REVIEW ARTICLE

Psychological harassment in the hospital nursing workplace: an integrative literature review

Michelle Adrianne da Costa de Jesus^I; Norma Valéria Dantas de Oliveira Souza^II; Carolina Cabral Pereira da Costa^III; Eloá Carneiro Carvalho^IV; Cristiane Helena Gallasch^V; Pedro Hugo Dantas de Oliveira Souza^VI

^I Nurse. Resident in Clinic Surgery, Faculty of Nursing, Rio de Janeiro State University. Brazil. Email: michelleadrianne@hotmail.com
^II Nurse. PhD in Nursing. Associate and Permanent Professor of the Graduate Program, Faculty of Nursing, Rio de Janeiro State University. Brazil. E-mail: norval_souza@yahoo.com.br
^III Nurse. PhD student and Master of Nursing, Rio de Janeiro State University. Brazil. E-mail: carolcuerj@hotmail.com
^IV Nurse. Lawyer. PhD student and Master of Nursing, State University of Rio de Janeiro. Assistant Professor, Nursing school, State University of Rio de Janeiro, RJ, Brazil. E-mail: eloagrossi@uol.com.br
^V Nurse. PhD in Nursing. Assistant Professor, Faculty of Nursing, Rio de Janeiro State University. E-mail: cristiane.gallasch@gmail.com
^VI Lawyer. Specialist in Civil Procedure at the Estácio de Sá University. National Agency of Supplemental Health, Rio de Janeiro. Brazil. Email: dantas_pedrohugo@yahoo.com.br

DOI: http://dx.doi.org/10.12957/reuerj.2016.26437

ABSTRACT

Objective: to identify and analyze the implications of psychological harassment for the organization of work and the hospital nursing worker. Methods: in this descriptive study, based on an integrative literature review, a search paper for papers was conducted in the Virtual Health Library database, between July and November 2015. Content analysis was then applied, and two categories emerged: Effects of moral harassment on the organization of hospital nursing work; and Effects of moral harassment in the health-disease process in hospital nursing workers. Results: the ten papers selected for this study were examined to determine the definition psychological harassment, types of aggression, consequences for labor organization and for workers' health. People who had been harassed suffered impaired professional performance and low self-esteem. Conclusion: psychological harassment has highly adverse impacts on the organization of work and on hospital nursing workers' health, and attitudes and management methods need to be reviewed.

Keywords: Occupational health; occupational health nursing; psychological stress; violence.

INTRODUCTION

The object of this study deals with bullying in the hospital nursing work. This object emerged from empirical observations on hospital services in which some workers were submitted to unpleasant situations by their bosses and/or co-workers, showing possible cases of moral harassment.

The world of work has undergone changes over the term of the neoliberal model, with consequent negative repercussions for workers such as the fear of unemployment, reduced availability of job positions, deterioration of labor, reduction and/or elimination of labor rights, versatility and multi-functionality of workers. Such repercussions have given origin to numerous situations in work environments that can be identified, for example, a tensions and conflicts in interpersonal relationships, which may precipitate moral harassment at work^1,2.

Health work is fundamental to human life, understood as a transformative and necessary action to society³. The nursing work is part of this perspective, whose goal is the human care. However, this activity has been developed under difficult situations due to the deterioration of relations and working conditions, firmly established since the advent of neoliberalism¹.

The deterioration of labor is a phenomenon that affects many professionals, with deregulation and loss of labor and social rights. This has caused psychophysical suffering and increased vulnerability to occupational diseases¹. Thus, occupational stress, burnout, depression, bullying and physical violence have increased in work environments².

Especially with regard to moral harassment at work (MHW), it is a fact that this includes the submission of workers to humiliating, embarrassing, repetitive and enduring situations during the workday, and on the exercise of labor functions. This is evidenced in authoritarian hierarchical relations where a negative behavior predominates, inhuman and unethical relationships, from one or more chiefs directed to one or more subordinates and among peers. These attitudes cause emotional destabilization in the harassed workers as well as mental disorders that negatively interfere with their health and quality of life and may even lead to death². Another important fact is that most harassed people are female, and this has a direct impact on the nursing profession, which is predominantly made up of women⁴.

Considering the importance of the topic, the following objectives are drawn up: to identify and analyze the implications of moral harassment to the organization of work and for the hospital nursing worker.

