Multiple employment relationships, precariousness and psychosocial suffering in the daily life of a university hospital

Abstract

Introduction  in a university hospital, multiple employment relationships are adopted, implying distinct contract regimes and also distinct employers. In this context, there are four types of employment relationships: civil servants, employees, outsourced workers, and public hired employees, who, working side by side, coexist with differences such as salaries, working hours, union representation, among others.

Objective  to understand the psychosocial demands faced by workers in the daily work environment of a university hospital.

Methods  Ethnographic study based on the framework of Social Psychology of Work. The following procedures were used: observation, field diary, interviews, and document analysis. The material produced was subjected to thematic analysis. Results: the different forms of employment relationships between workers and the studied hospital impose unequal relationships, giving rise to experiences of competition, hostility, individualization, uncertainty, insecurity, anguish, and injustice, shaping a work routine in which psychosocial suffering becomes an attribute of the job.

Conclusion  multiple employment relationships weaken the collective organization of workers, undermine rights, and establish a scenario of constant tension with repercussions on mental health.

Work Relationships; Precariousness of Work; Psychosocial Suffering; Daily Life; University Hospital

Resumo

Introdução  em um hospital universitário são adotados múltiplos tipos de vínculos de trabalho, o que implica regimes de contrato distintos e empregadores também distintos. Nesse contexto tem-se quatro modalidades de vínculo: servidores, funcionários, terceirizados e empregados, que, trabalhando lado a lado, convivem com diferenças como salários, carga horária, representação sindical, entre outras.

Objetivo  compreender as demandas psicossociais enfrentadas pelos trabalhadores no cotidiano de trabalho de um hospital universitário.

Métodos  estudo etnográfico, com base no referencial da Psicologia Social do Trabalho. Utilizaram-se os seguintes procedimentos: observação, diário de campo, entrevistas e análise de documentos. O material produzido foi submetido à análise temática.

Resultados  as diferentes formas de vinculação dos trabalhadores com o hospital estudado impõem relações desiguais a partir das quais emergem vivências de competição, hostilidade, individualização, incerteza, insegurança, angústia e injustiça, conformando um cotidiano de trabalho no qual o sofrimento psicossocial torna-se um atributo do trabalho.

Conclusão  os múltiplos vínculos de trabalho fragilizam a organização coletiva dos trabalhadores, pulverizam direitos e instauram um cenário de tensão constante, com repercussões à saúde mental.

Vínculos de Trabalho; Precarização do Trabalho; Sofrimento Psicossocial; Cotidiano; Hospital Universitário

Introduction

Social Psychology of Work is a field of research and intervention which, based on the interface between Social Psychology and the Social Sciences, aims to understand human phenomena at work, taking workers as protagonists in the construction of knowledge. Its characteristics include the use of different theoretical and methodological references and a consideration of the micro-political relationships that are established in everyday work, linked to broader structural conditions¹.

Studies of everyday life²-⁷ were taken as theoretical-methodological references and ethnography was the methodological strategy adopted⁸,⁹in this research.

Daily life is understood as a “field of apprehension of reality”¹⁰, in which the relationships that are established reveal social structures and historical processes. It is in everyday life that the political fabric that produces and reproduces the social order manifests or materializes, maintaining and sustaining interests, but also leaving gaps for confrontation, disagreement, and resistance²,⁵,⁶,¹¹.

In this sense, it is essential to know, albeit briefly, the history that led to the situation that was taken as the research problem, in order to move towards the objective.

Brazilian federal university hospitals (UH) are public services subordinate to federal universities, aimed at teaching, research, and extension through health care. They therefore combine two public macro-policies: education and health. They are managed by two ministries - the Ministry of Education (MEC) and the Ministry of Health (MS) - whose different conceptions of work organization have produced heterogeneous and diffuse work management practices¹²,¹³.

