Correlation between engagement and quality of life at work in Brazilian nursing professionals at the beginning of the Covid-19 pandemic

The aim of the study is to investigate the correlation between engagement and quality of life at work in nursing professionals, from a public hospital in the interior of the state of São Paulo, Brazil, at the beginning of the Covid-19 pandemic. We conducted a cross-sectional, descriptive, and correlational study, with nursing professionals between December 2020 and January 2021. We used the Brazilian versions of the Utrecht Work Engagement Scale and the Walton Model scale. The results showed that nursing professionals presented high scores for absorption (4.9) very high scores for vigor (5.2), dedication (5.6), and an overall score (5.2) for engagement. Most nursing professionals scored intermediate levels for fair and adequate compensation (51.9%) satisfactory levels for the other domains, and achieved the highest for social relevance (76.5%), for quality of life. Professionals with satisfactory levels of quality of life tended to have higher levels of engagement at work. Professionals were strongly engaged and satisfied with their quality of life at work at the beginning of the Covid-19 pandemic.


Introduction
Nursing plays an important role in hospitals internationally. In Brazil, the category is composed of college level professionals (Nurses) and medium/technical level professionals (Nursing Assistants and Technicians) and represents more than two million professionals. There is, however, an unequal distribution of these professionals in the na-As work engagement can influence QWL [16], it is important to understand work engagement levels and QWL of nursing professionals, to better understand their behavior. Moreover, producing knowledge that will subsidize the implementation of actions to improve the performance of the team, will positively impact the commitment of professionals and the quality of care, reduce the turnover of professionals and resulting costs.
Therefore, this study aimed to investigate the correlation between engagement and quality of life at work in nursing professionals from a public hospital in the interior of the state of São Paulo, Brazil, at the beginning of the Covid-19 pandemic.

Type of Study
Cross-sectional, descriptive, and correlational study was conducted between December 2020 and January 2021, with Nursing professionals from a medium-sized philanthropic general hospital (210 beds), located in the countryside of the state of São Paulo, Brazil. It is a reference hospital, which attends to high complexity procedures, women with high-risk pregnancy, neurosurgery, orthopedics, nephrology, cardiovascular surgery, and interventional cardiology procedures. There are 30 adult Intensive Care beds, 10 neonatal and pediatric intensive care beds.

Sample and Participants
The sample was estimated at 284 participants, considering the population of 606 Nursing professionals of the institution (145 nurses, 414 nursing technicians and 47 nursing assistants), confidence level of 95%, margin of error of 5%, reliability of 95% and an addition of 20% for losses. Professionals who were on vacation or away from work for any reason during the data collection period, those who did not answer the questionnaires completely, and professionals from an outsourced sector who occupied the physical structure of the institution, however had external managers, were excluded from the study.
All eligible professionals for the study were invited to answer the instruments, which was made available through the Research Electronic Data Capture (REDCap) platform, which respects the criteria established by the General Law of Data Protection. The final sample composed of 341 nursing professionals, including 93 nurses, 217 nursing technicians, 27 nursing assistants, and four professionals who did not reflect their professional category.

Procedures, Measurements, Variables and Outcome
The following three self-applied instruments were used for data collection: (a) an instrument elaborated by the authors, containing sociodemographic and characterization variables of the professionals, such as: gender, age, marital status, whether they have children or not, education, training period, means of transportation used and time to get to work, position and time of performance in the institution.
(b) the Brazilian version of the Utrecht Work Engagement Scale (UWES) was adapted and validated by Vazques et al. [24]. The UWES consists of 17 questions that evaluate the level of satisfaction of professionals with their work and considers three aspects of work engagement: vigor (six questions), dedication (five questions), and absorption (six questions) [23]. The UWES uses a seven-point Likert scale, where 0 = never; 1 = almost never; 2 = sometimes; 3 = regularly; 4 = frequently; 5 = almost always; 6 = always. The calculation of the scores was performed using the arithmetic mean of the answers to the questions that composed each dimension, ranging from zero to six [25]. c) an adapted version of the Walton model (QWL) validated in Brazil by Timossi et al. The instrument consists of 32 statements distributed in eight domains: fair and adequate compensation (two statements); working conditions (five statements); use of abilities (five statements); opportunities (four statements); social integration (four statements); constitutionalism (four statements); work and life (three statements) and social 4 of 13 relevance (five statements) [265]. The QWL questionnaire used a five-point Likert scale, where 1 = strongly disagree; 2 = disagree; 3 = neither disagree nor agree; 4 = agree; 5 = strongly agree. The higher the score, considering five as the maximum for the analyzed criterion, the more satisfied the professional [26].
The instruments were made available electronically, through the Research Electronic Data Capture (REDCap) platform, a free software for electronic data capture, which allows the creation of research instruments, provides features for collaboration, metadata workflow, security, auditing, and export to other statistical programs [27]. Two trained nurses voluntarily assisted the main researcher with data collection. In the explanation that preceded the application of the Consent Term, it was emphasized that the study was anonymous and did not present conflicts of interest with hospital administration. Subsequently, professionals were instructed to access the questions by means of a "QRCode" image. A link was sent via WhatsApp application to those who were unable to access the QRCode, without revealing participant identity. Data were collected between December 2020 and January 2021. Participants had access to the questionnaire after reading and signing the Informed Consent Form and thus agreed to participate in the study. The information required to answer the questionnaire was made available before each block of questions. The time frame to respond to the instruments was clarified.

