Quantitative approach
Of 209 participants, the percentage for women was 71.8%, see Table
1, and the mean age was 33 years (minimum 20; maximum 65 years); the majority of staff that work in the ACC is nursing at 53.2%.
Table 1
Distribution of professionals who work in the ICU of Valle del Cauca - Colombia during 2020–2021 (n = 209)
Nursing assistant | 14 | 6.7 | 34 | 16.3 | 48 | 23.0 |
Nurse | 25 | 12.0 | 80 | 38.3 | 105 | 50.2 |
Medical specialist | 7 | 3.3 | 2 | 1.0 | 9 | 4.3 |
General practitioner | 10 | 4.8 | 8 | 3.8 | 18 | 8.6 |
Physical therapist | 2 | 1.0 | 13 | 6.2 | 15 | 7.2 |
Respiratory therapist | 1 | 0.5 | 13 | 6.2 | 14 | 6.7 |
Grand Total | 59 | 28.2 | 150 | 71.8 | 209 | 100 |
For the total number of participants, the average number of years of study, including primary school, was 17.6 years (± 5.12); the average time in years of working seniority was 4.8 (± 5.6), and the average hours worked per week was 50.6 (± 10.3). Other population characterization data are found in Table
2.
Table 2
Characteristics of the health workforce of the CCAs of Valle del Cauca - Colombia 2020–2021 (n = 209)
Civil status | Married | 36 | 17,24% |
Divorcies | 7 | 3,34% |
Single | 130 | 62,20% |
Free Union | 35 | 16,74% |
Widower | 1 | 0,47% |
Level of study | Specialization | 27 | 12,91% |
Master’s degree | 9 | 4,30% |
PhD | 1 | 0,47% |
Undergraduate | 124 | 59,33% |
Technical | 48 | 22,95% |
Position in the company | Assistance | 182 | 87,08% |
Assistance and administrative | 21 | 10,04% |
Administrative | 6 | 2,87% |
Schedule | Rotating shift (morning- afternoon or night) | 187 | 89,47% |
Office hours (8 h a day) | 18 | 8,61% |
Rotating shift except nights | 2 | 0,96% |
Fixed shift at mornings | 1 | 0,48% |
Fixed shift at night | 1 | 0,48% |
Causes of disability in the last year * | COVID 19 | 35 | 76% |
Others** | 11 | 24% |
On the results the HWF is unsatisfied in four out of four dimensions of the QWL-GOHISALO with an average of 9.8 (± 1.7) for Integration into the workplace (59.8%), 9.6 (± 2.1) for Personal development (64%), 19 (± 3.2) for Satisfaction at work (74.2%) and 5.5 (± 2.1) for Free time management (76.6%). To see the comparative percentage distributions between these dimensions, Table
3.
Table 3
Distribution of the QWL-GOHISALO scores of the WHF in the ACC of Valle del Cauca– Colombia during 2020–2021 (n = 209)
Institutional Support for work | 68 | 32 |
Safety at Work | 66.5 | 33.4 |
Integration into the workplace | 40.2 | 59.8 |
Satisfaction at work | 25.9 | 74.2 |
Well-being achieved through work | 68 | 32 |
Personal development | 36 | 64 |
Free time management | 23.4 | 76.6 |
Regarding psychosocial risks, of the 15 dimensions measured, the most unfavorable for health are the pace of work (84%), insecurity in working conditions (68%), quantitative requirements (63%), job insecurity (58%), role conflict (45%) and justice (40%). The dimensions with the most favorability were the possibility of development (94%), sense of work (85%), clarity of role (67%), double presence (55%), emotional demands (40%), quality of leadership (35%) and vertical confidence (34%). Regarding the dimensions that were classified as intermediate, there are influence (39%) and predictability (37%).
