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Enfermería Global

On-line version ISSN 1695-6141

Enferm. glob. vol.20 n.62 Murcia Apr. 2021  Epub May 18, 2021 


Facing violence in nursing work hospital context and primary health care

Grasiele Fátima Busnello1    , Letícia de Lima Trindade2    , Daiane Dal Pai3  , Daiana Brancalione4  , Manoela Marciane Calderan4  , Kaciane Boff Bauermann5 

1Nurse. Doctoral student in Health Sciences. Universidade Comunitária da Região de Chapecó. Brazil

Nurse. Professor at the Universidade do Estado de Santa Catarina. Brazil

2Nurse. Post-doctorate in Nursing. Professor at the Universidade do Estado de Santa Catarina. Brazil.

Universidade Comunitária da Região de Chapecó. Brazil

3Nurse. Ph.D. in Nursing, Universidade Federal do Rio Grande do Sul. Brazil.

4Nurse. Nursing graduate, Universidade do Estado de Santa Catarina. Brazil.

5Nurse. Master's student in Nursing, Universidade do Estado de Santa Catarina. Brazi



Violence at work is defined as an action, incident, or behavior with a voluntary attitude of the aggressor, as a result of which a professional is assaulted, threatened, or suffers some damage during the performance of their work. The nursing team is exposed daily to situations of violence at work.


To understand and analyze the mechanisms of coping with violence used by nursing professionals in the hospital context and Primary Health Care.

Materials and Method

A mixed sequential explanatory study, with 198 nursing workers from a hospital and 169 from Primary Health Care, in a municipality in southern Brazil. The data were collected using a survey in the quantitative stage and interviews in the qualitative one analyzed through the software Statistical Package for the Social Sciences and by the thematic analysis.


It was identified that 51% of the participants were victims of violence, and the coping mechanisms used by the workers are individual and collective, with a predominance of the first, showing that the problem is often directed at the victim. Collective work was a contributing factor in tackling violence, with emphasis on dialogue and support among the team. However, there was no institutional support in the search for conduct in the face of episodes of violence and consequences for perpetrators.


The prevalence of violence was high in both scenarios, with different characteristics regarding the profile of victims and perpetrators. The importance of collective coping is reinforced, as the most effective way to combat violence in the workplace.

Keywords: Violence at work; Nursing; Coping Strategies; Primary Health Care; Hospital service


The International Labor Organization (ILO) characterizes violence at work as any action, incident or behavior based on a voluntary attitude of the aggressor, in which a professional is assaulted, threatened or suffers any damage or injury during the job or as a direct result of their work 1. Violence is classified as physical or psychological. Physical violence is the use of physical force against another individual or group of people culminating in some physical, psychological, or sexual damage. Psychological violence is categorized as the use of power, which can be through threats against an individual or a group of individuals, resulting in physical, mental, spiritual, moral, or social damage. Psychological violence is subdivided into verbal aggression, bullying, sexual harassment, and racial discrimination 2.

The prevalence of occupational violence against health professionals is high in several international studies3,4. Brazilian studies show the same 5.

However, the World Health Organization (WHO) highlights that, despite the magnitude of cases of violence, there are important data gaps since at least 60% of countries do not have quality information, hindering prevention and control of the problem(6. Existing research observed the lack of support from institutions and the underreporting of episodes of violence experienced by professionals 3)(7)(8).

Health workers, in particular the nursing team, have a daily exposure to situations of violence at work, many of them becoming the target of threats and aggressions from colleagues and users of services, enhanced by being closer to these people on their job 9.

Nursing workers are exposed daily to situations of violence in their workplaces, both in hospital settings and in Primary Health Care (PHC). To face these circumstances, the worker needs to use mechanisms combining cognitive efforts and behaviors to mitigate, eliminate, or change stressful situations.

From this perspective, the question that guided this investigative proposal stands out: what are the coping forms used by the nursing team in episodes of violence at work and factors associated with behaviors in the hospital and the Primary Health Care? To answer this question, this study aims to analyze the mechanisms for coping with violence, used by nursing professionals in the hospital and the Primary Health Care.


