Artigos

Conteúdo (article):

Violência ocupacional no campo da enfermagem durante a pandemia: uma análise de redes
Workplace violence in the field of nursing during the pandemic: a network analysis
Violencia laboral en el ámbito de la enfermería durante la pandemia: un análisis en red

Camila Lima Silva
Tatiane Araújo dos Santos
Paulo Felipe Ribeiro Bandeira
Fernanda Carneiro Mussi
Handerson Silva Santos
Luciano de Paula Moura
Jones Sidnei Barbosa de Oliviera
Bruno Guimarães de Almeida

Resumo
O ambiente laboral é um local de produção de subjetividades baseadas em percepções individuais e suas singularidades. Entre os possíveis encontros e desencontros no ambiente de trabalho a violência laboral pode se fazer presente. Este artigo tem o objetivo de investigar a ocorrência de violência laboral em trabalhadoras de enfermagem durante a pandemia da Covid-19. Trata-se de estudo transversal, com amostra de 2.188 respondentes. Utilizou-se banco de dados secundário sobre Riscos Psicossociais entre Trabalhadoras de unidades da rede de uma Secretaria da Saúde Estadual, com dados da Escala NAQ-R, sociodemográficos e ocupacionais. Aplicou-se o estimador EBICglasso na construção de matrizes de precisão/correlação, representadas através das arestas positivas e negativas; indicadores de centralidade betweenness, closeness e strength e, índice de influência esperada. As variáveis que mais impactaram na organização e manutenção da rede de ocorrência de violência ocupacional foram C24 (Foi pressionado a não reclamar um direito), C8 (Foram feitos comentários ofensivos à sua pessoa), C9 (Gritaram com o/a senhor/a ou o/a senhor/a foi alvo de agressividade gratuita) e C11 (Recebeu sinais ou dicas de que você deve pedir demissão ou largar o emprego). Conhecer as variáveis resultantes das relações de trabalho permite a construção de estratégias por parte do gestor público para inibi-las ou extingui-las promovendo a proteção das trabalhadoras.
Palavras-chaves:
Pandemia COVID-19; Violência no Trabalho; Enfermagem; Trabalho Precário; Riscos Ocupacionais.

Abstract
The work environment is a place where subjectivities are produced from individual perceptions and singularities. The aim of this study was to investigate the occurrence of occupational violence among nursing professionals during the Covid-19 pandemic. We conducted a cross-sectional study with a sample of 2,188 workers. We used the secondary database Psychosocial Risks among Workers in the SESAB Care Network, focusing on data collected using the Negative Acts Questionnaire-Revised (NAQ-R) and a sociodemographic and occupational questionnaire. Precision/correlation matrices were created using the EBICglasso estimator and represented by positive (blue) and negative (red) edges. Indices of centrality (betweenness, closeness and strength) and expected influence were calculated. The variables with the strongest impact on the organization and maintenance of the network of workplace violence were C24 (Have you been pressured not to claim something to which by right you are entitled?), C8 (Have offensive remarks been made about your person?), C9 (Have you been shouted at or target of spontaneous anger?) and C11 (Have you received hints or signals from others that you should quit your job?). Understanding specific variables in working relationships in the nursing work environment can help public managers develop strategies to address these factors and promote worker protection.
Keywords: COVID-19 Pandemic; Violence at Work; Nursing; Precarious Work; Occupational Risks.

