Violence in the workplace in Nursing: consequences overview

Objective: to refl ect on the consequences of workplace violence experienced by nursing professionals. Methods: this is a refl ection paper based on recent publications related to the subject, particularly researches carried out in Brazil and in other countries. Results: exposure to workplace violence has been associated with health problems in nursing professionals, which may be physical damage, emotional manifestations, and psychic disorders. It also affects the employee performance, his or her family and social interactions. Conclusion: this phenomenon is potentially noxious and costly, for it leads to suffering, illness, absence from work, and even death. This refl ection calls attention moreover to the importance of a safe and adequate health care work environment. Descriptors: Violence; Work; Workplace; Workplace violence; Nursing. RESUMO Objetivo: refl etir acerca das consequências da violência no trabalho experienciada por profi ssionais de enfermagem. Método: tratase de um artigo de refl exão que contou com o auxílio de publicações recentes relacionadas a esta proposta, sobretudo de pesquisas realizadas no Brasil e em outros países. Resultados: a exposição à violência no trabalho tem sido vinculada a problemas de saúde nos profi ssionais de enfermagem, que se apresentam por danos físicos, manifestações emocionais, transtornos e distúrbios psíquicos. Além disso, infl uencia o desempenho do trabalhador, sua dimensão familiar e social. Conclusão: aponta-se para o potencial nocivo e oneroso deste fenômeno, por ser capaz de ocasionar sofrimento, adoecimento, afastamentos do trabalho e até a morte. Esta refl exão sensibiliza, ainda mais, para a importância de ambientes de trabalho seguros e em condições adequadas na área da saúde. Descritores: Violência; Trabalho; Local de Trabalho; Violência no Trabalho; Enfermagem. RESUMEN Objetivo: refl exionar sobre las consecuencias de la violencia laboral experimentada por profesionales de enfermería. Método: artículo de refl exión que contó con la ayuda de publicaciones recientes relativas a la propuesta, particularmente de investigaciones realizadas en Brasil y en otros países. Resultados: la exposición a la violencia laboral ha sido vinculada a problemas de salud en los profesionales de enfermería, expresados como daños físicos, manifestaciones emocionales, trastornos y disturbios psíquicos. Además de ello, infl uye en el desempeño del trabajador, en su dimensión familiar y social. Conclusión: Cabe considerar el potencial nocivo y oneroso del fenómeno, capaz de ocasionar sufrimiento, padecimientos, licencias laborales e incluso la muerte. Esta refl exión pretende sensibilizar aún más sobre la importancia de ámbitos laborales seguros y en condiciones adecuadas en el área de salud. Descriptores: Violencia; Trabajo; Lugar de Trabajo; Violencia Laboral; Enfermería. Violence in the workplace in Nursing: consequences overview Violência no trabalho da Enfermagem: um olhar às consequências Violencia en el trabajo de Enfermería: una visión de las consecuencias REFLECTION Maiara Bordignon E-mail: bordignonmaiara@gmail.com CORRESPONDING AUTHOR


INTRODUCTION
Violence against health workers represents approximately a quarter of total work violent events (1) . These situations, therefore, have been observed, or else are routine for some nursing professionals. Analysis of violence suffered by nurses who worked in the emergency room, intensive care unit, and in Psychiatry units in Turkey has identified that most nurses (60.8%) have been exposed to verbal and/or physical violence from patients, visitors or health workers (2) .
A study (3) making further analysis of patient and visitor violence against nurses in swiss hospitals showed that 95% of nurses have experienced violence during their careers, 72% experienced verbal abuse, and 42% physical violence in the past 12 months. Factors such as emotional manifestations arising from health problems and pain, psychiatric disorders, alcohol and other substances abuse may influence people's behavior and make them verbally and physically violent (1) . Therefore, nursing and health care professionals are subjected to these events, for being considered normal among workers who establish contact with people in distress (1) .
In assessing occurrences in the past six months of workplace verbal and physical abuse of nurses who worked in hospitals in Amman (Jordan), there was prevalence of 37.1% and 18.3%, respectively (4) . Nurses with less experience and those working in the emergency room and in the intensive care unit had experienced more workplace verbal and physical abuse; and more than half expected to suffer violence at some point in his or her career (4) .
An inquiry conducted by the Regional Nursing Council of São Paulo (COREN-SP), Brazil, demonstrated from 8,332 respondents reports that 74% experienced some kind of violence in their workplace, 52% have suffered aggression two times or more, and 73% affirmed that the incidents recurred in their workplace (5) .
Statistics are disturbing compared to the number of nursing professionals in the world who have suffered workplace violence and are thus susceptible to its consequences. This article is based on reflection of some of the consequences of the workplace violence experienced by nursing professionals, and it aims at raising awareness, moreover, to the urgent need of a safe work environment and favorable conditions in health care services, minimizing risks and exposures.

