Violence as Psychosocial Risk in the Work of Psychiatric Nurses and Management Strategies

Methods: Qualitative study with 25 nurses working in a psychiatric hospital. Data collection was carried out from November 2014 to January 2015 through semi-structured interviews. The data were analyzed and organized into thematic categories following three stages: pre-analysis, exploration of the material and treatment of the results obtained. Participants were identified by the letter "E" and received sequential Arabic numeral numbers, thus guaranteeing the anonymity of the speeches. Thus, they were referenced from E1 to E25. The study was approved by the Research Ethics Committee of the University of São Paulo at Ribeirão Preto College of Nursing, Brazil.


Introduction
The environment of nursing work has passed through important changes, generating major impact on professional practice as a social space.These changes in the general context of society are the result of distinct modifications in the international labor market in which globalization and rationalization of work are tonics leading to adjustments in the process of organizing and structuring the work and developing new technologies [1].
In this context, the concern of health professionals with their own well-being at work is recent.These professionals used to focus their attention on issues specifically related to the theoretical and technical improvement of their activity and the use of equipment, leaving their own care, especially with regard to the risks inherent to their work activities, in second place [2].
It is noteworthy that there are many occupational hazards in the hospital environment, including the biological, ergonomic, chemical, physical and psychosocial risks.Thus, psychosocial risks stand out among these risks.This is especially present in the psychiatric hospital environment where the worker and the patient have a very direct relationship.Psychosocial risks are defined as aspects of the organization and work management, as well as the environment and social context that has the potential to cause psychological, physical and/or social damage [3].
Faced with this, the European Agency for Health and Safety at Work identified 10 psychosocial risks related to work that can affect physical and mental health of workers.These are divided into five broad categories: 1) New forms of employment contract and job insecurity; 2) Aging of the workforce; 3) Intensification of work; 4) High emotional load at work; and 5) lack of balance between family life and work [4].
Recently, different psychosocial risks in the scope of nursing work have been identified in psychiatric hospitals.Violence at work and its impact on the quality of life of these professionals has relevance in this context [5].However, the International Labour Organization defines violence in the workplace as any action, incident or behavior based on voluntary conduct of the offender as a result of which a professional is assaulted, threatened or suffers any damage or injury while performing his work or as a direct result of his work [6].
Thus, psychological or physical violence may result in deterioration of mental and physical health of both, the victims and of those who observe such situations.Violence can also lead to diminished selfesteem, depression, apathy, irritability, memory disorders, and in severe cases, paranoid disorders or suicide [4].
In this context, because nursing professionals spend longer times providing care and keep in direct contact with the customers, they are often exposed to psychosocial risk of violence.Thus, violence can significantly affect the organization of nursing work in psychiatric hospitals with negative consequences for the professional and for the patient.This, consequently, trigger losses to the institution.
However, in the daily work of psychiatric units whose patients present behaviors, attitudes and health conditions that may fluctuate rapidly, the nurse must not only gain knowledge about mental illnesses, but must know how to handle and/or control complex situations related to many patients that, some times, may have a violent behavior, use verbal aggression, extreme restlessness, or manifest episodes of delirium and confusion [5].
In this sense, nurses who work in psychiatric inpatient units develop daily tasks with different levels of demands and responsibilities.Depending on the environment and the way the work is planned and organized, these professionals may be exposed to risks such as violence, with negative consequences to their health and negative influence on the quality of the care provided to patients.
Based on these, this study presents the following questions: Does violence happen in the work of nurses who provide care in psychiatric hospitals?How is this violence?What management strategies are implemented to lessen this risk?
From these questions, identifying the presence of violence in the practice of psychiatric nurses should induce a reflection of these professionals on the characteristics of their work and an inference of new possibilities to manage the risk inherent to their activities.In addition, the identification of this risk is relevant to establish a consensus on the complexity of the psychosocial environment of psychiatric units.
About the relevance of this issue, the present research aims to contribute to fill gaps in the production of knowledge in this theme.The results can provide information for managers in detail for them to know the working conditions and psychosocial risk of violence to which psychiatric nurses are exposed, with a view to adopt measures and implement preventive and/or conservative strategies in the work environment, with a view to promoting and protecting the health of the worker.
Thus, this study aims to analyze the presence of violence as a psychosocial risk based on the perception of nurses in a psychiatric hospital and the management strategies implemented to deal with this risk.

