Pleasure and suffering in the elderly care in long-term care institution: perception of nursing workers Prazer e sofrimento no cuidado ao idoso em instituição de longa permanência: percepção dos trabalhadores de enfermagem El placer y el sufrimiento en el cuidado de ancianos en instituciones de larga estancia: la percepción de los trabajadores de enfermería

Objective: To identify the situations that create pleasure and suffering in the care of the elderly institutionalized in the nursing workers' perspective. Methods: Exploratory, descriptive and qualitative study, held with professionals of a Long-Term Care Institution for Elderly People (LTCI). The data were subjected to content analysis and to the Dejours' Theory of Psychodynamics of Work. Results: The pleasure is on the recognition of workers by the senior people, in contribution to the clinical improvement of these and the creation of bonds between all of them. The suffering is experienced by professionals in face of family estrangement, the functional decline of the elderly, which leads to their death and for living with the resistant behaviors of these. Conclusion: The nursing workers in LTCI experience mixed feelings. It stands out the reinterpretation of suffering as a way to achieve balance in the relationship between work-health-illness.


INTRODUCTION
Nursing has as focus the human being care during the entire cycle of life and in many degrees of complexity, providing physical and mental rehabilitation of individuals, as well as health promotion and prevention.At the same time the nursing staff care for individuals, they experience situations in their work context that can destabilize their physical and mental health.
According to the Theory of Psychodynamics of Work, labor activity cannot be considered neutral, because while this is a source of pleasure, it also influences negatively the subject.In this way, any work activity can cause suffering to the worker, leading him to somatic and psychological illness 1 .This fact is evident in the labor context of nursing, because the professionals of this area live with the suffering of patients and their families, besides the finitude of life, situations that generate feelings of sadness and impotence to professionals [2][3][4][5] .
However, the nursing work is not limited to situations that cause suffering and physical and mental illness of its employees.They also experience positive feelings in face of recovery and healing of individuals who are under their care and the consequent recognition of their work by these and their families, as well as the feeling of being performing a useful work 5 .Thus, the nursing work is complex and heterogeneous, encompassing simultaneously unhealthy activities, painful and difficult, as well as situations that allow the pleasure to job satisfaction 2 .
When it comes to labor suffering, generally the hospital becomes target of research, especially the intensive care units, emergency services and oncological services [3][4][5][6] .However, nursing professionals work in various areas of health, which feature situations that may also lead to conflicts between the workers and their work.Among these sites are the Long-Term Care Institutions for the Elderly (LTCI), providing assistance to the old people, dependent or not, who are in situations of social vulnerability.
It is known that the care of the elderly dependent requires the execution of activities that involve physical effort, concentration and planning, leading, over time, to physical and emotional stress for caregivers and, as a consequence, the emergence of feelings of discontentment and professional dissatisfaction.The assistance to this clientele generates a complex and varied range of feelings that directly influence the quality of care provided and the relationship of the workers with their labor activity and health [7][8][9][10] .
In this sense, the objective of this study was to identify the situations that cause pleasure and suffering in the care of elderly residents in LTCI in the nursing workers' perspective.

