ORIGINAL ARTICLE
DOI: 10.11606/issn.1806-6976.v13i2p86-92

Work-related violence in psychiatry in the perception of nursing workers¹

La violencia relacionada con el trabajo en psiquiatría en la percepción de los trabajadores de enfermería

Glaudston Silva de Paula^I; Elias Barbosa de Oliveira^II; Alexandre Vicente da Silva^III; Silvia Regina Carvalho de Souza^IV; Janaina Mengal Gomes Fabri^V; Olivia de Andrade Guerra^VI

^IIMSc, Professor, Faculdade Gama e Souza, Rio de Janeiro, RJ, Brazil
^IIIPhD, Associate Professor, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
^IVMSc, Assistant Professor, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
^VMSc, RN, Instituto Federal Nise da Silveira, Rio de Janeiro, RJ, Brazil
^VIMSc
^VIIMaster’s student, Faculdade de Enfermagem, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil

ABSTRACT

The objective in this study was to analyze the types of violence related to the work at a psychiatric inpatient service as perceived by the nursing professionals and to discuss the repercussions for the group members’ health. Qualitative and descriptive research, undertaken at a psychiatric inpatient service of a teaching hospital. The semistructured interview technique was used with 16 nursing workers. Content analysis was applied to the testimonies. It was identified that both psychological and institutional violence, deriving from the inappropriate work conditions, negatively affect the professionals and nursing practice. In conclusion, it is important for the institution to invest in preventive actions in order to promote the group’s health and the quality of the service offered.

Descriptors: Nursing; Violence at Work; Psychiatric Hospital; Occupational Health.

RESUMEN

Este estudio tuvo como objetivo analizar los tipos de violencia relacionada con el trabajo en una unidad de internación psiquiátrica en la percepción del personal de enfermería y discutir las implicaciones para la salud del grupo. Investigación cualitativa, descriptiva, cumplida en una unidad de internación psiquiátrica de un hospital universitario. Se ha utilizado la técnica de entrevista semiestructurada con dieciséis trabajadores de enfermería. Aplicada el análisis de contenido a los testimonios, se identificó que la violencia psicológica y institucional resultante de las condiciones de trabajo inadecuadas causan daño a los trabajadores y la práctica de enfermería.  La conclusión es la importancia de la institución invertir en acciones preventivas con el fin de promover la salud del grupo y la calidad del servicio.

Descriptores: Enfermería; Violencia en el Trabajo; Hospital Psiquiátrico; Salud Ocupacional.

Introduction

This is an excerpt from a Master’s thesis focused on work-related violence at a psychiatric internment service as perceived by the nursing professionals. In the theoretical-methodological approach of violence, knowledge and practices from different areas are involved, demanding multifocal, cross-disciplinary and intersectoral studies. In this article, we intend to use the concept of work-related violence as the voluntary action of an individual or group against another individual or group, which causes physical or psychological damage, occurred in the work environment or involving relations established at work, as well as related activities⁽¹⁾.

Beyond the identification of vulnerable activities or sectors, the importance of situational factors in the production of violent episodes becomes clearer based on interaction-focused approaches. In this line of thought, violence at work and work-related violence are considered as a possible consequence of interpersonal interactions that, in turn, are immersed in a broader organizational and social context, mediated by standards of behavior, customs, task characteristics and particularly work conditions and organization⁽²⁾.

Thus, factors like overcrowding and work burden, which make the hospital environment more hostile and are causally linked to stress and illness in nursing professionals, can favor the occurrence of violence due to the direct confrontation between patients and professionals. In that work situation, the low social support among the nursing workers can be a variable that favors the occurrence of violence, as these workers may not get organizational support to cope with situations that potentially generate occupational violence, a problem that has been hardly explored in Brazilian studies in which the hospital nursing work environment is described⁽³⁾.

What the work at a psychiatric hospital is concerned, it should be highlighted that the nursing team can get involved in situations of violence because it lives with the users and family members’ mental suffering day and night. In addition, nursing activities are developed in improper conditions due to the insufficient number of human and material resources. Therefore, the characteristics of psychiatric nursing work and its technical and relational requirements should be taken into account, which demand physical and mental efforts, as observed in psychiatric emergencies and in care for bedridden, sedated and/or contained patients who need continuing help and supervision⁽⁴⁾.

Besides the physical and mental wear deriving from the work in psychiatry, the nursing workers in this context are exposed to violence at work due to sexual, physical and psychological aggressions committed by patients, causing post-traumatic stress disorder with repercussions for health and quality of life. In view of the harmful effects of violence on mental health, organizational policies are recommended that are centered on a safe occupational environment, education and professional training to cope with it⁽⁵⁾.

