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Rev. Enferm. UFSM, v.12, e15, p.1-17, 2022
https://doi.org/10.5902/2179769266894
ISSN 2179-7692
Submission: 07/26/2021 • Acceptance: 02/07/2022 • Publication: 04/26/2022
Original Article
Verbal aggression against health professionals in primary and tertiary care: a mixed methods study
Agressão verbal contra profissionais de saúde da atenção primária e terciária: estudo de métodos mistos
Agresión verbal contra profesionales de la salud en atención primaria y terciaria: un estudio de métodos mixtos
Grasiele Fatima BusnelloI
Maiara Daís SchoeningerII
Kaciane Boff BauermannIII
Marina Klein HeinzI
Clarissa Bohrer da SilvaI
I State University of Santa Catarina. Chapeco, Santa Catarina, Brazil
II Municipal Health Department of São Miguel do Oeste – SC. Ipora do Oeste, Santa Catarina, Brazil
III Regional Health Management of Maravilha – SC. Maravilha, Santa Catarina, Brazil
Abstract
Objective: to analyze the occurrence of verbal aggression and factors associated with the phenomenon against health workers. Method: mixed study, sequential explanatory, developed from 2016 to 2019, with 647 health service workers from the West and Far West regions of Santa Catarina. The Survey Questionnaire Workplace Violence in the Health Sector and semi-structured interviews were used. Inferential and thematic statistical analyzes were carried out, respectively. Results: of the participants, 307 (47.4%) reported having suffered at least one episode of verbal aggression. This event was associated with the role of the worker, physical contact with the patient, recognition at work, and concern about violence at work. The testimonies point out the impacts on the health of workers and the fragility of the conducts after the episodes. Conclusion: verbal aggression is a typical violence of public health services, with victims who have a common profile and institutions with difficulty in managing this problem.
Descriptors: Violence at Work; Aggression; Primary Health Care; Tertiary Health Care; Health Workers
Resumo
Objetivo: analisar a ocorrência da agressão verbal e fatores associados ao fenômeno contra trabalhadores de saúde. Método: estudo misto, explanatório sequencial, desenvolvido de 2016 a 2019, com 647 trabalhadores de serviços de saúde das regiões Oeste e Extremo Oeste de Santa Catarina. Utilizaram-se o Survey Questionnaire Workplace Violence in the Health Sector e entrevistas semiestruturadas. Realizaram-se as análises estatística inferencial e temática, respectivamente. Resultados: dos participantes, 307 (47,4%) relataram terem sofrido ao menos um episódio de agressão verbal. Esse evento foi associado à função do trabalhador, ao contato físico com paciente, ao reconhecimento no trabalho e à preocupação com a violência no trabalho. Os depoimentos apontam os impactos na saúde dos trabalhadores e a fragilidade das condutas após os episódios. Conclusão: a agressão verbal é uma violência típica dos serviços públicos de saúde, com vítimas que possuem um perfil comum e instituições com dificuldade de manejo deste problema.
Descritores: Violência no Trabalho; Agressão; Atenção Primária à Saúde; Atenção Terciária à Saúde; Trabalhadores da Saúde
Objetivo: analizar la ocurrencia de agresiones verbales y factores asociados al fenómeno contra trabajadores de la salud. Método: estudio explicativo mixto, secuencial, desarrollado entre 2016 y 2019, con 647 trabajadores de los servicios de salud de las regiones Oeste y Lejano Oeste de Santa Catarina. Se utilizó el Survey Questionnaire Workplace Violence in the Health Sector y entrevistas semiestructuradas. Se realizaron análisis estadísticos inferenciales y temáticos, respectivamente. Resultados: de los participantes, 307 (47,4%) relataron haber al menos un episodio de agresión verbal. Este evento se asoció con el rol del trabajador, el contacto físico con el paciente, el reconocimiento en el trabajo y la preocupación por la violencia en el trabajo. Los testimonios apuntan los impactos en la salud de los trabajadores y la fragilidad de los comportamientos tras los episodios. Conclusión: la agresión verbal es una violencia típica de los servicios públicos de salud, con víctimas que tienen un perfil común e instituciones con dificultad en el manejo de este problema.
