Workplace violence and professional quality of life among primary care nurses

Abstract

Objective

To verify the association between workplace violence and quality of professional life in nurses from Basic Health Units.

Methods

This is a descriptive, cross-sectional and analytical study developed with 101 primary care nurses, whose data were collected using an instrument of sociodemographic, occupational and lifestyle characteristics, the Survey Questionnaire Workplace Violence in the Health Sector and the Professional Quality of Life Scale, to assess workplace violence and the quality of professional life, respectively. Data were analyzed descriptively and inferentially, using Wald’s chi-square test, considering p<0.05 as statistical significance.

Results

The prevalence of types of violence was 65.3% for verbal, 29.7% moral harassment, 17.8% physical, 1% sexual harassment and 1% racial discrimination. Low compassion satisfaction occurred with 54.5% of respondents, high burnout with 58.4% and high post-traumatic stress, 57.4%. Compassion satisfaction was associated with bullying at work (p=0.047), encouragement to report violence (p=0.040) and having consequences for offenders (p=0.018). There was no association between the types of violence and burnout. Posttraumatic stress was associated with physical workplace violence (p=0.047) and with the existence of procedures to report violence (p=0.018).

Conclusion

There was an association of workplace violence with the quality of professional life. It is necessary to create institutional measures to promote the quality of professional life, prevent workplace violence and standard procedures to guide professionals in the face of violent acts.

Workplace violence; Quality of life; Nurses; Primary health care; Occupational health

Resumo

Objetivo

Verificar associação entre a violência no trabalho e qualidade de vida profissional em enfermeiros de Unidades Básicas de Saúde.

Métodos

Estudo descritivo, transversal e analítico desenvolvido com 101 enfermeiros da atenção primária, cujos dados foram coletados por instrumento de características sociodemográficas, ocupacionais e de hábitos de vida, o Survey Questionnaire Workplace Violence in the Health Sector e a Professional Quality of Life Scale, para avaliar a violência laboral e a qualidade de vida profissional, respectivamente. Os dados analisados descritiva e inferencialmente, por meio do teste qui-quadrado de Wald considerando-se p<0,05 como significância estatística.

Resultados

As prevalências dos tipos de violência foram de 65,3% para a verbal, 29,7% assédio moral, 17,8% física, 1% assédio sexual e 1% discriminação racial. A baixa satisfação por compaixão ocorreu com 54,5% dos pesquisados, de alto burnout com 58,4% e de alto estresse pós-traumático, 57,4%. A satisfação por compaixão foi associada com assédio moral no trabalho (p=0,047), estímulo para relatar a violência (p=0,040) e ter havido consequências para o agressor (p=0,018). Não houve associação entre os tipos de violência com o burnout. O estresse pós-traumático esteve associado à violência física no trabalho (p=0,047) e com a existência de procedimentos para relatar a violência (p=0,018).

Conclusão

Houve associação da violência laboral com a qualidade de vida profissional. É necessário a criação de medidas institucionais para a promoção da qualidade de vida profissional, prevenção da violência laboral e procedimentos padrões para orientar os profissionais diante dos atos violentos.

Violência no trabalho; Qualidade de vida; Enfermeiras e enfermeiros; Atenção primária à saúde; Saúde do trabalhador

Resumen

Objetivo

Verificar la asociación entre violencia en el trabajo y la calidad de vida profesional en enfermeros de Unidades Básicas de Salud.

Métodos

Estudio descriptivo, transversal y analítico desarrollado con 101 enfermeros de la atención primaria, cuyos datos fueron recopilados a través de un instrumento de características sociodemográficas, ocupacionales y de hábitos de vida, el Survey Questionnaire Workplace Violence in the Health Sector y el Professional Quality of Life Scale, para que se evalúe la violencia laboral y la calidad de vida profesional, respectivamente. Análisis descriptivo e inferencial de los datos, por medio de la prueba de chi-cuadrado de Wald considerándose p<0,05 como significación estadística.

