Journal of Interpersonal Violence http://jiv.sagepub.com/ Workplace Violence: An Extensive Issue for Nurses in Pakistan−−: A Qualitative Investigation Asif Shahzad and R. K. Malik J Interpers Violence published online 3 January 2014 DOI: 10.1177/0886260513516005 The online version of this article can be found at: http://jiv.sagepub.com/content/early/2013/12/25/0886260513516005

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JIVXXX10.1177/0886260513516005Journal of Interpersonal ViolenceShahzad and Malik

Article

Workplace Violence: An Extensive Issue for Nurses in Pakistan—: A Qualitative Investigation

Journal of Interpersonal Violence 201X, Vol XX(X) 1­–14 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0886260513516005 jiv.sagepub.com

Asif Shahzad1 and R. K. Malik1

Abstract The objective of the present study was to examine the incidences of violence during nurses’ careers and their impacts on their work life in the Islamic Republic of Pakistan. The current article highlights workplace violence toward nurses as a serious issue in Pakistan, which is almost an unexplored area as data are scarce. Individual interviews were conducted, applying a qualitative approach for getting the in-depth knowledge about the subject. Grounded theory method was used for data analysis and NVIVO-10 was used for information processing. Majority of the nurses experienced violence in the previous 6 months of their career. Nurses also confirmed that verbal abuse was witnessed and although experienced frequently, they did not report it, as they believed that reporting was useless and no action would be taken. Most nurses reported that due to violence, they experience stress, low work performance, low job satisfaction, high absenteeism, and high turnover intentions. The results illustrated a clear trend of an increasing number of violence incidents toward nurses. The findings of the present study possibly will assist hospital administration to manage and reduce violence at workplace. Keywords workplace violence, nurses, hospitals, work performance, stress

1Management

Sciences, Bahria University, Islamabad, Pakistan

Corresponding Author: Asif Shahzad, PhD Scholar, Management Sciences, Bahria University, Shangrilla Road, E-8, Islamabad,, Pakistan. Email: [email protected]

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A nurse can be a male or a female, but in the present study, the focus is only on the female nurses. In Pakistani culture, nurses are considered to be oppressed group and are very vulnerable to workplace violence (Somani & Khowaja, 2012). Islam naturally and unquestionably gives women privileges, respect, and value. Unfortunately, female nurses involved in this profession receive less respect as the society has lack of respect toward the nursing profession. Conversely, it is clear that although Islam gives women privileges, Muslims do not. Women are denied their rights not only in Muslim community, but this is also a global phenomenon that is prevalent almost everywhere in the world (Ayranci, Yenilmez, Balci, & Kaptanoglu, 2006; Ayrancy, 2005; Budd, Arvey, & Lawless, 1996). Going back to the subject of women’s rights abused in Muslim society, the researchers were surprised that we listen to such problems even with the example set by the Prophet Muhammad (P.B.U.H): His approach toward women was characterized by politeness, equality, care and respect and yet it is regrettable that we hear of injustice and violence toward women in the name of Islam. The Islamic republic of Pakistan was established on August 14, 1947, and its population was estimated in 2012 to be more than 187 million making it the world’s 6th most populous nation. There is a multi-cultural and multiethnic society in Pakistan. Urdu is the national and English is the official language of Pakistan, and the constitution and laws of Pakistan are written in English. Unfortunately, majority of the Pakistani population lives under rural and feudal control (Niaz, 2003). In feudal system, there is no education, no autonomy, and women are treated like slaves or prisoners and violence against women in these societies is very common. In such societies, a woman’s personality is determined by the man’s wishes. If she is not dutiful, she is punished through beatings, isolated, and sometimes murdered. The social learning theory (Bandura, 1962) explains the phenomenon of violence toward women. According to (Bandura, 1962), the theory is based on the principle that perpetration and acceptance of physical and psychological abuse are conditioned and learned behaviors. The social situation is the most important in determining the frequency, form, circumstances, and target of aggressive actions. According to social learning theory, people learn how to behave by watching the behaviors of others. When people see that other people are treating women so rude, they tend to adopt this behavior and treat their women in the same manner as others are treating. In Pakistani organizations, most leaders follow the authoritarian leadership style, where the work and self-respect of employees are undervalued (Johnson, 1994). Authoritarian workplaces, including those where employees have little say in how they do their jobs or environments where managers bully employees, tend to have higher rates of on-the-job violence. According to social exchange theory (Blau, 1964), when