Descriptores: Violencia en el Trabajo; Agresión; Primeros Auxilios; Atención Terciaria de Salud; Trabajadores de la Salud
The phenomenon of violence is defined by the World Health Organization (WHO) as the intentional use of physical or authoritarian force, practiced against a person or group, which may result in physical injury, psychological harm, deprivation and death. In the work environment, violence can be expressed in physical or psychological form, the second subdivided into verbal aggression, moral harassment/intimidation, sexual harassment and racial discrimination.1
Health work, although characterized as a necessity for human development, points to a high potential for damage to the health of professionals in the area in view of its interventions aimed at the care of individuals. The exposure of these workers to the most diverse occupational hazards and to violence is a huge problem,2-3 with a global estimate of prevalence of 42.5% of non-physical violence and 24.4% of physical violence.3-4 Research indicates that the occurrence of workplace violence, as well as other psychosocial risks experienced by these professionals, can be considered as one of the main causes of suicide, depression, stress and anxiety.5-6
The consequences of violence can be difficult to recognize, especially when they do not leave physical marks on the worker. In this direction, there are verbal aggressions, understood as the breaking of verbal rules, which humiliate, degrade and disrespect the dignity and value of the person.1 Research reveals that psychological violence has been the most common in public health services,4-8 both in Primary Health Care (PHC)6,8 and in Tertiary.4,9-10 Some characteristics of these services can contribute to the worsening of violent situations against professionals, such as overcrowding, work overload, lack of human, material and physical resources, fast pace of work, delay in patient care, among others.3-7 In these places, verbal aggression is considered the most prevalent, typical and trivialized,9,11-12 causing impacts that directly reflect on the individual, on co-workers who witness the event, on the care provided to the user, on the organization and on society.3-8
In this sense, knowing that professionals working in different health sectors are exposed to verbal aggression at work, the research aims to analyze the occurrence of verbal aggression and factors associated with the phenomenon against health workers.
Mixed methods study, sequential explanatory, being the quantitative step transversal. In this combination, the first phase of the study is focused on the quantitative approach QUAN, which is followed by the qualitative step QUAL, which is the secondary phase and seeks to connect findings and a better understanding of the phenomenon, which contributes to the production of results that complement each other.13
The research was carried out in all PHC units in 23 municipalities in the West and Far West regions of the State of Santa Catarina and in the public referral hospital for the municipalities participating in the study. The population available for the study was 1,993 PHC workers, 102 ESF workers, and 553 hospital workers. Considering a 95% confidence interval and a sampling error of 5%, the probability sample consisted of 449 and 198 participants, respectively, totaling a sample of 647 professionals working in the health services of interest, the sampling method being non-probabilistic and the sample selected for convenience.
The following inclusion criteria were adopted: working as a doctor, nurse, nursing technician, nursing assistant, dental surgeon, oral health assistant, oral health technician or community health agent in the services for at least 12 months. Workers away from work for any reason during the data collection period were excluded from the study.
The participants answered the Survey Questionnaire Workplace Violence in the Health Sector,14 Portuguese version, validated in Brazil,15 following a single protocol and conducted by the researchers of the Research Group, who conducted the questions or left the instrument to be filled out by the participant during the work shift, as chosen by the respondent.
The instrument allows surveying the occurrence of physical violence (18 questions) and psychological violence. The latter is subdivided into verbal aggression (13 questions), intimidation/moral harassment (13 questions), sexual harassment (13 questions), and racial discrimination (13 questions), in the last 12 months, covering characteristics of the victim, the aggression and the perpetrator, consequences and institutional measures to control violence, with five-point and open-ended Likert-type responses.
For this article, sociodemographic variables were analyzed (age, sex, skin color, years of schooling, marital status, having children, tobacco and alcohol consumption, hours of sleep, medication use, type of medication, with or without prescription, and having chronic diseases) and work (type of employment, length of service, sector of work, function, position of manager/supervisor, weekly workload, work shift, complementary activity, experience in the health area, direct contact with the patient/user, number of professionals, interpersonal relationships, recognition at work, accidents, concern with violence) along with the domain of verbal aggression (frequency, aggressor, reactions and measures adopted by the victim in the face of aggression and with the aggressors). This instrument takes an average of 25 minutes to be answered by the participants.