In addition, the extension of violence at work puts an emotional and social strain on the individual, as well as organizational problems due to the lesser service quality, absenteeism and the workers’ search for medical treatment⁽⁶⁾. Therefore, the types of violence the workers are exposed to need to be investigated, with a view to verifying their existence in the public and private contexts and aiming to develop coping strategies⁽⁷⁾. Among the different forms the costs of violence can take, besides deaths, the clearest may be related to the workdays lost and the spending on medical and psychological treatment, or on court cases and indemnities for the workers, with incipient reporting systems for cases of work-related violence⁽⁸⁾.

The literature review was aimed at providing theoretical support for the study by accessing the Virtual Health Library (VHL), the databases of the Latin American and Caribbean Literature in Health Sciences (LILACS) and the Scientific Electronic Library on Line (SciELO). No Brazilian study was found in which the problem of occupational violence at work was discussed, and only three international articles. The relevance of the study is highlighted because it discusses a delicate theme in psychiatry, including proposals for coping measures, in view of the implications for occupational health and for the quality of care. In view of the above, the objective in this study was to analyze the types of work-related violence at a psychiatric inpatient service as perceived by the nursing workers and to discuss the repercussions for the group’s health.

Method

A descriptive study with a qualitative approach was undertaken⁽⁹⁾, aiming to understand the problem from the perspective of the individuals who experience it, that is, departing from the stakeholders’ daily reality, their satisfactions, disappointments, surprises and other emotions. Approval for the project was obtained from the Research Ethics Committee at the institution where the study was undertaken, registered in the National Research Ethics Committee under number 070.3.2012.

The place of study was a psychiatric care service of a public teaching hospital located in the city of Rio de Janeiro, RJ, Brazil. The service has 25 beds and is organized horizontally, consisting of cases that house four patients on average, using the Therapeutic Community as a care model. When the data were collected, the nursing service consisted of 22 professionals, being seven nurses and 15 nursing technicians.

In compliance with Resolution 466/12, after signing the Free and Informed Consent Form (FICF), 16 nursing professionals participated in the study (six nurses and nine nursing technicians), based on the following inclusion criteria: being a tenured and/or temporary staff member at the institution and having at least one year of experience in psychiatric work, these criteria being important for the work-related knowledge, skills and competences and for the perception of occupational violence. Six workers did not participate in the study because they did not comply with the inclusion criteria, while none of the interviewees refused to participate.

The professionals were informed about the voluntary nature of their participation and that they had the right to withdraw from the research in any phase without causing any damage or retaliation. The secrecy of the data was guaranteed and it was ratified that the results would be presented at scientific events and published in scientific journals. In the transcription of the testimonies, the following conventions were adopted: Nurse (N) and Nursing Technician (NT), followed by a numeral according to their order of entry in the text.

Before the researcher collected the data, a pilot-test was applied through digital records. After the transcription and analysis, some questions were reassessed and only one question was added to the script. The interviews were held in the second semester of 2012, after making an appointment at the interviewees’ convenience. The approximate length of the interviews was 30 minutes. To avoid interferences, the data were collected at the inpatient service, in a private room, on a preset date and time, at the participants’ availability.

The semistructured interview technique⁽⁹⁾ was chosen, using a script with open questions, which permitted the interaction between the researcher and the interviewees, favoring the contextualization of experiences and meanings, which contributed to clarify the research problem. In the collection of the testimonies, a structured tool was used to characterize the participants and a script with five questions on the environment, work conditions and the professionals’ perception of the work-related violence. Their answers were digitally recorded.

After the transcription, the testimonies were analyzed in the thematic content analysis technique⁽¹⁰⁾, based on the decoding of the text in different elements, which were classified and constituted analogical clusters. In the final phase, using the criteria of representativeness, homogeneity, reclassification and aggregation of the elements, the following results were obtained: psychological violence – when the patient assaults the team; medical hegemony – symbolic violence at work and psychological violence perpetrated by the family member.

Results

Psychological violence – when the patient assaults the team

The participants reported on psychological violence in view of the verbal and physical aggressions the patients committed under the team’s care. As for the verbal aggression, when committed by mental patients, it is naturalized at the workplace as an expression of dissatisfaction with the limits the team sets. In some situations, however, the aggression the team commits is considered as a threat on the professionals’ integrity and safety, mainly in cases of psychomotor agitation, when chemical (use of neuroleptic drugs) and/or mechanical contention is needed.

Psychiatric patient is kind of a swearword, mainly when he has no cigarettes or when he does not agree with a request, and also when he needs to be contained. I am scorned almost every shift! But it’s normal with their disease (N4).

