Prazer e sofrimento: avaliação de enfermeiros intensivistas à luz da psicodinâmica do trabalho Pleasure and suffering: assessment of intensivist nurses in the perspective of work psychodynamics Placer y sufrimiento: evaluación de las enfermeras intensivistas por la psicodinámica del trabajo

Objective: To evaluate the causal factors of pleasure and suffering to the intensive care nurses. Methods: Descriptive and quantitative study, with sample of 44 nurses of a private hospital. It was adopted the Scale of indicators of pleasure and suffering at work. Data were analyzed using descriptive statistics and discussed based on the psychodynamics of work. It was assessed internal consistency using Cronbach's alpha. Results: For the pleasure factors freedom of expression had a satisfactory evaluation and Professional achievement was critically appreciated. For the factors of suffering, it was observed a critical evaluation for the professional exhaustion, and a satisfactory assessment for lack of recognition. Conclusion: The study provided a better understanding of subjectivity printed in nursing work and reaffirmed the importance of examining the psychosocial nature of the work for the strengthening of actions in workers' health.


INTRODUCTION
The centrality assigned to work in the life of contemporary man is unquestioned and growing.More than generator ofgoods, services and means of subsistence, the work is seen as a means for purchase of personal identity and as a determining factor in the quality of life and for the construction of cultural, social, religious values 1 .
Nursing as a profession falls within the context of capitalist accumulation, where workers offer their workforce to be objectified and purchased according to the demand of the function.The process of nursing professional's work is marked by features Taylorist such as a) to fragmentation of tasks, b) the requirement of extreme dedication and c) constant monitoring by supervisors, health team professionals, family and customers 2 .
The practice of nursing in Intensive Care Units (ICU)-whose job object is a complex clientele and in high degree dependent on the nursing professional -represents a specialized segment of the nursing care, due to peculiarities of the physical structure of the sector and the dynamics of the process of caring, highly supported, rationalized and technology.It also requires an intense pace of work, permeated by unforeseen situations and conflicting, agility in decision-making and a care free of damage.In addition, the nursing professional is in constant contact with situations of suffering and death of human beings, which refers to their own anxieties, generating physical, psychic and social wearing 3 .
The health of the worker, in the complexity and fragmentation of labor organizations, must be studied under an interdisciplinary perspective, allowing itto understand the work as an area of organization of social life, in which the professionals are subjects who think and act about the job, although the capital relations militate against such actions.To this end, the Psychodynamics of Work becomes a proper approach in an attempt to unravel the dynamics of work situations and the possible harms to worker's health.
Based on the importance of working for the man and considering all the transformations that the working world has been suffering, it is understood that the productive activity can reflect positively or negatively on the worker.The organization of work, if propitious to the development of the individual and the collective labor, allows creativity and autonomy, creating predominantly pleasure.If, on the contrary, prints the inflexibility and rigidity in the tasks and relations, it favors the emergence of suffering, mental decompensating, occupational accidents, illness and even deaths 4 .
The healthy is experienced when it is possible to act on situations where collection and work pressures cause psychological instability.However, the illness arises due to a pathogenic suffering when it breaks the balance and it is no longer possible to circumvent the suffering; namely, when intellectual investments and psycho-affective of workers are no longer sufficient to meet the demands and duties imposed by the organization, there are health consequences constantly nursing professional 4,5 .
Daily suffering and intense must be understood, then, as a warning to the professional, indicating that something is not right.This suffer can be experienced lasting manner, however unconscious, due to the predominance of feelings of anguish, fear and inseurity 6 .
The objectives of this study are to analyze,measure and assess the risks of illness related to work of ICU nurse, from the Scale of Indicators of Pleasure and Suffering at work (EIPST), in the worker's health perspective.
Currently, aspects concerning the organization of work are gaining space in discussions about workers' health.This is because the psychosocial aspects of work reveal to be a relevant problem in different social and economic contexts and impact on mental and physical health of workers and, therefore, indicate the importance in being investigated.
In this perspective, revisit the work process of intensivists nurses and evaluatesthe factors generators of pleasure and suffering at work could allow a new drawing of this process in order to promote the exercise of nursing work healthier and of quality.

