PLEASURE-SUFFERING OF NURSES IN CARING FOR PEOPLE WITH MENTAL DISORDERS AND THEIR FAMILIES

Objectives: to measure and compare the pleasure-suffering indicators in Brazilian and Portuguese primary care nurses for the person/family in a mental disorder context. Method: this is a quantitative, descriptive-correlational, multicenter study with 500 nurses from Portugal and Brazil. Data collection was carried out via Google forms from April to August 2018, with a sociodemographic questionnaire and a scale of pleasure-suffering indicators at work. Results: In both countries, the reward-professional fulfillment domain was evaluated as satisfactory; insecurity/lack of recognition and wear/depletion as serious. Portuguese nurses assessed freedom of expression as satisfactory, Brazilian nurses as critical. In both countries there was a correlation between freedom of expression and length of service, working hours and gender; insecurity with training time, work performance, and workload; wear-depletion with working time in the current service and training time. Conclusion: nurses from both countries had critical levels of suffering at work. They assess, with reward and with the possibility of professional fulfillment, the care provided to the person and families in a mental disorder context, but their freedom of expression is compromised. portugueses para la persona / familia en el contexto de trastorno mental. Método: estudio cuantitativo, descriptivo-correlacional, multicéntrico con 500 enfermeros de Portugal y Brasil. Recogida realizada a través de Google forms de abril a agosto de 2018, con cuestionario sociodemográfico y escala de indicadores placer-sufrimiento en el trabajo. Resultados: en ambos países, el dominio gratificación-realización profesional fue evaluado como satisfactorio; inseguridad / falta de reconocimiento y desgaste / agotamiento como graves. Los enfermeros portugueses evaluaron la libertad de expresión como satisfactoria, los enfermeros brasileños como crítica. En ambos países existía una correlación entre la libertad de expresión y el tiempo de servicio, la jornada laboral y el género; inseguridad con el tiempo de formación, el desempeño laboral y la carga de trabajo; desgaste-agotamiento con tiempo de trabajo en el servicio actual y tiempo de formación. Conclusión: enfermeros de ambos países tenían niveles críticos de sufrimiento en el trabajo. Evalúan, con gratificación y con posibilidad de realización profesional, la atención brindada a la persona y sus familias en el contexto de la enfermedad mental, pero su libertad de expresión se ve comprometida.


INTRODUCTION
The guidelines of mental health and primary health care (PHC) policies in Brazil 1 and Portugal 2 advise that caring for the population of the health care network must be developed in a longitudinal, integral, and universal perspective, following the principles of the Unified Health System (Sistema Único de Saúde) and the guidelines of the National Health Service. They emphasize that PHC nurses must develop actions for promotion, protection, disease prevention, diagnosis, treatment, rehabilitation, and health maintenance for the person and his family, at all stages of the mental health-disease process. [3][4][5][6] With the epidemiological and care changes in the world mental health panorama, the inclusion of non-specialized actions in PHC that respond to the population's health needs to be aligned and articulated between the services, with a continuity of care and guided by the psychosocial model. In this process, studies show that PHC nurses can face physical and psychological suffering when dealing with specificities in which they do not feel qualified, and feelings of dissatisfaction can appear. 7 Otherwise, those who perform actions and do not recognize them as health mental patients also face suffering because they are not related to their work process. 8 In this understanding, this research focuses on the importance of verifying how the psychodynamics of work 9 occur in terms of pleasure-suffering of PHC nurses in the care provided to the person and the family in the context of mental disorder (MD) and to support political-pedagogical decisions in the training and continuing education of these professionals, promoting mental health actions in this area. Also, the choice of this group is due to the hypothesis that the demands and challenges that nurses face bring suffering when instituting mental health actions in PHC and the care relationship with the person and family in a mental disorder context.

OBJECTIVE
To measure and compare pleasure-suffering indicators in Brazilian and Portuguese primary care nurses for the person and the family in a mental disorder context.

