Types of workplace violence in nursing in the Family Health Strategy

Abstract

Objective

to analyze the occurrence of different types of violence in the work of Nursing in the Family Health Strategy and the implications of the labor and worker aspects.

Method

a mixed, explanatory, sequential study, with 169 nursing workers of the Family Health Strategy. As instruments of data collection, the Survey Questionnaire Workplace Violence in the Health Sector and the semi-structured interview were used.

Results

episodes of verbal aggression with better averages were found in the assessment of recognition and relationships at work and the highest use of medication. Workplace bullying was associated with the participants' white skin color, the position of nurse, more negative evaluations about work recognition and interpersonal relationships, and a greater concern with violence. Sexual harassment was associated with the position of nursing technician/auxiliary and the lack of encouragement to report violence. Racial discrimination was associated with brown/black skin color and reduced job satisfaction.

Conclusion and implications for practice

the analysis of the factors that are associated with specific types of violence makes it possible to better determine institutional measures and policies that minimize violent acts against nursing workers.

Keywords:
Violence at Work; Nursing; Worker Health; Family Health Strategy; Primary Health Care

Resumo

Objetivo

analisar a ocorrência dos diferentes tipos de violência no trabalho da Enfermagem na Estratégia Saúde da Família e as implicações dos aspectos laborais e do trabalhador.

Método

estudo misto, explanatório, sequencial, com 169 trabalhadores de Enfermagem da Estratégia Saúde da Família. Como instrumentos de coleta de dados, foram utilizados o Survey Questionnaire Workplace Violence in the Health Sector e a entrevista semiestruturada.

Resultados

foram encontrados episódios de agressão verbal com melhores médias na avaliação sobre o reconhecimento e os relacionamentos no trabalho e o maior uso de medicamentos. O assédio moral foi associado à cor da pele branca dos participantes, ao cargo de enfermeiro; apresentaram-se avaliações mais negativas acerca do reconhecimento laboral e dos relacionamentos interpessoais e uma maior preocupação com a violência. Já o assédio sexual relacionou-se ao cargo de técnico/auxiliar de Enfermagem e pela ausência de estímulo para os relatos de violência. A discriminação racial foi associada à cor da pele parda/negra e à redução da satisfação laboral.

Conclusão e implicações para a prática

a análise dos fatores que se associam aos tipos específicos de violência permite melhor determinar medidas e políticas institucionais que minimizem os atos violentos contra os trabalhadores de Enfermagem.

Palavras-chave:
Violência no Trabalho; Enfermagem; Saúde do Trabalhador; Estratégia Saúde da Família; Atenção Primária à Saúde

Resumen

Objetivo

analizar la ocurrencia de los diferentes tipos de violencia en el trabajo de enfermería en la Estrategia Salud de la Familia y las implicaciones de los aspectos laborales y trabajador.

Método

estudio explicativo secuencial mixto con 169 trabajadores de enfermería de la Estrategia Salud de la Familia. Como instrumentos de recolección de datos se utilizó Cuestionario de Encuesta de Violencia Laboral en el Sector Salud e la entrevista semiestructurada.

Resultados

se encontraron episodios de agresión verbal con mejores promedios en la evaluación del reconocimiento y las relaciones en el trabajo y mayor uso de medicamentos. El acoso moral se asoció con el color de piel blanco de los participantes, como enfermeras, presentaron valoraciones más negativas sobre el reconocimiento laboral y las relaciones interpersonales y mayor preocupación por la violencia. El acoso sexual, por su parte, se relacionó con el puesto de técnico / auxiliar de enfermería y la falta de estímulo para denuncias de violencia. La discriminación racial se asoció con el color de piel marrón / negro y una menor satisfacción laboral.

Conclusión e implicaciones para la práctica

el análisis de los factores que se asocian a tipos específicos de violencia permite determinar mejor las medidas y políticas institucionales que minimicen actos violentos contra trabajadores de enfermería.

