Violence Against Nurses In The Workplace

(	Ahmad Mohammad Hajaj Correspondence: Ahmad Mohammad Hajaj Jordan University of Science and Technology Email: hajaja@pmah.med.sa; ahmadhajaj@yahoo.com

Introduction
Violence against nurses is making headlines all over the world. It is considered an alarming phenomenon for nurses worldwide. Health care workers don't have immunity from violent encounters, nurses have reported they experienced workplace violence at least one in their professional period (Adib, Al-Shatti, Kamal, El-Gerges, & Al-Raqem, 2002; Beech & Leather, 2005).

In recent years, many studies show that violence against nurses has increased dramatically, and is considered a major health problem (Ayranci, 2005). There is a growing awareness in public opinion regarding violence against nurses. Violence has continued to be a major theme in television, music, advertising, and movies (Whelan, 2008). Violence was included in the 22 priority areas in the healthy people 2000 report (Presley & Robinson, 2002) .

All health care providers are facing more violence than ever before, all over the world. Nurses are the most exposed people of all health care providers to verbal, physical, emotional ,and sexual abuse (Jones & Lyneham, 2001). Nurses are the first and the most available health care provider at hospitals, they are always present in many stressful situations such as deaths, accidents, waiting to visit a doctor , dealing with critical situation in front of families, dealing with lovely persons for others , sending patients to the general floors, and providing the primary care for the patients . All of this may increase the time that they are being exposed to more abuse or violence from the patients or from their companions, than other health care providers(Gates, Ross, & McQueen, 2006; Glasson, 1995).

Many factors make nurses highly exposed to violence from patients and their companions more than other health care providers such as working long hours, hospitals overcrowded , continuous controlling of conditions all the time, nagging patients and families, lack of personnel, many stressful situations, shortage of nurses, and dealing with special and sensitive topics with patients and their families (Crilly, Chaboyer, & Creedy, 2004).

Definition of violence
There is no universal definition of violence in general .There are many different models, theories, philosophical beliefs regarding the definition of violence, causes, consequences, and strategies to solve the problem. Many words are used interchangeably when talking about violence like assault, threats, or workplace violence. Violence against nurses has many definitions, there is no consensus between the researchers about specific definitions of violence against nurses, but all the definitions are consistent with a range of behaviors from verbal abuse to physical assault (Behnam, Tillotson, Davis, & Hobbs, 2009).

The World Health Organization defines violence in general as "the intentional use of physical force or power , threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death , psychological harm, maldevelopment or deprivation" ( WHO, 2005).

Nachreiner et al (2007) define violence against nurses as any activity associated with the job, or any events that may happen in the work environment involving any intentional use of physical or emotional abuse against nurses, resulting in emotional and physical consequences. Jones & Lyneham (2001) defined violence as any behavior that intended to cause harm whether it results in it or not, it can be verbal, physical, active, passive, or forced on the victims. It may be direct or indirect, with or without weapon, with or without manifestations of anger to self or for others, with or without clinical signs and symptoms.

Other definitions for violence against nurses is anything that make nurses feel unsafe, afraid, or anything that alters their job through repression, intimidation, or anything that making them not as respectful a person as themselves in job as a nurse. It may be caused by patients, families, doctors ,colleagues, management, or anyone that makes them not comfortable, or creates feelings of inadequacy (Chapman & Styles, 2006).

Every violent situation contains mainly four parts; a perpetrator, causative factors, environment, and the target population. The perpetrator may be the person who commits the criminal act; the person who receives the services from nurses; employees or the relatives of the patients. The causative factors are related mainly to economical, social, emotional, spiritual, and psychological factors. Environmental factors may include population density, family instability, and racial disharmony. The target people, who are the fourth element , is anyone in the health care providers that may subject them to violence , but nurses are the most targeted people for violence (Ayranci, 2005).

Types of Violence
Nachreiner et al. (2007) reported the types of violence against nurses that may occur like physical, verbal, sexual, or a threat. The physical assault may occur when one is hit, slapped, chocked, pushed, grabbed, kicked, or subjected to any physical objects that are intended to cause harm or injury for the nurse. Some actions by relatives may occur such as, lack of trust of nurses, lack of compliance, not waiting for their turn to arrive. The threat may occur when someone uses words, actions, and gestures that are aimed at intimidating, frightening, or causing harm physically or otherwise.

