Psychological violence in the nursing work

Objective: to investigate and characterize psychological violence practices within teams in the relationship between patients, caregivers and other professionals with the nursing staff of the public hospital network of Caxias, in the State of Maranhão, Brazil. Method: descriptive, quantitative, cross-sectional study with data collected by form between November/2013-May/2014. Results: verbal aggression is the most common psychological violence subtype 95% (84), followed by bullying 27% (24). Emergency rooms 51% (45) are the most frequent place; patients 60% (53) are the main aggressors; nurses 76% (19) suffer more violence, being mostly female, young and inexperienced. Conclusion: the largest number of occurrences was of verbal aggression perpetrated by patients against nurses in the emergency room. Workers try to pretend that nothing happened or are inert in the face of violence. Employers do little about the case, referring to the need for strategies to control violence.


INTRODUCTION
Work is a process in which man and nature take part -it is something that is exclusively human.Human beings, through their actions, drive, regulate, and control their material exchange with nature, giving motion to the natural forces of their bodies, arms and legs, head, and hands, aiming to take possession of natural resources, giving those shapes which are useful to them, according to the project they had in their minds (1) .
According to Pires (2) , "health care work is essential work to human life, and it is part of the services sector.It regards to non-material production, work which is fulfilled at the time it is performed".
The activities in that sector are fundamentally important to social life, and are intended to meet human social survival conditions.Thus, the services sector is seen as required to maintain the social structure, aiming to protect and safeguard society, as is the case of education and health care systems, which provide conditions for society members to survive (2) .
Nursing work is part of the services sector, and it is predominantly performed by women who make use of knowledge from other sciences and of summarized knowledge form nursing itself, in order to apprehend the subject their field of expertise relates to (health care) (2)(3) .
Regarding violence, Michaud (4) deals with it as a phenomenon that is due to many causes, has many meanings, and is connected to social problems.It can be divided in several modalities, which makes it difficult to create one single definition which comprises the whole of it.Universal knowledge on violence must be admitted not to exist, as each society has its own definitions regarding what that phenomenon is, taking into account its criteria and values.
Even with the multiple meanings of the term violence, its etymology leads us to the Latin word violentia, meaning violent or ferocious character, force.Generally speaking, its general aspect refers to the idea of force, or of a natural power that, when it is applied against people or things in an excessive fashion, disturbing a certain natural order, becomes violence (4) .
It is an act of physical or psychic abuse against someone, many times leading to fear, intimidation, and oppression relationships.Not only is it represented by acts which express aggressiveness and brutality through the use of force against one's peers, but also by acts which lead to psychological disorders without the exchange of physical aggression (4) .
In regards to power, Bobbio, Matteucci, and Pasquino (5) explain as the ability and individual have to determine another person's behavior.When it is not fully exercised in social, political, or labor-related relationships, individuals most times resort to violence in order to ensure it.
Thus, violence is a means to reestablish power in order to ensure one has what one wishes, in order to suppress the impotence state they are going through; it is a burst with the impulse to destroy whatever is seen as a barrier to one's selfesteem and personal growth (6) .Violence starts in situations in which power is at risk of being lost, and it ceases when power is recovered, thus maintaining an inversely proportional relationship (7) .
A great many social relationships, as well as labor-related relationships, always comprise a superior person, who gives orders, and an inferior person, who obeys and submits themselves to those orders.Thus, work is oriented by the domain and power from capital owners, and in the submission of workers who report to an employer.This leads to asymmetrical relationships of power which may end up in workplace violence (8) .
Thus, workplace violence is defined as the negative behavior or action in a relationship between two or more people that is marked by aggressiveness and which may take place repeatedly or suddenly, including situations in which workers are intimidated, threatened, assaulted, or subject to offensive acts in labor-related circumstances (9) .
Psychological violence is the purposeful use of power against a person or group of people, aiming to control their actions, behaviors, beliefs, and decisions.That leads to one's troubled physical, mental, spiritual, moral, or social development.It is subdivided in verbal aggression, psychological and sexual harassment, and racial bias (10) .
Verbal aggression is understood as the crossing of verbal rules which humiliates, degrades, or indicates lack of respect to one's dignity and value.Racial bias is any threatening conduct which is based on ethnicity, race, language, nationality, religion, association with minorities, or any other unilateral status which affects dignity (9) .