Consequences of workplace violence in Nursing: what and whom it affects
Nursing professionals, besides facing challenging situations at work, e.g., dealing with patients and their families and experiences of loss on the death of patients, they can still face violence on the job and its consequences, since virtually all violent situations involve anguish, with a lasting and/or harmful influence in the victim's health (1,4) .
In this article, to organize the presentation of some of these consequences we considered the ones related to the worker's health, to the institution, and to health care. However, it is not possible to examine these consequences in isolation because they affect health care workers and, subsequently, other contexts in which they are inserted.
Workplace violence in nursing has effects on worker's health for decreasing general health, mental health, and vitality scores, as observed in nurses who felt threatened (6) , and in the increased levels of psychological distress related to bullying and verbal sexual harassment suffered by nurses and midwives (7) . These consequences indicate initially that workplace violence is not restricted to the workplace, it can also be harmful to worker's health and consequently to his or her life, as restates a study (4) on social and family life of nurses disturbed by negative effects of verbal and physical abuse.
Pain, sprain, hearing damage, palpitations, sleep disorders, stress, depression, fear of patients and/or visitors, and the feeling that the profession is not respected were complains made by nurses exposed to violence (2) . Nurses victims of physical violence and verbal abuse also reported fatigue, headaches, sleeping problems, fear, anxiety, and gastralgia (4) , which are predominant expressions of workplace violence in several studies (3)(4)8) . Also, psychological workplace violence experienced by Brazilian female nurses was assessed, confirming that high rates of aggression caused mental and physical disorders, loneliness, irritability, anger, sadness, low self-esteem, and crying; these last five consequences are also identified in low rates of aggression (9) . Furthermore, bullying is associated with burnout, both causing deep and destructive consequences to human beings (10) .
Such manifestations show that workplace violence makes nursing professionals psychically vulnerable, in addition to physical assaulted. It is proper to explain that foreign terms related to workplace violence (bullying or mobbing) refer to psychological harassment characterized by persecution, constant negative observations, isolation from social interaction, and dissemination of lies, which are cruel attempts of humiliating a worker or group of workers (1) .
Related to worker's health and directly connected to the institution's health care quality and costs, incivility in the workplace can result in sick leaves (one to five days) and physical wounds, with or without need of first aid, consultation or treatment, according to research conducted with nurses from a swiss hospital on patient's and visitor's violence (3) .
Patient's and visitor's violence are considered workplace hazard for healthcare professionals, mainly in nursing (3) who remain for more time interacting with patients and visitors (8) and nurses who work in intensive and intermediate care units, rehabilitation, and emergency room (3) . Although family and patients are usually responsible for acts (4) of violence in health care workplaces, one must take into consideration violence inherent to working relations between work partners or subordinates and supervisors, which sometimes occur in the workplace and may have severe consequences. Data provided by COREN-SP showed that 49% of 8,332 nursing professionals named patients as their aggressors, 49% family members, and, proportionally, working partners with a higher position (42%) (5) .
Health care sector restructuring affects considerably work conditions, since privatization, decentralization, and rationalization are processes often followed by personnel cuts, pay freeze, work overload and intense rhythms, more working hours, and subcontracting, among other factors potentially stressful and that may lead eventually to violence (1) . Moreover, most nursing professionals are female (5,9) (equivalent to 83.3% in São Paulo (5) ) and women are highly exposed to risk of violence, e.g., sexual harassment, in which most victims are women (1) .
Besides, in this context the results from the state of São Paulo showed that being exposed to risk of aggression, overwhelming tasks, and lack of proper structure to carry out activities, justified the work insecurity and impairment reported by 64% of workers (5) . It becomes evident thus that unfavorable working conditions are potential sources of suffering and illness for nursing professionals, and also refer to situations of violence, including institutional violence, disturbing and present in certain health care environments (8) .
From these informations, indicating the existence of multiple factors contributing to workplace violence (1) , it is believed that this matter requires further evaluation. The effective analysis of these elements is very complex, because important factors often prevail and interfere (1) .
