Workplace violence from the perspective of nurses in mobile pre-hospital care

Abstract

The objective was to understand violence in the workplace from the perspective of nurses in mobile pre-hospital care. This is a cross-sectional study with 67 nurses of mobile pre-hospital care guided by two questions: “What do you understand by violence in the workplace?” and “How do you perceive the occurrence of violence at work in the pre-hospital environment”. Data analysis was performed through the thematic analysis technique. Two categories emerged: what nurses understand by violence at work in the mobile pre-hospital environment; and how nurses perceive the occurrence of violence at work in the mobile pre-hospital environment. Actions of physical, verbal, psychological, behavioral, sexual violence were highlighted, as well as those arising from the characteristics of the work process, practiced by patients, people, professionals of the work institution, health professionals of reference hospitals and professionals with hierarchically superior positions, in the places of care, reception of patients and in the work organization, causing physical, mental and psychological complaints, displeasure in carrying out work activities and leave from work. The study points out the need to discuss the triggers of violence against professionals in pre-hospital care and specific public policies to prevent violence at work, aiming at the health of workers.

Keywords:
Violence at workplace; Pre-hospital Care; Nurses; Comprehensiveness in health; Employee health

Resumo

Objetivou-se compreender a violência no trabalho na perspectiva dos enfermeiros do atendimento pré-hospitalar móvel. Estudo transversal, com 67 enfermeiros do atendimento pré-hospitalar móvel. Realizado a partir de duas perguntas: “O que você entende por violência no trabalho?” e “Como você percebe a ocorrência da violência no trabalho no ambiente do pré-hospitalar”. Análise dos dados através da técnica de análise temática. Emergiram duas categorias: o que os enfermeiros entendem por violência no trabalho no ambiente pré-hospitalar móvel; e como os enfermeiros percebem a ocorrência da violência no trabalho no ambiente pré-hospitalar móvel. Destacaram-se ações de violência física, verbal, psicológica, comportamental, sexual, assim como advindas das características do processo de trabalho, praticada por pacientes, populares, profissionais da instituição de trabalho, profissionais de saúde dos hospitais de referência e profissionais com postos hierarquicamente superiores, nos locais de atendimento, de recebimento dos pacientes e na organização de trabalho, provocando queixas físicas, mentais e psicológicas, desprazer em realizar as atividades laborais e afastamento do trabalho. O estudo aponta a necessidade de discutir os fatores desencadeantes da violência contra os profissionais do atendimento pré-hospitalar e políticas públicas específicas à prevenção da violência no trabalho, visando a saúde dos trabalhadores.

Palavras-Chave:
Violência no trabalho; Atendimento pré-hospitalar; Enfermeiras e enfermeiros; Integralidade em saúde; Saúde do trabalhador

Introduction

The International Labor Organization (ILO) defines violence at work as “incidents in which the people suffer abuse, threats or attacks in circumstances related to their work, including the commute between home and work, which endanger, implicitly or explicitly, their safety, well-being and health” (ILO; 2020, p. 3). It is, however, a phenomenon with multiple denominations depending on the values, culture, feelings, factors and conditions involved, individualized by each victim, aggressor, witness, work institution, supervisory, operational and regulatory bodies, encompassing social and health issues (MACHADO et al., 2016; MINAYO, 2009; SCARAMAL et al., 2017).

Occupational violence suffered by nursing professionals is a real problem, worldwide, of high prevalence, through physical, sexual, verbal and moral acts against the worker (CONTRERA-JOFRE et al., 2020; DADASHZADEH et al., 2019; DREW; TIPPETT; DEVENISH, 2021; KNOR, et al., 2020; PEREIRA et al., 2020; RODRÍGUEZ-CAMPO; PARAVIC-KLIJN, 2017; SCARAMAL et al., 2017), perpetrated by patients, companions, popular in general, co-workers and hierarchical superiors (SÉ et al., 2020).

With regard, more specifically, to professionals who perform pre-hospital care (PHC), it permeates the places of care, ambulances, work units and reference hospitals (DADASHZADEH et al., 2019; KNOR et al., 2020; SÉ; SILVA; FIGUEIREDO, 2017), in a dynamic, unpredictable, vulnerable and diverse environmental context of social interactions (DREW; TIPPET; DEVENISH, 2021).