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employees experience that the leadership is concerned with the well-being of its workers, they are less likely to engage in violence. However, organizations in which leaders were primarily concerned with caring their own wellbeing were more likely to suffer from violence (Peterson, 2002). According to social exchange theory (Blau, 1964), reciprocity exists when one individual reacts in kind to another party’s actions. Positive reciprocity engages the propensity to return positive act with positive act and vice versa. Reciprocity also works in negative ways, negative dealings are met with negative dealings, pressure is met with pressure, and use of authority is met with use of authority. In Pakistan, where Muslims are in majority, workplace violence toward nurses is one of the biggest issues. Among all health care employees, nurses are at the highest risk of workplace violence (Adib, Al-Shatti, Kamal, EI-Gerges, & Al-Raqem, 2002), as they work closely with patients, patient’s relatives, doctors, and other paramedical staff members (Gerberich et al., 2005; Grace & Gaylord, 1995; McPhaul & Lipscomb, 2004; Rippon, 2000). Workplace violence is a general term that incorporates all kinds of abuse— behavior that embarrasses, degrades, or injures the well-being, self-respect, and worth of an individual or group (International Facility Management Association [IFMA], 2008). Generally, researchers defined workplace violence as an event of violent behavior that is physical, verbal, or emotional that takes place when nurses are badly treated, helpless, or beaten in situations linked to their work (Lipscomb, Silberstein, Slavin, Cocy, & Jenkins, 2003). In our day-to-day life, people tend to lump all workplace violence into a generic category. However, it is not limited to physical harm. Violence includes less overt but equally unacceptable behavior such as verbal bullying, psychological abuse, and irritation. Similarly, sexual harassment is a form of violence, including threats, damage, hostility, and conflicts that turn into fights (Dunkel, 1994). Many prominent researchers have classified workplace violence in two types: emotional/psychological violence and physical violence (Early & Williams, 2002; Ferns, 2005; Randle, 2003) and both these types of violence are equally observed in Pakistan. A U.S. study gives details that nurses were more likely at risk of violence than any other group of workers (Hutton, 2006). Another research on the same issue explained that violence rates among nurses were more than that of workers in non-health-care work settings (Hewitt & Levin, 1997; Sofield & Salmond, 2003). According to the survey of Society for Human Resource Management (SHRM; 1994), more than a third of the respondents reported having experienced workplace violence since 1989, with more than 80% of those incidents transpiring since 1991. Almost 54% said that between two and five acts of violence occurred in their workplaces from 1989 to 1993.