Resultados

Las prevalencias de los tipos de violencia fueron de 65,3 % para la verbal, 29,7 % acoso moral, 17,8 % física, 1 % acoso sexual y 1 % discriminación racial. La baja satisfacción por compasión ocurrió con el 54,5 % de los encuestados, de alto burnout con 58,4 % y de alto estrés postraumático, 57,4 %. La satisfacción por compasión estuvo asociada con acoso moral en el trabajo (p=0,047), estímulo para relatar la violencia (p=0,040) y que hayan existido consecuencias para el agresor (p=0,018). No hubo asociación entre los tipos de violencia con el burnout. El estrés postraumático estuvo asociado con la violencia física en el trabajo (p=0,047) y con la existencia de procedimientos para relatar la violencia (p=0,018).

Conclusión

Hubo asociación de la violencia laboral con la calidad de vida profesional. Se hace necesaria la creación de medidas institucionales para la promoción de la calidad de vida profesional, prevención de la violencia laboral y procedimientos estándar para orientar a los profesionales ante actos violentos.

Violencia laboral; Calidad de vida; Enfermeras y enfermeiros; Atención Primaria de salud; Salud laboral

Introduction

Occupational violence has been increasing gradually all over the world,(¹) becoming a major problem for Public Health, as it damages the health of workers.(²)

Occupational violence is understood as a negative behavior or action in a relationship that involves two or more people, determined by aggressiveness, which can happen repeatedly or abruptly, including situations in which workers are intimidated, threatened, assaulted or subjected to acts offensive in work-related circumstances.(³)

It can occur in the form of physical violence, which includes punching, kicking, slapping, shooting or pushing, and psychological violence, which is subdivided into verbal aggression, behavior that shows a lack of respect for human dignity; bullying, carried out repeatedly and in excess, by vindictive, cruel and malicious attacks; sexual harassment, undesirable, unilateral and unexpected behavior; and racial discrimination, threatening conduct based on race, color, nationality or religion.(⁴)

All professionals are subject to violence, however, the work environment of healthcare professionals is one of the most prone to its occurrence, especially those of nursing.(⁵) According to the report of the 108^toConference of the International Labor Organization (ILO), there was a 13% increase in violence against health workers in Latin America.(⁶)

Among the healthcare professionals who are likely to suffer acts of violence are Basic Health Unit (BHU) nurses, since their work process puts them in the “front line” due to welfare practices aimed at comprehensive care to the patient, family and community, as well as management routines, based on activities developed by the nursing staff and other professionals.(⁷)

Suffering violence interferes with the quality of professional life,(⁵) which, in turn, is understood in two aspects: the positive, compassion satisfaction, when the professional experiences joy in helping others, and the negative, the compassion fatigue, which involves feelings of emotional exhaustion and frustration with work, typical of burnout, as well as work-related trauma, characteristic of secondary traumatic stress.(⁸)

Although there are studies on the theme of violence and quality of life, there is still a knowledge gap, especially in understanding the factors associated with workplace violence and quality of professional life among BHU nurses.(⁹,¹⁰) Thus, it is believed that the study is relevant, as it can support the development of strategies in the search for a better quality of professional life for nurses and, in turn, assistance with more quality.

Thus, the research hypothesis raised was the existence of an association between workplace violence and the quality of professional life, with the aim of the study: to verify the association between workplace violence and quality of professional life in BHU nurses.

Methods

This is a quantitative, cross-sectional and analytical study, carried out in 40 BHU in the urban area of a city in the countryside of southern Brazil, with about 500 thousand inhabitants.

The study population consisted of 114 BHU nurses, who worked both internally and in the Family Health Strategy in their respective territories. To calculate the sample size, the finite population form was used, in which the prevalence of the outcome of 50% and 95% confidence interval was considered, obtaining a minimum number of 84 nurses.

Nurses who had been working for at least 12 months in BHU in the urban area were included, due to the similarity in their work characteristics and coverage, and who were not away from work due to licenses of any kind. Using these inclusion criteria, 101 nurses participated in the study.

For data collection, the data collection instrument containing three questionnaires was delivered, the first being a sociodemographic, labor and lifestyle characterization, with the following variables: age (years); skin color (white or non-white); sex (female or male); marital status (with or without a partner); family income (in reais, Brazilian currency); working time at the institution (years); physical activity (yes or no, with frequency and duration); medication use due to symptoms perceived as resulting from work activity (yes or no); interpersonal relationships at work (good/excellent or fair/bad); recognition at work (yes or no); and absenteeism due to illness (days). This questionnaire was submitted to a pilot test with 29 BHU nurses in neighboring cities, and due to its relevance, no adjustments were needed.