Palabras clave:
Violencia en el Trabajo; Enfermería; Salud del Trabajador; Estrategia de Salud Familiar; Atención Primaria de Salud

INTRODUCTION

Violence at work is considered a growing phenomenon, often naturalized in the daily life of Brazilian services, rarely measured, typified or understood, considered an inevitable risk for some workers, but little combated, treated or prevented. However, it is preventable and is an important cause of physical injury and, especially, of mental illness.¹

The World Health Organization (WHO) defines violence as the “intentional use or threatened use of physical force against another person or oneself that results in, or is likely to result in, injury, death, psychological harm.”^2:5

The healthcare sector is among those with a high potential for the occurrence of aggressions to workers. Health professionals are exposed to several risks mostly associated with constant contact with the public. Regarding violence, 69% of the cases are episodes involving patients.³

Some studies^4,5 have highlighted that violence in healthcare services mainly affects workers who are responsible for the first direct communication with patients and their families, i.e., Nursing professionals, making them more vulnerable. Research in other countries has indicated that, among health professionals, the highest prevalence of episodes of violence involves nurses.^4,6,7 The frequent experience of exposure contributes to the severity of the problem, since workers are frequent victims of this phenomenon, potentially in the Family Health Strategy (FHS).^8,9

Among the health scenarios in Brazil, the FHS stands out as the main model of Primary Health Care (PHC) in the country and an important service in the context of the Unified Health System (UHS). The PHC, guided by the National Primary Health Care Policy (NPHCP), also known as Basic Health Care (BHC) in the country, has been based on the FHS and was planned to meet the health needs of individuals in their singularity and complexity, aiming at comprehensive care,¹⁰ as well as the collectivities.

In this context, nursing professionals have been considered a vulnerable group to violence at work.⁵ In the FHS, a high occurrence of insults (44.9%), threats (24.8%) and physical aggression (2.3%) is identified, especially against doctors and nurses, and these professionals are more prone to manifest depressive symptoms and depression.¹¹

In the search for scientific productions, scarce national^12,13 and international^7,8 studies were found on the theme of violence in nursing work in the FHS. It is assumed, therefore, that there is a gap to be researched, reaffirming the relevance of investigations on the subject. Thus, this study is justified by the need to know the occurrence of violence at work in nursing in the FHS in order to offer a contextualization of the field of work of the profession and promote further debate and awareness in the investigated scenarios about violence at work.

Given the above, the following guiding questions were defined: “what types of violence in the FHS are workers of the Nursing team exposed and what are the influences of labor and worker aspects?” The study aimed to analyze the occurrence of different types of violence in nursing work in the FHS and the implications of labor and worker aspects.

METHOD

A mixed-methods study, of the sequential explanatory type, in which a quantitative stage (QUAN) was conducted followed by a qualitative stage (QUAL),¹⁴ carried out with the FHS of a municipality located in Southern Brazil. In the PHC of this municipality, the Basic Health Units (BHU) are called Family Health Centers (FHC), consisting of 26 FHC where 53 FHS are structured, which comprised the research scenario.

To define the participants, the inclusion criteria were: to be trained in the Nursing area (nurses, technicians, and Nursing assistants) and to have been working as a professional of the FHS for at least 12 months, as required by the research protocol for the Survey. Workers on leave for any reason during the data collection period were excluded. To define the participants of the first stage of the study, a sample calculation by eligible population category was carried out, considering a 95% confidence level and a 5% sample error. During the data collection period, the population of workers consisted of 53 nurses and 159 nursing assistants/technicians. Thus, the sample was composed of 169 nursing professionals, 47 nurses and 122 nursing assistants/technicians. The study considered nursing assistants and technicians in the same category for acting without distinction of tasks in the researched scenario. Among the workers who were not part of the sample, only one Nursing assistant refused to participate in the research, and the others did not fit the established selection criteria. The data collection period occurred between September 2018 and March 2019.

In the QUAN stage of the investigation, the demographic and labor characteristics of the workers were measured and, for the survey of violence that occurred in the last 12 months, the Survey Questionnaire Workplace Violence in the Health Sector was used, proposed by the WHO, the International Labor and Public Services Organization, and the International Council of Nursing,¹⁵ translated and adapted for the Portuguese language.¹⁶ The questionnaire measures the occurrence of types of physical and psychological violence, with psychological violence consisting of verbal aggression, workplace bullying, sexual harassment, and racial discrimination.

In the QUAL stage of the study, the professionals who participated in the previous stage were invited and selected by lot, considering their availability to participate in a semi-structured interview, including ten workers who responded that they had suffered different types of violence at work and eight workers who indicated in their answers that they had not been exposed to the phenomenon, but who signaled that they had observed violence against colleagues at work, totaling 18 participants. The number of participants in this stage was defined by data saturation,¹⁷ and the interviews were recorded and followed a semi-structured script. This stage also included non-participant observation, which was carried out in 14 FHC, totaling 56 hours of observation using a script.

