The results of this section are divided into three parts, referring respectively to the opinions of (i) union leaders, (ii) leaders of professional councils and associations and (iii) NHS managers.
Union leaders
VAHPITWP was considered a very important problem by all the interviewees. Verbal aggression was perceived as very frequent. The most worrisome type of violence was identified by two of the interviewees as bullying / mobbing, by colleagues and users alike. Physical violence was considered important for doctors and nurses who have to deal directly with patients, but not for other health professionals. "Institutional violence" was mentioned by two of the interviewees as resulting from the lack of competence of the managers of health services. Sexual harassment and discrimination were considered infrequent and it is believed that, when it happens, it is not reported, particularly when the person responsible for the violence is a more senior professional or manager.
One of the reasons why VAHPITWP was considered important was the growing number of cases being reported and their increasing severity, particularly of physical violence. According to the interviewees, this increase in the frequency of violence reflects two phenomena of modern society: on the one hand, the greater visibility of violence in modern culture and on the other, a growing perception by citizens of their rights, with the corresponding increase in the level of demands. This increased awareness of rights has not been accompanied by a similar increase in civic education.
No change has been observed as to the site of occurrence of violence: it was still perceived as being most common in the hospital emergency departments, in ambulatory care services and during home visits.
Leaders of professional councils and associations
All the leaders considered VAHPITWP an important issue.
The President of the Medical Council considered verbal violence the most frequent, particularly when doctors worked alone, such as GPs in the HCs. Nevertheless, the most worrisome form of violence, even if less frequent, is physical violence. Bullying / mobbing of doctors by patients, particularly in relation to access to sick leave certificates, is also quite significant. Doctor-versus-doctor violence was acknowledged. There was recollection of episodes of xenophobia, particularly against Brazilian colleagues, but no recollection of sexual harassment.
According to this interviewee, the pattern of violence has evolved. Verbal violence has increased the most. Physical violence has increased, particularly over the last 13 years. Violence among colleagues is also more frequent now than in the past, mostly because of too much work and overtime. This increase in the level of observed violence must also be seen in the context of a society also more violent now than in the past.
The most violent workplaces are the HCs. The reason is that in the HCs patients feel at home and are very familiar with the health personnel.
For the President of the Nursing Council there is a need to better understand the behaviours that result in aggression. This is important because of the impact of VAHPITWP on the quality of the care provided.
The most frequent and the most worrisome aggressive behaviours are those that lead to verbal aggression. Physical aggression is a minor problem and harassment and discrimination are very infrequent.
Violence, particularly verbal, increased significantly.
Violence is most frequently observed in emergency services, where nurses are most frequently the first-contact professionals.
For the other professional associations, different positions emerge.
For some, the most worrisome type of violence is that which results from institutional harassment because doctors may interfere with established interests, political and economic. This is particularly true in the case of public health doctors. This type of violence was also acknowledged by one other professional association, particularly in situations of competition for professional leadership positions – the loser is frequently persecuted and repeatedly humiliated by the winner, forcing many professionals to look for alternative workplaces in which to practice.
Violence among colleagues was also considered very frequent. Verbal aggression, as well as psychological pressure, appears masked as "threats of disciplinary procedures for negligence". Racial discrimination was not acknowledged as being worrisome. Sexual harassment was infrequent but "somewhat worrisome", as such instances are usually taken to court. As the proportion of female professionals increases, sexual harassment seems also to increase.
Once again, aggression against GPs was seen as most worrisome. GPs work alone in their consulting rooms. Also, the proportion of women GPs is higher than in other medical groups. Violence was perceived as particularly frequent against professionals working after normal working hours.
From the perspective of its impact, the most worrisome type of violence is the VAHPITWP that recurs daily: not physical violence – which is infrequent, although with more serious consequences – but rather bullying / mobbing.
Although VAHPITWP was seen as a very worrisome phenomenon on the increase, it is the opinion of interviewees that it must be seen in the context of a society ever more violent and less tolerant. While in the past violence was most frequent in the emergency services, now it is more generalised. One factor that contributes to this increase in VAHPITWP is the perception of health as "a most important value". Another factor is the increased professional and academic status of the nursing profession. Users are also different: better-informed and more sophisticated than in the past, more aware of their rights, they come to the health services with a more demanding attitude. Among the users some ethnic groups, as well as the drug abusers, are seen as particularly violent.
NHS managers
The NHS managers are divided into three groups: HC managers, hospital managers and managers of regional and central health departments.
Health centre managers
We interviewed the medical directors of six HCs. Only one of these interviews was a joint interview with the nursing director.
All the interviewees considered VAHPITWP a very important problem "(...) the most frequent type of violence is verbal violence (...) it happens every day. It may become extremely violent (...) we have been through serious episodes of violence". It is most frequent against nurses and administrative personnel. One of the HC managers considered physical violence as the most serious form of violence observed, followed by bullying / mobbing of the users. But all acknowledged all the forms of violence, although giving them different priorities. Sexual harassment was considered infrequent or absent "the white coat defends us, it is a dissuasive element (...)". Discrimination was also considered very infrequent.
Some said that VAHPITWP was becoming more frequent, while others claimed that violence was not becoming more frequent but had become more serious. These changes were attributed to the lack of information by the users and to poor communication skills of the health personnel. VAHPITWP reflected the fact that we "live in a violent world, people when coming to the HC bring with them a significant amount of stress, they are in a hurry (...) people are subjected to a lot of pressure and a visit to the HC is like a safety valve".