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According to (Johnson, 1994), 67% of the incidents were employee-toemployee or employee-to-supervisor, and serious harm occurred in 22% of the cases. Unfortunately in health care sector, workplace violence is either unreported or underreported (Ferns, 2005; Kindly, Peterson, & Park, 2005; Lewis, 2001; Randle, 2003). Similarly, in Canada, the number is very low to report the unpleasant incident of violence (Lanza, Demaio, & Benedict, 2005). Researchers have explored many reasons for underreporting of violence consisting of fear of repercussions, the occurrence of violence as part and parcel of the job, lack of help and co-operation from co-workers and supervisors, and no proper reporting system (Grace & Gaylord, 1995; Lanza et al., 2005). The outcome of workplace violence toward nurses includes deficiency/ absence from work, stress, and emotional pain (Barish, 2001; Lanza et al., 2005). Nurses experience disturbance, physical harms—and in more serious cases, never-ending disability or even death due to workplace violence (Early & Williams, 2002). Similarly, the victims of workplace violence tended to have reduced emotional and physical well-being, as well as low levels of organizational commitment (LeBlanc & Kelloway, 2002). Moreover, workplace violence is positively linked with turnover intentions and psychological distress (Tepper, 2000). Lately, workplace violence researchers have started to advocate for preventive measures to address workplace violence in hospitals (Anderson, 2002; Elliott, 1997; Fitzgerald, 1993). It is observed that nurses take their duties very seriously and try to provide the best care to their patients and deal with their families; however, it is also observed that in return, their services are not valued and they are not treated with respect (Anderson, 2002). In Pakistan, various techniques are used to reduce and manage workplace violence in hospitals. Most of the hospitals from public as well as private sector lack appropriate rules and procedures to report workplace violence incidents. In some hospitals, procedures about workplace violence do exist but practical and effective execution is absent. Therefore, events of violence are high in records but unreported or underreported. However, few hospitals strictly follow a zero tolerance policy to reduce workplace violence and provide safe environment for nurses and other paramedical staff to perform their duties effectively. The Agha Khan hospital in Pakistan has the zero tolerance policy with respect to workplace violence. Workplace violence toward nurses is common in every country, but they are more frequent and regular in Pakistan. In Pakistani context, very limited work has been done on workplace violence toward nurses, it’s almost an unexplored area. This is extremely important to plan more useful strategies regarding violence incidents to help out nurses in dealing with capably and with no difficulty. A safe and secure work setting

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will definitely attract hospital staff members and, specially, nurses to work and remain in the nursing career.

Method In Pakistan, there are a total 916 hospitals and 48,446 registered nurses. The participants of the present study were all registered nurses working in different public sector hospitals in Islamabad. Nurses from 3 public sector hospitals in Islamabad were interviewed. In the present study, individual interviews were conducted, applying a qualitative approach for getting the in-depth knowledge about the subject. A total of 140 nurses working in different wards were approached for interviews. Out of 140, only 20 nurses got agreed to be the part of the study and participated in interviews (Demographics are presented in Table 1). The interview questions/items were open ended, and most questions were adopted from the questionnaire used by the World Health Organization (WHO; 1997) project survey questionnaire because these questions fulfill the requirement of the present research. In instrument, there were questions/items such as, How worried are you about violence in your current workplace? Have you witnessed an incident of workplace violence; Have you reported an incident of workplace violence? In your opinion, what are the impacts of workplace violence on nurse’s daily life and work? and In your opinion, what are the three most important measures that would reduce violence in your work setting? Majority of the nurses were reluctant to give interviews due to the sensitivity of the subject; therefore, only 20 interviews could be conducted, and each interview took 20 to 30 min, including consent forms signed and an orientation about the interviews. The researchers read all interviews independently and used NVIVO-10 for information processing. One of the most significant developments in qualitative research in the past 20 years is the emergence of computer software that can assist in the use of qualitative data analysis. NVIVO removes many if not most of the clerical tasks associated with the manual coding and retrieving of data. For data analysis, grounded theory method (Strauss & Corbin, 1990) was used in the present research. Grounded theory outlines a few-step process in which the researcher moves: (a) First of all, the researcher begins with a general question; (b) relevant people and incidents are theoretically sampled; (c) relevant data are collected; (d) data are coded that generate concepts; (e) through a constant comparison of indicators and concepts, categories are generated, the crucial issue is to ensure that there is a fit between indicators and concepts; (f) relationships between categories are explored in such a way that hypothesis about connections between categories emerge; (g)

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Table 1.  The Main Characteristics of the Sample (N = 20). Characteristics Gender  Male  Female Age   Less than 30 years   30-40 years   More than 40 years Tenure   Less than 5 years   5-10 years   More than 10 years Education  Diploma  BSN  MSN Shift work   Shift rotation   Morning shift   Evening shift   Night shift Due to violence nurses experienced  Stress   Low work performance   Low job satisfaction  Absenteeism   Turnover intentions Violence experienced in the last 6 months   Verbal violence   Physical violence

Frequency

%

05 15

25 75

08 07 05

40 35 25

09 06 05

45 30 25

06 10 04

30 50 20

11 02 04 03

55 10 20 15

18 15 13 14 13

90 75 65 70 65

20 04

100  20

and the theory is explored using grounded theory process in relation to different settings from that in which it was generated.