LITERATURE REVIEW

MHW deserves attention from organizations mainly due to its wide extent and intensification in work environments, and its negative impact on worker's health and productivity of companies. Otherwise, it is assumed that the workplace should maintain a harmonious collective labor where interpersonal relations are permeated by respect, dialogue and solidarity. Instead of this, competitiveness, trivialization of injustice, isolation of workers, a sense of abandonment and loneliness is what has actually been observed with some frequency^5,6.

Furthermore, there are currently work contexts, including hospital work, which aim at maximum productivity and the achievement of various goals, pressing workers to become polyvalent, wearing down their psychophysical energy. Moreover, reduction of the expenses are often recommended, what results in reduction of the work force, with reduction of formal ties of work; fast work rhythm and the multi-functionality of workers. This context of insecurity increases competitiveness, which generate tensions and conflicts in hospital environment⁷.

Considering such a configuration of the world of work, we have understood that this may be an ideal context for the emergence of moral harassment, since this environment is hostile to professional collectives. Thus, workers are exposed to humiliating and embarrassing situations, compromising their identity, dignity, affective and social relations, and causing damage to physical and mental health^1,3. Moral harassment at work can happen among colleagues, clients, and family members, causing humiliation and/or embarrassment and sometimes triggering illness or aggravating pre-existing illnesses.

Other repercussions for the victim may include isolation and, in some cases, abusive use of alcohol and/or other drugs, request for dismissal, or dismissal by the employer, including for insubordination^1,7.

As a consequence of this situation, other physical and psychological symptoms may arise, such as: irritability, anxiety, fatigue, professional stress, low level of job satisfaction, low self-esteem, lumbalgy, depression, cardiovascular disorders such as tachycardia and arterial hypertension^8,9.

The impact of moral harassment at work on family relationships also stands out. This reduces the quality of life of the worker-family binomial, since psychic suffering and burnout syndrome are problems with high prevalence that affect professionals who are victims of this form of violence, with extreme cases of suicide¹⁰.

METHODOLOGY

The study consists in a descriptive survey of the type integrative literature review (ILR), consisting of six stages: elaboration of the guiding question of research; research or sampling in the literature; data collection; critical analysis of selected articles; discussion of results; and presentation of review/synthesis of the surveyed knowledge^11-14.

The question that guided this research was: What kinds of implications can moral harassment cause to the work organization and to the nursing worker in the hospital environment?

In order to answer this question, a survey was made in the Regional Library of Medicine database (BIREME), specifically in the Scientific Electronic Library Online (SciELO); the Latin American and Caribbean Literature on Health Sciences Information (LILACS); the Nursing Database (BDENF), theUnited States National Library of Medicine – PubMed; and the Cochrane Library (IBECS). We used the descriptors: nursing, worker's health, nursing work, psychological stress, violence, nursing, bullying, and the keywords mobbing and moral harassment. The search for publications in these databases occurred between July and November 2015.

The following inclusion criteria were used: articles published within the last 14 years, once Brazil had the first law project recognizing and condemning moral harassment in 2001; publications in Portuguese, Spanish or English; scientific production available in full-length in online databases; and publications prepared by health professionals. The exclusion criteria were: theses, dissertations, monographs and chapters of books; articles that were not in the public domain; and articles duplicated in the databases.

After mapping the selected studies, thematic content analysis was applied. This technique is composed of three stages: pre-analysis; exploration of material; treatment of results, inferences and interpretation¹⁵.

Thus, in relation to the effects of harassment on the work organization, 19 units of record (UR) were captured, giving rise to three themes: Effects of moral harassment in the satisfaction of the nursing worker; Effects of moral harassment on the relationships within the nursing staff; and Effects of moral harassment to the companies. These themes formed the first category, which was entitled: Effects of moral harassment in the organization of hospital nursing work .

The 48 URs that expressed the repercussions of moral harassment on the health of nursing workers originated the following themes: Psychological/psychosomatic repercussions; and Physical repercussions. These two themes gave rise to the second category entitled: Repercussions of moral harassment on the health-disease process in the hospital nursing worker.

RESULTS

Five combinations were made between descriptors and keywords, capturing 106 publications. From this, the exclusion criteria were applied and 10 articles were selected^7,10,16-23 to elaborate this ILR (P1 to P10), according to Figure 1. Articles were available at the databases: LILACS, BDENF and MEDLINE.

Figure 1: Selected and evaluated publications between 2006 and 2014. Rio de Janeiro, 2015.

Selected publications presented the definition of bullying at the workplace and discussed its consequences. In addition, they theorized on its causes in the labor organization, identifying and discussing its implications for nursing practice and pointing out solutions.

