Gender-violence against the female nursing staff of a Brazilian hospital in São Paulo City

OBJECTIVE: To estimate the occurrence of psychological, physical and sexual violence among female nursing staff. METHODS: This is a cross sectional study, conducted with a sample of 179 professionals (50 nurses and 129 nursing aides / nurse technicians) in a general hospital in the municipality of São Paulo, Southeastern Brazil, 2005-2006. A validated questionnaire was applied in face to face interviews with these professionals, conducted by trained interviewers. Psychological, physical and sexual forms of violence were addressed, involving both male and female aggressors who were classifi ed as: intimate partners, family members and other aggressors such as acquaintances and strangers. A descriptive analysis was undertaken, in which the frequency of the occurrence of the different types of violence was calculated with a 95% confi dence interval. RESULTS: The most frequent form of violence was intimate partner violence (63.7%; 95% CI: 55.7;70.4), followed by violence perpetrated by others (45.8%; 95% CI: 38.3;53.4) including patients and people accompanying them, colleagues within the fi eld of health, head nurses, acquaintances and strangers. Family members occupied the third place as aggressors, (41.3%; 95% CI: 34.0;48.9), and the majority of these were fathers, brothers, uncles and cousins. In general, the nursing staff did not seek help frequently when acts of aggression occurred: only 29.7% of those who suffered intimate partner violence; 20.3% whose aggressors were others and 29.3% whose aggressors were family members sought help. Those who did not perceive their experience as a form of violence represented 31.9% of the subjects interviewed. CONCLUSIONS: The rates of gender violence among female health professionals were important, particularly with respect to violence committed by intimate partners and family members. However, the proportion of these women who sought help was low, considering the fact that this group has a signifi cant educational level. DESCRIPTORS: Nurses, psychology. Women, Working. Spouse Abuse. Battered Women. Violence Against Women. Domestic Violence. CrossSectional Studies.


INTRODUCTION
Violence against women has been considered an important public health and social issue. 8It is also denominated "gender violence" because it is based on asymmetric power relations between men and women, in which women frequently fi nd themselves in a subordinate situation. 17,21The most common form of gender violence is committed by intimate partners.a It is estimated that 20% to 50% of the women in the entire world suffer from physical and/or sexual violence by their intimate partners or companions at least once in their lifetimes. 9 Brazil, a multicentric study conducted by the World Health Organization (WHO) revealed the following prevalences 7,19 for 2,128 women from 15 to 49 years: physical and/or sexual violence by an intimate partner at least once in their lifetimes was reported by 29.0% in São Paulo (SP) and by 37.0% in the Zona da Mata of Pernambuco (PE), a region with both urban and rural areas in the Northeast of Brazil.The proportion of physical violence by other aggressors was lower (21.0% in Sao Paulo and 13.0% in the Zona da Mata), being that the majority of these aggressors were members of the family.
Venturi et al 23 (2004) found rates of 27.0% for psychological violence, 33.0% for physical violence and 13.0% for sexual violence among 2,502 women, 15 years of age and older, in 24 Brazilian states.