For the records of observations during data collection, a Field Diary was used, identified by the initials (FD), which added information for the completeness of the interviews, recording facts, feelings, statements, and observations of workers after each stage of data collection. The QUAN data were coded, tabulated and analyzed using the software Statistical Package for the Social Sciences, version 21.0. Quantitative variables were described using measures of central tendency and dispersion: mean; standard deviation; median; minimum and maximum observed values; interquartile range and the estimate by confidence interval for the population mean based on the number of valid responses and 95% confidence level. The criterion for variable entry into the multivariate model was a p-value <0.10. Categorical variables were described using relative and absolute frequencies and continuous variables were described with measures of central tendency and dispersion. After the Shapiro-Wilk normality test, we used the chi-square test for association and the Mann-Whitney test to analyze the differences between the medians in the groups.

The data from the interview transcripts and observation excerpts were submitted to the Thematic Analysis technique.¹⁸ The pre-analysis of the findings was configured based on the floating reading of the material, identification of categories, subcategories and thematic units. The QUAN and QUAL were confronted, seeking relationships, convergences and divergences between the results, which allowed the deepening of the analysis of the occurrence of violence.

The study was approved by a Research Ethics Committee, via Plataforma Brasil, with approval under Opinion No. 2,835,706/2018. All participants signed the Free and Informed Consent Form (FICT). To preserve the anonymity of the participants in the use of the speech fragments, they were coded as: Nurse (N) or Nursing Technician/Nursing Assistant (NTA), followed by the order number of the instruments.

RESULTS

The QUAN sample was made up of 169 workers who make up the nursing teams that work in the FHS, most of whom were women (93.5%), with a mean age of 41.1 years (±8.8), white (n=154/91.1%), with a partner (n=119/70.4%), and with an average of one child. The professionals had, on average, 14 years of experience in the health area (minimum of 8 years and maximum of 20 years), with a weekly workload of 40 hours, only 7.7% had another job and 13% were managers of the service, and most of them established physical contact with the user (94.1%).

In the study, 141 workers revealed having suffered, in the last 12 months, 221 episodes of violence. Among them, 76 (45.0%) had suffered one type and 50 (29.6%), two types. The most commonly reported violence was psychological, especially verbal aggression (n=128/75.7%), psychological harassment (n=66/39.1%), sexual harassment (n=15/8.9%) and racial discrimination (n=7/4.1%). In addition, part of the sample (n=5/3.0%) reported having suffered physical violence. In the context, users were the main perpetrators, except for workplace bullying.

Table 1 presents the associations identified as significant between the different types of violence against FHS nursing workers and the sample characterization variables.

Table 1
Significant associations between the types of violence and the sociodemographic and labor aspects of FHS nursing professionals, Santa Catarina, 2020. (n=169)

