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Work-related violences and associated variables in oncology nursing professionals
Work-related violences in nursing professionals
Violências relacionadas ao trabalho e variáveis associadas em profissionais de enfermagem que atuam em oncologia
Juliano dos Santos1
jlnsantos@yahoo.com.br: http://orcid.org/0000-0001-9961-3576
Karina Cardoso Meira2
cardosomeira@yahoo.com.br: http://orcid.org/0000-0002-1722-5703
Juliana Chaves Coelho3
juccoelho@usp.br: http:// orcid.org 0000-0001-8781-7627
Eder Samuel Oliveira Dantas4
edersamuel_rn@hotmail.com: http:// 0000-0002-6595-6105
Lannuzya Verríssimo e Oliveira2
lannuzyacg@hotmail.com: http:// 0000-0002-6881-898X
Jonas Sâmi Albuquerque de Oliveira2
jonassamiufrn@yahoo.com.br:http://0000-0003-0303-409X
Angela Maria Geraldo Pierin3
pierin@usp.br: http://orcid.org/0000-0002-3274-7729
1 José Gomes da Silva Alencar National Cancer Institute
2 Federal University of Rio Grande do Norte School of Health
3 University of São Paulo School of Nursing
4 Onofre Lopes University Hospital of the Federal University of Rio Grande do Norte



Abstract
Occupational violence is a problem that health professionals are exposed to daily. This cross-sectional study aimed at identifying the prevalence of violence at work (verbal/physical) and the variables related to it in nursing professionals working in oncology. Physical or verbal aggression was assessed through self-report. The relationship between sociodemographic, psycho-emotional and work-related violence (verbal/physical) variables was analyzed using the Chi-Square, Fisher\'s Exact, Student T and Mann-Whitney tests. The study sample consisted of 231 nursing professionals. The prevalence of physical or verbal aggression reported in the last year was 61.5%. A higher prevalence of aggression was evidenced in professionals who stated that they were tired at the end of the shift and presented reduced concentration during the shift. It is noteworthy that workers who suffered violence presented high levels of burnout in all subscales, a higher Mean score on the work stress scale and a lower Mean with regards to sleep quality. The findings of this study point to the need for institutional measures to prevent and control occupational violence.
Key words: Violence at Work; Nursing Team; Human Resources in Health; Worker\'s Health.
Introduction
Violence is a phenomenon of high complexity and has multiple determinations that develop in society, and is influenced by history, culture, and politics1-2. It manifests itself in relationships permeated by oppression, intimidation, and fear, showing the proximity between violence and the exercise of power2-5, in hierarchical relationships where differences are transformed into inequalities2-5.
It is challenging to construct a single definition that encompasses all dimensions and multiplicities of violence2. Thus, in this study, we chose to characterize it as an action undertaken by an individual, a group, or countries that promote the deprivation of rights and the physical, psychological, and moral harm to an individual or group3-4.
This work-related phenomenon constitutes an expression of violence, which is defined as a voluntary act against an individual or group, causing physical and/or psychological damage in the workplace, comprising interpersonal relationships and activities associated with work. Furthermore, work-related violence is also characterized by the deprivation of fundamental labor and social security rights, negligence with regards to working conditions, as well as the naturalization of death and illnesses as a result of work2. It can be expressed through physical and/or psychological aggression, sexual harassment, abuse, and bullying, representing an important risk to which workers are exposed, impacting their health and with a direct impact on their work6-8.
In these scenarios, workers in the health sector stand out since they represent individuals that suffer from work-related violence, which corresponds to 25% of all violence in the workplace reported across the country6-8.
Regarding health professionals, when the proportion of violence is broken down into sectors of activity, important disparities in the magnitude of aggression suffered according to the area of activity and professional category are evident9-10. The highest risk sectors are psychiatry, emergency rooms, clinical units, and surgical units9-11; and the professionals most at risk are the nursing staff, who are three times more at risk of work-related violence when compared to other health professionals6.
