My topic is 

Workplace Violence in Nursing 

2-3 pages excluding the title page and reference page. (APA paper)

Double-spaced

Thispaper is worth 100 points total. This must be submitted prior to the start of class on

Monday Class, April 18, 2020, 11:59pm.

Tuesday Class, April 19, 2020, 11:00pm.

There will be 5 points deducted for every day the assignment is late up to one

week. After that point, the student will earn a score of “0”.

Introduction – 10pts

Introduce the topic and your reason for choosing this topic

Main topic- 45pts

 Describe and discuss the topic (15pts)

 The relationship to nursing (15pts)

 The impact of topic on a specific population (could be cultural, the nurse, the
health care profession, the student, education) different from the main focus. This

could be positive or negative or both- (15pts)

Summary- 10pts

Incorporate a minimum of 2 peer reviewed journal articles into your paper to provide

insight to your topic- 15pts

APA format -10pts

Grammar, spelling, punctuation- 10pts

You may have no more than ONE direct quote. Must be cited properly.

Length of paper is 2-3 pages. In addition you must have a title page and a reference page.

Times New Roman 12pt. Font

One inch margins

Double spaced

TITLE OF YOUR SPECIFIC MICP (NOT TO EXCEED 50 CHARACTERS)

1

TITLE OF YOUR SPECIFIC MICP (NOT TO EXCEED 50 CHARACTERS) 2

Title of Your Paper

Student Name

School of Nursing

Introduction to Professional Nursing

Due Date

Title of Your Paper

Begin body of paper here. This should be your introduction, which should include a definition of your topic.

Introduction

Introduce your topic to the reader. Don’t forget to include in-text citations throughout your paper for information that you get from one of your references (Lastname, 2018).

Topic Discussion

Describe and discuss your main topic. Include the focus of your topic, why you chose it, and what makes you interested in it.

Relationship to Nursing

Describe your topic’s relationship to nursing.

Impact on Specific Population

Describe the impact of your topic on a specific population different from the main focus. This could be cultural, the nurse, the health care profession, the student, and/or education. The impact could be positive or negative (or both).

Conclusion

Summarize your paper. No new information should be added to this section.

References

Lastname, A., Lastname, B., & Lastname, C. (2016). Title of the source without caps except Proper Nouns or: First word after colon. The Journal or Publication Italicized and Capitalized, Vol(Issue), Page numbers. https://doi.org/10.1000/182

Lastname, W. (2018). If there is no DOI use the permalink from EBSCO or the website URL. Journal Title, 10(7), 166-212. http://0-search.ebscohost.com.library.ecok.edu/login.aspx?direct=true&db=nup&AN=T700731&site=eds-live&profile=eds-nurs

SousaLS de, Oliveira RM, Ferreira YC et al. Workplace violence in the hospital…

English/Portuguese

J Nurs UFPE online., Recife, 12(10):2794-802, Oct., 2018 2794

ISSN: 1981-8963 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i10a236958p2794-2802-2018

WORKPLACE VIOLENCE IN THE HOSPITAL OBSTETRICS
VIOLÊNCIA NO TRABALHO EM OBSTETRÍCIA HOSPITALAR
VIOLENCIA EN EL TRABAJO DE LA OBSTETRICIA HOSPITALARIA

Luana Silva de Sousa1, Roberta Meneses Oliveira2, Yane Carmem Ferreira Brito3, Bruna Karen Cavalcante
Fernandes4, Francisca Gomes Montesuma5, Regina Cláudia Melo Dodt6

ABSTRACT

Objective: to identify the manifestations of workplace violence in hospital obstetrics, as well as their related
factors, consequences, and management strategies. Method: this is an integrative review, with search of
MEDLINE, Lilacs, CINAHL, SciVerse Scopus and SciELO virtual libraries. After reading the articles, the data
were extracted and analyzed. Results: the sample consisted of 11 articles, most of them from Australia. The
main types of workplace violence in obstetrics were verbal abuse, intimidation, humiliation, and bullying;
related to: workers with high level of negative affectivity; older and/or hierarchically superior co-workers;
day shift; patients and/or companions under stress or with mental disorder; overburdened environments/staff
shortages; consequences included the personal, professional and organizational spheres; and managerial
strategies involved incident reports, peer/family dialogues, safety protocols, continuing education.
Conclusion: there is evidence of workplace violence in hospital obstetrics with negative impact on
professionals, patients, and institutions. Studies about this phenomenon in Brazil are suggested, enabling to
apply them in the management of obstetric units. Descriptors: Nursing; Workplace Violence; Incivility;
Obstetrics; Obstetric Nursing; Delivery Rooms.

RESUMO

Objetivo: identificar os modos de manifestação da violência no trabalho em obstetrícia hospitalar, bem como
seus fatores relacionados, consequências e estratégias de gerenciamento. Método: trata-se de revisão
integrativa, com busca nas bases de dados MEDLINE, Lilacs, CINAHL, SciVerse Scopus e biblioteca virtual
SciELO. Após a leitura dos artigos, efetuaram-se a extração e a análise dos dados. Resultados: constituiu-se a
amostra de 11 artigos, a maioria de origem australiana. Os principais tipos de violência no trabalho em
obstetrícia foram abuso verbal, intimidação, humilhação e assédio moral; relacionados a: trabalhadores com
nível elevado de afetividade negativa; colegas de trabalho mais velhos e/ou hierarquicamente superiores;
plantão diurno; pacientes e/ou acompanhantes sob estresse ou com transtorno mental; ambientes
sobrecarregados/escassez de pessoal; as consequências incluíram os âmbitos pessoal, profissional e
organizacional; e as estratégias gerenciais envolveram relatórios de incidentes, diálogos com
colegas/familiares, protocolos de segurança, educação permanente. Conclusão: há evidências de violência no
trabalho em obstetrícia hospitalar com impacto negativo sobre profissionais, pacientes e instituições.
Sugerem-se estudos acerca desse fenômeno no Brasil, possibilitando aplicá-los na gestão de unidades
obstétricas. Descritores: Enfermagem; Violência no Trabalho; Incivilidade; Obstetrícia; Enfermagem
Obstétrica; Salas de Parto.

RESUMEN

Objetivo: identificar los modos de manifestación de la violencia en el trabajo de la obstetricia hospitalaria,
así como sus factores relacionados, consecuencias y estrategias de gerenciamiento. Método: revisão
integrativa, com busca nas bases de dados MEDLINE, Lilacs, CINAHL, SciVerse Scopus y biblioteca virtual
SciELO. Após a leitura dos artigos, efetuaram-se a extração e a análise dos dados. Resultados: la muestra fue
de 11 artículos, la mayoría de origen australiana. Los principales tipos de violencia en el trabajo en
obstetricia fueron abuso verbal, intimidación, humillación y asedio moral; relacionadas a: trabajadores con
nivel elevado de afectividad negativa; colegas de trabajo más viejos y/o jerárquicamente superiores; guardia
diurna; pacientes y/o acompañantes sobre estrés o con trastorno mental; ambientes sobrecargados/escasez
de personal; las consecuencias incluyeron los ámbitos personal, profesional y organizacional; y las estrategias
gerenciales envolvieron informes de incidentes, diálogos con colegas/familiares, protocolos de seguridad,
educación permanente. Conclusión: hay evidencias de violencia en el trabajo en obstetricia hospitalaria con
impacto negativo sobre profesionales, pacientes e instituciones. Se sugieren estudios acerca de ese fenómeno
en Brasil, posibilitando aplicarlos en la gestión de unidades obstétricas. Descriptores: Enfermería; Violencia
Laboral; Incivilidad; Obstetricia; Enfermería Obstétrica; Salas de Parto.
1Specialist, State University of Ceará/UECE. Fortaleza (CE), Brazil. E-mail: lusilvasousa_@hotmail.com ORCID iD: https://orcid.org/0000-
0002-6203-0024; 2Ph.D., Department of Nursing, Federal University of Ceará/UFC. Fortaleza(CE), Brazil. E-mail:
menesesroberta@yahoo.com.br ORCID iD: https://orcid.org/0000-0002-5803-8605; 3Master´s student, State University of
Ceará/PPSAC/UECE. Fortaleza (CE), Brazil. E-mail: yane_carmem@hotmail.com ORCID iD: https://orcid.org/0000-0003-4362-0296; 4Ph.D.
student, State University of Ceará/PPCCLIES/UECE. Fortaleza (CE), Brazil. E-mail: brunnakaren@hotmail.com ORCID iD:
https://orcid.org/0000-0003-2808-7526; 5Ph.D., State University of Ceará/PPSAC/UECE. Fortaleza (CE), Brazil. E-mail:
francisca.montesuma@uece.br ORCID iD: https://orcid.org/0000-0002-5838-7821; 6Ph.D., Federal University of Ceará/UFC. Fortaleza
(CE), Brazil. E-mail: reginadodt@yahoo.com.br ORCID iD: https://orcid.org/0000-0002-8323-8465

INTEGRATIVE REVIEW ARTICLE

https://doi.org/10.5205/1981-8963-v12i10a236958p2794-2802-2018

mailto:lusilvasousa_@hotmail.com

https://orcid.org/0000-0002-6203-0024

https://orcid.org/0000-0002-6203-0024

mailto:menesesroberta@yahoo.com.br

https://orcid.org/0000-0002-5803-8605

mailto:yane_carmem@hotmail.com

https://orcid.org/0000-0003-4362-0296

mailto:brunnakaren@hotmail.com

https://orcid.org/0000-0003-2808-7526

mailto:francisca.montesuma@uece.br

https://orcid.org/0000-0002-5838-7821

mailto:reginadodt@yahoo.com.br

https://orcid.org/0000-0002-8323-8465

Sousa LS de, Oliveira RM, Ferreira YC et al. Workplace violence in the hospital…

English/Portuguese

J Nurs UFPE online., Recife, 12(10):2794-802, Oct., 2018 2795

ISSN: 1981-8963 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i10a236958p2794-2802-2018

Hospital institutions face changes in work

processes and people management, such as

the precariousness of labor relationships and

the need to deal with demand that is always

greater than the supply of services. This

situation has been associated with conflicting

situations and ethical dilemmas that directly

interfere with the care provided.