Psychological workplace harassment is understood as humiliating behavior, which repeatedly and excessively discredits or discourages a worker or group of workers in their work environment.It is more common in authoritarian and asymmetric hierarchical relationships.Sexual harassment is seen as any unilateral, undesired sexual behavior which causes discomfort or embarrassment to men and women through force, coercion, threatening, or psychological influences (10) .
Gender as an analysis category was developed during the climax of new feminist theories, with the purpose of understanding inequalities between genders.Those inequalities are historically translated by the differences in biological characteristics between men and women, which are included in a sociocultural context which impresses each gender with distinct functions and characteristics (11) .This type of social relationship is extended to the political system, to legislations, to the government, and to employment relationships, and it leads to power imbalances between men and women.Thus, gender-related violence is another component which permeates nursing work, and it is mostly composed of female workers.This violence has its main grounds on asymmetrical relationships of power between men and women, in which women are perceived to be submissive to men (11)(12) .
The risk of violence to health care workers is greatly related to their contact with the public.Aggression from patients against workers takes place in several health care units, such as: psychiatric units (41%), emergency rooms (18%), clinical units (13%), and surgical units (8%).The group of health care workers who are exposed to the risk of violence the most are teams in ambulance, emergency, and nursing services (13) .
Psychological violence at work is another occupational risk which may damage the health of nursing workers, and it is seen as harmful to those workers' careers.That topic has not been studied by Brazilian researchers for a long time, and their research must be developed further (14) .
According to Fernandes et al. (15) and Santos et al. (16) , violence is a public health care problem which is present in all society sectors, and it needs to be discussed by all areas, aiming to minimize the damage from such aggression.
Considering the need for further deepening the knowledge related to the proposed topic, the risk for nursing workers to suffer violence and the complexity of the health care network in the surveyed municipality, which has 689 nursing workers and is a reference to 62 municipalities in the main health care region of eastern Maranhão state, further investigation is required regarding the issues surrounding the problem.
The contribution from this study to academic, professional, and social areas stands out through its identification and characterization of psychological violence in relationships with nursing workers.It also enables those workers to reflect, as, according to some studies (17)(18) , when they undergo those situations, they either cannot tell they suffered that kind of aggression or they are too afraid of losing their jobs or being coerced by aggressors, and that is why they do not report that to their superiors.This research also allows for reflection on the influence of violence in the relationships between those workers and their clients and on the quality of provided services.
Besides that, results serve as a base for guiding decisionmaking from managers in health care units regarding identified problems, in order to solve them through the creation of prevention strategies which may minimize those practices.
The facts above end up referring to the problem in this study.How does psychological violence is established in nursing teams, and in their relationships with patients and other professionals in the public hospital network of Caxias in Maranhão state?
In order to address this concern, this study aims to investigate and characterize psychological violence practices among teams, and in their relationships with patients, family and friend companions, and other professionals, in the public hospital network of Caxias, in Maranhão state.

METHOD
This study is characterized as descriptive, quantitative, and cross-sectional.The data were collected between November 2013 and May 2014 in the public hospital network of Caxias municipality, Maranhão state, which comprises a maternity hospital, a municipal general hospital, and a municipal children's hospital.It serves as reference to 17 cities in its regional perimeter, and to 47 cities in the health care region of eastern Maranhão.
The network has the largest number of nursing workers in the municipality (332), accounting for 49% of total nursing workers in all public and private health care facilities.
The study population comprised 332 workers, 60 of whom being nurses, 209 nursing technicians, and 63, orderlies, according to data from the Municipal Health Care Office (Secretaria Municipal de Saúde) and from the Brazilian National File of Health Care Facilities (Cadastro Nacional de Estabelecimentos de Saúde)/DATASUS The study sample was established as 121 workers through the sample calculation.In order to calculate the sample, a 6% sample error and a 90% confidence interval were applied.
At the end of the study, a 124-subject sample was obtained; out of those, 25 are nurses, 79 are nursing technicians, and 20 and orderlies, which therefore composed the minimum value that was established by the sample calculation.Sample components were selected through Simple Random Sampling, thus generating population representativeness.