METHODS
This is a descriptive and exploratory research with qualitative approach, conducted with nursing workers of six LTCI registered by the Department of Social Welfare and Citizenship (DSWC) of a city in the Northwest of Paraná/Brazil.Among the six institutions, two were philanthropic (LTCI A and B); three, private (LTCI C, D and E); and one, governmental (LTCI F).The LTCI B was that provided assistance to a greater number of elderly, with 94, followed by LTCI A with 53; LTCI C, 47; LTCI D, 45; L LTCI E 24; and LTCI F, with 15 seniors.In relation to the profile of clients served, it was found that most seniors had a high degree of dependency care, partially or totally dependent on the nursing staff.
In all LTCI studied, nursing care was characterized by routine activities including personal hygiene for the elderly, preparation and dispensing of medications, food offering, measurement of vital signs, organization of resting areas and nutrition of the elders and recreational activities with the clientele in question.The institutions count with the work of nursing in all shifts.
The inclusion criteria were acting for at least six months in the LTCI, since this is a period when the professional who is already included in the routine work of the institution and has knowledge about the elderly care, being able to answer the guiding questions of the study.There were workers who were not at the institution at the time of data collection, that is, those who were on leave from work or on vacation.
The number of interviews followed the criterion of saturation of information, that is, when the research problem had been adequately clarified and no new elements arose from the narration of the professionals.According to the data collected from each interview, the researcher analyzed whether the guiding questions were answered and all the interviews of each institution showed the general perception of nursing professionals about the object of study at the workplace in question.If the information collected in the institution saturated, the interviews on this site were closed and began on the next institution.It is noteworthy that respondents were approached individually, according to their availability to participate in the study at the time the researcher was in the institution.
Thus, the number of respondents were different between LTCIs, since the quality and richness of data were different among respondents and institutions, that is, some workers expressed with more detail than others, showing greater density in the information about the object of study.In this way, it was possible to identify all the workers' perceptions on the issue of the study with a different number of interviews in each institution.
It is also noteworthy that the number of respondents among the LTCIs also varied because of the difference in the amount of nursing workers in each institution, being included five professionals among the ten existing in the LTCI A, six among the 13 of LTCI B, seven of 17 of LTCI C, three of the eight of LTCI D, two among the five of LTCI E and four of seven at LTCI F. At the end of the interviews, took part in the survey 27 nursing workers of the six LTCIs.
For data collection was used the semi-structured interview conducted by the following guiding questions: At what point of your professional life did you think of working with the elderly?How was the beginning of your professional activities with the elderly and in that institution?What feelings do you experience in your work?In which situations?
Data collection took place between April and September of 2013.The interviews were conducted with the support of a digital recorder with an average duration of 37 min, transcribed in full and then analyzed based on the methodological referential of Bardin's Content Analysis 11 , which consists of a technical group, divided into three phases: pre-analysis, operation on the data followed by the treatment of the results, inference, and interpretation.
In the pre-analysis, successive readings of the interviews were conducted in order to systematize the data.In the first reading, it was highlighted the points of interest.Then, there was a new reading to review the points that were underlined earlier, in order to ensure the identification of all aspects of speeches.In the third reading, the data were organized according to the research objectives, performing the encoding of the data.It is understood as encoding the aggregation of the raw data in units which allow description of the characteristics of contents, that is, the data are organized according meaning units so that one can view them in an aggregated manner, facilitating the understanding and subsequent interpretation 11 .
In the exploration stage, it was held the categorization, that is, the transformation of raw data into organized data.This process consisted in finding groups and associations to respond to the objectives of the study.For this, the units of meaning have been grouped according to the thematic similarities, emerging two categories.
In the third and final step, there was the actual analysis of content, characterized by the inference and data interpretation of the three categories in relation to the findings of the scientific literature.
To better understand the relationship work-health-illness, the findings of this study were discussed in the light of the Christophe Dejours' referential of Psychodynamics of Work.This theoretical framework is dedicated to the analysis of the psychological processes involved in individuals' confrontation with the reality of the job.Its interest is focused on the experiences of the subjects at work, which are manifested by pain-pleasure and by developing action strategies that enable the state of normality of the workers in face of de-structuring of the work environmen 12 .
The study followed the guidelines of Resolution 466/12 of the National Health Council 13 and was authorized by the responsible of the institutions, as well as by the Permanent Committee on Ethics in Research Involving Human Beings, of the State University of Maringa, in Opinion Nº 207.426/2013.All participants signed the Term of Consent in two-ways and to ensure anonymity the lines were identified by the letter N to nurse, NT for nursing technicians and NA for nursing assistant, followed by arabic numerals in the order in which the interviews were conducted.

RESULTS AND DISCUSSION
Among the research subjects, there are five nurses, 12 nursing technicians and 10 nursing assistants; being 23 female, of all work shifts.The age of the workers ranged from 22 to 56 years, the time in the profession from one to 26 years and the work in the current LPIE between seven months and nine years.
The analysis of the interviews enabled the construction of two categories, the first related to generating situations of pleasure in the process of work with the elderly, and the second, to situations that cause suffering in this work context.