There may be difficulty in recording and collecting information on the occurrence of violence at work in the health area, as well as its characteristics, due to the variety of instruments used (CONTRERAS-JOFRE et al., 2020; SILVA; AQUINO; PINTO, 2014; SUN et al., 2017). It should be noted that a Brazilian study developed and validated a specific instrument for workplace violence suffered or witnessed by the nursing team (BORDIGNON; MONTEIRO, 2015).

Episodes of violence are often devalued and/or considered as part of the work of PHC because they involve care for people with life-threatening behavioral disorders, under the effects of licit and illicit substances or emotionally weakened, perpetuating a practice harmful to workers’ health (SCHABLON et al., 2018), with physical, mental and psychological repercussions (SCHABLON et al., 2018; WORM et al., 2016).

It is necessary to expand the discussions about the violence at workplace suffered, experienced and witnessed by PHC professionals and the knowledge of this phenomenon through the workers’ speech.

Given the above, this study aims to understand violence at workplace from the perspective of nurses in mobile pre-hospital care.

Method

Type of study: cross-sectional study, guided by the Consolidated Criteria for Reporting Qualitative Research (COREQ) tool (TONG; SAINSBURY; CRAIG, 2007). It is a thematic excerpt from a larger research, from the Graduate Program in Nursing and Biosciences – PPGENFBIO, of a federal university located in the state of Rio de Janeiro, entitled “Real and subjective dimensions of violence in the work of nurses in mobile pre-hospital care”, completed in 2019.

Unit of analysis: nurses working in mobile PHC (Prehospital Care) ambulances of the intermediate type, in the municipality of Rio de Janeiro.

Study scenario: 14 bases of mobile PHC ambulances of the intermediate type, of a state public service, located in the municipality of Rio de Janeiro.

Inclusion criteria: performance, for at least 12 months, in mobile PHC ambulances of the intermediate type. The period of operation was delimited in line with that applied in other studies, which consider the last 12 months measuring the occurrence of violence at work.

Exclusion criteria: professionals on leave from work due to vacation or leave.

Sample: participants were invited intentionally according to the schedule prepared by the authors for data collection. To define the total number of participants, the criterion of theoretical saturation of responses was applied (DENZIN, 1994). Thus, data collection was stopped in the collection of the 67th instrument, that is, the sample studied was then composed of 67 nurses.

Data collection: Data were collected between July and September 2018. A semi-structured instrument was used to characterize the time of work in the PHC and two open questions: “What do you understand by violence at work?” and “How do you perceive the occurrence of violence at work in the pre-hospital environment?” Nurses were approached at the mobile PHC ambulance bases of the intermediate type. At this moment, the objective, method of the study, approval of the Research Ethics Committee (REC) and authorization of the institution to carry out the research were presented. Those who agreed to participate were given the Informed Consent Form (ICF) and the research instrument, followed by the respective readings. Considering the characteristic of the work, with the possibility of leaving for urgent and emergency care at any time, and in order not to interfere with the work routine, it was agreed with the participants to collect the completed instruments after 15 days from the delivery date.

Data analysis: the thematic analysis technique was used, following the stages: pre-analysis; exploration of the material; treatment, inference and interpretation of the results (BARDIN, 2016).

Ethical aspects: the study followed the principles of Resolution number 466/2012 of the National Health Council, being approved by the REC, CAAE 86207918.0000.5285. The participants signed the ICF and were appointed through the acronym PHC, followed by a number from one to 67, according to the order of collection of the research instruments, to maintain the confidentiality of the identity.

Results

The participants’ records originated two categories: What nurses understand by violence at workplace in the mobile pre-hospital environment; and how nurses perceive the occurrence of violence at workplace in the mobile pre-hospital environment.

What Nurses Understand by Workplace Violence in the Mobile Prehospital Environment

Participants reported that they understand as violence at workplace, actions ranging from intolerance to sexual violence, perpetrated by patients, members of the work team and by professionals in higher positions.

Embarrassment, intimidation, abuse, disrespect, humiliation, intolerance practiced by leaders, subordinates, peers and customers in the workplace. This violence can be verbal, behavioral, physical, explicit or veiled (PHC 7).

I understand it to be an action that occurred with the worker during his work. This action can be physical, psychological, insulting, moral and/or sexual harassment (PHC 23).

The reports made it possible to identify the understanding of violence at work from psychological, emotional and physical consequences, as well as fear, anxiety, stress, work leave and willingness not to practice the profession.

Any action that the worker suffers in the work environment and that can generate physical and emotional damage to him, including leave from work (PHC 3).