The study included workers who had been employed for at least six consecutive months, or ones who had been employed for longer in staggered periods.Workers who were on leave or away from work for any reasons during the collection of data were not part of the study.
All data required for the research conduction were collected through a questionnaires with closed questions that had been prepared by the International Labor organization and previously tested by the NESC -Núcleo de Estudos de Saúde Coletiva (Center for Collective Health Studies) from Universidade Federal do Rio de Janeiro, which had been made available through the quoting of authors Palácios et al. (19) .It should be mentioned that a pilot test was previously applied, in order to adapt the questionnaire to the studied reality.
The research was conducted in four stages.Initially, workers were selected according to the study requirements.In order to do that, the nursing coordinators from each institution were requested to hand lists with the worker's names and hiring dates, as well as work rosters for each sector.Following that, workers were encouraged to take part in the study through the distribution of leaflets with information regarding workplace violence and the importance of conducting the research for their work and professional category.At that stage, proper times and places were discussed and agreed to by the workers, so they could answer the questionnaires.
After the questionnaires were answered, their data were formatted and divided in three categories (Nurses, Orderlies, and Nursing Technicians).Then they were analyzed and statistical calculations were made, according to the study objectives.As criteria to suspend or dismiss the research, the operational questions were adopted as subjects were unable to take part in the study, or at the end of it, when the established sample size was met, after the desired information had been obtained.
The analysis of quantitative data was conducted through SPSS software, which described the studied reality (descriptive statistics); it was also used to build and demonstrate results and frequencies and absolute and percentage numbers, as charts and tables.Numeric variables in the study were displayed as averages, and the ones regarding categories, through frequencies and percentages.
The research was conducted according to the rules and regulations governing research involving human beings, as per resolution 466/2012 and its complementary provisions.Subjects read the consent forms, signing it after having agreed to all research stages.The research project was evaluated by the Research Ethics Committee of Universidade Federal do Maranhão, which issued a positive official opinion, under CAAE no.16004713.8.0000.5087.
The fact that some questions in the questionnaire caused embarrassment and brought undesirable memories and strong emotions to the subjects should be highlighted as study risks.Thus, subjects were free to drop the study at any time.Besides that, the researchers committed to provide full assistance regarding those complications and any other risks not described which could cause harm to subjects.

RESULTS
The results allowed identifying records of eighty-eight psychological violence cases in the public hospital network in that municipality.Subtype verbal aggression was the most frequent one, with 95% (84) of cases, and it was followed by psychological harassment with 27% (24) cases.Sexual harassment, 9% (8 cases), and racial bias, 9% (eight cases) accounted for a smaller share of total cases.When sectors where violence episodes took place were analyzed, results point towards emergency rooms as the places where it is most frequent -51% (45) of all psychological violence cases were recorded in those places.
In regards to the profiles of workers who suffered any kind of psychological violence, 87% (77) are females.When the variables regarding age and length of experience of workers were analyzed, a higher percentage of cases was observed for the ones who were younger and less experienced.Nurses, the category with the smallest length of professional experience, nine years in average, was the one which suffered most violence cases -72% (13) out of the eighteen workers in the 20-39 age range had undergone a kind of violence.
Nursing technicians, the category with the second largest number of psychological violence cases, had an average 11.1 years of professional experience.50% (21) of the forty-two workers in the 30-49 age range had undergone a kind of violence.Orderlies, who were the most experienced category -with an average 15.4 years of employment, were the ones who undergone psychological violence episodes the least, around 30% (6) of workers in the 40-59 age range had been submitted to them.
As a reaction to psychological violence and its subtypes, results showed an expressive percentage of workers who "tried to pretend nothing had happened", 60% (53) or "had no reactions whatsoever", 25% (22).Besides that, in a very low percentage, only 11% (2) out of the eighteen nurses who were submitted to verbal aggression filed police reports and had their offenders prosecuted, which comes to show how little these workers care about those events.
By evaluating the conducts and measures to prevent, reduce, or eliminate violence in the workplace , 56% (40) of the workers in the General Hospital, 58% (19) of the Maternity Hospital, and 35% (7) of the ones in the Children's Hospital stated that no measures are enforced in their places of work.Besides that, the results show the adoption of "internal record of cases", and "training sessions on how to handle, face, and control violence situations in the workplace", which are shown to be important strategies for violence supervision and control, do not exist in surveyed institutions.