It’s problem when the patient is being contained! Because his behavior is a threat and we don’t know what can happen when we contain him (N12).

When the patient is having a crisis, there may be some kind of movement or he may cast some object! Therefore, we need to keep the environment safe, avoid any type of material that can entail risks (N10).

Medical hegemony – the symbolic violence at work

At the institution that served as the place of study, a service at a teaching hospital, various professional categories are present, as well as undergraduate and post-graduation students. Besides the patients and nursing residents, who develop their knowledge and practices in mental health, there are residents in medicine, psychology and social work, who are active at the nursing ward and outpatient clinic. According to the interviewees, verbal and behavioral expressions by the medical residents were identified, which represent work-related violence.

The medical residents cause a lot of work; mainly the novels, because they immediately start badmouthing the nursing team! To the extent of being offensive really! (N4).

The medical residents are very authoritarian and that makes us feel dissatisfied. But we stay silent at these behaviors, because we’re afraid of retaliations (NT2).

This thing of medical power over nursing is violence, besides the conflicts that end up occurring as a result, such as disagreements over therapeutic procedures (N5).

Violence committed by family members

In the context of care for mental patients, the family is a valuable resource related to the care delivered within the territory and in the hospital context itself, representing the support network and the fundamental affective bonds for the establishment of the treatment and the prevention of relapses. Nevertheless, in view of the hospitalization of their loved one, which is considered a traumatic event, and the lack of clarity with regard to the rules, the relative can visit the service with symptoms of anxiety, projecting his/her own exhaustion in the team and drifting into hostile attitudes.

[...] Once, I was verbally assaulted by a family member simply because I said I couldn’t go to the patient’s infirmary, who was her father (NT15).

[...] Another issue to dealing with the family. We face difficulties with some family members, who do not understand our service and pummel away at us for nothing. They arrive in a bad mood and talk to us as if we were nothing here! (N10).

But there’s the institution’s violence as well, where there aren’t sufficient workers, when there is a lack of material, when the environment itself favors violence (NT9).

Discussion

In the analysis of the hostile attitudes mental patients assume, reflections are due on the danger the patient with the disorder poses and some triggering factors of psychomotor agitation which, when managed by the team, can minimize the occurrence of violent episodes. Idle time, in combination of lack of care, enhances aggressive attitudes among the patients, leading to a gap between the patient’s needs and the team’s tolerance of these needs, which can contribute to the prescription of mechanical containment, when considering this patient’s risk for the physical integrity of the people around him⁽¹¹⁾.

Another relevant aspect in the approach of work-related violence prevention in psychiatry refers to the professionals’ specific training to cope with it, as the workers are not always academically prepared, not even after they take charge of the service⁽¹²⁾. Special attention is needed for the less experienced, newly graduated, younger professionals who are highly committed to the profession, factors that contribute for these professionals to take on defensive strategies or escape attitudes towards conflicting situations, such as violent episodes⁽¹³⁾.

What symbolic violence is concerned, committed by medical residents, this represents a contradiction in terms of teamwork as, through the Psychiatric Reform, the professional are stimulated to get organized horizontally, sharing knowledge and practices, discussing the situations daily and jointly determining the therapeutics that is to be established⁽¹⁴⁾. The dispute involving the nursing team and the other health professional possibly rests on the fact that the category’s status was enhanced by better qualification, making the nurse’s actions more significant in the field of health, including greater participation in decisions about the treatment, diagnosis and assessment of the patients under the team’s care⁽¹⁵⁾. Therefore, it is fundamental for the nursing team to always seek knowledge, leadership and autonomy at work with a view to facing existing conflicts, which can trigger the growth of the group⁽¹⁶⁾.

The predominance of women among the nursing workers goes back a long time and, over time, it has been associated with the patriarchal ideology of society, which stigmatizes nursing as an undervalued and inferior class in the group, because the object of their work and study of the category, care, is strongly linked with female activities. Besides this aspect, in nursing, women are victims of violence through the imposition of domination and authoritarianism by the medical class, remitting to the existing asymmetrical power relations between men and women⁽¹⁷⁾.

In a study involving nursing workers, the team members indicated that, in the past year, they had been victims of some form of violence. In the reports, psychological aggression by users, relatives of users, nurses and others (general audience, supervisors and physicians). Difficulties in interpersonal relationships, hostility and rudeness of users and/or relatives in dealing with people, as well as dissatisfactions originating in the deficient problem-solving ability of the health system were indicated as the main causes of verbal aggression⁽¹⁸⁾.