The daily work of health workers has been

configured as the scenario conducive to the

study of practices and behaviors translated

into risks for patients and organizations. The

destructive behavior in health work is

highlighted, which is about disrespectful

behaviors adopted in the practice

environment, involving complex multi-

professional interactions that harm workers,

patients, and organizations.1

The work in the context of hospital

obstetric care is highlighted, where multi-

powers are evident, as the scene of

institutional violence involving parturients,

doctors, and obstetricians. This scenario is

related to the fact that delivery and birth

have undergone transformations that reveal

its medicalization and migration to hospitals,

making some obstetric practices problematic

and triggering debates about delivery and

birth care.2

Thus, the University of Iowa’s Harm

Prevention Research Center classified violence

in four types to better determine the forms of

violence in the work context.3

This study focuses on type III violence,

which involves co-workers, including

physicians, nurses and nursing technicians,

students, and residents in hospital obstetrics.

There are also other widely publicized

concepts in the literature that permeate the

phenomenon of violence at work, such as

occupational violence and bullying at work,

which will be addressed in this re

search.

● To Identify the manifestations of

workplace violence in hospital obstetrics, as

well as their related factors, consequences,

and management strategies.

This is an integrative review of the

literature, guided by six steps: (1)

identification of the problem and definition of

the guiding question; (2) search and selection

of studies according to sampling criteria; (3)

data extraction; (4) critical analysis of the

selected studies; (5) interpretation of the

results and (6) preparation of the synthesis

and final report.4

A survey of scientific articles was carried

out in December 2017 in journals indexed in

the databases to compose the study sample:

Medical Literature Analysis and Retrieval

System Online (MEDLINE), Latin American and

Caribbean Literature in Health (LILACS),

Cumulative Index to Nursing and Allied Health

Literature (CINAHL), SciVerse Scopus and the

Virtual Library Scientific Electronic Library

Online (SciELO).

As search strategies, descriptors of the

theme registered in the Health Sciences

Descriptors (DeCS) and the Medical Subject

Headings (MeSH) were selected. The

descriptors related to violence at work were:

Workplace Violence, Bullying, Workplace

Bullying (MeSH only). The descriptors related

to the area of interest of the research were:

Obstetrics, Midwifery, Obstetrics, and

Gynecology Department, Obstetric

Departments and Nursing.

Then, the pairing of the descriptors with

the Boolean operator “AND” was performed,

with the objective of identifying studies that

contained one and another themes, always

considering a descriptor related to violence at

work and another related to the area of

interest. The combination of descriptor pairs

was performed in the title, abstract, and

subject fields.

The articles should answer the following

guiding question: how does the phenomenon

of violence at work in hospital obstetrics

occur, considering its modes of manifestation,

related factors, and impacts for those

involved?

Original articles of primary research,

available in full, published in Portuguese,

English or Spanish; and that responded to the

guiding question of the research were

included. Duplicate articles and those that,

after being screened and read in full, did not

address the purpose of the study were

excluded.

It should be emphasized that the inclusion

of temporal clipping regarding the period of

publication of the articles was not delimited,

since the purpose was to cover as many

manuscripts as possible on the theme,

considering the contemporaneity of the

phenomenon studied.

A data collection instrument was

elaborated for the analysis of the evidence

and construction of the synthesis of the

integrative review, with the purpose of

gathering the following information from the

articles: title, authors/year, journal,

INTRODUCTION

OBJECTIVE

METHOD

https://doi.org/10.5205/1981-8963-v12i10a236958p2794-2802-2018

Sousa LS de, Oliveira RM, Ferreira YC et al. Workplace violence in the hospital…
English/Portuguese

J Nurs UFPE online., Recife, 12(10):2794-802, Oct., 2018 2796

ISSN: 1981-8963 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i10a236958p2794-2802-2018

design/sample, objectives, and level of

evidence of the search.

Excerpts referring to variables of interest

in the review were also extracted from the

articles: ways of manifestation of violence at

work; sources; professionals involved and

contexts; characteristic behaviors and

impacts; management strategies.

The studies were analyzed critically by

reading in full. After analysis, a synthesis of

the selected studies was carried out, which

were later discussed, observing their

confluences and divergences.

Eleven articles were included in the

sample. Figure 1 shows the results of the

search.

Figure 1. Flowchart of study selection according to the Preferred Reporting Items for Systematic Reviews and

Meta-Analyzes (PRISMA). Fortaleza (CE), Brazil, 2017.

Title Authors,
Year

Journal Design and
Sample

Objectives Level of
evidence

Consultants as victims
of bullying and
undermining: a survey
of Royal College of
Obstetricians and
Gynaecologists
consultant experiences

Shabazz et
al., 2016

BMJ Open Cross-sectional
study with 278
physicians
experienced in
obstetrics and
gynecology.

To explore incidents of
bullying and humiliation to
physicians experienced in
obstetrics and gynecology.

VI

Midwifery student
exposure to workplace
violence in clinical
settings: an
exploratory study

McKenna;
Boyle,
2016

Nurse
Education
in Practice

Cross-sectional
study with 52
students of
obstetric nursing.

To examine the exposure
of obstetric nursing
students to violence in a
maternity hospital

VI

Psychosocial
Antecedents and
Consequences of
Workplace Aggression
for Hospital Nurses

Demir;
Rodwell,
2012

Health
Policy and
Systems

Cross-sectional
study with 207
general nurses
and obstetricians.

To test a two-stage model
of the antecedents and
consequences of
workplace violence among
nurses

VI

Midwifery student
reactions to workplace
violence

Shapiro;
Boyle;
McKenna,
2017

Women
Birth

Cross-sectional
study with 52
students of
obstetric nursing.

To explore the responses
of obstetric nursing
students to workplace
violence, as well as to
assess their impact

VI

Workplace aggression,
including bullying in
nursing and midwifery:
a descriptive survey
(the SWAB study)

Farrell;
Shafiei,
2012

Internation
al Journal
of Nursing
Studies

A descriptive
study with 1495
general nurses
and obstetricians.

To report on the nature
and extent of workplace
violence experienced by
nurses and midwives.

VI

Paramedic and
midwifery student
exposure to workplace
violence during clinical
placements in

Boyle;
McKenna,
2016

Internation
al Journal
of Medical
Education

Cross-sectional
study with 393
students of
paramedics and
obstetric nursing.

To identify the type of
violence in the work
experienced by
paramedical and obstetric
nursing students.

VI

RESULTS

Articles identified in databases
(n=30)

Publications after removing the

duplicates (n=25)

Articles included in the review (n=11)

Publications excluded after reading abstracts (n=12)

-Article not found in full for free (n=4)
-News/comment type article (n=3)
– Items that did not respond to the guiding question
(n=5)

Id
e
n
ti

fi
c
a
ti

o

n

S
c
r
e
e
n
in

g

In
c
lu

d
e
d

E
li
g
ib

il
it

y

Articles evaluated in full (n=13)
Full-text articles excluded (n=2)

It did not specifically examine or address violence at

work in obstetrics, or only address violence by

patients/visitors.

https://doi.org/10.5205/1981-8963-v12i10a236958p2794-2802-2018

Sousa LS de, Oliveira RM, Ferreira YC et al. Workplace violence in the hospital…
English/Portuguese

J Nurs UFPE online., Recife, 12(10):2794-802, Oct., 2018 2797

ISSN: 1981-8963 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i10a236958p2794-2802-2018

Regarding the distribution of the articles,

Figure 2 shows the articles inserted in the

review according to the variables of

methodological interest.

It was verified that the articles included in

the review were all in English, most of them

of Australian origin (7), showing that this is a

topic of interest by the researchers of that

country.

Regarding to the period, all have been

published since 2012, which coincides with

the recent mobilization of researchers around

the world in search of public policies and

studies on violence in the workplace,

including its consequences for those involved

in hospital settings and in general health.

Also, the journals in which these articles

were published are from different areas,

ranging from medical and nursing education to

journals geared to clinical practice. This

demonstrates that this problem is being and

should be increasingly addressed in the

educational and care spheres.

The most used methodology in the articles

(9) was cross-sectional studies involving

physicians specialized in gynecology and

obstetrics (2), general nurses and

obstetricians (5), obstetric nursing students

(2) and obstetric and paramedical nursing

students (1). One study used descriptive

research as a design.

In general, studies have emphasized the

types of workplace violence (9), their

antecedents (2) and consequences (5), as well

as the reactions and attitudes of the victims

(2).

A synthesis of the results of the research

was based on the variables of interest of the

review: main types of violence in work in

obstetrics and vulnerable groups; related

factors, perpetrators, and the work impact of

violence in obstetrics; and strategies for

management.

Australia – A pilot
study
Oppression and
exposure as
differentiating
predictors of types of
workplace violence for
nurses

Rodwell;
Demir,
2012

Journal of
Clinical
Nursing

Cross-sectional
study with 273
general nurses
and obstetricians.

To provide a background
model of bullying at work
to apply to a wider range
of workplace assaults,
including bullying and
different types of violence
among nurses.