Another consequence of workplace violence that relates directly to employer health care institutions is decreased organizational commitment associated with internal emotional abuse and bullying, as observed in nurses and midwives working in an Australian hospital (7) ; besides the impact on job performance (2) , decreased quality of work (4) , greater psychological demand, and decreased control over tasks (6) .
It is understood that these consequences may affect the quality of health care provided, since they increase chance of occurrence of adverse events. Therefore, violence contributes to the development of diseases, impairs both who suffers it and everyone around, and affects the quality of work (9) . Employers thus are likely to bear direct or indirect costs of production loss, low efficiency and productivity, decreased quality, damages on the institution's image, and reduction of the number of clients (1) .
It is important also to point out that among costs generated by violence there are, for example, health care and rehabilitation of victims, disabilities and invalidity, unemployment, and refresher courses for and reintegration of individuals that lost their jobs because of violent incidents (1) .
Besides, experiences of violence may lead to stressed, irritated, and unmotivated workers, which affect working context (8) . Nurses verbal and physically abused and/or subjected to high rates of aggression reported the idea/desire to leave their jobs (2,4,9) . Many victims of workplace violence break their institutional bounds because of trauma and fear that the violent incident may happen again (5) . This context adds up to the feeling of insecurity at the workplace (reported by 64.7% of health care professionals who worked in São Paulo) and low wages incompatible with activities performed (5) and identified in some institutions, among other factors that make nursing professionals consider quitting their jobs and the profession.
Lastly, every worker is unique and experience the incident in a particular way, depending on life history, capacity to deal with difficult situations, and resilience. Being a victim of workplace violence may have consequences for workers, but it does not happen the same way or happen in different intensity on different workers, it is not a rule. Truth is violence suffered by nursing professionals while exercising their functions has the potential to generate consequences, many of them are serious and have impact on workers' health and life, as well as on their relationship with work and health care institutions, and may extend to society. Workplace violence in health care unquestionably "has become a public health problem", which may undermine workers' health, their careers, and health care provided (8) .
Even if in this reflection we did not expect to go through all consequences of violence experienced by nursing professionals, hence this phenomenon repercussions go further, data gathered indicated hypothesis on what and whom these consequences have affected. Such analysis may provide information to health care institution managers, nursing professionals, and people interested in the subject to demonstrate how important is the development and incorporation of initiatives demanding appropriate working and organizational conditions, and aiming at making health care work environments safe; it is also important to enable nursing professionals provide quality health care (4) .
These initiatives also aimed at preventing workplace violence may include adoption of safety measures; improvement of work conditions, increasing the number of professionals hired; appropriate structure, materials, and equipments; training and fair remuneration; besides organizing services to allow access and reception of users in a health care management that promotes assistance excellence and a more satisfying job to the whole team, among others (8) . For this purpose, support and commitment of the health institution and its employees are essential for the consolidation of these initiatives at the workplace for preventing workplace violence (1) .

FINAL CONSIDERATIONS
Nursing professionals who experience workplace violence are likely to suffer physical and psychological distress, which may affect the worker's capacity to perform everyday activities, his or her relationship with other people, financial condition, quality of life, and the health care system. Moreover, the consequences of workplace violence in nursing affect the entire employer health care institution, for it affects its employees, which may lead to workforce reduction, illness or team impairment, compromise the quality of care provided, and generate costs.
Nursing professionals assume outstanding relevance in health care services. Therefore, the present circumstances in which many of these workers were, are or will be victims of workplace violence must change, not only in Brazil, but in the world. Participation of managers, workers, scientific community, and people in general are important in searching for adequate working conditions and service safety and quality, from which proposals strengthen of federal and regional agencies intervention, e.g., Regional Nursing Council of São Paulo, to foster development of new and adequate initiative strategies to improve more and more this field of action.

FUNDING
Thanks to the National Council for Scientific Development (CNPq) for granting a masters degree scholarship.