Work Organization , Psychological Violence and Moral Harassment : Panorama of the Brazilian Context in Health Institutions

In this qualitative study, we present experiences of psychological violence and moral harassment, establishing characteristics of the work organization (WO) from the perception of hospital employees. Participants were 13 women randomly selected from a list of health professionals provided by a Union of Workers of Health Establishments from the south of Brazil. The group was composed of Nursing Technicians and Nursing Assistants (69.22%), Cleaning Assistants (23.07%), and Kitchen Assistants (7.69%). A semi-structured interview with a guiding script served as instrument for data collection. The audio recording transcriptions were submitted to content analysis technique, which generated three thematic categories: 1) experiences of psychological violence, 2) occurrence of moral harassment, and 3) work organization in the health field. The information from the speeches showed substantial evidences of psychological violence and moral harassment suffered by health professionals in the specific context of the study.


Introduction
This occupational violence involving the health sector is considered a worldwide phenomenon (Palácios, 2003).It refers to all the forms of aggressive or abusive behavior or even any kinds of acts, postures and attitudes that may cause physical or psychological harm or discomfort in its victims or damage to the property.It may be per-formed by anyone (client/customer, colleague, robber or a person with whom the employee holds any professional relationship), while the individual (victim) is at work, on company business or going to or returning from work (Santos Júnior & Dias, 2004).
Among the universe of situations of work-related violence, psychological violence has been calling the attention of researchers and scholars, organizations and societies of the health field, the media, unions, workers and companies, due to its repercussions in the working field.Several behaviors can be incorporated under the designation of psychological violence in the work setting: humiliation, provocation of certain groups, discrimination and management through stress, abuse, fear or moral harassment (Soboll, 2008b).
Moral harassment is a specific and serious type of violence at work (Soboll, 2008a).Although contemplated in the international research agenda for more than 25 years (Soboll, 2008b), it has been studied in Brazil for about 10 years and concerns conducts occurring in the work environment that are abusive, intentional, frequent and repetitive.These conducts seek diminishing, humiliating, harassing, embarrassing, disqualifying and psychically demolishing an individual or a group, degrading their work conditions, reaching their dignity and risking their personal and professional integrity (Freitas, Heloani, & Barreto, 2008).
Occupational moral harassment manifests in the individual, organizational and social spheres.In the individual level, the victim's personality, identity and self-esteem are attacked, which are likely to trigger the development of a series of psychic and physical disorders.In the organizational level, adverse effects include sick leave and labor accidents, absenteeism and turnover increase with replacement costs, loss of working tools by lack of concentration, among others.The social level includes costs of labor accidents and premature disability of professionals, increased medical expenses and social security costs (medical licenses, hospitalizations, subsidized medicines and long medical treatments), suicide or early retirements (Freitas, Heloani, & Barreto, 2008).
The first Brazilian research specifically involving health professionals concerning violence in the workplace was performed concomitantly in countries with different degrees of socioeconomic development, such as South Africa, Bulgaria, Thailand, Lebanon, Portugal and Australia.The intention was, by means of a multicenter study, to quantify and qualify the phenomenon of violence in these environments.The report of the study, funded by the International Labor Organization (ILO), was released in 2003.The part of the study which took place in Brazil was conducted in the state of Rio de Janeiro, with 1569 interviews performed with health professionals in a general fashion.Among the greatest surprises evidenced by the study was the violence against health professionals performed by other health professionals, that is, the violence between colleagues and between bosses and subordinates.Although physical violence was also perceived, moral violence, called moral harassment, was the one that attracted most attention (Palácios & Rego, 2006).
In 2004, the World Health Organization (WHO) published orientations to health professionals, decision makers, managers, human resources directors, legal community, unions and employees about the theme.According to the publication, the prevalence of psychological violence and of moral harassment was respectively 39.5% and 15.2% (WHO, 2004).