What the registration of cases of verbal violence and the search for help to solve the problem are concerned, a certain degree of apathy by the nursing professionals is evidenced, whose explanations can be related to the fact that the psychological violence and its subtypes exert less impact, and are often part of these professionals’ daily work. In addition, other factors influence the posture of distancing in view of the violence, including fear, shame resulting from the situation experienced, lack of time, as well as non-recognition by employees and employers of the violent situations⁽¹⁷⁾.

Concerning the institutional violence the workers mentioned, with regard to the insufficient number of human and material resources, psychiatric nursing work is hard, in view of the care and the family experience with the mental patient, entailing mental and physical suffering at the same time. In addition, there are the difficulties inherent in the area itself, in which high levels of improvisation are required from these professionals, aggravated and revealed by the lack of proper conditions for daily work⁽¹¹⁾. Therefore, the social and financial costs of violence need to be taken into account, due to absenteeism, people’s dismissals and turnover, as well as different types of wear, ranging from the loss of the expectation to develop high-quality work to the discouragement to develop the work and reaching the physical aspect, through pain and somatization⁽¹⁹⁾.

In that sense, the visibility of violence and its work-related forms, based on the workers’ participation, can contribute to the construction of collective and organizational strategies that make the work healthier, allowing the workers to accomplish their work despite the threats and fear they experience⁽¹³⁾.

Conclusion

In the results, it was evidenced that, according to the study participants, the nursing team that works at a psychiatric inpatient service is mainly exposed to the psychological violence committed by patients, relatives and physicians, as well as to institutional violence, due to the lack of human and material resources. Psychological and institutional violence were associated, appointing the need for the managers to invest in human and material resources.

If, on the one hand, the workers associate the patients’ verbal aggressions with the clinical situation, on the other, they are dissatisfied with the psychological violence the family members commit. This problem signals the importance of the workers’ actions in the prevention of violence, which can be accomplished by empathetically welcoming the family in its suffering, providing clear information about the routine, the family’s rights and the relevance of family participation in the treatment.

The moral or symbolic violence committed by resident doctors highlights the workers’ need for social support, as a way to minimize the impotence and lack of support the group experiences. The institution is responsible for granting training to the workers, as a strategy to identify and cope with this problem in the workspace, which can positively influence the wellbeing, satisfaction and quality of the service provided.

Despite the study limitations due to the number of participants, and as it was developed at an inpatient service, making it impossible to generalize the results to other work contexts, further research in the area is recommended, in view of its clearly incipient nature, as well as measured focused on the control, prevention and social support of the stakeholders involved in situations of violence in psychiatric care.

References

1. Oliveira RP, Nunes MO. Work-related violence: a conceptual proposal.  Rev Saúde Soc. 2008 [Internet] 17(4):22-34 [cited Nov 21, 2015]. Available from: http://www.scielo.br/scielo.php?pid=S0104-12902008000400004&script=sci_arttext         [ Links ]

2. Campos AS, Pierantoni CR. Violência no trabalho em saúde: um tema para a cooperação internacional em recursos humanos para a saúde. Rev Eletron Com Inf INov Saúde. [Internet]  2010 [Acesso 18 jan 2014]; 4(1):86-2. Disponível em: http://www.obsnetims.org.br/uploaded/11_12_2013__0_16_5_2013__0_Violencia_no_trabalho_em_saude.pdf        [ Links ]

3. Vasconcelos IRR, Griep RH, Lisboa MT, Totemberg L. Violência no cotidiano de trabalho de enfermagem hospitalar. Acta Paul Enferm. [Internet] 2012 [Acesso 18 jan 2014];25(2): 40-7. Disponível em: http://www.scielo.br/pdf/ape/v25nspe2/pt_07.pdf        [ Links ]

4. Souza SRC, Oliveira EB, Mauro MYC, Mello R, Kestemberg CCF, Paula GS. Cargas de trabalho de enfermagem em unidade de internação psiquiátrica e a saúde do trabalhador. Revista Enferm UERJ. [Internet] 2015 [Acesso 16 fev 2016];23(5):633-8. Disponível em: http://www.e-publicacoes.uerj.br/index.php/enfermagemuerj/article/view/19563/15610        [ Links ]

5.Zeng JY, An FR, Xiang YT, Ungvari GS, Newhouse R, Yu DSF, et al. Frequency and risk factors of workplace violence on psychiatric nurses and its impact on their quality of life in China. Psychiatry Res. [Internet] 2013 [cited  May 11, 2016];210(2):510-4. Available from: http://www.sciencedirect.com/science/article/pii/S0165178113003296        [ Links ]