Findings During interview, a registered nurse shared her experience of a violent attack when she was performing her duty in a medical ward of a public sector hospital of Islamabad. As she told,

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On a Saturday night, I visited a young boy around 26 years of age, to give him dressing around his neck and give him a fresh bib. When I was finishing his dressing and I had my body close to him and my face to his neck, he tried to touch me and tried to kiss me. I immediately stopped changing his dressing and got away. I was very upset but I did not report it. Though, this incident occurred many years ago, yet it still bothers me and has a negative effect on my daily work performance.

Workplace violence incidents are high in numbers but underreported. Majority of nurses confirmed during interviews that when they tried to report violent incidents, the hospitals management did not support them. Moreover, nurses confirmed that verbal violence was witnessed and also experienced frequently, but they did not report and let it go, because they believed that reporting was useless and nothing would happen to address the issue. Some female participants replied that at times, patients and their family members tried to touch them but they were reluctant to report it due to shame and humiliation. In Pakistan, lack of respect toward nurses is a major contributing factor in workplace violence. During interviews, the following quotations affirmed the existence of violence. Yes I know about workplace violence. Workplace violence is one of the biggest issues in Pakistan. The patient’s attitude is not decent with us, they most of the time do not give respect to us. Yes I witnessed and experienced violence many times. Reporting system of our organization is not encouraging. Management does not support to report violence incidents. Due to violence I experienced stress. Workplace violence is linked with absenteeism, low job satisfaction, and decreased productivity. We need to take some actions on individual, organizational level and country level to reduce violence.

Almost, all the nurses acknowledged that during their nursing careers, they experienced at least once some kind of verbal violence (findings are presented in Table 1). Most of the nurses, strongly believed that there is a lack of encouragement and support from top management. The absence of training to prevent to report and to cope with the effects of the workplace violence is missing in most of the hospitals. The findings of the present study also showed that the majority of violence is done by patients and their companions. The study endorsed that most verbal violence happened during the morning shifts and physical violence happened during the night shifts. The findings of the present study also support the previous findings. In one study, nurses who had not experienced any violence reported the highest

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Job Sasfacon (-)

Stress (+)

(-)

Work Performance

Work Place Violence (+) Absenteeism (+)

Turnover Intenons

Figure 1.  (Theoretical framework)

job satisfaction, while those who had experienced emotional abuse and at least one other form of violence had the lowest job satisfaction (Hesketh et al., 2003). Another study showed that abuse caused nurses to be upset because they could not provide the appropriate care to meet patients’ needs, which subsequently influenced their productivity and increased their potential to make mistakes (Farrell, Bobrowski, & Bobrowski, 2006). Workplace violence and the subsequent inability of the nurse to provide good quality of care are detrimental to the nurse and the health care institution. Emotional reactions to violence include irritation, shock, fear, depression, nervousness, stress, mistrust, resentfulness, sleep disruption, tearfulness, panic attacks, and fear of returning to work (WHO, 1997). Organizations may face increased absenteeism, sick leave, property damage, decreased performance and productivity, security costs, litigation, worker’s compensation, and increasing turnover rates due to violence in the organizational setting (WHO, 1997).

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According to Hesketh et al. (2003), the majority of workplace violence incidents are not reported. In a study by Farrell et al. (2006), respondents reported that they had received the most help from talking with colleagues following aggressive incidents rather than with their manager or their professional organization. This suggests that while nurses may benefit from discussing their experiences of aggression, they are reluctant to make these incidents official. The consequences of unreported violent incidents include obscuring the understanding of the scope of the problem within the individual institution or sector, which may result in inadequate policies and programs to address the issue, and result in further incidents of violence.