METHOD
This is a quantitative, descriptive-correlational, multicenter study, reported following STROBE guidelines.
The participants of the study were 250 nurses from six family health units in the city of Porto and 250 nurses from 69 traditional UBS (Basic Health Units) -and/ or with the Family Health Strategy, from the six regional health coordinators in the city of São Paulo. The inclusion criteria were being a nurse, regardless of the length of professional experience and in the service, working in management and/or care.
The request to perform data collection was directed to the coordination of each service. We sent a link of the research with a Google forms form (description of the objective, collection instruments, and Informed Consent Form to make them available to nurses in their respective scenarios).
We researched from April to August 2018 in both countries, through a sociodemographic questionnaire containing age, gender, religion, marital status, academic qualifications, length of experience in the area, weekly workload, time of professional training, time of acting in the service/unit and training in MH throughout professional life. In the context of working with people and families x MD, we asked questions about the experience and frequency they face it, knowledge about health care needs, assessment of health needs conducted, assistance to the person and families, available in the service and unit, and the role of PHC MH care.
We used the Pleasure-Suffering at Work Indicators Scale (PSWIS) containing 30 items. 10 The factorial structure of the PSWIS contains two factors that assess the experiences of pleasure at work (freedom of expression -addressing the experience of freedom of thinking, organize and talk about the work -item 1 to 8; and reward-professional fulfillment -identification and pride with the work performed -item 9 to 17). As they are positive items, the specification, qualification, and frequency with they are experienced, the classification occurs in three different levels, with individual standard deviations: above 4 = more positive evaluation, satisfactory; between 3.9 and 2.1= moderate evaluation, critical; below 2.0 = rare evaluation, severe.
The two factors of suffering at work (professional wear/exhaustion (experience of uselessness, insecurity, frustration, exhaustion and stress at work -item 18 to 24) and insecurity (item 25 to 32 -the experience of indignation, injustice, and devaluation for not recognition of the work performed), with the occurrence of these experiences in the last six months of work (0= none, 1= once, 2= twice, 3= three times, 4= four times, 5= five times and 6= six or more times).
The analysis was conducted according to the following levels: below 2.0 = less negative evaluation, satisfactory; between 3.99 and 2.1 = moderate evaluation, critical; above 4= more negative evaluation, severe.
To assist and simplify the analysis and treatment of data, they were coded and entered into the statistical software IBM/SPSS -International Business Machines/Statistical Package for Social Sciences (Version 24. for Windows). The Z test was applied to compare two measures (or measure with nominal value), using their respective standard deviations, and to determine whether the difference between the two measures was significant. The difference was considered significant for Z values greater than 3.5. Z values between 3.0 and 3.5 were inconclusive, therefore, no difference between measurements. For a Z value below 3.0, there is no statistically significant difference.
The correlation between the PSWIS factors was performed using Spearman's correlation coefficient. The strength of association can be classified according to the intensity of its correlation, ranging from +1 to -1, classified according to the intensity: r = 1 perfect correlation; 0.80 < r < 1 too high; 0.60 < r < 0.80 high; 0.40 < r < 0.60 moderate; 0.20 < r < 0.40 low; 0 < r < 0.20 very low; r = 0 nil. We estimated internal consistency using Cronbach's alpha coefficient to assess the reliability of the factors.
In both countries, the project was approved by the Ethics Committee for Research with Human Beings (

Characteristics of the study population
There was a predominance of female professionals in both countries (Portugal -82.0%, Brazil -85.6%), with a mean age in Portugal of 42.0 years old (standard devia-tion=7.7) and of 36.3 years old in Brazil (standard devia-tion=7.7). In both countries, most of the sample is married (Portugal-71%, Brazil-57.2%) and Catholic (64.4%).
As Experience with people and families in the context of MD: Portugal -94.8% Brazil -63.3%. Brazilian nurses face daily people and families with MD (63.6%) and self-assess with very adequate knowledge about the health care needs of individuals and families in the context of MD (42%), compared to Portuguese nurses (1.2%). They assess that they have adequate knowledge about the role of PHC in care for MH (34.8%) compared to Portuguese nurses (47.6%). For Brazilian nurses, the assessment that the services where they work make about the health needs of the person and families in the context of the MD (33.6%) is very adequate, and the care provided to the person and families provided in the service is very adequate (40.4 %), compared to the Portuguese nurses -3.2% and 2.0% -, respectively, and the latter are those who do not have training in MH (66.2%) ( Table 1). Pleasure-suffering of nurses Table 2 shows the total results of the dimensions of the PSWIS scale. As to the pleasure factors, we observed that both in Brazil and in Portugal, the reward is evaluated as satisfactory. Freedom, on the other hand, is evaluated as critical in Brazil and satisfactory in Portugal. Concerning the factors of suffering, both in Brazil and Portugal, insecurity and weariness were evaluated as severe.
Regarding the pleasure factors, Table 03 shows that in the reward/professional fulfillment domain, Brazilian nurses had a higher average for the item "feel satisfied in performing their tasks, identify with the tasks" and "it is performed professionally", compared to the Portuguese. In the domain of freedom of expression, the Portuguese had a higher mean to the item "in my work, I can use my style" than Brazilians.  The factors of suffering were treated as follows: in the insecurity/lack of recognition domain, the items "fear of being fired for making mistakes, I feel insecure with the threat of losing my job, I feel insecure when I do not meet the company's expectations about my work, I feel recognition from the supervisor for the work I do, I feel insecure when I do not comply with the rhythm imposed by my company", Brazilian nurses achieved a higher mean.
The items "my job is exhausting, my job is tiring, I feel discouraged at work, I feel threatened with dismissal" from the professional exhaustion/wear domain showed that Portuguese nurses reported a higher mean. Brazilian nurses in the item "I feel threatened with dismissal" had the highest mean compared with the Portuguese nurses. Table 4 shows that in both countries, only the dimension reward -professional fulfillment did not show any correlation with the labor and sociodemographic variables. In all dimensions, the variables academic qualifications and marital status showed no correlation. There was a positive correlation between the two countries regarding the domain of freedom of expression and working hours, gender, and length of experience in the current service.