PHYSICAL AGGRESSION
Variables	Experienced Violence	Did Not Experience Violence		p-value *
Skin color	n(%)	n(%)		0.625
Black/Brown	0 (0.0%)	15 (100.0%)
White	5 (3.2%)	149 (96.8%)
Use of medication	n (%)	n (%)		0.157
Yes	4 (4.7%)	81 (95.3%)
No	1 (1.2%)	83 (98.8%)
Function				0.057
Nurse	2 (4.3%)	45 (95.7%)
Nursing Technician/Assistant	3 (2.4%)	119 (97.5%)
Stimulus for reporting violence				0.143
Yes	2 (7.7%)	24 (92.3%)
No	3 (2.1%)	140 (97.9%)
VERBAL AGGRESSION
Variables	Experienced Violence	Did Not Experience Violence	p-value*
Skin color	n(%)	n(%)	0.202
Black/Brown	13 (86.6%)	2 (13.3%)
White	115 (74.7%)	39 (25.3%)
Use of medication			0.037
Yes	69 (81.2%)	16 (18.8%)
No	59 (70.2%)	25 (29.8%)
Function			0.075
Nurse	36 (76.6%)	11 (23.4%)
Nursing Technician/Auxiliary	92 (75.4%)	30 (24.5%)
Stimulus for reporting violence			0.110
Yes	22 (84.6%)	4 (15.4%)
No	106 (74.1%)	37 (25.9%)
WORKPLACE BULLYING/INTIMIDATION
Variables	Experienced Violence	Did Not Experience Violence		p-value*
Skin color				0.047
Black/Brown	3 (20.0%)	12 (80.0%)
White	63 (40.9%)	91 (59.1%)
Use of medication				0.117
Yes	32 (37.6%)	53 (62.4%)
No	34 (40.5%)	50 (59.5%)
Function				0.010
Nurse	26 (55.3%)	21 (44.7%)
Nursing Technician/Assistant	40 (32.7%)	82 (67.2%)
Stimulus for reporting violence				0.080
Yes	13 (50.0%)	13 (50.0%)
No	53 (37.1%)	90 (62.9%)
SEXUAL HARASSMENT
Variables	Experienced Violence	Did Not Experience Violence		p-value*
Skin color	n(%)	n(%)		0,129
Black/Brown	3 (20,0%)	12 (80,0%)
White	12 (7,8%)	142 (92,2%)
Use of medication				0,206
Yes	8 (9,4%)	77 (90,6%)
No	7 (8,3%)	77 (91,7%)
Function				0,047
Nurse	2 (4,3%)	45 (95,7%)
Nursing Technician/Assistant	13 (10,6%)	109 (89,3%)
Stimulus for reporting violence				0,044
Yes	5 (19,2%)	21 (80,8%)
No	10 (7,0%)	133 (93,0%)
DISCRIMINAÇÃO RACIAL
Variáveis	Sofreu Violência	Não Sofreu Violência		p-value*
Skin color	n(%)	n(%)		0.001
Black/Brown	4 (26.5%)	11 (73.3%)
White	3 (1.9%)	151 (98.1%)
Use of medication				0.166
Yes	5 (5.9%)	80 (94.1%)
No	2 (2.4%)	82 (97.6%)
Function				0.180
Nurse	1 (2.1%)	46 (97.9%)
Nursing Technician/Assistant	6 (4.9%)	116 (95.0%)
Stimulus for reporting violence				0.303
Yes	0 (0.0%)	26 (100.0%)
No	7 (4.9%)	136 (95.1%)

• ^*
  p-value obtained by means of Pearson's chi-square test. Source: own elaboration.

Table 2 presents the associations of occupational violence with the sociolaboral characteristics of Nursing workers.

Table 2
Associations between the occurrence of different types of violence and socio-occupational characteristics, Santa Catarina, 2020. (n=169)