DISCUSSION
By analyzing sectors where violence episodes are the most frequent, a study that was conducted in the general hospital of Duque de Caxias, Rio de Janeiro state, confirms that even with the violence against nursing workers being present in all hospital spaces, such event most often takes place during emergency care, which is probably due to the tension in that environment that is caused by the intense number of patients (20) .
In regards to the profiles of workers suffering psychological violence, Zampieron et al. (21) found that female workers are the ones who suffer with workplace violence the most and are more vulnerable to violence situations, thus confirming the findings in this research.
The largest number of women among nursing workers nationwide is historical, and it has been associated throughout time to a patriarchal ideology from society, which stigmatizes nursing workers as an inferior and discredited class before all professions as a whole, which may be closely related to the occupational violence those workers experience (11,20) .
Besides that, many times female nursing workers suffer violence through domination and authoritarianism from the medical class, which tends to be a group with more males.Those situations allude to the asymmetrical relationships of power that exist between men and women.Furthermore, the expertise field of nursing, which relates to providing care, is strongly connected to feminine activities, which causes it to be discredited, as even with our society evolving throughout the years to offer gender equality, sexist demands on women are still frequent (20) .
Unlike these results, hospital institutions from northern Portugal (22) were observed to have the highest percentage of workplace psychological violence victims among male nursing workers (70% -19 cases), the smallest percentage (30% -51 cases) being for female workers.
In regards to age and professional experience from workers who undergone psychological violence episodes, a result that was similar to the one in this study was found by Vasconcellos et al. (23) and Barbosa et al. (14) , who observed the least experienced, newly-graduated, youngest, most committed professionals to be the ones suffering the most violence cases, especially verbal ones.
As regards to the professional profiles of workers who were submitted to psychological violence, according to Oliveira and D'Oliveira (24) , the ones most exposed are the ones with low education levels.That goes against the results in this research, which shows nurses, third-level professionals, as the ones to suffer violence the most in their professional category.They are followed by nursing technicians and orderlies, who have smaller education levels.
That fact was also observed by Vasconcellos et al. (23) , who found a higher percentage of psychological violence cases against nurses (75.4% -306 cases) as compared to the ones for nursing technicians (73.4% -212 cases) and orderlies (62.2% -464 cases).
Regarding the psychological violence subtypes nursing workers underwent the most, according to the surveyed literature, verbal aggression and psychological harassment figure as the most frequent ones (16,(22)(23) , thus confirming this study results, which show verbal aggression and psychological harassment as the psychological violence subtypes nursing workers were the most submitted to, with racial bias and sexual harassment accounting for smaller shares.
However, other authors (14,17,(25)(26) found sexual harassment as one of the main kinds of violence against nursing workers, unlike the results from this research, which show that violence subtype to be restricted to few cases, only for nurse and nursing technician categories.
Concerning the nursing workers' main offenders, according to some authors (14,(16)(17)23,(25)(26) , patients, in general, were reported to be the most frequent group, being followed by family and friend companions, colleagues, and bosses. Specificaly in regards to psychological violence, the main offenders in the literature and in this study results (14,17,(22)(23)(25)(26) were found to be colleagues and bosses.
A study that was conducted with nurses from a general hospital in São Paulo city confirms these same results, pointing out colleagues (39.7%), bosses (23.5%), patients (20.8%), and family and friend companions (16%) as the main psychological violence offenders.Besides that, workers were observed to seldom look for help after violence episodes -around 29% in all cases (24) , which confirms the indifference from those workers, similar to the results found here.
That situation is justified by the fact that a great many workers underestimates psychological violence and its subtypes as they are events with less serious impacts, and which are many times part of their daily working routines.They end up not filing police reports, nor do they search any ways to solve the problem.They only inform their family members, colleagues, and, much less frequently, their immediate superiors (20) .
Other factors such as fear, embarrassment from situations experienced, lack of time, and employees or employers failing to identify situations as violence are reasons why workers do not seek help after those episodes.In turn, the few workers who seek help frequently resort to the very institution they work at, to the police, to psychological support services, to their unions, and to religious support (24,27) .