Occupational violence was verified using the Survey Questionnaire Workplace Violence in the Health Sector, proposed by the World Health Organization (WHO), ILO and the International Council of Nursing,(¹¹) translated and adapted to the Portuguese language of Brazil.(⁴)The instrument verifies workplace violence, physical, verbal, moral, sexual or racial, in the last 12 months and characterizes situations of violence, victims and offenders.(⁴,¹¹)

Professional quality of life was assessed using the Professional Quality of Life Scale (ProQOL-V), an instrument developed by Stamm,(¹²) with a translated and validated Brazilian version.(¹³) The ProQOL-V consists of 28 items, divided into three subscales: compassion satisfaction assessed by ten items and compassion fatigue, analyzed by two dimensions, burnout and secondary traumatic stress, both verified by nine items each.(¹²)

For the ProQOL-V score, the scale scores were transformed into Zscores and these into Tscores, so that the scores ranged from 10 to 50.(¹²) In the sample of this study, the instrument demonstrated good internal consistency, according to Cronbach’s alpha values: compassion satisfaction (α=0.81), burnout (α=0.70) and secondary traumatic stress (α=0.70).

Between November 2019 and February 2020, the eligible instruments were given the instruments in the workplace and guidance on the research was provided. After filling it out, the participants placed the instruments in sealed urns, available in the work units.

Variables were presented through frequency distribution and measures of central tendency and variability. The results of the dimensions of professional quality of life were categorized into low and high, using the median, and associated with types of violence using Wald’s chi-square test, recommended for comparing two dichotomous qualitative variables. All analyzes were performed using the Statistical Package for Social Science^® (SPSS), version 20.0, considering p<0.05 as statistical significance.

The study was conducted respecting ethical aspects of research involving human beings, being approved by an Institutional Review Board with CAAE (Certificado de Apresentação para Apreciação Ética - Certificate of Presentation for Ethical Consideration) 17960819.5.0000.5231 and Opinion 3.537.838. All participants signed the Informed Consent Form.

Results

101 nurses participated in this study. Most were female (97%; n=98), aged 41 to 63 years (93.1%; n=94), with a partner (65.3%; n=66), white (87%; n=86.1%), with a monthly family income of 1 to 5 minimum wages (50.5%; n=51) (Brazilian minimum wage in 2020: R$1,045.00, about US$190,50), did not practice physical activity (65.3%; n=66) and employment relationship from 8 to 10 years (56.4%; n=57).

They reported good/excellent interpersonal relationships at work (88.1%; n=89), felt recognized for the work performed (54.5%) and absenteeism due to illness for 1 to 3 days (62.4%; n=63). Most used medication for symptoms they understood as due to work (68.3%; n=69), predominantly anxiolytics (34.7%; n=35) and antidepressants (22.8%; n=23).

The prevalence of types of violence that occurred at work in the last 12 months was 65.3% verbal, 29.7% moral harassment, 17.8% physical, 1% sexual harassment and 1% racial discrimination. As for the authorship of violence, regardless of the type, all study participants who suffered acts of violence had the patient as the main offender, followed by their family members and co-workers. Often, there were no consequences or punishment for the offenders, the leadership did not offer help and they reported dissatisfaction with the way the incident was handled.

The characterization variables associated with the occurrence of violence were racial discrimination with skin color (p=0.045), bullying with skin color (p=0.026) and medication use (p=0.029), especially of anxiolytics (p=0.037). Among nurses who were verbally abused, bullying predominated (p=0.003). Thus, sexual harassment was associated with racial discrimination (p=0.010).

The prevalence of low compassion satisfaction was 54.5%, high burnout, 58.4% and high post-traumatic stress, 57.4%. Compassion satisfaction was associated with bullying at work and encouragement to report violence (Table 1).