METHOD
The present work consists in cutting from an exploratory study of quantitative approach and transversal design, descriptive and inferential conducted between February and May 2008, with the main objective to measure and assess the risks of illness related to work of an intentional sample of44 nurses workers in ICU of a private hospital in Rio de Janeiro, from the Inventory of work and risk of Illness (ITRA) 7 .It was used as inclusion criteria the performance in Intensive Care for at least six months.
It was used the questionnaire technique for applying the ITRA, auto-applicableand validated 7 instrument, consisting of four interdependent scales to assess four dimensions of interrelation work and risks of illness: 1) Scale of assessment of the work context (EACT); 2) Scale of human cost at work (ECHT); 3) Scale of indicators of pleasure and suffering at work (EIPST); and 4) Scale for the evaluation of work-related injury (EADRT).
The results presented here refer to application of EIPST, composed of four factors, two evaluating pleasure (professional achievement and freedom of expression) and two evaluating suffering at work (lack of recognition and professional exhaustion).It is a Likert-type scale, aiming to evaluate, in the last six months, the occurrence of experiencing feelings of pleasure and suffering at work.To this end, seven answers options were presented: 0 = no time; 1 = once; 2 = twice; 3 = three times; 4 = four times; 5 = five times; and 6 = six times or more.
For the factors of pleasure, whereas items are positive, the analysis follows the following parameters: above 4.0 = more positive assessment (work is satisfactory); between 3.9 and 2.1 = moderate evaluation (work presents is critic); and below 2.0 = more negative assessment (work is severe).

Pleasure and suffering of intensivist nurses
Campos JF, David HMSL, Souza NVDO For the factors of suffering, whereas items are negative, the analysis must be carried out based on the following levels: above 4.0 = more negative assessment (work presents as severe); between 3.9 and 2.1 = moderate evaluation (work presents as a critic); and below 2.0 = less negative assessment (work is satisfactory).
The collected data were analyzed with the aid of application Statistical Package for the Social Sciences (SPSS) for Windows, version 12.0, which conducted descriptive statistics, such as frequency, average and standard deviation; calculated Coefficient Cronbach's Alpha, with a view to the establishment of internal consistency.
The results are discussed on the basis of the theoretical framework of the Psychodynamics of the Work.
The ethical precepts of the resolution 196/96 were obeyed, being approved by the institutional Research Ethics Committee, whose protocol number is 247.A free and clarified consent was signed by the participant.

RESULTS AND DISCUSSION
The results refer to the implementation of the EIPST, whose respondents were the nurses of ICU.The scale showed good intern consistency and, through the evaluation of the score obtained for the factors of pleasure, it was possible to perceive that freedom of expression presented a satisfactory, positive evaluation.Professional achievement, however, was appreciated so moderate, critical.On the factors of suffering, which are negative items, professional exhaustion presented a moderate rating, critique, and the lack of recognition, a satisfactory assessment (table 1).among colleagues, with µ = 5.06.
It is observed that, for nurses, this is the factor that most generates pleasure.As the definition of that factor, it can be affirmed that freedom of expression at work favors the construction of professional identity.The work must be an area of organization of social life in which the workers are seen as subjects that influence the work and are influenced by it, even with the whole capitalist relationship known in domination.Through work, a double transformation happens: the man acts on the nature, modifying it; and, at the same time, the work develops their potential 8 .
The identity is something that is built in relation to the other, i.e., it is marked by trial and recognition of the other.In nursing, it is virtually impossible to work alone, and work on intensive therapy is especially marked by collective actions.The construction of confident, very important in professional relations for worker's health, depends on the creation of a collective work in which build rules, norms and values, which guide the relationships within the organization of work and allowing a space for discussion in favor of individual and collective growth 5 .
It turns out that in fact there is a satisfaction in the studied population as regards relations among colleagues, these relations marked by solidarity, trust and cooperation, promoting a healthy environment and easing the contradictions imposed by work context.The collective work offers a reflection on the different work dimensions, allowing, thus creating conditions for the work sustainability 9 .Searches are being made in order to analyze the cooperation, solidarity, trust and engagement in group discussions as indicators of subjective mobilization 10 .