In regards to prevention and control measures, the creation of strategies to inhibit workplace violence is fundamental, with investments on the training of personnel to prevent and deal with violence episodes, and with mechanisms for institutions to have those acts reported, in order to improve work environments (26) .The results in this study found no such measures to exist in surveyed institutions.
According to Cezar and Marziale (18) , hospital emergency sector coordinators are aware of most violent behaviors against their teams, especially in regards to verbal aggression.They are also aware workers feel unsafe, as measures such as physical partitions between sectors, trained safety staff, and training sessions to deal with violence are not taken.Also, according to reports from those coordinators, who were noticed not to care about the subject, violence is seen as intrinsic to the nature of the occupations and accepted by workers as part of their routines (18) .
The trivialization of workplace violence is noticed on the attitudes of some workers who accept and repeat those practices as if they were normal and established in institutions as part of their organizational culture, even though they are the ones who go through those themselves (17) .
The implementation of proper measures and strategies to prevent violent acts would reduce the possibility of serious consequences to workers greatly (16) .Lima et al. (26) debate the need for workers to reconsider their values, in a way which leads to cultural change in their workplace, through constant and permanent dialog that is based on mutual respect and camaraderie among workers and the public they provide care to.
As a constraint in this study, the impossibility to cover the whole population of nursing workers in the public hospital network in that municipality stands out, as not all professionals accepted to take part in the study.Many of them were afraid to answer the survey, which deals with questions that are very specific to a controversial and compromising topic, even after being instructed and assured the secrecy of their data.
Another limitation, albeit not being the main objective of this study -but which would nonetheless make it richer -was the impossibility to deal with aspects regarding the structural violence in institutions and in the organization of the work these professionals are involved with.

CONCLUSION
The investigated nursing workers are relatively young, predominantly female, and considerably experienced in their fields.Their age was found to be proportional to their professional experience, as the violence episodes were found to be more or less frequent, which may serve as a subject for new studies intending on checking for such proportional relationship.
The professional category which underwent workplace violence the most is the one of nurses, followed by nursing technicians, and, to a smaller extent, orderlies.Psychological violence, which is predominant among workers, displays verbal violence as its most frequent subtype, followed by psychological harassment.Sexual harassment and racial bias follow with lower rates.
Hospital facilities where violence takes place the most are emergency rooms.Most workers "pretended nothing had happened" or "had no reactions whatsoever" when confronted with violence situations.The most frequent offenders are patients, followed by patients' family and friend companions, colleagues in their same ranks, and supervisors or bosses.
Managers and employers are visibly idle regarding the issues that involve measures to control and prevent violence in health care institutions.As workers were interviewed, few or no measures to control violence in surveyed institutions were found to exist.
No simple violence-preventing measures were found, such as the adoption of internal logs for previous violence episodes employees and clients are responsible for, or training sessions on how to handle, face, and control violence situations in the workplace.
That lack of investments in measures to control and prevent workplace violence ends up showing how much employers trivialize situations of violence their workers experience.In some occasions, the employees end up getting used to them, and do not consider those facts as labor-related risks.
According to the literature surveyed to support this study, few published studies mention the characterization of violence in the nursing professional environment, as most studies are focused on studying that phenomenon among other groups of workers.The measures to prevent that problem were another aspect which the literature leaves a lot to be desired.Therefore, it is necessary to give that phenomenon more visibility through other studies that sensitize workers and inspire them to think about violence and about the suffering they experience in their workplace.Individual and collective participation from workers is vital, regarding the reporting of abuse of power, discrimination, sexual harassment, and verbal aggression, thus keeping those episodes from being trivialized.
Besides that, studies which describe the creation of simple models with easily-implemented, accessible strategies to prevent, control, and minimize those actions in the workplace are extremely important.
Internally recording violence episodes, for example, would support the understanding of that phenomenon through the collection of data, as would the disclosure of those data in connection to the conduction of workshops, training sessions, and permanent education activities for hospital professionals, patients, and visitors -those could help workers and employers continuously seek solutions for that problem.

FUNDING
Agency Maranhão Research and Technological Development Support Foundation -FAPEMA, covered all costs regarding this publication.