Statistical Analysis
The data collected were tabulated and analyzed with the software IBM-SPSS, version 27.0 for Windows (SPSS, Inc., Chicago, IL, USA). Descriptive (relative and absolute frequencies, means, and standard deviations) and inferential (ANOVA and Correlation test) measures were applied, considering a significance level of 5% (p<0.05).
Quality of life at work was analyzed by calculating a mean score for the eight domains of the scale. The average scores obtained on a scale of one to five were converted into a scale of 0 to 100, allowing the classification of the quality-of-life level into: Unsatisfactory (scores between 0 and 24.99), Intermediate (scores between 25 and 75), and Satisfactory (scores between 75.1 and 100) [26].
Pearson's correlation test was used to analyze the correlation between engagement and quality of life at work, considering weak correlation for r values up to 0.39, moderate for values between 0.40 and 0.69, and strong for values equal to or greater than 0.70.

Ethical Considerations
Ethical approval for this study was obtained from the institutional ethics committee (decision: 4,349,861 -October 20, 2020; CAAE: 14262719.2.3001.5437). Informed consent was received from all participants before participating in the study. All procedures performed in this study were compatible with the ethical standards of the institutional research committee and with those of the Declaration of Helsinki and its comparable ethical standards.

Results
A total of 341 nursing professionals participated in the study: 93 (27.3%) nurses, 27 (7.9%) nursing assistants and 217 (63.6%) nursing technicians. The sociodemographic analysis showed that 89.4% of the participants were female, 73.3% were between 21 and 40 years, 49.3% were married or in a stable relationship, 60.4% had children; 29.0% had between one and less than four years of graduation, and 27.6% had graduated more than 10 years ago. Most professionals had worked at the institution for less than four years, and 34.9% had between one and less than four years of experience in the hospital (Table  1). No answer 2 0.6 The results for work engagement of nursing professionals showed high mean scores for absorption (4.9) very high scores for vigor (5.2), dedication (5.6), and an overall score (5.2) ( Table 2).  The analysis of the correlation between quality of life and work engagement, presented in Table 4, showed a strong and positive correlation between the social integration domain of QOL and vigor dimension of work engagement (r=0.88; p=<0.001); moderate positive correlation between QWL working conditions domain and vigor (r=0.40; p=<0.001), dedication (r=0.40; p=<0.001) and an overall score (r=0.41; p=<0.001) for dimensions of work engagement. The correlations were positive and weak for the other domains of QOL and dimensions of work engagement (Table 4). We also observed a tendency for professionals with satisfactory levels of quality of life to have higher levels of work engagement. It is noteworthy, however, that professionals with unsatisfactory levels of social integration, constitutionalism, and social relevance had higher levels of engagement (overall score) and absorption. Professionals with unsatisfactory levels of work and life showed higher levels of absorption (Table 4). Table 4. Analysis of the relationship between engagement and quality of life at work in nursing professionals in Brazil.