Resúmen
El lugar de trabajo es un espacio donde se producen subjetividades basadas en las percepciones individuales y sus singularidades. Entre los posibles encuentros y desencuentros en el lugar de trabajo, la violencia laboral puede estar presente. El objetivo de este artículo es investigar la ocurrencia de violencia laboral entre trabajadores de enfermería durante la pandemia del Covid-19. Se trata de un estudio transversal, con una muestra de 2.188 encuestados Se utilizó una base de datos secundaria sobre riesgos psicosociales entre las trabajadoras de las unidades de la red de un departamento de salud estatal, con datos de la escala NAQ-R, sociodemográficos y ocupacionales. Se utilizó el estimador EBICglasso para construir matrices de precisión/correlación, representadas por aristas positivas y negativas; indicadores de centralidad betweenness, closeness y strength; y el índice de influencia esperada. Las variables que más influyeron en la organización y mantenimiento de la red de sucesos de violencia laboral fueron C24 (Le presionaron para que no reclamara un derecho), C8 (Hicieron comentarios ofensivos sobre usted), C9 (Le gritaron o fue objeto de agresiones gratuitas) y C11 (Recibió señales o insinuaciones de que debía dimitir o dejar el trabajo). Conocer las variables resultantes de las relaciones laborales permite a los gestores públicos construir estrategias para inhibirlas o extinguirlas, promoviendo la protección de las trabajadoras.
Palavras clave: COVID-19 Pandemia; Violencia en el Trabajo; Enfermería; Trabajo Precario; Riesgos Laborales.



INTRODUCTION
Although not a recent phenomenon, workplace violence has become more visible since the 1980s across various settings, including healthcare facilities. According to the International Labour Organization (ILO), workplace violence is any action, incident or behavior that departs from reasonable conduct in which a person is assaulted, threatened, harmed or injured in the course of, or as a direct result of, his or her work(1).
Workplace violence arises from a complex interaction of different factors, including working conditions and the relationship between the worker and perpetrator. This type of violence can be classified as physical or psychological. The former includes attacks, beatings, assaults, spitting, kicking and even homicide, while the latter is subdivided into verbal abuse, moral harassment, sexual harassment and racial discrimination, including intimidation, coercion, denigration, slander, blackmail, verbal and non-verbal threats and verbal and non-verbal abuse(2).
Moral harassment in the workplace is any behavior, abusive conduct, words, acts or gestures that affect a person\'s dignity or physical or psychological integrity, endangering his or her job or degrading the working environment. In this type of violence, the harasser uses the victim\'s weak points to make them doubt themselves and progressively undermine their self-confidence(3,4).
According to the ILO(5), workplace violence poses a threat to the health and safety of workers and others in the world of work and can constitute a violation or abuse of human rights, being incompatible with safe and dignified employment.
The potential for aggression against workers is particularly high in the health sector as staff are constantly in contact with patients and their families, who may be under stress due to the illness or poor services and react violently to ensure that a health need is met. On the other hand, worsening working terms and conditions, including type of employment relationship, pay, working hours and work intensity, can contribute to violence between colleagues or between workers and their superiors(6,7).
One of the characteristics of workplace violence in the health sector is the varying forms of violence across different types of healthcare professionals, work settings (primary care centers, hospitals, urgent care centers, etc.) and job functions (care, diagnostic support, management, etc.)(8). Violence can be vertical from the top-down (where the aggressor is a superior), vertical from the bottom-up (where the aggressor is in an inferior position), horizontal (where both the victim and aggressor are at the same level in the work hierarchy) and organizational moral harassment (when companies encourage their employees to compete with each other by spreading fear through threats)(9).
Studies reveal that workplace violence in the health sector mostly affects workers in the field of nursing, with the prevalence of violent episodes being highest among nurses. Around one third of nurses worldwide are physically assaulted, one quarter are sexually harassed, and two thirds are subjected to verbal abuse. Episodes of violence or moral harassment have both institutional impacts, including a decrease in organizational commitment and decline in quality of work, and individual physical, psychological and/or social consequences, such as burnout and other mental disorders (6,10).
A joint study by the International Council of Nurses, the International Committee of the Red Cross, the International Hospital Federation, and the World Medical Association(11) revealed that violence and harassment towards doctors and nurses is endemic, regardless of a country\'s security situation. It also showed that violence by patients or their families against healthcare workers has worsened and become more frequent since the start of the COVID-19 pandemic.
In Brazil, a study by the Getúlio Vargas Foundation(12) showed that 33.5% of health workers reported having been subjected to moral harassment as a result of the pandemic, 6.4% said that the violence started in tandem with the health crisis, 18.6% reported that this type of violence had increased during the pandemic and 8.6% confirmed that levels of violence during the pandemic were the same as prior to the pandemic. One of the recommendations made by the authors was to strengthen mechanisms for reporting and tackling moral harassment towards health workers.
To strengthen mechanisms to address moral harassment it is vital to understand how this type of violence plays out in health work processes. Given the increase in workplace violence during the pandemic, including moral harassment, and the consequences of this type of violence for nurses’ mental and physical health, it is important to identify the most common forms of harassment in health services. In this respect, network analysis enables the researcher to visually explore relationships that occur simultaneously between multiple variables using graphs, incorporating advanced tools in statistical analysis, such as bootstrapping techniques and Bayesian inference, thus allowing the study of data complexity. With this technique, it is therefore possible to study complex and multifactorial phenomena(13).
By identifying the most common forms of violence at work and their impacts on workers’ health it is possible to develop effective strategies to combat this problem, prevent illness and promote workers\' health. The aim of this study was therefore to investigate the occurrence of occupational violence among nursing professionals during the Covid-19 pandemic.