After the quantitative stage, semi-structured interviews were carried out with 20 professionals, ten from PHC and ten from the Hospital, intentionally invited because they were identified as having suffered some type of violence at work in the quantitative stage and for responding affirmatively about their interest in participating in the next stage of research. At this stage, the interview quantity was defined by the data saturation criterion,16 when new experiences to better understand the phenomenon stopped being presented by the participants. These interviews took place by appointment and in a reserved place chosen by the participant, respecting the demand for services and the availability of the professionals, with an average duration of 30 minutes. The collections followed a script with questions about the occurrence of violence, consequences for the victim and perpetrator, behavior after the episodes and space for other statements about the phenomenon, previously elaborated, recorded in audio and transcribed. The collection period was from 2016 to 2019.
Quantitative data were analyzed using the Statistical Package for the Social Sciences software, version 21.0. Quantitative variables were described by absolute number, frequency and mean and standard deviation (±) or mean and interquartile range (according to the normality of continuous variables by the Kolmorov-Smirnov test). Factors independently associated with verbal aggression were adjusted using Poisson Regression, observing factors related to verbal aggression in the workplace, with variables with a value lower than 0.20 being considered. The significance level adopted was less than 0.05 and confidence intervals of 95% (95% CI).
Qualitative findings underwent Thematic Analysis,17 consisting of pre-analysis, exploration and data inference. In this process, the thematic categories emerged: Perpetrator of violence; Coping with violence: Consequences for the aggressor; and Consequences of violence for victims.
The project was approved by the Research Ethics Committee, via Plataforma Brasil, No. 713,728/30 of November 2015, No. 2,835,706/4 of August, 2018 and No. 3,414,195/9 of August 2019. The ethical aspects recommended by Resolution No. 466/2012 of the National Health Council were respected and everyone, after exposure of the study and acceptance, signed the Free and Informed Consent Term in two copies. Participants were identified according to the acronym of their function, being: doctor (DO); nurse (NUR), nursing technician (NT), nursing assistant (NA), dental surgeon (DS), oral health assistant (OHS), oral health technician (OHT) or community health worker (CHW), and work environment PHC or hospital (PHC or HOSP).
Table 1 shows the sociodemographic and work profile of the study participants, regardless of the report of verbal aggression.
Table 1 – Sociodemographic and work characteristics of the participants. West and Far West Regions, SC, Brazil, 2020. (n=647)
|
Variables |
n (%) |
|
Age (years) – average ± DP |
39.3 ± 9.0 |
|
Sex (n=645) |
|
|
Male |
62 (9.6) |
|
Female |
583 (90.4) |
|
Skin color (n=646) |
|
|
Black |
14 (2.2) |
|
Brown |
70 (10.8) |
|
White |
557 (86.2) |
|
Other |
5 (0.8) |
|
Schooling (years) – average ± DP |
14.2 ± 2.7 |
|
Marital Status (n=644) |
|
|
Single/Widowed/No partner |
166 (25.8) |
|
Married/With a partner |
478 (74.2) |
|
Number of children – mean (P25 – P75) |
1 (0 – 2) |
|
Chronic disease |
205 (31.9) |
|
Years of experience in the healthcare field – mean (P25 – P75) |
10 (4 – 15) |
|
Time in the institution (years) – mean (P25 – P75) |
7 (4 – 13) |
|
Function (n=647) |
|
|
Nurse |
135 (20.9) |
|
Nursing Technician |
186 (28.7) |
|
Nursing Assistant |
123 (19.0) |
|
Doctor |
25 (3.9) |
|
Dental Surgeon |
20 (3.1) |
|
Oral Health Technician |
5 (0.8) |
|
Oral Health Assistant |
16 (2.5) |
|
Community Health Agent |
137 (21.2) |
|
Weekly workload (hours) – average ± DP |
40.4 ± 3.8 |
|
Total workload (hours) – average ± DP |
42.6 ± 9.7 |
Regarding the occurrence of verbal aggression at work, it was evidenced that 307 (47.4%) participants reported having suffered at least one episode of this violence in the last year, with a mean of four aggressions. Most reported frequent physical contact with patients (65.9%).
The profile of the victims is characterized by an average age of 39.1 years (±8.3), 280 (91.5%), female, 270 (87.9%) white, with an average schooling of 14,8 years of study (±2.6) and a mean of 10 years (6-17) of experience in the health area. Also, 219 (71.6%) of the professionals stated that they were married or with a partner and 204 (66.4%) reported having one or more children. Table 2 highlights the particularities of the cases and the procedures adopted after the episode.
