ARTIGO ORIGINALRevista Cient.docx

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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.
protected]
Recebido: 22 de outubro de 2018 - Aceite: 10 de julho de 2019 |
Copyright © Ordem dos Médicos 2020
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
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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
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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
Port 2020 Jan;33(1):31-37
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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,
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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
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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 …
For your final project, your team will design a strategic
communication campaign aimed at influencing a specific target
audience to: (1) start a new positive behavior, (2) not start a
negative behavior, (3) change their current positive/negative
behavior (e.g., increase or reduce frequency), and/or (4) give up
a current negative behavior as a way to help address a social
issue/problem. This is a breakdown of steps 1-5.
It is recommended that you use the following breakdown as a
template for the paper.
Step 1: Describe the social issue, background, purpose, and
focus of your social campaign
· Briefly identify the social issue, sometimes referred to as the
“wicked problem,” your plan will be addressing (e.g., tobacco
use, air pollution, water contamination, literacy, homelessness,
etc.).
· Identify any sponsoring organizations you plan to collaborate
with in developing and implementing your campaign. These may
be local or national organizations.
· Summarize key background information leading to the
development of this plan, ideally using reliable statistics (e.g.,

percent of unplanned teen pregnancies)
· What is the campaign purpose, the intended impact (e.g.,
reduced teen pregnancies by 25% by 2020)?
· What is the campaign focus, the approach you will be using to
contribute to your plan’s purpose? Areas of focus may be
behavior-related, population-related, or product-related
strategies.
Step 2: Conduct a situational analysis (SWOT)
· What organizational strengths will your plan maximize?
· What organizational weaknesses will your plan minimize?
· What environmental opportunities will your plan take
advantage of?
· What environmental threats will your plan prepare for?
· What prior and similar campaign efforts are noteworthy?
Theoretical Models and Frameworks in Social Campaigns
Chapter 4
1
Role of Theories in Social Campaigns
2
Identify and select the right audience segment(s) to target

Identify the right set of of behaviors and goals to pursue in the
campaign
Gain a deeper understanding of target audiences to improve our
ability to influence social behaviors
Develop the right marketing mix (4P’s) to influence behavior
change or adoption beyond.
Self-Control Theory
3
Self-control is defined as an individual’s ability to forego
immediate or near-term pleasures that have some negative
consequences.
Behaviors requiring self-control are said to “drain” individuals.
Has 2 important implications for social campaigns in terms of
target behavior selection.
Choose target behaviors that require lower levels of self-control
(

Propose sequential changes in behaviors that require high levels
of self-control.
Goal-Setting Theory
Goals are best achieved when 5 principles are followed:
Clarity
Challenge
Commitment
Feedback
Task complexity
4
Self-Perception Theory
5
States that individuals often turn to observing their own
behaviors to better perceive their self-concept.
Campaigns should strive to get individuals to enact multiple
behaviors within a behavior category to promote long-term
changes.
Key is to select behaviors that are consistent with a person’s
self-concept.

Health Belief Model
T
6
Describes a set of beliefs that either motivate or discourage
people to take on certain health behaviors.
Health decisions made based on a cost-benefit analysis of the
situation:
Perceived threat vs. perceived efficacy
Perceived benefits vs. perceived costs of doing the
recommended behavior
Behavior adoption will only occur when perceived efficacy >
perceived threat & perceived benefits > perceived costs.
Health Belief Model
7

Perceived severity
Perceived susceptibility
Perceived benefits
Perceived costs
Cues to action
Behavior change will only occur under certain specific
conditions.
Theory of Planned Behavior
8
Developed to explain the relationship between attitudes and
behaviors.
Behavior is best predicted by behavioral intention.

Behavioral intention is predicted by:
Attitude towards performing the behavior
Subjective norm associated with the behavior
Perceived behavioral control
Integrative Model: Extension of TPB
9
Recently TPB has been reformulated to become the integrative
model of behavioral prediction.
Integrative model provides 2 important additions to TPB
Attitudes, norms, and PBC are all influenced by a variety of
background factors.
Environmental barriers can interfere with translation of
intentions into actual behaviors.

