Moral harassment among Brazilian primary health care and hospital workers

Abstract

Objective

To analyze the occurrence and factors related to workplace bullying among Brazilian health workers.

Methods

This is a cross-sectional study with 647 health professionals working in primary health care and hospital services in southern Brazil. A socio-occupational questionnaire and the Workplace Violence in the Health Sector Questionnaire were used. The Poisson regression model identified factors related to the phenomenon in the workplace.

Results

Of the professionals, 22.41% reported having been incident victims in the last 12 months. Factors related to bullying were: being a nurse (Prevalence Ratio (PR)=2.77; 95%CI 1.63 to 4.70) or nursing assistant (PR=2.73; 95%CI 1.61 to 4.61); having a chronic disease (PR=1.43; 95% CI 1.07 to 1.93); negative perceptions regarding recognition at work (PR=1.52; 95% CI 1.07 to 2.17); interpersonal relationships at work assessed as indifferent (PR=2.16; 95% CI 1.55 to 3.01); sleeping hours (PR=0.89; 95%CI 0.80 to 0.99); and demonstrating greater concern with violence (PR=1.76; 95%CI 1.10 to 2.82).

Conclusion

Workplace moral harassment was influenced by work factors, health issues and individual perceptions about work and violence.

Bullying; Workplace violence; Health personnel; Primary health care; Hospitals

Resumo

Objetivo

Analisar a ocorrência e os fatores relacionados ao assédio moral no local de trabalho entre trabalhadores de saúde brasileiros.

Métodos

Estudo transversal com 647 profissionais de saúde atuantes em serviços de Atenção Primária e Hospitalar da Região Sul do Brasil. Foram utilizados um questionário sociolaboral e o Questionário Workplace Violence in the Health Sector. O modelo de regressão de Poisson identificou os fatores relacionados ao fenômeno no local de trabalho.

Resultados

Dos profissionais, 22,41% relataram terem sido vítimas do incidente nos últimos 12 meses. Os fatores relacionados ao assédio moral foram: ser enfermeiro(a) (Razão de Prevalência (RP) = 2,77; IC95% 1,63 a 4,70) ou auxiliar de enfermagem (RP = 2,73; IC95% 1,61 a 4,61), possuir doença crônica (RP = 1,43; IC 95% 1,07 a 1,93), percepções negativas em relação ao reconhecimento no trabalho (RP = 1,52; IC 95% 1,07 a 2,17), relações interpessoais laborais avaliadas como indiferentes (RP = 2,16; IC 95% 1,55 a 3,01), horas de sono (RP = 0,89; IC95% 0,80 a 0,99) e demonstrar maior preocupação com a violência (RP = 1,76; IC95% 1,10 a 2,82).

Conclusão

O assédio moral no local de trabalho foi influenciado por fatores laborais, questões de saúde e percepções individuais sobre o trabalho e a violência.

Bullying; Violência no trabalho; Pessoal de saúde; Atenção primária à saúde; Hospitais

Resumen

Objetivo

Analizar la incidencia y los factores relacionados con el acoso moral en el trabajo entre trabajadores de la salud brasileños.

Métodos

Estudio transversal con 647 profesionales de la salud que trabajan en servicios de atención primaria y hospitalaria de la región sur de Brasil. Se utilizó un cuestionario sociolaboral y el cuestionario Workplace Violence in the Health Sector. Mediante el modelo de regresión de Poisson, se identificaron factores relacionados con el fenómeno en el lugar de trabajo.

Resultados

De todos los profesionales, el 22,41 % relató haber sido víctima del incidente en los últimos 12 meses. Los factores relacionados con el acoso moral fueron: ser enfermero(a) (Razón de Prevalencia (RP) = 2,77; IC 95 % 1,63 a 4,70) o auxiliar de enfermería (RP = 2,73; IC 95 % 1,61 a 4,61), tener enfermedad crónica (RP = 1,43; IC 95 % 1,07 a 1,93), percepciones negativas con relación al reconocimiento en el trabajo (RP = 1,52; IC 95 % 1,07 a 2,17), relaciones interpersonales laborales evaluadas como indiferentes (RP = 2,16; IC 95 % 1,55 a 3,01), horas de sueño (RP = 0,89; IC 95 % 0,80 a 0,99) y demostrar mayor preocupación con la violencia (RP = 1,76; IC 95 % 1,10 a 2,82).

Conclusión

El acoso moral en el trabajo estuvo influenciado por factores laborales, cuestiones de salud y percepciones individuales sobre el trabajo y la violencia.