VI

Nurses’ attitudes and
reactions to workplace
violence in obstetrics
and gynecology
departments in Cairo
hospitals

Samiret
al., 2012

Eastern
Mediterrane
an Health
Journal

Cross-sectional
study with 416
nurses from
gynecology and
obstetrics
departments.

To identify forms of
workplace violence
against obstetric nurses
and to assess their
reaction and attitudes.

VI

A Study of Workplace
Violence Experienced
by Doctors and
Associated Risk Factors
in a Tertiary Care
Hospital of South
Delhi, India

Kumar et
al., 2016

Journal of
Clinical and
Diagnostic
Research

Cross-sectional
study with 151
physicians directly
involved in
patient care.

To examine the types of
violence experienced by
physicians in various
departments, along with
possible causes and
effects on work
performance, incident
treatment, and
recommendations for
violence prevention.

VI

Bullying workshops for
obstetric trainees: a
way forward

Cresswell
et al.,
2015

The Clinical
Teacher

Intervention study
(workshop),
involving
obstetricians and
gynecologists,
trainees and other
professionals.

To hold a workshop to
address the issue of
bullying and humiliation
within the specialty.

VI

Occupational Violence
and Aggression
Experienced by
Nursing and Caring
Professionals

Shea et
al., 2016

Journal of
Nursing
Scholarship

Cross-sectional
study through
online research
with nursing
workers, totaling
4,891 members of
the Australian
Federation of
Nursing and
Obstetrics.

To examine the extent
and source of
occupational violence
(OVA) experienced by
nursing professionals. And
to examine the
contributions of
demographic
characteristics and safety
factors in the workplace
and individual in the
prediction of OVA.

VI

Figure 2. Distribution of articles analyzed according to variables of interest of the research. Fortaleza (CE), Brazil,
2017.

https://doi.org/10.5205/1981-8963-v12i10a236958p2794-2802-2018

Sousa LS de, Oliveira RM, Ferreira YC et al. Workplace violence in the hospital…
English/Portuguese

J Nurs UFPE online., Recife, 12(10):2794-802, Oct., 2018 2798

ISSN: 1981-8963 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i10a236958p2794-2802-2018

Initially, the main types of workplace

violence in the area of hospital obstetrics

were identified, as well as the groups most

vulnerable to this type of occupational

aggression.

According to the studies, the types of

violence that most occur in work in obstetrics

are: psychological, physical and sexual.5-6-7

The most common form of violence is

psychological violence, which includes

behaviors such as verbal abuse, humiliation,

and intimidation, which are also recognized as

forms of moral harassment at work.5,8

Psychological violence occurs in half or in

most meetings with perpetrators.6 Evil,

humiliation, sarcasm, and unjustified criticism

are also forms often found in the workplace.

In addition, attitudes of eye rolling, exclusion,

isolation and gossip were found in the

studies.7

Physical violence mainly involved drilling,

striking, pushing, scratching, and grabbing,

but less frequently cited in the literature.7,8

Studies have pointed to a small proportion of

sexual violence, most of which is instigated by

colleagues. 9,5 In the study, women

experienced sexual harassment more

frequently than men.5

Researchers say that students are also

subjected to sexual harassment in the

workplace. In addition, there seems to be a

lack of confidence in them to report such

behavior for fear of retaliation or not wanting

to be disinclined in an institution where they

may be applying for a job.9

For the most vulnerable groups to suffer

such violence, studies have shown that

students/trainees are the most verbally

abused and intimidated.9 One study also

showed that physicians are also victims of

workplace violence, unlike most studies that

point them out as perpetrators.6

In another study, statistically significant

differences were observed for gender,

function, and type of workplace. Male

respondents and those who were employed as

nurses were more subject to violence and

occupational aggression, as well as those

working in public hospitals or nursing homes.10

In addition, workers in the older age group

(56 or older) were more likely than younger

workers (18-25 years old) to experience

occupational violence. Those working in

private hospitals, general practice, local

government, and community services were

less likely to experience such violence than

those employed in public hospitals.

Respondents with the highest levels of job

overload were more likely to have

experienced occupational violence in the past

12 months.10

In the same study, a rather important

finding concerns the fact that workplace

safety factors, particularly prioritization of

employee safety, have been more important

in reducing the likelihood of occupational

violence than individual safety factors. These

findings are important to the health sector

because they highlight ways in which

policymakers and employers can address

violence in the workplace. For example,

strengthening factors in the workplace,

particularly greater prioritization of staff

safety in relation to patient safety, will

reduce the likelihood of violence against

health professionals.10

Regarding the related factors and

perpetrators of workplace violence in

obstetrical services, a study pointed out that

this may include a series of behaviors, such as

bullying. Although researchers have not yet

agreed on uniform definitions of these types

of aggression, there are consistent features

across all definitions of bullying and

violence.11

Bullying in the workplace was defined as

repeated and unreasonable behavior that

occurs among peers.7 The nature of bullying

included both psychological and physical acts.

Sources of bullying are distinct from violence,

with bullying being more from internal sources

(for example supervisors and co-workers) and

violence potentially originating from internal

or external sources (for example patients or

family members and friends of the patient).12

Given these differences in the concepts

that compose violence in the workplace, it is

important to consider all types of bullying and

violence in trying to understand and

investigate the antecedents and consequences

of these acts in the workplace among nurses.11

In this context, knowing the factors that

are related to workplace violence in obstetrics

can help in the investigation of the causes

that lead the perpetrators to adopt

undesirable behaviors, besides providing an

adequate management of this problem

considering the different scenarios in which

violence at work appears.

Thus, with regard to factors related to

violence at work, a study pointed to some

causes, highlighting internal and external

factors and their interaction. For example,

internal influences refer to characteristics

that affect the patient, such as their

personality or the effects of their illness.

DISCUSSION

https://doi.org/10.5205/1981-8963-v12i10a236958p2794-2802-2018

Sousa LS de, Oliveira RM, Ferreira YC et al. Workplace violence in the hospital…
English/Portuguese

J Nurs UFPE online., Recife, 12(10):2794-802, Oct., 2018 2799

ISSN: 1981-8963 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i10a236958p2794-2802-2018

External influences are concentrated on the

environment, such as noisy environments or a

shortage of personnel. In addition, drug abuse

by professionals, patient frustration due to

inadequate resources and intoxication were

also cited as contributing factors.7

Other research has stated that the main

factors contributing to experiences of

workplace violence are: the perpetrator’s

personality or mental illness, stressful and

overworked environments, including lack of

training, management support, and poor

communication among the staff.7

In a study of 207 general nurses and

obstetricians, different combinations of

working conditions (demands, control, and

support) and individual levels of negative

affect were associated with violence.11

There is a positive relationship between

the negative affectivity of the perpetrator and

the practice of bullying. The higher the level

of negative affectivity, the greater the

likelihood of practicing such violence. In

addition, there is a positive relationship

between morning shift work and bullying, with

morning shift workers more prone to bullying

than other shift workers.12

In the profile of these perpetrators, the

articles have shown that most of them are a

higher or older co-worker, and the main

culprits are physicians, clinical directors,

clinical secretaries, patients and family

members, managers and supervisors, and

executives.5, 6,7,8

Contributing to such findings, one of the

articles added that the biggest perpetrators

are co-workers. Also, women and people over

40 years old were the most likely and most

distressing perpetrators to deal with.7

In another research, both men and women

were reported as perpetrators. The study also

pointed out that violence at work is often

practiced by one or more individuals acting

independently.6

The perpetrator usually has a profile

already known and determined in

occupational relationships and it is more likely

that he can act allied to colleagues than

alone. This proves what the studies bring

about people who adopt these behaviors,

which hampers healthy interpersonal

relationships.

There are also studies addressing violence

by patients and family members of

services.7,9,10 Researchers point out that

obstetric nurses often work in enclosed areas

and confined to women, their partners and

families, as delivery rooms. Thus, labor and

birth can be stressful events for women and

their families, and it is not surprising that

professionals and students in the category

report verbal abuse and intimidation of

women, partners, and families in such clinical

contexts.9

Thus, perpetrators are not only those in the

position of health workers but also makeup

patients and their families, depending on the

form of violence to which the victims are

subjected. Therefore, knowing the root cause

of violence at work becomes fundamental and

urgent.

Another variable studied in this review is

the impact of violence in work on obstetrics,

including the reactions and consequences for

workers, organizations, and patients.

Research has pointed out that workplace

violence not only has short-term repercussions

but can also cause long-term harm that

reduces the quality of care provided by health

professionals as well as financial damage to

health care institutions that interfere with

productivity.13

In addition to harming one’s health, acts of

violence at work, directly and indirectly,

interfere with workers’ daily lives, as they give

rise to difficulties of confrontation,

organizational retaliation, demotivation,

fatigue, dissatisfaction, feelings of guilt, fear,

anguish. All this leads to the sickness of the

organization as a whole, which can generate

burden on the quality of care and patient

safety.