PHYSICAL AGGRESSION		Mean	Standard Deviation	p-value *
Education	Experienced violence	15.5	3.122	0.780
	Did not experience	15.3	2.836
Years of professional experience	Experienced violence	9.1	5.103	0.076
	Did not experience	15.3	8.630
Time of service	Experienced violence	5.4	3.460	0.495
	Did not experience	8.1	6.823
How many professionals work together	Experienced violence	10.0	11.597	0.230
	Did not experience	6.1	9.241
Satisfaction place of work	Experienced violence	4.8	0.447	0.151
	Did not experience	4.3	0.699
Recognition at work	Experienced violence	4.4	0.547	0.177
	Did not experience	3.8	0.939
Relationships at work	Experienced violence	4.2	0.447	0.357
	Did not experience	4.3	0.632
Concern with violence	Experienced violence	4.2	0.836	0.765
	Did not experience	3.9	1.120
VERBAL AGGRESSION		Mean	Standard Deviation	p-value*
Education	Experienced violence	15.4	2.695	0.376
	Did not experience	14.9	3.237
Years of professional experience	Experienced violence	14.4	7.789	0.234
	Did not experience	17.3	10.567
Time of service	Experienced violence	7.8	6.802	0.502
	Did not experience	8.6	6.668
How many professionals work together	Experienced violence	5.8	8.777	0.056
	Did not experience	7.4	10.807
Satisfaction place of work	Experienced violence	4.3	0.698	0.058
	Did not experience	4.3	0.674
Recognition at work	Experienced violence	3.7	0.955	0.010
	Did not experience	4.1	0.781
Relationships at work	Experienced violence	4.3	0.641	0.022
	Did not experience	4.5	0.540
Concern with violence	Experienced violence	4.0	1.005	0.098
	Did not experience	3.6	1.355
WORKPLACE BULLYING/INTIMIDATION		Mean	Standard Deviation	p-value*
Education	Experienced violence	15.6	3.073	0.151
	Did not experience	15.1	2.666
Years of professional experience	Experienced violence	14.1	8.589	0.151
	Did not experience	15.8	8.594
Time of service	Experienced violence	7.1	5.605	0.393
	Did not experience	8.6	7.368
How many professionals work together	Experienced violence	6.7	9.648	0.776
	Did not experience	5.9	9.104
Satisfaction place of work	Experienced violence	4.2	0.729	0.088
	Did not experience	4.4	0.667
Recognition at work	Experienced violence	3.6	1.021	0.013
	Did not experience	4.0	0.839
Relationships at work	Experienced violence	4.2	0.651	0.007
	Did not experience	4.4	0.592
Concern with violence	Experienced violence	4.2	1.023	0.004
	Did not experience	3.7	1.134
SEXUAL HARASSMENT		Mean	Standard Deviation	p-value*
Education	Experienced violence	14.6	2.065	0.183
	Did not experience	15.4	2.894
Years of professional experience	Experienced violence	13.2	7.816	0.325
	Did not experience	15.3	8.676
Time of service	Experienced violence	6.9	5.463	0.619
	Did not experience	8.1	6.876
How many professionals work together	Experienced violence	3.4	3.720	0.243
	Did not experience	6.5	9.638
Satisfaction place of work	Experienced violence	4.2	0.703	0.482
	Did not experience	4.3	0.697
Recognition at work	Experienced violence	3.8	1.014	0.852
	Did not experience	3.8	0.929
Relationships at work	Experienced violence	4.3	0.617	0.649
	Did not experience	4.3	0.630
Concern with violence	Experienced violence	4.4	0.828	0.113
	Did not experience	3.9	1.129
RACIAL DISCRIMINATION		Mean	Standard Deviation	p-value*
Education	Experienced violence	14.5	1.766	0.312
	Did not experience	15.4	2.871
Years of professional experience	Experienced violence	14.2	9.282	0.797
	Did not experience	15.2	8.601
Time of service	Experienced violence	4.9	4.686	0.264
	Did not experience	8.2	6.812
How many professionals work together	Experienced violence	3.5	2.878	0.812
	Did not experience	6.3	9.467
Satisfaction place of work	Experienced violence	4.8	0.378	0.049
	Did not experience	4.3	0.700
Recognition at work	Experienced violence	3.0	1.397	0.369
	Did not experience	3.8	0.910
Relationships at work	Experienced violence	4.5	0.534	0.471
	Did not experience	4.3	1.127
Concern with violence	Experienced violence	14.5	0.534	0.345
	Did not experience	15.4	1.127

• ^*
  p-value were obtained using the Mann-Whitney test, a test that compares the difference in medians due to the asymmetry of the variables. However, to facilitate the interpretation of the findings, we chose to present the means and standard deviation. Source: own elaboration.

The QUAL stage of the study included the participation of 18 workers, which allowed a better understanding of the phenomenon of violence among FHS workers. In this step, respecting the sequencing of the mixed explanatory study, it was possible to identify emerging aspects of the occurrence of violence in the work of nursing in the FHS, which allows deepening some aspects related to some data from workers.

The interviews and observations recorded in the FD made it possible to express how violence occurs with FHS workers. The quantitative results show the nurses most exposed to workplace bullying and the technicians/nursing assistants most exposed to sexual harassment, and the interviews below reveal the expressions of the victimized workers.

He [a physician colleague] used to get on my nerves about all my work procedures, he would even encourage patients to think that I didn't know how to perform nursing consultations properly, that my instructions were useless; this was repeated more than ten times in the last year. One day he told me that he was going to give me classes so that I could learn how to work… (E06)

During the observation, a professional nurse approached the researcher and commented that, during the electoral period, the manager instigated and pressured the nurse coordinators to run a political campaign and be present at political events in the municipality. The most embarrassing and humiliating fact occurred when the manager said that between a good and competent nurse and a good political nurse, his preference to keep in the coordination position was for the good political nurse...(FD)

This morning, I was made fun of by a male patient... he does it several and several and several times and I always try to talk him out of it, but it seems that I am held hostage by that situation, I feel embarrassed and coerced... Because what am I going to say, how am I going to curse him, for example, if I get an enmity, he might want to hit me when I go outside. (NTA105)

[…]every time he [the elderly patient] comes to the unit, he rubs up against us, he always has a way of touching us, I've been slapped on the butt, he gets close to talk in my ear, I get very embarrassed, I don't want to see him anymore; besides being abusive, he has no respect for the professionals. (NTA142)

About the findings related to skin color and/or ethnicity as an aspect associated with the occurrence of racial discrimination, the QUAL stage records are presented.