Methods
This is a descriptive study with qualitative approach of data.The setting was a public teaching mid-size psychiatric hospital located in a municipality in the countryside of São Paulo state.This hospital is a reference in the Unified Health System (SUS) regarding psychiatric hospitalizations and comprehensive care to people with mental disorders.
Participants were 25 assistant nurses working in the units of the hospital, exercising their activities for more than six months before the beginning of the study, that is, before start data collection.This is because enough time for these professionals to have experienced their work was needed for them to identify psychosocial risks in their work environment.
Recorded semi-structured interviews were conducted and transcribed.Scripts tested by nurses who have expertise in psychiatry and who did not took part on the process of data collection were used in interviews.The script contained two parts: the first had questions regarding data about participants such as age, gender, year of conclusion of their nursing course, and time since they started working in the institution.The second part had open questions related to their preparation to work in the hospital, environmental working conditions, occupational hazards present and strategies developed to manage them.
Data were analyzed and organized into thematic categories following three stages: pre-analysis, material exploration and treatment of results [7].It should be noted that for the identification of thematic units related to psychosocial risks, the statements of respondents were taken into account.
Participants were identified by the letter "I" and received a numbering in sequential Arabic numerals, guaranteeing thus the anonymity of speech.Thus, interviewees E1 to E25 were referenced.
The study was approved by the Research Ethics Committee (REC) of the Ribeirão Preto School of Nursing, University of São Paulo (EERP-USP) under the CAAE protocol: 33723714.5.0000.5393,and participants signed the Informed Consent.

Characterization of participants
Data revealed female predominance (22-88%), showing the explicit hegemony of women in nursing and corroborating with other studies in which women dominate this profession [8].Participants had ages between 27 and 57 years.
It was observed that there were professionals working in the mental health area since the beginning of their professional life, although researchers agree that experiences of nurses can contribute to the process of planning for decision-making and implementation of care in Mental Health [9].As for the training of professionals, it was observed that 24 nurses (96%) had post-graduate degree, 10 (40%) in the area of mental/psychiatric health; in addition, 10 reported having completed at least two post-graduate courses in the Lato sensu mode.
The workload of nursing professionals working in the hospital studied was 30 hours a week, six hours a day, but 12 (48%) nurses performed paid extra shifts at the hospital.It was also noted that five (20%) nurses had jobs in other places, whether providing assistance or teaching.A worker exercised the function of nurse in two jobs, each one with workload of 30 hours a week in the hospital.
The analysis of the speeches made possible reflections on the perception of nurses in relation to the psychosocial risk imposed by violence and management strategies promoted in the psychiatric hospital environment, which allowed the development of two categories: "Violence: fear and physical and emotional aggressions" and "Management strategies for the psychosocial risk of violence".

Category 1. Violence: fear and physical and emotional aggressions
The psychosocial risk factors related to working conditions to which nurses may be exposed include situations of violence experienced during their daily activities with patients in hospitals.It is important to point out that this issue is not a novelty, but incites great concern, especially in the health sector.Intimidation in the workplace can be considered a factor that contributes to increase the emotional demands imposed on the workers.
Thus, for both, the victims and the people who witness the situation, the violence and physical or psychological intimidation cause stress and can seriously affect the mental and physical health [4].This study identified the presence of violence manifested by patients and directed to workers.Data showed aggressive behavior toward nursing caregivers often related to decompensation of the psychological state.

[...] the patient is that sometimes affects my health, makes me more irritated, my unit receives patients with all diagnostics [...] most of these patients have the risk of running away, increased risk of aggression. They tease other patients, disturb the environment, and affect me [...]
I5.