METHODS
This cross-sectional study was approved by the research ethics committee of the School of Nursing, Federal University of Bahia (code CAE 5.380.246) and the Bahia State Department of Health’s research ethics committee (code CAE 46125821.4.3001.0052). The study is part of the macro-study "Working conditions, Covid-19 and lifestyle habits of nursing professionals working in the Bahia State Health Department" conducted by the Federal University of Bahia (UFBA) in partnership with the Bahia State Department of Health (SESAB) during the period 30 March 2020 to 27 February 2021.
We used the secondary database Psychosocial Risks among Workers in the SESAB Care Network, belonging to SESAB. The database contains the responses of 2,188 nursing professionals employed under the “Single Legal Regime” who worked during the COVID-19 pandemic, from 30 March 2020 to 27 February 2021. Of these, 578 (26.5%) are nurses and 1,610 (73.5%) nursing assistants or technicians. All nursing professionals who answered the survey forwarded by SESAB via the Integrated Workers\' Health Care Service (SIAST) were eligible to participate in this study. The exclusion criterion was individuals with missing data, who were not identified.
The following instruments were used by SESAB to collect the data: the Work Context Assessment Scale (EACT), the Negative Acts Questionnaire-Revised (NAQ-R) and a sociodemographic and occupational questionnaire. For the purposes of the current study, we used data collected using the latter two instruments.
The following sociodemographic and occupational variables were analyzed: gender, race/skin color and age group; job function (care, management or support) and work sector.
The NAQ-R was developed by Einarsen and Raknes(14). The original version consisted of 48 questions. The revised version has 22 items referring to negative behavior without making specific reference to the term moral harassment. The instrument is divided into two dimensions: person-related hostile reactions; and work-related hostile reactions(15,16). The instrument was validated for use in Brazil by Maciel and Gonçalves(17) after being tested with two samples: one consisting of workers from different sectors and the other made up of bank workers. The NAQ-R uses a five-point Likert scale with the following response options: never, now and then, monthly, weekly and daily. The response to all items are averaged.
The sociodemographic and occupational variables and the NAQ-R scores were organized and coded for data analysis purposes. The categorical sociodemographic and occupational variables were analyzed in Excel using absolute and relative frequencies. The dataset was then exported to JASP version 0.14.1.0 for network analysis based on the NAQ-R items.
Precision/correlation matrices were created using the EBICglasso estimator (adopted value 0.05) and represented by positive (blue) and negative (red) edges, where edge intensity indicates the magnitude of the relationship. To understand the role played by each variable in the network, three centrality indices were calculated based on node position and connection: betweenness, closeness and strength. The expected influence index, which measures the role a node is expected to play in the activation, persistence and remission of the network, was also calculated. It is important to note that the literature does not establish cut-off points for high and low centrality and the current study is a comparative analysis of the network variables.
Variables with a high betweenness index are more sensitive to changes in the network and may connect other pairs of variables. Variables with a high closeness index are rapidly affected by changes in any part of the network and may affect other parts. The node strength index - the sum of its connections with other nodes in the network, regardless of whether it has a positive or negative skew - is essential to understand which variables have the strongest connections within the network(18).
The correlation matrix allows immediate visualization of potential correlations between the variables before conducting a more advanced analysis using Pearson\'s correlation coefficient to determine the degree of relationship (linear dependence). The coefficient ranges from -1 to +1, where a negative correlation means that one variable decreases as the other increases (less than 0) and a positive correlation means that one variable increases as the other increases (value greater than 0). Assuming that the data are normally distributed, the significance of the correlation coefficient is determined based on the significance level (p-value) to test the null and alternative hypotheses (H), i.e.: H0: r = 0, no correlation; H1: r ≠ 0, correlation(19). Since the analysis involved a complex system and all interactions/effects within this system are important and should not be disregarded, the p-value (inference value) was not estimated.