The researcher, while performing observation in a PHU, observed an elderly male patient uttering racial discrimination against an indigenous nursing assistant. He approached the reception desk to request care and said he did not want to be served by the professional, calling him a “bugger”. (FD)

The patient arrived at the unit and, when he saw me, asked not to be seen by the “bugger”. (NTA 87)

During the morning of observations, a nurse approaches the researcher and reports that a black nurse assistant suffered racial discrimination from a patient for having muddy shoes on a day that rained a lot. She felt very humiliated and attributed it to her skin color... from that day on, she changes her shoes when entering the BHU. (FD)

In the QUAL stage, some professionals also revealed that they find more satisfaction in working in this workplace, since they feel less exposed to violence, which provides a sense of security.

After the end of a service, in which cordiality and respect between the nursing professional and the user in attendance is observed, the professional, at the end, verbalizes about her eight years of work in the unit, mentions that she likes what she does and about the satisfaction that the user's care gives her and about feeling safe in that place of work. (FD)

DISCUSSION

The study evidenced the high incidence (83.4%) of violence perpetrated against nursing workers in the FHS and this finding reinforces that found in other studies with PHC workers,^11,19 with results in agreement²⁰ and dissonance²¹ of other researches that used the same survey for the investigation. In another study carried out in the southern region of Brazil,⁹ the prevalence of violence was 69.8% and in Minas Gerais, 76.8% of the workers reported having suffered several episodes of aggression at work.²²

Psychological violence was the most prevalent type evidenced in this study, highlighting, among its subtypes, verbal aggression practiced against health professionals, confirming the findings of other studies.^1,12,19,23 This data makes it possible to say that the prevalence of verbal aggression may indicate failures in communication between users and health professionals.¹²

Regarding the identification of the main aggressor in acts against FHS nursing workers, the findings were similar to those of other studies,^1,10,12 which showed service users as the main perpetrators. Their behavior, by disrespecting the workers, generates professional dissatisfaction, a fact that can be linked, sometimes, to the users' misunderstanding of the precepts established in the PHC care model²⁴ and for feeling that they did not receive proper treatment.¹² Frequently, the lack of resoluteness of this level of care can also represent a contributing factor to trigger aggression and threats in the workplace by users.¹²

Physical violence revealed a statistical association with workplace satisfaction, proving that more satisfied workers suffered less physical violence. Not suffering the phenomenon has a positive impact on job satisfaction, feelings of recognition, and interpersonal relationships. Professionals working in the FHS model report that the reasons that generate satisfaction in the workplace are related to the team's commitment, favorable salary, welcoming practices, bond with users, autonomy to perform the work, resoluteness of care, affinity with the profession, and enjoyment for what they do.²⁴

It was identified that workers who suffered verbal aggression presented lower averages in the evaluation about recognition and relationships at work. Another investigation verified that having unfavorable interpersonal relationships was a significant factor for the outcome of violence among workers, and most victims of aggression revealed concern about the phenomenon in the workplace.²⁵ Also, the lack of recognition at work, expressed by lack of respect and verbal abuse, causes sickness, suffering, and depersonalization processes of the workers.²⁶ In addition to influencing worker performance, the consequences of violence at work permeate the healthcare institution, with important repercussions on the family and social dimensions of nursing professionals.²⁷

It was also found that the distribution of workers who use medications is higher among those exposed to verbal aggression. Another data found was that 50.3% of the workers use medications for the relief of depression, anxiety, increased levels of hypertension, among other pathologies. A study with PHC workers mentioned that they face pains and physical complaints related to the stress of the work environment, characterized by conflicts, lack of professional recognition, work overload, and lack of resources.²⁸

With regard to workplace bullying, the results indicated that white participants and nurses are more likely to suffer workplace bullying. This factor may be related to the fact that workers in this category are accustomed to intimidation in the services; however, this has repercussions in more negative evaluations about recognition and relationships at work, as well as a greater concern with violence in this context. The intimidation, to the worker, has caused illness, with negative repercussions in his work functions, and this has been considered accepted and reproduced in the organizational culture of health institutions.²⁹ In the international scenario,³⁰ it was identified that the Nursing professionals most exposed to this violence also manifested feelings of little recognition and confidence in the work they do. Workplace bullying has repercussions on the worker's health, destabilizing the physical and emotional balance, leaving permanent marks in the personal and work lives of the victims.³¹ Studies have proven that, regardless of the characteristics of nurses, as well as the frequency with which it occurs, workplace bullying has a negative impact on nurses' mental health and well-being.³²