Sexual harassment may occurred when the person experiences any type of unwelcomed sexual behavior, it may be caused by words or actions that may result in hostile and conflicts and stressful work environment (Deeb, 2003).

Verbal abuse may result when the person uses any words that intended to cause harm, or emotional problems for the nurse ,many types of verbal violence have been reported by researchers, such as degradation insults, slamming the table with the fist, hitting, abuse of power, mistreatment, eye contact with disdain, lack of appreciation and appraisal hostile unjustified behavior (Deeb,2003) .

Deeb. (2003) conducted a study about the workplace violence in the health sector in Lebanon. The study was qualitative and quantitative. The participants reported that violence is defined as verbal and nonverbal communication, or any behavior that intended to make harm physically or emotionally for the nurses.

Literature Review
The incidence of violence against nurses in the developing countries is not well documented. On the other hand violence in the developed countries has increasingly been brought into public attention since the mid-80 s. In 1987 the UK health and safety commission reported that 1 in 20 health care providers had been threatened with a weapon, and 87% of the staff was worried about being a victim of violence. In the USA , 100 staff of health care providers died from violence between 1980 and 1990 (Glasson, 1995).

Nurses in general are worried about violence, and constantly express fear of being subjected to violence. However, the reasons for their concerns differ between nurses working in hospitals, clinics, home care, public sector, or the private sector (Adib, et al., 2002; Çelebioglu, Akpinar, Küçükoglu, & Engin, 2010) .

Deeb. (2003) reported some reasons that make nurses worried about being subjected to violence such as poor salaries, lack of security, poor management of the directors of the nursing, nurses being involved in problems while providing caring for their patients, patients tendency to interfere with nurses work, constant presence of the family members while providing the care for the patients, and the relatives may compare their job with other staff, many nurses enter the room alone while providing care for the patients, many nurses touch the patients, and expose some parts of the patients so the nurses become offended by the way that patients look at them so nurses become afraid of sexual harassment.

Adib et al. (2002) conducted a cross sectional study about violence against nurses in health care facilities in Kuwait. The study involved all nurses working in the health related facilities in all the country in 1999.The majority of nurses were female 85% and 88% of the nurses were non -Kuwaiti. 48% of the sample reported they had experienced verbal abuse in the previous 6 months ago, and physical violence was reported by 7% of the sample. There were no reported cases of physical harm in 63% of patients that reported physical violence. Nurses who reported they had never experienced physical violence, were more likely to be male, had less experience in nursing, non-Kuwaiti, working in hospitals rather than in primary health care centers. The results showed that the verbal abusers were relatives of patients or friends; while the physical abusers were the patients themselves (51 %.) .Only 56% of verbal incidents and 72% of physical violence were reported.

Workplace violence in British and Columbia hospitals was studied by Hesketh et al. (2003). All registered nurses in Alberta and British Columbia were surveyed on their experiences regarding violence in the last 5 shifts. The results showed nurses were experiencing many reported cases of violence, especially in emergency, medical surgical units, and psychiatric units. Most violent people were the patients. The majority of workplace violence cases were not reported.

Workplace violence and abuse against nurses was studied in Iran. Violence against nurses has increased dramatically in Iran in recent years (Shoghi, et al., 2008). Verbal abuse was experienced by the majority of Iranian nurses during the last 6 months period. Physical violence was reported by 27% of the sample during the same period. No physical harm was reported in the 66% of the total cases that reported physical violence. One third of verbal abuse cases were reported, while 50% of physical cases were reported. The majority of nurses who reported abuse reported it was followed by inaction or actions which failed to satisfy the nurses. And the majority of nurses who were exposed to violence were men, not like other studies, and there was a higher positive relationship between the incidence of violence and years of job experience and the numbers of working hours. Nurses in the emergency department reported a higher incidence of violence than other nurses in other positions.
Workplace violence among Iraqi nurses was studied by AbuALRub et al (2007). The purpose of the study was to investigate the occurrence and the frequency of physical workplace violence among Iraqi nurses, and to investigate the contributing factors that may lead to violence, and to identify the strategies used to protect nurses from violence, and to identify the policies that were used to deal with the violence in Iraq.