Literature indicates that the occurrence of situations of psychological violence in the work environment, including moral harassment, is closely associated to the forms of work organization.In this respect, Dejours (1998) alerts that work organization (WO) is not only structured to moral violence, but also stimulates it.The WO involves biopsychosocial characteristics of the work, such as division of labor, affective and socio-professional relationships, working conditions, possibility of initiative and autonomy, degree of ambiguity regarding the results of the tasks, as well as the cooperation and communication level presented by the individuals (Dejours, Abdoucheli, & Jayet, 1994;Mendes, 2007).
Brazilian researchers have similarly shown that the way the work is organized and managed is, indeed, capable of directly influencing violent relations between people.That happens because these environments are ruled by uncertain and mutable procedures, broken promises, denied recognitions, arbitrary punishments, requirements of submission from some people and arrogance from others (Freitas, Heloani, & Barreto, 2008).
In this sense, this study aims at presenting experiences of psychological violence and moral harassment, establishing characteristics of the work organization from the perception of hospital employees.

Method and Materials
This study presents a cross-sectional exploratory design, from a qualitative approach.Participants were workers from health establishments, more precisely hospitals, on the job for at least three years.The workers who were laid off were excluded.The participants were randomly selected, from a list of health professionals provided by the Union of Workers of Health Establishments of Passo Fundo (Brazil) and the region (Sindisaúde).
Considering the saturation criteria proposed by Minayo (2010), the group was composed of 13 employees.The socio-demographic characteristics of participants are described in Figure 1.
A semi-structured interview with a guiding script was used as data collection instrument.The script was based on Hirigoyen (2005a) for questions related to psychological violence and moral harassment, and on Dejours (1998) for specific topics concerning work organization.Interviews lasted 1.5 hour average and were performed in the headquarters of Sindisaúde, in Passo Fundo.The interviews were entirely recorded and transcribed for further analysis by means of the content analysis technique, according to Bardin (2011), which generated three thematic categories.
Regarding the ethical conditions, the research was approved by the Research Ethics Committee of Universidade do Vale do Rio dos Sinos and the participants signed an Informed Consent Form.In order to ensure the confidentiality of the participants, they are identified in this article by means of a code composed of letters and a numbers.

Results and Discussion
The processing of the results through content analysis generated three thematic categories, namely: experiences of psychological violence, occurrence of moral harassment and work organization in the health field.

Experiences of Psychological Violence
This category characterizes the expressions of psychological violence that were present in the routine of the health services provided by the workers that were centered in management through injury and management through fear.These adverse processes are not characterized as being habitual or intentional, such as moral harassment.Because of that, they are presented within this category.
Passages were evidenced containing verbal offenses and rude behavior in public, to which workers were sporadically exposed.Such occurrences characterize management through injury, in which unprepared professionals submit employees to violent and disrespectful treatment, using insults.Even though these situations do not present repeatability, they have the potential of provoking adverse feelings (Hirigoyen, 2005a).This can be observed in the following quotes: "It happened to me, (the boss) called my attention in front of the colleagues, insulting, swearing, as I say, authority abuse, like this: 'I told you to shut up, shut your mouth, idiot!' Can you imagine?" (S1), and "For example, the doctor gets there and wants a tube.If the tube isn't there […] then you bring him another tube because it is an emergency, he says: 'you are so stupid, incompetent bug!' and throws the tube against the wall" (S3).
Management through fear was also demonstrated: "The number of employees instead of rising, decreases, there are days that we even have to help in the other health centers […] so, sometimes, it is hard to handle all the work.But we had better do so, because as they threaten us, there are a lot of people who want our position (S7).In this case, the threats, by means of implicit or explicit intimidation, aim at keeping employees adapted to the culture and to the objectives of the institution.This process is called management through fear (Hirigoyen, 2005a).
As it was possible to perceive, psychological violence, expressed in the form of management through injury or fear, is based on a social relationship of imposition, with the abuse of power, in the form of threats or as a concrete fact (Soboll, 2008a).These circumstances, in general, lead workers to ignore personal and professional ethical values in order to try to ensure the maintenance of an employment relationship.