Regarding satisfaction due to compassion– SC, more than half of the ACC health workforce is classified as high, which is equivalent to 67%, with an average score of 43.5 (SD = 5.3). Both burnout (BO) with an average score of 20.8 (SD = 7.7) and the secondary trauma scale (STS) with an average score of 17 (SD = 9) are classified on average between 46.4% and 26%, respectively. Two professionals are classified as “high” for BO and STS.
Most of the HWFs reported a low intention to rotate to another service (67%), to another institution (56%), to migrate to another city (63%) or to change to independent work (56%). In contrast, 66% reported a high intention to migrate to another country.
Qualitative approach
With narrative research based on hermeneutics through details expressed by the participants’ own words, a route was woven between the structured stories to men and women from different professions (3 doctors, 4 physiotherapists, 2 nurses and 1 nursing assistant) who work in both public and private ACCs to build knowledge.
In this part of the manuscript, two main themes are presented that emerge in the data analysis and that are not evaluated through the instruments applied in the quantitative approach but that emerged from the qualitative approach. The first “Discrimination and harassment as normalized practices” and the second “The faceless spirituality of THS in the UCIA.”
An additional theme emerges “multidimensionality of the QWL” expressed by the 7 dimensions (categories) that make up the instrument of the quantitative approach institutional support, job security, integration into the job, job satisfaction, well-being achieved through work, employee personal development and leisure time management, which are inserted in the analytical matrices of the approach to the integration of methods. See supplementary material at Mendeley Data [
34].
Discrimination and harassment as standard practices
Some reports from the participants show tolerance of various types of discrimination among them based on race, gender, age and profession, the latter perpetuated through practices of workplace harassment. An example of this situation is recounted by Amatista regarding her ethnic-racial group, who mentioned a broken voice and tears in his eyes:
“…a relative of a patient told me: I do not like being treated by people of your race, your color, I am ah! (Silence, she stutters) The truth is, I did not know whether to cry, laugh, shout, hit him… that shift I cried all 7 hours! I have never felt so humiliated, trampled on, beaten… because of my color! (M2(40)E).
Those who witnessed the situation chose to ignore what was happening, and it is evident how these become repeated behaviors framed in patrilineality. Said tolerance to something that is known to be wrong becomes a type of adaptation of the human being to the environment based on a patriarchal system, without sisterhood and that, in a few words, allows discrimination.
Impunity and “adapting” to living in a state of discrimination is a reality for many women, as Jade relates:
“It always happens to me, because I say that it is like the combination of the 2 things, being a woman and being black (pleasant laughter) it is very funny because they arrive and it is… and the doctor?! So sometimes… when I do not care about anything I let them hang around and when the boss says there’s the doctor sitting, then I, oh, is it that women doctors do not exist? and black worse!! I tell them… but then if I do not have a gown on I’m not a doctor, if I do not have something that says doctor… I’m not, but it is something I finally learned to be with"… “some say I’m very girl, that I am a woman” (M9(30)MD).
The foregoing highlights a fragmented being: ecological “me versus nature versus technology”, a social rupture “me versus the other” and a spiritual crisis “me versus me” that requires a frontal approach that involves ALL parties in search of compassion from and for the HWF.
Faceless spirituality
Hospices evolved from the public to the private within the framework of a capitalist society, which made it evident that the HWF, when seeing their physical and/or mental health threatened, frequently adapts and uses coping strategies; one of these is spiritual, and the other is religiosity, which helps reduce psychological distress, balance, and promote healing states. In the case of the health workforce, these strategies can promote quality of life at work, although they are not always recognized, well managed, or externalized.
A participating professional pointed out: “…I believe in angels but I’m not much of talking about that spiritual part with family members because it is something that we have always had to respect their beliefs, the taboo and the fear of offending them or being reckless. I do not want people to perceive what is not…” (M9(30)MD).
Those who work in the ACCs know that religion and spirituality have been absent from the discussions on the QWL of the HWF in the last 15 years. The interaction of the spiritual with the scientific has undergone modifications around the technological evolution from the rational to believe only in what can be proven, which is not compatible with spirituality, since it cannot be seen, proven or validated directly, so it is simply marginalized or downplayed.