DISCUSSION
In this study, it was evident that most are female and have a bachelor's degree (Brazil) and a licentiate degree (Portugal) as academic qualifications. Brazilian nurses have less training time. The workload is concentrated between 30 and 40 hours, and Brazilian nurses work, on average, 40 hours. Therefore, we can consider that the time dedicated to work puts Brazilian nurses more in contact with people and families in the MD context. Therefore, they consider that knowledge about the health care needs of the person and families in the MD context is adequate or very adequate.
In Portugal, knowledge about the role of PHC in mental health care is considered adequate and/or inadequate, findings that may result from the lack of training in the area throughout professional life. It was also evidenced in this study, leading to inadequate evaluation of the health needs and care provided in the service to the person/families in the MD context.
We know that professional experience combined with training is essential for qualified care and practice based on scientific evidence. 11 The Portuguese National Health System has encountered challenges to improve health care in PHC, particularly in mental health, in less privileged areas, with investment in human resources to cover the population and an expanded government vision of the expected future of PHC. 12 The freedom of expression dimension reached a criticality level in Brazil, and in Portugal it was satisfactory. Considering that work provides the construction of the professional's identity, and this is something that is built in the relationship with the other to imprint their creativity, production of occupational health, autonomy, and, consequently, professional fulfillment 13 , the workspace of the nurse must constitute an active place, where peers interfere in the work process of the other, in search of results that transform, modify and develop their potential. 14 Thus, the freedom of expression of Brazilian nurses is impaired. We believe that in the socio-historical context of the construction of the profession's identity, there are gaps regarding the understanding of their role as a mental health care agent in the context of PHC, which raises difficulties to properly discuss actions in specific terms. .208 * The correlation is significant at the 0.05 level (bilateral). ** The correlation is significant at the 0.01 (bilateral) level.
Both in Brazil and in Portugal, when nurses provide care to individuals and families with mental disorders, they have professional reward/fulfillment, as they identify and perform their tasks with satisfaction. In this logic, a study with Nursing professionals showed that satisfaction was related to professional commitment, by acting on the health of others. 15 Considering that satisfaction is closely related to subjectivity, emotion, and feelings, it is dynamic, active, and complex and determined by individual perception and needs, at varying and differentiated levels of importance, it impacts the quality of life of the professional, of the service, offered and can be regarded as similar to pleasure and reward. 16 In the exhaustion-wear dimension, for nurses in both countries, work is demotivated, tiring, and puts them under threat of dismissal. In this sense, these professionals are exposed to frustration, insecurity, risks of making care errors, 15 aspects that lead to a lack of recognition of the effort invested and potentialize mental suffering in the worker. 17 When analyzing the correlations, we observed that the freedom of expression dimension was bilaterally correlated with the workload and gender (negative), and length of work (positive) variables. The length of experience makes the professional feel more confident and experienced and, consequently, better evaluated, although this is a relatively young sample. Even though in academic training, decision-making competence is emphasized, and as this study is mostly made up of women, power relations must be considered as a risk factor to reduce freedom of expression in the gender issue.
The workload variable also interferes with the free expression of the study professionals, even though the workload is relatively extensive, which allows for more interaction between team members and cooperative work. Therefore, in the absence of space for dialogue between workers due to the overload of activities, freedom of expression is even more compromised.
For Brazilian nurses, the correlations of the insecurity dimension with the variables time since training and experience were positive, and negative for the workload. The short training and performance time does not allow for the return of superiors regarding the performance of the work performed. Also due to the high turnover and goals to be achieved, since most health services in the country have been managed by social health organizations, and a higher rate of dismissals, turnover, and instability of contracts, 18 insecurity can emerge.