Acoso escolar; Violencia laboral; Personal de salud; Atención primaria de salud; Hospitales

Introduction

Workplace violence is considered a global public health problem, due to its prevalence and serious consequences for workers involved in this process.(¹,²) Its occurrence is significant in the health area, where bullying stands out as a form of violence.(¹,³,⁴) Research indicates that the prevalence of workplace bullying was 28.4% and 30% among nursing professionals.(⁵,⁶) Researchers also point to the prevalence of workplace bullying among other professional categories in the health sector, such as doctors and pharmacists.(⁷) Thus, health professionals may be exposed to several risks to health and safety at work, including exposure to violence.(³)

In the literature, bullying, also called bullying by different researchers, has been identified as repeated behaviors of a vindictive, cruel or malicious nature with the intention of humiliating or destabilizing an individual or group of workers, such as constant criticism of work and exposure to situations of humiliation and embarrassment.(⁴,⁸,⁹) Aggressive behavior can be intentionally directed at the institution’s employees, co-workers and managers,(⁸,⁹) affecting the target individuals in their biological and psychological integrity, in addition to violating rights and negatively affecting labor relations.(¹⁰-¹²)

In addition to this, bullying victims can express feelings such as helplessness, doubts about themselves and their skills and abilities to exercise their profession, emotional exhaustion and reduced self-confidence, contributing to increased turnover, presenteeism, absenteeism and errors related to care.(¹³-¹⁵)

Studies indicate that exposure to bullying behavior has consequences for the individual and their profession as a whole.(¹⁶,¹⁷) The results reveal the impact of the phenomenon on workers’ health and professional work, as well as on patient care.(¹⁶,¹⁷) Thus, workplace bullying is a phenomenon to be considered by managers and occupational health teams.(¹) The identification of negative behaviors in interpersonal relationships at work can support initiatives to prevent workplace bullying.(¹⁶)

Therefore, this study aimed to analyze the occurrence and factors related to workplace bullying among Brazilian health workers.

Methods

This is a quantitative cross-sectional study.

The research was carried out at the Primary Health Care (PHC) health units of 23 municipalities in the West and Far West regions of the state of Santa Catarina, southern Brazil, and at the public reference hospital for these municipalities (hospital care – HC). This hospital is a reference for around 1.3 million people, in addition to substantially contributing to the training of health professionals in the region.

The participants were 647 health workers who worked in PHC and HC services, being included in both contexts: nurses (NUR), nursing technicians (NT) and nursing assistants (NA). In PHC, doctors (DOC), dental surgeons (DS), oral health assistants (OHA), oral health technicians (OHT) and community health workers (CHW) were included. For the sample calculation, a confidence level of 95% and a sampling error of 5% were considered, resulting in a sample of 647 health workers (449 working in the PHC and 198 in the hospital).

Health workers in the categories mentioned and in the surveyed services who have been working for at least 12 months in the services were included. Workers who were on vacation or leave of any kind during the period of data collection were excluded from the study.

The invitation to participate in the study was made in person, at which time the Informed Consent Form was presented and signed, in two printed copies.

After acceptance, data collection was performed by members of a Research Group, through training and a single protocol, from January 2016 to March 2019. Data collection was completed by the professionals after the researchers had access to the services of health and the invitation to participate in the study.

A 32-item socio-labor data questionnaire was designed by the researchers to assess the sample’s demographic characteristics, lifestyle and health, and work-related aspects. The Workplace Violence in the Health Sector questionnaire was also used, translated and adapted to Brazilian Portuguese.(¹⁸) This questionnaire includes items on the occurrence of workplace physical and psychological violence in the last 12 months and is applied worldwide to assess workplace violence. In this study, the 13 items related to workplace bullying were considered. These items assessed the self-reported frequency of workplace bullying last year (yes or no) and its characteristics, information about the aggressor, the victim’s reactions and coping measures.

Data analysis was performed using the Statistical Package for the Social Sciences (SPSS^®), version 21.0. The characteristics of the sample and cases of workplace bullying were described using descriptive measures, such as mean, median, minimum, maximum, standard deviation (SD), absolute frequency (n) and proportion (%). A Poisson regression model identified the factors related to workplace bullying, being considered variables with a value lower than 0.20. The significance level adopted was less than 0.05.

The study respected the ethical considerations recommended by the Brazilian National Health Council (Conselho Nacional de Saúde) and was approved by the Research Ethics Committee of the Universidade do Estado de Santa Catarina, via Plataforma Brasil, CAAE (Certificado de Apresentação para Apreciação Ética - Certificate of Presentation for Ethical Consideration) 90136718.6.0000.018. Professionals who voluntarily agreed to participate in the research signed the Informed Consent Form, ensuring confidentiality and anonymity in information use.

