536278 research-article2014
JIVXXX10.1177/0886260514536278Journal of Interpersonal ViolenceAbou-ElWafa et al.
Article
Workplace Violence Against Emergency Versus Non-Emergency Nurses in Mansoura University Hospitals, Egypt
Journal of Interpersonal Violence 2015, Vol. 30(5) 857–872 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0886260514536278 jiv.sagepub.com
Hala Samir Abou-ElWafa, MD,1 Abdel-Hady El-Gilany, MD,1 Samar E. Abd-El-Raouf, PhD Nursing,1 Samia Mahmoud Abd-Elmouty, PhD Nursing,1 and Rabab El-Sayed Hassan El-Sayed, PhD Nursing1
Abstract Workplace violence (WPV) against nurses is a common but neglected problem in Egypt. The objectives are to estimate the prevalence and associated risk factors of different types of violence against nurses working in the emergency hospital compared with those working in non-emergency clinics, circumstances of violence, type of perpetrators, and victims’ response. This cross-sectional comparative study was carried out at Mansoura University Hospitals, Egypt, during January 2013. The data were collected through the adapted version of a self-administered questionnaire developed by the International Labor Office/International Council of Nurses/World Health Organization/Public Services International on WPV in the health sector. All types of WPV are common among nurses. Precipitating factors for violent incidents identified by respondents are emergency specialty, having work
1Mansoura
University, Egypt
Corresponding Author: Hala Samir Abou-ElWafa, Department of Public Health and Community Medicine, Faculty of Medicine, Mansoura University, Mansoura 35516, Egypt. Email: [email protected]
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shift, and younger age. Violent incidents result in work dissatisfaction and consequently impair work productivity. Nurses working in emergency hospital experienced a higher level of different types of WPV. There is an urgent need to formulate and implement a policy for dealing with violent events. Keywords violence against nurses, physical violence, verbal violence, sexual harassment, emergency health care
Introduction Physical violence is dramatically increasing, especially in hospitals and other health care settings. Workplace violence (WPV) can be any act of physical violence, threats of physical violence, harassment, intimidation, or other threatening, disruptive behavior that occurs at the work site (U.S. Department of Agriculture, 1998). Violence at work includes not only observable physical acts but also psychological behaviors. Victims are subjected to bullying, threats, intimidation, sexual harassment, and other forms of psychological violence (Di Martino, 2002). Violence in the health care setting occurs 4 times more often than violence in any other private-sector industry (National Institute for Occupational Safety and Health [NIOSH] & Centers for Disease Control and Prevention [CDC], 2002). Emergency nurses are among the groups at highest risk for being exposed to an act of violence (Gerberich et al., 2005; NIOSH & CDC, 2002) such as being threatened, physically assaulted, or seeing the effect of violence on coworkers or patients (Gillespie, 2008). Workers in the health care sector have increasingly become victims of violence at their jobs in recent years. Health care workers accounted for 45% of all reported non-fatal assaults resulting in lost work, according to a 2005 report by the U.S. Bureau of Labor Statistics and in 2006, the Massachusetts Nurses Association reported that half of 172 nurses surveyed had been punched at least once in the past 2 years, while 44% reported frequent verbal threats and abuse (Prost, 2010). Violent perpetrators are typically patients or emotionally disturbed family members. Nurses are often at higher risk of physical assaults, because they are typically the first and most frequent medical personnel by the bedside of ill and sometimes angry or frustrated patients (Lothian, 2007). Although interest in WPV in the health sector has grown considerably within the developed world, it still appears to be an unrecognized issue in
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many developing countries (Kamchuchat, Chongsuvivatwong, Oncheunjit, Yip, & Sangthong, 2008). WPV directed at frontline health sector personnel has rarely been researched in developing countries including Egypt; thus, the real size of the problem in the health sector is largely unknown till now. So, the objectives of this study are to estimate the prevalence and associated factors of different types of violence against nurses working in the emergency hospital compared with those working in non-emergency clinic, circumstances of violence, type of perpetrators, and victims’ response.
Population and Methods Study Locality This study was carried out in Emergency Hospital and inpatients section of Internal Medicine Departments, affiliated to Mansoura University Hospitals. The catchment area is Dakahlia governorate (with a total population of more than 5,000,000) and neighborhood. The Emergency Hospital is a tertiary care hospital that provides free emergency care for the general population. The patients can be self-referred or referred from lower levels of health services. The hospital provides emergency services for 3 days per week (Sunday, Tuesday, and Thursday). There are 35 beds in the outpatients’ clinic and 129 beds in the inpatient sections. According to the statistics of 2011, there were a total of 164,362 emergency visits, out of which 12,004 were admitted to the inpatient sections. The non-emergency nurses included all nurses working in the Internal Medicine Departments of Mansoura University Hospital.
Study Design This is a cross-sectional comparative study.
Ethical Consideration The study was approved by the hospital director as there is no ethics research committee in the hospital. Nurses gave verbal informed consent. Data were collected during January 2013; using a predesigned self- administered questionnaire distributed to all working nurses in the emergency hospital on duty for at least 1 year. Out of 134 questionnaires distributed, 128 were returned (response rate = 95.5%). The questionnaire was distributed to 152 nurses working in Internal medicine departments and 147 questionnaires were returned (response rate = 96.7%)
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There is no identified appropriate instrument to be used in the investigation specified to WPV against nurses in Egypt. Thus, the questionnaire developed by the International Labor Office, International Council of Nurses, World Health Organization, and Public Services International (2003) regarding WPV in the health sector was used and adjusted for the study. Validity and reliability of the designed questionnaire were tested in previous studies. The modified culturally adapted Arabic version of this questionnaire was developed and used in a previous study in Saudi Arabia (El-Gilany, El-Wehady, & Amr, 2010). The adjusted questionnaire consisted of five sections. Data regarding personal and workplace characteristics were collected using the first part after deleting some questions such as job categories as our participants belong to one category. The second and third parts of the questionnaire were related to physical violence, verbal violence, bullying/mobbing, and sexual harassment; respectively. Examples of the questions included the following: (a) In the last 12 months, have you been physically attacked/verbally abused/bullied or mobbed/sexually harassed in your workplace? (b) Do you consider this to be a typical incident of violence in your workplace? (c) How did you respond to the incident? (d) Who attacked you? (e) Where did the incident take place? and (f) How did you respond to the incident? Furthermore, if a nurse experienced WPV in the past year, information such as nature, frequency, responses, consequences and satisfaction of incident handling, strategies, and policies to deal with the incident were sought. The following main changes indicated different aspects of WPV according to the Egyptian culture and context: Racial harassment is not known in Egypt, so this section (the fourth part) was deleted from the questionnaire. Also the fifth part was deleted as there is no formal policy for violence management in the studied hospital. Data were collected, reviewed, coded, and entered into the computer. Unpaired t test was used for comparing quantitative data. Chi-square test was used for comparing qualitative data. Logistic regression analysis was done to predict the independent predictors of different types of violence. Adjusted odds ratio (AOR) and their 95% confidence intervals were calculated. Statistical analysis was done using the SPSS program version 16.
Results Table 1 shows that the mean age of emergency nurses was higher than that of non-emergency nurses. The majority of both groups were females. Most of emergency and non-emergency nurses (71.1% and 74.5%, respectively) were married. There is statistically significant difference between both groups regarding all socio-demographic features.
