Strategies used by nursing staff in situations of workplace violence in a haemodialysis unit

Onélia da Costa Pedro Cordenuzzi Suzinara Beatriz Soares de Lima Francine Cassol Prestes Carmem Lúcia Colomé Beck Rosângela Marion da Silva Daiane Dal Pai About the authors

RESUMO

Objetivo

Identificar as estratégias utilizadas pelos trabalhadores de enfermagem de um serviço de hemodiálise em situações de violência perpetrada por pacientes durante a assistência.

Método

Pesquisa de abordagem qualitativa, do tipo descritiva e exploratória, que utilizou grupo focal com a participação de oito trabalhadores da equipe de enfermagem de um serviço de hemodiálise privado do sul do Brasil. Empregou-se a análise de conteúdo temática para tratamento dos dados.

Resultados

As estratégias utilizadas são descritas nas categorias: Tolerar a violência pela condição de saúde do paciente; Contornar as situações de conflito e ceder à solicitação do paciente; Adotar um posicionamento de rejeição à violência; e Se afastar do paciente agressor.

Considerações finais

Evidencia-se a necessidade de mobilização coletiva dos trabalhadores e, principalmente, da instituição como mediadora, na busca pela prevenção e não propagação da violência no ambiente de trabalho.

Enfermagem; Violência no trabalho; Estratégias; Diálise renal; Saúde do trabalhador

RESUMEN

Objetivo

Identificar las estrategias utilizadas por el personal de enfermería del servicio de diálisis en situaciones de violencia por parte de los pacientes durante la atención.

Método

Investigación cualitativa, descriptiva y exploratoria, que utilizó grupos de enfoque con la participación de ocho trabajadores del personal de enfermería de un servicio de hemodiálisis privada en el sur de Brasil. Se utilizó el análisis de contenido temático.

Resultados

Las estrategias utilizadas se describen en las siguientes categorías: Tolerar la violencia por la condición de salud del paciente; Contornar el conflicto y ceder a la petición de la paciente; Adoptar una posición de rechazo a la violencia y alejarse del paciente agresor.

Consideraciones finales

Pone de relieve la necesidad de la movilización colectiva de los trabajadores, principalmente de la institución como mediador en la búsqueda de la prevención en lugar de propagación de la violencia en el ambiente de trabajo.

Enfermería; Violencia laboral; Estrategias; Diálisis renal; Salud laboral

ABSTRACT

Objective

To identify strategies that nursing staff use at a haemodialysis unit in situations of violence by patients during care.

Method

Qualitative descriptive and exploratory research with focus groups and the participation of eight workers of the nursing staff of a private haemodialysis unit in southern Brazil. The data were subjected to thematic content analysis.

Results

The adopted strategies are described in the following categories: Tolerating violence due to the patient’s health condition; Working around conflicting situations and giving in to patient’s requests; Adopting a position of rejection to violence; and Staying away from the aggressor patient.

Final considerations

Workers and, above all, the institution in the role of mediator, must work together to prevent and discourage violence in the workplace.

Nursing; Workplace violence; Strategies; Renal dialysis; Occupational health

INTRODUCTION

Violence at work is a global phenomenon and a violation of human rights that affects the dignity of people by causing inequality, discrimination, stigmatisation, and conflict in the workplace(11. Organización Internacional del Trabajo, Consejo Internacional de Enfermeras, Organización Mundial de la Salud, Internacional de Servicios Públicos. Directrices marco para afrontar la violencia laboral en el Sector de la Salud [Internet] Ginebra: OIT; 2002 [citado 2015 agosto 12]. Disponíble en: http://www.ilo.org/wcmsp5/groups/public/---ed_dialogue/---sector/documents/publication/wcms_160911.pdf.
http://www.ilo.org/wcmsp5/groups/public/...
). It is growing public health problem worldwide(11. Organización Internacional del Trabajo, Consejo Internacional de Enfermeras, Organización Mundial de la Salud, Internacional de Servicios Públicos. Directrices marco para afrontar la violencia laboral en el Sector de la Salud [Internet] Ginebra: OIT; 2002 [citado 2015 agosto 12]. Disponíble en: http://www.ilo.org/wcmsp5/groups/public/---ed_dialogue/---sector/documents/publication/wcms_160911.pdf.
http://www.ilo.org/wcmsp5/groups/public/...

2. Pinar T, Acikel C, Pinar G, Karabulut E, Saygun M, Bariskin E, et al. Workplace violence in the health sector in Turkey: a national study. J Interpers Violence. 2015 Jun 28. pii:0886260515591976.
-33. Dal Pai D, Lautert L, Souza SBC, Marziale MHP, Tavares JP. Violence, burnout and minor psychiatric disorders in hospital work. Rev Esc Enferm USP. 2015 [cited 2015 Aug 12];49(3):457-64. Available from: http://www.scielo.br/pdf/reeusp/v49n3/0080-6234-reeusp-49-03-0460.pdf.
http://www.scielo.br/pdf/reeusp/v49n3/00...
), and healthcare workers are at an especially high risk of being assaulted during the performance of their work activities(22. Pinar T, Acikel C, Pinar G, Karabulut E, Saygun M, Bariskin E, et al. Workplace violence in the health sector in Turkey: a national study. J Interpers Violence. 2015 Jun 28. pii:0886260515591976.