Discussion and Conclusion Each and every nurse deserves to have occupational safety and secured environment at workplace to contribute quality services. In Pakistan, this is one of the biggest challenges for the hospital management to provide safe and secure work settings to nurses. The violence toward nurses is derived from numerous sources and the associated risks are complicated. Some people have a greater tendency for violence, such as previous record of violence, the past history of drug or alcohol misuse, mental confusion, and poor coping skills. The younger nurses with low-level education and less work experience are at higher possibility for being the victim of workplace violence. Due to insufficient staff/nurses and excessive workload, it becomes difficult for the nurses to provide quality care to the patients. Intrinsic nature of the situation such as violence-prone settings including psychiatric departments, residential facilities, emergency section, and work plan could be triggering factors toward workplace violence. Moreover, the organizational culture characterized by disconnected, restrictive, and authoritarian style is ready to increase patient’s feelings of disturbance. Similarly, work environment characterized by high co-worker help and synchronization can decrease risk of violence and absence of these elements in organizational culture may lead to workplace violence. A high level of violence has been connected with the factors such as the physical setting of the workplace, including low security, low visibility of work surrounding area, low lighting, and crowding. Illiterate patients and the patients coming from the areas/communities where crime rates are high may commit violent acts frequently as compared with educated and cultured people. The work performance of nurses can be enhanced by reducing violence incidents. The hospital administration can take few following steps to reduce workplace violence in the hospitals.

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1. Management should ensure that sufficient staff is available for proper care of patients. Satisfactory staffing can decrease crowding, work burden, waiting time, and work stress. 2. Management should match staff competencies with patient needs, pair inexperienced nurses with more senior nurses. They need to work on team basis instead of working alone or in isolation. 3. There must be appropriate lighting system (internal and external), to reduce violence incidents. 4. There must be education and training on workplace violence prevention programs for nurses and also other paramedical staff to deal with violence incidents professionally. 5. The role of supportive leadership is very important to reduce violence incidents in the organization. Nurses should report when they experience or witness any violence incident, and hospital managements should strengthen reporting mechanism of workplace violence in the hospitals. Leadership should encourage nurses to report violent incidents. Workforce including nurses and other paramedical staff must be informed and be made aware regarding workplace violence rules and regulations. At hiring time, the nurses should be informed about policies and reporting system. Similarly, patients and patient’s family members should be warned about the consequences of any misconduct with nurses and other paramedical staff. The present study showed that most of the verbal and physical violence was not reported by the nurses. The study also reflected that the absence of a proper reporting system and ruthless and silly reaction of their superiors and non-co-operative behavior of their colleagues contribute toward low reporting or underreporting of such incidents. By providing safe, healthy, and respectful work settings, we can attract more females in nursing profession. There is growing evidence that workplace violence contributes to deterioration of health care workers’ work life and health, affects patient care delivery, and hinders recruitment and retention of nurses. Appropriate workplace violence interventions are needed to address the growing crisis in health care organizations. Future research is necessary to better understand the issue of violence and how health care providers can minimize the number and severity of violent incidents.

Limitations The major limitation of the study was the generalizability of the findings as the research was conducted in the public sector hospitals of Islamabad, which

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limit the generalization of the findings to private sector hospitals. In future, it is recommended that such studies should be done in the private sector and different provinces of Pakistan. The response rate is a major limitation; 20 out of 140 is less than 15%. Workplace violence toward nurses is almost an unexplored area in Pakistan, and majority of the nurses were reluctant to give interviews due to the sensitivity of the subject, therefore, data are scarce. All the respondents of the study were full-time registered nurses having stable employment; therefore, they were involved in social exchange based employment relationships. The results, thus, may not be relevant to part-time nurses involved in an economic exchange based employment relationships.

