Workplace Violence in Nursing: Prevalence and Nature of Incidents in a Tertiary University Hospital

1. Introduction

Violence has emerged as an expanding phenomenon, often trivialized in the daily routine of healthcare services in Brazil. It remains a problem that is still insufficiently quantified, classified, or properly understood, and is sometimes perceived by professionals as an inherent risk of their work practice [1]. The World Health Organization (WHO) defines violence as the intentional use, or threat of use, of physical force against another person or against oneself, which results or is likely to result in injury, death, or psychological harm [2].

In the health sector, the document Framework Guidelines for Addressing Workplace Violence in the Health Sector was developed through a collaboration between the International Labor Organization (ILO), the International Council of Nurses (ICN), the World Health Organization (WHO), and Public Services International (PSI). It provides global guidelines for understanding and addressing workplace violence in healthcare services. In this document, workplace violence is defined as incidents in which workers are abused, threatened, or assaulted in circumstances related to their professional activities, including commuting to and from work, constituting an explicit or implicit challenge to their safety, health, and well-being [3].

The ILO, in turn, in its Convention on Violence and Harassment (2019), defines violence and harassment in the world of work as a range of unacceptable behaviors and practices, or threats thereof, occurring once or repeatedly, that aim at, result in, or are likely to result in physical, psychological, sexual, or economic harm [4].

According to the WHO, between 8% and 38% of healthcare professionals experience physical violence at some point in their careers, while an even larger number are exposed to verbal aggression or threats [5]. In the case of nursing, verbal and physical violence, as well as threats, occur so frequently that, in many contexts, they are already perceived as an inherent part of the job. This process of normalization contributes to the underreporting of violent incidents [6].

Despite international recognition of violence as a serious occupational problem, its magnitude remains underestimated in Brazil, marked by high levels of underreporting and by the normalization of such episodes in the daily routine of healthcare services. National studies indicate that the phenomenon is still insufficiently explored in terms of measurement and classification [7].

The situation becomes even more concerning among nursing professionals. A survey conducted by the Regional Nursing Council of São Paulo (“COREN-SP”) in 2023 revealed that 80% of professionals had already experienced some type of aggression in the workplace, with 90% of these incidents being verbal in nature. Additionally, 48% reported having been assaulted more than once [8]. In the Federal District, a study conducted by “COREN-DF” in 2022 found that 82.7% of professionals had experienced physical violence, with at least one verbal or physical aggression occurring daily [9].

These data highlight the magnitude of the phenomenon and the difficulty in adopting effective prevention and response strategies. The nursing team, due to its frontline role in care, direct and continuous contact with patients and families, and long working hours, stands out as one of the most vulnerable groups. A study conducted in a public hospital in southern Brazil revealed that 15.2% of healthcare professionals had experienced physical violence, while 48.7% had been victims of psychological violence, including verbal aggression (35.4%), moral harassment (24.9%), racial discrimination (8.7%), and sexual harassment (2.5%) [10].

Another study, carried out in hospital units of the 8th Health Region of Paraná, found that 44% of nursing professionals had experienced some type of workplace violence in the previous 12 months. Verbal violence was the most prevalent (47.7%), followed by physical violence (11.9%) and sexual harassment (2.8%) [11].

Moral harassment and verbal violence in the hospital environment are therefore frequent realities for nursing professionals, manifesting mainly through humiliation and verbal aggression perpetrated by hierarchical superiors or coworkers. Their consequences include psychological harm such as anxiety, depression, feelings of incapacity, and loss of interest in the profession [12].

The repercussions of workplace violence go beyond immediate physical harm, affecting workers’ productivity, mental and physical health, and social relationships. In addition, such violence compromises professional safety and the quality of care provided, weakening processes aimed at humanizing healthcare. Given this scenario, the urgency of implementing institutional strategies for prevention, psychological support, and disciplinary measures to minimize the impacts of violence in the hospital context becomes evident [12].

Thus, it is essential to deepen the understanding of the prevalence, nature, and characteristics of violence in the hospital environment, especially among nursing professionals. In this regard, the present study aims to analyze the prevalence and nature of workplace violence incidents experienced by the nursing team in a tertiary-level university hospital.