3. Dal Pai D, Lautert L, Souza SBC, Marziale MHP, Tavares JP. Violence, burnout and minor psychiatric disorders in hospital work. Rev Esc Enferm USP. 2015 [cited 2015 Aug 12];49(3):457-64. Available from: http://www.scielo.br/pdf/reeusp/v49n3/0080-6234-reeusp-49-03-0460.pdf.
http://www.scielo.br/pdf/reeusp/v49n3/00...

4. Vasconcellos IRR, Abreu AMM, Maia EL. Occupational violence experienced by nursing staff in hospital emergency service. Rev Gaúcha Enferm. 2012 [cited 2015 Aug 12];33(2):167-75. Available from: http://www.scielo.br/pdf/rgenf/v33n2/24.pdf.
http://www.scielo.br/pdf/rgenf/v33n2/24....
-55. Vasconcellos IRR, Griep RH, Lisboa MTL, Rotenberg L. Violence in daily hospital nursing work. Acta Paul Enferm. 2012 [cited 2015 Aug 12];25(spe):40-7. Available from: http://www.scielo.br/pdf/ape/v25nspe2/07.pdf.
http://www.scielo.br/pdf/ape/v25nspe2/07...
).

The nursing staff is exposed to violence at work on a daily basis. This violence is mostly expressed through verbal aggression on the part of the patient and their family members, who, dissatisfied with the service, direct their dissatisfaction to whomever is on the front line of care, namely, the nurses(44. Vasconcellos IRR, Abreu AMM, Maia EL. Occupational violence experienced by nursing staff in hospital emergency service. Rev Gaúcha Enferm. 2012 [cited 2015 Aug 12];33(2):167-75. Available from: http://www.scielo.br/pdf/rgenf/v33n2/24.pdf.
http://www.scielo.br/pdf/rgenf/v33n2/24....
).

A study found that chronic renal patients undergoing haemodialysis are more vulnerable to stress and are more prone to respond to threatening situations with higher levels of anxiety(66. Valle LS, Souza VF, Ribeiro AM. Estresse e ansiedade em pacientes renais crônicos submetidos à hemodiálise. Estud Psicol (Campinas). 2013 [citado 2015 ago 12];30(1):131-8. Disponível em: http://www.scielo.br/pdf/estpsi/v30n1/14.pdf.
http://www.scielo.br/pdf/estpsi/v30n1/14...
). Consequently, the European Dialysis and Transplant Nurses Association and the European Renal Care Association (EDTNA/ERCA) proposed recommendations to prevent and manage violence and aggression in renal units(77. Zampieron A, Saraiva, M, Pranovi R, editors. EDTNA/ERCA recommendations for prevention and management of violence and aggression in renal units. Madrid: Imprenta Tomás Hermanos; 2010. Available from: http://www.edtnaerca.org/pdf/education/V&A_Book.pdf.
http://www.edtnaerca.org/pdf/education/V...
). This initiative ratifies that violence at work in dialysis units is a growing worldwide phenomenon(88. Jones J, Nijman H, Ross J, Ashman N, Callaghan P. Aggression on hemodialysis units: a mixed method study. J Ren Care. 2014;40(3):180-93.).

This phenomenon gains even greater proportions when we consider its possible long-term effects, since the direct or indirect exposure to violence at work can result in psychological aggravations, like anxiety(99. Gates DM, Gillespie GL, Succop P. Violence against nurses and its impact on stress and productivity. Nurs Econ. 2011;29(2):59-66, quiz 67.). Some of repercussions include the loss of efficiency and quality of work, the distancing of nursing staff from patients and colleagues, questioning the value of work, depression, suffering and the illness of workers(44. Vasconcellos IRR, Abreu AMM, Maia EL. Occupational violence experienced by nursing staff in hospital emergency service. Rev Gaúcha Enferm. 2012 [cited 2015 Aug 12];33(2):167-75. Available from: http://www.scielo.br/pdf/rgenf/v33n2/24.pdf.
http://www.scielo.br/pdf/rgenf/v33n2/24....
).

There is evidence that exposure to violence at work in health services is associated with psychological problems(33. Dal Pai D, Lautert L, Souza SBC, Marziale MHP, Tavares JP. Violence, burnout and minor psychiatric disorders in hospital work. Rev Esc Enferm USP. 2015 [cited 2015 Aug 12];49(3):457-64. Available from: http://www.scielo.br/pdf/reeusp/v49n3/0080-6234-reeusp-49-03-0460.pdf.
http://www.scielo.br/pdf/reeusp/v49n3/00...
, 1010. Edward KL, Ousey K, Warelow P, Lui S. Nursing and aggression in the workplace: a systematic review. Br J Nurs. 2014;23(12):653-4, 656-9.). It is linked to the occurrence of workplace accidents and absenteeism and tends to reflect negatively on employee job satisfaction and recognition(33. Dal Pai D, Lautert L, Souza SBC, Marziale MHP, Tavares JP. Violence, burnout and minor psychiatric disorders in hospital work. Rev Esc Enferm USP. 2015 [cited 2015 Aug 12];49(3):457-64. Available from: http://www.scielo.br/pdf/reeusp/v49n3/0080-6234-reeusp-49-03-0460.pdf.
http://www.scielo.br/pdf/reeusp/v49n3/00...
). In addition, violence can affect the entire team and compromise the quality of care provided to patients(1010. Edward KL, Ousey K, Warelow P, Lui S. Nursing and aggression in the workplace: a systematic review. Br J Nurs. 2014;23(12):653-4, 656-9.).