This reality can be associated with the hierarchization of the nursing work process and the stratification of professionals according to their level of education12. Brazilian nursing consists of three professional categories, namely: nurses, nursing technicians, and nursing assistants. Hygiene, comfort, and less complex activities are aimed at the latter, while more complex management and care activities are attributed to nurses12. In this context, less value and social recognition are attributed to nursing activities that are associated with domestic work such as bathing, diaper changing, and feeding, among others, reflecting gender inequalities7-9
In addition, we can highlight the nature of work routines that require direct and intense contact with patients and caregivers - sometimes weakened by illness or dissatisfied by the lack of resolution of the health care provided, as well as by the repetition of invasive procedures and lonely night shifts. In contrast, we can highlight the difficulties inherent in health services, such as delays in care, lack of sufficient professionals, and inadequate infrastructure6-8.
Another peculiarity of the professional nursing category is that it is mainly composed of women7-9, which may explain the high prevalence of violence suffered since the work environment reflects the gender inequalities present in the patriarchal society, and thus, women have greater work-related suffering due to bullying, sexual harassment, and stigmas of weakness and lower intellectual capacity13-14.
In this sense, a study carried out with women professionals who worked in nursing identified a high prevalence of verbal, physical, and sexual violence in the workplace (45.8%, 95%CI 38.5-53.4) that were perpetrated by patients, caregivers, and work colleagues11. In nursing professionals working in the psychiatry, urgency, and emergency sectors, physical aggression was the most prevalent, and in other areas, verbal aggression was the most prevalent13.
Work-related violence, despite being present in high levels, has several impacts on the work process, namely: increased absenteeism, greater dissatisfaction with work, and alterations in the mental health of nursing workers7-9. It is not a public health problem that receives the needed attention, reflecting the lack of knowledge of notification procedures by the victimized professionals and the underuse of these instruments by the management7, which causes the invisibility of violence, hinders diagnosis, planning, implementation, and evaluation of prevention and control actions for this harm to workers\' health.
Given this reality and the scarcity of studies that analyze the occurrence of occupational violence in nursing professionals working in oncology, the present study aimed to identify the prevalence of violence at work (verbal/physical) and the related variables (sociodemographic, performance professional, sleep quality, psycho-emotional - Burnout and work-related stress) in nursing professionals working in a High Complexity Oncology Center in the state of Rio de Janeiro.
Method
Type of study, location, period, sampling, and inclusion criteria
A cross-sectional study carried out with nursing professionals who worked at a hospital specialized in cancer treatment in the state of Rio de Janeiro.
This study is part of a larger research project entitled "Cardiovascular Risk and Allostatic Load in Nursing Professionals working in Oncology: bio-psychoemotional and work-related variables" presented to the "Adult Health Nursing Graduate Program – PROESA (Programa de Pós-Graduação “Enfermagem na Saúde do Adulto)" from the School of Nursing at the University of São Paulo.
The sample calculation resulted in 220 professionals from a population of 574 nursing professionals and was performed using the SPSS version v.20.0 program, with a confidence level (α) of 5% and power of 80% (1-β) for the prevalence of hypertension of 40%. It is noteworthy that the selection of members of the sample took place through simple random sampling, using the method of the computational draw through a list of employees provided by human resources.
The inclusion criteria were individuals that were part of the nursing team (auxiliaries/technicians and nurses), worked in the cancer patient care division in inpatient units, and were linked to the institution for at least one year. Professionals who were on leave (n=11) and pregnant women (n=1) during the data collection period were excluded. Eight professionals who refused to participate in the study were replaced. With the aim of making up the selected sample (n=220), the 10% (n=22) that were part of the pilot study, and the replacement of any losses (n=115) were drawn, totalling 357 participants, 231 of which comprised the final sample (Figure 1).
Data collection was performed by a professionally trained team that consisted of 3 nurses from 12/01/2013 to 06/30/2015, a total of 18 months, in a quiet and private environment, close to the professional\'s work environment.
Data collection took place through interviews. Participants were contacted in person, by phone, and/or by email, and received information about the study. Those who agreed to participate had a day and time scheduled to collect the data. After reading and signing two copies of the free informed consent form, guidance for filling out the questionnaires were initiated, and the data collection process began. The study was approved by the Research Ethics Committee under CAAE: 13329513.3.0000.5392, Opinion 320.343.
A questionnaire on the sociodemographic variables related to work, habits, and lifestyles was applied and, subsequently, the filling in of instruments that analyzed psycho-emotional variables was requested such as the Work Stress Scale (WSS), Maslach Burnout Inventory (MBI), Self-Reporting Questionnaire (SRQ-20), and Pittsburgh Sleep Quality Index (PSQI). It should be noted that all these instruments were validated for use in Brazil and showed high validity and reliability.