Situations that cause pleasure in the institutionalized care of the elderly
Nursing workers experience pleasure during the care of the elderly.They claimed to be satisfied when they realize the recognition of their work by the elderly, expressed through gestures and words of gratitude.

[...] It is amazing you get to do something for someone and, in return, the person gives you a hug, a kiss. They are sincerely grateful, it is priceless. Do your job and see the person appreciating you, makes me happy (NT 8). [...] It is nice to know that are elderly who recognizes what you do, your effort. This is the best part of the job (NT 10).
The recognition is a symbolic way of return given to the subject in order to compensate for the effort invested in carrying out the work, which leads to the construction of worker's identity and, consequently, the experience of pleasure and professional achievement 14 .This appreciation is essential for the individual to experience the pleasure in working, giving meaning to what they perform, avoiding the alienation resulting from the contempt and lack of direction toward work 1 .
Study of nursing workers who care for hospitalized elderly show the relationship of the appreciation of the care given with the experiences of pleasure, as well as reveals that older people generally recognize more the dedication of professionals, naturally showing their gratitude for them 10 .

Pleasure and suffering of nursing workers
Mariano PP, Carreira L The recognition by the elderly allows workers to confirm the implementation of good work, giving them satisfaction for feeling competent.Situations that motivate the nursing workers to perform their jobs with more dedication and quality.This appreciation shows itself as decisive in subjective mobilization of intelligence and identity of the subject in their work performance, that is, in developing their skills and building their professional profile.This dynamic is set in the psychodynamics of work as "work motivation", which leads the individual to experience pleasure in the employment context 14 .
Having their own work recognized stimulates the nursing workers in that area, even if initially this was not their choice.

I did not like so much to take care of elderly people. I always thought of working in hospital. Then I went to work in a home and I was in love with this area, I was charmed with the elderly, for their feedback [...] (EA 9).
The job market has become highly competitive and the relationship of supply and demand of employment is increasingly disproportionate, since job opportunities are always reduced compared to the number of individuals willing to carry out a work activity.These, in turn, submit to jobs that do not match their desires and affinities, because of the need for survival.This is the current reality of nursing, which drives the workers to exercise their function in certain areas that are not of their preferences, causing them discontentment and dissatisfaction 15 .
It was observed that many of the LTCI nursing workers did not want to work in this area.However, living with the elderly and the perception of recognition of care by them, enabled the reinterpretation of suffering, that is, the transformation of situations that previously generated suffering and now provide pleasure to the worker.It was noted, therefore, the importance of the recognition of employees for the experience of pleasure in the work environment.
Other workers said that they always wanted to act in the field of Gerontology and, therefore, they feel satisfied because they were working on a LTCI.The pleasure for these professionals is directly linked to the fact of dealing with elders, an also observed aspect in other studies with professionals who care for the elderly 10,16 .This shows that the work freely chosen favors the experience of pleasure, being a source of professional success 12 .

[...] Today I am professionally fulfilled, because I like what I do, working with the elderly. It is the profession that I like and in the area I like (NA 7).
By identifying themselves with the activity performed, these workers experience daily the pleasure, viewing the work not only as a source of income, but, mainly, as a fulfillment of their desires as professionals.Studies on the suffering and pleasure of nursing staff who work in other services, such as Intensive Care Unit (ICU) and hemodialysis, also showed the pleasure mediated by identification with the work 5,17 , confirming the results of this research.
The creation of affective bonds between the workers and the elderly is another source of pleasure.As these links intensify themselves, occurs the replacement of the relationship strictly professional for a family relationship, which generates pleasure for all involved and transforms the work in source of happiness and satisfaction.