Among the main risk factors for violence against women, Jewkes et al 12 (2002) point out: masculine behaviors of control; higher schooling of women, making them critical of male oppression; social stereotypes of men and women based on sexual differences.According to this author, personal experience of violence during childhood or the experience of a close friend or relative may stimulate the reproduction of violent behavior in adult life; other factors stimulating the reproduction of violent behavior would be poverty, besides alcohol and illicit drug abuse. 12e repercussions of Intimate Partner Violence (IPV) have been investigated with respect to women's mental, physical, sexual and reproductive health.It may cause stress, fear, physical traumas, gynecological problems and even fetal and maternal mortality. 2,20e World Health Organization (WHO) 14 and the Pan-American Health Organization (PAHO) b have demonstrated their concern with the issue, given that gender violence has a negative impact on the mental, physical, sexual and reproductive health of women.Approaching the issue of violence against women is becoming the competence of health professionals, for health services are frequently sought out by victims of this type of violence. 24World Health Organization.Multi-country study on women's health and domestic violence against women: summary report of initial results on prevalence, health outcomes and women's responses.Some studies indicate the strategic position of nurses and the nursing staff in dealing with the issue.It is contended that the majority of these professionals are females 6 and that they are the fi rst to approach victims of violence within the health services.4,18 Victims of violence tend to sub-inform violence due to their fear of the aggressor, social shame, economic dependence, impunity, lack of specialized services and because the situation they are experiencing is not recognized as violence.20,c The diffi culty health professionals manifest in dealing with these cases may be related to their own experiences with this type of violence.10,18,22 Studies have indicated the occurrence of IPV among nursing professionals.Janssen et al 11 (1998) in a study involving 198 obstetric nurses working in a Canadian hospital, found that 26.9% reported having suffered psychological violence, 14.6% reported they had suffered physical violence and 8.1% sexual violence.According to the authors, the rate of violence committed against these nurses by an intimate partner at least once in their lifetimes (38,0%) was higher than the rate of IPV reported by Canadian women in the population at large (29,0%).Díaz-Olavarrieta et al 5 (2001) identifi ed among 1,150 nursing professionals (283 nurses and 867 nursing aides / nurse technicians) working in Mexican hospitals, that the rates of psychological violence were 40.0% and of physical and/or sexual violence were 14.0% (164).
Violence experienced by health professionals is still not widely investigated throughout the world, thus contributing towards the reproduction of an idealization according to which these professionals would be "immune" to their gender, constituting a gap in knowledge with respect to this issue.The objective of this study was to estimate gender violence experienced by nursing staff, characterizing the aggressors, the attempt to fi nd assistance and how violence was perceived by the victim.

METHODS
This is a cross-sectional study conducted between 2005 and 2006, with nurses and nursing aides/ nursing technicians working in a general hospital within São Paulo City.d The sample size was calculated, based on a population of 499 nursing professionals; the estimated prevalence of physical and/or sexual violence was 18.0%, based on a study concerning Mexican nurses, (Díaz-Olavarrieta et al 4 2001), so as to detect a 5% va-riation, with a 95% level of confi dence (95% CI).The calculated sample obtained, including a 20% increase to account for eventual losses, was 187 professionals.The sample also contemplated the estimated prevalence of 20.5% obtained in a Brazilian populational study.a Among the 187 nurses and nursing aides/nursing technicians allotted to participate in this study, three nurses were excluded.In two cases this was due to their refusal and in one case a maternity leave was the motive for exclusion.Likewise, fi ve auxiliary nurses/ nurse technicians allotted to the study did not participate, either due to their refusal (three cases) or because they were on medical leave (two cases).Therefore, there were a total of eight exclusions and the fi nal sample was revised for 179 professionals, being that 50 were nurses and 129 were nursing aides/ nursing technicians.
The study instrument contemplated sociodemographic variables; b episodes of violence; the attitude of seeking help and perception of the experience of violence.
The questions concerning violence were based on the instrument utilized by the "Multi-country study on women's health and domestic violence against women".c This instrument was granted by the Brazilian coordinators of the WHO multicentric study.a Violence was approached in its psychological, physical and sexual forms, involving both male and female aggressors, grouped together as: intimate partners (by formal consensual unions or dating practices in the present or past), family members or relatives (except intimate partners), and other aggressors such as acquaintances (neighbors, colleagues, chiefs at the hospital) and strangers.
Due to the cultural subjectivity that perpassses this issue, particularly with respect to psychological violence, 14 the term "violence" was not utilized and the episodes were described by concrete acts, so as to increase this study's sensibility: • psychological violence: insults, humiliation, intimidation or threats; • physical violence: slap, push, shove, hit with a fi st or something that can hurt, kick or beat, choke or use or threaten to use a gun, knife or other weapon against her; • sexual violence: physically forced to have sexual intercourse, to have sexual intercourse when she does not want because she feels frightened or threatened and being forced to engage in sexual practices considered degrading or humiliating.