Violence was considered inherent to the NHS in situations such as short-term contracts. This reflected violence as part of the general societal culture. The media were an important factor in perpetuating this type of violence. The rights movement, unlinked to a responsibilities movement was also an important explanation of the current trend: people claim more and more rights but do not recognise their responsibilities. This is partially associated with the public servant image that users have of health professionals "I pay a lot of taxes to ensure your income so you had better produce the goods". Another pattern emerging, particularly during home visits, is the blaming of the health care services for all social ills.
Hospital managers
In each of the six hospitals, we interviewed jointly the medical and nursing directors.
VAHPITWP was referred to as a natural expectation in the hospital setting that should not be seen out of this context. It is a "professional hazard". It was also seen as a mechanism to try to obtain the attention that the patient feels entitled to. It must be perceived more as a conflict rather than conscious, deliberate and systematic violence. It is important to understand that not all professionals see aggression as aggression against themselves as professionals; they ignore it because the professional tries to understand the reactions of the patients in the context of his or her situation:
"This phenomenon of violence against health professionals (...) was very frequent when XXX (the Minister of Health who during the 1980s initiated a campaign to "moralize" public sector professional practice) was the minister of health. She encouraged campaigns against doctors and patients felt encouraged (to take positions such as) 'it is now that I am going to get at them'. Otherwise it occurs sporadically ... People protest very easily. They protest very easily and become aggressive against some professionals for any little thing".
For one interviewee, physical violence was the most visible type of VAHPITWP, standing side by side with psychological and verbal violence. For all the others, verbal violence was the most frequent type of VAHPITWP and physical violence was considered infrequent. For one, bullying / mobbing was uncommon, while another acknowledged the bullying / mobbing exerted by relatives over the professionals as "not uncommon". This type of violence was reflected in the frequent use of expressions such as: "you guys work here, but we are paying your salaries, so you must do as we wish (...), if I catch you outside (...)". Sexual harassment and racial discrimination were considered infrequent. Sexual harassment, when it happens, has to do with illness in the elderly or in services directed at teenagers or young adults. Infrequent complaints of racial discrimination were presented by some black doctors against patients. This has usually to do with dissatisfaction in relation to the care provided, mixed with the racial issue. A new type of aggression has to do with attempts to intimidate the professional with threats of denouncing him or her through the media.
VAHPITWP is most frequent in the hospital emergency department, because that is where disturbed individuals (drug addicts, alcoholics, mentally disturbed, people in pain, etc.) are most frequently found. Most cases of physical violence occur there.
VAHPITWP has been on the increase for the past 20 years. This has to do with a change of the dependency of patients in relation to professionals, giving rise to situations of violence against patients; this has changed and patients have more rights now. Verbal and physical violence are on the increase. Violence begets violence, and in a violent society repercussions must be expected in all sectors, including health:
"Violence is increasing in Portuguese society and health suffers from this influence. The battle for audiences promotes a witch hunt for mistakes and negligence in health, resulting in a climate of untrustworthiness and insecurity in relation to health care. (...) promoting in the public's opinion an expectation of better health care, far above the supply capacity. All this primes people for violence as soon as there is a deviation from the expectations, resulting in aggression and animosity. If there is no capacity for attentive listening, persuasion and negotiation, the result is violence".
In terms of the evolution of violence, one interviewee perceived it as being less frequent against doctors but all the others acknowledged it as a problem either on the increase or stable (one interviewee) but of similar frequency for all professional groups (more frequent against nurses, according to one of the interviewees). This is particularly true for verbal violence. There are also changes in the pattern of verbal violence: while in the past it was more like verbal lashing, now it is more verbal threats. Some of the respondents are not sure that physical violence is more frequent, but they perceived the physical violence as being of "a different intensity".
The managers of the regional health authorities and of central departments of the ministry of health
We interviewed six public sector health managers at central and regional level.
All the interviewees considered VAHPITWP as an important problem. As to the most important form of VAHPITWP, the opinions varied from four that considered psychological violence, including verbal violence (one) and bullying / mobbing (one) as the most important. One of the interviewees considered that physical violence was not very relevant and another one considered it worrisome, reflecting a lack of mechanisms to ensure the security of the health professionals, particularly in situations when health professionals meet their clients behind closed doors. Physical violence was also considered very important for emergency care crews called to provide emergency non-institutional care. Verbal aggression was also identified as frequent against health professionals manning emergency telephone lines and against administrative health personnel. Sexual harassment was considered infrequent, not visible or unknown. Physical violence was perceived as, if not the most important, the most worrisome, the most visible and the one that most frequently led to court cases.
One of the interviewees considered that racial discrimination was most frequent against the users of the health services rather than towards the professionals. Another stated that racial discrimination against health professionals existed and that it might amplify other forms of violence.
Regarding the observed trends in the evolution of VAHPITWP, most interviewees considered that VAHPITWP in general was on the increase. The current level of VAHPITWP was partly attributed to the "eternal" disorganization of the health services and to the lack of management skills.
"Some people have too much power (...) they misunderstand their role (...) and this leads to the creation of barriers to the personnel working under them. This is particularly visible (...) in hospitals".
One other interviewee considered that current violence trends reflected the level of violence in society. A third attributed it to greater media visibility, and because people more frequently now than in the past dare to challenge professional opinions. One considered that we may not be seeing an increase in the incidence of violence but rather a greater visibility, because of the role of the media or even, according to another, due to intensity of the violence observed today. A new form of violence, violence against property, is associated with the emergence of drug addicts.
Violence was perceived as most frequent in HC consultation rooms and reception desks and in hospital emergency care departments. In hospitals, violence by patients' escorts was considered more frequent than in HCs