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                    ORIGINAL
ARTICLE

Received: 07/08/2024
Accepted: 12/20/2024

The relationship between workplace
violence, anxiety, and depression in
nurses during the COVID-19 pandemic
A relação entre violência no trabalho, ansiedade e depressão em
trabalhadores da enfermagem durante a pandemia de covid-19
Ana Paula Nogueira de Magalhães1 , Diego de Oliveira Souza1 ,
Sónia Mafalda Pereira Ribeiro2
ABSTRACT | Introduction: Workplace violence severely affects nurses, and the COVID-19 pandemic has intensified this issue,
resulting in physical and mental illness, which seriously affects their work and lives. Objectives: To analyze the relationship between
workplace violence, anxiety, and depression among front line nurses in the fight against COVID-19. Methods: This mixed-methods
study simultaneously collected qualitative and quantitative data in three municipalities in Alagoas, Brazil, between January and June
2022. The qualitative data were derived from interviews with six nurses, using the thematic oral history technique. The quantitative
data were derived from a questionnaire administered to 131 clinical and practical nurses. Results: The oral histories indicated
anxiety-related feelings, such as fear, nervousness, worry, and panic, which made the workers vulnerable to violence. According
to the quantitative data, 53.4% (n = 70) of nurses experienced violence, primarily psychological (n = 69; 52.7%). Anxiety and
depression symptoms were present in 21.4% (n = 28) and 30.5% (n = 40) of the nurses, respectively, and violence was significantly
associated with both anxiety (p = 0.003) and depression (p = 0.004). Conclusions: The results show that nurses suffer a high
prevalence of violence. The association between violence, anxiety, and depression reinforces the need for structural initiatives to
combat violence and protect the lives of those who care for the health of the population.
Keywords | workplace violence; nursing, team; anxiety; depression; occupational health.
RESUMO | Introdução: A violência relacionada ao trabalho afeta gravemente os trabalhadores da enfermagem. A pandemia de
covid-19 intensificou essa problemática, levando esses trabalhadores ao adoecimento físico e mental, com sérias implicações para
seus trabalhos e suas vidas. Objetivos: Analisar a relação entre violência no trabalho, ansiedade e depressão entre trabalhadores
da enfermagem da linha de frente contra a covid-19. Métodos: Estudo de métodos mistos, com coleta simultânea de dados
qualitativos e quantitativos em três municípios de Alagoas, Brasil, entre janeiro e junho de 2022. Para os dados qualitativos, foram
realizadas entrevistas com seis enfermeiras, utilizando a técnica da história oral temática. Para os dados quantitativos, aplicou-se
um questionário com 131 enfermeiros e técnicos de enfermagem. Resultados: Os depoimentos das histórias orais evidenciam a
presença de sentimentos relacionados à ansiedade, como medo, nervosismo, preocupação e pânico, o que deixou os trabalhadores
vulneráveis à violência. Os dados quantitativos demonstram que 53,4% (n = 70) dos trabalhadores da enfermagem sofreram
violência, sobretudo psicológica (n = 69; 52,7%). A ansiedade foi identificada em 21,4% (n = 28) dos trabalhadores da enfermagem,
enquanto 30,5% (n = 40) apresentaram depressão. A violência apresentou associação significativa com a ansiedade (p = 0,003)
e com a depressão (p = 0,004). Conclusões: Os resultados constatam a alta prevalência da violência sofrida pelos trabalhadores
da enfermagem. As associações encontradas entre violência, ansiedade e depressão reforçam a necessidade da promoção de ações
estruturais para o enfrentamento da violência e para a proteção da vida daqueles que cuidam da saúde da população.
Palavras-chave | violência no trabalho; equipe de enfermagem; ansiedade; depressão; saúde ocupacional.

1

Complexo de Ciências Médicas e Enfermagem, Universidade Federal de Alagoas, Campus Arapiraca, Arapiraca, AL, Brazil.

2

Instituto Superior Miguel Torga, Centro Lusíada de Investigação em Serviço Social e Intervenção Social, Coimbra, Portugal..