RESULTS
Most of workers who responded the questionnaire were women (91.0%), self-declared black/brown (71.0%), aged between 41 and 59 years (35.2%) and worked in direct patient care (62.0%): 95.3% in inpatient facilities and 4.7% in intensive care units (ICUs).
The network of workplace violence suffered by nursing professionals working in health facilities run by SESAB during the pandemic (Figure 1) and the correlation matrix (Figure 2) were developed using JASP.

Based on the magnitude of the relationship between the nodes, indicated by edge thickness and color, the network shown in Figure 1 is weighted and non-directional, which is more appropriate for cross-sectional studies(13).The network’s strong edges are mostly positive (blue), meaning that the direction of the relationship between the edges is the same. Only the edge between C32 and C33 is negative (red), which means that each of these variables have the opposite direction of relationship (C32, positive; C33, negative). It is important to highlight that the closer two nodes are to each other, the stronger the relationship between them(13). Figure 2 is a graphical representation of Table 1 showing the 34 items of the network of workplace violence according to the centrality indices (betweenness, closeness, strength, expected influence).
The variables with the highest expected influence and centrality indices (Table 1) were C24 (Have you been pressured not to claim something to which by right you are entitled?), C8 (Were offensive comments were made about you?), C9 (Were you shouted at or target of spontaneous anger?) and C11 (Have you received hints or signals from others that you should quit your job?). These variables have the quickest and most significant impact on the organization and maintenance of the network.

Figure 1 - Network of workplace violence in the nursing work environment in SESAB facilities during the pandemic (NAQ-R scale). Salvador, Bahia, Brazil, 2021.


Figure 2 - Correlation matrix of workplace violence in the nursing work environment in SESAB facilities during the pandemic (NAQ-R scale). Salvador, Bahia, Brazil, 2021.













Table 1 – NAQ-R variables in the network of workplace violence showing betweenness, closeness, strength and expected influence. Salvador, Bahia, Brazil, 2021.

Variables Betweenness Closeness
Strength Expected influence
C24. Have you been pressured not to claim something to which by right you are entitled (for example, sick leave, holiday entitlement, travel expenses)? 2.343 1.157 1.044 2.539
C8. Were offensive remarks made about your person (about your habits or origins) attitudes or your private life? 1.444 1.105 0.138 1.249
C9. Were you shouted at or target of spontaneous anger (or did someone show anger towards you)? 0.505 0.085 1.595 1.168
C11. Have you received hints or signals from others that you should quit your job? 0.844 0.326 0.434 1.129