The situation of multiple jobs at the UH was consolidated in the 1990s. With the 1988 Constitution and the approval of Law No. 8.112, which instituted the “Single Legal Regime for civil servants of the Union, municipalities, and public foundations”¹⁴, the hospital’s workers became federal civil servants, with contracts regulated by the Single Legal Regime (RJU). However, during the 1990s, with a shortage of staff, the hospital started hiring employees through a university foundation, with contracts regulated by the Consolidation of Labor Laws (CLT)¹⁵. At the same time, companies were hired to provide support services: cleaning, laundry, security, and maintenance. This led to the entry of yet another contingent of workers with different ties: outsourced workers. In 2011, the federal government created the Brazilian Hospital Services Company (EBSERH) to manage the UHs¹⁶. In this context, EBSERH began to hire workers as public employees. In 2014, the UH signed a contract with EBSERH and began receiving public employees in a wide range of professional areas.

Since 2015, the hospital’s workforce has been made up of: civil servants, employees (CLT), outsourced workers, and public employees (EBSERH). Each of these types of employment relationship has specific differences, such as the legal provision governing the employment relationship (RJU for civil servants and CLT for employees, outsourced workers, and public employees), the employer (the state directly for civil servants, a foundation for civil servants, a third-party company for outsourced workers, and a public company for employees), as well as the employment contract itself, which provides for different requirements and rights (salaries, hours, benefits, bonuses) and other conditions resulting from negotiations collectively agreed between the different employers and the different organizations representing the workers.

A similar situation has been mapped in other studies and they point to the same reality in other UHs¹³,¹⁷,¹⁸.

In UHs in general, and in the UH studied specifically, there is a context in which workers who share the same space and use the same work tools, carrying out activities together, are differentiated by their employment relationship. The relationships established daily find their matrix in the hybrid composition of the workforce. The link is, if not the main one, a fundamental distinguishing feature. This configuration gives rise to several commitments.

The sense of class or collective that is identified in this way is fragmented, undermining the feeling of belonging and solidarity, the result of “management by fragmentation” which culminates in the process of individualization¹⁹, identified as the basis of modern people management. Insecurity is intensified, as “management by threat” becomes possible, in which workers subject to the most precarious contracts are constantly reminded of the vulnerability of their jobs, a phenomenon in the world of management that has been mapped and named “manipulation by fear”²⁰. The most precarious workers are subjugated, they accept, abide, obey, and, when faced with the difficulty of coping or finding forms of resistance, they suffer. Others, if they don’t suffer because of the vulnerability of their jobs, do so because of the uncertainties that are increasingly present. Even those who enjoy the best guarantees are apprehensive about the transformations to which they are subjected and whose repercussions affect everyone.

The suffering that takes place therefore has its political genesis. It is in the web of relationships that are established daily that civil servants, employees, outsourced workers, and public employees meet to work and realize the demands they will have to face as a result of the different ways in which they are linked to the hospital.

Studies on outsourcing point out that the “social precariousness of work [...] proves to be a strategy of domination that affects all workers, even if in a differentiated and hierarchical way”²¹ (p. 16). In this sense, it is understood that, although in different ways and with different consequences, all workers are affected by this process of the “degradation of work”²¹.

The concept of “subjective precariousness” defines the “feeling of precariousness that stable wage earners can experience when they are confronted with ever-increasing demands at work and are permanently preoccupied with the idea of not always being in a position to respond to them”²² (p. 45). If job insecurity on different scales ends up affecting all workers to some extent²¹, the demands of work in the context of employment, which result from the ways in which it is organized, end up generating a precarious subjectivity²², which promotes psychosocial suffering among workers²³.

The distinction made based on the employment relationship implies an inequality that translates into limitations for some and possibilities for others, restrictions on one side and advantages on the other, obligations and benefits distributed on an unequal scale, depending on the contractual relationship, forging a context of asymmetrical rights that affects workers on a daily basis. It is not uncommon for them to hold similar jobs or perform similar functions, although they meet different requirements and enjoy different rights, which inevitably leads to comparisons and conflict situations that cause psychosocial suffering.

In this context, understanding psychosocial demands becomes relevant. It is understood that this understanding can contribute to proposing care strategies, considering both the staffing policy for the UHs and the practices developed in each UH. This study is therefore justified.

This article presents part of the results of the doctoral research carried out between 2015 and 2019. The study is part of the tradition that has been built up in Brazil by the Social Psychology of Work²⁴, with the aim of understanding the psychosocial demands faced by workers in the day-to-day work of an UH.

Methods

An ethnographic study was carried out. The Social Psychology of Work is the starting point and everyday life studies were adopted as the theoretical-methodological framework.