Results

A total of 647 health professionals participated in the study, 69.4% from PHC and 30.6% from HC. The sample characteristics are presented in Table 1.

Table 1
Characterization of study participants

Variables	n(%)
Age (years)	39.3* ± 9.0†
Sex
Male	62(9.58)
Female	583(90.10)
Did not answer	2(0.30)
Skin color
Black	14(2.16)
Brown	70(10.81)
White	557(86.08)
Other	5(0.77)
Did not answer	1(0.15)
Education (years)	14.2* ± 2.7†
Marital status
Single/widow/no partner	166(25.65)
Married/with partner	478(73.87)
Did not answer	3(0.46)
Number of children – median, minimum and maximum	1(0 – 2)
Years of experience in the health field - mean	10(4 – 15)
Time working at the institution (years) - median	7(4 – 13)
Work sector
Hospital care	198(30.60)
Primary Health Care	449(69.40)
Role
Nurse	135(20.87)
Nursing technician	186(28.75)
Nursing assistant	123(19.01)
Doctor	25(3.86)
Dental surgeon	20(3.09)
Oral health technician	5(0.77)
Oral health assistant	16(2.47)
Community health worker	137(21.17)
Holds a managerial/supervisory position	90(13.91)
Weekly workload (hours)	40.4* ± 3.8†
Works at another institution	52(8.04)
Work shift
Morning	48(7.41)
Afternoon	43(6.64)
Night	75(11.59)
Weekend	4(0.61)
Weekday	472(72.95)
More than one type	4(0.61)
Did not answer	1(0.15)

• n=647; *Mean; † Standard deviation

The results show that 22.41% (n=145) of professionals reported having suffered bullying at work in the last year. Table 2 highlights the characteristics of the cases of bullying reported by workers, as well as their impact on victims and the measures taken in the face of violent events.

Table 2
Characteristics of workplace bullying cases

Variables	n(%)
Do you consider this a typical situation in your workplace?
Yes	77(53.10)
No	68(46.90)
Who assaulted you the last time you were harassed?
Others (unidentified, patients and family members)	70(48.27)
Co-workers	41(28.27)
Head/supervisor	31(21.37)
Did not answer	3(2.06)
If co-worker
Doctor	38(92.68)
Nursing team	2(4.88)
Other	1(2.44)
Where the incident occurred
Inside the institution	137(94.48)
Out of institution	6(4.13)
Did not answer	2(1.37)
Do you think the incident could have been avoided?
Yes	107(73.79)
No	38(26.21)
Was any action taken before the event?
Yes	36(24.82)
No	107(73.79)
Did not answer	2(1.37)
By whom was any action taken in front of the event?
Head	25(69.44)
Co-worker	4(11.11)
Other	3(8.33)
Did not answer	4(11.11)
Consequences for the aggressor*
None	115(79.31)
Verbal warning	17(11.72)
Other	5(3.45)
Do not know	4(2.76)
Interrupted treatment/was transferred to another sector	3(2.07)
Police registration	1(0.69)
Lawsuit against the aggressor	0(0.00)
Did your employer or supervisor offer help?*
Offered opportunity to speak	64(44.14)
Did not offer	52(35.86)
Offered advice	22(15.17)
Other support	11(7.59)
Degree of satisfaction about how the incident was handled
Totally dissatisfied/dissatisfied	98(67.59)
Satisfied/totally satisfied	23(15.86)
Unresponsive	22(15.17)
Did not answer	2(1.38)
If you did NOT report or talk about the incident with others, why didn’t you do it?*
Considered that no action would be taken anyway	25(17.24)
Fear of negative consequences	21(14.48)
Other	14(9.65)
It was not important	8(5.51)
Did not know who to report to	8(5.51)
Felt ashamed	3(2.06)
Felt guilty	0(0.0)

• n=145; * In this question, participants could tick more than one answer

Professionals’ main reactions regarding the occurrence of workplace bullying were: 1) telling a co-worker (n=90; 62.07%); 2) telling their boss (n=79; 54.48%); 3) telling friends and family (n=47; 32.41%); 4) asking the person to stop (n=45; 31.03%); and 5) 24.14% (n=35) of professionals had no reaction. Only 14.48% (n=21) of victims reported the violent event. Professionals’ main problems experienced after the occurrence of violence were: 1) remaining very/extremely “super alert” (n=80; 55.17%); 2) extreme/frequent feelings that the activities became more painful (n=69; 47.58%); 3) avoiding thinking and talking about the episode (n=69; 47.58%); and 4) presenting memories, thoughts, memories or images of what happened (n=68; 46.89%).

