Satisfação no trabalho no contexto hospitalar : uma análise segundo o gênero Job satisfaction in a hospital context : an analysis according to gender

Objective: To assess job satisfaction in a public hospital according to workers' gender. Methods: It was conducted a secondary analysis with mixed method, from a sample of 308 subjects: 240 women and 68 men. Results: Almost half of women played functions of nursing. The most common function among men was the administrative. Men showed greater overall satisfaction, as well as for the three domains assessed. In adjusted analyses, statistical significance was observed only for the "Working Conditions" domain, indicating that the physical aspects of the job generate the larger asymmetries between the genders, especially in relation to toilets and level of noise in the environment. Conclusion: Since the other differences between the groups did not result significant in the adjusted analysis, it is concluded that the lower levels of satisfaction of women have been influenced by their expressive concentration in nursing functions, the most dissatisfied professional group in this study.


INTRODUCTION
Despite the remarkable achievements made by women over the last decades, certain disparities remain striking when comparing genders in the labor market, such as wage discrimination, occupational segregation and the difficulty of professional growth 1 .In the professional world, the perception of equities and inequalities between genders focuses on job satisfaction (JS), as a study carried out in the city of Rio de Janeiro 1 has verified.JS is traditionally described as an emotional state resulting from the evaluation of one's own work or work experience, from which the work can generate a pleasant or unpleasant emotional state 2 .
In studies on JS, the attention has been driven its determinants, for example, the gender of workers.Among them, researches conducted in England, in the US and in Spain have found that women had higher levels of satisfaction when compared to men [3][4][5] .In Brazil, in the city of Rio de Janeiro, it wasn't identified different levels of JS among female and male nurses 6 .In the same city, another study, this time conducted with professionals from a Mental Health Service, has found lower JS level among women 7 .Similarly, a research conducted with 130 nursing professionals from companies and from the five Brazilian regions has found that men had more JS than women 8 .
These findings indicate that the literature on the relationship between JS and gender is still inconsistent, as it sometimes presents higher JS in women, and sometimes the contrary.Meanwhile, the pressure for inclusion and justice among genders remains growing in the professional world.Confronting the discrimination suffered by women is increasingly becoming an imperative for organizations 1 .In this context, the objective of this study consisted of comparing the JS between men and women who worked in the Women's Hospital Professor Aristodemo Pinotti -Caism/Unicamp (Caism), which is a public university hospital that fully assists the National Health System and that is located in the city of Campinas, in the state of São Paulo.Caism is a tertiary and quaternary levels hospital, specialized in women's and newborns' health.Its coverage area includes more than 100 municipalities, which corresponds to about five millions of people.The hospital has 139 beds and 1,157 employees, where 922 (79.7%) are women and 235 (20.3%) are men.