The justification of this study proposal lies in the fact that, despite the recurrent acts of violence at work and the negative effect of violence in the work and health of nursing staff, this subject has been little explored in the hospital setting(22. Pinar T, Acikel C, Pinar G, Karabulut E, Saygun M, Bariskin E, et al. Workplace violence in the health sector in Turkey: a national study. J Interpers Violence. 2015 Jun 28. pii:0886260515591976.

3. Dal Pai D, Lautert L, Souza SBC, Marziale MHP, Tavares JP. Violence, burnout and minor psychiatric disorders in hospital work. Rev Esc Enferm USP. 2015 [cited 2015 Aug 12];49(3):457-64. Available from: http://www.scielo.br/pdf/reeusp/v49n3/0080-6234-reeusp-49-03-0460.pdf.
http://www.scielo.br/pdf/reeusp/v49n3/00...

4. Vasconcellos IRR, Abreu AMM, Maia EL. Occupational violence experienced by nursing staff in hospital emergency service. Rev Gaúcha Enferm. 2012 [cited 2015 Aug 12];33(2):167-75. Available from: http://www.scielo.br/pdf/rgenf/v33n2/24.pdf.
http://www.scielo.br/pdf/rgenf/v33n2/24....
-55. Vasconcellos IRR, Griep RH, Lisboa MTL, Rotenberg L. Violence in daily hospital nursing work. Acta Paul Enferm. 2012 [cited 2015 Aug 12];25(spe):40-7. Available from: http://www.scielo.br/pdf/ape/v25nspe2/07.pdf.
http://www.scielo.br/pdf/ape/v25nspe2/07...
, 1111. Silva IV, Aquino EML, Pinto ICM. Violência no trabalho em saúde: a experiência de servidores estaduais da saúde no Estado da Bahia, Brasil. Cad Saúde Pública. 2014;30(10):2112-22.). To date, no Brazilian studies on the strategies used by nursing staff in conditions of violence at haemodialysis units have been identified.

Therefore, the research question was: What strategies does the nursing staff at a haemodialysis unit use when confronted with violence by patients during care?

The aim of this paper is to contribute to the production of knowledge on the subject of “violence at work suffered by nursing staff of a haemodialysis services”, and to identify the strategies used by nursing staff in a haemodialysis unit in situations of violence perpetrated by patients during care.

The proposition of this paper should provide visibility to the subject and encourage reflection on the identification and effectiveness of strategies used by nursing in relation to violence on the part of patients in haemodialysis. It is also intended to prevent the dissemination of violence and promotion of the health of workers.

METHODOLOGICAL APPROACH

This is a qualitative, exploratory, and descriptive study(1212. Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 14. ed. São Paulo: Hucitec; 2014.), conducted with the focus group technique (GF)(1313. Thofehrn MB, Montesinos MJL, Porto AR, Amestoy SC, Arrieira ICO, Mikla M. Grupo focal: una técnica de recogida de datos en investigaciones cualitativas. Index Enferm. 2013 [citado 2015 agosto 12]; 22(1-2):75-8. Disponible en: http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1132-12962013000100016&lang=pt.
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) for the production of data with the nursing staff of a haemodialysis service in southern Brazil.

The setting was a private service funded by the Unified Health System that receives an average of 300 patients of a regular haemodialysis programme. The nursing staff of the service consisted of seven nurses, 13 nursing assistants, and 35 nursing technicians. The inclusion criteria for participant selection were active members of the nursing staff, and working at the service for more than three months. We excluded the workers who were on leave or in a probationary period at the time of data collection (working for less than three months at the unit).

To compose the groups, the workers were invited using posters displayed in the murals of the unit with information on the study, the inclusion and exclusion criteria, and contact information of the researcher responsible for the study. Of the 50 workers who met the criteria, 11 expressed their interest in participating in the study by contacting the researcher and eight attended the meetings.

Data were collected in June 2010 during to GF sessions with an average duration of 90 minutes each. The meetings were held in a location that guaranteed the privacy and comfort of the participants in the institution itself, at the times and days previously scheduled with the workers.