The study was carried out at a UH linked to a federal university, which went from being a support body for the university to becoming a subsidiary of EBSERH. Over the years, in order to stay in business, it has adopted various types of employment relationship.

It’s worth mentioning that, before the research began, I worked as an occupational psychologist in the hospital’s human resources department for over 10 years, an experience that enabled me to develop the research problem. Considering the complexity of the hospital’s workforce, the human resources department plays an important role in mediating relations between workers and between workers and the organization.

The workplace therefore became the field of research and my experiences as a worker contributed greatly to the research process. As a researcher, I returned with the intention of answering the questions raised, seeking an understanding formulated “up close and from the inside”⁸.

After a year away, in the period from January to May 2016 and from January to March 2017, I started going to the UH between three and four times a week. The people management division was the locus from which I situated myself so that I could contact the workers in the most varied conditions (type of employment contract, professional category, length of service, hierarchical position, etc). At that time, I tried to adopt a stance that would allow me to be strange about what was familiar to me, the effort of someone who carries out participant observation²⁵.

Various procedures, instruments and materials were used: observation, field diaries, document analysis, interviews, as well as records recovered from situations I had previously experienced, the result of a kind of retrospective participant observation³.

The following sections contain some of the material collected and analyzed, resulting from field diaries, retrospective records, and, also, some interviews. Excerpts from records made before the research was proposed were used with the workers’ permission. To obtain authorization, I met with each worker, presented the record, and explained the contribution it would make. Once they had given their permission, confidentiality was also agreed upon, with names or any information that could lead to identification being changed or omitted.

Seventeen interviews were carried out with professionals from the health and administrative areas, both at university and high school level, and from different professional categories, a general services assistant, as well as some managers at different hierarchical levels, of those, 13 women and four men aged between 27 and 60.

The interviews were scheduled in advance and carried out in rooms at the UH itself, based on the assumption that a conversation would emerge²⁶ duly guided by a script with two topics: living with workers of different ties on a daily basis and the relationship between daily experiences and psychosocial suffering.

The interviews were recorded, then transcribed and analyzed, looking for units of meaning, based on the following stages: familiarization, proposal of initial codes, search for themes, delimitation of themes, and production of analyses²⁷.

Initially, I looked for themes in the content of each of the 17 interviews. These initial themes became thematic axes, considering the way in which they stood out from the content of each interview and appeared across the transcripts as a whole. Finally, they were reviewed and condensed into five axes: “Differences and inequalities and their daily manifestations”; “EBSERH’s subsidiary UH: work, changes, and permanence”; “Impacts on activity: obstacles and impediments”; “Precarization of work in the public service”; and “Repercussions on health”; The results presented in this article refer to the latter.

Each section contains excerpts from the material analyzed and the daily experiences and psychosocial demands faced by the workers.

The names that appear have been created to guarantee the anonymity of the people who collaborated with the study. The project was submitted through Plataforma Brasil and approved by the Research Ethics Committee No. CAAE 56405416.9.0000.5561, on June 20, 2016.

Results and discussion

The titles given to each section were taken from what the workers said at different times during the fieldwork. They were selected with reference to the reports that show the emergence of psychosocial suffering in daily work life as a result of the workers living together in different types of relationships and were therefore taken from the material that was condensed into the thematic axis “Repercussions on health”.

“See how I get?”

The first moments of fieldwork were marked by reunions with countless workers with whom I had a frequent relationship with in view of the activities I carried out as an occupational psychologist. One of these meetings proved to be emblematic due to the condition of my interlocutor. A civil servant who had worked at the UH for over 10 years who had held management positions, when she met me, she showed a different demeanor from what she normally displayed. I remember that her rapid speech was what caught my attention. When we started talking, I explained about the research and my purpose at that moment in the hospital. She, in turn, went on to talk about the changes the hospital had undergone following the arrival of the EBSERH public employees. As the conversation progressed, we looked for a room where we could talk without being overheard by other people or even interrupted.