We developed a study of mixed methods using the sequential explanatory research strategy, which involved initially collecting quantitative data, using the results to direct the collection of qualitative data10, allowing to deepen some findings. The research scenario brought together the primary and tertiary care levels, involving a public hospital and 26 Basic Health Units (UBS). This scenario represents the Health Care Network, in a municipality in southern Brazil, selected intentionally due to empirical observation about the exposure of workers to violence at work.

In the QUAN stage, the inclusion criteria for participation in the study were: being part of the professional nursing category, has been working at the institution for more than 12 months. We excluded from the study workers on leave of absence, on vacation, or during the period of data collection. A sample calculation by scenarios was used considering 95% confidence and 5% error, 50% prevalence, calculated with the help of WINPEPI version 11.32. During the data collection period, the population in the hospital includes 75 nurses, 22 trainee nurses, 413 nursing technicians, and 22 nursing assistants, and the PHC had 53 nurses, 11 nursing technicians, and 148 nursing assistants. Thus, 51 nurses, 141 technicians, and six nursing assistants working at the hospital; and 47 nurses, 113 nursing assistants, and nine nursing technicians in the PHS participated in the study, totaling 367 nursing workers, by calculating sample by scenario and by category. They were selected by lot, based on the list of active workers during the study period.

The sample of participants answered the Survey Questionnaire Workplace Violence in the Health Sector, proposed by WHO, ILO, and Public Services and International Nursing Council11 translated and adapted to Portuguese2. The instrument addresses the occurrence of physical and psychological violence. Psychological violence is composed of verbal aggression, bullying, sexual harassment, and racial discrimination, which includes characteristics of the aggression, the perpetrator, the victim, reactions, and measures adopted.

In the QUAL stage, workers were considered exposed to violence, selected for convenience, from the questionnaire application, and contemplated the report of the experiences lived in the situation of violence at work. For this stage of the study, the total number of participants was defined by information saturation, requiring 15 interviews with hospital workers and 18 interviews with UBS workers. We invited 33 selected participants to answer an interview with semi-structured questions, focused on the worker's perception of the theme of the study, with questions about: how situations of violence are treated in the workplace and what coping strategies for situations are used. These interviews were recorded on audio, followed a script, and enabling to better understand the violence at work by the professionals.

Data collection took place in two moments, in the hospital scenario from October 2014 to December 2017 and in the PHC scenario from September 2018 to March 2019 at the professionals' workplace, with the authorization of health institutions through a previous contact presenting the objectives and getting the signature of the Informed Consent Form in two copies. We tried not to intervene in the teams' work dynamics and data collected in the different care shifts.

We coded, tabulated, and analyzed the data using the Statistical Package for the Social Sciences (SPSS) software, version 23.0. The QUAN variables were described as mean and standard deviation or median and interquartile range. Categorical variables were described by absolute and relative frequencies. To compare the means, we applied the t-student test for independent samples. In the case of asymmetry, we also used the Mann-Whitney test.

Pearson's chi-square or Fisher's exact tests assessed the association between categorical variables. To control confounding factors, Poisson Regression analysis was applied. The scenario for the entry of the variable in the multivariate model was that it should have a value of p <0.20 in the bivariate analysis. However, only variables with p <0.10 remained in the final model. The level of significance adopted was 5% (p <0.05) and the analyzes were performed using the SPSS version 21.0 program.

The analysis of the interviews after their transcription used the thematic analysis of the testimonies, according to Bardin12. The testimonies were organized into general categories, subsequently into subcategories, and the following manuscript will discuss: (1) how situations of violence are treated in the workplace; (2) the problem of violence is often directed at the victim and (3) mechanisms for coping with violence in nursing work.

To preserve the anonymity of the participants, they were coded as Nurse (N), Nursing Technician (NT), and Nursing Assistant (NA), followed by the order number of the instruments.

The study complied with ethical prerogatives for research involving human beings and was approved by the Research Ethics Committee (opinions 933,725/2014 and 2,835,706/2017). Participants signed an informed consent form and an authorization term for voice recording.