The results show that, among NUR and NA, the probability of suffering workplace bullying was 177% and 173% higher, respectively, when compared to CHW. Professionals with self-reported chronic diseases were 43% more prone to workplace bullying compared to the group without these diseases. The results also indicate that, for every additional hour of sleep, the probability of being bullied in the workplace decreased by 11% (Table 3).

Table 3
Poisson regression model on factors associated with workplace bullying

Variables	PR *	Confidence interval (95%)	p-value
Role†
Nurse	2.77	1.63 - 4.70	0.001
Nursing technician	1.61	0.96 - 2.69	0.069
Nursing assistant	2.73	1.61 - 4.61	0.001
Doctor	1.75	0.80 - 3.80	0.160
Dental surgeon	1.60	0.56 - 4.59	0.378
Community health worker (reference)	1
Have chronic non-communicable diseases
Yes	1.43	1.07 – 1.93	0.017
No	1
Sleeping hours	0.89	0.80 - 0.99	0.034
You feel recognized at work
Not at all/a little	1.52	1.07 – 2.17	0.020
Unresponsive	1.19	0.84 - 1.68	0.332
Recognized/highly recognized (reference)	1
How you assess the interpersonal relationship at work
Not at all satisfied/little satisfied	1.57	0.83 - 2.94	0.164
Unresponsive	2.16	1.55 - 3.01	0.001
Satisfied/very satisfied (reference)	1
How worried you are about workplace violence
Not at all/little worried (reference)	1
Unresponsive	1.31	0.77 – 2.23	0.312
Worried/very worried	1.76	1.10 - 2.82	0.018

• n=647; *PR - Prevalence Ratio; ^† It was not possible to analyze oral health assistants’ and oral health technicians’ roles due to the absence of reports of workplace bullying in these professional categories

Moreover, workers who felt less recognized at work, that is, “little” to “not at all” recognized, were 52% more likely to experience bullying than those who felt recognized or highly recognized. The study also showed that health professionals who assessed interpersonal relationships at work as indifferent were 116% more likely to experience violence than professionals who were satisfied or very satisfied with their relationships. The probability of suffering workplace psychological harassment was 76% higher among workers who reported being concerned or very concerned about workplace violence, compared to those not concerned or little concerned (Table 3).

Discussion

In this study, the majority of the sample (90.10%) was composed of female health professionals. Other studies also demonstrate that in health services, the workforce is mainly composed of women who are often the target or witness of situations of workplace violence, including psychological harassment.(⁶,⁹,¹⁹-²¹)

The findings indicated that 22.41% of professionals reported having been victims of workplace bullying last year. Studies have shown similar rates in health services in Brazil, which ranged from 24.9% to 27%.(³,²¹) In other countries, 15.3% of Italian nurses in a hospital were exposed to the incident(²²). In Turkey, a survey revealed that the majority of nursing managers were exposed to repeated and hostile behavior in their work environment.(²³)

Co-workers were among the most frequent aggressors in this study, 92.68% of the medical category. An American study corroborates these findings, showing that approximately 42% of nurses were victims of verbal abuse by the medical category and 5.2% of these reported the violent incident one or more times a week, which represents a repetitive and systematic process.(²⁴) These results suggest the importance of addressing the topic in medical students’ education, seeking to avoid incorporating negative behaviors into professional medical practice.(¹⁹)

The survey showed that most harassed professionals believed the incident could have been avoided. Furthermore, in most cases no action was taken and there were no consequences for the perpetrator. There is also the fact that most victims expressed dissatisfaction with the way the incident was handled. It is known that underreporting contributes to the absence of decisions that lead to change and often implies the absence of strategies that challenge the cyclical nature of the workplace bullying, favoring a path that can transform those who are bullied into future aggressors.(¹⁹,²⁵)

It was also evidenced in the research that the main problems experienced by professionals after the occurrence of workplace bullying included: remaining very/extremely “super alert”; showing feelings that the activities became more painful; avoiding thinking and talking about the episode; and experiencing memories, thoughts and memories of violence. The literature identifies broad negative consequences of the violent incident for the victims, such as physical and psychological symptoms, damage to individual well-being and social relationships, in addition to the intention to leave job, highlighting the importance of policies to prevent workplace bullying.(⁹,¹⁰,¹⁴,¹⁶,²³,²⁵,²⁶)

In this study, most victims who did not report the incident and considered that no action would be taken in any way, or reported fear of punishment, with negative consequences. In a survey carried out in the USA, it was identified, in nurses’ view, that reporting harassment involves a lot of time and financial investments, without bringing the expected results.(²⁷) The frequent absence of incentives/forms of registration and report in the work context(²⁸) can also be related to the results found.