2. Materials and Methods

2.1. Ethics Statement

This study was conducted in accordance with national and international ethical guidelines for research involving human subjects. The protocol was approved by the Research Ethics Committee in Health of the Federal University of Santa Catarina (“UFSC”), under Consolidated Opinion No. 7,241.146 and CAAE No. 80554324.7.3001.0121, issued on July 27, 2024. All participants signed the electronic Informed Consent Form (ICF) before completing the questionnaire. Participation was voluntary, ensuring anonymity, confidentiality, and the possibility of withdrawal at any time without any consequences.

2.2. Study Design, Study Population, Recruitment, and Data Collection

This is a cross-sectional, exploratory, and descriptive study conducted with nursing professionals working in hospital units of a large university hospital located in southern Brazil, with 890 beds and predominantly serving the Brazilian Unified Health System (“SUS”).

The eligible population included nurses, nursing technicians, and nursing assistants with an active employment contract and at least one year of work experience at the institution. This criterion aimed to ensure familiarity with the organizational environment and institutional practices. The invitation to participate was distributed by the nursing directorate to the various care sectors, including medical wards, emergency, intensive care, surgical units, cardiovascular care, nephrology, diagnostic imaging, neonatology, pediatrics, psychiatry, maternal and child health, and the surgical center.

For sample size calculation, a population of 2,518 professionals was considered, with a sampling error of 4%, a 95% confidence interval, and an estimated outcome proportion of 50%, resulting in a minimum required sample of 503 participants. The final sample consisted of 573 professionals.

Data collection took place between August 12 and September 9, 2024, through an online form sent via institutional email. The Informed Consent Form (ICF) was made available on the electronic platform, and only after agreement was the questionnaire released. Participants were informed about the estimated completion time (15–20 minutes), the non-obligatory nature of responding to questions that caused discomfort, and the possibility of withdrawing at any time.

2.3. Variables, Data Sources and Measurement

The main variable of the study was the occurrence of workplace violence in the hospital setting (yes/no). The forms of violence investigated included: physical violence, psychological violence, verbal aggression, intimidation/moral harassment, sexual harassment/violence, and discrimination (racial, gender-based, ageism, and ableism). For each type, occurrence in the past year, frequency, and aggressor profile were assessed.

Sociodemographic and occupational characteristics included: age, sex, gender, self-reported skin color, marital status, sexual orientation, presence of disability, professional category, work sector, work shift, years of professional experience, and educational level.

The consequences of violence were measured through specific questions addressing perceived safety in reporting, fear of retaliation, incident reporting, use of occupational health services, work leave (medical certificate/social security), medication use, psychological treatment, and intention to resign or change professions.

The data collection instrument was a structured questionnaire developed by the authors to reflect the reality of the professionals and the specificities of the hospital environment. The online form was self-administered and completed directly by the participants.

2.4. Statistical Analysis

Data were analyzed using the Statistical Package for the Social Sciences (SPSS), version 26.0. Descriptive analyses included absolute and relative frequencies for categorical variables, as well as means and standard deviations for continuous variables.

The association between the occurrence of workplace violence (dichotomous variable) and sociodemographic, occupational, and institutional characteristics was assessed using Pearson’s chi-square test (χ²). Values of p < 0.05 were considered statistically significant. Post hoc analyses with Bonferroni correction were conducted to identify specific differences between categories.

3. Results

A total of 573 nursing professionals participated in the study, the majority of whom were women (81.3%), with a mean age of 43.95 years (SD = 8.44). Nursing technicians represented 61.8% of the sample. The average length of professional experience was 19.32 years. Complete characteristics are presented in Table 1.

3.1. Prevalence and Types of Labor Violance

Workplace violence was reported by 71.2% of participants. Moral harassment/intimidation (76.5%), verbal violence (49.8%), and psychological violence (43.9%) were the most prevalent manifestations. Physical violence (8.1%), sexual harassment (5.6%), and discrimination showed lower, yet still relevant, prevalence rates. Table 2 presents the details.

3.2. Consequences of Violence

Among the 408 professionals who experienced violence, relevant repercussions were observed: fear of retaliation (70.7%), formal reporting (33.7%), medication use (32%), psychological treatment (47.5%), and work leave (24.9% with medical certificate; 8.4% through social security). Intentions to resign (50.2%) and to change professions (42.6%) were also frequent. Moral harassment and psychological violence showed the most significant associations (Table 3).