Any type of situation that generates fear, anxiety, stress for the worker, by boss, hierarchical superior, co-worker or client (PHC 14).

All kinds of actions that lead you to discomfort, displeasure in exercising your work activities [...] (PHC 15).

Work overload during shifts in the PHC that contributes to deprivation of rest, food, hydration and physiological eliminations are understood by some participants as violence at work.

Every type of action [...] even basic unmet needs (hunger, sleep, thirst, tiredness, exhaustion and pain) (PHC 15).

[...] We suffer from different types of assaults everywhere. Often we are deprived of rest and food (PHC 21).

Any kind of physical or verbal aggression. In addition to event overload without time to perform basic functions such as feeding and doing physiological needs (PHC 31).

How nurses perceive the occurrence of violence at work in the mobile pre-hospital environment

Participants perceive violence in the work of the PHC during the consultations carried out in risk areas, with individuals carrying firearms and in places with sale or use of narcotics, characterizing an unsafe work environment.

Assistance in potentially violent risk scenarios: armed men, explicit use of narcotics [...] (PHC 4).

When I go to some risk area and start having symptoms of anxiety and fear, such as tachycardia and tremors (PHC 14).

When we are called to events inside communities, the risk of suffering any type of violence is very high, as we are very vulnerable to the war scenario installed in the state of Rio de Janeiro (PHC 48).

Violence at work is also perceived by the participants in the working relationships with the professionals of the medical regulation center and professionals of the patients’ destination hospitals.

[...] In hospitals where the rescuer finishes his/her care provided by professionals of the institutions (PHC 1).

[...] It also happens on the part of physicians, in the hospitals where we take the victims. We often receive their dissatisfaction with the system through inflammatory and even disrespectful speeches (PHC 8).

[...] lack of credibility of regulatory physicians who do not accept our information about the clinical condition of patients, making us mere transporters of patients to the hospital (PHC 24).

The perception of violence at work by patients and/or companions dissatisfied with waiting for care is also mentioned.

Violence happens at different times and presents itself in different ways. The verbal occurs by various means, popular inflamed by the delay in service [...] (PHC 8).

I perceive it through verbal aggressions due to several reasons ranging from delay in care to patient dissatisfaction with reference hospitals, for example (PHC 29).

The perception of violence is considered as a culture inherent to work in PHC and reaffirmed in the absence of monitoring of workers who routinely suffer and witness situations of violence at work.

I notice on every level. I perceive it [violence] as a practice or almost a culture in the pre-hospital environment [...] (PHC 7).

I perceive it [violence] as routine, to the point that we are often not even able to identify it as such [...] (PHC 16).

A total lack of respect for the professional, who is often trivialized and treated with disregard. A fact that causes serious emotional and physical disorders and is not accompanied/supported by its consequences (PHC 55).

Discussion

The speeches stood out as understanding and perception of violence at work, actions of physical, verbal, psychological, behavioral, sexual violence, as well as arising from the characteristics of the work process, practiced by patients, popular, professionals of the work institution, health professionals of the reference hospitals and professionals with hierarchically superior positions. Violence that occurs in the places of care, patient reception and work organization, causing physical, mental and psychological complaints, displeasure in carrying out work activities and leave from work.

As for the violence suffered by nurses in places of care to the population, the participants mentioned the patients’ discontent with the waiting time of the ambulances as a generating factor. The lack of knowledge of the population about the functioning of the PHC service, regarding the prioritization of life-threatening care and the imaginary and real waiting time, trigger the aggressiveness of patients, family members and companions (KNOR et al., 2020; OLIVEIRA et al., 2020; RODRÍGUEZ-CAMPO; PARAVIC-KLIJN, 2017), against health professionals (PARAVIC-KLIJN; BURGOS-MORENO, 2018).

Research pointed out inadequacies in users’ knowledge about screening, life risk assessment and vehicle commitment in the context of PHC, with statements that ambulances should be used for free transport and for easy access to other services, regardless of the complaint or condition presented (VERONESE; OLIVEIRA; NASK, 2012). Nurses from a PHC service claim that the lack of knowledge of the population impairs assistance in emergencies (MATA et al., 2018).

Violence at work was also expressed in care in risk areas with continuous exposure of workers to situations of fear and stress due to the feeling of insecurity, the presence of armed individuals and places of sale of narcotics. These are work environments with extreme risk to professionals due to the possibility of armed confrontations. The dangers inherent to work activities, the absence of social support and the trivialization of violent acts suffered by workers are determinant for the development of emotional exhaustion, low professional achievement, leave from work and desire to no longer exercise the profession (HAN et al., 2021; OLIVEIRA et al., 2020; SÉ et al., 2020).