METHODS
We developed a secondary analysis of previously collected data in the validation study of the "Job Satisfaction Questionnaire at the Women's Hospital Professor José Aristodemo Pinotti-Caism/Unicamp" (QST-Caism) 9 .As the objective of the original study was to validate the referred questionary, this study further examined the original database in order to scale possible differences in job satisfaction according the gender of the participants.
The QST-Caism, used in the collection of the original data, contains 19 items divided into three domains ("Interpersonal Relationship", "Personal achievement" and "Working Conditions"), as well as a space for registering the participants' comments.The questionnaire has also a space for the participants to freely write about the aspects of work that cause them satisfaction or insatisfaction.Although this questionnaire can be tested in other health institutions, it is important to note that its content was drawn from the specific context of the Women's Hospital Professor José Aristodemo Pinotti-Caism/Unicamp.All data analyzed in this study (qualitative and qualitative) were collected through this questionnaire.
The QST-Caism was made available to the hospital workers over the internet through the Lime Survey software Version 1.91.To access the questionnaire, the subjects used a password that was provided to them after signing the Informed Consent (IC).The printed version of the QST-Caism was answered by the individuals without internet access.
As for the processing of the data, this study used mixed methods, with concomitant collection, primacy of the quantitative approach and encrusted design 10 .In other words, this was a quantitative and qualitative study, with the simultaneous collection of two types of data, and where the quantitative interpretation was prioritized for the analysis, being then corroborated by the qualitative data.The speeches of the subjects were submitted to thematic content analysis, through which the texts were grouped in the following units of meaning, "dissatisfaction with the restrooms", "sense of injustice by the differences between workers from Unicamp and Funcamp", "hierarchical relationships", "presence of noise in the workplace" and "working hours".In the second phase, these lines, after being group, were encrusted in an quantitative data analysis, which allowed the enrichment of its interpretation.The subject whose speeches are reproduced in this study were named by acronyms, according to the following coding: "NFE" to "nurse", "TEC" for "nursing technician" and "ADM" to "administration worker".
With respect to the sample, the validation study of the QST-Caism included 328 subjects.From this total, only the participants who had responded at least 70% of the specific questions on JS and who had responded about their gender were considered eligible for the study.
A hypothesis test was used for the ratio in order to check if there was any statistically significant difference in the percentage between the sample and the population.By using the Shapiro-Wilk test, it was found that the data distribution wasn't normal.Then, for comparing the categoric variables between the genders the Pearson's chi-squared test was used; or when the value was below 5, the Fisher's exact test was applied.The Mann-Whitney and the Kruskal-Wallis tests were applied to compare the scores as for the position, working hours and type of employment relationship.Due to the statistically significant difference in the "position", "working hours" and "type of employment relationship" between the genders, the comparison of JS scores was redone with adjustment for these covariates, through the analysis of covariance.The level of significance adopted for the analytical tests was 5%, i.e., p < 0.05.All an statistical analysis used the program "Statistical Analysis System for Windows," version 9.2.

Job satisfaction according to gender
Bacha AM, Grassiotto OR, Cacique DB, Carvasan GAF, Machado HC This study was funded by the Caism itself, with the approval of the research project by the Ethics Committee of the Medical Science College from the University of Campinas (Opinion 306.348, on 06.20.2013), as well as by the Research Committee of the Caism.All participants in the study signed an informed consent form.The passwords for accessing to the online questionnaire were distributed randomly and without any information that could identify the subjects, such as their names or registration numbers.

RESULTS
From the total of 328 subjects who participated in the validation of the QST-Caism, 19 did not respond at least 70% of the specific questions about the JS and were excluded from it.One participant who didn't respond the question about the gender was also excluded.Of the remaining 308 subjects, 240 were women and 68 men, yielding a ratio of 3.5 between the groups.This result is close to the proportion between the genders in the hospital, 3.9 women for every man.Moreover, as for the proportion of 3.5, this value is in the acceptable range of the ratio between groups, that is from 2 to 4 11 .Besides, through the hypotheses tests for proportion, it was verified that there was no statistically significant difference in the percentage between the sample and the population, with p = 0.441.
The comparison between the genders in terms of age, education, position, working hours, employment relationship(i.e.contracted by Unicamp or outsourced), working arrangements (CLE or CLT), contract time and position is shown in Table 1.Males and females showed statistically significant differences regarding the function performed, working hours and type of employment relatonship.Almost half of the women performed tasks related to nursing, whereas most men wielded administrative functions (such as programmers, secretaries, archivists, receptionists and statistics, among others).
Slightly over 70% of the men worked in full-time, while less than half of the women worked in the same hours.Approximately 70% of the women were hired by the State University of Campinas (Unicamp), while 53.7% of men had this type of work relationship.There weren't any statistically significant differences between the genders in terms of education, job, work type, age and working time in the hospital.
As for the JS levels between genders, men had a higher overall score than women, with statistically significant difference in the bivariate analysis but not in the multivariate analysis (Table 2).The highest SJ of the men was also expressed in the three evaluated domains.In relation to the domain "Interpersonal Relationship", this difference was statistically significant in the bivariate analysis.In "Working Conditions", the difference between the groups obtained significance in both bivariate analysis and multivariate analysis.In " Personal achievement", the difference between the groups was only 0.6, with statistical significance in the bivariate analysis only to the work schedule, in which men showed higher ST.
Regarding the other evaluated items, it was also observed significant differences in the bivariate analysis for the boss's ability to solve problems, the manners which co-workers treat each other, the access to restrooms and the level of noises at the workplace.In all these cases, the highest scores were referring to the group of men.Women had higher JS in items about job stability, professional achievement, employee benefits and salary.None of these cases, however, presented statistical significance.Among the items that comprise the domain "Working Conditions", the one that refers to the restrooms also showed significance in the comparison between genders (Table 2).
The general ST scores and domain for the characteristics "position", "working hours" and "type of work relationship" are described in Table 3, which does not stratify the sample between men and women.The lowest scores were obtained by workers who worked in the nursing area, working on the night shift and had been hired by Funcamp (not by the Unicamp).The exception was the domain "Working Conditions" in which the Unicamp workers were dissatisfied.