[...] the patients I work with.., it's always critical, at anytime I can be beaten, you pass, the patient is screaming, spitting, throwing things [...] you have to be very attentive to any eventuality, verbal or physical aggression, emotionally, this is very tense, usually, when you are assaulted, you feel very bad emotionally, you feel very down, emotionally fragile [...]
I10.
This health sector is among those with the greatest number of studies on violence at work, showing high potential for the occurrence of attacks directed to workers.Although health professionals are exposed to various risks, largely related to the constant contact with the public, 69% of cases of violence consist of episodes involving patients [10].
Thus, agitated and/or aggressive patients often have low insight on their morbidity and impaired critical judgment of reality.These patients may have difficulty in recognizing that they are sick and therefore may not accept that they need help.Depending on the degree of agitation, they pose a risk to their own physical integrity and also the physical integrity of health professionals and other patients [11].
However, despite the attention the theme has received, the subject on violence in health work still presents a major challenge.The combination of these factors increases the workload and stress of professionals, making it difficult to maintain the workforce and to attrack more professionals to these area.Moreover, it reduces the efficiency of the service.Violence in the workplace remains as a complex and difficult topic to approach [10].
In this sense, physical aggressions directed to nursing workers hitherto narrated in the literature correspond to scratches, pinches, kicks, slaps, squeezes against the wall, bites and aggression with the use of objects or weapons [12,13].Reinforcing these findings, nurses are often more exposed to violence in their workplace in relation to other health professional, and this has negative consequences on their performance [14].
However, violence in the health sector goes beyond individual aggressions and offenses.Violence endangers the productivity, the quality of care and the development of daily and professional activities.Women are more vulnerable in this context [15].These assumptions are in line with the speeches of the nurses that participated in the present study.They clearly said that in addition to physical aggression, they also hear verbal threats, to offend even their families.

[...] patients pass [...] threatening you and cursing. It is indeed a very stressful work environment, you have to be very attentive to any threat [...]
I10.
As a result of these attacks, of both physical and verbal nature, participants also reported the presence of fear among workers depending on the type of patient: [...] we assist patients that are increasingly complex, regarding the disease [...] patients are very decompensated, and often violent against themselves, against others and this creates a tense atmosphere, and causes fear in people [...] I12.

[...] I think what is more tiring on the work environment is the problem with delinquencies at work, antisocial personality disorder in which the nurse is often a target, we have to put limits to the patient and this leads me too much stress, because we are human, and we feel fear, [...] I'm afraid of finding these patients on the street [...]
I15.
According to the testimonies of participants, fear of the aggressor is notorious, as threats in the workplace may be extended to outside the workplace and even when the worker goes to the bosom of his/her family.
In this context, psychosocial risks related to work can be prevented and successfully managed, regardless of the dimension or type of company.However, these risk management strategies must be implemented to minimize or control the effects of stressful situations caused by such risk.

Category 2. Management strategies for the psychosocial risk of violence
Psychosocial risks perceived by nurses point to the need for development of organizational and/or individual strategies in order to minimize or control the effects on workers.
As the organization of work increases its importance in the relationship work/health, this requires new strategies in order to change the working conditions.Regarding organizational strategies, the statements of participants revealed that the institution does not offer any professional activity that they perceive as a means to improve the psychosocial work environment: [...] I think that the institution does not provide resources, on the contrary, the environment, the form of service seems to generate conflicts within the team, with other teams, with your supervisor. I12.

I13.
Organizational strategies should lessen the risks inherent to the worker's daily routine, helping the professional to take decisions.The positive work and an effective risk assessment system are tools that can be used by managers in the various spaces of the service.However, although these organizational strategies were not observed in the daily work of these nurses, professionals realize that these are aspects that could facilitate and/or minimize the effects of stressful hazards as follows:

[...] the institution does nothing about it, a work such as psychological support could be carried out, even if periodic or annual, individually. We see many employees who have relational problems with peers and with the sector, I think this should be done.
I6.

