Outline of violence suffered by the hospital emergency department nursing team
Ana Paula da Fonseca da Costa FernandesI; Joanir Pereira PassosII
Occupational nurse. Master in Nursing and Biosciences from the Federal
University of the State of Rio de Janeiro. Brazil. E-mail: email@example.com
II Nurse. PhD in nursing. Full Professor, Federal University of the State of Rio de Janeiro. Brazil. E-mail: firstname.lastname@example.org
Objective: from the nursing team's viewpoint, to characterize the violence suffered in their relationship with users or companions/visitors in a hospital emergency department of the public health system. Method: this is a portion of a qualitative, descriptive study using content analysis technique, by interview of 24 nursing professionals working in the emergency department of a public hospital in Rio de Janeiro in 2012. The study was approved by the research ethics committee. Results: verbal and physical violence were identified in the four categories that emerged, which were also found to be multifactorial. Conclusion: problems were found relating to hospital management as a factor in triggering violence, the main mitigating/aggravating factor being management of the nursing team for this situation. Because of underreporting, studies in this area are helpful when taking measures to promote and protect nurses' health.
Descriptors: Nnursing; worker's health; violence; work conditions.
Hospital emergencies are among the sectors that pose greater risk of violent events1. The classification of prioritization according to level of complexity, the delay of consultations, and the lack of clarifications by professionals are cited as the causes of such events2. Violence from contact with patients/family members has increased worldwide3-5. Studies point to an underreporting of cases5,6 that prevent the availability of reliable data as well as the protection of workers. Because nursing professionals have greater contact with patients, they are more exposed to this type of violence4,6,7. Nursing technicians are identified as the category that suffers the most with physical violence8.
Thus, this study defined as object the violence suffered by nursing professionals in hospital emergency rooms. The objective of the study was: to characterize, from the point of view of nursing professionals, the violence suffered from their relationship with users or companions/visitors in the public health system in a hospital emergency service.
Due to the underreporting of violence, studies in this theme are essential to contribute to the protection of the health of the exposed workers, as well as to contribute to the creation of public policies on the subject in order to guarantee the safety in the work of nursing professionals.
From the sociological and psychodynamic point of view, aggressiveness is the first reaction to frustration and varies according to the degree of interference with the frustrated response and the number of frustrated responses9. However, violence cannot be explained under a single strand. The Ecological Model of the World Health Organization (WHO) points to the multifactorial causes of violence resulting from the individual's social, individual, relational, environmental and cultural conditions10.
Corroborating the above, psychology theories have addressed the importance of learning models of violence, initially focusing on the individual's relational levels. Thus, violence is learned from models whose emotional load is strong and aggressive behaviors are easily diffused. Aggressiveness is stimulated, uninhibited and imitated9.
As for nature, there are two types: physical violence, with physical, sexual or psychological damages; and psychological violence, through the deliberate use of power and producing damages to mental, physical, moral, spiritual or social development11. Both aim at controlling the actions of the other.
Individuals may experience negative emotions during hospitalization. Patients may react violently to stimuli when they have their expectations regarding the illness/hospitalization process frustrated. Therefore, situations of disease can be sources of stress, especially in the hospital environment1-5.
This is an excerpt from a descriptive, qualitative research. The scenario was a public hospital in Rio de Janeiro, whose emergency room is open and operates 24 hours a day. Nursing professionals assigned to the emergency and present at the time of data collection were included in the study. Nursing professionals who, although working in the emergency room were formally assigned to other hospital sectors were excluded.
Professionals working in the three shifts were invited to share in the study, totaling 24 interviewees in the year 2012. Of these, six were nurses, ten nursing were technicians and eight were nursing assistants. Semi-structured interviews with an average duration of 60 minutes were used for data collection. The interviewees (I) were identified by acronyms, specifying the sex - woman (W) and man (M) - and the order of the interview. Example: IW1, IM3 and so forth. Data were treated using the content analysis technique according to Bardin12.
Four categories emerged from the treatment of the speeches, namely: Organizational problems; Human factors that influence violence; Forms of violence; User profile. It should be clarified that the study design was evaluated by the Research Ethics Committee of the hospital, field of research, under register CEP 49/10. All interviewees signed the Informed Consent Term.