Table 1
Association between compassion satisfaction and occupational violence in the study sample

Variables	Compassion satisfaction (n=101)
	High	Low	p-value*
	n(%)	n(%)
Physical workplace violence
No	40(48.2)	43(51.8)	0.246
Yes	6(33.3)	12(66.7)
Witnessing situations of physical workplace violence
No	38(47.5)	42(52.5)	0.439
Yes	8(38.1)	13(61.9)
Verbal aggression at work
No	13(37.1)	22(62.9)	0.215
Yes	33(50.0)	33(50.0)
Moral harassment at work
No	28(39.4)	43(60.6)	0.047
Yes	18(60.0)	12(40.0)
Sexual harassment at work
No	46(46.0)	54(54.0)	0.269
Yes	0(0.0)	1(100.0)
Racial discrimination at work
No	46(46.0)	54(54.0)	0.269
Yes	0(0.0)	1(100.0)
Procedures for reporting violence
No	23(41.1)	33(58.9)	0.314
Yes	23(51.1)	22(48.9)
Encouragement for reporting violence
No	35(42.2)	48(57.8)	0.040
Yes	11(61.1)	7(38.9)

• ^*Wald’s chi-square test

There was no association between the types of violence and burnout. Physical workplace violence was associated with post-traumatic stress, as well as procedures for reporting violence (Table 2).

Table 2
Association between post-traumatic stress and occupational violence in the study sample

Variables	Secondary traumatic stress (n=101)
	Low	High	p-value*
	n(%)	n(%)
Physical workplace violence
No	39(47.0)	44(53.0)	0.047
Yes	4(22.2)	14(77.8)
Witnessing situations of physical workplace violence
No	35(43.8)	45(56.3)	0.640
Yes	8(38.1)	13(61.9)
Verbal aggression at work
No	16(45.7)	19(54.3)	0.643
Yes	27(40.9)	39(59.1)
Moral harassment at work
No	30(42.3)	41(57.7)	0.920
Yes	13(43.3)	17(56.7)
Sexual harassment at work
No	43(43.0)	57(57.0)	0.291
Yes	0(0.0)	11(00.0)
Racial discrimination at work
No	43(43.0)	57(57.0)	0.291
Yes	0(0.0)	1(100.0)
Procedures for reporting violence
No	18(32.1)	38(67.9)	0.018
Yes	25(55.6)	20(44.4)
Encouragement for reporting violence
No	32(38.6)	51(61.4)	0.081
Yes	11(61.1)	7(38.9)

• ^*Fisher’s exact test

Having consequences for offenders was associated with high compassion satisfaction (p=0.018). The fact that measures were taken in relation to the violent act and that the manager provided assistance to the victim did not show a significant relationship with the dimensions of professional life quality.

Discussion

The characterization of nurses in this study revealed that most were at an age of “professional maturity”, i.e., at the height of their cognitive, technical and nursing practice skills,(¹⁴)with skills to face adversity and solve daily work problems. In line with this study, nursing is considered a female activity and women perceive violence differently and seek greater support in the face of the violence suffered. Men, on the other hand, due to the predominance of virility and historically rooted ego, also suffer, however, it is little publicized and expressive.(¹⁵)

In this study, most were sedentary, however, physical activity is essential in promoting and maintaining quality of life and brings important benefits to mental health, enabling greater satisfaction during their work activities(¹⁶) and decrease in occupational stress.(¹⁷)

The present study showed that there are nurses using anxiolytics and antidepressants. Similar data were found in a study with healthcare professionals from hospitals in Alagoas State, which identified a prevalence of 37.4% of anxiolytic use.(¹⁸)Nursing professionals, in most cases, pay more attention to people’s care, to the detriment of their self-care. This is due to lack of time for leisure activities, carelessness with food or appearance. Still, this behavior may be a reflection of the work environment, in which actions aimed at nursing workers’ health rarely take place.(¹⁹)

Verbal violence predominated among the nurses in the study in question, followed by bullying and physical violence. Similar data were evidenced in a study carried out in China, showing that violence of a non-physical nature is higher among nursing professionals (71%), when compared to physical violence (7.8%), with emphasis on verbal aggression and harassment sexual.(²⁰)

A Brazilian study found that being a victim of bullying at work causes a person to undergo a significant change in their life and in their sociocultural environment, making it difficult for them to routinely develop their activities and interact with other people, as well as it can be the genesis for burnout.(²¹)

It is emphasized that bullying against nursing professionals is a practice that has become common, presenting itself as a problem to be faced as a priority by the actions of managers, in order to protect workers and, in turn, increase the quality of care in services.(²²)

All participants in this study who suffered acts of violence had offenders, in descending order, the patient, family member and co-workers. A study carried out in Brazil also showed that the most frequent offenders were patients and their relatives or companions, followed by co-workers of the same hierarchical level and administrators or heads.(²³) A study developed in Chile identified nurses, family members, followed by patients, the general public, members of the team, boss or supervisor, and external colleagues as the main offenders.(²⁴)