Ethics committee number: 5013
Funding: Fundação de Amparo à Pesquisa de Alagoas, Brazil, in association with the Programa de Pesquisas para o Sistema Único de Saúde and the Brazilian Ministry
of Health through the Departamento de Ciência e Tecnologia da Secretaria de Ciência, Tecnologia, Inovação e Insumos Estratégicos em Saúde and in partnership with
the Conselho Nacional de Desenvolvimento Científico e Tecnológico (process E:60030.0000000196/2021).
Conflicts of interest: None
How to cite: Magalhães APN, Souza DO, Ribeiro SMP. The relationship between workplace violence, anxiety, and depression in nurses during the COVID-19 pandemic.
Rev Bras Med Trab. 2025;23(1):e20241337. http://doi.org/10.47626/1679-4435-2024-1337

This is an Open Access article distributed under the terms of the Creative Commons Attribution, License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Rev Bras Med Trab. 2025;23(1):e20241337

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Magalhães APN et al.

INTRODUCTION
Workplace violence has become more frequent, and
its relevance for worker health is increasing. Workplace
violence has been analyzed in relation to: (1) violent acts
committed by individuals involved in the work process
and (2) the inherently violent nature of degrading work,
due to organizational issues, work conditions, and work
dynamics.1 This study will focus on the former, i.e.,
violence against nurses committed by any individual
directly or indirectly involved in the work process.
Although structural violence appears in an underlying
form, the two dimensions are intertwined.
The health sector is notorious for workplace violence,
especially among nurses,2 the health profession with the
largest number of workers. Bordignon et al.3 report that
nurses who are victims of violence are susceptible to a
series of consequences in both their professional and
personal lives.
Some of these consequences are related to mental
health, such as stress, burnout, anxiety, and depression.
In a Saudi Arabian study of 118 nurses, 56% reported
having suffered at least one type of workplace violence,
resulting in high levels of stress, emotional exhaustion,
low personal fulfillment, and depersonalization, which
suggests the presence of burnout.4
Pang et al.5 studied a sample of 6,771 Korean nurses,
finding that verbal violence and sexual harassment
increased depressive symptoms, which in turn increased
turnover.5 In another study of 238 psychiatric nurses
in Taiwan who had experienced violence, 75.9% had
depressive symptoms.6
The uncertainty, stress, and precarious working
conditions experienced during the COVID-19 pandemic
(2020 to 2022) aggravated the problem of workplace
violence, resulting in more cases of psychological
violence, discrimination, and physical aggression
among health care workers.7,8 Mental health problems,
including anxiety and depression, also increased
during this period through a multifaceted process that
included greater workplace violence.9 A study of 532
nurses in southeastern Brazil corroborated this finding,
intimidation and/or violence at work during the
pandemic were associated with psychosis, obsessiveness/
compulsiveness, somatization, and anxiety.10
Rev Bras Med Trab. 2025;23(1):e20241337

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According to the above-cited studies, violence plays
an important role in the illness process, especially
in relation to mental health. Therefore, research that
directly studies workplace violence, not only as a
variable, but as an object of study, is relevant. In view of
this, the present study analyzed the relationship between
workplace violence, anxiety, and depression, among
front line nurses during the COVID-19 pandemic.

METHODS
This parallel-convergent mixed methods study
compared quantitative and qualitative data to identify
convergences, in a process of general interpretation of
the results.11
This article is derived from “Risks and demands of/
at nursing work during the COVID-19 pandemic in
Alagoas,” a study that included clinical and practical
nurses who cared for COVID-19 patients for at least 1
month in hospitals in three cities in the state of Alagoas,
Brazil, from April 2020 to April 2021. The 1-month
inclusion criterion was due to the high turnover of
workers during the pandemic, given that many had
precarious employment relationships. Workers who
were on vacation or work leave due to belonging to a
risk group were excluded.
Only nurses were included in the qualitative
stage. Six semi-structured interviews were conducted
online using the Zoom and Google Meet platforms.
The sample size was determined through information
saturation. The interview script was prepared by the
authors based on the thematic oral history method to
contextualize the experience of working on the front
lines against COVID-19, including workplace violence.
Two undergraduate nursing students conducted the
interviews after receiving training, guidance, and
supervision from a nursing professor with experience
in occupational health and qualitative research. The
interviews were recorded, transcribed, and analyzed from
the perspective of occupational health and historicaldialectical materialism, seeking to capture relevant
details that converged with the quantitative data.
In the quantitative stage, cross-sectional data was
collected from a convenience sample. Of the 681 workers