The researcher responsible for conducting the topics (moderator) and two observers who helped record the meetings also participated(1313. Thofehrn MB, Montesinos MJL, Porto AR, Amestoy SC, Arrieira ICO, Mikla M. Grupo focal: una técnica de recogida de datos en investigaciones cualitativas. Index Enferm. 2013 [citado 2015 agosto 12]; 22(1-2):75-8. Disponible en: http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1132-12962013000100016&lang=pt.
http://scielo.isciii.es/scielo.php?scrip...
). In the first session, we presented the objective and rationale of the research and asked participants to read and, if they agreed with the terms, to sign the informed consent statement. Subsequently, the moderator notified the participants that an essential prerogative for the proper development of this group was a statement of ethical confidential and respectful commitment, which was signed by all group participants(13).

In the first session, the workers responded a characterisation tool with information on sex, age, professional category, and time in service. To protect their identities, the participants were identified with the letter “T” followed by sequential Arabic numeral according to the order of delivery.

Then, the group was asked to explain how they define violence at work and to report any experiences at work in the dialysis unit. At the end of the meeting, the participants agreed that the most significant expression of violence in nursing work came from the haemodialysis patients.

In the second session, the workers addressed the strategies they use to deal with violence by answering the question, “Which nursing strategies do you use in situations of violence perpetrated by patients during the haemodialysis service?”. The discussions were recorded in audio, as agreed by the participants, and later transcribed in full using a text editor for later analysis along with the records of the observers.

After exhaustive reading of the material, the data were analysed using the thematic content technique(1212. Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 14. ed. São Paulo: Hucitec; 2014.) according to the stages of pre-analysis, material exploration, and processing of results. The data were analysed around the theme, “strategies used by the nursing staff of a haemodialysis service in situations of violence by patients during care”, and structured into four thematic categories described in the results of this study.

The study is based on a master’s dissertation(1414. Cordenuzzi OCP. Violência no trabalho da enfermagem em um serviço de hemodiálise [dissertação]. Santa Maria (RS): Programa de Pós-Graduação em Enfermagem, Universidade Federal de Santa Maria; 2011.) and observed with the recommendations for the ethical conduct of research involving humans. The study received a favourable opinion from the ethics research committee of the Universidade Federal de Santa Maria (UFSM) with the number of the Certificate of Presentation for Ethical Assessment (CAEE) 0017.0.243.000-10.

RESULTS

Eight members of the nursing staff participated in this study, of which six were women and two were men, aged from 24 to 49 years, with a four to 28-year background in nursing. Of the eight participants, two were nurses, four were technicians and two were nursing assistants. In relation to the time worked in the haemodialysis unit, the period ranged from two to 17 years.

The strategies used by the nursing staff of the haemodialysis unit in situations of violence by patients during care were represented in the following categories: Tolerating violence due to the patient’s health condition; Working around conflicting situations and giving in to patient’s requests; Adopting a position of rejection to violence; and Staying away from the aggressor patient.

In the first category, tolerating violence due to the patient’s health condition, the workers mentioned they understood that patients resorted to violent behaviour because they refused to accept their disease and dependent on treatment.

Thus, they used to strategy of tolerating violent behaviour due to the patient’s condition and the consequent constraints imposed by the disease and treatment, as noted in the statements below:

Sometimes I put myself in the place of the patient and you know what? If I were doing haemodialysis and wanted to be late, I wouldn’t “care”, you know? So there is a huge conflict if I think about it and put myself in the place of the patient (T1).

I ask myself, if I had to depend on a machine and a person, be financially dependent. I think I would be very angry if I were deprived of certain things in my life [...]. I understand when they are violent (T4).

The participants demonstrated how they perceived the other, and believed that by putting themselves in the place of the patients, they could experience their feelings regarding their disease when they were being aggressive. The statements above refer to certain tolerance of the nursing staff in relation to assaults by patients on haemodialysis.

This tolerance is ratified by the strategy working around conflicting situations and giving in to patient’s requests to prevent assault. In this category, the workers said that they tried to “circumvent” potential situations of conflict and mask their disapproval by remaining silent or yielding to the will of patients, even if that meant violating recommendations or service standards to prevent an assault, as shown below.

Many times I tried to talk, tried to appease. It often helped (T1).

The idea is to avoid aggression! I’ll be correct if I am acting accordance with rules and regulations of the company. But it is our defence, because I do not want to be assaulted, I want to work well, I want him [the patient] to be well, and then you end up giving in, you know? So, I don’t want to create an environment of aggression (T2).

Because if you do, if you stand up for yourself, it causes this general discomfort in the room [haemodialysis]. So it’s better to take it as a joke or try to circumvent it, not face it “full force” (T4).

This strategy can be related to the fact that the patient who is being violent will continue attending the service, that is, the worker who is the target of this aggression will probably have to provide care to this same patient in the near future. Moreover, the workers justified the strategy of working around and yielding in certain situations to prevent them from getting worse and not cause overall discomfort since the haemodialysis rooms are collective and the other patients witness these episodes of violence. The statements that follow clarify these claims:

We want to maintain the harmony and always try to make it a pleasant environment and not allow that bad feeling to set in. It’s because we have to see them again, another day is another day, a new situation, but I think it is through conversation, dialogue or, even, our own silence. Because I am the professional who is there when they need me, and then there is that issue: violence begets violence, so I don’t have to attack the same way that he’s attacking me, I won’t swear it him, either (T6).