The occurrence of physical and/or verbal violence was evaluated based on the question: “Have you ever suffered physical and/or verbal aggression during hospital work in the last year?”, with the possibility of a dichotomous answer (yes or no). If the answer to this question was positive (yes), the workers were asked about the aggressor, with the possibilities of answers, not mutually exclusive, being patients, companions, and professionals. Professionals who had more than one employment relationship were instructed to investigate the occurrence of violence at work at the study site.
The sociodemographic variables evaluated were sex, age, marital status, Ethnicity, and Monthly family income (R$). The work-related variables were: Professional category; Graduated time (in years); Type of bond; Type of position; Highest education level completed; Number of employment relationships; Weekly working hours; Institutional working time (in years): Work scale; Shift work; Had an accident while working in the hospital; Worked whilst being tired; End the shift feeling psychologically tired and Decreased concertation during the shift (Chart 1).
In order to identify the presence of stress, perceived stress was evaluated through the question: "Do you consider yourself a nervous/stressed person?" and through the Work Stress Scale (WSS). The WSS is a unifactorial instrument with 23 Likert-type items (1: strongly disagree, 2: disagree 3: partially agree, 4: agree and 5: fully agree). The total score of the scale ranges from 23 to 115 points. In this study, the definition of cut-off points was performed by means of thirds (low, moderate, and high)15-16.
Physical aggression was considered as the use of force that results in physical or psychological harm, and verbal aggression as the use of words in offensive attitudes aiming to humiliate, slander, or shame individuals or a group2,5.
Burnout syndrome was investigated using the Maslach Burnout Inventory (MBI), version HSS (Human Services Survey)17-18, which has three dimensions - emotional exhaustion, depersonalization, and low professional achievement, subdivided into 22 items. In the present study, the presence of Burnout syndrome was identified by the occurrence of high levels in the three dimensions, concomitantly (emotional exhaustion ≥ 27, depersonalization ≥ 10, and low professional achievement ≤ 33), based on the recommendations in the table provided by the instrument manual.
Furthermore, the subjective quality of sleep was tracked using the Pittsburgh Sleep Quality Index (PSQI), constructed with the aim of providing a standardized measure of sleep quality. It consists of 19 self-report questions grouped into seven components: 1 – subjective sleep quality (evaluates individual perception of sleep quality); 2 – sleep latency (time required to start sleep); 3 – sleep duration (how long one remains sleeping); 4 – habitual sleep efficiency (relation between the number of hours slept and the number of hours spent in bed, not necessarily sleeping); 5 – sleep disorders (presence of situations that compromise sleep hours); 6 – use of sleeping medication and 7 – daytime sleepiness and daytime disturbances (refers to changes in mood and enthusiasm for performing routine activities). Each component will receive scores ranging from 0 to 3. A sum of the scores in each question will compose the global score with scores ranging from 0 to 21, the higher the score, the worse the sleep quality13. An overall score > 5 indicates that the individual is presenting a poor quality of sleep pattern13.
Data were recorded and tabulated in a spreadsheet with the aid of Microsoft Windows Excel through double entry.
Descriptive analysis was performed using absolute and relative frequencies for categorical variables and means and standard deviations (SD) for quantitative variables. Then, the existence of a statistically significant difference between the occurrence of violence and the nominal or ordinal variables was assessed using Pearson\'s Chi-square test, likelihood ratio, or Fisher\'s exact test. And for continuous variables, the Mann-Whitney U test or Student\'s t-test was used, depending on the distribution of the variable under study. Values of p ≤ 0.05 were considered significant and the data were analyzed using the R statistical program version 3.2.1.
Results
Most nursing professionals were female (82.7%), non-white (54.5%), lived with a partner (70.6%), with an Mean age of 39.6 years (SD=8.3), and an Mean monthly income of R$9,045,000 (SD=4,416.17). (Table 1).
Regarding the professional variables, there was a predominance of nursing assistants/technicians (63.6%), almost all of whom worked in the care area (97.4%), were statutory (80.1%), and had the highest level of residency training and specialization (43.4%). It is also noteworthy that the majority reported an employment relationship (56.3%), had a day shift as a fixed schedule (53.2%), worked alternate shifts (59.7%), with an Mean of 52.0 working hours (SD=15.5), and 8.6 institutional working hours (SD=7.5). (Table 2).