Social Cognitive/Learning Theory
10
The core determinants of health behavior change include:
Knowledge of risks and benefits
Perceived self-efficacy
Outcome expectancies for benefits & costs
Perceived facilitators and impediments
Self-efficacy can be increased via direct observation or
vicarious observation as well as through reciprocal
determinism.
Social Norms Theory

11
Assumption is that in many situations, people misperceive
norms due to:
Pluralistic ignorance
False consensus
Correction of misperceptions with disclosure of actual norms
may help:
Decrease risky behaviors
Increase preventive behaviors
Increase discussion of controversial or sensitive social problems
Norms can either be explicit or implicit in nature, as well as
subjective or personal.
Social Norms Theory

12
Two main types of norms are targeted in social campaigns:
Descriptive and injunctive norms.
Each type of norm motivates social behavior for a different
reason.
Misperception of norms more commonly occur under certain
conditions:
Behavior is highly visible and public
Greater coverage or portrayal in the media
High level of social distance from the comparison source
Extended Parallel Process Model
13
Theory explains the conditions under which fear appeals
succeed and fail.
Evaluation of fear appeal initiates two message appraisals:

Threat appraisal
Efficacy appraisal
Threat appraisal occurs first before efficacy appraisal
Four possible combinations after message appraisals:
Low threat & low efficacy
High threat & high efficacy
Low threat & high efficacy
High threat & low efficacy
Anger Activism Model
Anger is triggered by awareness of the obstruction of a goal and
motivates removal of barriers.
Extent of activism to perform the target behavior depends on
several factors:
Level of anger experienced
Level of efficacy perceived

Prior attitudes about the target behavior
Four clusters based on the model:
Activist group.
Empowered group
Angry group
Disinterested group
14
Negative State Relief Model
15
Argues that people are by nature motivated to “get rid of
feelings of negative affect, while desiring feelings of positive
affect. “
Emotional appeals designed to elicit sadness, guilt, and
compassion are some common approaches to motivate social
behaviors.
Different triggers are needed to elicit the right emotions in the
audience:

Sadness
Guilt:
Compassion
Additional Frameworks
16
Nudge framework & behavioral economics
Nudges are defined as indirect suggestions
Behavioral economics remind us that people do not always act
rationally in making behavior decisions
Examples of nudge campaigns include:
Grocery stores
Would you like to downsize that?

Red light/green light system
Additional Frameworks
Science of habit framework
Researchers have identified 3 components that make up any
given behavioral habit (Cue, routine, and reward)
Hierarchy of effects model
Six levels are:
Awareness
Knowledge
Liking
Preference
Conviction
Purchase

Hierarchy can be broken up into 3 key areas of focus for a
campaign to create impact
Cognitive impact
Affective impact
Conative impact
Campaigns can try to promote good habits or alter bad habits
The 10-Step Social Marketing Plan
Chapter 2
1
Perspectives on Social Marketing
2

The Production Perspective – Keep costs down & make it
accessible.
The Product Perspective – Focus on quality, performance, &
innovation.
The Selling Perspective – It’s all about promotion & doing so in
an aggressive manner.
The Relationship Perspective – It’s all about cultivating the
relationship via integrated marketing.
Describe the Social Issue, Background, Purpose, & Focus
3
Social issue: Identify the wicked problem
Background: Facts & information
Purpose: What is the potential impact of a successful
campaign?
Focus: Identify the specific approaches to contribute to the
plan’s purpose

Situational Analysis (SWOT)
4
Strengths: Organizational strengths & assets
Weaknesses: Organizational weaknesses
Opportunities: Environmental factors facilitating your
campaign
Threats: Environmental factors inhibiting our campaign
Past or similar efforts
Selecting Target Audiences
5
Identify the bull’s-eye for your campaign effort

Focal segments
Interpersonal influencers
Institutional influencers
Provide a rich description of audiences to help identify the right
set of campaign strategies
Size
Demographics
Geographical location
Values and lifestyle
Stage of change
Behavior Objectives & Goals
6

Behavior Objective: Specific behavior we want to influence the
target audience to DO
Target Goal: Campaigns need to specify SMART goals to
achieve
Specific
Measurable
Attainable
Relevant
Time bound
Identify Barriers, Benefits, Motivators, Competition, and
Influential Others
7
Barriers: Anticipated costs for the target audience
Benefits: Anticipated rewards for the target audience

Motivators: Incentives that can motivate acceptance of the
targeted behavior
Competition: Factors reinforcing their current behavior
Influential others: People that are likely to affect our behaviors
on a personal level.
Develop a Positioning Statement
8
Describes how you want your target audience to see the target
behavior
Involves influencing audiences to develop a specific mindset
Cognitive beliefs
Emotional reactions
The two pathways are referred to as active vs. passive approach
to influencing social behaviors.