DISCUSSION
This study found that the female group when compared to male, had lower levels of the three JS domains evaluated, and so in the overall score of the QST-Caism.These results are similar to two other Brazilian studies that compared the JS of health professionals by gender, where it was identified higher levels of JS among men 7,8 .However, similarly to the study by Rebouças and his collaborators 7 , this study found that many of these differences were statistically significant in the bivariate analysis but not in multivariate analysis.Thus, it can be assumed that some of the differences identified in this study are not directly related to the gender of the subjects, but the characteristics "position", "working hours" and "type of employment relationship", which presented significant differences between men and women.It's necessary, therefore, to examine how these properties would have influenced the JS according to the genders of the workers.
Regarding the duties performed by the study subjects, it is important to note that women occupied mostly assistance positions (particularly in nursing).They had thus direct contact with patients and worked in places such as ambulatories, wards, ICU, surgery center and obstetric center.In contrast, most of the men worked in administrative positions, usually in places like offices, using the computer as their main working tool.
It's unquestionable that, at the care, the delicate nature of the work requires the employees less autonomy and flexible schedules, and often require professionals to remain standing for long periods (e.g. during surgery).In addition, the work is done in places that, given their own physical structure, not always allow adequate air conditioning (a spacious hall from an ambulatory, for example).Moreover, administration workers tend to remain seated most of the time.Besides that, they clearly have more autonomy and flexibility of schedules, even for absolutely basic situations, such as, for example, go to the bathroom whenever they need it.

Job satisfaction according to gender
Bacha AM, Grassiotto OR, Cacique DB, Carvasan GAF, Machado HC It's not surprisingly, therefore, that the lowest general levels and of domain of JS have been identified among nursing professionals, who are mostly females.That is, even if it's supposed that there isn't any asymmetry in the JS according to the gender of the hospital staff, it must be recognized that many from the women's group focuses is concentrated in more dissatisfied positions.Indeed, the feminization of various health care professions is a well known phenomenon in the sexual division of labor, making it necessary to discuss how this phenomenon relates to the lowest degrees of JS demonstrated by the women in this study.

Job satisfaction according to gender
Bacha AM, Grassiotto OR, Cacique DB, Carvasan GAF, Machado HC Firstly, it is important to emphasize that professional autonomy is considered one of the factors that contribute the most to the JS of nursing workers 12 .In contrast, one of the components that can harm the autonomy of these professionals-and that was identified in this study -is the management style, especially when it's marked by aggressiveness, although perpetrated by professionals in the same category 12 .In this sense, a nurse reported: The supervisors [...] leave much to be desired, some are very friendly, polite, whereas others are very rough and and gets easily irritated.(ENF1) Another nurse reported:

There has been very frequently abuse of authority and moral abuse. (ENF2)
And one nursing technician said: We are threatened all the time.(TEC1) Considering these reports, all from women, it's noteworthy that studies have found that, indeed, the female group suffers more psychological harassment in the workplace than men 13,14 .However, It's also identified in the literature researches in which men had the highest prevalence of this problem 15,16 .Given this inconsistence, it should be noted that in this study were not identified any reports of men with complaints of moral harassment either by their peers or by the manager.To complete, there is the fact that the female group had lower scores than men in all items of the domain "Interpersonal Relationships", which deals with aspects such as hierarchical relationship and treatment education among colleagues.

