, since good relationships promote greater engagement with tasks and consequently more proactivity, reduction of absenteeism and presenteeism and high-quality care delivery 17 .
The reported feelings of submission to other professionals might derive from the historical and cultural development of the nursing profession, traditionally characterized by silence, charity and submission, which effects have reached the present time. The hegemonic role of and high value given to physicians at the expense of nurses weaken the latter's image and influence their sense of recognition and self-accomplishment 18 .
This stereotype should be broken to advance to true multiprofessional action, in which each category has specific roles and attributions. Nurses should be recognized as indispensable for the care of patients and as the single group that provides integrated care to people from birth to death. Nurses should be duly valued and motivated and be granted enough autonomy in their job 19 . Autonomy ensures the right to control and perform one's own tasks 20 in a responsible and safe manner in regard to all involved actors (patients, their families, health care staff, among others). The responsibility of nurses requires them to apply their skills to practice and managing teams according to the technical-scientific knowledge they learn during their early training and further competencies acquired later on 21 . However, the organization of hospital nursing work is still largely grounded on Taylorism and Fordism, i.e. on a hierarchical division and fragmentation of labor, in which the emphasis falls on protocols and standards, on doing over thinking. This situation, together with the biomedical paradigm in force, results in greater power and autonomy for the physicians 22 , while nurses have to permanently struggle for a space of their own, power and autonomy. These factors lead to mental disorders and inadequate coping strategies, such as taking legal or illegal drugs.
We observe that by its intrinsic characteristics, nursing work causes physical and mental exhaustion, which is one further reason for this population of workers to have resource to psychoactive substances -often without medical supervision -to improve their frame of mind. However, this behavior interferes with their performance, tasks and quality of life 23 . A study found that 75% of nurses took some psychoactive substance, while only 30% reported regular intake under medical supervision. Reasons adduced were stress, tiredness, work overload and lack of solidarity or team spirit 24 . Another study with hospital nurses found association between smoking, drinking and taking sedatives and occupational factors, mainly the physician-nurse relationship, institutional support and autonomy 5 .
The participants in our study also mentioned power relations as a reason to take psychoactive substances. Power relations are ubiquitous in all labor interactions, which are often hierarchical, objective and impersonal to the point they come to pass unnoticed. Nevertheless, they do manifest in the behavior of workers, in addition to eventually becoming a cause of distress as a function of how they are established. This is to say, power management might have positive or negative influence on the performance of tasks and the work environment 25 .
The participants' narratives and the literature in general indicate that nurses see in legal or illegal psychoactive substance a solution to their daily problems at work. Although the available evidence points to the harmful effects of the work environment on the mental health of nurses and quality of care delivery, stakeholders are not yet fully committed to change this deplorable situation. Workers and managers should jointly formulate strategies to overcome this predicament.

CONCLUSION
In the participants' perception reasons to take psychoactive substances were staff and material shortages, conflict in interpersonal relationships, lack of autonomy, submission, and power struggles.
Since we only analyzed two public hospitals, our findings cannot be generalized. As further limitations, we analyzed subjective aspects and thus the results might have been influenced by circumstantial and individual factors. Therefore, additional studies are needed on the relationship between work environment and psychoactive substance intake by nurses as a means to cope with adverse situations in the workplace.