3.3. Profile of the aggressors

The main external aggressors were family members/companions (29.4%) and patients (18.4%). Among internal aggressors, leadership (37.3%), coworkers (28.4%), and immediate supervisors (26.2%) stood out. When the aggressor was a member of the healthcare team, nurses (44.9%) were the most frequently reported (Table 4).

3.4. Hostility Perception

Hostility in the work environment was perceived by 65.6% of professionals and showed a significant association with experiencing violence (79.9% vs. 54.3%; p < 0.001) and witnessing violence (83.5% vs. 64.5%; p < 0.001), as shown in Table 5.

4. Discussion

This study revealed a high prevalence of workplace violence among nursing professionals, with moral harassment/intimidation, verbal violence, and psychological violence standing out. These findings are consistent with national and international investigations that identify nursing as one of the professional categories most exposed to occupational violence, whether due to frontline positioning, close contact with patients and families, or the hierarchical structure of healthcare services [10,11,12,13]. In various contexts, non-physical violence tends to surpass physical violence, influenced by organizational climate, work overload, and managerial styles [10,11,14].

In the present study, moral harassment emerged as the most frequent type of violence and the one with the greatest number of significant associations with negative outcomes, such as illness, medication use, work leave, and intention to resign. This pattern reinforces evidence that moral harassment is a robust predictor of occupational stress, burnout, and worsening of care indicators, corroborating research that highlights its impact on professional identity, patient safety, and organizational climate [12,15,16].

Verbal and psychological violence also showed a strong association with emotional distress and turnover intention, findings consistent with studies indicating that such forms of violence produce moderate to severe stress, lower job satisfaction, increased care errors, and greater likelihood of work leave [17,18]. In particular, psychological violence has been identified as a risk factor for increased turnover intention, mediated by reduced professional satisfaction [18].

Although less frequent, physical violence, sexual harassment, and discrimination reveal important vulnerabilities. Research indicates that physical episodes may involve significant risk, including assaults with objects and the need for medical care and work leave [19,20]. In the case of sexual violence, recent studies show a growing trend, often perpetrated by patients, reinforcing the persistent risk scenario for nurses [21]. Racial, gender, age-based, and ableist discrimination emerge as forms of institutionalized violence, often rendered invisible but with a direct impact on well-being, engagement, and perceptions of organizational support [22,23,24,25]. This set of practices reinforces structural inequalities and undermines the retention of workers belonging to minority groups.

Among the consequences observed, the use of medication, seeking psychological treatment, work leave, and intention to resign stand out, indicating that workplace violence goes beyond immediate harm and constitutes a phenomenon that generates physical and psychological strain. The literature also shows a direct link between repeated exposure to violence, increased burnout, and a higher likelihood of care-related errors, compromising the quality and safety of care [26].

Underreporting, identified in this study, reflects a global trend. Research shows that most episodes remain unreported due to fear of retaliation, institutional distrust, or the normalization of violence in the hospital environment [14,27,28]. These factors contribute to underestimating the magnitude of the phenomenon and hinder the development of effective prevention strategies. The perception of a hostile environment, significantly associated with experiencing and witnessing violence, reinforces the importance of organizational climate as a determinant of the phenomenon, as already evidenced in studies conducted in Brazilian and international public hospitals [10,11,29].

From an organizational perspective, the findings reinforce the need for robust and multifaceted institutional policies. Strategies such as accessible reporting systems, leadership training, clear response protocols, psychological support for victims, and accountability mechanisms are recommended by international organizations, including the ILO and WHO [3,4]. Effective interventions should involve continuous actions, monitoring of indicators, and active participation of teams, promoting psychologically safe environments aligned with occupational health prevention principles.

5. Conclusions

Workplace violence proved to be highly prevalent among nursing professionals, presenting multiple forms and significant impacts on health, well-being, performance, and job retention. Moral harassment, verbal and psychological violence were the most common forms, while discrimination and physical and sexual violence, although less frequent, revealed persistent vulnerabilities.

The consequences identified — including illness, medication use, seeking psychological care, and the intention to resign or change professions — highlight the magnitude of the problem and its effects on the workforce. Underreporting and the perception of a hostile environment reinforce institutional barriers that hinder effective prevention and response.

The findings of this study underscore the need for institutional and public policies that promote safe environments, efficient reporting systems, and strategies for prevention and victim support. Addressing workplace violence is essential for valuing the nursing profession, protecting workers, and improving the quality of care.