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Abou-ElWafa et al. Table 1. Socio-Demographic and Occupational Profiles of the Study Groups. Emergency (128), n (%) Age 40 22 (17.2) M ± SD 33.1 ± 6.9 Gender Male 13 (10.2) Female 115 (89.8) Marital status Single 26 (20.3) Married 91 (71.1) Divorced/widow 11 (8.6) Duration of employment 5 72 (56.2)
Non-Emergency (147), n (%)
Test of Significance
79 (53.7) 46 (31.3) 22 (15.0) 30.7 ± 8.2
χ2 = 21.1, p ≤ .001 t = 2.6, p = .01
5 (3.4) 142 (96.6)
χ2 = 5.1, p = .024
35 (24.1) 108 (74.5) 2 (1.4)
χ2 = 7.98, p = .018
83 (57.2) 64 (43.5) 7.8 ± 3.8
χ2 = 16.5, p ≤ .001 t = 7.6, p ≤ .001
79 (53.7) 68 (46.3) 127 (86.4) 111 (75.5)
χ2 = 19.2, p ≤ .001 χ2 = 0.99, p = .32 χ2 = 0.04, p = .8
113 (80.7) 27 (19.3)
χ2 = 39.2, p ≤ .001
The mean duration of employment for emergency nurses was longer than non-emergency nurses. Regarding work time, most of emergency nurses (78.9%) and 53.7% of non-emergency nurses work full time. About three quarters of both groups work night shift. As regards the number of colleagues, 56.2% of emergency nurses work in groups of more than five colleagues, while 80.7% of non-emergency nurses work in groups of up to five colleagues. There is statistically significant difference regarding all items of occupational profile except work shift and night shift. It was found that 54.7% expressed that they are very worried about violence compared with 6.8% only of non-emergency nurses. Regarding the type of violence experienced during the past year, 28.1% of emergency nurses reported exposure to two types of violence, while 46.9% of non-emergency
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Table 2. Worry About and Exposure to Violence Among the Study Groups. Emergency (128), Non-Emergency n (%) (147), n (%) Test of Significance Worry about violence Absolutely none 11 (8.6) None 6 (4.7) Somewhat 15 (11.7) Worried 26 (20.3) Very worried 70 (54.7) Type of violence during past year None 18 (14.1) One type 30 (23.4) Two types 36 (28.1) Three types 31 (24.2) Four types 13 (10.2) Past year prevalence of violence 62 (48.4) Physical violencea Verbal violence 77 (60.2) Bullying/mobbing 69 (53.9) Sexual harassment 39 (30.5) aBeating,
34 (23.1) 50 (34.0) 32 (21.8) 21 (14.3) 10 (6.8)
χ2 = 97.2, p ≤ .001
30 (20.4) 69 (46.9) 39 (26.5) 6 (4.1) 3 (2.0)
χ2 = 40.5, p ≤ .001
48 (32.7) 63 (42.9) 49 (33.3) 16 (11.0)
χ2 = 7.1, p = .008 χ2 = 8.2, p = .004 χ2 = 11.5, p = .001 χ2 = 16.2, p ≤ .001
pushing, pinching, kicking, biting, and slapping.
nurses reported exposure to one type of violence. There is statistically significant difference between both groups regarding the worry about and type of violence. Concerning the past year prevalence of violence, verbal violence showed the highest prevalence and sexual harassment showed the least prevalence among emergency and non-emergency nurses (Table 2). Logistic regression analysis of significant independent predictors of violence showed that emergency specialty, having work shift, and younger age of the nurse are associated with physical violence (OR = 2.2, 0.2, 1.6, and 1.5, respectively), while emergency specialty and having work shift are associated with verbal violence (OR = 2.0 and 0.5, respectively), and emergency specialty is the only predictor for bullying/mobbing (OR = 2.1), and lastly emergency specialty, having work shift, younger age of the nurse, and number of colleagues are associated with sexual harassment (OR = 5.2, 0.3, 1.9, 0.5, and 2.8, respectively; Table 3). Table 4 shows that inside the hospital was the most common place for physical, verbal violence, and bullying, while for sexual harassment, 52.7% of persons reported that it occurred outside the hospital.
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Abou-ElWafa et al. Table 3. Logistic Regression Analysis of Significant Independent Predictors of Different Types of Violence. Physical AOR (95% CI) Specialty Emergency 2.2 [1.3, 3.8] Non-emergency r (1) Work shift No 0.2 [0.1, 0.5] Yes r (1) Age 5
Verbal AOR (95% CI)
Bullying/ Mobbing AOR (95% CI)
Sexual AOR (95% CI)
2.0 [1.2, 3.4] r (1)
2.1 [1.3, 3.5] r (1)
5.2 [2.4, 11.0] r (1)
0.5 [0.2, 0.9] r (1)
0.3 [0.1, 0.9] r (1) 1.9 [1.1, 2.6] 0.5 [0.2, 1.6] r (1) 2.8 [1.3, 6.0] r (1)
Note. Variables included in the regression models are specialty, age, gender, marital status, duration of employment, nature of work (full time or part time), shift work, night shift, and number of colleagues at workplace. AOR = adjusted odds ratio; CI = confidence interval; r = reference group.
Relative/visitor was the most common type of perpetrator for physical, verbal violence, and bullying (61.8%, 63.6%, and 50.8%, respectively), while 36.4% of respondents reported that the perpetrator was one of the colleagues for sexual harassment. Concerning victim’s response to violent incident for physical, verbal violence, and bullying, 71.8%, 77.1%, and 73.7% of persons reported that they take no action against violent acts (respectively), while about half of those exposed to sexual harassment reported that they pretend that it never happened. As regards physical violence and sexual harassment, extreme distress is the most frequent reply to statements concerning distress as a result of violent attacks. For verbal violence and bullying/mobbing, extreme distress is also the most frequent reply except for “feeling like everything I did was an effort” (Table 5). Table 6 shows that the majority of nurses (96%) suggested availability of security personnel to prevent and control violence and the least frequent suggestion was changing work environment and flow (24.7%).
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Table 4. Place of Violence, Perpetrator, and Response of Victim to Violent Incidents. Physicala (110), Verbal (140), n (%) n (%) Place of event Inside hospital Outside hospital Patients’ room Perpetratorb Patient Relative/visitor Colleagues Manager/supervisor General public Victim’s responseb No action Pretend it never happened Told the person to stop Tried to defend oneself Told colleague/ friends/family Reported it to senior staff Request for vacation/transfer Called hospital security
Bullying (118), Sexual (55), n (%) n (%)
48 (43.6) 23 (20.9) 39 (35.5)
91 (65.0) 38 (27.1) 11 (7.9)
84 (71.2) 23 (19.5) 11 (9.3)
24 (43.6) 29 (52.7) 2 (3.6)
22 (20.0) 68 (61.8) 5 (4.5) 16 (14.5) 13 (11.8)
38 (27.1) 89 (63.6) 8 (5.7) 13 (9.3) 34 (24.3)
29 (24.6) 60 (50.8) 7 (5.9) 23 (19.5) 18 (15.3)
17 (30.9) 17 (30.9) 20 (36.4) 1 (1.8) 0
79 (71.8) 17 (15.5)
108 (77.1) 11 (7.9)
87 (73.7) 28 (23.7)
27 (49.1) 28 (50.9)
21 (19.1)
21 (15.0)
19 (16.1)
21 (38.2)
32 (29.1)
31 (22.1)
28 (23.7)
1 (1.8)
10 (3.6)
2 (1.4)
1 (0.8)
1 (1.8)
10 (9.1)
20 (14.3)
10 (8.5)
2 (3.6)
26 (23.6)
4 (2.9)
—
1 (1.8)
16 (14.5)
25 (17.9)
19 (16.1)
—
aSeven (6.4%) of the incident were associated with weapons. Eighteen nurses (16.4%) reported injuries due to physical violence (scratches, wound, and contusion). bCategories are not mutually exclusive.