Contradictorily, at present in this conflict, quality parameters are established in care from the holistic perspective, but without fully incorporating care in the spiritual dimension, both for patients and for the people who make up the health workforce.
The HWF is integrated into a capitalist society that encourages them to be productive by focusing on material aspects and not on holistic professional development in the CAC. The impact of technology has made the open and shared management of spirituality difficult and results in processes where health has become a commodified good.
Mixed methods integration
This consolidation process in terms of convergence, complementarity and/or divergence resulted in the findings combined with two main topics, the first, “What the HWF that works in the ACCs gains”, see Table
4 and the second, “The sacrifices of the HWF in the exercise of their profession” see Table
5.
Table 4
Results of the convergent parallel design “what the HWF that works in the ACCs earns” to interpret the QWL of the HWF in a region of Colombia 2020–2021
Most of the HWF in ACC are satisfied with institutional support, job security and well-being achieved through work | • Training and permanent updating • Experience time • Balance between salary and work effort • Endowment and inputs • Disconnection with work • Individual/group celebrations and rituals • Institutional support • Technology evolution • Plant contracting • Feeding during shifts | Convergent |
The intention of the HWF to rotate to another service, another HSPI, another city or to independent work is low | • Thoughts of leaving the service • Situations that favor the intention of breaking | Divergent |
Most of the HWF have a favorable exposure to psychosocial risk for health in the dimensions of leadership quality, possibility of development, sense of work, clarity of role, double presence, vertical trust and emotional demands | • Personal spirituality present but not visible • altruistic • Committed • Acceptance of hierarchies • Personal satisfaction from the duty fulfilled • Highly trained and efficient • Disciplined • Compliance with protocols and institutional regulations • Permanent training opportunity with technological updating | Complementary |
The HWF of the ACCs has a high satisfaction for compassion | • HWF compassionate with patients, but not always with the colleagues • Satisfaction of saving lives •Empathy with patients and work team | Complementary |
The HWF of the ACCs has low compassion fatigue (Burnout - BO and secondary trauma stress - STS) | • Dehumanization of care • ICU with open or closed doors • Suffering and loss of patients managed through follow-up with therapists • Mechanisms of psychological protection against pain or periods of crisis • Work under pressure is best done in a team | Complementary |
Regarding the factors that positively influence their QWL, some hypotheses are proposed as to why they continue working at the ACC despite having other dimensions in which they are not satisfied, which will be pointed out in the following section. The quantitative results regarding the dimensions of the QWL that have approximately 58% of the HWFs satisfied are related to the link that exists with the health institution where they work, described by those elements such as the acceptance of supervision by their superiors, the opportunities of promotion, autonomy and work processes themselves in the current position they hold.
This description converges with the stories of Zafiro and Amatista regarding technology training, length of experience, balance between salary and work effort, resources and inputs, and disconnection from work:
“This Saturday I spent the night, it was a little complicated because patients came to me to intubate, I rested little, fortunately I have a good team to work with and we squared up the room quickly” (M4(33)FT).
“…it is my first day as an ICU coordinator, bringing all these experiences and knowledge that I have obtained over 9 years in critical care… I feel simply happy! Now comes a week of meetings and little by little strengthening my new role, I just hope it takes me on the best path, and prove to myself that it was the best decision” (M1(40)E).
“For me, hierarchies are leadership, they must exist, they are the people who have clear objectives and who guide people to achieve those objectives” (M9(30)MD).