Job satisfaction according to gender
Bacha AM, Grassiotto OR, Cacique DB, Carvasan GAF, Machado HC significant difference were observed in relation to restroom, with greater JS from the male group.It is worth noting that this study was developed in a hospital specialized in women's health, which is the reason why almost all of the public assisted by the institution are female.From that point, it was mentioned that the restrooms with free access are used by patients, which makes employees to use those whose access is only possible through keys.For men, the restrooms with free access are little used by the patients, and the users are mostly of drivers or patients`s companions.Consequently, the availability of toilets for the female works arias tend to seem smaller than for the male group, even though there are restrooms for exclusive use of both genders.Therefore, it is probable that by improving the dissemination of the availability of exclusive use of toilets for workers can significantly improve the SJ in women.Still, there shall be deemed to be discussed with the workers the distance and ease of access to these toilets, especially in the case of older professionals or with some limited mobility.
In the domain "Working Conditions", it was also observed a statistically significant difference between men and women regarding the level of noises.Despite this differences, it is important that workers of both sexes have complained of this problem.An administration worker, for example, reported: There is a motor that is all day and every day making noises, one bad factor related to noise.(ADM2)

A nursing technician said:
The noise level is high, either in the outdoor units, or in units [...] some people speak too loud [...] and disproportionate laughs are frequent among employees.(TEC3) The greater the dissatisfaction of women regarding this issue, it can be assumed that this was due to the predominance of the female group in the care.In hospitals, the noise pollution is responsible for increasing anxiety, loss of sleep, pain perception and prolonging the convalescence of patients 18 .Aware of this, the female group engaged in the care may, in fact, show greater concern about the noise level in the workplace.
As for the limitations of this study, we can highlight the secondary analysis of the data.In this type of research, once the data are analyzed in order to meet different purposes from those of the original study, the adjustment between the new issues and the data effectively available, may face some obstacles.In this work, this was expressed at low power pf the sample to compare the JS between genders, considering that the minimum recommended value is 80% 11 .The sample showed satisfactory power (85.3%)only to compare the JS in "Working Conditions", confirming the statistical significance identified in this domain.For the overall score of the QST-Caism, this power was 48.9%, with significance level of 5%.For the domains "Interpersonal Relationship" and "Personal achievement," the power of the sample was 57.5% and 5.8%, respectively.
The absence in the literature of studies that report the use of the QST-Caism in other hospitals is also a limitation to be highlighted, since it prevents the discussions about results of the research using other types of instruments.In addition to that, the design of the study itself, for being cross-sectional imposes some known biases, especially the impossibility of establishing a causal relationship between the independent variables and the outcome studied, in this case, gender and job satisfaction.

CONCLUSION
This study found that the female group had lower levels of JS in all domains and in the overall score of the QST-Caism.In an multivariate analysis, this difference remained significant only in regards to the domain "Working Conditions", indicating that the physical aspects of the work are the ones that generate the biggest differences between men and women.Among these aspects, the access to toilets and the level of noises constituted the largest asymmetries, always to the detriment of the female portion of the sample.
Once the remaining differences between the groups weren't significant in the adjusted analysis, we assume that the lowest levels of JS of women have been influenced by the significant female concentration in nursing roles, which constitute the most dissatisfied group of the study.Among the factors that may have reduced the JS of these professionals, stood out the critics to the management style adopted by some supervisors and work in shift, on holidays and on weekends.
On the "personal achievement" domain, which addresses issues such as salary, job stability and employment benefits, there were no statistically significant differences between men and women.This result shows that, in the Caism, there isn't an unequal relationship between men and women in relation to these aspects.

Table 1 .
Characterization of the sample by the gender of the subjects (n = 308).Campinas, SP, Brazil, 2013 * p-value refers to the chi-squared tests; †, ‡ Fisher's exact test and Mann-Whitney; § number of participants: female (n = 240) and male (n = 68).There was a lack of information provision in some sociodemographic variables.** Supervision of sections and directors of departments or divisions.

Table 2 .
Comparison of the satisfaction levels at work between genders in the three assessed domains, in descending order of satisfaction in each of the domains (0-100 point scale).Campinas, SP, Brazil, 2013 * SD: Standard deviation.p-value refers to the Mann-Whitney test.Value-pc is related to the analysis of covariance (ANCOVA) adjusted to occupation, working hours and type of employment relationship.Number of participants: female (n = 240) and male (n = 68).** Personal Protective Equipment (PPE).