It was evident that the participants’ main reactions in relation to what happened included reporting to co-workers, superiors, friends and family members. Some reported having asked the person/aggressor to stop, and a significant number did not react. A survey carried out in Turkey showed that silence was among the coping methods used by nurse managers in situations of workplace violence.(²³) In relation to psychological violence and its subtypes, the literature indicates that a significant percentage of workers “try to pretend that nothing happened” and a low percentage records what happened so that a lawsuit can be filed against the aggressor.(²¹)

Studies point to the need to structure plans for monitoring violence in health institutions, highlighting the importance of an organizational culture that encourages the registration of cases and training processes on the subject.(⁶,²¹,²⁹,³⁰) Furthermore, it is important that victims and witnesses of violence are welcomed and supported to face harassment, reducing the effects on individuals and their work.(³⁰)

The results also indicated that NUR and NA were more prone to workplace bullying than CHW. Several publications analyze the incident and its occurrence among nursing professionals.(⁹,¹⁶,²⁷,³¹,³²) Such studies indicate that these professions are frequently harassed in their daily work, listing possible intervening factors, including exposure to harsh and arbitrary criticism of their performance during training, organizational factors that hinder collegiality and trust in work relationships and the intense pace of work.(²⁶,²⁷,³²)

The survey also showed that the probability of experiencing workplace bullying was higher among workers with chronic diseases compared to those without these diseases. A study on psychological harassment with American nurses corroborates this result, as it revealed the existence of personal prejudices or prejudices related to health issues.(²⁷)

It is worth highlighting the evidence that, for every additional hour of sleep, the probability of being bullied at work decreased by 11%. This finding is consistent with a previous study that demonstrated an association between this form of violence and sleep problems.(¹²) Workers who felt little or no recognition at work were more likely to experience this type of workplace violence than those who felt recognized or highly recognized. Therefore, a live network that supports collective actions to facilitate interpersonal relationships, favor peaceful coexistence and encourage dialogue and respect in the work environment is especially important.(³³)

Finally, workers who were concerned or very concerned about workplace violence were more likely to experience bullying, the understanding and concern of professionals with violence may be factors that make them more sensitive to the problem, as well as its effects on their health and the environment. The authors also mention that violence in health services is often naturalized, rarely measured and fought,(³) which ends up contributing to greater concern among victims. It is necessary that health professionals realize that no type of violence can be part of work,(²⁸) and concern with violence is an indication of its existence.

This study has limitations: 1) the cross-sectional design adopted restricts the analysis of causality; 2) the use of quantitative data alone makes it difficult to access subjectivity, which could favor the understanding of the phenomenon studied; and 3) the possibility of recall bias, as health professionals were invited to report bullying experiences related to last year.

The health context needs innovations, especially with regard to worker protection and and the preservation of people’s rights and citizenship. Despite the limitations, this study reveals and characterizes the occurrence of workplace bullying in health services and its consequences for workers, contributing to the visibility of cases of harassment and initiatives for prevention.

Conclusion

The study showed that 22.41% of health professionals reported having been victims of workplace bullying last year. No action was taken on the violent incident in most cases, often observing the aggressor’s exemption. This fact can generate a cyclical process, little visible and without prevention strategies. Furthermore, factors associated with workplace bullying were identified as aspects related to work, health issues and individual perceptions about work and violence. These factors include being a NUR or NA, having a chronic illness, having negative perceptions about recognition at work, interpersonal relationships at work assessed as indifferent, sleeping hours and greater concern with violence. The results support intersectoral and multidisciplinary interventions that reduce, prevent and address workplace bullying in health services.

Acknowledgments

The authors are grateful to all professionals and health service workers who participated in the study. We also thank the Santa Catarina Innovation Support Research Foundation (FAPESC - Fundação de Amparo à Pesquisa e Inovação do Estado de Santa Catarina) for the financial incentive to carry out this research, process 2019TR1157, and all members of the Study Group on Health and Work for their contributions.

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Edited by

Associate Editor (Peer review process): Alexandre Pazetto Balsanelli (https://orcid.org/0000-0003-3757-1061). Escola Paulista de Enfermagem, Universidade Federal de São Paulo, SP, Brasil

Publication Dates

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

History

• Received
  6 June 2021
• Accepted
  29 Nov 2021