[...] the institution does not provide anything, I think it would very interesting if it did, for example, gymnastics, recreation time within the working hours.
I7.
[...] I think that the institution could provided something, mainly because we deal a lot with the mental health of people, but we have first to feel well for doing this, because how will we hear the problem of the other if we ourselves are not taking care of our own problems?
The risk control is the "systematic process by which risks are identified, analyzed and managed, and workers are protected" [16].This approach to solving problems is well established as a strategy to combat the various risks inherent to the work and represents an evaluative strategy of all psychosocial risks at work.
However, there are many risk management actions that have less significant results because they aim at workers individually or use a standardized solution without making the proper diagnosis of the problem.It is therefore essential that any strategy implemented be evaluated, because raising the knowledge about if a given instrument has worked out well as regards the reduction of psychosocial risk and damage associated with it also enables a reappraisal of the whole situation and provides the basis for organizational learning.
In the context of health relations vs. work, professionals seek control over the working and environment conditions in order to become healthier.Thus, in addition to organizational strategies, the worker can use individual strategies to alleviate the consequences of psychosocial risks.In this regard, individual strategies adopted by the worker as ways to ease tensions and/or risks generated by the workplace were observed in this study.These include use the presence of family, going to the movies, listening to music, reading, practicing physical exercise, searching for therapies, religion, travelling and making tours.
In this perspective, the presence of the family can be a resource used by professionals to soften the impact of stressful situations.Being with family, children and loved ones seems to improve the ability to cope with problems encountered in day to day work.This was highlighted in the reports of the nurses: [...] I used to do therapy, got to fitness center, but today I'm just staying with my family, going to the club with the kids. I11.

[...] I enjoy my children later, and I can take them to swim and to practice judo, I can participate in their education, see what is happening at school, pick up their notebooks, making this a personal leisure to me
Based on this premise, leisure activities like going to the mall, movies, watching movies, listening to music, going to events like concerts and theater, reading habits, among others, were cited as resources that some nurses identified as a form of entertainment and distraction.These greatly helped in the smoothing of the sufferings, anxieties or concerns generated in the workplace.reports were compiled that included trips, outings to clubs, swimming pools, bars, restaurants, excursions in purchasing centers and beauty salons, such as leisure and entertainment activities that are used individually by study participants considered aspects that provide rest and relief:

[...] I seek some forms of recreation, especially listening to music.
I13.

[...] I like going to the pool, sunbathe, drink a beer, a barbecue because who doesn't like it, right.
I13.

[...] I love to read, especially religious books geared to human behavior psychology, and I think we have to do what we really like.
I16.
Regarding leisure activities, these are defined as non-mandatory activities that are interesting and desired by the individual, freely chosen and motivating [17].Leisure is something that is present in people's lives, promotes many benefits to quality of life, helping to combat stress, facilitating the circulation of the blood, as well as promoting homeostasis, or balance in the internal functioning of the body, collaborating to maintain good health [18].
In this context, leisure activities should not be practiced only on holidays or weekends, but in any free time that the person may want to experience such activities.This would return on their day to day by promoting a feeling of wellbeing, leading to positive behavioral changes in their work environment [19].
However, the use of religious/mystical practices can contribute to the alleviation of the present risks as described below: [...] I have the habit to say a prayer before work, before beginning the duty.

I14.
The behavior of seeking religious and mystical beliefs has been associated with the search for the removal of a problem [20].In this respect, the strategy is used to relieve stresses, and is considered palliative because it does not involve the problem itself.Health professionals of various categories have found support in religion as a strategy to relieve the tensions of work, by providing inner peace and spiritual support [21].
However, the importance of beliefs and religiosity is demonstrated in the way of managing conflicts/ risks arising from working conditions even if this consists in an individual action.
Furthermore, sports such as walking, jogging, weight lifting, gymnastics, aerobics and dance were identified by nurses as strategies to alleviate the anxieties and sufferings accumulated during the daily work at the hospital.[...] I found out exercise, it was something I did not use to do, I'm doing it for five months now, so that to me, this is an outlet, because it is a moment that I have for myself, because it brings me really a feeling of well-being, then this is one of the strategies that I have found for my well-being.