However, some chains show that the toyotist model of labor organization, which promotes and encourages teamwork, has the purpose of appropriating more than work, improving productivity and, consequently, increasing the exploitation of the worker 11 .
The second factor analyzed, professional achievement, deals with the experiences of professional gratification, pride and identification with the work they do.It is composed of nine items: 1) satisfaction; 2) motivation; 3) pride of what they do; 4) well-being; 5) professional achievement; 6) valorization; 7) recognition; 8) identification with the tasks; and 9) personal gratification with the activities.
The largest contribution to the positive assessment of this dimension for intensivist nurses fit the following items: proud for what theydo, with µ = 4.65; and identification with the tasks, with µ = 4.45.
This factor has a moderate rating, critic; that is, items that are important to experiences of pleasure at work have not been well evaluated in their entirety.
For professionals surveyed, the most valued items reflect the personal identification with the profession, i.e. demonstrate that nurses like and identify with the activities they carry out.Nursing is a type of work with a very peculiar feature: only works in this profession who really likes it, because the professional undergo critical conditions of work and the intense involvement with the suffering and the intimacy of others The first of this scale factor is freedom of expression, which reflects the experience of freedom to think, organize, and talk about the work.It is composed of eight items: 1) freedom with the leadership to negotiate what it is needed; 2) freedom to talk about my work with colleagues; 3) solidarity among colleagues; 4) confidence among colleagues; 5) freedom to express opinions in the workplace; 6) freedom to use creativity; 7) freedom to talk about working with line managers; and 8) cooperation among colleagues.
The items presented the highest averages in this factor, contributing positively to the experiences of pleasure at work were solidarity among colleagues, with µ = 5.36, and cooperation

Pleasure and suffering of intensivist nurses
Campos JF, David HMSL, Souza NVDO It is very common to hear that nursing is a vocation, a gift.But, at the same time, it is forgotten that, despite being essential to affinity for the type of activity to be carried out, the nurse is a professional like any other; so, are equally important aspects such as recognition, valorization, satisfaction, among others.
Based on this mistaken thinking that the nursing profession is a gift, the capitalist logic found "fertile ground" in Brazilian nursing, which has its roots in the sense of piety and charity.The qualities of good professional obedience are emphasized, respect for hierarchy, humility and spirit of serving -disciplined, obedient and alienated.Because of this, until today the nursing workers face serious professional difficulties, as fragile political organization, low pay and lack of autonomy 12 .
It is true that the sense of pride by the activity exercised relates closely with the possibility of helping the sick, to relieve even partially the suffering, to be useful and to participate actively in the treatment and, consequently, their sharein the positive results achieved.
For intesivist nurses, the pleasure experienced at work can relate to the motivation that they claim to have, since the factors pride for what they do, good relationship with the team and satisfactory working conditions are essential and are present in the evaluation sample.
In the workplace to which workers are exposed, it is common that these encounter situations that flee to prescribed activities.To deal with these situations and ensure continuity of production effectively, the professional uses his intelligence and creativity.However, intelligence, creativity and effectiveness of solutions that the worker proposes are effectively judged by peers (whether co-workers or the leader).If assessed, these situations can generate satisfaction and intense pleasure in the worker, intensity is proportionally related to the complexity of the challenge resolved.Thus, creates the impression of professional identity in the workplace through its recognition.The possibility of giving meaning to the suffering experienced by the worker is in its recognition in this environment, enabling the transformation of suffering in pleasure 13 .
For this factor, the items that most negatively influence, contributing to the professional illness, are stress, with µ = 4.59, and emotional exhaustion, with µ = 4.11.The assessment of this factor, although moderate, critical, presented items with very high averages.
Technological and organizational changes introduced in the productive process by capitalist logic, in addition to allowing companies increased productivity and, consequently, profits, implicated in the emergence of physical and mental disorders in workers' health.In the document of the Commission of the European communities, quoted by the same authors, states that the "[...] diseases considered emerging, like stress, depression or anxiety, as well as the violence at work, harassment and intimidation are responsible for 18% of the health problems associated with the work, a fourth part of which involves two weeks or more of work absence" 14 .