[...] we cope with it, try to adapt, working around it. If we didn’t work around some situations, the attacks would more serious. Not to mention the other patients who end up seeing everything, it create this bad feeling in the [haemodialysis] room (T5).

Although the strategy mentioned above is common and considered partially effective, part of the group disagreed with this approach since they also recognised how harmful these experiences can be, as shown below:

I realised that it was best to remain silent. But deep down I was suffering ... (T1).

In addition to the suffering, some workers argued that yielding to the will of patients because they are afraid of being assaulted encouraged even more violence, especially in relation to colleagues who follow the standards and recommendations of the service, as shown below:

You minimise it today and create more violence for your colleagues tomorrow (T8).

As a result, the workers also used the strategy of adopting a position of rejection to violence, especially in cases they considered more serious, such as those that involve patients with a history of aggression. This strategy constitutes the third category of the study.

The workers believed that adopting a firm attitude through a private conversation or signalling that violence is unacceptable, even without solving the problem, prevents or mitigates new episodes of aggression. This category is exemplified in the following lines:

Because we have to take a firm position [...] sometimes I think it’s not acceptable [...] the recurrent aggression comes from the actual patients (T7).

When I think the patient crossed the line, I have to be tough, I think our attitude, there, in our position, we’re giving ourselves to the care, I think we have to have a firmer hand, even if it causes discomfort or if the [haemodialysis] room gets more agitated, it creates this climate, because the next time the patient thinks of assaulting you, he will think differently (T3).

We don´t always solve it, but we try to talk to the patient privately, it works a little (T5).

Some nurses have a firm hand with him [patient] and, when we try to create a milder climate, it’s useless, he acts up again! You have to talk seriously to “calm the waters”, and that does not mean it stops, he didn’t stop with the attacks (T6).

As noted in the statements above, this strategy is considered partially effective because it relieves the situation, but does not solve the problem. The participants stated that the strategy of imposing respect must be used in certain situations to signal that the violence is not acceptable. However, they believed that in other situations this is not the best option because it can make matters worse, that is, cause a new problem. This point is exemplified in the following statement:

It’s just that, sometimes, if we have to be firm, things snowball [...] Because if you are firm, sometimes, you end up creating a bigger conflict (T4).

According to the lines above, the coexistence during the years of treatment helps workers identify patients with a history of violent behaviour and assess conflict situations that can evolve into acts of aggression. These issues can have an impact on the choice of the strategy adopted in the various situations of violence.

Staying away from the aggressor patient was another strategy mentioned by the nursing workers of the haemodialysis service. In this category, the participants stated that, after the episode of aggression, they stopped caring for or approaching the patient who committed the violent act. The lines that follow make up the category:

A defence shield, I do not go to protect myself from aggression, and most colleagues get defensive [...], I stop providing care for “that patient” [with a history of aggression] that he must not bother me, because after an aggression we need to “take a break” for us and for the patient and, at least for a few days, you’re stay away, you need to stay away (T2).

Sometimes I see that some colleagues are worried and try to avoid the patient. So, many times, he doesn’t have anything else to do and that is what he does: I’m not going to puncture that one because these days he said this, this, and that. So, we try to avoid them. We see that people are apprehensive, but many times, there is this huge anxiety, the person has to stay in the room or sometimes she [worker victim of aggression] stays in the room and has to listen to horrible things and is still unable to metabolise everything, and has to stay and cope with that the whole time (T8).

According to the participants, this strategy is also used collectively, that is, the other members of the team cooperated so that, over a period, the employee who suffered the assault did not have to provide care to the patient who committed the violent act. In serious cases, the head of the unit intervened and, if considered necessary, offered the worker the possibility of changing shifts to avoid contact with the patient and new assaults. These statements exemplify such situations:

Most of the colleagues act defensively. And try to defend themselves! And then the team spirit, the colleague already comments that a given patients is giving her problems. We work together and it works! So, if I don’t have a problem, let me tend to that patient (T2).

Some patients have a wonderful fistula and, for some reason, you just can’t get the puncture right, so you avoid him, and we usually approach a colleague and say: “Take that patient because I am having problems getting it right.” It’s to make sure you do not get it wrong and he [the patient] gets violent with you (T6).

The head of the unit intervenes in the case of a very serious assault, makes the switch [of shift], and that is how I went to the afternoon shift because of a patient, and that helps, too. (T8).

The strategy to stay away from a patient who has assaulted a member of staff was addressed during the discussions given the possibility that, at some point after the episode of aggression, the patient has a complication and the same worker has to provide immediate care. From this perspective, “T1” mentioned the need to discuss situations in which workers stay away from patients after aggression, as noted in the statement below:

I think it’s something that needs to be worked out, because you’re a professional. I’ve witnessed this, because it happened with a worker and a patient and there was the patient with low blood pressure. However, the person did actually provide the care, but not very willingly. I understand that sometimes a person needs some time, they need to change room and I understand that the people have to cope (T1).