We found that the publications analyzed the behaviors that signal suffering caused by moral harassment at work, as well as the coping strategies adopted by nursing professionals in face of such violence. We also identified that bullying in nursing is an act of race and gender discrimination, and that age, social status, level of education and workload were relevant aspects considered. Figure 2 shows the units of meaning and categorization of the elements that reflect these situations.

Figure 2: Distribution of units of record, units of meaning and categorization of records. Rio de Janeiro, 2015.

Category 1: Effects of moral harassment in the organization of hospital nursing work

We observed that WMH propitiates effects in the work organization that can affect the satisfaction and the feeling of being part of a team, part of the work, as well as feeling of facing the company that admits or practices the harassment. In this perspective, it was found in publications P2, P3, P4, P5, P7 and P10 that workers become unsatisfied with work, besides having their self-confidence and professional performance compromised, associated with lack of interest for the work, prompting the abandonment of the employment bond.

We observed in the publications P2 and P5 that the interpersonal relationship between the members of the team becomes conflictive, and there is no confidence in the professional collective. Furthermore, we identified that living in a conflictive work environment affects the health of the whole group, generating a feeling of inability to help the harassed individual.

We verified that the company that allows or does not perceive the bullying has itself many losses, such as: absenteeism, withdrawals and replacements, factors that impact on productivity. The complaint generates increase expenses for the company due to legal proceedings, as described in articles P4, P5 and P6.

The constant confrontation of workers with aggressors can generate emotional and even physical disorders and, in some cases, cause early retirement, which will further burden the company, as quoted in publications P1, P3, P5 and P10.

In articles P1, P2, P3, P8 and P9, we found that the permanence of this worker in the company can be harmful, increasing the possibility of error, which compromises the quality of care provided.

Category 2- Repercussions of moral harassment on the health-disease process in the hospital nursing worker

Publications P1, P3 and P10 show that moral harassment has repercussions on the health of the harassed worker, causing physical and/or psychological problems. We also found in articles P2, P5, P7 and P9 that bullying can potentially generate diverse forms of pain in the whole body, gastrointestinal complaints, eating disorders, bulimia and/or anorexia. It is emphasized that chest pain, migraine and impaired sleep pattern were the signs/symptoms most valued by the harassed workers.

Respiratory problems were reported in publications P2, P5, P7 and P9, represented by dyspnea and asthma crisis. There were also cardiac alterations such as tachycardia and arterial hypertension. Dermatological disorders have also been cited, with skin inflammation and alopecia. Publication P7 pointed out that bullying can cause harm to the affective life, with decreased libido, sexual dysfunctions and behavior.

Bullying can also generate serious psychological problems, such as: repetitive and confused thoughts related to the frequent memories of aggressions experienced, as well as fear, crying, resentment, sorrow, loneliness, melancholy, apathy and extreme sadness, when recalling the moments lived. These feelings may lead to depression, as evidenced in publications P1, P3, P4, P5, P7 and P9.

Articles P3, P5, P7 and P9 pointed out that constant anxiety and stress trigger problems of lack of concentration and initiative associated with fatigue. In publications P1, P3, P7 and P9, we found that the reduction of self-esteem and the feeling of helplessness foster social isolation, the use and abuse of illicit drugs, alcohol, cigarettes and medicines.

DISCUSSION

The publications provided evidence that harassment results in destructive effects for the harassed people, for the professional group, the families involved with such phenomenon, the productivity of the company, and the quality of the services offered to the population. Therefore, this is a phenomenon that needs to be more widely publicized and debated in work environments, in academy and in society as a whole, in order to strengthen the legal apparatus against the MHW, so that harassed workers may have right to treatments and indemnities and to create strategies to identify the offenders, with the aim of also treat their psychological problems.

This research left clear that moral harassment in nursing can cause loss of interest in work and activity, aggravation of existing diseases, as well as emergence of new diseases. The MHW is often practiced in a disguised way, with the intention of diminishing self-esteem and emotionally and professionally destabilizing the victim. However, such phenomenon reaches proportions that lead to imbalance in the workplace, damage to the company and threat to the dignity and health of workers^24,25. Behaviors related to disqualification, with attacks to the skill and competence of the harassed person, have negative consequences, among them social isolation and the intention to quit the job^25,26.