Stress at work is a result of interaction among many psychological demands, less control in the production process and lower social support received from colleagues and bosses, in the work environment 15 .Despite being in Brazil, scarce statistical data on the subject, it is believed that it should look similiar.As nursing did not remain outside of any modification of this productive context and exploratory, it is also noted in this profession the presence of occupational stress.When trying to understand this situation, it will certainly be possible to elucidate problems like professional dissatisfaction, low productivity, absenteeism, occupational diseases, among others.
The importance and concern with the issue of stress currently refers to its association with illness or suffering it causes in the worker.Several are physical symptoms; the most commonly reported are fatigue, headaches or body, insomnia, palpitations, intestinal changes, nausea, tremors, cold extremities and constant colds.Among the psychological, mental and emotional symptoms are decreased concentration and memory, indecision, confusion, loss of sense of humor, anxiety, nervousness, depression, anger, frustration, worry, fear, irritability and impatience.Studies show associations between work stress and psychiatric disorders, diseases of the digestive system, musculoskeletal disorders, negative auto-evaluation of health condition, absenteeism at work, cardiovascular disease and its major risk factors such as hypertension and unhealthy habits (smoking, alcoholism and other drug consumption) 15 .
In addition, stress has been discussed enough the Burnout Syndrome, which refers to constant feelings of failure and exhaustion of the employee in relation to its work.Some aspects are more relevant in this syndrome, including emotional exhaustion, depersonalization and the lack of involvement in the work 16 .
Among these three aspects, by performing closely related to the second item most valued of the factor, only discussing the emotional exhaustion, understood as power failure by associated with the feeling of emotional exhaustion, because the professionals report does not have conditions to spend energy to perform of the activity 14 .
The suffering that the individual presents in front of these situations negatively affect on health status, professional performance, inlife as a whole, reflecting also in social, economic aspects and on the organization of work in which it inserts.The search exacerbated by productivity is faced with an insurmountable boundary, the human being itself.Thus, the lack of motivation, alienation, depression, stress and, more recently, the Burnout remain a challenge for institutions 14 .

Pleasure and suffering of intensivist nurses
Campos JF, David HMSL, Souza NVDO Several components are recognized as threatening to the occupational environment of nurses; among them are 1) the reduced number of nursing professionals in health care in relation to the excessive activities that they perform; 2) difficulties in delimit the different roles among nurses, technicians and nursing assistants; and 3) the lack of clear recognition among the general public who is the nurse.In addition, the inadequate compensation requires professionals to have more than a working link, resulting in a monthly charge extremely long and exhausting.
The increasing demand of psychotropic drugs in medical services is targeted for study that disputes the approach of occupational medicine currently exerted, which seeks to explain the symptoms of depression and anxiety disorders solely by the life story of the subject, without taking into account the context of the organization of work and its effects on the lives of trabalhadores 17 .Furthermore, the positioning of the institutions against the individual who falls ill due to exposure to stress in the workplace's blaming the victim, emptying any political initiative to modify situations arising from the specific environment of work 15 .
Despite the insecurity and fear being widely discussed items in searches involving Psychodynamics of work and pleasure-suffering, it turns out, in the studied population, that these feelings are most often disregarded, since there is recurrence for the option "no time", with regard to insecurity and fear in the past six months.
The fear is closely related to the possibility of being fired 4 .The institution search, are not common dismissals without just cause; in addition, you cannot tell a hostile environment, generating insecurity and fear officials due to the ghost of resignation.This data can be verified by socio-demographic data already exposed, in which most professionals (56.9%) work for more than five years at the institution.
Fear can trigger on workers using individual and collective defensive strategies, such as intensification of work, increasing the suffering, silence, individualism, among others 4 .