Activity
In the following 2 TV spots, what is the key “take-away”
message communicated by the campaigners?
In your opinion, who are the target audience(s) for the 2 TV
spots?
How effective do you think the TV spots were at expressing the
positioning statement of the littering campaign?
Overall do you think the ads are effective at convincing people
not to litter? Why or why not?
Develop the Strategic Marketing Mix
10
Product: Description of the target behavior highlighting
benefits & additional incentives.
Core product
Actual product
Augmented product

Price: Perceived costs associated w/ taking up the target
behavior.
Useful to mention disincentives
Place: Description of the delivery system to be used for
campaign-related goods/services.
Promotion: Specific ways the campaign messages are to be
marketed (messenger, channels, slogans)
Developing a Monitoring & Evaluation Plan
11
Four areas of assessments
Inputs
Outputs
Outcomes

Impact
How will you measure?
Identify the specific procedures for documenting observations
When?
When do you start the monitoring & evaluation process.
Budget & Finding Funding
12
Product-related costs
Price-related strategies
Place strategies
Promotion
Evaluation

Implementation Plan
Often considered the “real marketing plan”
Focus is on identifying who will do what, when, and for how
long.
Ideally, social campaigns should plan to implement their plan
for at least 3 years.
Why Is Systematic Planning Important?
Clarify purpose
Make appropriate decisions
Setting realistic objectives and goals
Ability to create real behavior change
It’s not linear, re-evaluate and adjust along the way

Where Does Research Fit In?
Audience Insights
Chapter 8
1
Applying Exchange Theory
2
To influence behaviors among target audiences, it is critical
they perceive benefits equal to or greater than perceived costs.
Exchange theory within the social marketing context differs
from its use in the economic context:
Focuses on exchanges that may involve more than 2 parties
Applies to more than a simple exchange of money for tangible
goods/services

Focuses on products that may be more symbolic or intangible
Applying Exchange Theory
Successful exchange requires identification of 5 elements.
Perceived barriers
Perceived benefits
Perceived motivators
Perceived competition
Perceived influential others
Identifying Barriers
I
4
Questions to address to help determine barriers:
What concerns do they have?
What do they think they will have to give or give up?
Do they think they can do it?
Why haven’t they done it in the past, or on a regular basis?
Why did they quit doing it?

Realize barriers can be internal or external & real or perceived
Identifying Benefits
5
Key question to answer:
What does the audience say is in it for them?
Benefits appealing to campaigners or campaign funders may not
necessarily appeal to the target audience.
Campaigns are most effective when highlighting benefits
relevant to the audience.
Desired Benefits for Target Audiences
Autonomy

Demonstrating competence
Sense of belonging (i.e., satisfies need for inclusion)
Provides us a sense of meaning or life purpose
Reflects self-identity
Provides justice for self or others
Elicits positive emotions or feelings
Cognitively economical
Potential Motivators
Refers to ideas that might make your target audience more
likely to do the marketed behavior.
Specifically, consider if there are things that you could:
Say

Give
Show
Do for them
Identifying the Competition
8
Any social campaign will need to identify and overcome several
types of competition.
Sources of competition include:
Preferred alternative behaviors
Behaviors been doing forever
Organizations & groups promoting counter-behaviors
Identifying the Competition

9
An alternative framework used by campaigners to determine
competition highlights 4 sources:
Commercial counter-marketing
Social discouragement
Involuntary disinclinations
Apathy
Difficult to overcome these competitive forces within a
campaign to influence behaviors.
Identifying Influential Others
10
Social campaigns can more effectively appeal to their target
audiences by identifying others they:
Listen to

Watch or model after
Look up to or admire
Campaigns targeting midstream audiences may work better than
downstream audiences.
Two-step flow model offers a reasonable explanation
Formative Research for Audience Insights
11
Formative research serves 3 critical functions for the campaign
planner.
Understand audiences’ needs and preferences
Identify the most effective strategies or message approaches to
reach the targeted audience
Decide on the best channels to use for distributing & placing
campaign messages