Discussion Nurses are at the most risk of WPV among health care providers (Kingma, 2001; Nachreiner, Gerberich, Ryan, & McGovern, 2007) and may be victims of WPV 3 times greater than other health care team members (Buchan, Kingma, & Lorenzo, 2005). In our study, the majority of respondents are females and have work shift. Emergency nurses had on average been employed about 1½ times as long as
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Table 5. Victims’ Distress Due to Violent Attacks in Different Types of Violence. Problems and Complaints
Physical Bullying/ Sexual Violence (110), Verbal Violence Mobbing (118), Harassment n (%) (140), n (%) n (%) (55), n (%)
Repeated distributed memories, thoughts, or image of the attack Not at all 5 (4.5) 12 (8.6) 7 (19.5) 4 (7.3) A little bit 17 (15.5) 9 (6.4) 16 (13.6) 1 (1.8) Moderately 15 (13.6) 33 (23.6) 25 (21.2) 11 (20.0) Quite a bit 32 (29.1) 31 (22.1) 23 (19.5) 19 (34.5) Extremely 41 (37.3) 55 (39.3) 47 (39.8) 20 (36.4) Avoid thinking about or talking about the attack or avoiding having feeling related to it Not at all 12 (10.9) 7 (5.0) 6 (5.1) 0 A little bit 8 (7.3) 27 (19.3) 9 (7.6) 1 (1.8) Moderately 18 (16.4) 25 (17.9) 24 (20.3) 4 (7.3) Quite a bit 22 (20.0) 39 (27.9) 23 (19.5) 12 (21.8) Extremely 50 (45.5) 42 (30.0) 56 (47.5) 38 (69.1) Being super-alert or watchful and on guard Not at all 8 (7.3) 21 (15.0) 11 (9.3) 0 A little bit 19 (17.3) 14 (10.0) 5 (4.2) 1 (1.8) Moderately 22 (20.0) 27 (19.3) 28 (23.7) 1 (1.8) Quite a bit 24 (21.8) 34 (24.3) 26 (22.0) 22 (10.0) Extremely 37 (33.6) 44 (31.4) 48 (40.7) 31 (56.4) Feeling like everything I did was an effort Not at all 20 (18.2) 9 (6.4) 20 (16.9) 0 A little bit 9 (8.2) 28 (20.0) 9 (7.6) 2 (3.6) Moderately 22 (20.0) 33 (23.0) 29 (24.6) 13 (23.6) Quite a bit 23 (20.9) 39 (27.9) 34 (28.8) 18 (32.7) Extremely 36 (32.7) 31 (22.1) 26 (22.0) 22 (40.0)
non-emergency nurses (12.3 ± 5.96 years) and about 1½ times as many of them had been employed for more than 10 years in that group compared with the other. This is similar to the results of the study of violence against nurses working in U.S. emergency departments (EDs); it was found that 52.1% of them primarily worked the day shift. The mean ± SD emergency nursing experience was 12.1 ± 8.8 years, and experience in the respondent’s current ED was 7.6 ± 7.2 years. Most respondents (84.4%) were women (GackiSmith et al., 2009). The high incidence of WPV in EDs is well documented in many studies (Çelik, Çelik, Agırbas, & Ugurluog, 2007; Crilly, Chaboyer, & Creedy, 2004;
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Table 6. Suggestions of Nurses to Prevent and Control Violence. Suggestiona
n (%)
Availability of security personnel Liaison with police Penalty for perpetrators Training on violence prevention and control Administrative measures Policy for care for victims Changing work environment and flow Hot line for immediate reporting of events aCategories
264 (96.0) 203 (73.8) 116 (42.2) 159 (57.8) 221 (80.4) 109 (39.6) 68 (24.7) 164 (59.6)
are not mutually exclusive.
Ergün & Karadakovan, 2005; Erickson, Williams-Evans, & Tenn, 2000; Lyneham, 2000; Stirling, Higgins, & Cooke, 2001). In our study, during the past year 28.1% of emergency nurses reported exposure to two types of violence, while 46.9% of non-emergency nurses reported exposure to one type of violence. Verbal violence showed the highest prevalence and sexual harassment showed the least prevalence among both groups. A similar result was reported among hospital nurses in Hong Kong; the most prevalent violence was verbal abuse (73%), followed by bullying, physical abuse, and sexual harassment. Also, 20% of nurses recalled more than 10 instances of various types of WPV over the previous 12 months (Kwok et al., 2006). The same was reported by Ergün and Karadakovan (2005) in a descriptive survey in Turkey on ED nurses who found that verbal violence was more frequent than physical violence (98.5% and 19.7%, respectively). Many of the verbally violated respondents (53.8%) had been violated more than 15 times in their professional career. In the study conducted in Iran by Esmaeilpour, Salsali, and Ahmadi (2011), it was found that 91.6% of nurses reported experiencing verbal abuse and 19.7% physical violence in the past 12 months. Similar findings were reported by Ergün and Karadakovan (2005) who reported that nurses faced physical violence at least once in the same time period. Studies have also shown that the experience of verbal abuse is more common than physical violence (Crilly et al., 2004; Kamchuchat et al., 2008; Kwok et al., 2006; Landau & Bendalak, 2008; Lin & Liu, 2005; O’Connell, Young, Brooks, Hutchings, & Lofthouse, 2000; Oweis & Diabat, 2005). In our study, physical violence included beating, pushing, pinching, kicking, biting, and slapping. The same result was found in the United States, some of the most common types of physical violence experienced by more
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than 50% of nurses working in EDs were “spit on,” “hit,” “pushed/shoved,” “scratched,” and “kicked.” In terms of verbal abuse, 70% or more of respondents experienced being “yelled/cursed at,” “intimidated,” and “harassed with sexual language” (Gacki-Smith et al., 2009). In the present study, logistic regression analysis showed that emergency specialty, having work shift, younger age of the nurse, and number of colleagues are significant independent predictors of different types of violence. In Turkey, the frequency of verbal violence had significant association with the age and experience of ED nurses. Violence exposures were more likely to occur between 4:00 p.m. and 8:00 a.m. and with family or friends of patients as the perpetrators (Ergün & Karadakovan, 2005). This is similar to our results where most of violent incidents occurred during the afternoon and night shifts in both settings (74% in emergency and 66.6% in non-emergency; data not shown in tables). However, Duhart (2001) found that for all health care settings, violence exposures were more likely to occur between 6:00 a.m. and 6:00 p.m. This contradiction may be explained by Duhart studying hospital-wide violence and not focusing on the ED. In addition, violence from visitors would most likely occur during hospital visiting hours. However, the ED allows patient visitors around-the-clock, thereby shifting the times when violence is most likely to occur (Gillespie, 2008). In the current study, physical, verbal violence, and bullying were reported to occur most frequently inside the hospital, while for sexual harassment, outside the hospital was the most frequent. The same findings were reported for physical violence and verbal abuse incidents in Iran as they occurred mostly near the patients’ bed (48.5%) and in nursing stations (49.1%), respectively (Esmaeilpour et al., 2011), that is, inside the hospital. In our study, relative/visitor was the most common type of perpetrator for physical, verbal violence, and bullying, while for sexual harassment, 36.4% of respondents reported that the perpetrator was one of the colleagues. This is similar to the results of nurses in Hong Kong; nurses who had experienced WPV within the previous 12 months reported that patients and their relatives were the main perpetrators in all cases. Other major perpetrators included nursing colleagues, seniors, managers, and doctors (Kwok et al., 2006). However, in the study of WPV against Iranian nurses working in EDs, patients’ relatives were the most common source of both kinds of violence (84.9%) and verbal abuse (84.7%; Esmaeilpour et al., 2011). Concerning victim’s response to violent incident, it was found that for physical, verbal violence, and bullying, 71.8%, 77.1%, and 73.7% of persons reported that they take no action against violent acts, while about half of those exposed to sexual harassment reported that they pretend that it never happened. The same results were found in the study of Hong Kong; most
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nurses (82%) who experienced verbal abuse tended to cope with the problem by confiding in friends, family members, or colleagues. The response was similar for other types of abuse. The second most common response by nurses was to ignore the incident (42%); very few (1%-3%) chose to seek help from the union. Other means of coping with the problem included shopping, praying, or taking revenge. In one extreme case, a nurse attempted suicide following verbal and physical abuse (Kwok et al., 2006). In the present study, small percent (9.1%, 14.3%, 8.5%, and 3.6%) of victims of physical, verbal violence, bullying, and sexual harassment reported violent acts to senior staff, respectively. This result was much lower than that reported by Ergün and Karadakovan (2005), in Turkey, who found that half of the emergency nurses in their study believed in reporting assaults when minor injuries occurred. Ergün and Karadakovan believed that a formal and reliable system can track occurrences of violence exposures by emergency nurses so that administrators can use this data to develop programs that increase staff safety and reduce the occurrence of violence exposures. Our results showed that, physical violence and sexual harassment exert extreme distress in the form of repeated distributed memories, thoughts, or image of the attack, avoid thinking about or talking about the attack or avoiding having feeling related to it, being super-alert or watchful and on guard, and feeling like everything I did was an effort. As regards verbal violence and bullying/mobbing, extreme distress is also the most frequent reply to all statements of distress except for “feeling like everything I did was an effort.” The same was reported in the study of WPV against Iranian nurses, who mentioned that, as a result of WPV, 40% of physically violated nurses and 25.8% of verbally abused nurses had been extremely bothered by repeated disturbing memories, thoughts, or images of the attack. Avoiding thinking about or talking about the attack, or avoiding having feelings related to it, was present in 28.6% of physically and 23.3% of verbally abused nurses who had been extremely bothered. About 57% of physically violated nurses had been extremely bothered and 31.9% of verbally abused nurses had been quite a bit bothered by being “super-alert” or “watchful and on guard.” Finally, 62.8% of physically and 42.3% of verbally abused nurses had been extremely bothered by feeling that everything they did “was an effort” (Esmaeilpour et al., 2011).