These factors are complementary to the 60% favorability in the health of the ACC workforce regarding the risk of psychosocial exposure within the framework of their ability to understand the situation of others (patients, relatives or coworkers who suffer) and generate compassion for them, as well as in the stories that show the double shifts to earn more money, established by the shortage of personnel in times of COVID-19 or without it, putting the relationship with their domestic responsibilities to the limit. Aquamarine and Sapphire refer:
“Today I extubated a patient! It made me very happy because it had been more than two months since I had extubated a patient. Almost all the patients have died… Almost all of them obese, with comorbidities of hypertension/diabetes and they have become complicated! That has kept me happy this turn, I have no desire to leave (Aquamarine smiles). It is very emotional to know that lives can begin to be saved even with the shortage of medicines and supplies due to the pandemic” (M10(28)FT).
“For me, the most positive thing is always when I manage to get a patient through, that for me is like an adrenaline rush” (M9 (3)MD).
Opportunities to develop skills and knowledge become stimulating factors that give meaning to work through their occupational profiles, according to the functions they perform in their positions. the stories of Caicedonia and Esmeralda that support a complementary finding when integrating the results:
“During the pandemic we have had to learn many things and the institution has been in charge of training us” (H8(27)MD).
“When they train you feel empowered by what you are doing” (M10(28)FT).
“Not everyone has the same thirst for knowledge” (M4(33)FT).
However, when reviewing other reports, divergence is found, although health institutions develop training activities, considering that the work environment in the ACCs requires the use of technology and that it advances by leaps and bounds, not all of them consider it a priority for their health workforce and they are not enough or needed.
This could be because the institutions do not include a training program that considers the academic level, motivations, age, and seniority of the HWF to develop the activities that, in addition, takes into account the different learning systems immersed in the andragogy of care with the respective monitoring of the learning process. This statement is supported in the stories of Opal and Amethyst:
“It is a quite big challenge because many times the technology should come accompanied by training and the training is not always the best considering that we do not have much time available” or “I have colleagues who still struggle with the computer to open the program to be able to making nursing notes, for example, does not help them, so they become stressed, despite the training” (H3(36)E).
“I have a staff of 30, 40, 50 and we are not all strong in handling an ultrasound machine or other processes that require the use of technology. We do not have the same learning ability, so if you as a company or institution do not provide education to handle technology, the technology is going to stay there and not everyone is going to take advantage of it. The technologies themselves are good but the institutions do not invest in the education of personnel” (M2(40)E).
Additionally, it is likely that the high compassion satisfaction represented by 67% of the HWF who participated in this study with low compassion fatigue by 63% is reinforced by the factors described above, giving the most positive possible result described in the literature (16) for the HWF that is satisfied in three of the seven dimensions of the QWL, probably because they receive reinforcement from their work in a positive way. This HWF has no significant concerns about being "stuck" or inexperienced to do their job, either as individuals or within their organization, becoming influential to their peers and their institution. HWF may be welcomed by patients who attend it and by those who seek its help.
Divergence is found between the low intention to rotate or leave the profession because in the reports the HWF refers that they do have thoughts of changing their workplace to another health institution where they have the possibility of improving their quality of life. Like for example when Sapphire says:
“A colleague went on vacation, and they loaded the rest of us with work, it’s really very heavy right now. I have even thought about quitting… it really causes me a lot of stress” (M4(33)FT).
The results are diverse, with some consistent with the qualitative and quantitative findings and others divergent. It stands out that the health workforce is highly committed, resilient, and adapts by providing an organizational culture that resists leaving the ranks of the ACCs for a limited time.
This section shows significant aspects for the HWF that works in the ACCs of the present study due to being dissatisfied with the QWL evidenced in 69% of the labor force with respect to 4 of 7 of its dimensions, which in turn are related to 71% of the HWF who have exposure to unfavorable psychosocial risk for health. The data are convergent when the imbalance is evident between the level of preparation of the HWF and the respect of the contractual rights of connection to the HSPI with a compensation system that shows concern for future work regarding salary type, forms of payment, hours, and job position, with consequences on their job stability, as reflected in the combined analysis.