A general model for conducting formative research is KAPB
model.
1. Knowledge
2. Attitudes
3. Practices
4. Beliefs
Data Sources for Audience Insights
Literature and research
Discussions with peers and colleagues
Original research
Steps 1 and 2: Social Issue, Purpose, Focus, Situation Analysis

Chapter 5
Describing the Social Issue
2
The social issue is best defined as the “wicked problem” to be
addressed.
Identify sponsoring organization(s)
Provide relevant background information
Use facts and credible data to justify why this social issue.
3 main sources include:
Current statistics
Precipitating events
Disturbing trends

Describe the Purpose
3
Highlight benefits or impacts of the program
Typically a social marketing campaign has 1 of 4 purposes in
mind.
Typically have as its purpose to decrease or reduce, improve,
increase, or eliminate something in order to yield societal
benefits
Different from campaign objectives or campaign goals
Campaign objectives
Campaign goals
Describe the Focus

4
Social marketing campaigns address 1 of 3 areas of focus.
Behavior-related
Population-related
Product-related
A set of criteria helps campaign planner decide which area(s) of
focus to concentrate on:
Behavior change potential
Market supply
Organizational match
Funding potential & appeal
Impact
Situational Analysis

5
Conduct SWOT
Internal Factors: Resources, Expertise, Management Support,
Past Performance
Strengths to maximize
Weaknesses to minimize
External Forces: Cultural, Socioeconomic, Economic,
Political/Legal, External Publics
Opportunities to take advantage of
Threats to prepare for
Review of past/similar efforts
Organizational Assessment
6

Resources
Service delivery capabilities
Management support
Issue priority
Internal publics
Current alliances & partners
Past performance
External Assessment
7
Cultural forces
Technological forces
Demographic forces

Natural forces
Economic forces
Political/legal forces
External publics
Review of Past Efforts
8
Target audiences - who has not yet been reached?
Strategies - what has been tried to influence behaviors?
Results - what findings have their efforts yield?
Lessons learned - what has worked? What has not worked?
Existing research - reliance on other campaign data to build
your case.

Potential materials to use - reliance on other campaigns for
marketing materials
The Role of Exploratory Research When Choosing Focus
Exploratory Research: This is done prior to the implementation
of the campaign.
Phase identifying campaign purpose & focus
Functions to help provide data on problem severity & identify
populations at greatest risk; as well as highlight potential areas
of focus.
Phase of situational analysis
Functions to help provide data for your overall audit of
strengths, weaknesses, opportunities, & threats
Key Informant Interviews:
Past and similar efforts

Selecting Audiences
Chapter 6
Audience Segmentation
2
Defined as the process of creating homogenous segments
Campaigners can either adopt an a priori process or a post-hoc
process.
Segmentation of audiences can be based on traditional variables
or theory-driven variables.
Benefits of Segmentation
3
Increased effectiveness
Increased efficiency

Provide input for resource allocation
Provide input for developing strategies
Traditional Variables
Demographic factors
Age, gender, education, income, social class
Geographical factors
Region of country, neighborhood,
Psychographic factors
A person’s lifestyle, membership in various social
organizations, & media exposure
Behavioral factors
Usage rate, user status, loyalty status, readiness for adoption
4
Stages of Change Model
5
Individuals can be classified into 5 stages of readiness for
behavior change:
Pre-contemplation

Contemplation
Preparation
Action
Maintenance
Termination stage applies to individuals that have moved
beyond the point of relapses for a problematic behavior.
Patterns of behavior change occur in a spiral fashion due to
relapse or changes in motivation.
Diffusion of Innovations Model
Diffusion of innovation theory classifies individuals into 1 of 5
categories in terms of readiness for adoption:
Innovators
Early adopters
Early majority
Late majority
Laggards
Behavioral influence approach varies based on the diffusion of
innovation category people belong to.