In the relations between teams, psychological violence in work emerges as a product of envy, rivalry and the experience of interpersonal conflicts, jealousy of competence and success of the other, fear of economic instabilities that generate unemployment, and so forth^27,28. There is evidence that the practice of harassment may become even more pleasurable for the harasser when practiced before the co-workers of the harassed person; such co-workers, instead of using their consciousness and taking a stance, become mere spectators, as if oblivious to the suffering of the victim. A true pact of silence and tolerance of such violence is then established, whereby the victim's work colleagues remain inert, whether for fear of unemployment or of being likewise humiliated, contributing to the success of the perverse manipulation undertaken by the aggressor²⁷.

There are also cases in which, while the harassed-sick people conceal the disease and work with pain and suffering, healthy people who do not present productive difficulties, but who carry the uncertainty of having them, reproduce the leaders' discourse and begin to discriminate the unproductive co-workers, humiliating them^28,29.

Harassment creates absenteeism and turnover of the workforce, which in turn leads to increased expenses with contractual terminations, selections and training of personnel, increased labor claims for moral damages, as well as causing a breakdown in the reputation of the company³⁰. When moral harassment takes place at work, there is a possibility of various forms of punishment, whether for the harasser or for the employer company that allowed or even encouraged the harassment. Bullying that causes injury to the victim generates an obligation to compensate that harm, and the offender has the duty to mend the damage caused by means of payment in cash, according to judicial decision.

The consequences of moral harassment are serious and can be analyzed from the point of view of the victim and of the aggressor³¹. In the case of victims, tension, anxiety, tiredness, depression, suicide attempts and death are common³². From the perspective of the aggressors, this also has consequences, as they may have to bear the financial burden of economically indemnifying the victim, of losing their job after finding out the fact, of being demoralized before their family and friends for being considered insensitive and cruel, and may also result in discrimination and social segregation^32,33.

Bullying at work causes several problems to the health of workers, mainly of psychosomatic nature, which destabilize their lives. As a consequence, workers have suffered from Burnout Syndrome, which is the set of symptoms and signs that comes mainly from work pressure^33,34.

Crying crises, insomnia, depression, thirst for revenge, digestive disorders, suicidal ideation, alcoholism, increased blood pressure and dizziness are also considered to be effects of MHW^35,36.

Depression is one of the leading causes of withdrawal among health workers. Anxiety, insomnia, palpitations, hypertension, cardiovascular disorders, tremors, fatigue, irritability, headaches, abdominal pains are some of the evils experienced by the victim.

CONCLUSION

The discussion about harassment has happened in several countries and areas of knowledge and action, such as nursing and psychology, making it an interdisciplinary subject worthy of further investigations. The theme, though, has still incipient scientific production.

The study led to the conclusion that moral harassment generates, in the work organization sphere, absenteeism, isolation, withdrawal of employment. In the relations among team members, there was the establishment of conflicts, lack of confidence and reproduction of the practice of aggression, due to the fear of becoming the next target. For nursing workers in the hospital environment, the repercussions of moral harassment affect the health-disease process, which may be physical and psychological.

The effects of moral harassment on the work organization and health of the hospital nursing workers are very negative, and, it is necessary to review attitudes and management methods in order to prevent any type of violence, whether visible or hidden. We suggest, therefore, that the organizations adopt social educative and punitive measures directed to harassers.

Moreover, the issue of bullying needs greater visibility, broadening discussions, research and exposure of results in the national and international scenario, because, beside denouncing and disclosing its negative effects, this may contribute to the creation of strategies and proposals for prevention and elimination. We also recommend the planning of support groups within companies, with the presence of a specialized team, in order to identify aggressions, manage conflicts and create support networks.

The good functioning of companies cannot be based solely on economic results, but also by the salubrity of their work environments, which must be permeated by harmonious relations and a logistics that allows the workers to develop their activities with creativity and autonomy, proper to their functions and positions.

REFERENCES

1. Gonçalves FGA, Souza NVDO, Pires AS, Santos DM, D'Oliveira CAFB, Ribeiro LV. Neoliberal model and its implications for the health of nursing workers. Rev enferm UERJ. [internet] 2014 [cited 2016 Mar 25]; 22(4):519-25. Available from: http://www.e-publicacoes.uerj.br/index.php/enfermagemuerj/article/view/15395/11646

2. Ministério do Trabalho e Emprego (Br). Assédio moral e sexual no trabalho. Brasília (DF): 2010.

3. Schmoeller R, Trindade LL, Neis MB, Gelbcke FL, Pires DEP. Nursing workloads and working conditions: integrative review. Rev. Gaúcha Enferm. (Online) [Internet]. 2011 [cited 2015 Ago 29]; 32(2):368-77. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1983-14472011000200022&lng=pt . http://dx.doi.org/10.1590/S1983-14472011000200022