A study conducted with physicians

experienced in obstetrics and gynecology has

demonstrated the reported impact on

professional and personal life, which

encompasses a broad spectrum of suicidal

ideation, depression, sleep disturbance, and

loss of confidence. When the victims were

asked if the problem was being solved, most

answered no.6

Corroborating with the above research,

authors have identified that, in addition to

the anguish experienced by victims, patient

safety is compromised by the effects of these

negative attitudes. Those who report such

behaviors are rarely professionally satisfied.6

A study of obstetric nursing students

revealed that for some of them, experiences

of violence resulted in becoming more closed

of interactions and cautious.9 Consequently,

negative emotions are experienced at high

levels and the cycle repeats.11

Violence in the workplace tends to cause

students to show signs of posttraumatic stress,

permeating more intrusive behaviors than

evasion. In addition, undue suffering can be

https://doi.org/10.5205/1981-8963-v12i10a236958p2794-2802-2018

Sousa LS de, Oliveira RM, Ferreira YC et al. Workplace violence in the hospital…
English/Portuguese

J Nurs UFPE online., Recife, 12(10):2794-802, Oct., 2018 2800

ISSN: 1981-8963 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i10a236958p2794-2802-2018

generated and affect the way students view

the chosen profession.13

Another study identified that students do

not report acts of workplace violence against

them since they do not want to jeopardize the

opportunity to obtain a job.5 Therefore, it

becomes essential to raise awareness about

this issue from professional training to the

postgraduate level, besides the performance

of the permanent education in the health

institutions to guarantee spaces of discussion

and construction of formal communication

channels that permeate the inter-professional

relationships.

Although they do not perceive that they

are suffering some kind of violence at work or

do not attach importance to these episodes,

the existence of destructive behaviors in

health work that have several consequences

for the individual (professional or student) is

noticed. Therefore, understanding the impact

that this violence generates is essential to the

development of strategies that can prevent or

even deny these negative attitudes.

Finally, the strategies to combat violence

at work in obstetrics were raised.

Researchers have argued that while

workplace violence is an important welfare

issue that needs to be addressed, it is useful

to explore effective ways to deal with

workplace violence.13

Two things are clear: First, most of these

interventions focus on the victim, or the

organization, rather than prioritizing the

perpetrator. Second, it is true that the victim

needs support because, within the

organization, he has less support than the

perpetrator.6

Often victims do not receive adequate care

from institutions that do not know the

problems. Structures/policies need to be put

in place to enable people to feel free to

report violence in the workplace and access

the help they need.13

Such interventions need to involve health

professionals and universities including a

review of current reports and inadequate

investigative processes that not only leave

those who complain dissatisfied with the

outcome but also harm others involved. Both

preventive and disciplinary interventions

require effective evaluation through effective

feedback monitoring.6

Institutions need a reporting process where

students and other workers have confidence in

using it and where appropriate action will be

taken. More comprehensive information on

available units and occupational health and

safety protocols, both at the workplace and at

university, can provide the victims with

confidence to report such incidents.5,9,13

Given this high rate of violence in the

workplace and relatively low rate of reporting

of incidents of violence, hospitals should

develop effective guidelines to restrict

workplace violence and protect nursing staff

and students through a mandatory incident

reporting, review of safety team

responsibilities, and incident follow-up by

management.14

Facing this, integrating universities and

health institutions in the management of

violence at work becomes an appropriate

means to adopt more ethical and humanized

postures from training to professional

performance.

Another point is the need for training and

sensitization of health workers and students

before attending training sessions on how to

deal with workplace violence and the

importance of reporting exposure to these

behaviors.5

Researchers point to the need for training

to improve the safety of staff at work, as well

as raise staff awareness of acceptable

workplace behaviors to combat bullying.7

Educational seminars are recommended in

which health workers develop communication

and stress management techniques or conflict

resolution anger to effectively manage

violence in the workplace.14

Managers must recognize that not only

working conditions are important, but

individual variations from personal

dispositions can often play a role and

individual reactivity can influence

perceptions. Management can act to address

the cause and pay special attention to the

demands.11

The active participation of managers in

policies to prevent and combat violence at

work is a preponderant factor for the use of

knowledge, skills, and attitudes that allow the

appropriate decision making regarding

violence management.

Increasing the support of the supervisor

and colleague seems to be important in

preventing certain types of workplace

aggression, bullying, and internal emotional

abuse. Also, the negative effects of bullying

and internal emotional abuse on

organizational commitment can be reduced.11

Investigating a workplace model in a

variety of types of violence increases the

understanding of workplace-related areas to

reach and intervene, with the aim of reducing

the occurrence, and associated negative

consequences, of violence in the workplace.12

https://doi.org/10.5205/1981-8963-v12i10a236958p2794-2802-2018

Sousa LS de, Oliveira RM, Ferreira YC et al. Workplace violence in the hospital…
English/Portuguese

J Nurs UFPE online., Recife, 12(10):2794-802, Oct., 2018 2801

ISSN: 1981-8963 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i10a236958p2794-2802-2018

Psychological aggression is the type of

workplace violence most commonly

experienced by professionals in the field of

hospital obstetrics, with vulnerable groups

being students/trainees and nurses. The

personality of the perpetrator, stressful and

overworked environments are contributing

factors to this type of violence. Most of the

perpetrators are medical, managerial, but

may involve patients and family members. As

a consequence, this type of violence

generates difficulties of confrontation,

retaliation, demotivation, fatigue,

dissatisfaction, feelings of guilt, fear and

anguish to the victims.

Management strategies include reporting

system, occupational health and safety

protocols, training and awareness raising for

health workers and students, and conflict

management.

It is worth mentioning the need for studies

aiming to deepen the analysis of the thematic

with practical application of these strategies,

as well as evaluation and feedback of the

professionals involved in the area. We also

suggest studies about this phenomenon in the

Brazilian context of obstetric care, enabling

to apply it in the management practice in this

area.

1. Oliveira RM, Silva LMS, Guedes MVC,

Oliveira ACS, Sánchez RG, Torres RAM.

Analyzing the concept of disruptive behavior

in healthcare work: an integrative review*.

Rev Esc Enferm USP [Internet]. 2016 [cited

2018 Jun 02]; 50(4):695-704. Available

from:

http://www.scielo.br/pdf/reeusp/v50n4/008

0-6234-reeusp-50-04-0695

2. Organização Mundial da Saúde.

Maternidade segura: assistência ao parto

normal: um guia prático [Internet]. Genebra:

OMS; 1996 [cited 2018 June 2]. Available

from:

http://www.saude.mppr.mp.br/arquivos/File

/kit_atencao_perinatal/manuais/assistencia_a

o_parto_normal_2009

3. Injury Prevention Research Center.

Workplace violence: a report to the nation.

Iowa City: University of Iowa [Internet]. 2001

[cited 2018 Junee 02].

Available from:

https://www.dgs.pt/departamento-da-

qualidade-na-saude/observatorio-da-

violencia/estudoint2-pdf.aspx

4. Mendes KDS, Silveira RCCP, Galvão CM.

Revisão integrativa: métodos de pesquisa para

a incorporação de evidências na saúde e na

enfermagem. Texto & contexto enferm

[Internet]. 2014 [cited 2018 June

2];17(4):758-64. Available from:

http://www.scielo.br/pdf/tce/v17n4/18

5. Boyle MJ, Mckenna L. Paramedic and

midwifery student exposure to workplace

violence during clinical placements in

Australia: a pilot study. Int J Med Educ

[Internet]. 2016 [cited 2018 June 2];7:393-9.

Available from:

https://www.ncbi.nlm.nih.gov/pmc/articles/

PMC5149425/pdf/ijme-7-393

5. Shabazz T, Parry-Smith W, Oates S,

Henderson S, Mountfield J. Consultants as

victims of bullying and undermining: a survey

of Royal College of Obstetricians and

Gynaecologists consultant experiences. BMJ

Open [Internet]. 2016 [cited 2018 June

2];6(6):[about 5 p.]. Available from:

http://bmjopen.bmj.com/content/bmjopen/

6/6/e011462.full

6. Farrell GA, Shafiei T. Workplace

aggression, including bullying in nursing and

midwifery: a descriptive survey (the SWAB

study). Int J Nurs Stud [Internet]. 2012 [cited

2018 June 2];49(11):1423–31. Available from:

https://www.ncbi.nlm.nih.gov/pubmed/2277

0947

7. Samir N, Mohamed R, Moustafa E, Abou Saif

H. Nurses’ attitudes and reactions to

workplace violence in obstetrics and

gynaecology departments in Cairo hospitals.

East Mediterr Health J [Internet]. 2012 [cited

2018 June 2];18(3):198-204. Available from:

https://www.ncbi.nlm.nih.gov/pubmed/2257

4471

8. McKenna L, Boyle MJ. Midwifery student

exposure to workplace violence in clinical

settings: an exploratory study. Nurse Educ

Pract [Internet]. 2016 [cited 2018 June

2];17:123-7. Available from:

https://www.ncbi.nlm.nih.gov/pubmed/2667

2901

9. Shea T, Sheehan C, Donohue R, Cooper B,

De Cieri H. Occupational violence and

aggression experienced by nursing and caring

professional. J Nurs Scholarsh [Internet]. 2017

[cited 2018 June 2];49(2):236-43. Available

from:

https://sigmapubs.onlinelibrary.wiley.com/do

i/pdf/10.1111/jnu.12272

10. Demir D, Rodwell J. Psychosocial

Antecedents and Consequences of workplace

aggression for Hospital Nurses. J Nurs

Scholarsh [Internet]. 2012 [cited 2018 June

2];44(4):376-84. Available from:

https://sigmapubs.onlinelibrary.wiley.com/do

i/abs/10.1111/j.1547-5069.2012.01472.x

CONCLUSION

REFERENCES

https://doi.org/10.5205/1981-8963-v12i10a236958p2794-2802-2018

http://www.scielo.br/pdf/reeusp/v50n4/0080-6234-reeusp-50-04-0695

http://www.scielo.br/pdf/reeusp/v50n4/0080-6234-reeusp-50-04-0695

http://www.saude.mppr.mp.br/arquivos/File/kit_atencao_perinatal/manuais/assistencia_ao_parto_normal_2009