Conclusion WPV is a challenge in EDs. Lack of nurses’ safety and security in the workplace and their dissatisfaction regarding violent incidents can influence their
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work performance and productivity and quality of patient care in emergency situations. Recognition of the magnitude and risk factors for WPV is an essential initial step to prevent and respond to violence incidents. Designing educational programs to prepare nurses for potentially violent situations and improving workplace safety and environmental controls together with enforcement by laws can decrease EDs violence.
Study Limitations Our study has some limitations. The first is the relatively small number of nurses in a single tertiary care emergency hospital. Second, the findings are based on self-reported data with the possibility of recall bias and there is no way to verify missing data and the accuracy of data. Finally, no data were collected about nature of perpetrators, as this was difficult with multiplicity of violent events and multiplicity of perpetrators that are unknown to the victims.
Recommendations WPV in ED is not going to disappear as long as visits continue to increase, and there is a lack of safety and security measures at the ED level. The control measures of violence fall into the categories of administrative/policybased practices, employee training, environmental control, and security equipment and personnel. Emergency hospitals must have a policy and procedure regarding management of violent incidents. Immediate and appropriate response to any violent incident with appropriate investigation of serious incidents with rapid access to trained security and/or law enforcement personnel at all times. Formal risk assessments together with training nurses in the recognition of early predictors of violent behaviors are necessary. All Health Care Workers (HCWs) within the ED should be aware of the risk of violence and should be prepared for unpredictable events; in addition, security systems should be installed. A response system should exist in each ED to address the distress of the victims, including support and counseling, in addition to the prevention and investigation. Further research is warranted to explore the nationwide magnitude of the problem to test the effectiveness of different intervention measures. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References Buchan, J., Kingma, M., & Lorenzo, F. M. (2005). International migration of nurses: Trends and policy implications. International Council of Nurses. Cited in Esmaeilpour, M., Salsali, M., & Ahmadi, F. (2011). Workplace violence against Iranian nurses working in emergency departments. International Nursing Review, 58, 130-137. Çelik, S. S., Çelik, Y., Agırbas, I., & Ugurluog, Ö. (2007). Verbal and physical abuse against nurses in Turkey. International Nursing Review, 54, 359-366. Crilly, J., Chaboyer, W., & Creedy, D. (2004). Violence toward emergency department nurses by patients. Accident and Emergency Nursing, 12, 67-73. Di Martino, V. (2002). Workplace violence in the health sector—Country case studies: Brazil, Bulgaria, Lebanon, Portugal, South Africa, Thailand and an additional Australian study. Geneva, Switzerland: International Labour Office, International Council of Nurses, World Health Organization, and Public Services International. Retrieved from http://www.who.int/violence_injury_prevention/ injury/en/WVsynthesisreport.pdf Duhart, D. T. (2001). Violence in the workplace, 1993-1999 (Publication No. NCJ190076). Washington, DC: Bureau of Justice Statistics. Retrieved from http://bjs .gov/content/pub/pdf/vw99.pdf El-Gilany, A., El-Wehady, A., & Amr, M. (2010). Violence against primary health care workers in Al-Hassa, Saudi Arabia. Journal of Interpersonal Violence, 25, 716-734. Ergün, F. S., & Karadakovan, A. (2005). Violence towards nursing staff in emergency departments in one Turkish city. International Nursing Review, 52, 154-160. Erickson, L., Williams-Evans, S. A., & Tenn, M. (2000). Attitude of emergency nurses regarding patient assaults. Journal of Emergency Nursing, 26, 210-215. Esmaeilpour, M., Salsali, M., & Ahmadi, F. (2011). Workplace violence against Iranian nurses working in emergency departments. International Nursing Review, 58, 130-137. Gacki-Smith, J., Juarez, A. M., Boyett, L., Homeyer, C., Robinson, L., & MacLean, S. L. (2009). Violence against nurses working in US emergency departments. The Journal of Nursing Administration, 39, 340-349. Gerberich, S. G., Church, T. R., McGovern, P. M., Hansen, H. D., Nachreiner, N. M., Geissner, M. S., . . .Jurek, A. (2005). Risk factors for work-related assaults on nurses. Epidemiology, 16, 704-709. Gillespie, G. L. (2008). Consequences of violence exposures by emergency nurses. Journal of Aggression, Maltreatment & Trauma, 16, 409-418. International Labor Office, International Council of Nurses, World Health Organization, and Public Services International. (2003). Workplace Violence in the Health
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Sector Country Case Studies Research Instruments—Survey Questionnaire (Joint Programme on Workplace Violence in the Health Sector). International Labor Office, the International Council of Nurses, World Health Organization, and Public Services International, Geneva, Switzerland: Author. Retrieved from http://www.who.int/violence_injury_prevention/violence/interpersonal/en/ WVquestionnaire.pdf Kamchuchat, C., Chongsuvivatwong, V., Oncheunjit, S., Yip, T. W., & Sangthong, R. (2008). Workplace violence directed at nursing staff at a general hospital in Southern Thailand. Journal of Occupational Health, 50, 201-207. Kingma, M. (2001). Workplace violence in the health sector: A problem of epidemic proportion. International Nursing Review, 48, 129-130. Kwok, R. P., Law, Y. K., Li, K. E., Ng, Y. C., Cheung, M. H., Fung, V. K., . . .Yen, P. F. (2006). Prevalence of workplace violence against nurses in Hong Kong. Hong Kong Medical Journal, 12, 6-9. Landau, S. F., & Bendalak, Y. (2008). Personnel exposure to violence in hospital emergency wards: A routine activity approach. Aggressive Behavior, 34, 88-103. Lin, Y. H., & Liu, H. E. (2005). The impact of workplace violence on nurses in South Taiwan. International Journal of Nursing Studies, 42, 773-778. Lothian, D. (2007). Nurses confront violence on the job. CNN. Retrieved from http://edition.cnn.com/2007/HEALTH/07/11/nurse.violence/index.html?_ s=PM:HEALTH Lyneham, J. (2000). Violence in New South Wales emergency departments. Australian Journal of Advanced Nursing, 18(2), 8-17. Nachreiner, N. M., Gerberich, S. G., Ryan, A. D., & McGovern, P. M. (2007). Minnesota nurses’ study: Perception of violence and the work environment. Industrial Health, 45, 672-678. National Institute for Occupational Safety and Health & Centers for Disease Control and Prevention. (2002). Occupational hazards in hospitals [DHHS (NIOSH) Publication No. 2002-101]. Cincinnati, OH. Retrieved from http://www.cdc.gov/ niosh/docs/2002-101/ O’Connell, B., Young, J., Brooks, J., Hutchings, J., & Lofthouse, J. (2000). Nurses’ perceptions of the nature and frequency of aggression in general ward settings and high dependency areas. Journal of Clinical Nursing, 9, 602-610. Oweis, A., & Diabat, K. M. (2005). Jordanian nurses perception of physicians’ verbal abuse: Findings from a questionnaire survey. International Journal of Nursing Studies, 42, 881-888. Prost, M. (2010). Violence in nursing. Human Resource Executive Online. Retrieved from http://www.hreonline.com/HRE/story.jsp?storyId=349192043 Stirling, G., Higgins, J. E., & Cooke, M. V. (2001). Violence in A&E departments: A systematic review of the literature. Accident and Emergency Nursing, 9, 77-85. U.S. Department of Agriculture. (1998). The USDA handbook on workplace violence prevention and response. Retrieved from http://allnurses.com/nurse-colleaguepatient/physical-violence-against-750925.html