Table 2 - Characteristics of cases of verbal aggression at work. West and Far West Regions, SC, Brazil, 2020. (n=307)
|
Variables |
n (%) |
|
Consider aggression a typical situation in the workplace (n=306) |
|
|
Yes |
209 (68.3) |
|
No |
97 (31.7) |
|
Perpetrator of the last episode of aggression (n=299) |
|
|
Patient |
165 (55.2) |
|
Patient's family/caregivers |
35 (11.7) |
|
Coworkers Manager/Supervisor |
43 (14.4) 28 (9.4) |
|
Other |
28 (9.4) |
|
Colleague aggressor (n=41) |
|
|
Doctor |
37 (90.2) |
|
Nursing team |
2 (4.9) |
|
Other |
2 (4.9) |
|
Location of the aggression incident (n=296) |
|
|
Within the institution |
275 (92.9) |
|
Outside the institution |
21 (7.1) |
|
Believe the incident could have been avoided (n=303) |
|
|
Yes |
203 (67.0) |
|
No |
100 (33.0) |
|
Was there any action taken in response to the event? (n=303) |
|
|
Yes |
93 (30.7) |
|
No |
210 (69.3) |
|
Consequences for the abuser (n=272) |
|
|
None |
246 (80.1) |
|
Verbal warning |
26 (8.5) |
|
Interrupted treatment/was transferred from sector |
4 (1.3) |
|
Police report |
7 (2.3) |
|
Process to the aggressor |
0 (0.0) |
|
Do not know |
15 (4.9) |
|
Other |
9 (2.9) |
|
Offer of help by employer or supervisor (n=305) |
|
|
Did not offer |
110 (36.4) |
|
Offered advice |
46 (14.2) |
|
Offered opportunity to speak |
126 (41.7) |
|
Other support |
23 (7.6) |
|
Degree of satisfaction with how the incident was handled (n=298) |
|
|
Totally dissatisfied/dissatisfied |
186 (62.4) |
|
Indifferent |
50 (16.8) |
|
Satisfied/Totally Satisfied |
62 (20.8) |
The interviews highlighted the characteristics of the aggressions suffered by the professionals, which corroborates the quantitative findings (Table 2). The corresponding testimonies were assigned to the thematic category “Perpetrator of violence”:
[...] he [patient] wanted to be seen immediately and then he started to offend, not only me but the whole team. He invaded the doctor's office, verbally attacked her. (NUR PHC5)
Look, verbal aggression is so common here in the unit that I already consider it normal, we don't even pay much attention anymore. (NUR PHC6)
The episode that impressed me the most was a fight with a doctor. (NUR HOSP2)
Table 3 highlights the possible associations with those who suffered or not verbal aggression, using the Poisson Regression model on the factors.
Table 3 - Factors associated with suffering from verbal aggression. West and Far West Regions, SC, Brazil, 2020
|
Variables |
Suffered verbal aggression n (%) |
Did not suffer verbal aggression n (%) |
PR† |
Confidence interval (95%CI) |
p-value |
|
Function |
|
|
|
|
<0.001 |
|
Nurse |
89 (29.0)* |
46 (13.5) |
2.12 |
1.56 – 2.89 |
|
|
Nursing technician |
77 (25.1) |
109 (32.1)* |
1.51 |
1.10 – 2.07 |
|
|
Nursing assistant |
86 (28.0)* |
37 (10,9) |
2.52 |
1.87 – 3.39 |
|
|
Doctor |
6 (2.0) |
19 (5.6)* |
0.81 |
0.40 – 1.64 |
|
|
Dental surgeon |
9 (2.9) |
11 (3.2) |
1.44 |
0.82 – 2.51 |
|
|
Oral Health Technician |
1 (0.3) |
4 (1.2) |
0.77 |
0.12 – 4.97 |
|
|
Oral Health Assistant |
5 (1.6) |
11 (3.2) |
1.24 |
0.57 – 2.69 |
|
|
Community Health Agent |
34 (11.1) |
103 (30.3)* |
1.00 |
- |
|
|
Frequent physical contact with patients |
238 (77.8) |
188 (55.3) |
|
|
<0.001 |
|
Patients with most contact |
|
|
|
|
0.772 |
|
Children/Adolescents |
5 (1.7) |
8 (2.5) |
1.45 |
1.18 – 1.77 |
|
|
Adults/Elderly |
71 (23.4) |
75 (23.1) |
1.45 |
1.21 – 1.74 |
|
|
Both |
227 (74.9) |
241 (74.4) |
1.00 |
- |
|
|
Satisfied with where you work |
|
|
|
|
0.024 |
|
Not at all satisfied/Somewhat satisfied |
14 (4.6) |
7 (2.1) |
0.022 |
1.06 – 2.02 |
|
|
Indifferent |
74 (24.3) |
62 (18.2) |
0.027 |
1.03 – 1.57 |
|
|
Satisfied/Very Satisfied |
217 (71.1) |
271 (79.7)* |
- |
- |
|
|
Feel recognized at work |
|
|
|
|
<0.001 |
|
Not at all/A little |
64 (20.8)* |
34 (10.0) |
1.49 |
1.21 – 1.83 |
|
|
Indifferent |
98 (31.9) |
95 (28.0) |
1.09 |
0.92 – 1.31 |
|
|
Recognized/Very Recognized |
145 (47.2) |
210 (61.9)* |
1.00 |
- |
|
|
Assessment of interpersonal relationships at work |
|
|
|
|