Discussion
The sociodemographic profile of nursing professionals in this study corroborates other studies and is consistent with the profile of Brazilian nursing professionals, which highlights the predominance of nursing technicians and female prevalence in the profession [2,[4][5][6]29,30], despite the trend of increasing male professionals in this professional category [310].
The evaluation of the levels of engagement of nursing professionals showed that they have an important sense of concentration and pleasure, which connects these nursing professionals to work, as well as very high levels of energy and mental resilience, involvement, and enthusiasm with work. These results are consistent with other studies on work engagement with Brazilian nursing professionals [28,29] from other countries [32][33][34][35], and evidence that professionals were highly engaged and aligned with the work environment and activity at the beginning of the COVID-19 pandemic. Maintaining engagement requires articulation between personal and professional capacities, and the autonomy of the professional in the workplace [35].
Similarly, it was observed that most professionals presented satisfactory levels of QWT, especially in relation to workers' perception of the hospital's social responsibility, quality of services provided, and workers' care. These results show that the company's investment in adequate conditions for employee well-being that favor development and organizational justice contribute to increased quality of life and worker engagement [35,36]. Moreover, we observed that the professionals evaluated presented intermediate levels of QWL and related it to the adequacy of remuneration to work and equity criteria. This is a sensitive situation for all Brazilian nursing professionals, who are negatively impacted by wage inequalities and poor remuneration [37,38], leading them to retain more than one job. Associated with long working hours, the impairment of QWL related to the perception of fair and adequate compensation can exacerbate physical and emotional exhaustion, impairing the professional's performance [39][40][41].
However, we emphasize that although engagement is considered a stable phenomenon, it is related to organizational and work characteristics [42,43]. Therefore, we believe that engagement levels of the professionals evaluated may have changed since the time of this evaluation, as the health scenario generated by the Covid-19 pandemic has negatively impacted the work process in health services [44][45][46].
The tendency that professionals with satisfactory levels of quality of life showed higher levels of engagement at work shows the importance of the company investing in programs and actions that increase worker satisfaction, improve interpersonal relationships, well-being, and physical and mental health of workers. Effective actions of valorization and attention to the workers' health positively impacts the desire to remain in the company and decrease the costs associated with turnover and absenteeism [47].
However, periods of intense labor demands can cause physical and emotional fragility, as experienced during the COVID-19 pandemic. During these times, an increase in worker engagement may increase, although there may be unsatisfactory perception of some aspects that compromise work life quality [48]. This may explain the presence of professionals with unsatisfactory levels of social integration, constitutionalism, and social relevance with higher levels of absorption (concentration and attention) and engagement (enthusiasm, attention, and euphoria).
Similarly, we believe that the high level of absorption displayed by workers with unsatisfactory levels of work and life is due to the impact of the COVID-19 pandemic. During this period, the uncertainties related to lack of information about the risks of transmission and death, negatively influenced other spheres of health workers' lives, like their relationships with their families. COVID-19 pandemic resulted in professionals immersing themselves in work and they experienced difficulties to disengaging from the work environment [48,49].
Engagement is a mediating variable in the relationship between organizational justice and organizational citizenship behaviors, that is, when employees are treated fairly, equitably, with dignity and respect, they may feel more engaged in their jobs [50].
Job satisfaction is significantly related to the psychological empowerment of nursing professionals. This empowerment is manifested through four cognitive experiences: meaning, competence, self-determination, and impact. Competence has similarity with the domain use of abilities, of QOL [51]. This relationship was evidenced in our study, which indicated lower levels of engagement among professionals with unsatisfactory level of skill use, while professionals who presented satisfactory level of skill use had higher engagement at work.
The main limitation of this study is related to the cross-sectional design, which does not allow establishing cause and effect relationships. However, its results make a great contribution by presenting a diagnosis of the relationship between engagement and QOL in nursing professionals at the beginning of the Covid-19 pandemic. Thus, the knowledge produced will support future analyses and discussions about the impact of the overload and physical and emotional stress caused by the Covid-19 pandemic on the levels of engagement and QOL of these professionals.

Conclusions
The study showed that nursing professionals were strongly engaged and satisfied with their quality of life at work at the beginning of the Covid-19 pandemic. Work engagement showed a positive correlation with QOL, reinforcing the importance of health institutions to create strategies for valuing nursing professionals, based on aspects that influence job satisfaction and engagement.
Moreover, it is evident that the precariousness of resources experienced by most Brazilian health institutions and evidenced by the COVID-19 pandemic, reinforces the need to devise strategies that raise QWL and work engagement of nursing professionals, such as work recognition and appreciation.
We suggest that new studies be developed after the pandemic, to evaluate its impact on the levels of engagement and quality of work life of nursing professionals who worked on the front line.  Data Availability Statement: The datasets generated during the current study are not publicly available but are available from the corresponding author on reasonable request.

Conflicts of Interest:
The authors declare no conflict of interest.