DISCUSSION
The results from the network are inseparable from the market rationale that has entered the SUS since the reform of the state apparatus in the 1990s, introducing notions of rationalization and productivity that are incompatible with a service guided by the promotion of the common good and universal access. According to Druck et al(20) "the forms of control, management and organization of work, definition of the role of the state and labor market regulation constitute a new regime of accumulation in which the flexibilization/worsening of working terms and conditions has become a central strategy". Workplace violence and moral harassment in health work are the fruit of this new approach to workforce management and the health crisis lays bare and exacerbates this problem.
Workplace violence is one of the typologies of precarious work identified by Druck(21). Its occurrence means that the job may be classified as precarious in terms of insecurity and health at work, which have consequences for worker\'s physical and mental health. This type of violence is related to the management model and productivity standards(21).
This fear-based management approach focused on the pursuit of productivity and disregarding human limits(21) engenders a permanent state of insecurity in the labor market in order to ensure the submission of workers and further exploit their added value. Since contemporary work encompasses all spheres of life and occupies every moment of workers’ lives, people\'s core concern is no longer employment but rather unemployment. Out of fear, women workers submit themselves to situations of vulnerability and individual accountability(21).
These situations are illustrated in the network by variables C.11 (Have you received hints or signals from others that you should quit your job?) and C24 (Have you been pressured not to claim something to which by right you are entitled).
Precarious work encompasses dimensions such as job insecurity, individual worker-employer bargaining relations, low wages and economic deprivation, limited workers’ rights, lack of social protection, and powerlessness to exercise legally entitled workers’ rights(22).
Workforce control has undergone a process of sophistication through the prism of precarious employment. This sophistication includes silencing workers using institutional norms and arrangements that result in a series of questions being excluded from processes in the work environment and/or fear-based management, which takes the form of abuse of power and moral harassment(23,24).
One of the nuances of precarious work, fear-based management is used in subtle ways, with workers who claim their rights being labelled as problematic and uncooperative, and seeking to disrupt team harmony and prevent targets from being achieved. In this type of setting, union leaders and members are censored, and organizations use various techniques to prevent or hinder access to workers’ rights.
During the Covid-19 pandemic, using the health emergency as a justification, public and private health institutions hired nursing professionals under temporary contracts in which day/shift pay and banking hours instead of paying overtime were common practice. Other characteristics of precarious work included intensification of working time, shortages of personal protective equipment at the beginning of the pandemic and poor equipment quality, and lack of training and collective protection measures(25).
The underlying tone of care provision has been worsening working terms and conditions. The toll has been greatest on nursing professionals, as they stand out among essential health workers, who have been denied worker’ rights and had their right to claim what they are entitled to curtailed through mechanisms of moral harassment. Such situations appear to be the mainstay of both private health organizations seeking to expand profit margins during the pandemic and public services striving to guarantee care through outsourcing and other forms of flexible contracting.
Fear-based management further exacerbates violence at work as it places workers under constant pressure, eroding interpersonal relationships and fragmenting worker solidarity as competitiveness becomes the key to keeping a job. This is illustrated in the network by variables C8 (Have offensive remarks been made about your person (about your habits or origins) attitudes or your private life?) and C9 (Have you been shouted at or target of spontaneous anger (or did someone show anger towards you)?).