Table 5
Results of the convergent parallel design “the sacrifices of the HWF in the exercise of their profession in ACC” to interpret the QWL of the HWF in a region of Colombia 2020–2021
Most of the HWF in ACC are dissatisfied with the integration into the job, job satisfaction, personal development of the worker and free time management | • Discrimination by profession • Adverse events • Delays in payment of wages • Ignorance of labor policies • Gender discrimination • Double work • Shortage of advanced technology • Payment of salary glosses • Salary differences • Retaliation | Convergent |
The intention of the HWF to migrate to another country is high | • Clear signs of wear with verbalization of boredom or dissatisfaction with working conditions • Verbalization of the desire to migrate to another country | Complementary |
The majority of the HWF obtained an unfavorable psychosocial risk exposure score for health in the rhythm of work, insecurity in working conditions, quantitative demands, job insecurity, role conflict, justice, influence and predictability | • Shortage of FLS or minimal hiring of personnel to reduce organizational costs • Overload of those who are linked • Uncertainty and labor instability due to types of contracting outsourced or on terms • Broken employment relationship between the organization and the FLS due to outsourcing • Conflict management is not always fair • FLS adapted to working conditions due to the need to receive a salary • The organizational culture allows certain degrees of autonomy, but with role conflicts • Invisible spirituality toward patients and their families | Complementary |
It was also found that there is a dedication to work almost exclusively juxtaposed to a majority of the HWFs with a global feeling of displeasure with aspects associated with the use of their skills for activities that sometimes do not belong to their current position. As Esmeralda expresses it:
“We must take care of the oxygen cylinders, that doesn’t seem to be my function because in the other institutions where I have worked that is done by the messenger, stretcher bearer… in charge of medicinal gases… I have to go down several floors and walk several floors to the central pharmacy carrying that oxygen cylinder, see if they can change it there for a new one and carry it up again to leave it full for my partner. So be tenacious, because sometimes there is no… you miss the trip, you return with nothing! But thank God, today there were” (M10(28)FT).
The work activity itself does not motivate the staff in relation to the scope of their achievements and is related to unfavorable expectations of job growth and intangible benefits under situations that challenge their own physical, mental, and spiritual health daily with a frequent sensation of being at risk. In this regard, Rubí relates:
“Right now I am in treatment because I had an anxiety crisis… it started in July and it was very strong but I did not want to continue the medical and pharmacological treatment with the psychiatrist and about 15 days ago the anxiety crisis recurred” (M5(25)FT).
And Sapphire expresses:
“…communication is very difficult, especially with doctors, the more professionals the more difficult… there is a very ugly gap!!…if it is difficult between the professional and the specialist, now imagine yourself with an assistant” (M4(33)FT).
Regarding the administration of free time, the HWF exercises control over what he does with himself; however, the way in which the institution schedules the shift rotation of health personnel influences the availability of time, which causes a fracture between the work situation in relation to the enjoyment of life with family and friends. This situation may explain the frequent social and family isolation that those who work in the ACCs are subject to. As Lapis Lazuli and Amethyst relate:
“Sometimes you don’t notice it, but you take your work tasks home"… “it affects your family, the social role that you also fulfill at the community level… my wife tells me that I arrive every days when during the week I am an ogre and on the weekend I am loved” (H1(40)MD).
“They affect you in the sense that you don’t have time and that you live stressed, you always live tired and sleepy, then it gets to the point where you live at work and go home to sleep” (M2(40)E).
Other results related to spirituality or aspects of discrimination or workplace bullying, described in the qualitative section, when analyzed, are divergent from the data resulting from the measurements with the use of QWL instruments, exposure to psychosocial risk and satisfaction/compassion fatigue, because these instruments do not incorporate items that demonstrate these situations in the work context that undoubtedly influence the QWL of the HWF in the ACCs. The ProQoL instrument has an item related to spirituality, but when making a global score aimed at fatigue or satisfaction due to compassion, it loses relevance in this regard.