Furthermore, it is noteworthy that a large proportion of the professionals worked being often/sometimes tired (92.2%), ended the shift feeling psychologically tired (87.0%), and frequently/sometimes manifested decreased concentration during the shift (62.3%). (Table 2).
Through the evaluation of Burnout syndrome, stress through WSS, and common mental disorders, it was found that the study subjects showed a high level of emotional distress (55.0%), high level of depersonalization (64.1%), high level of low professional achievement (73.2%), and 39.0% presented a high of level Burnout in the three subscales. Regarding stress, there was a similarity between the different response categories of the scale (Low Moderate and High Stress), however, 57.6% of the sample had common mental disorders. (Table 3).
In the sample, 61.5% (n=142) were exposed to violence at work in the last year, be it physical and/or verbal. The main perpetrators of violence were caregivers, patients, and other health professionals. It is noteworthy that the largest proportion of professionals who suffered violence lived with a partner (76.8% vs 60.7%, p=0.009) and ended their shift often/sometimes feeling psychologically tired (69.0% vs 62, 3%, p=0.003) as compared to those who did not suffer violence. (Table 2). Furthermore, professionals who suffered violence considered themselves stressed (50.0% vs 36.0%, p=0.037), and had lower Mean sleep quality when compared to professionals that were not exposed to verbal/physical aggression (p=0.016).
It is noteworthy to mention the fact that professionals who suffered violence had a higher proportion of emotional exhaustion/burnout, depersonalization, a high level of low professional achievement (p<0.0001), and a high level of Burnout in the 3 subscales (p<0.0001) when compared to professionals who have not suffered violence. Likewise, there was a higher Mean score of stress at work among those professionals (p=0.015). (Table 3).
Furthermore, professionals who reported aggression (verbal/physical) had a higher prevalence of decreased concentration during the shift (69.0 vs 51.7%, p=0.008) (Table 2), and also showed a higher mean in the overall PSQI score (9.1 vs 8.1, p=0.016) (Table 3).
Discussion
Work-related violence represents a deliberate act against an individual or a professional, characterized by physical or psychological aggression that occurs in interpersonal relationships in the workplace, depriving workers of an essential labor right, which is the work process\' safety2,4, with significant impacts on workers\' health and quality of work performed.
In the present study, there was a high prevalence (61.6%) of verbal/physical aggression in the last year among nursing professionals who worked in a hospitalization sector specializing in oncology, with this health problem being related to psycho-emotional changes: low sleep quality/sleep quality; high-level of burnout in all subscales (exhaustion/emotional burnout, depersonalization, and low achievement) and higher mean score on the job stress scale.
It should be noted that this reality cannot be considered an isolated event or misfortune, but a phenomenon that is structurally linked to socioeconomic, cultural, and organizational issues of work institutions1-5. This assumption is confirmed when evaluating the proportion of aggression reported by nursing workers in the oncology sector under study, as well as in hospitals in southern Brazil (63.2%)20, in the state of Rio de Janeiro (46.7%) 21, in the city of Londrina, where 100% of nurses and 88.9% of nursing technicians reported having suffered violence22.
In the hospital institution of the present study, attention is drawn to the higher prevalence of verbal/physical aggression in nursing technicians/assistants (62.7%), which may be a reflection of the hierarchization of Brazilian nursing, in which direct patient care activities are performed primarily by these workers12, increasing their exposure to suffering violence from companions and patients due to direct and continuous contact throughout the shift21,23. Also, their work activities are predominantly performed by women, and are considered tasks of lesser importance due to their link to domestic work12, increasing the chance of being disrespected by health service users and their families and suffering violence10,24, due to the inequality of that permeate social relations in a patriarchal society14.
Added to the characteristics of the nursing work process, the specificities of care for cancer patients must be considered, as in these inpatient services, patients are often physically debilitated, exhausted with treatments (surgical, chemotherapy, or radiotherapy), with pain due to the therapy or extension of the disease, or in end-of-life care. A situation that promotes a high level of stress and suffering for patients and their companions/relatives, increases the risk of the occurrence of verbal/physical aggression if their health and care needs are not met with the readiness desired by them.