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Author Biographies Hala Samir Abou-ElWafa, MD, is a lecturer of Industrial Medicine and Occupational Health at Public Health and Community Medicine Department, Faculty of Medicine, Mansoura University, Egypt. Her research examines musculoskeletal disorders in different occupational settings. She investigates hazards of municipal solid waste on waste collectors focusing on respiratory, musculoskeletal, and hepatitis C issues. Her work concerned with different aspects of occupational health and industrial medicine. Abdel-Hady El-Gilany, MD, is a professor of Public Health and Preventive Medicine, Faculty of Medicine, Mansoura University, Egypt. He worked in Ministry of Health and King Faisal University, Saudi Arabia. He published 176 articles in local and international journals. His research interest is different fields of public health and community medicine. Samar E. Abd-El-Raouf, PhD Nursing, is a lecturer of Community Health Nursing, Faculty of Nursing, Mansoura University, Egypt. Her research investigates nurses’ role in family planning counseling. She examines the effect of health education for families having an HCV infected member. She is interested with different aspects of community health nursing. Samia Mahmoud Abd-Elmoaty, PhD Nursing, is a lecturer of Community Health Nursing, Faculty of Nursing, Mansoura University, Egypt. Her research investigates quality of life among lepromatous patients. She examines the impact of educational program for anemic pregnant women on their pregnancy outcome. She is interested with different aspects of community health nursing. Rabab El-Sayed Hassan El-Sayed, PhD Nursing, is a lecturer of Pediatric Nursing, Faculty of Nursing, Mansoura University, Egypt. Her research investigates the effect of positive touch and massage on premature infants. She examines the perceived image of nurses by school - age children. She is interested with different aspects of pediatric nursing.
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JIVXXX10.1177/0886260514536278Journal of Interpersonal ViolenceAbou-ElWafa et al.
Article
Workplace Violence Against Emergency Versus Non-Emergency Nurses in Mansoura University Hospitals, Egypt
Journal of Interpersonal Violence 2015, Vol. 30(5) 857–872 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0886260514536278 jiv.sagepub.com
Hala Samir Abou-ElWafa, MD,1 Abdel-Hady El-Gilany, MD,1 Samar E. Abd-El-Raouf, PhD Nursing,1 Samia Mahmoud Abd-Elmouty, PhD Nursing,1 and Rabab El-Sayed Hassan El-Sayed, PhD Nursing1
Abstract Workplace violence (WPV) against nurses is a common but neglected problem in Egypt. The objectives are to estimate the prevalence and associated risk factors of different types of violence against nurses working in the emergency hospital compared with those working in non-emergency clinics, circumstances of violence, type of perpetrators, and victims’ response. This cross-sectional comparative study was carried out at Mansoura University Hospitals, Egypt, during January 2013. The data were collected through the adapted version of a self-administered questionnaire developed by the International Labor Office/International Council of Nurses/World Health Organization/Public Services International on WPV in the health sector. All types of WPV are common among nurses. Precipitating factors for violent incidents identified by respondents are emergency specialty, having work
1Mansoura
University, Egypt
Corresponding Author: Hala Samir Abou-ElWafa, Department of Public Health and Community Medicine, Faculty of Medicine, Mansoura University, Mansoura 35516, Egypt. Email: [email protected]
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shift, and younger age. Violent incidents result in work dissatisfaction and consequently impair work productivity. Nurses working in emergency hospital experienced a higher level of different types of WPV. There is an urgent need to formulate and implement a policy for dealing with violent events. Keywords violence against nurses, physical violence, verbal violence, sexual harassment, emergency health care
Introduction Physical violence is dramatically increasing, especially in hospitals and other health care settings. Workplace violence (WPV) can be any act of physical violence, threats of physical violence, harassment, intimidation, or other threatening, disruptive behavior that occurs at the work site (U.S. Department of Agriculture, 1998). Violence at work includes not only observable physical acts but also psychological behaviors. Victims are subjected to bullying, threats, intimidation, sexual harassment, and other forms of psychological violence (Di Martino, 2002). Violence in the health care setting occurs 4 times more often than violence in any other private-sector industry (National Institute for Occupational Safety and Health [NIOSH] & Centers for Disease Control and Prevention [CDC], 2002). Emergency nurses are among the groups at highest risk for being exposed to an act of violence (Gerberich et al., 2005; NIOSH & CDC, 2002) such as being threatened, physically assaulted, or seeing the effect of violence on coworkers or patients (Gillespie, 2008). Workers in the health care sector have increasingly become victims of violence at their jobs in recent years. Health care workers accounted for 45% of all reported non-fatal assaults resulting in lost work, according to a 2005 report by the U.S. Bureau of Labor Statistics and in 2006, the Massachusetts Nurses Association reported that half of 172 nurses surveyed had been punched at least once in the past 2 years, while 44% reported frequent verbal threats and abuse (Prost, 2010). Violent perpetrators are typically patients or emotionally disturbed family members. Nurses are often at higher risk of physical assaults, because they are typically the first and most frequent medical personnel by the bedside of ill and sometimes angry or frustrated patients (Lothian, 2007). Although interest in WPV in the health sector has grown considerably within the developed world, it still appears to be an unrecognized issue in
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many developing countries (Kamchuchat, Chongsuvivatwong, Oncheunjit, Yip, & Sangthong, 2008). WPV directed at frontline health sector personnel has rarely been researched in developing countries including Egypt; thus, the real size of the problem in the health sector is largely unknown till now. So, the objectives of this study are to estimate the prevalence and associated factors of different types of violence against nurses working in the emergency hospital compared with those working in non-emergency clinic, circumstances of violence, type of perpetrators, and victims’ response.
Population and Methods Study Locality This study was carried out in Emergency Hospital and inpatients section of Internal Medicine Departments, affiliated to Mansoura University Hospitals. The catchment area is Dakahlia governorate (with a total population of more than 5,000,000) and neighborhood. The Emergency Hospital is a tertiary care hospital that provides free emergency care for the general population. The patients can be self-referred or referred from lower levels of health services. The hospital provides emergency services for 3 days per week (Sunday, Tuesday, and Thursday). There are 35 beds in the outpatients’ clinic and 129 beds in the inpatient sections. According to the statistics of 2011, there were a total of 164,362 emergency visits, out of which 12,004 were admitted to the inpatient sections. The non-emergency nurses included all nurses working in the Internal Medicine Departments of Mansoura University Hospital.
Study Design This is a cross-sectional comparative study.