RESULTS AND DISCUSSION
The nursing professionals interviewed were mostly female (79.25) in age group between 20 and 30 years (41.7%) and have worked in the emergency sector since the date of admission (87.5%). The professionals said to work in all sectors of the emergency, taking turns in these sectors through exchanges of on call service and re-shifts.
The categories produced with the participants' discourses are presented and discussed below.
This category covers aspects related to management of problems, poor work processes and high number of patients who seek the unit through their own means. Work processes encompass the organization and dimensioning of work spaces, while management problems include lack of infrastructure and human and material resources.
Here, in our emergency, we do not provide adequate care because of the space and the rush and the insufficient number of professionals compared with the high number of patients. (IW6)
Environments with excessive sensory stimulation from noise, excessive or poor lighting, lack of space, and excessive heat or cold, contribute to increase irritability and stress levels of individuals and may stimulate their aggressive behavior. In line with these findings, the literature mentions the infrastructure of healthcare spaces, lack of human and material resources, work organization and overcrowding as factors that generate stress and trigger violence among patients seeking care in hospital emergencies2. These problems also influence the suffering of workers13 and the quality of the care provided14, and can contribute to the inadequate coping with situations of violence.
These factors somehow contribute to the frustrated expectations of patients seeking solutions to their health problem in emergency services, to resolve their fears and anguish that permeate the process of becoming ill/being hospitalized. The care act focused on the biomedical model, centered on the pathology and having doctors as central figures, is also noticeable in emergency services15.
The patient is seen as a disease, and this can lead to a lack of humanization of care by the team. The feelings that surround the process of becoming ill/being hospitalized allied to the non-humanized care provided can sharpen the violence on the part of patients or their relatives who sees their expectation regarding care frustrated.
We hear a lot of complaints about service delays. So, most of the violence happens because it takes too long, they start swearing, and the doctor is not here. The complaint is always this: absence of doctors and the delay of care. (IM5)
In short, the work organization in emergency services directly interferes with the quality of the health service provided to the population. Problems of this nature have their genesis in the lack of commitment to humanization of care by health managers, directors and professionals who make up the multiprofessional team. Therefore, principles such as respect, solidarity, ethics and human recognition must be valued by all. It is possible to reduce situations of violence in nursing work spaces.
Human factors that influence violence
The way nursing professional react may have a positive or negative repercussion, aggravating or minimizing a situation of violence. Inadequate responses of professionals, through rude words, using threats, irony and debauchery are perceived by the respondents as strategies of defense against the violence suffered, as we can see, below:
I usually ignore them or mock; I laugh or sometimes show power. (IW13)
I discussed with her because [...] we know that we shouldn't, that's 'yes, ma'am', but that's in theory. In practice it is not quite like that. (IW8)
An aggressive response and irritability before a situation of violence are behaviors that add risk and aggravate situations of violence. Since violence is a reaction to frustration, its variation is directly proportional to the degree of interference with the response to frustration. Thus, the greater the stimulus through aggressive behaviors on the part of nursing professionals, the greater is the intensity of the frustration and the more intense is the aggression9.
Negative attitudes towards an episode of violence can be considered as coping strategies in the face of situations of psychic suffering of the professional who suffered violence in the workplace. The respondents' statements point to the creation of specific defensive systems for fear of violence. Defense strategies, therefore, aim at protecting the professional against the painful effects of poor work organization. They can alleviate the suffering coming from work, reducing the chances of physical and mental illness16.
Lack of professional recognition and spaces for dialogue combined with heavy workload and the sense of helplessness contribute to the degradation of the mental health of profissionals17, and bad relationships among peers and lack of confidence in the service have been described as factors that contribute to loss of professional satisfaction18, and may exacerbate negative reactions to violence.
On the other hand, the presence of the security professionals, the team and also the empathy of the attacked professionals were cited as mitigating factors. Studies point to the importance of social support networks and trust and cooperation among peers for the mental health of professionals and for job satisfaction8,17,19.