Occurrence of Moral Harassment
This category shows that moral harassment is a reality to the health workers participating in this research.The reason we discuss these data is the finding of the harassing situations, as well as other criteria that must be present in the case of moral harassment, such as the occurrences being habitual and personal.
Health workers informed that they perceive themselves as victims of moral harassment on the job: "I think I am a victim, because of the insults saying that I am practically old, that I do not serve for the service" (S10), and "I feel discriminated and part of these humiliations is moral harassment" (S11).Such passages mention terms that refer to harassing conducts: "discrimination", "insults" and "humiliations".It is possible to infer that they are facing some manifestation of psychological violence.Zaballa (2001) gives credit to the previous statement by including among the components of psychological violence, conducts such as shouting, insults, reprimands, public or private humiliations, and false accusations.
Soboll (2008b) presents three indicators of psychological violence at work: 1) the abuse of power in the relationships; 2) inappropriate behavior concerning the rules of social harmonic living; 3) repercussions in the employee's health and life.The experiences presented in the previous parts of the passages refer to the second indicator, giving them the status of psychological violence.
How is it possible to suppose that this type of psychological violence portrayed by the subjects of the research can be categorized as moral harassment in the workplace, as stated by the interviewees?First, some acts to which they were exposed are analyzed in detail.In the following passage, acts of isolation, refusal of communication, verbal offenses in public and attacks to the professional competence are presented: "So, they (the colleagues) go like this: 'Oh my God, when is she going to move on, what a fool, she is not good for nursing', and I notice that they are talking about me, one day even a patient saw that and mentioned it to me […] I feel isolated, they don't invite me to have snacks with them, they don't talk nicely to me, […] It happened to me once, a doctor got to me and said: 'you are definitely stupid, I will sew your fingers because you are worth nothing'.One day I went there to get the drain he (doctor) had asked and he said: 'no, this is not the one I asked, you are so stupid, you should pay more attention, it looks like you live under a rock' […] It happened once, the doctor asked me to withdraw a medication, then I withdrew it, then he went back and asked for another medication, and I said, what medication do you want me to make again?Then, he said: 'besides being slow, stupid, you don't even listen'.Wow, for me that was [pause] I locked myself in a room and cried a lot that day" (S11).
In the next passage, the verbal offenses intending to attack the performance of the professional activity are highlighted, stating that the person would not be sufficiently active due to the age and years of work in the institution: "They go like this: 'she cannot handle the job anymore, what's going on?' and they talk to each other about it […] They say that I am getting old, that I am not good enough for the job anymore, I think that is harassment, right?[…] I feel sad, I feel hurt by the boss, I have already told her that I don't think things are like that, you know […] It is humiliating to make you feel like you are not good enough for the job, it is humiliation, it is humiliating you" (S10).
It is possible to verify in these verbalizations, abusive and disrespectful conducts which are typical of moral harassment at work.That is mentioned because those behaviors are included in the description of the most frequent conducts of moral harassment, according to Hirigoyen (2005b) and Leymann (1996).Four specific implicit criteria should be taken into consideration when trying to recognize the occurrence of such phenomenon (Freitas, Heloani, & Barreto, 2008;Rezende, 2006;Soboll, 2008b).They are: 1) Habitual and repetitive occurrence: hostile conducts must occur repetitive times throughout the working day, for a determined period.Isolated occurrences do not qualify as moral harassment.The exact duration is not consensual, though, it is essential to identify a continued and insistent practice; 2) Personal nature: the hostile actions are not directed to a group of people, but to a person in particular.It is possible for more than one person from the same group to mutually be the target of the aggressions, but the process is directed and personal; 3) Geographic limit: it should occur within the workplace, between the people who belong to the same work organization and are linked to it through a contractual relationship, or the ones who directly or indirectly depend on the company (outsourced personnel); 4) Intention to harm: harassment seeks harming in order to decrease the scope of action or forcing the resignation from the company or from a project.The target is defined by means of subtle or explicit traps.