Ethical Consideration The study was approved by the hospital director as there is no ethics research committee in the hospital. Nurses gave verbal informed consent. Data were collected during January 2013; using a predesigned self- administered questionnaire distributed to all working nurses in the emergency hospital on duty for at least 1 year. Out of 134 questionnaires distributed, 128 were returned (response rate = 95.5%). The questionnaire was distributed to 152 nurses working in Internal medicine departments and 147 questionnaires were returned (response rate = 96.7%)
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There is no identified appropriate instrument to be used in the investigation specified to WPV against nurses in Egypt. Thus, the questionnaire developed by the International Labor Office, International Council of Nurses, World Health Organization, and Public Services International (2003) regarding WPV in the health sector was used and adjusted for the study. Validity and reliability of the designed questionnaire were tested in previous studies. The modified culturally adapted Arabic version of this questionnaire was developed and used in a previous study in Saudi Arabia (El-Gilany, El-Wehady, & Amr, 2010). The adjusted questionnaire consisted of five sections. Data regarding personal and workplace characteristics were collected using the first part after deleting some questions such as job categories as our participants belong to one category. The second and third parts of the questionnaire were related to physical violence, verbal violence, bullying/mobbing, and sexual harassment; respectively. Examples of the questions included the following: (a) In the last 12 months, have you been physically attacked/verbally abused/bullied or mobbed/sexually harassed in your workplace? (b) Do you consider this to be a typical incident of violence in your workplace? (c) How did you respond to the incident? (d) Who attacked you? (e) Where did the incident take place? and (f) How did you respond to the incident? Furthermore, if a nurse experienced WPV in the past year, information such as nature, frequency, responses, consequences and satisfaction of incident handling, strategies, and policies to deal with the incident were sought. The following main changes indicated different aspects of WPV according to the Egyptian culture and context: Racial harassment is not known in Egypt, so this section (the fourth part) was deleted from the questionnaire. Also the fifth part was deleted as there is no formal policy for violence management in the studied hospital. Data were collected, reviewed, coded, and entered into the computer. Unpaired t test was used for comparing quantitative data. Chi-square test was used for comparing qualitative data. Logistic regression analysis was done to predict the independent predictors of different types of violence. Adjusted odds ratio (AOR) and their 95% confidence intervals were calculated. Statistical analysis was done using the SPSS program version 16.
Results Table 1 shows that the mean age of emergency nurses was higher than that of non-emergency nurses. The majority of both groups were females. Most of emergency and non-emergency nurses (71.1% and 74.5%, respectively) were married. There is statistically significant difference between both groups regarding all socio-demographic features.
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Abou-ElWafa et al. Table 1. Socio-Demographic and Occupational Profiles of the Study Groups. Emergency (128), n (%) Age 40 22 (17.2) M ± SD 33.1 ± 6.9 Gender Male 13 (10.2) Female 115 (89.8) Marital status Single 26 (20.3) Married 91 (71.1) Divorced/widow 11 (8.6) Duration of employment 5 72 (56.2)
Non-Emergency (147), n (%)
Test of Significance
79 (53.7) 46 (31.3) 22 (15.0) 30.7 ± 8.2
χ2 = 21.1, p ≤ .001 t = 2.6, p = .01
5 (3.4) 142 (96.6)
χ2 = 5.1, p = .024
35 (24.1) 108 (74.5) 2 (1.4)
χ2 = 7.98, p = .018
83 (57.2) 64 (43.5) 7.8 ± 3.8
χ2 = 16.5, p ≤ .001 t = 7.6, p ≤ .001
79 (53.7) 68 (46.3) 127 (86.4) 111 (75.5)
χ2 = 19.2, p ≤ .001 χ2 = 0.99, p = .32 χ2 = 0.04, p = .8
113 (80.7) 27 (19.3)
χ2 = 39.2, p ≤ .001
The mean duration of employment for emergency nurses was longer than non-emergency nurses. Regarding work time, most of emergency nurses (78.9%) and 53.7% of non-emergency nurses work full time. About three quarters of both groups work night shift. As regards the number of colleagues, 56.2% of emergency nurses work in groups of more than five colleagues, while 80.7% of non-emergency nurses work in groups of up to five colleagues. There is statistically significant difference regarding all items of occupational profile except work shift and night shift. It was found that 54.7% expressed that they are very worried about violence compared with 6.8% only of non-emergency nurses. Regarding the type of violence experienced during the past year, 28.1% of emergency nurses reported exposure to two types of violence, while 46.9% of non-emergency
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Table 2. Worry About and Exposure to Violence Among the Study Groups. Emergency (128), Non-Emergency n (%) (147), n (%) Test of Significance Worry about violence Absolutely none 11 (8.6) None 6 (4.7) Somewhat 15 (11.7) Worried 26 (20.3) Very worried 70 (54.7) Type of violence during past year None 18 (14.1) One type 30 (23.4) Two types 36 (28.1) Three types 31 (24.2) Four types 13 (10.2) Past year prevalence of violence 62 (48.4) Physical violencea Verbal violence 77 (60.2) Bullying/mobbing 69 (53.9) Sexual harassment 39 (30.5) aBeating,
34 (23.1) 50 (34.0) 32 (21.8) 21 (14.3) 10 (6.8)
χ2 = 97.2, p ≤ .001
30 (20.4) 69 (46.9) 39 (26.5) 6 (4.1) 3 (2.0)
χ2 = 40.5, p ≤ .001
48 (32.7) 63 (42.9) 49 (33.3) 16 (11.0)
χ2 = 7.1, p = .008 χ2 = 8.2, p = .004 χ2 = 11.5, p = .001 χ2 = 16.2, p ≤ .001
pushing, pinching, kicking, biting, and slapping.
nurses reported exposure to one type of violence. There is statistically significant difference between both groups regarding the worry about and type of violence. Concerning the past year prevalence of violence, verbal violence showed the highest prevalence and sexual harassment showed the least prevalence among emergency and non-emergency nurses (Table 2). Logistic regression analysis of significant independent predictors of violence showed that emergency specialty, having work shift, and younger age of the nurse are associated with physical violence (OR = 2.2, 0.2, 1.6, and 1.5, respectively), while emergency specialty and having work shift are associated with verbal violence (OR = 2.0 and 0.5, respectively), and emergency specialty is the only predictor for bullying/mobbing (OR = 2.1), and lastly emergency specialty, having work shift, younger age of the nurse, and number of colleagues are associated with sexual harassment (OR = 5.2, 0.3, 1.9, 0.5, and 2.8, respectively; Table 3). Table 4 shows that inside the hospital was the most common place for physical, verbal violence, and bullying, while for sexual harassment, 52.7% of persons reported that it occurred outside the hospital.
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Abou-ElWafa et al. Table 3. Logistic Regression Analysis of Significant Independent Predictors of Different Types of Violence. Physical AOR (95% CI) Specialty Emergency 2.2 [1.3, 3.8] Non-emergency r (1) Work shift No 0.2 [0.1, 0.5] Yes r (1) Age 5
Verbal AOR (95% CI)
Bullying/ Mobbing AOR (95% CI)
Sexual AOR (95% CI)
2.0 [1.2, 3.4] r (1)
2.1 [1.3, 3.5] r (1)
5.2 [2.4, 11.0] r (1)
0.5 [0.2, 0.9] r (1)
0.3 [0.1, 0.9] r (1) 1.9 [1.1, 2.6] 0.5 [0.2, 1.6] r (1) 2.8 [1.3, 6.0] r (1)
Note. Variables included in the regression models are specialty, age, gender, marital status, duration of employment, nature of work (full time or part time), shift work, night shift, and number of colleagues at workplace. AOR = adjusted odds ratio; CI = confidence interval; r = reference group.