There are security officers here [...] and their presence here, closer, gives us support, no doubt. (IW3)
She's already nervous. I'll come, I'll talk to her, I'll sit with her, calm her down. Or talk to the mother, to the father, whoever is there, and take my shift in a good mood, the rest of the shift. (IW15)
Strategies such as conflict avoidance, physically leaving the place, and non-involvement are seen as relievers of the stress caused by conflicts2, and also lessen the likelihood of aggravation of violence. The contact with family members and friends and the maintenance of affection circles are pointed out as positive coping strategies for the maintenance of mental health among the interviewed professionals20.
Forms of violence
Verbal, physical and psychological violence were mentioned, which have eventually culminated in work accidents at accidents in the way to the work place. It is important to emphasize the definition of violence used in this study, which is the "intentional use of force or physical power, action or threat, against oneself or against another person, or a group or community, that causes or is very likely to cause injury, death, or psychological, developmental damages or deprivations"10:5.
When she was leaving the service [...] they were there on the footbridge, waiting for her ... and she was bitten there. (IW4)
I've already been called incompetent, they almost beat me up. My friend came up behind me [...] I got the message right away and ran out. (IW12)
The companion said that he was keeping an eye on me and that [...] if the patient died he would kill me [...], and that I did not know what I was getting myself into. (IW1)
Studies show the exposure of nursing professionals to physical, verbal and psychological violence, pointing patients and family members/companions as the main aggressors in the nursing work environment in hospital emergencies1,4,21. Verbal violence is the most frequently cited, including insults, humiliations and threats3,6,7,22.
The literature and the present study reveal a poor notification of cases, which makes it difficult to create and implement preventive measures against violence and improve public policies for the safety of nursing professionals in their work spaces6. Underreporting also prevents the study of the characteristics of violence in the workplace as well as the most affected professionals, which would contribute to specific and possibly more effective actions against workplace violence11 .
Profile of users
According to the interviewees, the difficulties faced by the population, due to their socioeconomic conditions, prompt individuals to express their dissatisfaction with the care received at the health unit in a violent manner.
It is because here, because it is a public hospital, receives many people of community for hospitalization; these people have a low cultural level and are sometimes very aggressive. They suffer from many things and they come here with a very heavy emotional load. (IW19)
It's about education. I will not even tell you that it is of the social condition, because education interferes. Education comes from home; you did not go to college to learn education. Education is already with you. (IM2)
Studies highlight the personality of patients as a risk factor for triggering violent attitudes towards frustrations. These findings corroborate learning theories about violent behaviors based on violent examples arising both from the scope of family and community relations as well as media stimulation, and from the concept of a multifactor nature of violence9,10.
Violent behaviors are facilitated by imitation and disinhibition of aggressive instincts and activation of aggressive actions already structured in the past9. Therefore, individual characteristics of patients such as impulsiveness, low level of schooling, aggressive antecedents and even history of ill-treatment should be taken into account10.
A study also highlights other aspects such as predominance of elderly people, of patients affected by chronic diseases, and whose classification of risk was established between emergence and urgency23. Such aspects can reinforce the feeling of frustration related to the care provided, contributing to violent reactions on the part of the population.
Based on the four categories emerging from the analyzed discourses, it was possible to delineate the violence suffered by the nursing professionals participating in the present study.
Factors that trigger situations of violence were evidenced in the category of organizational problems, with emphasis on hospital management, including insufficient infrastructure of the work place and high demand for services allied to lack of information about the flows of service for the population.
The category human factors that influence violence highlighted the aggravating or mitigating factors that outline the consequences of the violence suffered. In this sense, the social support network tends to minimize violent episodes. On the other hand, debauchery, insinuations and neglect on the part of professionals tend to aggravate or unleash a latent situation.
Regarding the category of forms of violence, several manifestations of verbal violence, besides physical violence, were identified, thus confirming the multifactorial nature of the problem.
Finally, the profile of users was the category that pointed aspects related to clients and their families such as education and socioeconomic level, which also influence on the way they deal with frustrations and obstacles related to becoming ill/being hospitalized.
As for the limitations of this study, a small sampling and a single scenario hinder the generalization of the results. However, the findings express a local reality that needs to be transformed to improve the working conditions of the nursing staff and the quality of care.
Nurses are encouraged to report the cases of violence to institutional authorities with a view to promoting preventive measures and resolving these problems.
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