In this study, racial discrimination was associated with skin color, and bullying was associated with skin color and medication use, especially anxiolytics. An investigation carried out in a municipal health service in the Minas Gerais State showed that workers, after experiencing acts of violence, reported greater dissatisfaction with their health.(²⁵)

Moral harassment related to racism in the workplace is historically present in society’s work relations, therefore, whether within workers, the fight against racism still persists today, even in the face of strategies to deal with these discriminatory acts.(¹⁵)

Sexual harassment was associated with racial discrimination in this investigation. This is an alarming fact, as this is a worrying phenomenon, as the nursing team suffers from presenting a dual threat, gender and professional, in addition to the difficulty in reporting such episodes, due to cultural barriers.(²⁶)

The low compassion satisfaction found in the study among nurses was associated with suffering moral harassment and not being encouraged to talk about this fact. The work routine associated with the lack of incentive to report the violent act contributes to professional exhaustion, workers’ illness, impairing patient care.(²⁷) Work environments in which managers and workers actively participate in work processes, debating violence, can reduce cases and risks of workplace violence.(²⁸)

Authors are emphatic in stating that nurses as managers need to articulate a dialogue between those involved in situations of violence, develop institutional protocols for prevention, protection and monitoring that reduce acts of workplace violence, thus promoting mental health healthcare professionals as well as preventing diseases and injuries.(²⁹)

It is essential that nurses have attitudes to recognize and denounce violence in the appropriate instances, so that this problem is visible so that government spheres, nursing councils, their unions and managers of health institutions can implement actions of prevention of violence and protection of nurses.(¹)

Secondary traumatic stress was related to suffering physical violence and the lack of conduct for them to report what had happened. These facts place nursing workers in a state of vulnerability to the onset of occupational diseases. Suffering workplace violence causes damage and harm to workers’ health, especially mental health.(³⁰) Aggressive acts can lead to post-traumatic stress, greatly interfering with nurses’ health, generating absenteeism and discontent with their work.(³¹)

High compassion satisfaction was directly associated when measures were taken against offenders, however, even in view of the measures taken by the manager in relation to offenders and having provided assistance to the victim, there was no association with the dimensions of quality of professional life. A study indicated that workers who are victims of workplace violence need social and organizational support, which must involve emotional and legal help from the management, so that workers can maximize their quality of professional life.(³²)

A study carried out in Korea showed that nurses who had frequent experience of workplace violence had low compassion satisfaction, high strain and secondary traumatic stress, which, in turn, negatively influenced their work-related quality of life.(³³) Another study carried out with nurses in an emergency unit of a hospital in the United States indicated that suffering workplace violence, in addition to physically and mentally affecting nursing professionals, can interfere with the quality of professional life.(³⁴)

Finally, it is worth noting that the workplace violence suffered by nurses should be seen uniquely, taking into account the experiences and social interaction that the victim shows with other people. Spaces need to be created for listening and discussions about the difficulties faced in the work environment in order to promote strategies that enable the reduction of risks in the work environment, strengthening mechanisms and processes to protect workers.(³⁵)

The study had limits because it was developed with BHU nurses from only one Brazilian city, which prevents its generalization. It is suggested that further studies be carried out in order to increase knowledge about the factors associated with workplace violence and the quality of life among BHU nurses.

Conclusion

Workplace violence was associated with quality of professional life, as low compassion satisfaction was related to bullying and lack of encouragement to report violence, and secondary post-traumatic stress was associated with physical violence and the absence of standardized procedures in the face of violent acts. This study contributes for BHU managers together with workers to seek actions that make it possible to guarantee the human rights of workers. It is also emphasized that the study collaborates so that nurses reflect on the violence they are exposed to in their work environments and seek strategies to protect themselves, such as the creation of protocols to prevent acts of violence and measures to be taken against them. Thus, it will be possible to maximize the quality of life and well-being of professional nurses and other workers.

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Edited by

Associate Editor (Peer review process): Paula Hino (https://orcid.org/0000-0002-1408-196X) Escola Paulista de Enfermagem, Universidade Federal de São Paulo, SP, Brazil

Publication Dates

• Publication in this collection
  06 June 2022
• Date of issue
  2022

History

• Received
  2 Dec 2020
• Accepted
  14 June 2021