The larger workload allows the professional more time in contact with the population and work environment, expanding the development of skills. Compared to Portuguese nurses, who have a smaller workload, the goals to be achieved can be high and time-restricted. Nowadays, in the health sector in general, in Portugal, there is no planning process involving human resources. 19 As for the training time of newly graduated professionals, there seems to be, in the Brazilian reality, a tendency for nurses to believe and feel less prepared for professional practice. In this sense, it rescues the importance of continuing education to meet the needs of academic training as a strategy for solving problems within the work process and concrete specificities in health services. 20 We observed the opposite in Portugal, where the time of academic training extended to the country's reality in terms of career advancement and salary remuneration and even compared to neighboring countries. According to a study carried out with 250 Portuguese nurses, there is a positive and significant relationship between the opportunities to learn, grow and feel satisfaction with job. 21 Although the weekly workload in Brazil is slightly higher than in Portugal, the correlation with the insecurity dimension can put these nurses in the condition of thinking that, even producing, that is, working more, they do not achieve the expected result for the service. Thus, working more, they will feel tired, at risk of developing psychological distress, ill, insecure, and, therefore, unable to feel recognized.
In the bilateral correlation between the professional exhaustion-wear dimension (experience of uselessness, insecurity, frustration, exhaustion, and stress at work) and the variables time since training and working, we observed that nurses in both countries have a severe index for this dimension. These factors are due to the high demand for performance, financial instability, and stress generated by situations of workplace violence. 22 In both countries, the insecurity and weariness/lack of recognition dimensions reached a severe level and can even reach the point of violence at work, which does not occur in isolation, on the contrary, it involves changes and social demands that arise, such as access by the population health services, working conditions and also gender issues. Faced with unfavorable working circumstances, nurses can suffer violence, in addition to bullying, which compromises professional leadership, as well as the quality of health care offered. 23 The socio-historical context of the Nursing work process is linked to manual activities, which even reflects on the professional's remuneration and echoes in a feeling of suffering as opposed to the pleasure related to work. In the dimension of reward/professional fulfillment, nurses from both countries feel pleasure in their job only in terms of execution and identification with the tasks/actions of MH in PHC.
Although we are aware of the weaknesses in training that do not lead them to properly exercise mental health care in this context, the movement of insertion of this field of knowledge in PHC has been a constant and may be reverberating in these professionals. 24 In the mental health area, a reasonable balance has not yet been reached between the biological and psychosocial issue of mental disorders, and the middle ground becomes something complex, influencing the training processes of nurses, who seek improvement, especially in the daily life of mental health actions in the community. 25 The result of the actions they carry out, even not recognizing them as powerful, refers to the principles of comprehensive care, something that cannot be discarded. As a result, they feel pleasure only when they can use their style to guide their actions, that is, they need the freedom to express their creativity and build care outside the specialty spaces, based on their experiences and evidence.
The literature shows that the understanding of pleasure and suffering at work is of great importance to promote workers' health and improve the quality of care. By recognizing the factors that cause suffering and pleasure, there are indicators for institutions and professionals to try to improve the work environment, so that it is more pleasant to do it and minimize the risk of illness. 25

Study limitations
As this is a cross-sectional study with a convenience sample, the limitations lie in the possibility that the results suffer a temporal bias and cannot be singled out for other populations, due to the specificity of the one studied. Therefore, we suggest further studies to establish other factors involved in the pleasure and suffering of nurses in primary care for the person and family in the context of mental disorder, as well as actions to strengthen or deconstruct them.

Study contributions
This study contributes to the Nursing area by identifying strengths and weaknesses in the training and work process of nurses in primary care in the person and family in the context of mental disorders. These results support the implementation of policies in the scope of undergraduate education and permanent education and reflection on current practice, to rethink improvements in mental health care provided by nurses working in PHC.

CONCLUSION
The study showed that nurses from both countries had critical levels of suffering at work due to insecurity, exhaustion, wear, discouragement at work, and fear of dismissal, which are associated with the variables time since training and working. Although nurses are satisfied with the work environment, freedom of expression is compromised and negatively associated with workload and gender.
The complexity involved in caring for the person and the family in mental health context requires the qualification of nurses working in PHC. For the most part, when the person does not feel prepared to assist them, they may experience psychological distress. The nurses carried out the care of the person and the families in the context of the mental disorder with satisfaction, therefore, they evaluate it with reward and with the possibility of professional fulfillment.