When at least one act of any form of violence above mentioned was reported by the interviewee, it was considered violence.Physical violence, occurring in intimate relations was classifi ed as either moderate (slap, push, shove) or severe (punch, kick or beat, choke or use/threaten to use a gun, knife or other weapon).
Each episode of violence that occurred in the twelve months prior to the interview was explored with respect to its characteristics, frequency and the interviewee's perception of the event.
Violence committed by intimate partners and relatives was denominated "violence within intimate relationships".Particularly with respect to IPV, physical violence was considered moderate when, at least once in her life, the interviewee reported that she was slapped, an object was thrown at her, she was pushed, shoved, or shaken up and down and severe when she was punched, kicked, beaten, strangled, burnt, threatened or attacked with a gun, knife or other arms. 7ring the interview, the act of seeking for help in dealing with the aggression and the places where it was sought were also registered.The perception of violence experienced by the women interviewed was measured, comparing the revelation of the episodes of aggression to the question, "do you consider that you have suffered violence at least once in your life?", that was posed directly after completing the part of the questionnaire dedicated to questions concerning violence.
The sample of 179 women was taken into consideration for all the variables except for those concerning intimate partnerships (frequency of IPV and search for help), in which case only those women who had had an emotional and sexual partnership at least once in their lives, 177 interviewees, were considered.
All data was digitalized in a 2.6 version of the FoxPro software, being double entered and the 13.0 version of the SPSS software was utilized in analysis.Descriptive analysis was conducted, calculating the frequencies of the types of violence with a 95% confi dence interval.
Ethical concerns and procedures were present throughout the various phases of this investigation.During the pilot study, care was taken in order to fi nd the best format and site for the interviews.Ethical concerns were also incorporated in the process of training the interviewers (a nurse and a psychologist), who both had previous experience with this theme.Anonymity of the institution and of the women interviewed was

RESULTS
On Table 1, the sociodemographic characteristics of the women interviewed are presented.These women, who represent all sectors of the hospital, were, on the average, 37.6 years old (sd=9.9)and only four professionals had only completed junior high school or had not completed high school (eight to ten years of schooling).In 86% (154) of the cases, women were classifi ed as pertaining to socioeconomic strata "B" and 72 (40.2%) declared they were the "head of their family".As to the forms of IPV, the majority experienced these aggressions more than once in their lives: psychological violence (87; 82.9%), physical (37; 62.7%) and sexual violence (45; 90.0%).Reports of the occurrence of the three forms of violence in the 12 months prior to the interview were less frequent.
Thirty three women (29.5%; 95% CI[13.2;25.2])sought some form of help when they were confronting IPV: 15 (45.5%) sought the police, 11 (33.3%)sought psychological support, 6 (5.4%) sought support from the family and one (0.9%) the hospital itself.There was one loss with respect to this question.Seventy eight women interviewed did not seek any service or any form of assistance when faced with the offense experienced.Among the latter, 19 (24.3%) stated they desired to seek some form of assistance.The kind of support most desired was psychological support, identifi ed by 13 (68.4%) of them.Fear of exposure, lack of time and fi nancial limitations were reported as obstacles to seeking help.
The episodes of psychological violence by other aggressors were the most frequent form of violence (68; 38.0%), as in the cases of IPV and violence by relatives.They occurred predominantly in the 12 months prior to the interview.However, almost half of the incidents (33; 48.5%) of psychological violence occurred the year before the interview.Aggressions were recurrent during their lifetimes for the majority of the women interviewed and with respect to the three forms of violence: psychological (50; 73.5%), physical (13; 68.4%) and sexual violence (6; 85.7%).
The main aggressors for psychological violence were, in the majority of the cases, male colleagues at work (27; 39.7%) and bosses (16; 23.5%), corresponding to 60.0% and 35.0%, respectively.The principal aggressors in cases of physical violence were patients and people accompanying the patients (9; 47.7%) and strangers (7; 36.8%); in cases of sexual violence these rates were (3, 42.8%; 4, 57.1%, respectively).Colleagues at work and bosses were not reported in any of the cases of physical and/or sexual violence by other aggressors.