A descriptive exploratory survey was used; the sample was 116 Iraqi nurses. The results showed that the majority of nurses reported that they have experienced physical abuse. Few nurses reported there were specific policies regarding workplace violence. At the end of that study nurses were asked an open ended question about the contributing factors for the violence against them, and the policies and measures that were used to solve the problem. Most nurses reported the main causes of violence against nurses in Iraq were related to the nature of the Iraqi environment, because nowadays there is no clear system after the war, insufficient beds for a huge numbers of victims, high mortality rate, bad image for nurses in Iraq, and there was no clear policy regarding violence. There was poor support from higher administrators for nurses, lack of assertive legislations, lack of programs and training courses regarding workplace violence.

Violence against Emergency Nurses
Conflicts and problems with health care providers in emergency departments have increased recently worldwide. Patients and their families are highly dependent on medical staff especially nurses concerning patient's needs, and proper medical management (Lin & Liu, 2005).
Many doctors don't empower the patients by providing support for patients, nor provide good information about them, or at least listen to them in emergency rooms. Nurses consider the public face for the patients and other medical staff. Nurses are usually the first person that patients and their families meet, so nurses are often blamed. Patients don't blame physicians, because they are afraid that a physician may not treat them properly, or refuse to care for them. In effect nurses become a scapegoat for the patients (Lin & Liu, 2005; Presley & Robinson, 2002; Whelan, 2008).

Nurses in emergency department reported higher incident of physical abuse more than other nurses (Behnam, et al., 2009; Crilly, et al., 2004; Hesketh, et al., 2003; Presley & Robinson, 2002). Emergency nurses reportedly experienced violence weekly; the increased level of violence is due to many causes such as increased numbers of patients and families using drugs, or they are alcoholic, or have many psychiatric disorders, stressful environment in the emergency department, presence of weapon, open access for the emergency department for 24 hours, quarrels victims arrive at hospitals angry and aggressive, and the high flow of violence from the community in to the emergency department. In addition, many emergency rooms were crowded, and hand a prolonged waiting times to see the doctors, and shortage of nurses; all of those factors add stress to that people who are already having difficulties in adapting and coping with the highly stressful situations (Adib, et al., 2002; Çelebioglu, et al., 2010; Chapman & Styles, 2006; Lin & Liu, 2005; Nachreiner, et al., 2007).

Gates and colleagues. (2006), conducted a study to describe the violence experienced by workers in the emergency departments, during the 6 months before surgery. The sample was 242 workers from 5 hospitals who were included in the study. The results showed that all workers in the emergency department had verbal assault from patients or families at least once; the paramedics reported 100% of them experienced verbal abuse, while nurses reported 98% had experienced verbal abuse. Nurses and physicians were the highest group that experienced violence in comparison with other workers in the emergency department.42% of workers reported sexual harassment from patients while nurses reported levels of 21% of sexual harassment compared with doctors 13%. There were 319 reported cases of violence from patients, and 10 cases were reported from families. 65% of workers in the emergency department didn't report the violence to hospital authorities. The majority of nurses didn't report they attended training programs in the previous year. The results found a strong relationship between violence, job satisfaction, and feeling of safety.

Another study that described violence towards emergency nurses by patients was conducted by Crilly et al. (2004), and was done in Australia. The study identified the incidence of violence in 2 emergency departments. The contributing factors and the circumstances were identified in the study. 70 nurses were included in the study; the majority of nurses reported 110 episodes of violence in the last 5 months period, which means 5 violent incidents happened per week. Violence was reported mainly on evening shift. Nurses in that study were pushed, sworn at, or kicked. Nurses reported the majority of violent people were under the influence of alcohol or drugs, or had mental illnesses, which is accompanied by other research that found that the majority of violent people were alcoholic or drug abuser, or with mental diseases(Chapman & Styles, 2006; Merecz, Rymaszewska, Moscicka, Kiejna, & Jarosz-Nowak, 2006; Nolan, Soares, Dallender, Thomsen, & Arnetz, 2001).

The type of nurse's license may affect the chances of being subject to violence. While the registered nurses are considered the largest health occupation in USA , and licensed practical nurses are considered the second largest group of health care providers (Merecz, et al., 2006). Nachreiner et al. (2007) conducted a study to compare the experiences of violence between registered (RN) nurses and licensed practical nurses (LPN), to investigate the contributing factors and to gain insight to solve the problem. A random sampling of 6,300 licensed nurses was surveyed over the last one year. Self reported violence and demographic data was obtained. The results showed that LPNs had higher rates of physical and nonphysical violence. Nurses who experienced violence were mainly dealing with mental illness patients and nurses who were providing primary care for the patient while working in clinics resulted in decreased risk for exposure to violent conditions.