I then asked her to allow me to take notes so that I could later, if she consented, use those records as information also derived from the research work. She talked about her recent experiences at work and when she recounted a situation she had been through a few months ago, she showed me her trembling hands and uttered the phrase that heads this section: “See how I get?”. As she recalled what she had experienced and narrated it in detail, the pace of her speech once again accelerated. Here are excerpts from the field diary:

She describes the constant tension she has experienced since the arrival of the “EBSERH people”. She details a meeting in which her performance was publicly criticized. She feels “persecuted and disrespected”. As she recounts the days leading up to the meeting and the meeting itself, she shows and perceives herself to be anxious (speech accelerated and breathless, voice shaky and embarrassed). “See how I get?”. “Ambush” and “trap” are expressions she uses to try to describe the atmosphere she experienced.

“It was like I was floating, I couldn’t pay attention to anything, you were talking to me and I wasn’t listening, I was just thinking about it.” “I felt numbness in my hands”. “I was and am tense all the time”. “Then I sleep badly and wake up not wanting to come”. “I didn’t fall ill, but after a month I had a urinary infection.” “I took valerian for a long time to slow me down” (Field diary, 2016).

Suffering, although described from a specific situation, is not referred to in a circumscribed way, as something experienced and overcome or a feeling triggered by a past event and remembered as part of that past. On the contrary: in describing her sensations, she is still affected in such a way that her suffering is updated, indicating a permanence of this state.

The immediate solution adopted, consuming a substance so that he could “slow down” also refers to this understanding that is being established, that it is necessary to adjust to the new conditions. Suffering is then presented as a new work requirement to which one must adapt.

Here are some other excerpts from the field diary:

She says she lives in a climate of daily discomfort, where constant tension is the norm. She says she has withdrawn and communicates with the team only as much as is necessary. She sees no alternative. “I still feel like this, accelerated, agitated, sometimes shaky” (Field diary, 2016).

The emotional state narrated and presented by the civil servant shows in a very concrete way the onset of suffering in her life at work and how this occurs from living with other workers with different ties. She began her narrative with the arrival of EBSERH, referring to the previous condition and the current working conditions at the UH. This condition adds other contours and brings closer the understanding of what is pointed out as a corollary, for the workers, of the transition process that has taken place within universities and public hospitals, with the adoption of new forms of management: the emergence of psychosocial suffering²⁸.

It is important to pay attention to the fact that the worker in question is a civil servant, i.e. her employment status is more secure than that of workers with different contracts and, in this sense, less precarious, which would guarantee a more favorable condition for resistance or situations like the one she experienced.

I would point out that even in less precarious conditions, civil servants also suffer. The proliferation of jobs within public services makes work precarious in many ways, including affecting workers’ health and thus affecting everyone²¹.

A similar result was found in a study that analyzed the experiences of two workers from the same professional category with different employment contracts in the same public service²⁹. Although with different motivations, both reported suffering in the face of the precarious work they recognized in the service.

“It’s just that we see a lot of people like that here”

The “like that” referred to by an public employee in the sentence that titles this section refers to the state of constant tension, a kind of continuous state of alert that destabilizes workers emotionally.

There are multiple hierarchies, and there are also multiple arbitrary behaviors based on the differences between the bonds, the repercussions of which are felt as pressure, injustice, and anguish, and even lead to crying. Here are excerpts from some of the interviews:

All you do is receive orders and demands. It’s a lot of pressure. Very tense. You never relax. You don’t feel well. The mind doesn’t work well. You have to work under pressure, seeing people who aren’t committed [referring to workers with different contract], you have to be committed in order for things to work out, because of your responsibility, you know? (Interviewee: Outsourced worker Ana [39 years old/16 years working at the UH], 2016).

Then I get to work with that enthusiasm, that spirit. Then, suddenly, I’m faced with an injustice. It distresses me. Demotivates, in fact. Angry. I’m angry! Why is it that for some people it’s one thing and for others it’s another? (Interviewee: Public employee Laura [28 years/1 year working at the UH], 2016).

I let myself cry at home. I’ve cried here too, in hiding. I’ve even locked myself in the room and cried. Either I’d let it out or I’d go crazy. That’s when I realize how bad this is for the health of the worker, these bonds, different regimes within an institution (Interviewee: Civil servant Ema [39 years old/13 years working at the UH], 2016).

These are varied manifestations, described taking themselves as a reference and, also, the others with whom they work and from whom they also perceive changes in the way they experience work.