It was evident that sexual harassment was more common and more repeated among nursing technicians/assistants. Regarding this type of violence, we also identified the difficulty for workers to report the episodes because they feel afraid and ashamed.³³

It was found that noticing that there is no encouragement to report violence was associated with sexual harassment and that, in general, professionals do not identify this resource in the context of the service. Encouraging the reporting of these situations can be conducted through effective communication, and should prioritize listening as a strategy for managing violence.²⁴ In this sense, ways to contain all types of violence against nursing professionals are proposed, as well as the development of measures for the protection of victims, considering the aspects that are associated with each type.

The analysis of racial discrimination revealed that being black and brown-skinned is more likely to suffer racial discrimination, and the excerpts of speeches and observations strengthen these findings, despite the small number of these in the sample researched, which may signal the magnitude of this problem. The Regional Council of Nursing, in a study on the profile of Nursing in Brazil, presented a reality traced by historical marks, characterized by racial and social inequalities, in which black people were excluded from professionalization in the category and those who work suffer episodes of prejudice. Racism was veiled and naturalized, evidenced in the refusal of patients to be attended by black professionals and the feeling of lack of professional recognition.³⁴

From the results of the study, there emerges the need to rethink intervention strategies with a view to preventing and/or mitigating the occurrence of violence at work. Some models advocate strategies that include the approach on several levels: individual, relational, and organizational. Strategies at the individual level are related to the beliefs, attitudes and behaviors of each person; relational strategies focus on how people relate and communicate with others and, finally, organizational strategies focus on the organizational climate and structure, as well as on policies and procedures.³⁵ The authors confirm that the strategies with the greatest potential for effectiveness are organizational ones, essentially focused on healthy work environments that prevent the existence of any of the types of violence.³⁵

The QUAN and QUAL results are complementary, strengthening data analysis and favoring the understanding of this complex phenomenon that occurs in the FHS scenario involving Nursing.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

The study revealed that the FHS nursing workers are exposed to violence in their environment. It was proven that verbal aggression, markedly illustrated in the speeches and observations, has implications among the professionals in lower averages in the evaluation about recognition and relationships at work, as well as the use of medicines is more prevalent among those exposed to this type of aggression.

Workplace bullying was influenced by the color of white skin, among nurses, and has repercussions in lower averages in the evaluation of recognition and relationships at work and greater concern about violence at work with greater difficulty in reporting the phenomenon. Sexual harassment was significant among nursing technicians/assistants, influenced by the lack of encouragement to report violence. Finally, racial discrimination was associated with black/brown skin color, presenting a reduction in satisfaction with the workplace, with all types of harassment being more difficult to observe and report by the professionals, who talk about the fear and shame in reporting the episodes.

The results of this study point to the need for planning measures against violence and for guidelines that make safe and welcoming work possible for workers, a primordial factor for maintaining workers' health, as well as for the quality of care provided to users.

The individualized analysis of the different types of violence at work in nursing in the FHS and its associations with the sociodemographic and labor characteristics of these professionals indicate specific conduct for each phenomenon and reinforce the importance of reporting and denouncing episodes for the management of health services.

The study was limited to investigating violence only with Nursing workers who work in the FHS; however, other healthcare workers may also be exposed to the phenomenon. It is recommended that further research be carried out considering the expansion of participants and approaches.

• FINANCIAL SUPPORT

  This work was carried out with the support of the Coordination for the Improvement of Higher Education Personnel - Brazil (CAPES) - Funding Code 001; doctoral scholarship granted to Grasiele Fatima Busnello. Research Support Foundation of Santa Catarina (FAPESC) (Research Funding Edital PAP/FAPESC TR1153), coordinated by: Letícia de Lima Trindade.

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Edited by

ASSOCIATE EDITOR

Gerson Luiz Marinho

Publication Dates

• Publication in this collection
  09 Apr 2021
• Date of issue
  2021

History

• Received
  27 Oct 2020
• Accepted
  15 Feb 2021