Habitual occurrence, one of the most important criterion to accurately verify the classification of moral harassment, had references made by the interviewees in their declarations: "Lately she has been despising me, for almost a year" (S8); "Things have been the way I told you for around four years" (S10); and "I have noticed these things happening to me for around eight months, I want to change sectors" (S11).These declarations reveal that the typical actions of moral harassment happened, in the perception of the interviewees, in an insistent way, occurring from eight months (S11) up to four years (S10).
Personal nature was another criterion that could be observed in the declarations, demonstrating that people recognize themselves as targets of abusive conducts: "Moral harassment is like this, you work with many people, many people in the department and you are the one who has to listen to all the things, that you are the one who doesn't do the things right around there.Everybody is ok, except for you, you are the one insulted in front of everybody" (S8); and "I have already seen the things that happen to me happening to another person, when I worked in another department, you know?But now, in the sector I work, I am the one who goes through these stuff […] This is very offensive to me, I would like to be treated like my other coworkers are" (S10).
The intention to harm, as a characteristic to identify the phenomenon of moral harassment can be perceived in the next passage: "I guess she is doing all this because she wants me to leave the hospital […] And now, lately, she despises me way more than she used to, I guess she wants me to get revolted and leave the hospital, she wants me to resign you know, especially because she knows that next month there will be the election again, and that only happens to me, you know?" (S8).
In this case, the aggressor's ultimate intention is to force the employees to resign, by means of abusive conducts.The path to resignation, as identified in the speeches, would go through the phase of the victims' emotional destabilization.The victims, unable to bear the frequency of the colleagues' and/or bosses' behaviors, would willingly request their resignation, and because S8 has job stability as a member of the union's board, the subject cannot be fired due to its legitimate right.Harassment serves, thus, as a tool for the company to get rid of that employee.Union representatives are, according to Hirigoyen (2005b), commonly victims of moral harassment, once that they are customarily seen as those who act against the organizations.

Work Organization in the Health Field
Health workers have established a relationship of cause-effect between the management and their work organization and the experiences of moral harassment.Thus, they displayed the following: "Look, moral harassment happens because of our routine, which is stressful in my opinion, you know.The person is there, stressed, there is the lack of employees and the lack of a humanized culture.If everyone thought differently, it wouldn't lead to that.The pressure, the stress, the medical culture of arrogance helps that to occur" (S11); and "It is possible to see so much moral harassment here because I think the daily pressure is very high, between the management and the workers that's why it happens, I think it happens on a daily basis, everyday there is some kind of harassment between the colleagues, between the employees because every day there is a lot of pressure, a lot of stress" (S3).
According to this theoretical approach, it is possible to state that moral harassment in the workplace is closely related to the elements of the environment and to the work organization, such as the style of leadership, the type of organization, work demands, the control over the tasks, as well as the organizational climate and internal communication.Soboll (2008b) clarifies the causal relationship between the work context and moral harassment stating that the work organization plays a central role when one evaluates the occurrence of moral and workplace harassment.The author complements that besides allowing it, organizations stimulate the occurrence of these practices through some of the aspects that concern the way work is organized.
In this research, a series of characteristics of the work organization of health employees were presented, when they were inquired about what could cause moral harassment inside organizations.Besides, the conditions of the working tools are precarious and insufficient.Similarly, there is the pressure of time to fulfill the tasks that are pertinent to the functions.
According to the interviewees' speeches, that generates the sensation of discomfort and stress in the work routine: "The working condition is not very good because I cook for almost a thousand eight hundred people in the morning and the things are old, I mean, I need to use the oven, I have an oven with twelve containers, and there are three cooks that need to use it, then I get, I get stressed, all that confusion and the short time, you know?The condition of the materials is bad, the kitchen is really scrapped.We have around three thousand employees, seven days a week, only in the cafeteria there are almost three hundred employees, that's why we have the scrapping of the materials" (S7); and "In our department, I'm talking about our department ok, our department is really scrapped, the infrastructure is bad, it is very small, and all that stress and confusion every day, we have to improvise things because the service has to be provided the way they want, and it is all in a rush and you had better do everything" (S8).