Among the 82 women who reported psychological violence by other aggressors, 24 (29.3%)sought some service/support: 11 (45.8%)sought the institution in which they worked, fi ve (20.8%) chose to seek the police service, three (12.5%)sought psychological support, two (8,3%) sought the Conselho Regional de Enfermagem [Regional Nursing Council] and one (4.2%)sought religious support.Two women did not reveal the source of support they sought.Nine of the 58 women who did not seek support stated they would have liked to have done so: six (66.7%) stated they wished they had sought psychological support, two (22.2%) would like to have sought support from the institution where they work and one (11.1%)wished she had sought the police service.The motives for not seeking support were lack of time and fear of retaliation by the aggressor, both of which were also mentioned by women whose aggressors were members of the family.Financial limitations, a motive also mentioned by victims of IPV, was another explanation for not seeking help as well as fear of retaliation from the institution in which they worked.
The rates of overlap between IPV, violence by relatives and by other aggressors were important.Among the 112 women who reported some type of IPV, 52 (46.4%) also reported some form of violence by other aggressors and 51 (45.5%) stated they had suffered some form of aggression from a family member.Considering the entire sample, 16 (8.9%) of the women interviewed declared they had been victims of all three types of aggression (Figure).
Among the 160 (89.4%) interviewees that reported some act of aggression, 109 (68.1%) perceived it as violent.The lowest rate of perception of the act experienced as violence occurred among the women who reported incidents of violence by other aggressors (56; 68.3%).Among the interviewees who replied affi rmatively to any of the questions concerning IPV, the perception of the incident experienced as violent was 71.4% (80).For the reported acts of aggression by relatives, 78.4% (58) perceived these as violent.

DISCUSSION
This is the fi rst study in Brazil to approach the theme of gender violence among female nursing professionals.Its potential limitations are the subjectivity surrounding the defi nition of violence and disclosure bias.Violence, particularly of a psychological order, has a polysemic character, that is, it may assume different meanings depending upon the cultural context of a specifi c social group. 14For this reason, the women interviewed were asked objectively about their experiences in this respect, by reference to situations and concrete acts, 14 by means of a questionnaire culturally adapted to Brazil.a As to disclosure, studies have indicated that experiences of violence tend to be underestimated because of diffi culties with this respect, since it is a stigmatizing situation, involving shame and fear. 8,9In this sense, in order to diminish this bias, some ethical and methodological concerns guided the development of this study b that are indispensable when approaching women who are living in a situation of violence.
The exclusion of professionals that were on medical leave for a period greater than 15 days may have contributed towards a reduction in the frequencies of violence.In thesis, these professionals would have a greater probability of suffering from violence, since the latter is associated to health problems. 2,9e rates of IPV found in the present study are consistent with those found in other national and international studies, presenting similarities, and, in some cases, even higher proportions of violence.However, cultural differences, distinctions in the samples as well as similarities with respect to the instrument utilized in each study should be taken into consideration.
In relation to women in the population at large, the frequency of physical and/or sexual violence (44.1%) presented itself within the limits found by Heise et al 9 (1999).Also, in comparison to Brazilian data, 23,c the rates of physical/sexual violence and the isolated forms of violence were greater among the nursing professionals from São Paulo.
a When compared to international studies, 5,11,13 particularly among nursing professionals, the rates of intimate partner violence are frequently higher among the professionals from São Paulo.The rate of physical/sexual violence found in this study is more than twice the estimated prevalence utilized in Mexico (18.0%). 5However, in that study, self-administered questionnaires were utilized whereas in this study a face to face technique was employed.Furthermore, Mexican women may present greater diffi culty in verbalizing IPV due to fear of social retaliations. 1 b The expressive masculine participation in this type of violence is also indicated by WHO c (2005) and reinforces the perception that this is a form of gender violence, since men are the main aggressors and women their primary victims.Despite the fact that a large part of the episodes of IPV occurred in the 12 months prior to the interview, their possible sequels may endure for years.