This is an Open Access article distributed under the terms of the Creative Commons Attribution, License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Workplace violence, anxiety, and depression

invited to participate, 131 responded to the online
questionnaire (19.2% response rate).9,12 The sample power
was 87% (calculated a posteriori) based on the following
parameters: n = 131, α = 0.05, and effect size = 0.3.
This study used the Questionário Individual para
Avaliação da Saúde dos Trabalhadores (Individual
Questionnaire for Worker Health Assessment),
an instrument developed by the Worker Health
Assessment and Monitoring Program (Programa de
Evaluación y Seguimiento de la Salud de los Trabajadores
- PROESSAT)13 after translation, adaption, and
validation for speakers of Brazilian Portuguese.14 This
instrument includes questions about living and working
conditions and their health impact in the form of
presumptive diagnoses.13
The research instrument and the informed consent
form were uploaded as Google Forms and were sent to
workers by email and/or WhatsApp between January
1 and June 30, 2022. The estimated response time
was 3 weeks.
The dependent variable was “having suffered
workplace violence during the pandemic” (yes, no).
The following were considered independent variables:
sociodemographic data (sex, age group, race),
professional category (clinical nurse, practical nurse),
violence type (verbal, psychological, physical, sexual),
aggressor type (patients and/or family members,
coworkers, superiors), in addition to presumptive
diagnosis of anxiety (yes, no) and depression (yes, no).13
Presumptive diagnosis of anxiety disorder and depression
was based on the feelings the workers reported on the
questionnaire. The anxiety-related questions were: “Do
you consider yourself easily irritable?”; “Do you feel
afraid for no reason?”; “Do you have difficulty sleeping
or staying asleep?”; “Do you worry excessively about
insignificant setbacks?”; “Do you often feel worried?”;
“Have you ever had any a problem with anxiety?”; and
“Have you ever been treated at a mental hospital?” The
depression-related questions were: “Do you often feel
sad or unhappy?”; “Do you often want to die?”; “Are you
very afraid of losing your job?”; “Does the future seem
uncertain or hopeless to you?”; “Are you indifferent
to violence?”; “Do you have a hard time starting a
conversation in meetings?”; and “Do you prefer to
ignore your problems?” According to PROESSAT

This is an Open Access article distributed under the terms of the Creative Commons Attribution, License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

recommendations,13 at least four positive answers were
required in each section for a presumptive diagnosis of
anxiety or depression.
Quantitative data analysis began by determining the
frequency distribution of individual variables. Pearson’s
chi-square test was used to identify associations between
workplace violence, anxiety, and depression; the
significance level was set at 5%. The data were analyzed
in SPSS 25.0.
To combine the results, it was decided to begin with
the qualitative data, because after analysis they were
less specific regarding workplace violence. A summary
of each oral history is presented, highlighting elements
related to mental health and narratives of violence,
allowing connections with the quantitative data.
Each participant in the qualitative stage was identified
by the letter N and a number (i.e., N1 to N6) to ensure
anonymity. This study conformed to National Health
Council Resolutions 466/2012 and 510/2016 and
was approved by the Universidade Federal de Alagoas
Research Ethics Committee (decision 4,525,156).
All workers provided written informed consent and
participated voluntarily.

RESULTS
The experience of each interviewed nurse is
summarized below:
N1: After graduating in 2018, she was balancing her
master’s studies with working on the front lines against
COVID-19. She chose to work during the pandemic to
make a contribution and gain experience. She reported
difficulties with work overload, constant deaths, a lack
of experience with the new disease, and isolation from
her family.
N2: With 9 years of experience as a nurse, she considered
the pandemic to be the greatest challenge of her career.
She reported that the beginning of the pandemic was
frightening, especially because they were facing an
unknown enemy. Dealing with so many deaths, the
isolation of her daughters, and managing the nursing
team were extremely difficult. According to her, the
intense psychological burden led to exhaustion among
the nurses.