Through the passages, it is also possible to perceive that the employees are exposed to unhealthy activities without receiving the salary difference referent to it, as required by Brazilian labor legislation: "So, in radiology in theory, we should work only four hour right, and receive a higher pay for risky job because that is a risky place, because of the radiation, but we don't receive it" (S7).
The excess of work and, on the other hand, the shortage of employees, is characteristic of the work organization in the health field, and what guarantees the adherence to such context without complaints or protests is, once again, the threat of losing their jobs: "Look, the working conditions there are pretty bad, the department where I work is the biggest one, with 45 patients, and they are severely ill patients, you know, most of them come from the ICU, in the ICU there are 2 patients for every assistant, and there we have 8 patients for every assistant, sometimes even 13.It is a lot of pressure to handle all those patients, the medication, take care of them, plus the computer, because we need to check everything on the computer, right?" (S10).
Specifically about the excessive workload, S13 verbalizes: "Everyone in the sector is overworked, ok.They give us fifteen minutes to have breakfast but we can't even drink the coffee, we have to keep working without eating, if you stop for all that time you won't have enough time to do all the things, what can we do".
The reduction on the number of employees and the demand for an increase in the production rhythm are some of the effects of the uncontrolled search for profitability.The employees are demanded to have intense dedication to the company's interests, adopting in the hierarchical relationships, utilitarian, authoritarian and manipulative behaviors through a relation of domination, generating the feeling of uncertainty, dissatisfaction and exhaustion in the work environment (Dejours, 2005).Hirigoyen (2005b) clarifies that it is not the work overload itself that is responsible for moral harassment, because that could occur in a work environment where there are few tasks to be performed.For the author, what favors harassment is, mainly, the work environment where there are not intern rules, neither for behaviors nor for methods.Everything seems to be allowed, the power of the bosses is unlimited, just like what they demand from the employees.
The sensation of never being able to reach the productivity considered to be ideal could be perceived through the following declarations: "They always want things better, always better, but it is never good" (S2); and "I never get there, I try, try, and it is never good" (S3).
Thus, the employees continually feel unsuccessful and frustrated, once that even trying their best, they cannot reach the demanded pattern.They become psychological hostages from the organization, in an interminable process of searching for the best performance and, as a consequence, receiving recognition (Pagés, Bonetti, De Gaulejac, & Descendre, 1987).Regarding recognition, one of the participants' states: "They demand, demand, but never give us a compliment" (S13).
When the management worries about productivity more than anything and sees the employees minimally as humans but purely as resources, they feel needy which can lead them to conducts of submission or rebellion (Hirigoyen, 2005b).The employees are also obligated to accept sudden changes in their shifts, as highlighted in the following passage: "What they push the most is the night shift, we arrive there and the schedule is there, you check the schedule and you are scheduled to work nights for a month.Then, whether you want it or not, whether you can or cannot, you have to go.The coworker who questioned that, she was fired.That is the warning, right.You'd better keep quiet" (S9).
According to the declarations gathered in the interviews, the employees submit themselves to a work organization marked by poor conditions and, above all, stressful conditions due to, in most cases, the psychological pressure mechanisms that threaten their jobs.The work organization usually makes it look like the ones that are employed should submit to the degradation of the work climate without complaining, once that they are privileged (Freitas, Heloani, & Barreto, 2008).The fact that they have a job is the reason for them to be threatened of losing it.
Competitiveness is accepted and at times stimulated internally, thus provoking disrespectful reactions among coworkers, assented by the managers: "It is stressful because you get there, they want production, and I have a calmer way of doing things, I don't like to do things in a hurry, because you are dealing with lives, I like to do things slowly but well-done, but since the rhythm has to be in full speed, my coworkers start staring at me, calling me the 'health turtle', saying I'm not good for this kind of work.And the boss just watches, she doesn't say anything" (S11).