The profile of the sample studied in the hospital QUAN stage represented 198 workers in the nursing category, of whom 141 were nursing technicians, 51 nurses, and six nursing assistants. Among them, n=165 (84.2%) were female, with an average of 28.6 (± 6.6) years old, n = 130 (66.7%) had partners, with an average of one child, average education of 14.3 (± 1.8) years of study, with experience average professional of eight years, with a minimum of three years and a maximum of 16 years, and weekly workload of 42.1 (± 5.0). Most workers n = 167 (86.5%) have frequent contact with patients, do not have a managerial position or a double job. Regarding the lifestyle habits of the participants in this scenario, we observed that n = 08 (4.1%) are smokers and n = 65 (33.3%) use alcoholic beverages once or twice a week. Most sleep less than eight hours a day and 31.6% use medications.

In the PHC environment, 169 nursing professionals were investigated in the QUAN stage, n = 47 (27.8%) nurses, n = 09 (5.3%) nursing technicians and n = 113 (66.9%) nursing assistants. Among these professionals, n = 158 (93.5%) were female, with a mean age of 41.1 (± 8.8) years old, n = 119 (70.4%) have a partner, (70.4%) have on average one child, with an average education of 15.4 years, professional experience of 14 years on average (between eight and 20 years of experience). As the nursing staff in the hospital area, in PHC also most n = 159 (94.1%) have frequent physical contact with patients during work activities, do not have a leadership position or double bond. In this scenario, we also observed that most of them are not a smoker n = 161 (95.27%), with similar alcohol consumption, with the same average hours of sleep (7.1 hours). However, the professionals in the PHC have a greater record of the use of some medication (98.8%). In both scenarios, the most mentioned medications were anxiolytics, psychotropics, and other medications to control chronic diseases, such as antihypertensive drugs.

Most workers who suffered violence at work in the hospital environment were women n = 89 (89%), white, n = 86 (85.1%) with 14.7 years of studies (± 2/p = 0.001), without a partner n = 41 (41%), with fewer children. Most of them were nurses, n = 38 (37.6%), who were in frequent contact with patients n = 95 (94.1%). Also, for each additional point on the scale of concern about violence in the workplace (3.7 ± 1.2), there is a 14% increase in the likelihood of suffering violence at work.

In the context of PHC, the profile was similar, formed by women, n = 158 (94.3%), white, n = 154 (90.1%), with 15.4 ± 2.8 years of studies, married or living with a partner n = 119 (70.4%). The nursing techniques n = 09 (28%) were more frequent victims, also in frequent contact with patients. For each additional point on the scale of concern with violence in the workplace, there is a 12% increase in the likelihood of suffering workplace violence.

The study enabled to identify the aggressors, in which the co-worker in the hospital environment is the most frequent n = 47 (32%), followed by others with 26%, with other aggressors not identified by the victims, for example, outsourced workers, aggression by bonding, among others. The patient represented 22% of the aggressors, the partner/family member with 11%, and the bosses with 9%. When the aggressor was the co-worker, the medical colleague was the most cited (84.2%). When investigating the PHC scenario, the data revealed that the main aggressor against nursing workers was the patient (91.12%), followed by the boss (26.62%) and then co-workers (10.05%).

As for the existing behaviors in the episodes of violence against nursing in both scenarios, the QUAN and QUAL data found are shown in the display below.

DISPLAY I.  Mechanisms for coping with violence at work in the hospital setting and Primary Health Care, Santa Catarina, 2020. (n = 367) 

* significance level adopted was 5% (p <0.05). Source: research data.


The findings of this study reveal a percentage of victims of violence, reinforcing data obtained from other national13)(14)(15 and international3)(16)(17 studies. Most of the victims of violence were nursing technicians in the PHC scenario and nurses in the hospital environment, in both scenarios, white women had most of the aggression.

The co-worker represented the most frequent aggressor in the hospital environment, different from the PHC scenario, in which the patient was the most common perpetrator, as shown in other studies5)(13)(18)(19.

When dealing with forms of coping with violence, we realized that they can be individual or collective. Individual coping is perceived in attitudes such as the use of escape strategies, not focused on problems, but on personal resources. Authors20 point out that, although the worker finds forms of defense against occupational stress factors, some conflicts are not noticed by him, nor by bosses and managers, which can negatively impact his work process.

Collective work was a contributing factor in the fight against violence, as shown in statements that address support between the team and dialogue. However, this is restricted to welcoming and emotional support to the victim, demonstrating the lack of incentive and institutional support in the search for behaviors in episodes of violence, a fact also found in other studies7,8.