0.001 |
|
Not at all satisfied/Somewhat satisfied |
16(5.2)* |
3 (0.9) |
1.20 |
- |
|
|
Indifferent |
48 (15.6) |
39 (11.5) |
1.47 |
1.18 – 2.00 |
|
|
Satisfied/Very Satisfied |
243 (79.2) |
298 (87.6)* |
1.60 |
1.22 – 2.10 |
|
|
Concern about violence at work |
|
|
|
|
<0.001 |
|
Not at all/Little worried |
41 (13.4) |
115 (33.8)* |
1.00 |
- |
|
|
Indifferent |
73 (23.9) |
82 (24.1) |
1.57 |
1.17 – 2.10 |
|
|
Worried/Very Worried |
192 (62.7)* |
143 (42.1) |
1.62 |
1.24 – 2.12 |
|
|
There are procedures for reporting violence at work location‡ |
101 (32.9) |
138 (40.9) |
- |
- |
0.042 |
|
There is encouragement to report violence in the workplace‡ |
103 (33.8) |
108 (32.1) |
- |
- |
0.723 |
*Statistically significant association by the residuals test adjusted to 5% of significance. †PR - Prevalence Ratio. ‡The calculation of PR and CI does not apply to these questions.
It was evidenced that the functions of nurse and nursing assistant have an increase in the probability of suffering verbal aggression by 112% and 152%, respectively, when compared to community health agents. Employees who felt little recognized or unrecognized at work had a 49% higher prevalence of the event, and those who were not at all satisfied or not at all satisfied in the interpersonal relationship at work had an increased chance of suffering verbal aggression at work by 46%.
When asked about the reactions that the professional had in the face of the occurrence of verbal aggression at work, it was identified that 59.6% (n=183) told a colleague; 55.4% (n=170) reported to a boss; 30.3% (n=93) told friends and family; 28% (n=86) asked the person to stop, and 24.4% (n=75) of the professionals had no reaction to the event. Still, 24.8% (n=76) of victims registered the aggression, but the instrument does not allow identifying where and in which document it was made. The data obtained are reinforced by the reports arranged in the thematic category “Confronting violence”:
We talk, we kind of vent to each other as a team. Which I think is the only thing we do, let off steam with each other. And, if it's something more serious, we even have an occurrence book that we can report [...]. (NA PHC1)
I shut up, then. I stopped answering the patient, attended him and released him. And then I went and talked to the coordinating nurse, gave the patient's name, told her everything that was happening, I think she recorded it too. (NA PHC3)
[...] we sit and talk as a group, discuss the case [...]. (NUR HOSP1)
In this sense, the data confirm that there is a deficit regarding the conduct/measures that must be taken to avoid the recurrence of these events. Victim support has progressed, but is still inexpressive in most cases, as reported in the excerpts below:
[...] I even looked for help, you know, but they advised me to try to solve it. It didn't work out very well, I even tried to explain myself, but the colleague didn't want to know anything. So it stayed that way, an unbearable situation, until I asked to leave. (NUR HOSP3)
[...] the class bodies, they don't support us, it's no use, it's a waste of time, they don't act as they should. (NUR HOSP2)
Regarding the category “Consequences generated for the aggressor”, the statements also reinforce the quantitative findings regarding the timid consequences for the aggressor:
It was passed on, but no, I don't think it went on [...] it took years for the person [...] she still continued working in the place for a long time and now she left, so it didn't go so. (NT HOSP1)
I believe that violence at work is not even addressed [...] which is actually a daily topic, but unimportant. (NUR HOSP3)
It is noteworthy that the main problems experienced by professionals after the occurrence of violence were: 117 (38.6%) remained very/extremely “over-alert” (n=117; 38.6%); extreme/frequent feelings that activities became more painful (n=115; 38.1%); avoiding thinking and talking about the episode (n=98; 32.5%); and presenting memories, thoughts or images of what happened (n= 92; 30.5%).