The violence illustrated in the network may also related to gender issues, given that more than 80% of the nursing workforce are women(25). A study of violence and harassment against women at work revealed that 76% of women had been victims of violence in the workplace, four out of ten had been target of name-calling, sexual innuendos or had their work excessively supervised, and 37% had their work belittled and observations disregarded(26).
The workplace violence illustrated in the network is even more serious considering that it is institutional. The latter is perpetrated by public bodies and agents, manifesting itself in different ways, ranging from social discrimination to verbal, physical and even sexual violence(27,28). Threats of violence negatively affect the patient-health professional agreement. This has consequences for clinical care, particularly affecting nurses and doctors(29).
As well as external violence, there is internal workplace violence, which takes place within the workplace between colleagues, managers and employers. This type of violence has different causes and is intimately associated with the deterioration of interpersonal relationships. A study of moral harassment among Portuguese nurses found that nurses suffers an average of 11 acts of aggression in their main workplace. The most common types of aggression were communication blocking and being discredited at work, and moral harassment was mostly horizontal and vertical from the top-down(30). Different studies on interpersonal violence have shown that it may be negatively associated with mental health problems, especially depression, in adult men and women(31,32) and can damage the work environment and, consequently, the performance of healthcare organizations(29).
A systematic review(33) of prevalence rates of workplace violence against health care workers concluded that prevalence is high, especially in Asian and North American countries, psychiatric and emergency department settings, and among nurses and physicians. Verbal abuse (57.6%) was the most common form of non-physical violence, followed by threats (33.2%) and sexual harassment (12.4%).
Sometimes workers are not actually aware that they have been subjected to violence and even when they are do not usually find the help they need at work. As a result, the worker often only gets proper assistance when they develop a condition that requires specialist care and/or time off work, such as depression, burnout and heart disease(34,35).
The centrality and expected influence indices for variables C24, C8, C9 and C11 show that these variables are sensitive to change and the relationship between them affects other variables in the emergent network. Future studies should focus on interventions addressing variables C24, C8, C9 and C11 to reduce or eliminate workplace violence in nursing work.
Study Limitations
This study has some limitations. First, the data are from a secondary database and were collected by SESAB. Second, the data are from both indirectly and directly managed public services in the state of Bahia, meaning that caution should be exercised when extrapolating the findings to workers in private services.
Contributions to the Area
The results show that violence and harassment in the nursing work environment during the pandemic was characterized by pressure not to claim workers’ rights, insinuations about dismissal, verbal violence and violence between workers and between workers and patients .
Our findings therefore contribute to existing knowledge by providing new insights into violence in the field of nursing and offering perspectives on this issue that can help shape actions that mitigate risk and provide female workers mechanisms that enable them to safely report violence without feeling threatened with dismissal or harassed.
CONCLUSIONS
The analysis of the network of violence in the nursing work environment in SESAB services during the pandemic (NAQ-R) revealed that the variable with the greatest impact was being pressured not to claim something to which by right you are entitled. Other variables with a strong influence were offensive remarks, being shouted at or target of spontaneous anger, and receiving hints or signals from others that you should quit your job. These findings reveal deepening precarity of employment relationships.
The identification of the main nodes related to harassment and violence in the nursing work environment during the pandemic can help public managers develop strategies to address the determinants of violence highlighted in this study.
While this study focuses on harassment and violence during the pandemic, the findings confirm the chronic problems affecting female nursing professionals resulting from the deterioration of public services and worsening working terms and deepening precarity of employment.