Violence arising from the places where patients are received stems from relationship difficulties with health professionals. After performing the PHC, patients, when necessary, are referred to health units for continuity of care (Brazil, 2002). However, an increase in spontaneous demand through patients brought by ambulance teams can generate dissatisfaction among professionals at the destination units and aggressive behavior against PHC workers. (MELLO, 2015).

Difficulty in relationships with regulatory physicians was also mentioned as a cause of violence at work. Professional devaluation, lack of autonomy for decision-making and lack of space for reflection during the regulation of events with physicians from the medical regulation center, as well as in other studies (PEREIRA et al., 2020; MELLO, 2015), become harmful to workers who describe them as acts of labor violence.

Restriction of autonomy is associated with the development of stress at work (CARVALHO et al., 2020), feelings of professional devaluation, risk to the worker’s psychosocial well-being, low professional performance, demotivation, absenteeism and work violence. Decision-making power is an important tool for the management of stressful work and high professional self-esteem (ARAÚJO et al., 2020) and the good interaction between members of multiprofessional teams contributes to safe, efficient and quality care for the population (MATA et al., 2018).

The discussion on violence at work extends to the biological needs of workers. The overload during shifts due to the demand for care, added to the development of managerial and administrative functions, result in deprivation of rest, difficulty in cleaning and water, nutritional intake and impaired physiological eliminations. The particularities of work in the PHC (PEREIRA et al., 2020; ROSA et al., 2020) include the availability of professionals during the shift, full time, to respond to occurrences in an agile manner and early emergency assistance to victims, making it impossible to maintain a care routine, interpreted by the worker as violence to the body.

The perception of violence at work was also mentioned in the consequences to the body and mind of workers, who, due to continuous exposure to fear, anxiety and stress, can develop diseases associated with the world of work, with burnout syndrome, emotional exhaustion and low professional achievement, requiring leave from work or even the desire to no longer exercise the profession (HAN et al., 2021; OLIVEIRA et al., 2020).

Violence was referred to as a work-related culture in the PHC. However, violence at work must be repressed (CONTRERA-JOFRE et al., 2020), society raised awareness and the risks of violence at work identified (LEUCHTER et al., 2020). Records and complaints must be made in any situation of violence to raise awareness, increase visibility, implement prevention measures, mitigation interventions and resilience strategies, minimizing damage to the mental and physical health of professionals who provide care in the pre-hospital environment (DREW; TIPPETT; DEVENISH, 2021; HAN et al., 2021; OLIVEIRA et al., 2020).

Finally, studies point out as strategies to reduce violence at work, in the context of PHC, educational actions and campaigns carried out by the media, aimed at the population, against violence to health professionals, improving the quality and efficiency of pre-hospital care services and measures to protect workers considering the profile of aggressors and situations of exposure to the risk of violence (CANESIN et al., 2020; LEUCHTER et al., 2020; SANTOS et al., 2020).

It is reiterated that in view of the complexity of the experiences, conceptions, individual values, environment and social relations that permeate the characterization of violence, this article did not intend to conceptualize this phenomenon, but rather to identify how nurses understand work-related violence in PHC.

Because it was carried out with nurses working only in one municipality, the results presented here may not represent the reality understood and perceived by professionals from other locations or pre-hospital care institutions. However, despite the geographical limitation, it constitutes a contribution to new scientific investigations in Public Health, in view of the particularities of work in PHC and the risks to which workers are exposed.

Conclusion

Study participants express violence at work through understandings and perceptions, without concern for pre-established concepts. They understand violence at work in PHC through physical, verbal, psychological, behavioral and sexual acts, perpetrated by patients, people, professional colleagues and professionals with hierarchically superior positions, during the work process external and internal to the organization, with negative biopsychosocial consequences.

It is necessary to discuss the triggering factors of violence against PHC workers for the elaboration, implementation and execution of protection strategies for professionals, as well as specific public policies to prevent violence at work, aiming at the health of workers.

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Edited by

Editor: Daniela Geremia

Publication Dates

• Publication in this collection
  13 Nov 2023
• Date of issue
  2023

History

• Received
  10 Sept 2021
• Accepted
  05 July 2022
• Reviewed
  31 May 2022