While some are burdened by the weight of the demands, the obligation to commit and the responsibility to make things work, requiring them to be so ready that they have no choice but to be vigilant at all times (“Never relax”), others find the daily intermittencies, the lack of desire to go to work, which is almost like giving up, the hardships that leave them “distressed”, “demotivated”, “angry”.

Public services, as work spaces, are also a space for guaranteeing rights. The last institutional corners guided by democratic values and autonomy in the face of market rules and “business ethics”²⁸, these services are gradually distancing themselves from their institutional model, getting lost among market-oriented organizations. Dismissal, precariousness, outsourcing, rehiring, among other expressions, become part of the management vocabulary in public services. They become natural.

Workers who, because they identify with working in these spaces or even because they need a job, have become attached to them, albeit under different conditions, are witnessing this process of transformation, which can also be understood as a process of deterioration or decay of their own ethics, that of the common good, which characterizes, or at least should characterize, public services³⁰.

“I don’t deserve this [...] planting in the desert”

By producing conflictual relationships, based on comparison and competition, the hybrid conformation of work teams makes it difficult to establish solidary relationships that can favor the creation of bonds and a sense of identification between workers. The “systematic individualization of employee management” is a strategy of modern work management¹⁹.

The story of an employee who came to me when I was still working at the hospital to share her suffering illustrates this condition well. Her speech denounces an “anguish” experienced over time, a perennial suffering that made up a cycle in which, at a certain point, it was intensified to such an extent that it became unbearable.

She has worked at the UH for over 20 years and has been a manager for over 10, and she felt proud of her career at the hospital. Here is an excerpt from the record I made, which was later incorporated into the material analyzed:

She begins to talk about the “anguish” she feels as the end of the year approached. The “uncertainty” and “lack of security” in planning or organizing life for the following year. She says that in recent years it has been difficult to live with some “ghosts”, to hear jokes about whether or not to stay at UH, always with “irony” and “sarcasm”. As a manager, she is targeted by other workers and ends up being harassed. “I live in a situation of uncertainty. It’s like planting in the desert. This was the Christmas of uncertainty, I don’t deserve to get to December again with the same feeling” [she becomes emotional, her voice choked with tears]. “It’s all anguish here”. At the end of the conversation, she clarified that, in fact, she had already made up her mind. She was going to resign. She couldn’t stand that way of being at work any longer. She spoke again about how difficult it would be to say goodbye to the UH: “I made my life here, I learned everything I am today as a professional. I owe a lot to the hospital,” she said emotionally. But she went on to highlight the feelings she experienced at Christmas and how she became certain that she would not be able to continue. She concluded by crying: “I don’t deserve this” (Field diary [retrospective records], 2015).

My request to this employee to include her testimony in the material to be analyzed in the research was not without reason. Precise in her use of words, she described how uncertainty, insecurity, and the impossibility of planning for the immediate future, given the frequent threat of dismissal, gave body to her suffering, which she called “anguish”.

As if all these tensions weren’t enough, which are also the tensions experienced by other workers whose relationship with the public service puts them in a situation of constant vulnerability when it comes to employment, the employee was also harassed in the form of constant provocations, making her experiences at work even more distressing.

Several studies show that this type of event - harassment, insults, disdain, teasing, and belittling - comprise a type of violence at work, psychological violence. There is evidence that being exposed to this type of situation at work increases the possibility of developing depressive disorders, mood disorders, and anxiety disorders³¹.

Faced with this context and with no prospect of change, but on the contrary, realizing the recurrence of this suffering and how much her experiences at the UH accentuated her anguish year after year, the employee found her way of coping in resigning. Despite being emotionally fragile, during the narrative she was confident when she said: “I don’t deserve to get to December again with the same feeling “, “I don’t deserve this”.

“Every day is agony”

The concept of “subjective precariousness” is defined as: “the feeling of not being ‘at home’ at work, of not being able to rely on your professional routines, your networks, the knowledge, and skills accumulated through experience or passed on by older people”¹⁵.

One of the civil servants interviewed refers to this feeling “of not being at home”, a kind of estrangement from what could or should be familiar, given the routine at work. In her own way, she says she can’t find any reasons, which makes daily life “a painful thing”:

I think there’s a lack of motivation. The feeling is that you’re working for something that isn’t yours. It’s a painful thing, you know? Every day is agony (Interviewee: Civil servant Carmem [28 years old/4 years working at the UH], 2016).