The fourth factor, the lack of recognition, reflects conditions of injustice, indignation and devaluation due to lack of recognition of the work.Is composed of eight items: 1) lack of recognition of the effort; 2) lack of recognition of performance; 3) depreciation; 4) indignity; 5) worthlessness; 6) disqualification; 7) injustice; and 8) discrimination.
This factor obtained, within the range, a satisfactory, positive evaluation; the two items that presented the highest averages, contributing to a moderate appreciation of the factor, were lack of performance recognition, with µ = 2.90, and lack of recognition of the effort, with µ = 2.79.Fortunately, the results obtained with the assessment of this factor shows that are not frequent experiences of suffering caused by these items.
The lack of recognition has in the process of formation of the subject's identity, the assertion of utility, social or economic technique of the activity exercised and the expression of the individuality and uniqueness of the worker.The lack of recognition of work hinders the transformation of suffering in pleasure, since recognition is essential in the process of mobilizing subjective and professional engagement 4,13 .
It is known that, in nursing, the lack of recognition is historical and still stands today.The difficulty of defining the specific skills of the nursing skills of other professionals negatively influence the professional who, in certain situations, if not positioning by insecurity in set, to recognize their own role.
Another important factor in the determination of such a framework is the Division of the profession by categories (assistants, technicians and nurses), threading this hardly understood not only by the general public, but by members of the multidisciplinary team.The classification of all as nurses generates a feeling of devaluation and depersonalization, because the formation of categories is completely differentiated and their functions and responsibilities also differ.
In addition, one can cite a cultural aspect of overvaluation of know doctor.The credit for the success of the treatment is generally given only to medical professional who holds healing power.The portion which fits nursing professionals is often undervalued or seen as an act of charity.For being a profession essentially manual, the Act of caring for own nursing ultimately occupy a position of less importance in the eyes of patients, their families and the professionals themselves, when compared to medical actions.It reflects even in the remuneration of the activities of nurses, which, by charging a value for carrying out its activities, is often regarded as an inhumane person, since the practice of nursing is seen historically as an act of serving other without lucrative intentions.In this picture, there is a historical context for the lack of recognition of the activities and the efforts of the professional in question, which affects actively in their experiences of suffering.
The analysis of each work and reality of each particular profession helps to find the pleasure-pain-generating factors.Although they differ among themselves, the experiences of pleasure-pain are closely related to the work context (Organization, professional relationships and working conditions).Factor in common between the research presented earlier is the importance of subjective relations among peers and their weight in the experiences of pleasure and transformation of suffering.
It is known that it is impossible to conceive of work organizations that, somehow, do not allow the suffering of the professional.The pleasure-pain results from the interrelation between the workers and the working context.Health and pleasure at work are processes that are constantly changing and must be conquered daily.Health at work is the result of the way the worker faces the conflicting situations present in the context of work 9 .
Knowing all predisposing factors to suffering and its possible repercussions on health and illness, professional asks workers to remain in a State of normalcy in front of all these risk factors.It is believed that this state of normalcy reflects a balance Pleasure and suffering of intensivist nurses Campos JF, David HMSL, Souza NVDO unstable between distress and defense strategies and mobilizing subjective used by professionals 5 .
The defensive strategies are mostly in collective actions, with which the employee intends to modify, transform and minimize aspects present in the context of work resulting from the conflict between prescribed and real, which makes sofrer 9 .When using these defenses, there may be a process of alienation and crystallization of the worker, making it difficult and decreasing the possibilities of modification of work situations.

CONCLUSIONS
The application of EIPST and the use of the Psychodynamics of referential Work allowed the discussion concerning the influence of the Organization and dynamics of labor in intensive care nurse; In addition, it was also possible to analyze the factors generators of pleasure and suffering for that same professional.
This study contributes to a better understanding of subjectivity printed on nursing work.Reaffirms the importance of examining the psychosocial nature of work and the need to introduce this perspective in public policy development of safety and health at work, which is still limited to discussions about physical issues and labor and ergonomic health professional repercussions.
Although the EIPST be an instrument created for workers in general, it was internally consistent for nurses in specific.However, it is clear the same limitation to evaluate in depth the influences work on worker's health due to the subjectivity involved in constructs in question.