Based on the qualitative analysis, the consequences of the episodes of violence that appeared the most in the testimonies are psychological, the feeling of incompetence, impacts on physical health, demotivation, isolation and fear, difficulties in teamwork and the feeling of “guilt”. The “Consequences of violence for the victim” were highlighted, illustrated in the reports:
You suffer from it, it marks you for the rest of your life [...] not only at work but at home too, there are many cases where the person cries, cries, only cries, depressed [...]. (NT HOSP1)
You end up being taken by a lot of stress [...] and really, this stress, it manifests itself physically, usually with muscle pain, that issue of tension, headaches, malaise, indisposition [...], it is what happens the most. (NUR HOSP ICU 11)
Victims who claimed not to have reported or talked about the incident with other people did not do so, according to a significant portion (37.8%), considering that, in any case, no action would be taken; because fear of negative consequences emerged (22.1%); or considered that it was not important (19.4%).
After the incident, I became even colder with the patients, the way of treating them, especially the men, for fear that they would do something to me, but that was after the fact that happened. (NT CC2)
[...] Nowadays, you are afraid to meet these people, because you never know the attitudes they have. (NT HOSP1)
There is no way not to be concerned [about violence in the health scenario], because there are many events and more and more cases, people are more stressed, with less tolerance. (NUR APS10)
The testimonies, however, indicate that episodes of violence in the workplace had negative repercussions, interfering with the work process and interpersonal relationships.
Surveys4,8-9 highlight the prevalence of verbal aggression, corroborating the data presented in this study. Meta-analysis conducted in China,18 with 47 studies on violence in the health workplace, highlighted a prevalence of 61.2% of verbal abuse. In Hong Kong,19 a survey showed 39.2% of verbal aggressions with nursing workers. In Iran,20 a study carried out in the hospital environment identified a high percentage (78.1%) of victims of verbal aggression.
The present research showed that, for the most part, the participants considered the situation typical in the work environment. Organization1 monitors and signals that situations of violence have become daily in public health services in several countries. Authors2-4,21 describe that nursing workers are daily exposed to violent situations and this phenomenon occurs both in PHC work environments and in hospital environments. It should be noted the increase in discussions on the topic internationally,19 pointing out female nursing workers as the main victims.
It was also evidenced that nursing professionals have an increase in the probability of suffering verbal aggression at work between 51% and 152%, when compared with community health agents. Literature shows that this profession is often violated in their daily work.22 Some intervening factors, such as intense pace of work, provision of health care, and first contact with the individual in a fragile situation, may be related to the occurrence of the event.3 Although sex is not a variable associated with verbal aggression, the occurrence of this violence among female nurses, mostly, once again intends to reflect on the structuring machismo of Brazilian society, which often permeates the health sector.