In view of the complexity that pervades the studied subject, the participants showed that they considered several factors when using strategies in situations of violence at work. These factors include the health condition of patients in haemodialysis and concerns with the possible implications and the spreading of violence among the people involved, especially the worker who was assaulted, and regarding the quality of the care offered to the patient and aggressor.

DISCUSSION

The first strategy used by the participants of this study was to tolerate the violence due to the health condition of patients in haemodialysis. In this regard, authors(66. Valle LS, Souza VF, Ribeiro AM. Estresse e ansiedade em pacientes renais crônicos submetidos à hemodiálise. Estud Psicol (Campinas). 2013 [citado 2015 ago 12];30(1):131-8. Disponível em: http://www.scielo.br/pdf/estpsi/v30n1/14.pdf.
http://www.scielo.br/pdf/estpsi/v30n1/14...
) state that these patients experience particular conditions due to the need to access health services, their dependence on treatment, the strict water and dietary control, and work-related restrictions. These conditions characterise the losses that are inherent in the illness and the treatment that also affects their relatives, that is, the repercussions are not merely personal and they also affect the family and social lives.

In another investigation, the members of a multidisciplinary healthcare team recognised that the burden of disease and haemodialysis treatment can negatively affect patients’ behaviour. Patients often feel frustrated when faced with the losses and limitations of chronic kidney disease and dialysis treatment, and are therefore more prone to irritability(88. Jones J, Nijman H, Ross J, Ashman N, Callaghan P. Aggression on hemodialysis units: a mixed method study. J Ren Care. 2014;40(3):180-93.). Another study shows that many patients direct their troubles and anger regarding their medical condition toward the nursing staff, and may even verbally and, in extreme cases, physically assault them(1515. Morais EM, Fontana RT. Dialytic unit as a scenario of exposure to risk. J Res: Fundam Care online. 2014. Apr/Jun [cited 2015 Apr. 19];6(2):539-49. Available from: http://www.seer.unirio.br/index.php/cuidadofundamental/article/view/2648/pdf_1238.
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).

The strategy of tolerating violence due to the health condition of patients partially follows the recommendations of the EDTNA/ERCA to the prevention of violence in renal units. However, the recommendations clearly state that violence cannot be intrinsic to the work, that is, there is a need for prevention, early identification and the adoption of conducts that stop the spreading of violence(77. Zampieron A, Saraiva, M, Pranovi R, editors. EDTNA/ERCA recommendations for prevention and management of violence and aggression in renal units. Madrid: Imprenta Tomás Hermanos; 2010. Available from: http://www.edtnaerca.org/pdf/education/V&A_Book.pdf.
http://www.edtnaerca.org/pdf/education/V...
).

The participants of this study showed concern with patients, and sought to understand the reactions and feelings of patients regarding their disease, which can be considered positive. However, merely tolerating aggression due to the patients’ health condition is not an effective strategy and can even be harmful because it tends to encourage the spreading of violence.

In relation to the discourse of unconditionally accepting manifestations of violence suggests that these professionals tend to deny their feelings of displeasure due to the circumstances of providing care. The acceptance of this experience is backed by the hegemonic discourse of enforcing humanisation at any cost and thus legitimises the notion that care only evokes pleasant sensations. However, this denial can negatively affect the health of workers since the lack of opportunities to talk and listen about unpleasant situations at work prevents any mental elaboration of their suffering(1616. Dal Pai D. Violência no trabalho em pronto socorro: implicações para a saúde mental dos trabalhadores [tese]. Porto Alegre (RS): Escola de Enfermagem, Universidade Federal do Rio Grande do Sul; 2011.).

The prolonged use of this strategy causes the trivialisation and naturalisation of violence at work. These common tendencies in health services prevent the visibility of violence and its consequences on the sufferers because they mask the real magnitude of the problem of violence at work(33. Dal Pai D, Lautert L, Souza SBC, Marziale MHP, Tavares JP. Violence, burnout and minor psychiatric disorders in hospital work. Rev Esc Enferm USP. 2015 [cited 2015 Aug 12];49(3):457-64. Available from: http://www.scielo.br/pdf/reeusp/v49n3/0080-6234-reeusp-49-03-0460.pdf.
http://www.scielo.br/pdf/reeusp/v49n3/00...
).

The second strategy identified in this study was to circumvent the conflict situations and give in to the request of the patient to prevent attacks, which partially agrees with the main recommendation of the EDTNA/ERCA regarding the need for prevention and early detection of possible situations of violence. According to the recommendations, the nursing staff should try to create an atmosphere of non-violence by remaining receptive to the needs of patients(77. Zampieron A, Saraiva, M, Pranovi R, editors. EDTNA/ERCA recommendations for prevention and management of violence and aggression in renal units. Madrid: Imprenta Tomás Hermanos; 2010. Available from: http://www.edtnaerca.org/pdf/education/V&A_Book.pdf.
http://www.edtnaerca.org/pdf/education/V...
).