http://www.saude.mppr.mp.br/arquivos/File/kit_atencao_perinatal/manuais/assistencia_ao_parto_normal_2009

http://www.saude.mppr.mp.br/arquivos/File/kit_atencao_perinatal/manuais/assistencia_ao_parto_normal_2009

https://www.dgs.pt/departamento-da-qualidade-na-saude/observatorio-da-violencia/estudoint2-pdf.aspx

https://www.dgs.pt/departamento-da-qualidade-na-saude/observatorio-da-violencia/estudoint2-pdf.aspx

https://www.dgs.pt/departamento-da-qualidade-na-saude/observatorio-da-violencia/estudoint2-pdf.aspx

http://www.scielo.br/pdf/tce/v17n4/18

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5149425/pdf/ijme-7-393

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5149425/pdf/ijme-7-393

http://bmjopen.bmj.com/content/bmjopen/6/6/e011462.full

http://bmjopen.bmj.com/content/bmjopen/6/6/e011462.full

https://www.ncbi.nlm.nih.gov/pubmed/22770947

https://www.ncbi.nlm.nih.gov/pubmed/22770947

https://www.ncbi.nlm.nih.gov/pubmed/22574471

https://www.ncbi.nlm.nih.gov/pubmed/22574471

https://www.ncbi.nlm.nih.gov/pubmed/26672901

https://www.ncbi.nlm.nih.gov/pubmed/26672901

https://sigmapubs.onlinelibrary.wiley.com/doi/pdf/10.1111/jnu.12272

https://sigmapubs.onlinelibrary.wiley.com/doi/pdf/10.1111/jnu.12272

https://sigmapubs.onlinelibrary.wiley.com/doi/abs/10.1111/j.1547-5069.2012.01472.x

https://sigmapubs.onlinelibrary.wiley.com/doi/abs/10.1111/j.1547-5069.2012.01472.x

Sousa LS de, Oliveira RM, Ferreira YC et al. Workplace violence in the hospital…
English/Portuguese

J Nurs UFPE online., Recife, 12(10):2794-802, Oct., 2018 2802

ISSN: 1981-8963 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i10a236958p2794-2802-2018

11. Rodwell J, Demir D. Oppression and

exposure as differentiating predictors of types

of workplace violence for nurses. J Clin Nurs

[Internet]. 2012 [cited 2018 June 2];21(15-

16):2296-305. Available from:

https://onlinelibrary.wiley.com/doi/abs/10.1

111/j.1365-2702.2012.04192.x

12. Shapiro J, Boyle MJ, McKenna L.

Midwifery student reactions to workplace

violence. Women Birth [Internet]. 2018 [cited

2018 June 2];31(1):e67-e71. Available from:

https://www.womenandbirth.org/article/S18

71-5192(16)30263-3/fulltext

13. Samir N, Mohamed R, Moustafa E,

Abou Saif H. Nurses’ attitudes and reactions

to workplace violence in obstetrics and

gynaecology departments in Cairo hospitals.
East Mediterr Health J [Internet]. 2012 [cited
2018 June 2];18(3):198-204. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/2257
4471

Submission: 2018/06/08
Accepted: 2018/07/28
Publishing: 2018/09/01

Corresponding Address

Bruna Karen Cavalcante Fernandes
Rua Michele, 30
Bairro Passaré
CEP: 60861-444 ― Fortaleza (CE), Brazil

https://doi.org/10.5205/1981-8963-v12i10a236958p2794-2802-2018

https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2702.2012.04192.x

https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2702.2012.04192.x

https://www.womenandbirth.org/article/S1871-5192(16)30263-3/fulltext

https://www.womenandbirth.org/article/S1871-5192(16)30263-3/fulltext

https://www.ncbi.nlm.nih.gov/pubmed/22574471

https://www.ncbi.nlm.nih.gov/pubmed/22574471

Copyright of Journal of Nursing UFPE / Revista de Enfermagem UFPE is the property of
Revista de Enfermagem UFPE and its content may not be copied or emailed to multiple sites
or posted to a listserv without the copyright holder’s express written permission. However,
users may print, download, or email articles for individual use.

A
R

TI
G

O
O

R
IG

IN
A

L

Revista Científica da Ordem dos Médicos www.actamedicaportuguesa.com 31

RESUMO
Introdução: A violência no local de trabalho é um dos principais fatores de risco no mundo do trabalho. Os trabalhadores da saúde
apresentam um risco superior. O nosso estudo teve como objetivo caracterizar a violência física e verbal num hospital público e definir
estratégias de prevenção e vigilância em saúde ocupacional.
Material e Métodos: Estudo observacional transversal monocêntrico, conduzido num hospital público em Lisboa com trabalhadores
da saúde. Foi realizado um inquérito qualitativo com entrevistas em profundidade a seis trabalhadores e um inquérito quantitativo
com questionários a 32 trabalhadores. Aceitou-se um nível de significância de 5% na avaliação das diferenças estatísticas. O teste de
Mann-Whitney e o teste exato de Fisher foram usados para calcular os valores de p.
Resultados: Os principais resultados são: (1) 41 episódios reportados na fase quantitativa; (2) 5/21 [23,81%] vítimas notificaram o in-
cidente; (3) 18/21 [85.71%] vítimas reportaram estados de hipervigilância permanente; (4) 22/28 [78,57%] participantes não conheciam
ou conheciam mal os procedimentos de notificação; (5) 24/28 [85,71%] consideravam possível minimizar o problema.
Discussão: A violência é favorecida pelo acesso livre às zonas de trabalho, ausência de agentes de segurança e polícia ou falta da
respetiva intervenção. A baixa notificação contribui para a ausência de medidas organizacionais. O estado de hipervigilância relatado
reflete o efeito prejudicial da exposição a fontes de stress e ameaça.
Conclusão: A violência no local de trabalho é um fator de risco relevante, com impacto negativo na saúde dos trabalhadores e merece
uma abordagem individualizada no âmbito da saúde ocupacional, cujas áreas e estratégias prioritárias foram definidas neste estudo.
Palavras-chave: Fatores de Risco Profissionais; Prevenção; Saúde Ocupacional; Trabalhadores da Saúde; Violência no Local de
Trabalho

Workplace Violence in Healthcare: A Single-Center Study
on Causes, Consequences and Prevention Strategies

A Violência no Local de Trabalho em Instituições
de Saúde: Um Estudo Monocêntrico sobre Causas,
Consequências e Estratégias de Prevenção

1. Escola Nacional de Saúde Pública. Universidade NOVA de Lisboa. Lisboa. Portugal.
2. Emergency Department. Hospital Professor Doutor Fernando da Fonseca. Amadora. Portugal.
3. CISP – Centro de Investigação em Saúde Pública. CHRC – Comprehensive Health Research Center. Escola Nacional de Saúde Pública. Universidade NOVA de Lisboa. Lisboa.
Portugal.
4. Occupational Health Department. Centro Hospitalar Universitário de Lisboa Central. Lisboa. Portugal.
 Autor correspondente: Helena Sofia Antão. sofintao@gmail.com
Recebido: 22 de outubro de 2018 – Aceite: 10 de julho de 2019 | Copyright © Ordem dos Médicos 20

20

Helena Sofia ANTÃO1,2, Ema SACADURA-LEITE3, Maria João MANZANO4, Sónia PINOTE4, Rui RELVAS4,
Florentino SERRANHEIRA3, António SOUSA-UVA3
Acta Med Port 2020 Jan;33(1):31-37 ▪ https://doi.org/10.20344/amp.11465

ABSTRACT
Introduction: Workplace violence is one of the main risk factors in the professional world. Healthcare workers are at higher risk when
compared to other sectors. Our study aimed to characterize physical and verbal violence in a public hospital and to define occupational
health prevention and surveillance strategies.
Material and Methods: Single center observational cross-sectional study, carried amongst healthcare workers in a public hospital in
Lisbon. A qualitative survey was carried out through six in-depth interviews. A quantitative survey was carried through questionnaires
delivered to 32 workers. A significance level of 5% was accepted in the assessment of statistical differences. The Mann-Whitney test
and the Fisher’s exact test were used to calculate p values.
Results: The main results are: (1) 41 violence incidents were reported in the quantitative phase; (2) 5/21 [23.81%] victims notified
the incident to the occupational health department; (3) 18/21 [85.71%] victims reported a permanent state of hypervigilance; (4) 22/28
[78.57%] participants self-reported poor or no familiarity with internal reporting procedures; (5) 24/28 [85.71%] participants believed it
is possible to minimize workplace violence.
Discussion: Workplace violence is favored by unrestricted access to working areas, absence of security guards and police officers
or scarce intervention. The low notification rate contributes to organizational lack of action. The state of hypervigilance reported in our
study reflects the negative effects of threatening occupational stressors on mental health.
Conclusion: Our results show that workplace violence is a relevant risk factor that significantly impacts workers’ health in a noxious
manner, deserving a tailored occupational health approach whose priority areas and strategies have been determined.
Keywords: Healthcare Workers; Occupational Hazard; Occupational Health; Prevention; Workplace Violence

INTRODUCTION
Workplace violence is considered one of the most seri-
ous occupational hazards by the International Labour Of-
fice.1 The Occupational Safety and Health Administration
(OSHA) defines workplace violence as any act or threat of
physical violence, harassment, intimidation, or other threat-

ening disruptive behavior that occurs at the workplace,
ranging from threats and verbal abuse to physical assaults
and even homicide.2 Motivation to work, job security and job
mobility have also been reported to be negatively impacted.3
The exposure to stressful events at work is likely to increase