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Magalhães APN et al.

N3: After graduating 2 years ago, she immediately got

a job at the hospital. She reported feeling that the
profession is undervalued, although she enjoys the
relationship with patients. She described the pandemic
using words such as fear, ignorance, frightening, and
traumatic. Especially at the beginning, she had to work
double shifts due to the large number of patients and
the shortage of nurses. Many professionals became
sick, overloading staff who remained at work. She felt
physically exhausted. Emotionally, she felt bad at the
beginning, but felt better later on.
N4: Two months after graduation, she started working on
the front lines against COVID-19, where she remained
for 1 year and 7 months. She reported that when the
first patients arrived, she was very scared, nervous,
and panicked. It was a terrifying time because she
didn’t know how to take care of people. It was very
exhausting, with many tasks and insufficient resources.
She believed that the worst part was controlling her
emotions and dealing with the death of patients
she knew.
N5: A nurse for 18 years, management asked her to work
in the COVID-19 sector. She considered the beginning
of the pandemic a terrible experience due to the lack
of beds and nurses and large number of patients. She
reported feeling scared and tired, since she only got 1
hour of rest during 24-hour shifts. She lived in fear of
infecting her partner at home. She spent a lot of time
away from her family and faced distressing days; she
was reluctant to go to work.
N6: Having graduated 6 years ago, she reported liking her
profession. She first took a technical course and then
completed an undergraduate degree. She was working
in a general hospital and worked on the front line
against COVID-19 for 2 years. She reported that the
worst period was prior to the beginning of vaccination,
when there were many deaths, including young people.
She felt tired and constantly worried about her family.
Thus, some of the statements indicate psychological
suffering, such as characterizing the pandemic as
frightening or terrible, in addition to feelings of fear,
anguish, fatigue, exhaustion, psychological burden,
worry, nervousness, and panic. Such a scenario would
be conducive to violence, which, in turn, can heighten

Rev Bras Med Trab. 2025;23(1):e20241337

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psychological suffering. One report describes a specific
case of violence:
[...] but the time came for the family members to arrive
at the ICU and, without authorization, they invaded
the ICU and said we killed their family member, that
we were the ones who killed him, because yesterday
he was fine and today he was dead. Even though
we said that the patient was unstable and that his
COVID progressed quickly [...] the families couldn’t
understand sometimes. Families would come bursting
in and say that we killed their relative, curse us, and
say that they wished the ICU ceiling would fall on us.
So, imagine us in this agony, this frustration, this work
overload, this rush, and still having to deal with such
scenes. It just wiped us out mentally. (N4)
It should be acknowledged that the general
population also faced a significant psychological burden
during the pandemic, especially due to the fear of death
and the loss of family members. N4’s report highlights
this, showing how verbal and psychological violence
becomes an additional psychological burden for nurses.
To analyze the relationship between violence and
psychological distress, quantitative data on violence,
anxiety, and depression are presented below.
Of the 131 participants in the quantitative stage,
80.2% (n = 105) were women, 41.2% (n = 54) were
between 30 and 39 years old, and 65.6% self-identified
as mixed race (n = 86). Regarding professional category,
39.7% (n = 52) were clinical nurses and 60.3% (n = 79)
were practical nurses (Table 1).
As shown in Table 1, 53.4% (n
​​ = 70) of the nurses
suffered some type of violence during the COVID-19
pandemic, especially psychological violence (52.7%).
The main perpetrators were patients/family members (n
= 48; 36.6%), followed by coworkers (n = 33; 25.2%)
and superiors (n = 29; 22.1%).
Regarding psychological distress, 21.4% (n = 28) of
the nurses had symptoms of anxiety, while 30.5% (n = 40)
had symptoms of depression. According to the inferential
analysis, workers who suffered violence had the highest
prevalence of anxiety and depression; there was a positive
association between workplace violence and anxiety (p =
0.003) and violence and depression (p = 0.004) (Table 2).