Another aspect highlighted in the findings was the fact that workers who felt not at all or little recognized at work had a 49% higher prevalence of an event, and those who were not at all satisfied or little satisfied in their interpersonal relationship at work had an increase in the prevalence of experiencing verbal aggression at work of 46%. Evidence shows that professionals exposed to violence, in addition to being dissatisfied and less committed, are more susceptible to errors during work performance, as well as to job abandonment.12
Regarding the perpetrators of violence, studies confirm the data obtained in this research, in which the most frequent aggressors were patients,4,8,23 followed by family members and/or companions4,8,24 and, in third place, co-workers.4,8,24 However, research14 diverges, pointing co-workers in second place. Aggression between co-workers, in different situations, is characterized as a way to vent the frustration caused by violent situations, configuring workers as mass victims of structural violence, which can generate other types of violence, undermining the moral integrity of the worker.4
Regarding the consequences for the aggressor, a national study25 reveals the scarcity of measures or warnings against the phenomenon. A survey26 points out underreporting of violent episodes, with the absence of measures to contain recurrent episodes. Researchers reinforce the importance of reporting and denouncing episodes for the management of health services.21
As consequences of the event of violence for the victim, studies corroborate that the main implications come from expressions of psychic suffering, which lead to fear and insecurity. Furthermore, the quality of care provided to users is impaired due to the feeling of lack of protection, incompetence, lack of motivation and difficulties in teamwork, which negatively interferes with the work of the professionals.27
With regard to coping with violence, a study showed that the nursing team tends to adopt silence as a way to protect themselves from violence from aggressors, and seek support and help from other people, especially the work team.28 Authors29 highlight that the mechanisms for coping with violence in the workplace can be individual or collective. Individual coping is seen in attitudes such as the use of escape strategies focused on personal resources. A study mentions as a collective strategy that the nurse, as the leader of the nursing team, has a relevant role in articulating a dialogue between those involved in situations of violence, collaborating in the elaboration of institutional strategies that minimize the perpetuation of cases of violence at work.30
In this context, the importance of protocols or other devices for handling violence at work is highlighted. Specific public policies for health professionals, which focus on their safety and well-being at work, are essential, with regard to the institutional fight against violence.7
It is considered as a limitation of the study not to observe the working conditions and the ways of dealing that can potentially expand the understanding of the contexts of violence. Also, the cross-sectional research, in specific scenarios, with the impossibility of comparing the occurrence of violence at the two levels of care, is another limit of the investigation. Thus, it is evident the need to carry out further investigations to document the aggression suffered against health professionals, in order to monitor trends in the incidence and profile of violence at different levels of service to users.
A set of findings are identified as contributions of the study that can lead to strategies for coping with violence, such as awareness-raising campaigns, as well as the development and implementation of incident management instruments, including notification and actions to address the problem in the interprofessional team, thus enhancing the culture of peace in health services. Still, there is evidence that allows the identification of variables associated with the occurrence of verbal aggression, for its demystification and denaturalization.
The findings confirm that verbal aggression is a typical violence of public health services, with victims who have a common profile, most of them women members of the nursing team, in constant contact with patients, who are the most prevalent perpetrators. The results can contribute to advances in the forms of prevention of violence, potentially primary, of verbal aggression, which also impacts on maximizing the quality of care provided to users, by enhancing the culture of peace in health services.
The feeling of recognition at work is significantly lower among victims and the concern about the occurrence of violence is greater, demonstrating that these events have an impact on workers' expectations of their work, and potentially on their health. Qualitative data indicate the change in the worker's behavior after the episodes and point to the institutions' difficulties in managing verbal aggression in PHC and hospital services. Thus, it is suggested to qualify the formal procedures and the notification of these events in these places, through a policy of valuing the episodes, promoting a culture of denaturalization of verbal aggression in public health services.
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Promotion / Acknowledgment: Research Support Foundation of Santa Catarina (FAPESC) (Research Financing Public Notice PAP/FAPESC TR1153) and Coordination for the improvement of higher education personnel (Capes/fee; PhD scholarship).
Author contributions
1 – Letícia de Lima Trindade
Corresponding Author
Nurse. Postdoctoral - Email: letrindade@hotmail.com
Conception and/or development of the research and/or writing of the manuscript; review and approval of the final version.
2 – Grasiele Fatima Busnello
Nurse. Doctor in Science - Email: grasibusnello@gmail.com
Conception and/or development of the research and/or writing of the manuscript; review and approval of the final version.
3 – Maiara Daís Schoeninger
Nurse. Master’s in nursing -Email: maia_schoeninger@hotmail.com
Conception and/or development of the research and/or writing of the manuscript; review and approval of the final version.
4 – Kaciane Boff Bauermann
Nurse. Master in Nursing -Email: kacianebb@hotmail.com
Conception and/or development of the research and/or writing of the manuscript; review and approval of the final version.
5 – Marina Klein Heinz
Nursing Academic - Email: marinakleinheinz@gmail.com
Conception and/or development of the research and/or writing of the manuscript.
6 –Clarissa Bohrer da Silva
Nurse. Doctor in Nursing -Email: clabohrer@gmail.com
Review and approval of the final version.
Scientific Publisher: Tania Solange Bosi de Souza Magnago
Associate Publisher: Silviamar Camponogara
How to cite this article
Trindade LL, Busnello GF, Schoeninger MD, Bauermann KB, Heinz MK, Silva CB. Verbal aggression against health professionals in primary and tertiary care: a mixed methods study. Rev. Nurse UFSM. 2022 [Access in: Year Month Day]; vol.12 e15: 1-17. DOI: https://doi.org/10.5902/2179769267045