A
R

TIG
O

O
R

IG
IN

A
L

32Revista Científica da Ordem dos Médicos www.actamedicaportuguesa.com

Antão HS, et al. Workplace violence in healthcare, Acta Med Port 2020 Jan;33(1):31-37

cognitive activation that can be described as worrying or
having repetitive thoughts, triggering autonomic arousal
and emotional stress.4 Length of exposure has been re-
ferred as determinant to the severity of these effects.4,5 The
impact of workplace violence on health is of greater concern
when workers are permanently involved with other citizens
which is the case of healthcare,3 where the risk of aggres-
sion is four times higher than in the general private sector.6
Additionally, it threatens the quality of the care provided to
patients.1,7 According to the European Foundation for the
Improvement of Living and Working Conditions (Eurofound)
14.9% of workers in the European Union suffer some kind
of workplace violence.3
Notification is the key to identify and prevent this hazard.
In the past, aggressions have been considered confidential
by healthcare workers and their importance has been mini-
mized by hospital administrations.8 Aggressions were felt as
a part of their job and notifying was found useless.9 Some
workers limit their notifications to verbal reports to supervi-
sors.10 Some authors explain the rising trend of workplace
violence in healthcare based on an increase in consumption
of illicit drugs, ignorance, intolerance and lack of respect
that became widespread in some societies.9,11
Hospitals are especially concerned about the rising inci-
dence of violent events.12
Workplace violence prevention strategies can be includ-
ed into two broad categories: pre-incident strategies, which
encompass legislation and management (e.g. organization-
al policies, work design), design of the work environment,
education and training; and post-incident strategies, which
include incident reporting and psychological intervention for
affected workers.13
Some of the actions proposed to control this hazard in-
clude administrative measures such as flagging the files of
patients with a history of violence against healthcare work-
ers,14 penalties to perpetrators of violent actions against
medical workers8 and, on a broader scale, teaching the
youngest members of the population to respect and assist
medical personnel.8
Fleming and Harvey15 proposed a structural approach
to the problem where risk assessment (including worksite
audits, training assessments and past violence incident
reviews) plays a major role. These authors also highlight-
ed the need for an adequate number of healthcare work-
ers (since long waiting times increase the odds of patient
hostility) and safety personnel. Gatekeeping working areas
should ensure minimal public access to rooms where pa-
tients receive medical care.15
Hamblin et al7 described a systematic approach to vio-
lence prevention supported by a “Checklist of Suggested
Prevention Strategies for Workplace Violence in Hospital
Units”.
Arnetz et al succeeded in demonstrating significant dif-
ferences in the progression of violence indexes in a 2-year
follow-up randomized control trial where workplace inter-
ventions were supported by checklists and implemented
by interdisciplinary teams while performing their usual daily

activities.16
Fully understanding the phenomenon of workplace vio-
lence and setting up an effective occupational health plan
had been defined as one of the Occupational Health De-
partment needs for the year of 2018 in a hospital located in
Lisbon, Portugal. Our research was designed to meet these
needs.
The present study therefore aimed to: (1) Characterize
physical and verbal violence regarding the circumstances
of the occurrence, impact and consequences on workers;
(2) Assess the level of familiarity of workers with internal
notifications procedures and the extent of their application;
(3) Collect suggestions from workers on how to avoid or
minimize workplace violence incidents and (4) Define inter-
ventional strategies directed to the improvement of working
environment safety.

MATERIAL AND METHODS
Study design, population and procedures
This was a single center observational cross-sectional
study, carried in a public hospital located in Lisbon from
April to May 2018.
To be enrolled, individuals had to have experienced or
witnessed physical or verbal violence within the previous
24 months and belong to one of the following professional
groups: medical doctors, nurses, nursing assistants and
technical assistants.
An exploratory qualitative survey was carried out
through semi-structured in-depth interviews with six workers
selected by the occupational health psychologist from the
violence incidents notification registry on a most recent en-
trance basis. The registry is drawn from notifications made
by workers through an interface available at their working
terminals, the Health Event & Incident Management, HER+.
Oral consent was obtained prior to the interview scheduling.
A quantitative survey was carried out in the emergen-
cy department based on a mixed open and closed-ended
questionnaire delivered to workers who agreed to par-
ticipate after being opportunistically selected at their work-
place (workers circulating in the emergency room areas
during the aforementioned period to carry the survey were
approached and invited to participate).
The questionnaires were delivered to a sample of 32
workers. The authors considered this sample size an ac-
ceptable trade-off between the size of the population (272
workers) and the available human and time resources.
Both surveys were performed by one of the authors.

Script and questionnaires
The script and the questionnaires administered were
specifically built for the present study.
The exploratory qualitative phase script was based
on the available literature.11,17,18 It included three sections:
section A was directed to the experience of violence itself
(description of the episode of violence, circumstances, con-
sequences and actions), section B was directed to percep-
tions on workplace safety and section C aimed to assess

A
R
TI
G
O
O
R
IG
IN
A
L

Revista Científica da Ordem dos Médicos www.actamedicaportuguesa.com 33

the interviewee insight on the importance and prevention of
workplace violence.
The quantitative phase questionnaire was based on the
hospital formulary for workplace violence analysis and on
the qualitative phase outcomes. It included two sections:
section A was aimed at victims of violence and section B
was aimed at witnesses of violence incidents. Participants
could fill in both sections. The two sections included both
open-ended and closed-ended questions concerning: (1)
type of violence (physical or verbal); (2) whether the ag-
gressor was a patient, a patient next of kin or a co-worker;
(3) circumstances of the occurrence; (4) incident descrip-
tion; (5) presumed motives for the aggression; (6) victim’s
reactions and attitudes; (7) level of satisfaction towards the
way the institution coped with the incident; (8) personal
impact suffered by the victim; (9) possibility and ways of
avoiding workplace violence; (10) level of familiarity about
internal procedures on workplace violence and (11) whether
the strategies recommended in those procedures were im-
plemented.
Given the observational character of the study, authors
declared that this study did not require informed consent or
review/approval by the appropriate ethics committee.

Data analysis
In the qualitative phase, handwritten notes were taken
during the in-depth interviews. Each interview’s content
was summarized in sections covering the main qualitative
outcomes: description of the incident, sequelae and conse-
quences, attitudes, safety perceptions, organizational level
of concern, problem dimension and suggestions. The goal
of this simplified analysis was to highlight the victim’s expe-
rience and to bring to life particular phenomena associated
with these experiences.19
Upon completion and collection of the quantitative phase
questionnaires, demographics and answers to closed-
ended questions were recorded in spreadsheets. Answers
to open-ended questions were coded and classified into

categories. Answers were screened for consistency, name-
ly, comparison between answers to questions common to
sections A and B, personal impact scorings and compari-
son between answers provided to level of familiarity about
internal procedures and implementation of recommended
strategies.
Statistical analyses were performed using Microsoft
Excel 2016 MSO, Open Epi – Open Source Epidemiologic
Statistics for Public Health 3.01 and Social Science Statis-
tics 2019. Descriptive statistics were provided for all items.
Inference statistics calculations were used to assess the dif-
ferences between means and proportions and the associa-
tion between categorical variables; the level of significance
accepted was of 5%. The Mann-Whitney test and the Fish-
er’s exact test were used to calculate p values.

RESULTS
Demographics
In the quantitative phase, 28 workers returned valid
filled in questionnaires, which corresponds to 10.3% of the
emergency department staff.
The demographic characteristics of the survey popula-
tion are depicted in Tables 1 and 2.

Qualitative phase
In the qualitative phase, interviewees reported mostly
incidents of physical violence where the aggressor was ei-
ther a patient, a patient next of kin or a co-worker. Some
incidents occurred in circumstances where the victim was in
charge either of deciding the admission of a patient to a clin-
ical meeting or of gatekeeping the patient next of kin’s ad-
mission to the care providing area. There were also reports
of incidents involving aggressions by an elderly disturbed
patient whose psychiatric medication had been discontin-
ued and a victim’s subordinate in the context of shift work
scheduling decisions. The interviewees mentioned unre-
stricted access to working areas, absence of safety agents
and police officers (or lack of their active interventions) as

Table 1 – Demographic characteristics of the qualitative study participants (n = 6)

Participants Gender Age(years)
Professional

category/ department
Tenure in the hospital

(years)
Participant 1 M 52 Technical assistant/ Emergency 10

Participant 2 F 59 Nurse/ Urology 37

Participant 3 F 50 Nurse/ Orthopedics 28

Participant 4 F 58 Doctor/ Pediatric emergency 18

Participant 5 F 34 Nurse/ Internal medicine 11

Participant 6 F 44 Nurse assistant/ External consultation

14

Table 2 – Demographic characteristics of the quantitative study participants (n = 28)

Variable Medical Doctors Nurses NA TA Total
n 12 12 3 1 28

Gender (M/F) 4/8 4/8 0/3 0/1 8/20

Age (years) mean ± SD; median 41.58 ± 11.65; 38.50 38.08 ± 8.92; 42.00 53.34 ± 5.51; 56.00 50; 50 41.64 ± 10.65; 42.00

Tenure in the hospital (years) mean ± SD; median 14.67 ± 10.66; 13.50 13.50 ± 10.05; 16.50 17.67 ± 2.52; 18.00 25; 25 14.86 ± 9.67; 16.50
NA: nurse assistants; TA: technical assistants; SD: standard deviation

Antão HS, et al. Workplace violence in healthcare, Acta Med Port 2020 Jan;33(1):31-37

A
R
TIG
O
O
R
IG
IN
A
L

34Revista Científica da Ordem dos Médicos www.actamedicaportuguesa.com

Antão HS, et al. Workplace violence in healthcare, Acta Med Port 2020 Jan;33(1):31-37

favoring the incidents’ occurrence. Most of the interviewees
reported psychological sequelae; nevertheless, severity
seems to dilute over time. Some expressed feelings of de-
termination and assertiveness when figuring out how they
would act if similar situations happened again. Hospital
management is found not to be sufficiently concerned or
aware of the problem and not having violence prevention as
a top priority. Some of the interviewees believe notifying is
useless.