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permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Workplace violence, anxiety, and depression

Table 1. Sociodemographic characteristics and violence suffered by nurses, Alagoas, Brazil, 2022 (n = 131)
Characteristics

n

%

Characteristics

n

%

Suffered psychological violence

Gender
Female

105

Male

26

Other

80.2

Yes

69

52.7

19.8

No

62

47.3

Yes

53

40.5

No

78

59.5

-

-

Age range (years)

Suffered verbal abuse

< 20

-

-

20-29

31

23.7

30-39

54

41.2

40-49

40

30.5

50-59

5

3.8

Yes

3

2.3

≥ 60

1

0.8

No

128

97.7

Mixed

86

65.6

Black

14

10.7

Yes

48

36.6

White

27

20.6

No

83

63.4

Yes

33

25.2

No

98

74.8

Race

Indigenous

-

-

Asian

4

3.1

Professional category

Suffered physical violence
Yes

5

3.8

No

126

96.2

Suffered sexual violence

Suffered violence from patients and/or their
family members

Suffered violence from coworkers

Suffered violence from superiors

Clinical Nurse

52

39.7

Yes

29

22.1

Practical Nurse

79

60.3

No

102

77.9

Suffered violence while commuting to work

Suffered violence during the pandemic
Yes

70

53.4

Yes

37

28.2

No

61

46.6

No

94

71.8

Table 2. The association between workplace violence,
anxiety, and depression, Alagoas, Brazil, 2022 (n = 131)
Suffered workplace violence
Yes
n (%)

No
n (%)

Yes

22 (78.6)

6 (21.4)

No

48 (46.6)

55 (53.4)

Yes

29 (72.5)

11 (27.5)

No

41 (45.1)

50 (54.9)

Variables
Anxiety

p-value*
0.003

Depression

0.004

* Pearson’s chi-square test.

DISCUSSION
The results of this study demonstrate that nurses
suffered a high prevalence of violence during this period,
and that there was an association between workplace
violence, anxiety, and depression.

This is an Open Access article distributed under the terms of the Creative Commons Attribution, License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

The precarious working conditions during the
pandemic, associated with high patient mortality and
social isolation resulted in intense physical and mental
exhaustion for nurses. “This context led to psychological
suffering and an increased possibility of exposure to
workplace violence.”15 On the other hand, the violence
may have triggered symptoms of anxiety and depression,
creating a vicious cycle.
According to Seligmann-Silva,15 mental disorders
resulting from psychological distress develop through
work-related mental exhaustion and are, therefore,
the result of workplace violence itself. Workplace
violence is intertwined with structural violence, which
is expressed through precarious working conditions,
especially overload, long working hours, instability, and
devaluation. These conditions have been associated
with workplace violence, as well as different forms of
psychological distress.8,15

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Magalhães APN et al.

In a cross-sectional study of 2,796 Chinese nurses,16
49.12% (n = 1,360) reported suffering at least one
episode of violence in the last 6 months. The following
effects stood out: 1) decreased enthusiasm at work (n
= 122; 65.24%); 2) anxiety, depression, and anger (n
= 110; 58.82%); 3) intention to change careers (n =
71; 37.97%); 4) insomnia (n = 38; 20.32%); and 5)
suicidal behavior (n = 6; 3.21%).
As noted, nurses were mainly affected by
psychological violence. This type of violence includes
threats, verbal abuse, harassment, and bullying17 and
often appears in moments of acute anxiety, resulting
from situations of extreme fatigue, when everyone is “on
edge”,15 as in the context of the COVID-19 pandemic.
The oral histories of our sample describe anxietyrelated feelings, such as fear, irritation, worry, and panic.
The tension and lack of emotional control experienced
during the pandemic may have led to both violence
and increased anxiety. A study of 1,030 Chinese
health workers18 found that workplace violence had a
significant impact on worker anxiety.
Regarding depression, exposure to violence can
lead to mental fatigue and feelings such as frustration,
loss of meaning, and self-devaluation, resulting
in discouragement, sadness, slowed thinking, and
difficulty participating in social activities.15
In the present study, nurses who experienced
violence had a higher frequency of depression than
those who did not. These findings corroborate previous
findings of a strong relationship between violence
and depressive symptoms.19,20 A prospective study
of Danish workers21 found an association between
workplace violence and depression 2 years after
workers had suffered violence, demonstrating its longlasting consequences. These consequences include
complex forms of suffering, such as burnout and
behavioral problems, whose repercussions sometimes
make it impossible to continue working.6,10
The main aggressors were patients or their family
members. A Chinese study22 found that the main
reasons for family member violence against health
workers were patient deaths and dissatisfaction with
treatment. Hospitalization is an intense process for
patients and family members that leads to high levels
of anxiety, stress, and suffering; the risk of violence