6. Selligmann-Silva E. Trabalho e desgaste mental: o direito de ser dono de si mesmo. São Paulo: Cortez; 2011. 623 p.         [ Links ]

7. Barbosa R, Labronici LM, Sarquis LMM, Mantovani MF. Psychological violence in nurses’ professional practice. Rev Esc Enferm USP. [Internet] 2011[cited Oct 17, 2015]; 45(1):26-32. Available from: http://www.scielo.br/scielo.php?pid=S0080-62342011000100004&script=sci_arttext

8. Baptista CB, Campos AS, Reis JC, Schall VT. Violence in health work: analysis of basic health units in Belo Horizonte, Minas Gerais. Rev Trab Educ. [Internet] 2011[cited Nov 30, 2015];9(2):295-17. Available from: http://www.scielo.br/scielo.php?pid=S1981-77462011000200008&script=sci_arttext        [ Links ]

9. Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 13ª. ed. São Paulo: Hucitec; 2013. 408 p.         [ Links ]

10. Bardin L. A Análise de Conteúdo. Lisboa (PO): Edições 70; 2010. 282 p.         [ Links ]

11. Moreira LHO, Loyola CMD. Involuntary commitment: implication for psychiatric nursing practice. Rev Esc Enferm USP. [Internet] 2011 [cited Ago 30, 2015]; 45(3):692-9. Available from: http://www.scielo.br/scielo.php?pid=S0080-62342011000300021&script=sci_arttext        [ Links ]

12. Velloso ISC, Araujo MT, Alves M. Workers at a basic health unit who interface with violence. Acta Paul Enferm. [Internet] 2011 [cited Ago 30, 2015];24(4):466-71. Available from: http://www.scielo.br/pdf/ape/v24n4/a04v24n4.pdf        [ Links ]

13. Spagnol CA, Santiago GR, Campos BMO, Badaró MTM, Vieira JS, Silveira APO. Conflict situations experienced at hospital: the view of nursing technicians and auxiliaries. Rev Esc Enferm USP. [Internet] 2010 [cited Sept 20, 2015];44(3):803-11. Available from: http://www.scielo.br/pdf/reeusp/v44n3/36.pdf        [ Links ]

14. Pinho LB, Hernandez AMB, Kantorski LP. Mental health workers’: contradictions and challenges in the psychiatric reform context. Esc Anna Nery. [Internet]. 2010 [cited Sept 20, 2015];14(2):260-7. Available from: http://www.scielo.br/pdf/ean/v14n2/07.pdf

15. Lancman S, Girardi MIG, Castro ED, Tuacek TA. Repercussions of violence on the mental health of workers of the Family Health Program. Rev Saúde Pública. [Internet] 2009 [cited Sept 12, 2015];43(4):682-8. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-89102009000400015        [ Links ]

16. Chaves RN, Alves ALS. Power relations in the hospital unit: a perspective of physicians and nurses. Diálogos Cienc. [Internet] 2012 [cited Jun 25, 2015]; 10(30):159-64. Available from: http://dialogos.ftc.br/index.php?option=com_content&task=view&id=315&Itemid=74        [ Links ]

17. Lima GHA, Souza SMA. Violência psicológica no trabalho da enfermagem. Rev Bras Enferm. [Internet] 2015 [Acesso 18 jan 2016];68(5):817-23. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-71672015000500817        [ Links ]

18. Santos AMR, Soares JCN, Nogueira RF, Araujo NA, Mesquita GV, Leal CFS. Institutional violence: routine experiences of the nursing team. Rev Bras Enferm. [Internet] 2011 [cited Ago 14, 2015];64(1):84-90. Available from: http://www.scielo.br/pdf/reben/v64n1/v64n1a13.pdf        [ Links ]

19. Magnus CN, Merlo ARC. Suffering-Pleasure: Dynamics of Work of Mental Health Professionals Public of a Psychiatric Hospital. PSICO. [Internet] 2012 [cited Ago 15, 2015]; 43:185-92. Available from: http://revistaseletronicas.pucrs.br/ojs/index.php/revistapsico/article/view/11695        [ Links ]

Received: Mar. 14^th 2016
Accepted: Jan. 23^rd 2017

Corresponding Author:
Elias Barbosa de Oliveira
Universidade do Estado do Rio de Janeiro. Facculdade de Enfermagem
R. São Francisco Xavier, 524
CEP: 20550-900, Rio de Janeiro, RJ, Brasil
E-mail: cppgenf@gmail.com

¹Paper extracted from Master’s Thesis "Violência laboral como risco psicossocial à saúde dos trabalhadores de enfermagem de um hospital psiquiátrico" presented to Faculdade de Enfermagem, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil. Supported by Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), Brazil.