REFERENCES

1. Organização Internacional do Trabalho (OIT). Programa conjunto: nueva iniciativa contra la violência laboral em el sector da salud. Genebra: OIT, 2008.
2. Bernardes MLG, Karino ME, Martins JT, Okubo CVC, Galdino MJQ, Moreira AAO. Workplace violence among nursing professionals. Rev Bras Med Trab. 2021 Feb 11;18(3):250-257. doi: 10.47626/1679-4435-2020-531.
3. Leite JA, Silva DA. Assédio moral: ocorrências nas relações de trabalho da Enfermagem. Enferm Foco. 2022;13:e-202237. DOI: https://doi.org/10.21675/2357-707X.2022.v13.e-202237.
4. Sousa LS de, Oliveira RM, Santiago JC dos S, Bandeira É da S, Brito YCF, Alves HFA, et al.. Predictors of moral harassment in nursing work in critical care units. Rev Bras Enferm [Internet]. 2021;74(3):e20200442. Available from: https://doi.org/10.1590/0034-7167-2020-0442.
5. Organização Internacional do Trabalho. Gestão dos riscos psicossociais relacionados com o trabalho durante a pandemia da COVID-19. ISBN: 9789220357804. 2020 6. Tsukamoto SAS, Galdino MJQ, Robazzi ML do CC, Ribeiro RP, Soares MH, Haddad M do CFL, et al.. Violência ocupacional na equipe de enfermagem: prevalência e fatores associados. Acta paul enferm [Internet]. 2019Jul;32(4):425–32. Available from: https://doi.org/10.1590/1982-0194201900058
7. Kafle S, Paudel S, Thapaliya A, Acharya R. Workplace violence against nurses: a narrative review. J Clin Transl Res. 2022 Sep 13;8(5):421-424.
8. Oliveira, MVL. Assédio moral na enfermagem: uma abordagem quantitativa [dissertação]. São Paulo: Universidade de São Paulo, Escola de Enfermagem; 2018 [citado 2023-08-30]. doi:10.11606/D.7.2019.tde-08052019-123156.
9. Silva AKL da, Marinho MID, Machado LS da SX, Queiroz JLF de, Jucá RM do N. Assédio moral no trabalho: do enfrentamento individual ao coletivo. Rev bras saúde ocup [Internet]. 2019; 44:e22. Available from: https://doi.org/10.1590/2317-6369000015918
10. Vincent-Höper S, Stein M, Nienhaus A, Schablon A. Workplace aggression and burnout in nursing: the moderating role of follow-up counseling. Int J Environ Res Public health. 2020; 17(9):3152. http://dx.doi.org/10.3390/ijerph17093152.
11. Thornton J. Violence against health workers rises during COVID-19. Lancet. 2022 Jul 30; 400(10349):348. doi: http://dx.doi.org/10.1016/S0140-6736(22)01420-9.
12. Fundação Getúlio Vargas. A pandemia de Covid-19 e os(as) profissionais de saúde pública no Brasil - 4ª Fase. Lotta G, Fernandez M, Magri G et al., organizators. Escola de Administração de Empresas de São Paulo. [Internet]. 2021 Apr. Available from: https://static.poder360.com.br/2021/04/fgv-estudo-saude-covid-19-9abr2021.pdf.
13. Leme DEC, Alves EVC, Lemos VCO, Fattori A. Network analysis: a multivariate statistical approach for health science research. Geriatr Gerontol Aging. 2020; 14:43-51. DOI: http://dx.doi.org/10.5327/Z2447-212320201900073.
14. Notelaers G, Einarsen S, De Witte H, Vermut J. Estimating the prevalence of bullying at work: a latent class cluster approach. Work stress. 2006;20(4):288-301.
15. Tsuno K, Kawarami N, Inoue AE, Abe K. Measuring workplace bullying: reliability and validity of the japanese version of the Negative Acts Questionnaire. J Occup Health. 2010; 52:216-26.
16. Christ HD. Estudo de adaptação e fidedignidade do Questionário de Atos Negativos – Revisado
(QAN-R) para o português do Brasil [dissertação]. Porto Alegre: Pontifícia Universidade Católica do Rio Grande do Sul, 2011.
17. Maciel RH, Gonçalves RC. Pesquisando o assédio moral: a questão do método do Negative Acts Questionnaire (NAQ) para o Brasil. In: Soboll LAP (org.). Violência psicológica e assédio moral no trabalho. São Paulo: Casa do Psicólogo; 2008:167-85.
18. Silva IV, Aquino EML de, Pinto IC de M. Características psicométricas do Negative Acts Questionnaire para detecção do assédio moral no trabalho: estudo avaliativo do instrumento com uma amostra de servidores estaduais da saúde. Rev bras saúde ocup [Internet]. 2017;42:e2. Available from: https://doi.org/10.1590/2317-6369000128715
19. Epskamp S, Borsboom D & Fried E.I. Estimating psychological networks and their accuracy: A tutorial paper. Behav Res 50, 195–212 (2018). https://doi.org/10.3758/s13428-017-0862-1.