[...] they treat us like children; they kiss us and hug. Here to me is like family. I leave my home going to my second home. It is very pleasing! (NT 2).
[...] we hug and kiss, it turns into a family.It is gratifying, we are so happy with that.Some people complain of their service, but I do not, in my service is hug and kiss all day (NA 7).
This affective relationship between nursing workers and elderly patients emerges from the long coexistence between them, since the professionals perform care for the same old people for a long time.This feature is also understood in some services of care for people with chronic diseases, such as hemodialysis and oncology units, where the patients receive daily care of the nursing staff for months or even years, providing the establishment of bond between them 5,6 .
This emotional involvement between the nursing staff and the individuals under their care denotes a spiritual character about the care, since the benefits of this relationship transcend the physical health of the patient, addressing the feelings of charity and love to the next, positively influencing the degree of professional satisfaction, resulting in the experience of labor pleasure 18 .
For the Psychodynamics of Work, the pleasure may emerge in the working environment, when this provides conditions for interaction and socialization, which strengthens the development of worker's identity and enables the transformation of work in

Pleasure and suffering of nursing workers
Mariano PP, Carreira L its favor 1 .In this sense, long-term care influences positively the relationship of nursing workers with their technical function, as well as the quality of the assistance.
The nursing staff also feel pleased to see the improvement of the clinical situation of the elderly through its assistance, either by the technical knowledge or attention given to the patient.
[...] when I see an old man that looks good because of my care, I feel so happy.I realize that I am making a difference, helping them to get well [...] we feel useful here ( NT 11).
We want them to be good, so when we see them better, we know that it has a little bit of our help [...] I feel happy with that.We realized that we were part of this improvement (NA 7).
When there is compatibility between the content and objective of the task to be carried out and the unconscious worker desires, the pleasure becomes experienced in the work 12 .This association is clear in the speeches above when the worker expressed the wish that the elderly remain healthy and the satisfaction to realize that, through its work, collaborates to this.
Feelings of pride and usefulness are clear in the testimonies of workers when they report their contribution to comfort, pain relief and progression of the health status of the elderly.The act of caring for others who are fragile and dependent, enables to the nursing staff very pleasant feelings experiences, especially of being useful, which consequently gives them a sense of developing a socially noble task 5 .
These feelings are often expressed by nursing staff, regardless of their area of expertise, because this profession has as central focus on the caring of the human being.In this way, the pleasure on the patient's clinical improvement is found in other studies with nursing professionals from various fields 2,5,6,17,18 .
When the occupation works as a source of pleasure, whether by the construction of the identity of the subject, by its recognition and by its professional achievement, it allows the employee to become subject of the action, dominating the work and not being dominated by it 1 .

Labor suffering when taking care of the elderly in LTCI
Suffering at work arises when the worker's connection with the work organization is blocked, due to the difficulties of negotiation, of the different forces that involve the desire of production and the worker's desire.In this sense, the study of suffering is directed to the interrelationship of workers with their jobs and the defensive strategies that are used to handle this relationship 12 .
In relation to the nursing worker and their activities with the elderly in LTCI, were identified some situations that cause distress, among them, the fact of watching the distancing and disinterest of the family towards the elderly.
The sons leave their parents here and do not come to visit them, and do not care about the mother and the father, come here and leave them just because they are paying for it.So it is hard to see that [...].This breaks my heart (NT 2).

[...] it disgusts me to see the family bringing the elderly and just paying the hosting of them here. And we have to see that and not say anything, we cannot forget that we are at work (NT 1).
The impossibility of professional intervention in family relationship is an even stronger factor in generating the suffering of workers.When freedom at work decreases, that is, the subject cannot have initiative in face of an event, the relationship between the worker and its job is blocked because it does not have the freedom to make use of their psychomotor, psychosensorial and mental skills, generating the suffering.The use of intelligence to suit some events at work to their personality allows the reducing of the psychic load and the development of pleasure at work 19 .
The absence of family relationship was also identified in the study with nursing workers who take care for hospitalized seniors 10 .This finding indicates that, regardless of the elderly being institutionalized and living with the abandonment of the family, they seem to be present in the daily life of the professionals who provide assistance to this age group.
Some behaviors from elderly resistant to the standards and established routines at LTCI and in the nursing work organization can be generator of suffering to professionals during the care routine.Seniors have behaviors that, sometimes, professionals do not like or that go against the rules and routine of the institution, becoming generators of workers suffering during the care.