Observing the set of information of the participants in coping violence, we observed that individual strategies are mostly used, an aspect added to the few behaviors taken with the perpetrators, hindering the nursing to face the problems in the work context.

Analyzing the findings regarding the mechanisms of coping with violence, we could see that in the hospital context, most professionals claim that there are procedures for reporting violence in their workplace. They also state that there is a stimulus for reporting violence in their workplace and that the boss and co-workers are the main stimulators of this report.

In the context of PHC, the findings were the opposite since most professionals claim that there are no procedures for reporting violence in their workplace, and there is a lack of incentive to report violence in their workplace, and when this report exists, the patients are the main stimulators. Research carried out in PHC centers in Serbia showed that health professionals consider it useless to denounce violence as management will not take any action. However, the participants affirm that, if there was greater managerial and institutional support, violence would be more frequently reported 16.

We also noticed the lack of behavior and notification of episodes of violence, both in the QUAN and QUAL stages, as well as the lack of support and institutional positioning. A study found that the interviewees consider violence to be normal in nursing work; however, they never participated in training on how to act in these events21. The WHO indicates that violence can be avoided. 6 However, its naturalization and the lack of measures appears frequently in other investigations on the topic3)(22)(23)(24.

An investigation found in Jordan showed that respondents stated failing to report incidents of violence because they believe it is useless. Some did not report it because they thought it was unimportant, and the employer never offered advice, reporting opportunities, or other types of support3.

In Slovenia, the main reason for the lack of notification and reports of episodes of violence at work was the belief that the report would not change anything23. An investigation in Turkey found that nurses living in this situation said that they hurt their physical health and/or psychology. However, only 1.8% of them received professional help22. Other authors found that most participants reported the absence of policies to deal with violence at work24. This is a criticism of how the prevention of violence at work has been treated by the institutions, showing failures in the responses of health leaders and institutions23.

Violence has repercussions on the strain of nursing workers, sometimes causing damage to workers' health, both physical and psychological such as the emergence of somatic diseases, contributing to demotivation with the profession. Also, violence weakens interpersonal relationships and can interfere with the quality of care provided to the patient.

The set of findings allows reflecting that the planning of the work process and the guarantee of necessary resources for the good functioning of the service can be protective factors for workers. In this sense, the use of tools, such as the nursing process, protocols, and resolutions that support nursing practice, should be part of the team's daily routine to ensure autonomy in the development of care, guaranteeing safe and humanized assistance. These tools contribute to the strengthening and enhancement of the profession, empowering professionals, and contributing to safe work environments.


The study of violence in the hospital and primary health care contexts revealed the profile of victims and perpetrators, which are important findings to understand the phenomenon and map unique measures to face the problem in different contexts, reaffirming the importance of continuous studies on the theme and in different care settings.

When analyzing the forms of coping, we found that the individual coping was the most used by the victims, mainly the escape strategies, not focused on the problem. In this sense, we reinforce the importance of collective coping as the most effective way to combat violence in the workplace.

Despite the victims showed the existence of a procedure for reporting the episodes, the resource is not, or is little used, as the victim feels insecure about the report and still considers it useless by the lack of behavior of the institution in these episodes, pointing to the trivialization of the problem.

The study limitations were the impossibility of aggregating all participants in the QUAL, failing to listen to other participants. On the other hand, the study corroborated with knowledge produced, using new elements for the understanding and analysis of violence, especially about the forms of coping used by the victim in the occurrence of this problem, which is common worldwide.

When investigating the subject, we could analyze the dimension of the issue, to promote the creation of measures for the prevention, protection, and confrontation of workplace violence. Nursing workers, aware of how violence occurs, become more vigilant, understanding that only specific actions do not solve the problem. Each worker should reflect on their daily actions and identifies in their daily lives, attitudes that favor the culture of violence, but, also, they need more efficient institutional measures. Actors from all sectors, especially in the management of health services, need to act in an integrated and coordinated way to elaborate strategies and public policies that favor the prevention of violence and the promotion of a culture of peace.


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Received: April 28, 2020; Accepted: October 05, 2020

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