Violence by other aggressors represented the second largest rate of violence.The working environment was the principal locus of psychological violence committed, mainly, by colleagues, chiefs, and patients/patients' relatives or friends accompanying them.
Nursing professionals are particularly vulnerable to violence in the working environment, above all in hospital services. 15,16Their direct and continual interaction with patients and the fact that most professionals are women may contribute towards the greater risk of aggression. 15,16 general, nursing professionals were not immune to situations of violence; on the contrary, within the municipality of Sao Paulo, higher rates of violence were found among them than in the female population at large, as occurred in Canada as well. 11It is possible that the ethical and methodological procedures taken in this study, including the fact that a nurse conducted most of the interviews, contributed towards a higher rate of disclosure.a The rate in which help or support was sought was low (29.7% in IPV; 20.3% in violence by relatives and 29.3% in violence by other aggressors).In IPV, when psychological, physical and sexual violence are conjugated, the act of seeking for help was more frequent, in accordance with the WHO fi ndings b (2005).Fear, shame with respect to the situation, and lack of time were the motives more frequently alleged for not seeking help in the three types of violence being studied, as other studies have also indicated.c,d The lack of recognition of their own experience as violence varied from 21.6% for violence by relatives to 31.7% for violence by other aggressors.Daily violence by close relatives during childhood and by intimate partners in adult life may have contributed to the naturalization and banalization of violence.
One of the conclusions of this study is that the nursing professionals investigated, make up a special group of women, for they occupy important positions in confronting gender violence.In the fi rst place, as women, and, therefore, as possible victims of this type of aggression and also as professionals who care for others, suffering violence in their workplace.In addition, these experiences may have consequences in terms of the health of these professionals' health and may interfere with their work as caretakers as well. 10,18nssen et al 11 (1998) consider that the opportunity to be heard and to voice their lived experiences may represent an important strategy in the management of violence experienced by nursing professionals.
Furthermore, it is vital to instrumentalize professionals with respect to this issue, by elaborating and implementing protocols geared towards integral and interdisciplinary care for clients who are victims of violence.

Table 1 .
Sociodemographic characteristics of the nursing professionals interviewed in the general hospital.Sao Paulo, Southeastern Brazil, 2005-2006.N=179IPV was referred by 112 (63.7%; 95% CI[55.7;70.4])intervieweesand the rates of the different forms of violence and the period when it occurred are indicated on Table2.Psychological violence was the most frequent form of violence both during the lifetime and in the 12 months prior to the interview, being reported in a total of 105 cases (59.3%).
Some form of psychological, physical or sexual violence, either by intimate partners, relatives or other aggressors was reported by 160 (89.4%; 95% CI [83.9;93.5]) of the women interviewed.aWorldHealth Organization.Putting women's safety fi rst: ethical and safety recommendations for research on domestic violence against women.Genebra/Programme in evidence for health policy.Publication WHO/EIP/GPE/99.2,2003

Table 2 .
Forms of violence by intimate partner experienced by nursing professionals (multiple answers), aged 20 to 59 years, interviewed in a general hospital.Sao Paulo, Southeastern Brazil, 2005-2006.N=179 * Valid for 176 women interviewed the women that reported them, 48.1% (26) and 50.0%(21), respectively.Although it was less frequent, sexual violence, when declared, occurred more than once in a lifetime for 64.7%(11)of the women who reported it.mentionedthepoliceservice, three (16.7%)mentionedfamilysupportand one interviewee did not declare what kind of support or service she wished she had sought.Lack of time, feeling ashamed to tell someone about the experience, dismay or discouragement by close relatives, fear of retaliation by the aggressor were the primary reasons mentioned for not seeking help.Almost half of the women interviewed (82; 45.8%; 95% CI[38.3;53.4]) reported some incident of violence by other aggressors, as indicated on Table

Table 3 .
Forms of violence by relatives and other aggressors experienced by nursing professionals in a general hospital.Sao Paulo, Southeastern Brazil, 2005-2006.N=179