[...] here you have to accept many things they (the elderly) do, they are at an age that is futile trying to fix certain behaviors and sometimes it is difficult. [...]. It requires a lot of patience (NA 5). [...] to work with elderly you must like it, because you have to be very patient. You have to feed someone, the other does not want to take a shower, it is not that always easy [...] (NA 3).
Care for the elderly demand certain skills of the professionals such as communication, patience to deal with the constant requests and the persistent behavior of the elderly and energy to Pleasure and suffering of nursing workers Mariano PP, Carreira L perform basic care that are generally repetitive.The professional who does not identify with the work, begins to experience negative feelings such as dissatisfaction and frustration.
Facing these negative feelings, the work turns into a painful activity, that offers difficulty and mental overload to the employees, promoting the professional dissatisfaction and the decreased willingness to perform the labor activity, compromising the quality of care provided by these individuals to the institutionalized elderly, as well as the health of the worker.
To execute a job generator of suffering is triggering factor of occupational illness, with an emphasis on work-related stress, which can be constant, leading to psychomatization, that is, the installation of symptoms and physical limitations on the worker.In this sense, the Burnout Syndrome, usually identified among the nursing workers, considered the employment stress chronification, may lead to physical and emotional exhaustion, depersonalization and professional dissatisfaction 20 .
To accompany the functional decline and clinical worsening of the elderly is another situation that generates suffering in nursing workers.The work means the creation of identity by doing and producing and, is in the satisfaction of these aspects, that the worker has experiences of pleasure 21 .Thus, the inability of the nursing workers front of rehabilitation of elderly health, affect the production of work and, consequently, their satisfaction and occupational pleasure.
[...] it is very sad to see that the elderly comes here walking, talking and, suddenly, demoting and stay in bed.It is sad to see that, because we accompany it and cannot stop it [...] (N 1).

[...] we do everything that has to be done, but we do not see any result, no matter how much we try, we do not see progress in the person (NT 2).
The suffering on the pain of others seems to be inherent to the nursing work, because this situation was found in other studies with professionals who care for the elderly, as well as patient with chronic problems and/or with unfavorable prognoses to life 2,6,10,17 .
In near-death situations, it was observed that the nursing workers search for "subjective pleasure", that is, the one arising from the consciousness of providing to the individual the appropriate care to their needs and a dignified death, which qualifies him as an ethical professional 10 .
[...] I see as a palliative care, so I do not expect that it will improve the patient's health, what we have to do is leave him well.So, it is a care for their comfort [...] ( NA 10).
Death is often seen as a reflection of the failure of the assistance provided, as the nursing professionals take the responsibility to save, cure or even ease the pain of the other 2 .Thus, employees express feelings of agony, impotence and dissatisfaction on the loss of the elderly after the investment and effort for its recovery.
During the academic training, the nursing professional coexists with technical learning, which seeks the preservation of human life.Considering this perspective and culturalhistorical and subjective aspects, it is noticed that, sometimes, the phenomenon of death is not recognized as natural of the existence of the being, which ends up generating frustration in the team, because they cannot reverse the situation of finitude 22,23 .
It is very hard when they die, because you do your best for their improvement, for them to live and, even then, they end up dying (NT 5).
I have tried to revive many seniors, but without success.I did my best, all I could, but it did not revert the situation.Then it is hard to deal with death, there is not much that you can do [...] (N 4).
The suffering of the worker facing the patient's death was also reported by nursing staff who care for hospitalized elderly, providing care in intensive care units and oncology, even in the international scenario, showing that this suffering is always experienced in the nursing profession, since professionals live daily with the finitude of life 2,6,17,24 .
In the presence of these situations that cause distress in the labor context of nursing, these workers need to rationalize these circumstances as characteristics of the profession, immutable and permanent aspects to all who assist people with physical and mental limitations, as well as a disease process.Labor suffering on the rehabilitation of disability and death of patients should be reframed by the professionals, in order to not limit their performance and job satisfaction, and must be understood and accepted by them.
In the context of LTCI, the establishment of a bond and daily living for a long period with the elderly, potentiate the feelings of loss and sadness experienced by workers.The role of professionals is left out and is replaced by that of people who have lost a loved one.
They are sorely missed, every day you were talking with them, caring for them and when they die it's empty and you are so used to feeding them, taking for a bath that you forget that the person died and you go there in the room to get them (NT 6).