I23.
In this sense, sports practiced as a form of recreation result in satisfaction and pleasure.They also promote human development when activities lead to the understanding of values such as respect, solidarity and team spirit [22].Moreover, physical activity has been widely cited as a factor that lessens tensions faced by workers in several industrial segments.Seeking for professionals who can help in psychosocial management was also one of the strategies mentioned in this study.

[...] I also usually go to a psychologist, do music therapy for at least 15 to 20 minutes a day.
I10.
[...] I use the morpho-analysis therapy, which is a look that we have of the body with the mind, I learned a lot to have this look, then, morphoanalysis has also allowed me a different care and helps me a lot with my work.Today I always try to come back for a look about how I am feeling and that comes from my learning sessions. I15.
[...] I am also doing orthomolecular treatment that reviews magnesium, selenium, serotonin, because I have found that my emotional side was fragile.

I22.
It is true that some of the consequences of poor management of psychosocial risks related to work are stress, weakened mental health, exhaustion, difficulty in concentrating and propensity to make more mistakes, problems at home, alcohol and drug abuse, cardiovascular disease and musculoskeletal problems [23].
For companies, the consequences are related to the overall performance of the worker, such as increased absenteeism, presenteeism (employees attend work despite being sick and unable to effectively perform their functions) and increased accident rates and personal injury.
In this perspective, recommendations such as implementation of a management focused on people and appreciation of the nursing team through dialogue, acknowledgement, respect, encouragement, stimulus, continuing education programs with a focus on personal and professional development, effective system of internal communication, plans for job positions and wages, and inclusion of nursing workers in the decision-making process are some measures that promote professional satisfaction [24].

Conclusion
Psychosocial risks constitute organizational factors related to aspects of planning, organization and management of work.Thus, the unique dynamics and peculiarities of the nursing activity in the tertiary level of care for people with mental disorders make the actors in this context to be exposed to several psychosocial risk factors that lead to a constant state of tension which, in turn, may cause stress or other diseases.
The practice of the nurse towards patients with mental disorders inserted brings together a complex web of situations related to direct patient care, which in this study focused on the violence suffered by this professional.In this context, nurses have to face many situations because he deals directly with the mentally ill patient.Depending on how work is organized, such professionals may be exposed to violence that may lead to psychological distress caused by work.
Additionally to the identification of psychosocial risk of violence, it was observed that this can be managed through individual and organizational strategies.In this regard, it is important to note that, for the management of this risk, it will always be necessary to carry out a situational diagnosis, so that strategies consistent with this damage may be planned.
However, it is known that exposure to violence can cause health problems to the targeted individuals, making them feel tense, worried, inattentive and less efficient in performing their tasks.Therefore, the presence of violence in the workplace, depending on the available resources and depending on the worker himself, may result in negative effects on the health of professionals.
Thus, this research has identified some management strategies adopted by nurses in the situation of psychosocial risk of violence.These include the use the presence of family, going to the movies, listening to music, reading, practicing physical exercise, searching for therapies, religion, travelling and making tours.
However, in order to prevent and manage psychosocial risks and their negative impact on the workplace, preventive actions should be directed to the risk factors in the workplace and should be implemented at the organizational level.Actions directed to workers in individual basis would be a complement.
However, this research has a limitation as regards the occupational category that participated and the type of institution selected, since the study chose to address only one category of nursing practitioners and an institution of public nature.Other nursing team members who could also raise aspects of occupational risks and other institutions of different legal nature were not included.In this sense, it is recommended to extend the study for future research including other professional categories in order to get a broader view of reality.
Therefore, it is necessary that preventive measures be taken in the professional practice, promoting safety in the workplace.Evaluative processes in organizations should be strengthened in order to know the status of the various services offered, their flaws and their potential, thus providing discussion of actions to improve the training and the practice of nurses in the mental health context.
[...] what I often is hiking, but I have swimming pool at home, I go there and do water aerobics, some exercise [...].I18.