20. Druck G, Sena J, Pinto M, Araújo S. A terceirização no serviço público: particularidades e implicações. In: Campos A, organizator. Terceirização do trabalho no Brasil: novas e distintas perspectivas para o debate. [Internet]. Brasília: Ipea; 2018. p. 113-41. Available from: https://repositorio.ipea.gov.br/bitstream/11058/8709/1/A%20Terceiriza%c3%a7%c3%a3o.pdf.
21. Druck G. Trabalho, precarização e resistências: novos e velhos desafios?. Cad CRH [Internet]. 2011;24(spe1):37–57. Available from: https://doi.org/10.1590/S0103-49792011000400004
22. Morais Colombaroli AC. Medo E Apoio Ao Autoritarismo Na Contemporaneidade. Revista Internacional Interdisciplinar INTERthesis, [s. l.], v. 17, n. 1, p. 1–18, 2020. DOI 10.5007/1807-1384.2020.e61236. Available from: https://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=143466986&lang=pt-br&site=eds-live.
23. Benach J and others, What should we know about precarious employment and health in 2025? framing the agenda for the next decade of research, International Journal of Epidemiology, Volume 45, Issue 1, February 2016, Pages 232–238, https://doi.org/10.1093/ije/dyv342
24. Moura-Paula MJ de, Moreira PAA, Ferraz DL da S. Management techniques and organizational silencing: a manager’s account. Organ Soc [Internet]. 2020Apr;27(93):216–30. Available from: https://doi.org/10.1590/1984-9270933
25. Druck G. Trabalho, precarização e resistências: novos e velhos desafios?. Cad CRH [Internet]. 2011;24(spe1):37–57. Available from: https://doi.org/10.1590/S0103-49792011000400004
26. Ferreira IQBP et al. Repercussions of the labor reform on nursing work in the context of the covid-19 pandemic. Revista Brasileira de Enfermagem [online]. 2022, v. 75, n. Suppl 1. https://doi.org/10.1590/0034-7167-2022-0058.
27. Goes E. O loop das desigualdades. Nacla Reporting on the Americas since 1967. [Internet]. June 27, 2022. New York: 2022. Disponível em: https://nacla.org/brasil-COVID-desigualdades.
28. Galvão P. Percepções sobre a violência e o assédio contra mulheres no trabalho (Instituto Patrícia Galvão/Locomotiva, 2020). Available from: https://ilocomotiva.com.br/wp-content/uploads/2022/01/percepcoes-sobre-violenciaassedio-mulheres-trabalho.pdf .
29. Pai DD, Sturbelle ICS, Santos C, Tavares JP, Lautert L. Physical and psychological violence in the workplace of Healthcare professionals. Texto Contexto Enferm [Internet]. 2018; [cited 2020 jun 28];27(1):e2420016. DOI: https://doi.org/10.1590/0104-070720180024200165.
30. Azeredo YN, Schraiber LB. Institutional violence and humanization in health: notes to debate.Ciênc. saúde coletiva [Internet]. 2017;[cited2020 jul 06];22(9):3013-22. DOI: https://doi.org/10.1590/1413-81232017229.13712017.
31. Vargas L, Vélez-Grau C, Camacho D, Richmond TS, Meisel ZF. The Permeating Effects of Violence on Health Services and Health in Mexico. J Interpers Violence. 2022 Jul;37(13-14):NP10883-NP10911. doi: https://doi.org/10.1177/0886260521990832. Epub 2021 Feb 2.
32. da Silva João, A. L., & Saldanha Portelada, A. F. (2019). Mobbing and Its Impact on Interpersonal Relationships at the Workplace. Journal of Interpersonal Violence, 34(13), 2797–2812. https://doi.org/10.1177/0886260516662850
33. Ziaei, S., Hammarström, A. The relationship between interpersonal violence in adulthood and mental health: a longitudinal study based on the Northern Swedish Cohort. BMC Public Health 23, 637 (2023). https://doi-org.ez10.periodicos.capes.gov.br/10.1186/s12889-023-15525-x
34. Zhen-Duan J, DeJonckheere M, Raglin Bignall WJ, Galván J, Saavedra N, Berenzon Gorn S. Interpersonal Violence and Psychological Well-Being: Perspectives of Low-Income Patients, Social Workers, and Medical Doctors in Mexico City, Mexico. J Interpers Violence. 2022 Jan;37(1-2):681-704. doi: https://doi.org/10.1177/0886260520915543. Epub 2020 Apr 20.
35. Liu J, Gan Y, Jiang H, Li L, Dwyer R, Lu K, Yan S, Sampson O, Xu H, Wang C, Zhu Y, Chang Y, Yang Y, Yang T, Chen Y, Song F, Lu Z. Prevalence of workplace violence against healthcare workers: a systematic review and meta-analysis. Occup Environ Med. 2019 Dec;76(12):927-937. doi: https://doi.org/10.1136/oemed-2019-105849. Epub 2019 Oct 13.
36. Silva GN. (Re)conhecendo o estresse no trabalho: uma visão crítica. Gerais, Rev. Interinst. Psicol. [Internet]. 2019 Jun [citado 2023 Ago 30]; 12(1):51-61. Available from: http://dx.doi.org/10.36298/gerais2019120105.