Violence Against Mental Health Nurses
Recent studies suggests that violence against mental health nurses has increased (Nolan, et al., 2001). The association between mentally ill patients and violence against nurses has undoubtedly been emphasized in the media. The general impression of mental health patients are that they victims of violence not the perpetrators of violence. The general public believe that mentally ill patients are not dangerous and unpredictable; many attempts were done to change this view point (Adib, et al., 2002).

Continuous exposure to violence among mental health nurses led them to accept it as a normal part of their job; nurses failed to demand better strategies to protect them from abusive patients. The environment of nurses in psychiatric hospitals make the patients more aggressive and anxious; inadequate staffing levels, inappropriate training program, uncoordinated treatment interventions worsen the problem, and make the patients more aggressive and abusive (Jones & Lyneham, 2001).

Nolan et al. (2001) conducted a cross cultural study to compare the experiences of violence between Swedish and English mental health nurses. Many studies had been done in each country in this field, but it was the first study in comparing the levels of violence between 2 cultures. The researchers adopted and agreed on the definition of violence against nurses to be used in 2 countries. 296 nurses were included in the study from England, and 720 nurses were included from Sweden. The questionnaire was 20 items, designed to investigate the number, type, severity of violence, effects on self-esteem and satisfaction, and extent to which support provided following the incident happened. The results showed that 71% of English nurses had experienced violence; compared with 59% of Swedish nurses, in the last year. 60% of nurses reported the experience of being subject to violence from mentally ill patients several times. The majority of incidents of violence reported by English nurses were with family members. 2 thirds of Swedish nurses and half of English nurses had never been injured as a result of violence at work .English nurses reported lower levels of self-esteem than Swedish nurses.

The researchers found a positive correlation between perceived influence over work and self-esteem. The results showed that younger nurses , or nurses working in the community, or nurses who receive little support after the incident of violence, are at greater risk for experiencing more violence from mentally ill patients (Chapman & Styles, 2006; Hesketh, et al., 2003; Merecz, et al., 2006; Nolan, et al., 2001).

Consequences of Workplace Violence Against Nurses
Although violence against nurses increased in the workplace recently, it is considered a significant problem in health care providers. The effect of violence exceeds the number of incidents reported, but it has a significantly profound traumatic effect on the primary, secondary, and tertiary victims. Many nurses are suffering from post traumatic stress disorder. All the violent incidents didn't not affects the victim alone, but also harm the aggressor and the people around them. The consequences may occur at different levels, and the severity of the incident varies according to the conditions that are found in that situation. The levels of consequences may occur at many levels,; it may occur at individual level, or at workplace atmosphere, or at the level of services that are provided in health care settings (Adib, et al., 2002; Çelebioglu, et al., 2010; Chapman & Styles, 2006; Lin & Liu, 2005).

The consequences that may occur at the individual level are, resignation of nurses from their jobs, injury, pain, stigma, crying, post traumatic symptoms, and many physical symptoms, firing of employees, suicidal ideation, many psychological problems, less job satisfaction, negative effect on team work, frustration, depression, feeling of being threatened, anger, isolation, distraction, increased medical errors, increased workload on the peers (Whelan, 2008).
While the consequences on the level of work, tension, absence of trust, chaos of work, uncomfortable media for work, aggressive behaviors among peers, delegation, increased workload , absence of team work, and stressful environment (Gates, et al., 2006).

On the level of the services that are provided in the health care settings, bad quality of services, bad image about the health care providers, shortage of nurses, many nurses start to work in many different areas to avoid being subject to violence, physical damage for the health care settings, bad image from other healthcare providers about the health services that provided in that hospital are noted (Beech & Leather, 2005).

Reporting of Violence
The frequency and severity of violence against nurses is not well documented. Many methodological problems were found in reporting and identification of the actual cases of the violence against nurses worldwide. Some studies reported physical violence alone, while others reported the verbal violence, and other studies reported the threats of being subjected to violence (Jones & Lyneham, 2001).