In the oncology service under study, at the time of the study, there was no reported lack of material resources for nursing care, however, there was a deficit of professionals, considering the highly specific and complex care that is required25. These workers reported more than 50 hours of Mean weekly work, due to the high proportion of professionals with more than one employment relationship (39.7%) and the possibility of carrying out extra shifts at the institution in order to make up for the shortage of professionals25 , a reality that aims to supplement their monthly family income, amplifying the wear and tear of these workers25. It can generate behaviors that increase the likelihood of violence occurring due to stress, fatigue, and inattention20-22.
In this sense, workers who suffered physical/verbal aggression reported, in greater proportion, finishing the shift feeling psychologically tired, with reduced attention during the shift, with a lower Mean of sleep quality, with a higher Mean in the scale of stress at work. In addition to a higher prevalence of high levels of exhaustion/wear, depersonalization, and low professional achievement, which may be associated with the previously mentioned professional deficit, and the characteristics of the clientele assisted with sudden changes in the clinical condition, oncological emergencies, and, in addition to death and grief often experienced by these workers26-27. These psycho-emotional changes can result in failures in care, motivating aggressive reactions from both patients, their companions, or even members of the team itself28-39.
The design of this cross-sectional study does not allow us to identify whether these psycho-emotional changes emerged after the episode of aggression or whether their existence increased the risk of violence at work. However, it is known that the presence of violence generates dissatisfaction at work20 and a feeling of professional devaluation6, which in turn causes irritability in workers, interferes with the quality of care provided and patient safety, increasing the risk of these workers suffering physical or verbal violence20, feeding back the cycle of violence at work.
The high prevalence of verbal/physical aggression observed in nursing workers deserves great attention from the management of the hospital under study, since even though it was not the focus of this work, studies have shown that Post Traumatic Stress Disorder (PTSD) is the most common mental health problem after experiencing a traumatic event in the workplace39. A review study found that 10 to 18% of professional victims of violence at work will develop symptoms that meet the PTSD criteria. In addition, these workers have a higher risk of using antidepressants and anxiolytics (RR=1.45; 95%CI 1.01-2.33)40. The presence of PTSD as a result of an accident at work has been related to absenteeism and can impact the relationship of this professional with the health team and with patients due to the greater probability of irritation, difficulties in concentration, and communication39-40.
However, despite the great magnitude and transcendence of this public health problem, it is still neglected by managers8, as they believe that verbal aggression is part of health work, given the fragility of patients and the inability of the health system and services to attend to health needs, with health professionals being the representatives of the state in which users and their families will present all their discontent for not having their right to guaranteed health6,20,41.
It is also important to highlight that, although this study is a situational study, which did not use a standardized scale for the assessment of violence, in addition to not discriminating the type of violence suffered, it has its importance in giving visibility to the violence experienced by nursing professionals who work in oncology, highlighting its high prevalence and impacts on their mental health.
Conclusion
It was evident that the nursing professionals of a High Complexity Center in Oncology, in the state of Rio de Janeiro, who made up the sample of this study, presented a high level of prevalence of self-reported violence, perpetrated mostly by caregivers and patients. Thus, this study reveals a violent face in which nursing professionals, whose work activity is of great importance, are exposed daily.
Furthermore, nursing professionals who reported having suffered violence had a higher level of emotional exhaustion, depersonalization, burnout, in addition to a higher mean of low professional achievement, occupational stress, and poor sleep quality. Therefore, the phenomenon of violence at work has a negative impact on the health of these professionals and, consequently, on the performance of their professional activities, which may lead to a decrease in the quality of care provided and patient safety.
This study points to the urgency of institutional demands aimed at protecting nursing professionals in their work environments, which must necessarily go through the education of caregivers and patients and, above all, professional development. In addition, it was the first Brazilian study to assess occupational violence in nursing workers who work in inpatient units specializing in cancer patient care.

Collaborations

JS participated in the conception, study design, writing of the article, its critical review and approval of the review to be published. KCM participated in the conception, study design, analysis and interpretation of data, writing of the article, its critical review and approval of the version to be published. JCC participated in the writing of the article or its critical review, and c) approval of the version to be published. ESOD participated in the writing of the article or its critical review, and c)approval of the version to be published. LVO participated in the writing of the article or its review review, and c) approval of the version to be published..JSAO participated in the writing of the article or its critical review, and c) approval of the version to be published. SGPA participated in the writing of the article or its critical review, and c) approval of the version to be published. AMGP JS participated in the conception, study design, article writing, critical review and approval of the review to be published.


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