The use of this strategy can be related to the dynamics of the work in haemodialysis services, which mainly involves routine and extended contact with patients over the years. This approach can help patients and workers in these settings establish ties and consequently reduce the occurrence of conflicts(1717. Prestes FC, Beck CLC, Tavares JP, Silva RM, Cordenuzzi OCP, Burg G, et al. Percepção dos trabalhadores de enfermagem sobre a dinâmica do trabalho e os pacientes em um serviço de hemodiálise. Texto Contexto Enferm. 2011 [citado 2015 abr 18];20(1):25-32. Disponível em: http://www.scielo.br/pdf/tce/v20n1/03.pdf.
http://www.scielo.br/pdf/tce/v20n1/03.pd...
). Thus, the strategy of working around and yielding can be reinforced by the awareness of workers that patients who commit acts of violence will continue to use the service, that is, there is a possibility that the worker who suffered the violence will have to continue providing care to this same patient in the near future.

Therefore, it is important to understand the expectations of patients regarding the provided care in order to identify potential non-conformities that may adversely reflect on their relationship with the members of the health team. Moreover, workers must be committed to the provision of quality care and encouraged to develop the skill set they need to deal with conflict situations(1111. Silva IV, Aquino EML, Pinto ICM. Violência no trabalho em saúde: a experiência de servidores estaduais da saúde no Estado da Bahia, Brasil. Cad Saúde Pública. 2014;30(10):2112-22.).

These requirements are especially justified in the work of nursing staff in haemodialysis units due to the specific characteristics, such as the technical complexity and interpersonal relations that are established between patients and team members. The participants showed that they were eager to prevent violence so as not to place the other patients in the dialysis room in uncomfortable situations when they witnessed an assault.

However, according to the participants of this study, the strategy of working around and yielding is partially effective because it prevents the violence at that moment, but encourages aggression on other team members. The different conducts of the workers can trigger new attacks, that is, by circumventing and yielding to the wishes of the patient that go against service recommendations or standards to ensure momentary self-protection, the worker can encourage the spreading of violence at work.

The previously planned approach of not accepting violence was mentioned by participants as a strategy that they use in some cases of violence from patients with aggressive behaviour and a history of aggression. This strategy can signal an attempt by the nursing staff to avoid suffering from the mental manifestations of violence to which they are exposed in haemodialysis services, considered an occupational hazard in these work scenarios(1515. Morais EM, Fontana RT. Dialytic unit as a scenario of exposure to risk. J Res: Fundam Care online. 2014. Apr/Jun [cited 2015 Apr. 19];6(2):539-49. Available from: http://www.seer.unirio.br/index.php/cuidadofundamental/article/view/2648/pdf_1238.
http://www.seer.unirio.br/index.php/cuid...
).

Similarly, a study on violence in two London haemodialysis services identified that the assaults, although recurrent, were from a minority of patients with substantially grave outcomes that caused the mental and emotional suffering of workers(88. Jones J, Nijman H, Ross J, Ashman N, Callaghan P. Aggression on hemodialysis units: a mixed method study. J Ren Care. 2014;40(3):180-93.). Thus, the strategy of rejecting the violence mentioned by the participants of this study can also be an attempt to prevent new episodes of aggression.

However, the workers themselves stated that the approach of not accepting violence used with certain patients only alleviates the problem and does not solve it. Similarly, they stressed that this strategy needs to be evaluated to prevent the situation from getting worse. The reports of the participants contemplate the guidelines of the EDTNA/ERCA, stating that workers should try to control the situation and ensure that your own behaviour does not generate inappropriate responses in others(77. Zampieron A, Saraiva, M, Pranovi R, editors. EDTNA/ERCA recommendations for prevention and management of violence and aggression in renal units. Madrid: Imprenta Tomás Hermanos; 2010. Available from: http://www.edtnaerca.org/pdf/education/V&A_Book.pdf.
http://www.edtnaerca.org/pdf/education/V...
), especially in patients.

Regarding the claim that this strategy only lessens the violence, we believe in the need to adopt institutional recommendations that guide the conduct of workers in situations of possible conflict. This measure can support workers and ensure more effective results for the prevention and spreading of workplace violence.

This context also reaffirms the need for measures that may prevent violence at work in health services. As an example, one study suggests the creation of systems to monitor violent episodes and the victims, and the adoption of measures to contain aggressors(33. Dal Pai D, Lautert L, Souza SBC, Marziale MHP, Tavares JP. Violence, burnout and minor psychiatric disorders in hospital work. Rev Esc Enferm USP. 2015 [cited 2015 Aug 12];49(3):457-64. Available from: http://www.scielo.br/pdf/reeusp/v49n3/0080-6234-reeusp-49-03-0460.pdf.
http://www.scielo.br/pdf/reeusp/v49n3/00...
).

An investigation carried out in Australia states that prolonged contact with patients over the years of treatment is one of the causes of burnout among the nursing workers who work in dialysis services(1818. Dolan G, Strodl E, Hamernik E. Why renal nurses cope so well with their workplace stressors. J Ren Care. 2012;38(4): 222-32.). The proximity of the staff and patients in these services can facilitate the projection of frustrations from the patients to the workers through verbal and physical assaults(1515. Morais EM, Fontana RT. Dialytic unit as a scenario of exposure to risk. J Res: Fundam Care online. 2014. Apr/Jun [cited 2015 Apr. 19];6(2):539-49. Available from: http://www.seer.unirio.br/index.php/cuidadofundamental/article/view/2648/pdf_1238.
http://www.seer.unirio.br/index.php/cuid...
, 1818. Dolan G, Strodl E, Hamernik E. Why renal nurses cope so well with their workplace stressors. J Ren Care. 2012;38(4): 222-32.), which refers back to the strategy of staying away from aggressors reported by the participants of this study.