Rev Bras Med Trab. 2025;23(1):e20241337

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increases if treatment expectations are not met.23
However, nurses also suffer violence from patients/
family members due to structural problems in the
health system, such as precarious working conditions
and lack of adequate resources.8,24
Work-related violence is exacerbated among nurses
because the profession is predominantly female, i.e., the
violence they face is intensified by inequality of power
between the sexes, which is part of society in general
and health care in particular. Throughout history,
women have suffered violence in social spaces, and the
same applies to nurses, since their workplace is marked
by gender-based inequality and hierarchization.23
Some strategies have been developed to prevent
violence against nurses. A study by the European
Federation of Nurses Associations8 mapped actions,
policies, and programs to combat violence. In Portugal,
a national program has been in force since 2019 to
raise awareness about the early detection of risks and
antecedents of violence. In Finland and Switzerland,
the phenomenon of violence against nurses has
been included in the national nursing curriculum. In
France, a closer link between hospitals and the police
has been developed to increase safety: a contact
person is designated for each hospital, and staff who
suffer violence are supported after filing a complaint.
Emergency departments are also actively monitored
and the police can perform safety assessments for
any health facility. The United Kingdom’s National
Health System works with the police and the Crown
Prosecution Service to help victims obtain evidence
and provide quicker, more efficient legal proceedings.
Staff are trained on how to deal with violence, and
immediate mental health support is provided for staff
who have been victimized.
In Brazil, strategies for confronting violence include
training nurses to recognize situations of violence and
promoting effective communication, in addition to
creating institutional protocols that involve reception,
listening spaces, victim referral, case notification,
and protecting workers through specific laws.10,2527
However, the persistent increase in workplace
violence within the health system reinforces the
need to for persistent collective strategies to address
this phenomenon.3

This is an Open Access article distributed under the terms of the Creative Commons Attribution, License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Workplace violence, anxiety, and depression

This study has some limitations. First, the data were
collected online during social isolation in the midst
of the COVID-19 pandemic, which makes it difficult
to generalize the results. Second, the cross-sectional
nature of the quantitative data prevents determination
of a causal relationship between workplace violence
and anxiety and depression symptoms. However,
the findings are consistent with the literature and are
important for reflecting on the relationship between
violence, mental suffering, and coping mechanisms.

CONCLUSIONS
The results showed that nurses suffer a high
prevalence of violence. The association between

violence, anxiety, and depression indicates the need for
initiatives to confront violence and protect the health
and lives of caregivers. These initiatives should lead to
strategies that address behavioral issues and, above all,
organizational and structural issues, modifying work
processes that create the conditions in which violence
can occur.
Author contributions
APNM was responsible for conceptualization, formal analysis,
investigation, methodology, validation, writing – original
draft, and writing – review & editing. DOS was responsible for
the conceptualization, formal analysis, funding acquisition,
investigation, methodology, project administration, supervision,
validation, writing – original draft, and writing – review & editing.
SMPR participated in the interpretation and formal analysis,
methodology, validation, and writing – review & editing. All authors
have read and approved the final version submitted and take
public responsibility for all aspects of the work.

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Correspondence address: Ana Paula Nogueira de Magalhães – Av. Manoel
Severino Barbosa, s/n – Bairro Bom Sucesso – CEP: 57309-005 – Arapiraca
(AL), Brazil – E-mail: paula_nog@arapiraca.ufal.br

2025 Associação Nacional de Medicina do Trabalho
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