Instrument: Open-Ended Interview Questions Workplace Violence Toward Nurses   1. Would you like to briefly introduce yourself? (name, age, marital status, work experience, and education.)   2. Would you like to briefly describe your job description?   3. Do you like the nature of your job?  4. Are you satisfied with the working environment of your organization?   5. What kind of problems do you face while working with others and dealing with patients?   6. Do you have any idea about the term workplace violence?   7. How worried are you about violence in your current workplace.  8. Do you feel you are adequately trained in what to do in these situations?   9. Does your department have a system in place for alerting hospital security when help is needed? 10. Have you witnessed an incident of workplace violence? 11. Have you reported an incident of workplace violence? 12. In your opinion, what are the impacts of workplace violence on nurses’ daily life and work? 13. Has your employer developed specific policies on workplace violence? 14. In your opinion, what are the three most important measures that would reduce violence in your work setting? 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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Hewitt, J., & Levin, P. (1997). Violence in workplace. Annual Review of Nursing Research, 15, 81-99. Hutton, S. (2006). Workplace incivility. Journal of Nursing Administration, 36, 22-28. International Facility Management Association. (2008). Violence in the workplace: The role of the facility manager.The Association. Johnson, D. L. (1994). Workplace violence: Why it happens and what to do about it. EAP Digest, 14, 18-22. Kindly, D., Peterson, S., & Park, H. D. (2005). Nurses experiences in psychiatric units with high risk of assault. Archives of Psychiatric Nursing, 19, 169-175. Lanza, M., Demaio, J., & Benedict, M. (2005). Patient assault support group: Achieving educational objectives. Issues in Mental Health Nursing, 26, 643660. LeBlanc, M., & Kelloway, E. (2002). Predictors and outcomes of work place violence and aggression. Journal of Applied Psychology, 87, 444-453. Lewis, M. (2001). Bullying in nursing. Nursing Standard, 15, 39-42. Lipscomb, J., Silberstein, B., Slavin, T., Cocy, E., & Jenkins, L. (2003). Perspectives on legal strategies to prevent workplace violence. Journal of Law, Medicine & Ethics, 30, 166-172. McPhaul, K., & Lipscomb, J. (2004). Workplace violence in health care: Recognized but not regulated. Online Journal of Issues in Nursing, 9, 7. Niaz, U. (2003). Violence against women in South Asian countries. Archives of Women’s Mental Health, 6, 173-184. Peterson, D. (2002). Deviant workplace behavior and the organizations ethical climate. Journal of Business and Psychology, 17, 47-61. Randle, J. (2003). Bullying in the nursing profession. Journal of Advanced Nursing, 43, 395-401. Rippon, T. (2000). Aggression and violence in healthcare professions. Journal of Advanced Nursing, 31, 452-460. Society for Human Resource Management. (1994). SHRM survey reveals extent of workplace violence. EAP Digest, 14, 25. Sofield, L., & Salmond, S. (2003). A focus on verbal abuse and intent to leave the organization. Orthopaedic Nursing, 22, 274-283. Somani, K., & Khowaja, K. (2012). Workplace violence towards nurses: A reality from the Pakistani Context. Journal of Nursing Education and Practice, 2, 148153. Strauss, A., & Corbin, J. (1990). Basics of qualitative research: Techniques and procedures for developing grounded theory. Thousand Oaks, CA: Sage. Tepper, B. (2000). Consequences of abusive supervision. Academy of Management Journal, 43, 178-190. World Health Organization. (1997). World Health Report. Geneva, Switzerland: Author.

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Author Biographies Asif Shahzad is currently doing PhD from Bahria University Islamabad Campus in the field of Management Sciences. His area of research is organizational behavior. He won the best Paper Award in 4th SAICON International Conference held in Bhurbon, Murree, Islamabad, Pakistan on 5-7 December 2012. R. K. Malik teaches Qualitative Research course to PhD students, She had worked in Bahria University and currently she is working as Director SZABIST Islamabad campus.

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Workplace Violence: An Extensive Issue for Nurses in Pakistan-: A Qualitative Investigation.

The objective of the present study was to examine the incidences of violence during nurses' careers and their impacts on their work life in the Islami...
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