6
Diffusion of Innovations Model
Other Segmentation Models
8
Healthystyles segmentation
Health orientation
Lifestyle behaviors
Readiness for behavior change
Environmental segmentation
Alarmed
Concerned
Cautious

Disengaged
Doubtful
Dismissive
Generational Segmentation
Segments of audiences based on the generation they were born
into:
Traditionalists
Baby boomers
Generation X
Generation Y
Millennials
Generation Z/post-millennials
9
Evaluating Segments
Effectiveness Potential
Segment size
Problem incidence
Problem severity
Defenselessness
Efficiency Potential
Reachability
General responsiveness

Incremental costs
Responsiveness to marketing mix
Organizational capabilities
10
Target Audience Selection
11
In selecting the final target audience, social marketing
campaigns can engage in:
Undifferentiated marketing
Differentiated marketing
Concentrated marketing
Choice of segments can also be decided based on 1 of 4 guiding
principles.
Greatest need

Readiness to change
Accessibility/reach
Best match to organization
Crafting a Desired Positioning Statement
Chapter 9
1
What is a Positioning Statement?
2
Defined: Designing the organization’s actual and perceived
offering in such a way that it lands on and occupies a distinctive
place in the mind of the target audience
Format: We want (target audience) to see (target behavior):

As a clear set of actions
As easy to do despite perceived barriers
As a set of benefits
As better than the alternatives
In a new light
Behavior-Focused Positioning
Focus is on describing clearly the specific behavior.
Goal is to get people to retain and recall knowledge regarding
how to carry out the behavior.
Particularly useful positioning strategy when dealing with a new
behavior or a complex behavior.
3
Barriers-Focused Positioning
4

Highlights how easy and simple it is to perform the target
behavior despite barriers.
Goal is to build feelings of self-efficacy within the target
audience.
Some good campaign examples include:
Quit lines for smokers
Recycling programs for cell phones & electronics
Benefits-Focused Positioning
5
Goal is to highlight the benefits for the target audience in doing
the promoted behavior.
Emphasis of this type of positioning is on clearly
communicating the incentives for taking up the targeted
behavior.
Competition-Focused Positioning
Focus is on highlighting how the target behavior is superior to

competing behaviors.
The goal is to create competitive superiority for your promoted
behavior.
Benefit-to-benefit superiority
Benefit-to-cost superiority
Cost-to-benefit superiority
Cost-to-cost superiority
6
Repositioning
7
Focus is on changing the current positioning statement for your
target behavior.
Due to 3 reasons:
New audiences
Image problem
Poor evaluation

Three changes should be made to reposition a campaign that
suffers from an image problem.
More fun
More accessible
More normative
Positioning and Branding
Campaign positioning is related to the concept of branding in 3
ways.
Positioning help campaigns establish their brand identity
Positioning Help campaigns foster a specific brand image
Positioning helps campaign become a brand through using
different visual elements.
Ethical Considerations of Positioning
It is vital campaigners try to be ethical when using positioning
Behavior focused
Benefits focused
Barriers focused
Competition focused
Repositioning

9
Pretesting Research
10
Process of testing campaign messages for its perceived
effectiveness prior to implementation.
There are 5 key elements to be assessed as part of pretesting.
Attention
Message comprehension
Strong and weak points within the message
Personal relevance of the message
Identifying sensitive or controversial elements
Behavior Objectives and Setting Target Goals

Chapter 7
1
Setting Campaign Objectives
2
Behavior: What do you want your audience to do?
Set of 5 criteria helps to narrow down behavioral choice
Impact, willingness, measurability, market opportunity, &
market supply
Knowledge: What do you want your audience to know?
Refers to objective information provided to your audience. Not
opinion.
Belief: What do you want your audience to believe?
Refers to messages aimed at altering attitudes, opinions, or
feelings

Criteria for Selecting Behavior
Relative to other behavior options, how does a given social
behavior rate in terms of:
Impact
Willingness
Measurability
Market opportunity
Market supply
3
Behavioral Objective: Energy ConservationBehavior
ImpactWillingnessMeasurabilityMarket OpportunityMarket
SupplySwitching to fluorescent light bulbsUse less hot
waterAdjusting thermostat settingLine dry your wet laundry
Rate Each Scale 1-5 where 5 is high.
Best guesses relative to others on the List
4
Knowledge Objectives: Examples

5
Information to motivate behavior
% of women who have heart attacks
Why cigarette butts are harmful to environment
Amt. of energy saved by unplugging unused electronics
Information to assist audience to do the behavior
How to prepare for an earthquake
Phone number for battered women
Belief Objectives: Examples
6
Beliefs can be influenced via messages as well.
Increased physical activity will help you sleep better

You are at risk texting and driving
Proper disposal of your pet’s waste makes a difference
Beliefs are individual perceptions & often can be identified via
looking at different models of behavior change
Specifying Target Goals
7
Social campaigns need to identify specific projected goals they
hope to achieve.
Changes must be attributable to the campaign.
Goals should be described using the SMART acronym.
Specific
Measurable
Achievable