Quantitative Phase
Types of violence
In the quantitative phase of the study, 28 healthcare
workers answered valid questionnaires (10.8% of the emer-
gency department staff). A total of 41 violence incidents
were reported. The number of incidents per type of violence
are summarized in Fig. 1. There were no significant gender
differences in the victims’ group: 36.36% (IC 95% [16.26%
– 56.47%]) of males in the victims’ group versus 30.00%
(IC 95% [9.92% – 50.08%]) in the witnesses’ group (p value
= 0.4574). Violence witnesses reported more physical vio-
lence incidents than verbal incidents. Verbal violence was
described as “insults”, “threats”, “obscene words and ges-
tures”, “violent speech” and “chiding” or simply designated
as “verbal violence”. Physical violence was described as
“kicking”, “tearing the doctor’s clothes”, “hand raising at the
victim”, “punch attempt” or simply “physical aggression”.

Motives
According to the participants, the main reasons underly-
ing the aggressions were “long waiting time”, “patients and
population rudeness/ disrespect towards healthcare profes-
sionals” and “psychiatric disturbance”. Fig. 2 depicts the
absolute number of incidents attributable to each of these
classes.

Figure 1 – Violence type, number of incidents (n = 41)
PVP: physical violence from patient; PVNK: physical violence from next of kin; VVP:
verbal violence from patient; VVNK: verbal violence from next of kin; VVCW: verbal
violence from co-worker

VVCW
(3)

VVNK

(13)

VVP
(11)

PVNQ
(7)

PVP
(7)

Figure 2 – Presumed aggressor’s motives (n = 55)
‘Other’ is a heterogeneous class that includes mentions to the aggressor’s personality
traits and emotions, lack of information provided to the patient/ next of kin and facilities
unfriendly features.

Long waiting time

Rudeness/ disrespect

Psychiatric disturbance

Other

0 5 10

14

15

20

6

15 20 25

Reactions and attitudes
Only five out of the 21 participants who were victims of
aggression (23.81%) notified the incident, all of them in a
context of verbal violence. The main attitudes taken were
“asking the aggressor to stop” (14) and “calling the police”
(7). None of the victims stopped working or went on sick
leave because of the aggression.

Satisfaction towards the institution
Most participants answered the specific question on the
level of satisfaction towards the way the institution coped
with the incident by choosing the option “neither satisfied
nor unsatisfied”. Although physical violence victims showed
lower satisfaction levels than verbal violence victims, the
difference was not statistically significant (mean value 3.40
IC 95% [2.92 – 3.88] vs 3.13 IC 95% [2.72 – 3.54], p value
= 0.4295). The reasons pointed out for dissatisfaction were
“absence of action”, “no changes have been made”, “ab-
sence of support to workers”, “it is pointless to make a noti-
fication”, “no consequences for the aggressor”.

Personal impact and consequences to the victim
Sixteen out of the 21 victims (76.19%) reported having
experienced at least one of the five personal impacts listed:
disturbing and recurrent memories or thoughts, avoiding
thinking or talking about the incident, being hypervigilant,
suffering from insomnia or loss of appetite and having to
make an effort to work. Being hypervigilant was the most
mentioned, chosen by 15 out of the 21 victims (71.43%).
In the witnesses’ group, 12 out of 18 (66.67%) believed
the violence incident changed the way the victim faced
work, including job satisfaction and intent to leave, and
pointed out feelings of fear, unsafety, sadness, demotiva-
tion, exhaustion, stress and lack of professional recognition.
Although a higher proportion of participants in the vic-
tims’ group reported a negative personal impact compared
to the witnesses’ group on the same subject, the difference
was not statistically significant (76%; IC 95% [55% – 97%]
vs 55%; IC95% [33% – 77%], p = 0.1721).
The highest average score of agreement was found to
the sentence “I am proud of my job” and lowest score was
found to the sentence “I am thinking about quitting or ask-
ing to be moved to a different department (3.69 and 1.33,

A
R
TI
G
O
O
R
IG
IN
A
L

Revista Científica da Ordem dos Médicos www.actamedicaportuguesa.com 35

respectively, in a scale of 0 – 4, where 0 stood for “never”
and 4 stood for “always”). Table 3 summarizes the answers
provided to this question.

Familiarity with internal procedures on workplace vio-
lence
Most participants (22 out of 28, 78.57%) self-reported
poor or no familiarity with the hospital’s internal reporting
procedures on workplace violence. Those who had been
working in the hospital for less than five years self-reported
higher unfamiliarity when compared to those with a longer
working history; the difference was statistically significant
(mean value 3.75; IC 95% [3.43 – 4.07] vs 2.89; IC 95%
[2,45 – 3,34], p value = 0.0414, in a scale of 1 – 4, where
1 stood for “I am familiar with the procedures” and 4 stood
for “I am not familiar with the procedures”). Fig. 3 shows
the level of familiarity with internal procedures on workplace
violence self-reported by all participants in the quantitative
study sample.

Implementation of recommended strategies
Only eight out of the 21 victims (38.10%) declared hav-
ing implemented specific strategies recommended by the
hospital’s internal procedures for situations of workplace
violence; these ranged from verbal communication with the
aggressor (“dialogue”, “explanations for the causes of de-
lay”, “speak calmly”) to notification and request for help.

Ways to avoid or minimize workplace violence
Only four out of 28 (14.29%) replied negatively to the

answer “Do you believe it is possible to avoid or minimize
workplace violence?”. Suggestions on how it could be
avoided or minimized were provided by 23 workers and
ranged from gatekeeping of working areas, increasing the
number of security guards and healthcare workers in the
emergency department (for shorter waiting times), to infor-
mation about waiting times and programs designed to in-
crease the respect towards healthcare professionals. Fig. 4
depicts the number of answers per class of suggestions.

DISCUSSION
This study is probably one of the first to comprehensive-
ly describe workplace violence in a healthcare organization
using concomitantly qualitative and quantitative surveys
with the specific goal of designing a tailor-made Occupa-
tional Health prevention program.
It is known that the presence of security guards in
healthcare institutions discourage aggressive behaviors
and have been associated with improved feelings of safe-
ty in healthcare workers.20 The phenomenon of workers
mistrusting the usefulness of the notification process has
been previously reported.6,18,21 It has also been described
that the productivity and commitment of workers increase
when management teams show a candid interest in em-
ployees and in their behaviors (a phenomenon described
as the ‘Hawthorne effect’).6 This is especially relevant for
healthcare workers due to the inner rhythm and intensity
of their job profile. It is highly undesirable that this feeling
of uselessness towards notification becomes generalized,
since notification is the corner stone of understanding and

Figure 3 – Level of unfamiliarity with internal procedures on workplace violence (n = 28)
[mean ± SD: 3.14 ± 0.93; median: 3; P25: 3; P75: 4]

0 5 10

2 10 124

15 20 25 30

I am familiar (score 1) I am relatively familiar (score 2) I am poorly familiar (score 3) I am not familiar (score 4)

Table 3 – Personal impact of the violence incident (n = 21)

Personal impact – items Number of participants scoring ≥ 1 Mean score Min – Max

I have disturbing and recurrent memories or thoughts 7 2.43 1 – 4

I avoid thinking or talking about the episode 8 2.38 1 – 4

I am hypervigilant 18 2.27 1 – 4

I suffer from insomnia or loss of appetite 1 2.00 2 – 2

I have to make an effort tp go to work 7 2.14 1 – 4

I feel enough energy to do my job 13 2.92 1 – 4

I am proud of my job 16 3.69 2 – 4

I am thinking about quitting or asking to be moved to a different department 6 1.33 1 – 4

Antão HS, et al. Workplace violence in healthcare, Acta Med Port 2020 Jan;33(1):31-37