Pleasure and suffering of nursing workers
Mariano PP, Carreira L

[...] the day she died is as if I had lost my mother [...]it is a feeling as if it happened with someone in your family (AE 7).
The work done by the nursing staff has mixed feelings, because at the same time that the creation of bonds is a determining factor in the experience of pleasure, the experience of the death of the elderly also influences negatively, which complicates the coexistence of the professionals with this feature of their working context.
The worker does not go to the workplace as a "new machine", it has a history, aspirations, desires, motivations, psychological needs, making each individual have unique and personal characteristics that influence their suffering relationship in work 1 .Thus, practitioners react differently on the death of elderly.While some of them see death as something natural and expected as part of the life cycle, others experience the feeling of sadness that comes to influence their health, time to overcome and return to the routine of work.
[...] the last one who passed away I stayed all day in bed, I did not get up for anything (NT 10).
[...] there was a grandfather who died here and I felt bad for about 15 days, kind of under the weather, it was hard to me getting better again (NT 6).
The characteristics of occurrence of death can generate different feelings among the workers, for instance the death of an elderly debilitated with unfavorable prognosis, they already await its death, which alleviates the suffering of the team.
[...] in the case of that lady who died suddenly, we receive the news as an impact, because she was feeling well.Different from another lady who was suffering and we expected her death at any time [...].When we do not expect the death of the elderly, we feel sadder (NT 9).
In the case of sudden death of an elderly with good health, the feelings experienced are of surprise and even shock on the unexpected, causing death even more difficult to be accepted.
It is observed that situations that cause suffering to these nursing workers present strong influence on their job satisfaction.Studies point out that if a small portion of the nursing team is not satisfied with their work, the entire care quality provided by the team can be compromised.Thus, it is essential to evaluate the satisfaction of these professionals, to be designed and implemented actions that seek to promote satisfaction and, consequently, experience of working pleasure for these workers, having in mind the quality of care directed to patients 23,25 .

FINAL CONSIDERATIONS
It was identified in the speeches of respondents the reinterpretation of suffering, especially by those who did not want to work in LTCI, from the experience of situations that cause pleasure, as recognition of the importance and value of their work by the elderly.
The reinterpretation of suffering is essential for the worker to reach a balance in the relationship between work-health-illness, as it allows the transformation of the situation which generates suffering, directing it to pleasure.The workers give a new meaning to work, promoting their professional growth and satisfaction, the development of their identity at work, besides being motivational factor in improving performance.
The daily life for a long period with the same individuals constitutes a specific feature of the work in the service of LTCI, enabling the creation of affective links between the workers and the elderly, relationship that affects both in the experiences of pleasure, as in the suffering, arousing mixed feelings.This finding is consistent with the Dejourian School's assumption that pleasure and suffering experiences are ambiguous and inherent in the whole context of work.
The findings of this study show that, as well as intensive care units and emergency services, LTCI have situations that cause pleasure and suffering to nursing professionals, demonstrating that the relationship between the individuals and their work should be investigated in various areas of activity of this profession, not limited to the hospital setting.
The lack of studies on the pain and pleasure of nursing workers in institutionalized elderly care, refers to the need for further researches concerning the influence of this work process on the professionals' physical and psychological health, as well as on the quality of care provided by these professionals.
It is worth pointing out the limitation of the approach of feelings and perceptions, since these are abstract aspects subject to the influence of the moment in which the individual is, to the subjectivity and to the interpretation of each worker.However, it is believed that this study can provide subsidies to stimulate discussions on issues related to experiences of pleasure and suffering, in order to promote the reinterpretation of pain and obtaining pleasure in nursing work at LTCI.

I
feel fulfilled and happy for them in appreciating us.I feel I am doing my job well.Then, I try to work harder, do my best [...] (NT 9).