Relevant
Time-bound
Resources for Setting Target Goals
A variety of options are available to provide benchmarks that
can be used to help set target campaign goals.
Here are some examples...
CDC’s Behavioral Risk Factor Surveillance System
Healthy People 2020
Data from peers in other agencies
Data from nonprofits and foundations with a related focus
Academic studies
Federal agencies
8
Alternative Means for Goal Setting
In situations where clear benchmarks are not available, the
campaign can focus on setting goals for:
Campaign awareness
Knowledge change
Beliefs
Response to campaign elements
Intent to change

9
Defining and Distinguishing Social Marketing
Chapter 1
What Is Social Marketing?
Social marketing is a process that uses marketing principles and
techniques to:
Influence behavior change
Utilize a systematic planning process
Focus on priority audience segments
Deliver a positive benefit for individuals and society
Differs from other forms of marketing:
Commercial marketing
Nonprofit/NGO marketing

Public sector marketing
Cause promotions marketing
Comparing Social & Commercial Marketing
Similarities
Adopt a customer orientation
Operate from an exchange theory perspective
Rely heavily on marketing research
Engage in audience segmentation & creation of unique
marketing mix
Measure results to improve for the future
Differences
Beneficiaries for commercial marketing are corporations and
shareholders
Beneficiaries for social marketing are society and individuals
Linkage to Strategic Communication Campaigns
4
Strategic communication campaigns can be studied from the
lens of social marketing.
Strategic communication campaigns have the same planning

process.
Who Does Social Marketing?
Public sector agencies
Nonprofit organizations and foundations
Professionals working in certain for-profit organizations
Professionals working in social marketing organizations
Social Issues Addressed via Social Marketing Campaigns
Health-related behaviors
Injury prevention-related behavior
Environmental behaviors
Community involvement behaviors
Financial behaviors

Additional Ways to Influence Individual Behaviors
Reliance on technology & science
Enactment of policies, laws, regulations
Improvements in infrastructures & built environments
Changes in corporate policies & business practice
Greater education through schools, news, & media
Targeting Upstream and Midstream Audiences
Common Barriers to Influencing Behaviors
Inconvenience and lack of accessibility
Unwillingness to give up pleasure/comfort
Potential harm to self or our relationships

Lack of confidence in personal skills or will power
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 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: [email protected] ORCID iD:
https://orcid.org/0000-
0002-6203-0024; 2Ph.D., Department of Nursing, Federal
University of Ceará/UFC. Fortaleza(CE), Brazil. E-mail:
[email protected] ORCID iD: https://orcid.org/0000-0002-5803-
8605; 3Master´s student, State University of
Ceará/PPSAC/UECE. Fortaleza (CE), Brazil. E-mail:
0296; 4Ph.D.
student, State University of Ceará/PPCCLIES/UECE. Fortaleza
(CE), Brazil. E-mail: [email protected] ORCID iD:
https://orcid.org/0000-0003-2808-7526; 5Ph.D., State
University of Ceará/PPSAC/UECE. Fortaleza (CE), Brazil. E-
mail:
7821; 6Ph.D., Federal University of Ceará/UFC. Fortaleza
(CE), Brazil. E-mail: [email protected] ORCID iD:
https://orcid.org/0000-0002-8323-8465

INTEGRATIVE REVIEW ARTICLE
2018
mailto:[email protected]
https://orcid.org/0000-0002-6203-0024
https://orcid.org/0000-0002-6203-0024
https://orcid.org/0000-0002-5803-8605
https://orcid.org/0000-0003-4362-0296
https://orcid.org/0000-0003-2808-7526
https://orcid.org/0000-0002-5838-7821
https://orcid.org/0000-0002-8323-8465
English/Portuguese
ISSN: 1981-8963 ISSN: 1981-8963
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 research.
● 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
2018
English/Portuguese
ISSN: 1981-8963 ISSN: 1981-8963
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.
2018
English/Portuguese
ISSN: 1981-8963 ISSN: 1981-8963
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.
2018
English/Portuguese
ISSN: 1981-8963 ISSN: 1981-8963
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
2018
English/Portuguese
ISSN: 1981-8963 ISSN: 1981-8963
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 …
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
This paper 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
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

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