This strategy can favour the collective action of workers and, in more serious situations, of service managers, and its preventive and protective can prevent the initial violence or a new assault. In this sense, an investigation in public hospitals of southeastern Brazil found that participants with low social support at work reported a higher occurrence of verbal violence(55. Vasconcellos IRR, Griep RH, Lisboa MTL, Rotenberg L. Violence in daily hospital nursing work. Acta Paul Enferm. 2012 [cited 2015 Aug 12];25(spe):40-7. Available from: http://www.scielo.br/pdf/ape/v25nspe2/07.pdf.
http://www.scielo.br/pdf/ape/v25nspe2/07...
).

A study found that cooperation among colleagues was one of the elements that contributed to the job satisfaction of workers in a haemodialysis service of southern Brazil. This finding refers to the favourable impact of good interpersonal relationship among the members of the nursing staff on the health of workers(1919. Prestes FC, Beck CLC, Magnago TSBS, Silva RM. Pleasure-suffering indicators of nursing work in a hemodialysis nursing service. Rev Esc Enferm USP. 2015;49(3):465-72. Available from: http://www.scielo.br/pdf/reeusp/v49n3/0080-6234-reeusp-49-03-0469.pdf.
http://www.scielo.br/pdf/reeusp/v49n3/00...
) and of the adoption of strategies in situations of exposure to violence on the part of patients, as indicated by the results of this study.

Although this strategy is considered crucial to the re-establishment of workers, especially soon after the violent episode, workers who suffer some form of violence from patients must provide care to the assailant. Therefore, psychological support and the reinforcement of measures such as dialogue, respect, and the appreciation of workers and their health can add value to nursing care(1515. Morais EM, Fontana RT. Dialytic unit as a scenario of exposure to risk. J Res: Fundam Care online. 2014. Apr/Jun [cited 2015 Apr. 19];6(2):539-49. Available from: http://www.seer.unirio.br/index.php/cuidadofundamental/article/view/2648/pdf_1238.
http://www.seer.unirio.br/index.php/cuid...
). Thus, institutional measures aimed at occupational health that provide the tools, skills, and support workers need to overcome the effects of exposure to violence at work are needed to promote the well-being and safety of patients and staff.

FINAL CONSIDERATIONS

The protective strategies used by the nursing staff refer to attempts to prevent the outbreak of violence on the part of patients in the haemodialysis unit and, consequently, the suffering that this experience causes workers. To this end, the workers used predominantly individual strategies that denote a level of acceptance and tolerance to all assaults, but they also mentioned collective actions and attitudes of non-acceptance of violence, that, according to the participants, relieve, but do not solve the problem.

The health condition of patients and the chronic nature of haemodialysis treatment can encourage the use of strategies of acceptance and tolerance to all manifestations of violence. Although these strategies can be relevant in some moments, they must be socialised among the group, discussed, and institutionally oriented in order to assess the singularities and agree on the situations that can be momentarily accepted or tolerated.

These initial measures can strengthen the workers who suffer aggression and the group as a whole, and support an approach that helps workers understand and meet the expectations of patients, but it can also signal the non-acceptance of new episodes of violence. To this end, nurses, as leaders of the nursing staff, should insert themselves in the work and act as the articulators of the ongoing dialogue between those involved. They should also collaborate in the development of ongoing assessments of institutional guidelines for prevention, protection, and monitoring that minimise the perpetration of workplace violence.

The identified strategies indicate that the participants have advanced in relation to the initial goal of reporting the use of these strategies and initiate reflections on the possible motivations and consequences of aggression on the part of patients, although there should be advancements in these reflections and in the establishment of institutional guidelines of non-tolerance for violence in the studied service. This advancement may positively reflect on the health of workers in the service as a whole and on the care they provide to patients in haemodialysis.

A limitation of the study was the impossibility of generalising the results given the adopted method and the specific study scenario. However, the complexity of the subject in question justifies new studies that consider the singularities and experiences of the persons involved. Thus, we suggest further studies on violence in haemodialysis units for the inclusion of new data and advancements in relation to the results obtained in this study.

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    » http://www.scielo.br/pdf/reeusp/v49n3/0080-6234-reeusp-49-03-0469.pdf

Publication Dates

  • Publication in this collection
    2017

History

  • Received
    26 Sept 2015
  • Accepted
    11 Jan 2017
Universidade Federal do Rio Grande do Sul. Escola de Enfermagem Rua São Manoel, 963 -Campus da Saúde , 90.620-110 - Porto Alegre - RS - Brasil, Fone: (55 51) 3308-5242 / Fax: (55 51) 3308-5436 - Porto Alegre - RS - Brazil
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