Relative/visitor was the most common type of perpetrator for physical, verbal violence, and bullying (61.8%, 63.6%, and 50.8%, respectively), while 36.4% of respondents reported that the perpetrator was one of the colleagues for sexual harassment. Concerning victim’s response to violent incident for physical, verbal violence, and bullying, 71.8%, 77.1%, and 73.7% of persons reported that they take no action against violent acts (respectively), while about half of those exposed to sexual harassment reported that they pretend that it never happened. As regards physical violence and sexual harassment, extreme distress is the most frequent reply to statements concerning distress as a result of violent attacks. For verbal violence and bullying/mobbing, extreme distress is also the most frequent reply except for “feeling like everything I did was an effort” (Table 5). Table 6 shows that the majority of nurses (96%) suggested availability of security personnel to prevent and control violence and the least frequent suggestion was changing work environment and flow (24.7%).
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Table 4. Place of Violence, Perpetrator, and Response of Victim to Violent Incidents. Physicala (110), Verbal (140), n (%) n (%) Place of event Inside hospital Outside hospital Patients’ room Perpetratorb Patient Relative/visitor Colleagues Manager/supervisor General public Victim’s responseb No action Pretend it never happened Told the person to stop Tried to defend oneself Told colleague/ friends/family Reported it to senior staff Request for vacation/transfer Called hospital security
Bullying (118), Sexual (55), n (%) n (%)
48 (43.6) 23 (20.9) 39 (35.5)
91 (65.0) 38 (27.1) 11 (7.9)
84 (71.2) 23 (19.5) 11 (9.3)
24 (43.6) 29 (52.7) 2 (3.6)
22 (20.0) 68 (61.8) 5 (4.5) 16 (14.5) 13 (11.8)
38 (27.1) 89 (63.6) 8 (5.7) 13 (9.3) 34 (24.3)
29 (24.6) 60 (50.8) 7 (5.9) 23 (19.5) 18 (15.3)
17 (30.9) 17 (30.9) 20 (36.4) 1 (1.8) 0
79 (71.8) 17 (15.5)
108 (77.1) 11 (7.9)
87 (73.7) 28 (23.7)
27 (49.1) 28 (50.9)
21 (19.1)
21 (15.0)
19 (16.1)
21 (38.2)
32 (29.1)
31 (22.1)
28 (23.7)
1 (1.8)
10 (3.6)
2 (1.4)
1 (0.8)
1 (1.8)
10 (9.1)
20 (14.3)
10 (8.5)
2 (3.6)
26 (23.6)
4 (2.9)
—
1 (1.8)
16 (14.5)
25 (17.9)
19 (16.1)
—
aSeven (6.4%) of the incident were associated with weapons. Eighteen nurses (16.4%) reported injuries due to physical violence (scratches, wound, and contusion). bCategories are not mutually exclusive.
Discussion Nurses are at the most risk of WPV among health care providers (Kingma, 2001; Nachreiner, Gerberich, Ryan, & McGovern, 2007) and may be victims of WPV 3 times greater than other health care team members (Buchan, Kingma, & Lorenzo, 2005). In our study, the majority of respondents are females and have work shift. Emergency nurses had on average been employed about 1½ times as long as
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Table 5. Victims’ Distress Due to Violent Attacks in Different Types of Violence. Problems and Complaints
Physical Bullying/ Sexual Violence (110), Verbal Violence Mobbing (118), Harassment n (%) (140), n (%) n (%) (55), n (%)
Repeated distributed memories, thoughts, or image of the attack Not at all 5 (4.5) 12 (8.6) 7 (19.5) 4 (7.3) A little bit 17 (15.5) 9 (6.4) 16 (13.6) 1 (1.8) Moderately 15 (13.6) 33 (23.6) 25 (21.2) 11 (20.0) Quite a bit 32 (29.1) 31 (22.1) 23 (19.5) 19 (34.5) Extremely 41 (37.3) 55 (39.3) 47 (39.8) 20 (36.4) Avoid thinking about or talking about the attack or avoiding having feeling related to it Not at all 12 (10.9) 7 (5.0) 6 (5.1) 0 A little bit 8 (7.3) 27 (19.3) 9 (7.6) 1 (1.8) Moderately 18 (16.4) 25 (17.9) 24 (20.3) 4 (7.3) Quite a bit 22 (20.0) 39 (27.9) 23 (19.5) 12 (21.8) Extremely 50 (45.5) 42 (30.0) 56 (47.5) 38 (69.1) Being super-alert or watchful and on guard Not at all 8 (7.3) 21 (15.0) 11 (9.3) 0 A little bit 19 (17.3) 14 (10.0) 5 (4.2) 1 (1.8) Moderately 22 (20.0) 27 (19.3) 28 (23.7) 1 (1.8) Quite a bit 24 (21.8) 34 (24.3) 26 (22.0) 22 (10.0) Extremely 37 (33.6) 44 (31.4) 48 (40.7) 31 (56.4) Feeling like everything I did was an effort Not at all 20 (18.2) 9 (6.4) 20 (16.9) 0 A little bit 9 (8.2) 28 (20.0) 9 (7.6) 2 (3.6) Moderately 22 (20.0) 33 (23.0) 29 (24.6) 13 (23.6) Quite a bit 23 (20.9) 39 (27.9) 34 (28.8) 18 (32.7) Extremely 36 (32.7) 31 (22.1) 26 (22.0) 22 (40.0)
non-emergency nurses (12.3 ± 5.96 years) and about 1½ times as many of them had been employed for more than 10 years in that group compared with the other. This is similar to the results of the study of violence against nurses working in U.S. emergency departments (EDs); it was found that 52.1% of them primarily worked the day shift. The mean ± SD emergency nursing experience was 12.1 ± 8.8 years, and experience in the respondent’s current ED was 7.6 ± 7.2 years. Most respondents (84.4%) were women (GackiSmith et al., 2009). The high incidence of WPV in EDs is well documented in many studies (Çelik, Çelik, Agırbas, & Ugurluog, 2007; Crilly, Chaboyer, & Creedy, 2004;
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Table 6. Suggestions of Nurses to Prevent and Control Violence. Suggestiona
n (%)
Availability of security personnel Liaison with police Penalty for perpetrators Training on violence prevention and control Administrative measures Policy for care for victims Changing work environment and flow Hot line for immediate reporting of events aCategories
264 (96.0) 203 (73.8) 116 (42.2) 159 (57.8) 221 (80.4) 109 (39.6) 68 (24.7) 164 (59.6)
are not mutually exclusive.