A
R
TIG
O
O
R
IG
IN
A
L

36Revista Científica da Ordem dos Médicos www.actamedicaportuguesa.com

Antão HS, et al. Workplace violence in healthcare, Acta Med Port 2020 Jan;33(1):31-37

effectively approaching the problem of workplace violence.
Blando et al6 have underlined that an intense ‘customer ser-
vice’ focus may worsen workplace violence by supporting a
“the customer is always right” mindset which can lead to lit-
tle or no action taken by intimidated healthcare profession-
als when faced with patients or their next of kin exhibiting
abusive behaviors.
Because our quantitative phase was carried out in an
emergency department, the ‘healthy worker effect’, through
which workers who have experienced severe workplace
violence episodes, resulting in serious sequelae, are less
likely to keep on working in risky environments like emer-
gency departments,20 may explain the self-reported low in-
tention to quit and the high level of job pride.
Although our study had not been designed to determine
frequencies of occurrence, a higher number of verbal vio-
lence incidents have been reported which is aligned with
previous findings.21
Descriptions and motives mentioned for both verbal and
physical violence are similar to those described elsewhere,
although alcohol and drug abuse (classified as psychiatric
disturbances in our study) seem to have a lower expres-
sion.
The low number of self-reported notifications (5 out of
21 victims, 23.81%) is consistent with the qualitative phase
findings and strongly adds to the vicious circle of ignorance
and organizational lack of action that we have already re-
ferred to.
The state of hypervigilance self-reported by most of the
victims (18 out of 21, 85.71%) reflects the prolonged cogni-
tive and physiological activation related with repeated ex-
posures to threatening stressors.22 The opinions expressed
by witnesses about the personal impact and consequences
on victims (two thirds of the participants describing these
effects as fear, feelings of unsafety, sadness, demotivation,

exhaustion, stress and lack of professional recognition as
described in the results section) are also consistent with the
theoretical background of workplace violence.
Some of the findings concerning the noxious effects of
workplace violence have also been described in burnout
studies in healthcare workers that have been previously
carried out in our country,23 although our study reflects
mainly feelings of emotional exhaustion rather than cyni-
cism or reduced personal accomplishment.
One of our most concerning findings is the participants’
unfamiliarity with internal procedures on workplace vio-
lence. This unfamiliarity, common in organizations as de-
scribed by other authors,13,24 adds to and worsens the feel-
ings of unsafety and loss of control experienced in conflict
situations; the fact that it was found to be higher amongst
workers with shorter tenures is of special concern, since it
is expected that procedural details are provided to workers
as soon as they join the organization.
The three types of suggestions provided by participants
on how to avoid or minimize workplace violence (gatekeep-
ing the access of patients/ next of kin to working areas,
increasing the number of healthcare workers and security
guards, informing and educating patients and the popula-
tion) are adjusted to the deficiencies found in our study and
it is our conviction that they should be taken into account
when setting up an occupational health program specifically
in this hospital.
Based on other studies14-18 and on our own knowledge
of occupational health issues, we recommend that interven-
tional strategies directed to the improvement of the safety
of the working environment should also include a clear en-
dorsement from top management, notification encourage-
ment across the whole organization, risk assessment and
stratification to prioritize interventions amongst the various
physical areas, training and follow-up on workplace vio-
lence procedures provided to all workers at risk, definition
of sanctions to violent patients and their next of kin and en-
suring sufficient occupational health personnel so that all
strategies can be successfully implemented. These preven-
tion strategies should be complemented by a medical sur-
veillance protocol specifically directed to workers at higher
risk, including those who have been victims of violence in-
cidents. This surveillance protocol should also specifically
ensure the monitoring of workers’ mental health.
The main limitations of our study are the small sample
size, the opportunistic basis for selection of participants
(instead of a randomization approach) and the absence
of formal quality control in the qualitative phase. As addi-
tional limitations, we point out two aspects that may have
contributed to an information bias of unknown extent. First,
because it was based on questionnaires directed to events
that could have happened up to 24 months before the time
of enquiry, the accuracy of some of the data collected could
have been impaired by memory. Second, having only lis-
tened to one version of the facts (aggressors have not
been enquired) could have also led to a somehow distort-
ed picture of the violence incident and its circumstances.

Figure 4 – Ways of avoiding or minimizing workplace violence
(n = 31)

Other

(6)

Information and
education

(6)

More healthcare and
safety guards

(6)

Gatekeeping access to
working areas

(13)

A
R
TI
G
O
O
R
IG
IN
A
L

Revista Científica da Ordem dos Médicos www.actamedicaportuguesa.com 37

Finally, the type of physical injury as well as its location,
severity and prognosis were not explored in depth.

CONCLUSION
Our results show that workplace violence is an impor-
tant occupational hazard that significantly impacts workers’
health and wellbeing in a noxious manner. Familiarity with
internal notification procedures and workplace safety are
areas of improvement that have been clearly identified, as
well as interventional strategies directed at these improve-
ments. Specific programs designed to increase notification
rates should also be further studied in order to identify best
in class strategies.

PROTECTION OF HUMANS AND ANIMALS
The authors declare that the procedures were fol-
lowed according to the regulations established by the Clini-
cal Research and Ethics Committee and to the Helsinki

Declaration of the World Medical Association.

DATA CONFIDENTIALITY
The authors declare having followed the protocols in
use in their working center regarding data publication. In-
dividuals’ participation demanded an oral consent. Written
consents were waived.

CONFLICTS OF INTEREST
The authors have no conflicts of interest to declare.

FUNDING SOURCES
This research has not been funded.

ACKNOWLEDGEMENTS
The authors would like to thank Professor Baltazar
Nunes, head of INSA’s Epidemiological Research Unit, for
his contribution to the statistical review of this manuscript.

REFERENCES
1. International Council of Nurses, Public Services International, World

Health Organization, International Labour Office. Framework Guidelines
for Addressing Workplace violence in the Health Sector: The training
manual; 2005 [accessed on 2019 Jun 6]. Available at: https://www.ilo.
org/safework/info/instr/WCMS_108542/lang–en/index.htm.

2. Occupational Safety and Health Administration. Workplace Violence
[accessed on 2019 Jun 6]. Available at: https://www.osha.gov/SLTC/
workplaceviolence/.

3. Eurofound (2015), Violence and harassment in European workplaces:
Causes, impacts and policies, Dublin [accessed on 2019 Jun 6].
Available at: https://www.eurofound.europa.eu/sites/default/files/ef_
comparative_analytical_report/field_ef_documents/ef1473en .

4. Reknes I, Notelaers G, Magerøy N, Pallesen S, Bjorvatn B, Moen BE,
Einarsen S. Aggression from patients or next of kin and exposure to
bullying behaviors: a conglomerate experience? Nurs Res Pract. 2017:
1-12.

5. Fang H, Zhao X, Yang H, Sun P, Li Y, Jiang K, Wu Q. Depressive
symptoms and workplace-violence related risk factors among
otorhinolaryngology nurses and physicians in Northern China:a cross-
sectional study. BMJ. 2018;8:1-9.

6. Blando J, Ridenour M, Hartley D, Casteel C. Barriers to effective
implementation of programs for the prevention of workplace violence in
hospitals. Online J Issues Nurs. 2015;20.

7. Hamblin LE, Essenmacher L, Upfal MJ, Russell J, Luborsky M, Ager
J, Arnetz JE. Catalysts of worker-to-worker violence and incivility in
hospitals. J Clin Nurs. 2015;24:2458-67

8. Hinsenkamp M. Int Orthop (SICOT) (2013) 37: 2321. [accessed on 2019
Jun 6]. Available at: https://doi.org/10.1007/s00264-013-2129-5.

9. Gallant-Roman MA. Strategies and tools to reduce workplace violence.
AAOHN J. 2008;56:449-54.

10. Findorff MJ, McGovern PM, Wall MM, Gerberich SG. Reporting violence
to a health care employer: a cross-sectional study. AAOHN J. 2005;53:
399-406.

11. Wolf LA, Dela AM, Perhats C. Nothing changes, nobody cares:
Understanding the experience of emergency nurses physically or
verbally assaulted while providing care. J Emerg Nurs. 2014;40:305-10.

12. Arnetz J, Lipscomb J, Ogaitis J. In search of effective solutions to curb
workplace violence. ED Manag. 2017;29:41-4.

13. Wang S, O’Brien-Pallas LL, Hayes L. A review and evaluation
of workplace violence prevention programs in the health sector.
Toronto: Nursing Health Services Research Unit. 2008 [accessed
on 2019 Jun 6]. Available at: https://pdfs.semanticscholar.org/7733/
f6e7d378ae23690372cde9b8c69484d275de .

14. Groenewold MR, Sarmiento RF, Vanoli K, Raudabaugh W, Nowlin S,
Gomaa A. Workplace violence injury in 106 US hospitals participating in
the Occupational Health Safety Network (OHSN), 2012-2015. Am J Ind
Med. 2018;61:157–66.

15. Fleming P, Harvey HD. Strategy development in dealing with violence
against employees in the workplace. Perspect Public Health. 2002;122:
226-32.

16. Arnetz JE, Hamblin L, Russell J, Upfal MJ, Luborsky M, Janisse J,
Essenmacher L. Preventing patient-to-worker violence in hospitals:
outcome of a randomized controlled intervention. J Occup Environ Med.
2017;59:1-23.

17. Copeland D, Henry M. Workplace violence and perceptions of
safety among emergency department staff members: Experiences,
expectations, tolerance, reporting, and recommendations. Int J Trauma
Nurs. 2017;24: 65-77.

18. Ramacciati N, Ceccagnoli A, Addey B, Rasero L. Violence towards
emergency nurses. The Italian National Survey 2016: a qualitative study.
Int J Nurs Stud. 2018;81:21-9.

19. Streubert H, Carpenter D. Qualitative research in nursing, 5th ed.
Philadelphia: Wolter Kluwer Health, Lippincott Williams & Wilkins. 2011.

20. Partridge B, Affleck J. Verbal abuse and physical assault in the
emergency department: Rates of violence, perceptions of safety, and
attitudes towards security. Australas Emerg Nurs J. 2017;20:139-45.

21. Nikathil S, Olaussen A, Gocentas RA, Symons E, Mitra B. Workplace
violence in the emergency department: A systematic review and meta-
analysis. Australas. 2017;29:265-75.

22. Ursin H, Eriksen HR. The cognitive activation theory of stress.
Psychoneuroendocrinology, 2004; 29: 567-92.

23. Maroco J, Maroco AL, Leite E, Bastos C, Vazão MJ, Campos JADB.
Burnout em profissionais da saúde portugueses: Uma análise a nível
nacional. Acta Med Port. 2016;29:24-30.

24. Findorff, MJ, McGovern PM, Sinclair S. Work-related violence policy: A
process evaluation. AAOHN J. 2005;53:360-9.

Antão HS, et al. Workplace violence in healthcare, Acta Med Port 2020 Jan;33(1):31-37