4. Organização Internacional do Trabalho. Programa conjunto: nueva iniciativa contra la violência laboral em el sector da salud. Comunicado de prensa OIT [Internet] [cited 2016 Mar 26]. Available from: http://www.ilo.org/global/about-the-ilo/newsroom/news/WCMS_071411/lang--es/index.htm

5. Dejours C, Abdoucheli E, Jayet C. Psicodinâmica do Trabalho: contribuições da Escola Dejouriana à análise da relação prazer, sofrimento e trabalho. São Paulo: Atlas; 2009.

6. Vercesi C. Assédio moral no trabalho: implicações individuais, organizacionais e sociais. Rev Psicol Organ Trab. 2009; 9(1):68-85. 7. Lisboa MTL. Moral harassment in nursing working settings. [periódico na Internet]. 2010 Mar [cited 2015 Ago 29]; 15(1):9-11. Available from: http://www.revenf.bvs.br/scielo.php?script=sci_arttext&pid=S1414-85362010000100001&lng=pt

8. Cahú GPR, Rosenstock KIV, Costa SFG, Leite AIT, Costa ICP, Claudino HG. Scientific production in journals online on the practice of bullying: an integrative review. Rev. Gaúcha Enferm. (Online) [Internet]. 2011 [cited 2015 Set 07]; 32(3): 611-19. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1983--14472011000300025&lng=pt . http://dx.doi.org/10.1590/S1983-14472011000300025

9. Caran VCS, Secco IAO, Barbosa DA, Robazzi MLCC. Moral harassment among professors in a public university in Brazil. Acta paul. enferm. [Internet]. 2010 [cited 2015 Set 07]; 23(6):737- 44. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0103-21002010000600004&lng=pt . http://dx.doi.org/10.1590/S0103-21002010000600004

10.Fontes, KB, Pelloso SM, Carvalho MDB. Tendency of the studies on moral harassment and nurses. Rev. Gaúcha Enferm. [Internet]. 2011 Dez [cited 2015 Set 07]; 32(4):815-22. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1983--14472011000400024&lng=pt . http://dx.doi.org/10.1590/S1983-14472011000400024

11.Souza MT, Silva MD, Carvalho R. I ntegrative review: what is it? How to do it? Einstein (São Paulo) [Internet]. 2010 Mar [cited 2015 Set 21]; 8(1):102-6. Available from: http://www.scielo.br/scielophp?script=sci_arttext&pid=S1679-45082010000100102&lng=pt. http://dx.doi.org/10.1590/S1679-45082010RW1134

12.Gerhardt TE, Silveira DT. Métodos de Pesquisa. Porto Alegre (RS): Editora UFRGS; 2009. 13.Triviños A. Introdução à pesquisa em ciências sociais: a pesquisa qualitativa em educação. São Paulo: Atlas; 2008.

14.Polit DF, Beck CT, Hungler BP. Fundamentos de pesquisa em enfermagem: métodos, avaliação e utilização. 5ª ed. Porto Alegre (RS): Artmed; 2004.

15.Bardin L. Análise de conteúdo. São Paulo: Edições 70; 2011. 16.Cezar ES, Marziale MHP. Occupational violence problems in an emergency hospital in Londrina, Paraná, Brazil. Cad. Saúde Pública [Internet]. 2006 Jan [cited 2015 Nov 08]; 22(1): 217- 21. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-311X2006000100024&lng=pt . http://dx.doi.org/10.1590/S0102-311X2006000100024

17.Johnson SL. International perspectives on workplace bullying among nurses: a review. Int Nurs Rev. 2009; 56(1):34-40.

18.Yildirim D. Bullying among nurses and its effects. Int Nurs Rev. 2009; 56(4):504-11.

19.Lewis PS, Malechaa A. The impact of workplace incivility on the work environment, manager skill, and productivity. J Nurs Adm. 2011; 41(1) 41-7.

20.Azevedo AL, Araújo STC. A visibilidade do assédio moral no trabalho de enfermagem. Rev Pesqui Cuid Fundam. 2012; 4(3):2578-84.

21.Rodwell J, Demir D, Flowe RL. The oppressive nature of work in healthcare: predictors of aggression against nurses and administrative staff. J Nurs Manag. 2013; 21(6): 888-97.

