Verbal abuse and mobbing in pre-hospital care services in Chile

ABSTRACT Objective: to determine the perception of verbal abuse and mobbing and the associated factors of paramedic technicians (nursing assistants) and professionals (nurses, midwives, kinesiologists) in the pre-hospital care areas of three regions in the south of Chile. Methods: descriptive and correlational study was performed within the professional community and a two-stage sample of the paramedic technician population in three regions. The questionnaire “workplace violence in the health sector” (spanish version) was applied after signing the informed consent. Results: 51.4% of professionals and 46.6% of paramedic technicians consider they have been verbally abused during last year. 17.6% of paramedic technicians and 13.5% of professionals perceived mobbing. A low percentage of these events are reported. In only one case of mobbing, the aggressor was legally penalized. No significant differences were found between the job categories and the studied regions. Conclusions: A high percentage of participants in each group perceived verbal abuse and non-minor percentage perceived mobbing, but most of these events are not reported.

a long time with the intention of causing damage; consequences can be devastating for the victims, who may suffer a number of psychological disorders (11)(12) ". For many years, psychological violence has been underestimated; however, it occurs many times through repetitive attitudes that may be relatively unimportant, but in the long term, they can become a severe form of violence (5,10,13) . This research is based on the Interactive Model of Violence proposed by Chappell and Di Martino in 1998, which is based on the Model of Poyner and Warne; this model tries to explain workplace violence from a multifactorial point of view, where the interaction of several risk factors from the aggressor, the victim and the environment where these actions occur are related (2,14) . See Figure 1.
In Chile, the violence phenomenon has been studied from the perspective of users and healthcare providers within the hospital, where psychological violence has always been more common than physical violence in the workplace, this is similar to the information provided in other investigations in Latin America and the rest of the world (15)(16) . On the other side, mobbing has been reported by healthcare providers within the hospital as an increasing phenomenon (12,(17)(18) .
Many international investigations have proven that most violence events occur in emergency services, psychiatric hospitals and nursing homes (19) . In Chile,  Rev. Latino-Am. Enfermagem 2017;25:e2956.

Results
The biosociodemographic and employment characteristics and the history of violence, the professionals and the paramedic technicians are summarized in Table 1 and 2. The Verbal abuse and mobbing perception are summarized in Figure 2.   Rev. Latino-Am. Enfermagem 2017;25:e2956.

The statistically significant variables in relation to
the variables under study are summarized in Table 3.
No significant differences were found between the job categories and the studied regions.  (16,19) .

Discussion
Apparently, insults, teasing, and physical threats are common in Chile, South America and all over the world.
This type of violence has the lowest-level legal sentences, contrary to cases of physical violence; because of this, people tend to accept insults without the abuser being legally penalized. Therefore, the abuser, knowing that he/she will not suffer any punishment, feels free to verbally abuse the victim (15) .
The main verbal abusers, in descending order, were: relatives of the customer, patients, public, a staff member, head or supervisor, and external colleagues.
This ranking corresponds to both job categories, as mentioned in other studies performed in Argentina, Italy, Iran, Gambia, Jordania, and Chile (19)(20) .
Public aggressiveness is one of the main variables relatives, and the general public (21) .
It is surprising to know that in both job categories, there is a low percentage of workers who report verbal violence events to their bosses; the reasons for not reporting can be summarized in "it is useless"and "it was not important". These results are similar to the ones found in countries (22) .
In recent years, a new type of violence has been discovered; this type of violence increases systematically over time and its consequences can be devastating, it is called 'mobbing' (12,23) . Even though percentages are low in both job categories, it is important to note that this harassment dynamics occurs in pre-hospital care areas and affects fellow employees and their respective bosses.
Both working categories state that this phenomenon occurs with low frequency in the workplace, but it causes stress to workers, as stated in the literature and by subjects in both job categories in this study.
It is important to note that sex variable was important for the perception of mobbing. Female workers are more vulnerable than male workers to suffer certain types of workplace violence (5) . The sex of the person in a male world, which characterizes this type of job, and the competitiveness they must face every day for a space in the workplace make them more likely to suffer this type of violence.
On the other side, childhood abuse suffered by paramedic technicians was also related to the perception of mobbing. As mentioned above, childhood abuse is a variable that influences the way a person will react when he/she faces certain types of violence, as in this case (2,14) .
The fact that a low percentage of mobbing and verbal abuse victims decide to report these incidents is surprising. Generally, professionals and paramedic technicians do not report these violence events because "reporting is useless" and "because they think the event was not important". It is important to notice that mobbing, despite being a continuous form of harassment, is considered by workers as unimportant even though it causes problems that may destroy labor relations (22)(23) .
Harassment suffered by healthcare workers can be fatal for users, because it can affect workers' performance, they may become emotionally vulnerable, and get tired after the constant attacks against them, resulting in poor healthcare services for users (2,5,13,24) .
When the workers from both job categories had the chance to ask for help regarding mobbing incidents, they stated that they had only been given chance to talk about the incident and that they had not received any professional help. This made professionals and paramedic technicians feel dissatisfied with the outcome of the events, and led other staff members of prehospital care to avoid reporting new mobbing episodes in their workplace, because they knew their workplace problems would not be solved, leading to a vicious circle in the work environment. In studies performed in other countries, one of the actions that are taken in order to stop these mobbing incidents and that seems worth for healthcare entities to take into account is the prevention of mobbing by encouraging workers to get along well with each other and to interact with each other in order to minimize these violence episodes, as well as by encouraging workers to report these violent incidents in the workplace.

Conclusion
Pre-hospital care areas are not free of suffering violent incidents when providing healthcare services.
Verbal abuse is the most prevalent, followed by mobbing events have appeared among workers of healthcare areas. It is absolutely necessary to encourage workers to report violence episodes that occur while providing healthcare services and those events that occur in the workplace in order to protect qualified professionals and paramedic technicians who attend medium to highly complex emergency calls, because the environment of these healthcare services must be free from any type of violence.