This employee worked in a department that suffered a major impact with the arrival of EBSERH employees. As this is a job whose activities can be described as administrative, the UH’s transition from being an academic body of the university to becoming a subsidiary of EBSERH meant that many civil servants had to carry out new tasks assigned by the company. The results of these tasks had nothing to do with the hospital and the university, but rather referred to answers to be given from the subsidiary to the company’s headquarters, which she clearly didn’t feel part of. That’s why she describes her day-to-day work as “agony”. The suffering comes from the strangeness of the job, from being forced to carry out tasks she doesn’t identify with.

Among the psychosocial repercussions, found among workers in public hospitals and universities who have started to adopt management forms characteristic of private companies, is the feeling of not belonging to the place, which is directly related to the multiplicity of ties: “Among the functional aspects that are being lost among hospital and university workers, they mention the feeling of belonging; this is related to their type of contracting”³².

Employee Mirela describes how the confrontational attitudes adopted by some workers have repercussions on their daily lives and end up generating even more suffering, due to the discrimination and persecution they must live with:

They feel wronged. Some get angry. Then, depending on their condition, some start fighting. And others become more and more reclusive. Then they start to realize that they don’t have a voice in there, that they are suffering prejudice and discrimination. And then some fight and others close themselves off. And that, I believe, has repercussions on health.

If the person is a fighter, they’ll go into the fight. Then there’s the other side: if they starts to get into the fray too much, they starts to be disliked by their boss. And there’s a lot of pressure and anxiety. A lot of people are falling ill. Some get sick, sometimes they take a vacation, do something and manage to get back on their feet. But there are people who can’t. There are people who are in the INSS [Instituto Nacional do Seguro Social] because of this, because of this issue of depression and anxiety (Interviewee: Employee Mirela [39 years old/2 years of work]).alat the UH, 2016).

The ways in which suffering is experienced and expressed can enhance it. Those who withdraw into themselves and suffer in silence are weighed down by the effort to endure adversity in order to stay sane, although they don’t always succeed. For those who react differently and express their indignation, seeking to clash in the political arena so that they can resist in everyday life, the concern about persecution also weighs heavily, since they become “disliked by their boss”.

The way each worker copes with suffering depends on multiple factors, including those of a psychosocial nature. Once again, I think it’s important to highlight the political dimension, as the way workers cope also depends on their position in the hierarchy of relationships. As employee Mirela analyzed, it is “depending on their condition” that workers adopt their own way of dealing with suffering and, as she also points out, this “has repercussions on health”.

Conclusion

The different ways in which workers are linked to the UH impose different relationships on a daily basis, from which inequalities emerge and unfold in experiences of competition, hostility, individualization, uncertainty, insecurity, anguish, and injustice. These experiences lead to the emergence of psychosocial suffering, with the aggravating factor that this comes to be understood as an attribute of the job to which it is necessary to adapt.

Multiple employment relationships weaken the collective organization of workers, pulverize rights, and create a scenario of constant tension, with direct repercussions on health in general and mental health more specifically. This creates a process of job insecurity in various dimensions, from which workers suffer, as they face a daily work routine marked by psychosocial suffering.

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• Information about academic work:
  This work is based on Juliano Almeida Bastos’s doctoral thesis “Servidores, funcionários, terceirizados e empregados: a babel dos vínculos, cotidiano de trabalho e vivencias dos trabalhadores em um serviço público”, presented in 2019 to the Postgraduate Program in Social Psychology at the Institute of Psychology of the University of São Paulo.
• Data availability:
  The data cannot be made publicly available due to ethical restrictions.
• Presentation of the study at a scientific event:
  The author informs that this study has not been presented at a scientific event.

• Funding:
  The author declares that the work was supported by a doctoral scholarship, process No. 88881.135001/2016-01, provided by the Coordination for the Improvement of Higher Education Personnel and that there are no conflicts of interest.

Edited by

• Editor-in-Chief:
  José Marçal Jackson Filho

Data availability

The data cannot be made publicly available due to ethical restrictions.

Publication Dates

• Publication in this collection
  15 Nov 2024
• Date of issue
  2024

History

• Received
  06 Sept 2022
• Reviewed
  18 Apr 2023
• Accepted
  28 Apr 2023