Little cases have been reported from nurses about their experience of violence, because there is no standard instrument measurement for reporting violence. Nurses found that being involved in violence give them feeling of stigma of being abused, because reporting incidents often conflict with other data that found in the systems, because different instruments, measurements, and definitions have been used. The stigma of being involved in the violence from the patients cause reactions such as fear, shame, threat, isolation, feeling of inferiority in front of peers and limits reporting of the actual cases (Ayranci, 2005).
Nurses found reporting the incident was followed by nothing or improper actions, that didn't satisfy the nurses (Adib, et al., 2002). Nurses reported the actions that were taken were not satisfactory, nurses consider reporting as just time consuming, it lacks formalization, and there were no clear policies regarding the incident. Most nurses consider being victim of violence is the part of their job, and there is no need to report (Chapman & Styles, 2006; Shoghi, et al., 2008)

Policies and Violence Against Nurses
There are no specific measures taken in case of violent incidents reported in many health care centers. Many problems were solved by social workers in the hospital. There is lack of policies that deal with incidents especially violence against nurses. The supervisor or the general manager acts as a mediator between the nurse and the abuser and tries to solve the problems, and to interfere with the conflict. Whenever, the patient, is responsible violent behavior, the general impression that nurses have to be more patients , and to they have is to tolerate patients behaviors as they can stand it (Presley & Robinson, 2002). Most nurses indicated that there are no specific policies regarding violence and workplace violence (Merecz, et al., 2006; Shoghi, et al., 2008).

Strategies to prevent Violence Against Nurses
The Registered Nurses' Association of Ontario (RNAO) takes a 'Zero Tolerance' approach to violence in the workplace. RNAO believes that all nurses have to work in a safe environment, and to use many strategies to keep them safe and protected from violence (Hesketh, et al., 2003). Hospitals have a responsibility to provide policies, strategies, procedures, and interventions to keep their staff safe and protected from violence especially nurses. Governments have to support any interventions or strategies that make nurses safe in their job, which will enhanced safety, and promote job satisfaction (Chapman & Styles, 2006; Wand & Coulson, 2006).

RNAO suggested many interventions to limit the violence against nurses in the workplace. The strategies need an association between nurses, hospitals, administrators, society, organizations, and the individual perspective. Each sector have to do some actions that lead to a decrease in the violence against nurses(Wand & Coulson, 2006) .

Societal organizations have to increase their funding on health care systems, to ensure highest quality of care, and the safest environment for the health care providers. Mental illnesses patients and alcoholic patients have to be supported in their recovery like providing homes, or educational or facilitating opportunities for jobs for those people. Using multi sectorial strategies to address the root of the causes like dealing with poverty and social exclusion will decrease the incidence of violence and will strengthen communities(Stubbs, Winstanley, Alderman, & Birkett-Swan, 2009).

While using strategies at the workplace level, which are the main strategies that can be used by nurses directly, the results will be seen by nurses, like using a zero tolerance policy which will decrease the violence against nurses significantly, and this policy has to be disseminated to all staff, family members, clients, and visitors. Adequate staffing will ensure delivering the care for the patients in a faster way. Continuous educational programs for all nurses, about violence, conflict management, resolving problems, dealing with critical situations, time management, team work, and communication, will be very helpful in decreasing the incidence of violence against nurses. Providing an immediate action plan from the managers and supervisors at the shift especially should be incorporated, especially during night shift, because the majority of violence cases were reported at night. Law agencies have to be included in the management of actual or potential threat, and increasing the security men in the hospital, and with provision of a special program for them about dealing with specific situations like violence against nurses. Support for nurses increase their awareness about reporting the cases(Kling, Yassi, Smailes, Lovato, & Koehoorn, 2010).

While the individual level, many strategies have to be taken ,each individual has the responsibility to respect each other, and to deal with nurses in a more respectful way, without any discrimination based on race, religion, sex, color , ethnicity , or profession (Kling, et al., 2010).

Conclusion
Violence against nurses increased recently; nurses consider violence as one part of their job, so the actual number of cases worldwide is not well documented. There are insufficient policies regarding violence worldwide. Many strategies have been used to prevent violence, but all nurses have to invent more strategies to have them feel them safe in their work, and to feel satisfied.

Nurses have to do more research studies to identify the causes and prevalence of the actual causes, and they have to make difference in the policies, regarding reporting, and follow up the incidents, and use legislation to support being in a safe environment.

Arabic countries have a high prevalence of poverty, low socioeconomic status, unemployment, low level of education, high morbidity of comorbid illnesses, and all of that put nurses high risk of being a victim of violence, so Arabic nurses have to invent strategies to keep them safe in their environment, and to change the policies to support safety, prevent injury, prevent harm, and prevent being at risk for all nurses.

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