Generalized competitiveness, which is a common characteristic of contemporary work organizations, reinforces the feeling of hostility, envy and indifference towards others, which becomes the object of hate and resentment (Freitas, Heloani, & Barreto, 2008).Alkimin (2007) contributes to this discussion by stating that the current organizational model requires multitasking and production in an accelerated rhythm, provoking competitiveness among workers, once that even the mechanism of psychological pressure regarding unemployment makes people try to excel through the destruction of others.
The next quote also portraits competitiveness used as the background for moral harassment actions.In this situation, after reporting a series of humiliating acts performed by the coworkers, from verbal abuse to isolation, S11 concludes by saying: "I don't know if that's because I'm the most recent one to join the group, or if they also feel threatened, even because the boss never said anything to me, I have even seen her complimenting me many times in front of them and I think some of them didn't like it, so they keeping doing this, but it hurts me, I would really like to be able to talk more to them".
Another participant mentioned competitiveness, stating that the dispute between health professionals, in this case the Nursing Technicians, increase over time: "I notice the difference from when I started until now.Competition has always existed, but nowadays it is fiercer, because there was an increase of professionalizing schools, an increase in the number of professionals.So today, they demand a lot from you, they request a lot from you because they know it is full of professionals out there.As they say, 'if you don't do it our way, the way we want, there is a million people out there'.And there really is, that's the worst.You know, even my coworkers, it is one trying to excel over the other because actually, everyone knows that" (S4).
The data discussed in this category demonstrate that it is common for managers to 'use' the health professionals' market surplus for both ensuring the adherence to the working conditions and stimulating an internal disrespectful and insensitive competitiveness, to accelerate the rhythm of production.In this perspective, the worker is not perceived as the subject of a relationship, but as the object that 'serves' to the good productivity rates of a health institution.Excessive competitiveness, a product of globalization, according to Heloani (2003), increases the appearance of harmful forms of treatment concerning the management, which can use the power to humiliate and disrespect people.
It was observed that moral harassment and other forms of psychological violence occur in a 'ripple' effect, that is, it is disseminated in all hierarchical levels.Managers are also submitted to the abusive acts of the work organization.Soboll (2008a, p. 38) refers to the "ripple" effect as the act of "transmitting stress", in other words, the managers reproduce on the employees all the pressure or hostile behavior that are imposed on them, as well, and that all happens in a context where only the results are considered in the performance assessment process.
This may be illustrated by an interviewee: "In order to show a good performance to their bosses, because as I said there is a hierarchy, what they do to us, I'm sure somebody does to them, so they end up throwing all that on us, because they are also demanded and they end up demanding from us, but as we are in a greater number, they think that by screaming or abusing or by staring at us they will overpower us" (S12).
Regarding this aspect, Soboll (2008b) alerts that thinking people in managing positions as always abusive, that is, without being subject to the pressures of work organization, would lead us to live a psychopathological epidemic.On the other hand, the author ponders that there are people who take advantage of the spaces in the structure and in the organizational policies to practice inhumane acts.Some people feel powerful, safe and self-confident when they underestimate and dominate others, which can easily lead to moral harassment, especially when such behaviors are associated with the issue of excessive competitiveness (Heloani, 2008).

Conclusion
The work in health services presents peculiarities that, indeed, indicate the need for developing healthier human relationships between the professionals, as indicated by the participants.However, the consistent information found in the speeches shows substantial evidences of psychological violence and moral harassment suffered by health professionals.In this context, we find several records of experiences of psychological violence, of the occurrence of moral harassment and of the influence of the work organization in the occurrence of this phenomenon.
Regarding its limitations, the study is performed with workers associated with a union, which may represent biases, and data cannot be generalized to the whole category, since only one group of subjects is deeply studied.
Finally, it is important to highlight that the study is able to clarify the comprehension regarding a problem that has been spreading in the organizational context of health institutions.Despite Brazilian governmental actions and the efforts of ILO, the phenomenon persists in these organizations.Thus, it is expected that this study contributes to more effective and permanent actions to reverse such context and to stimulate other researches.