22.Santos SIL, Andrade CG, Costa ICP, Santos KFO, Costa SFG, França JRFS. Psychological harassment int He ambit of nursing: na integrative literature review. Cogitare enferm. [Internet]. 2014 Mar [cited 2015 Nov 08]; 19(1):159-65. Available from: http://www.revenf.bvs.br/scielo.php?script=sci_arttext&pid=S1414-85362014000100024&lng=pt

23.Cahú GRP, Costa SFG, Costa ICP, Batista PSS, Batista JBV. Moral harassment experienced by nurses in their workplace. Acta paul. enferm. [Internet]. 2014 Abr [cited 2015 Nov 08]; 27(2): 151-6. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0103-21002014000200011&lng=pt . http://dx.doi.org/10.1590/1982-0194201400027

24.Silva AF, Costa SFG, Batista PSS, Zaccara AAL, Costa ICP, Duarte MCS. Moral harassment: a study with nurses of the family health strategy. J Res Fundam Care. 2015; 7(1):1820-31. 25.Mesquita SKC. Produção científica: assédio moral no âmbito do trabalho em enfermagem. Revista da Universidade Vale do Rio Verde. 2015; 11(2):327-32.

26.Silva de Paula G, Fontes Reis J, da Conceição Dias L, Damásio Dutra VF, de Souza Braga AL, Antunes-Cortez E. Suffering of Psychic Training Nursing Unit Hospital. Aquichan. 2010; 10(3):267-79.

27.Aguiar MR. Assédio moral: problema antigo, interesse recente [Internet]. 2008. [Cited 2015 Nov 18]. Available from: http://www.egov.ufsc.br/portal/sites/default/files/anexos/23353- 23354-1-PB.pdf

28.Confederação Nacional dos Trabalhadores da Saúde. Assédio moral no trabalho atitude para mudar. 3ª ed. Brasília (DF): CNTS; 2015.

29. Elias MA, Navarro VL. The relation between work, health and living conditions: negativity and positivity in nursing work at a teaching hospital. Rev. Latino-Am. Enfermagem [Internet]. 2006 Ago [cited 2015 Mai 20]; 14(4): 517-25. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104--11692006000400008&lng=pt . http://dx.doi.org/10.1590/S0104-11692006000400008

30.Brito AM, Oliveira IJ, da Silva CB, Cerqueira AJS, Silva RC, Cerqueira RS, et al. Assédio moral: impacto sobre os profissionais de enfermagem. Revista Digital. Buenos Aires. 2013; 18(181). [cited 2015 Nov 20]. Available from: http://www.efdeportes.com/efd181/assedio-moral-sobre-os-profissionais-de-enfermagem.html

31.Ministério da Previdência Social (Br). Saúde e segurança do trabalho: estudo da revidência Social indica mudança nas causas de afastamento do trabalho. [Internet]. [Update 2014]. [cited 2015 Nov 20]. Available from: http://www.previdencia.gov.br/2014/04/saude-e-seguranca-do-trabalho-estudo-da-previdencia-social-indica-mudanca-nas-causas-de-afastamento-do-trabalho/

32.Portal do Servidor (Br). Assédio moral no trabalho.[Internet]. nº123, fev. 2011. [cited 2015 Nov 03]. Available from: http://www.senado.gov.br/senado/portaldoservidor/jornal/Jornal123/senado_assedio_moral.aspx

33.Candido TH. Assédio moral acidente laboral. São Paulo: Editora LTDA; 2011.

34.Moreira DS, Magnago RF, Sakae TM, Magajewski FRL. Prevalence of burnout syndrome in nursing staff in a large hospital in south of Brazil. Cad. Public [Internet] health. Jul 2009 [cited 2015 Jun 24]; 25 (7): 1559-68. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-311X2009000700014&lng=pt . http://dx.doi.org/10.1590/S0102-311X2009000700014

35.Bobroff MCC, Martins JT. Moral harassment, ethics and psychological stress in the workplace. Rev. Bioét. [Internet]. Aug 2013 [cited 2016 Jan 15]; 21 (2): 251-8. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1983-80422013000200008&lng=pt . http://dx.doi.org/10.1590/S1983-80422013000200008

36.Lima GHA, Sousa SMA. Psychological violence in the nursing work. Rev. Bras. Enferm. [Internet]. Oct 2015 [cited 2015 Apr 13]; 68 (5): 817-23. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-71672015000500817&lng=en . http://dx.doi.org/10.1590/0034-7167.2015680508i