Ergün & Karadakovan, 2005; Erickson, Williams-Evans, & Tenn, 2000; Lyneham, 2000; Stirling, Higgins, & Cooke, 2001). In our study, during the past year 28.1% of emergency nurses reported exposure to two types of violence, while 46.9% of non-emergency nurses reported exposure to one type of violence. Verbal violence showed the highest prevalence and sexual harassment showed the least prevalence among both groups. A similar result was reported among hospital nurses in Hong Kong; the most prevalent violence was verbal abuse (73%), followed by bullying, physical abuse, and sexual harassment. Also, 20% of nurses recalled more than 10 instances of various types of WPV over the previous 12 months (Kwok et al., 2006). The same was reported by Ergün and Karadakovan (2005) in a descriptive survey in Turkey on ED nurses who found that verbal violence was more frequent than physical violence (98.5% and 19.7%, respectively). Many of the verbally violated respondents (53.8%) had been violated more than 15 times in their professional career. In the study conducted in Iran by Esmaeilpour, Salsali, and Ahmadi (2011), it was found that 91.6% of nurses reported experiencing verbal abuse and 19.7% physical violence in the past 12 months. Similar findings were reported by Ergün and Karadakovan (2005) who reported that nurses faced physical violence at least once in the same time period. Studies have also shown that the experience of verbal abuse is more common than physical violence (Crilly et al., 2004; Kamchuchat et al., 2008; Kwok et al., 2006; Landau & Bendalak, 2008; Lin & Liu, 2005; O’Connell, Young, Brooks, Hutchings, & Lofthouse, 2000; Oweis & Diabat, 2005). In our study, physical violence included beating, pushing, pinching, kicking, biting, and slapping. The same result was found in the United States, some of the most common types of physical violence experienced by more
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than 50% of nurses working in EDs were “spit on,” “hit,” “pushed/shoved,” “scratched,” and “kicked.” In terms of verbal abuse, 70% or more of respondents experienced being “yelled/cursed at,” “intimidated,” and “harassed with sexual language” (Gacki-Smith et al., 2009). In the present study, logistic regression analysis showed that emergency specialty, having work shift, younger age of the nurse, and number of colleagues are significant independent predictors of different types of violence. In Turkey, the frequency of verbal violence had significant association with the age and experience of ED nurses. Violence exposures were more likely to occur between 4:00 p.m. and 8:00 a.m. and with family or friends of patients as the perpetrators (Ergün & Karadakovan, 2005). This is similar to our results where most of violent incidents occurred during the afternoon and night shifts in both settings (74% in emergency and 66.6% in non-emergency; data not shown in tables). However, Duhart (2001) found that for all health care settings, violence exposures were more likely to occur between 6:00 a.m. and 6:00 p.m. This contradiction may be explained by Duhart studying hospital-wide violence and not focusing on the ED. In addition, violence from visitors would most likely occur during hospital visiting hours. However, the ED allows patient visitors around-the-clock, thereby shifting the times when violence is most likely to occur (Gillespie, 2008). In the current study, physical, verbal violence, and bullying were reported to occur most frequently inside the hospital, while for sexual harassment, outside the hospital was the most frequent. The same findings were reported for physical violence and verbal abuse incidents in Iran as they occurred mostly near the patients’ bed (48.5%) and in nursing stations (49.1%), respectively (Esmaeilpour et al., 2011), that is, inside the hospital. In our study, relative/visitor was the most common type of perpetrator for physical, verbal violence, and bullying, while for sexual harassment, 36.4% of respondents reported that the perpetrator was one of the colleagues. This is similar to the results of nurses in Hong Kong; nurses who had experienced WPV within the previous 12 months reported that patients and their relatives were the main perpetrators in all cases. Other major perpetrators included nursing colleagues, seniors, managers, and doctors (Kwok et al., 2006). However, in the study of WPV against Iranian nurses working in EDs, patients’ relatives were the most common source of both kinds of violence (84.9%) and verbal abuse (84.7%; Esmaeilpour et al., 2011). Concerning victim’s response to violent incident, it was found that for physical, verbal violence, and bullying, 71.8%, 77.1%, and 73.7% of persons reported that they take no action against violent acts, while about half of those exposed to sexual harassment reported that they pretend that it never happened. The same results were found in the study of Hong Kong; most
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nurses (82%) who experienced verbal abuse tended to cope with the problem by confiding in friends, family members, or colleagues. The response was similar for other types of abuse. The second most common response by nurses was to ignore the incident (42%); very few (1%-3%) chose to seek help from the union. Other means of coping with the problem included shopping, praying, or taking revenge. In one extreme case, a nurse attempted suicide following verbal and physical abuse (Kwok et al., 2006). In the present study, small percent (9.1%, 14.3%, 8.5%, and 3.6%) of victims of physical, verbal violence, bullying, and sexual harassment reported violent acts to senior staff, respectively. This result was much lower than that reported by Ergün and Karadakovan (2005), in Turkey, who found that half of the emergency nurses in their study believed in reporting assaults when minor injuries occurred. Ergün and Karadakovan believed that a formal and reliable system can track occurrences of violence exposures by emergency nurses so that administrators can use this data to develop programs that increase staff safety and reduce the occurrence of violence exposures. Our results showed that, physical violence and sexual harassment exert extreme distress in the form of repeated distributed memories, thoughts, or image of the attack, avoid thinking about or talking about the attack or avoiding having feeling related to it, being super-alert or watchful and on guard, and feeling like everything I did was an effort. As regards verbal violence and bullying/mobbing, extreme distress is also the most frequent reply to all statements of distress except for “feeling like everything I did was an effort.” The same was reported in the study of WPV against Iranian nurses, who mentioned that, as a result of WPV, 40% of physically violated nurses and 25.8% of verbally abused nurses had been extremely bothered by repeated disturbing memories, thoughts, or images of the attack. Avoiding thinking about or talking about the attack, or avoiding having feelings related to it, was present in 28.6% of physically and 23.3% of verbally abused nurses who had been extremely bothered. About 57% of physically violated nurses had been extremely bothered and 31.9% of verbally abused nurses had been quite a bit bothered by being “super-alert” or “watchful and on guard.” Finally, 62.8% of physically and 42.3% of verbally abused nurses had been extremely bothered by feeling that everything they did “was an effort” (Esmaeilpour et al., 2011).
Conclusion WPV is a challenge in EDs. Lack of nurses’ safety and security in the workplace and their dissatisfaction regarding violent incidents can influence their
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work performance and productivity and quality of patient care in emergency situations. Recognition of the magnitude and risk factors for WPV is an essential initial step to prevent and respond to violence incidents. Designing educational programs to prepare nurses for potentially violent situations and improving workplace safety and environmental controls together with enforcement by laws can decrease EDs violence.
Study Limitations Our study has some limitations. The first is the relatively small number of nurses in a single tertiary care emergency hospital. Second, the findings are based on self-reported data with the possibility of recall bias and there is no way to verify missing data and the accuracy of data. Finally, no data were collected about nature of perpetrators, as this was difficult with multiplicity of violent events and multiplicity of perpetrators that are unknown to the victims.
Recommendations WPV in ED is not going to disappear as long as visits continue to increase, and there is a lack of safety and security measures at the ED level. The control measures of violence fall into the categories of administrative/policybased practices, employee training, environmental control, and security equipment and personnel. Emergency hospitals must have a policy and procedure regarding management of violent incidents. Immediate and appropriate response to any violent incident with appropriate investigation of serious incidents with rapid access to trained security and/or law enforcement personnel at all times. Formal risk assessments together with training nurses in the recognition of early predictors of violent behaviors are necessary. All Health Care Workers (HCWs) within the ED should be aware of the risk of violence and should be prepared for unpredictable events; in addition, security systems should be installed. A response system should exist in each ED to address the distress of the victims, including support and counseling, in addition to the prevention and investigation. Further research is warranted to explore the nationwide magnitude of the problem to test the effectiveness of different intervention measures. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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Author Biographies Hala Samir Abou-ElWafa, MD, is a lecturer of Industrial Medicine and Occupational Health at Public Health and Community Medicine Department, Faculty of Medicine, Mansoura University, Egypt. Her research examines musculoskeletal disorders in different occupational settings. She investigates hazards of municipal solid waste on waste collectors focusing on respiratory, musculoskeletal, and hepatitis C issues. Her work concerned with different aspects of occupational health and industrial medicine. Abdel-Hady El-Gilany, MD, is a professor of Public Health and Preventive Medicine, Faculty of Medicine, Mansoura University, Egypt. He worked in Ministry of Health and King Faisal University, Saudi Arabia. He published 176 articles in local and international journals. His research interest is different fields of public health and community medicine. Samar E. Abd-El-Raouf, PhD Nursing, is a lecturer of Community Health Nursing, Faculty of Nursing, Mansoura University, Egypt. Her research investigates nurses’ role in family planning counseling. She examines the effect of health education for families having an HCV infected member. She is interested with different aspects of community health nursing. Samia Mahmoud Abd-Elmoaty, PhD Nursing, is a lecturer of Community Health Nursing, Faculty of Nursing, Mansoura University, Egypt. Her research investigates quality of life among lepromatous patients. She examines the impact of educational program for anemic pregnant women on their pregnancy outcome. She is interested with different aspects of community health nursing. Rabab El-Sayed Hassan El-Sayed, PhD Nursing, is a lecturer of Pediatric Nursing, Faculty of Nursing, Mansoura University, Egypt. Her research investigates the effect of positive touch and massage on premature infants. She examines the perceived image of nurses by school - age children. She is interested with different aspects of pediatric nursing.
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