Factors and Characteristics of Workplace Violence Against Nurses: A Study in Iran

Abstract

Violence against nurses is a serious problem that can affect negatively the quality of nursing care. The extent of violence against nurses in Iran and the factors leading to this violence have not been known. Thus, the aim of this study was to investigate all forms of violence against nurses in Shahrekord hospitals in 2014. In this 2014 study, 100 nurses working in Shahrekord’s Hajar, Kashani, and Social Security branch hospitals were studied. Data were collected through standardized questionnaires on workplace violence, as well as demographic data, in health units on five types of violence, including physical and verbal violence, intimidation and bullying, ethnic violence, and violation of chastity. The analysis was done by SPSS (Version 19) software. All nurses indicated that during some period of their work, they had been subjected to at least one type of violence; the highest prevalence of mental violence was belonged to the subtype of intimidation and bullying (91%). The primary agents of violence against nurses were patients and their relatives. Factors such as gender, age, work experience, and nursing shifts played important roles in the distribution of violence. In ethnic violence, the only factor affecting nurses was race (p < .05). The highest rate of violence against nurses was due to mental or psychological violence. To minimize violence in hospitals, authorities should consider appropriate preventive strategies, good management, proper protective measures, and public education.

Keywords

violence in the workplace nurse hospital

Introduction

Workplace violence has been considered as an international concern which often the employees are exposed to. Violence in the workplace is defined in different ways; in fact, the specialized and comprehensive definition of workplace violence is those events where the employees are misused, threatened, or attacked in their working environment by other individuals (International Labour Office, International Council of Nurses [ICN], World Health Organization [WHO], & Public Services International [PSI], 2002). These situations include while working in the workplace, during transit to the workplace, and while on employment-related outings or appointments. Workplace violence is categorized into two main groups: physical and mental or psychological (Whelan, 2008). There is a subset of different forms of abuse within these two major forms of abuse: verbal abuse, bullying and mobbing, as well as sexual and racial abuse that may overlap both groups (Kwok et al., 2006).

According to the WHO, nurses are exposed to the highest risk of workplace violence among all professions. The effect of workplace violence, according to nurses, is the most important reason for leaving the nursing profession (Mechem, Dickinson, Shofer, & Jaslow, 2002). Although all employees of hospitals are exposed to violence, nurses are at the highest risk because they provide direct service to patients and play a pivotal role in the quality of services provided to these patients. Despite the importance of the role of nurses, health systems and especially hospitals have been unable to ensure the safety of frontline nurses against workplace violence (Aghajanloo, 2008; Çelik, Celik, Ağırbaş, & Uğurluoğlu, 2007; Kwok et al., 2006; Öztunç, 2006). The experience of occupational violence has led to outcomes such as chronic impatience, anger and frustration toward patients, lack of sympathy with patients, and mental or physical abandoning of patients by the nurse (McCarthy, 1985).

According to past studies, the most important reasons for violence against nurses include age (prevalence among the young), being male, low social or economic classes, preexisting psychological disorders, refusal of treatment, personality disorder, and having a history of hospitalization and a history of psychological violence (Gates, Gillespie, & Succop, 2011; Joubert, du Rand, & van Wyk, 2005; Kingma, 2001; Rafati, Zabihi, & Hosseini, 2012). Ghasemi and Rezaei (2007) in their study of Iran have shown that 21.3% of nurses have experienced physical assault at least once and 25% of those cases have led to some injuries. Another study in Portuguese has shown that violence has been a burdensome factor in most hospitals such that 100% of nurses, 88.9% of technicians, 88.2% of nurse assistants, and 85.7% of doctors have been victims of violence in their workplace (Cezar & Marziale, 2006). In other studies, it has been reported that most cases of violence against nurses were in the form of verbal, physical, and sexual violence (Gates et al., 2011; Kamchuchat, Chongsuvivatwong, Oncheunjit, Yip, & Sangthong, 2008; Kennedy, 2005; Talas, Kocaöz, & Akgüç, 2011).

Despite the high prevalence of violence in medical care centers, there are no comprehensive statistics around the prevalence of this problem in Iran. One of the major problems associated with studying the types of violence nurses experience in the workplace is due to the deep and comprehensive view of this problem from the patients’ point of view. This unidirectional approach to the rights of medical personnel is a prevalent view; however, the individual’s right to be safe should be consistent across all settings whether they are personnel, patients, or nurses. They should all be able to communicate with others without any fear of violence, and in the case of violent behavior, legal proceedings should be the next step (Qodsbin, Dehbozorgi, & Tayari, 2009). However, past studies have rarely dealt with all dimensions of violence against nurses and rarely have considered effective factors for prevention in all hospital wards.

Objective

Thus, due to the significance of this issue, this study has investigated the status of different types of violence against nurses and effective factors to low or stop workplace violence.

Patients and Methods

Study Population and Sampling

This is an analytical and descriptive study with the statistical population including all nurses working in public hospitals of Shahrekord (due to the lack of private hospitals in this city). First, in a pilot sample of 35 subjects, the rate of violence was calculated as .93 (p), and according to Cochran’s sample size formula, there was a reliability of 95% and error of .05; the sample size was considered as 100 individuals.

Inclusion criteria were having a BA in nursing and a paramedic diploma and at least 6 months’ working experience in each of the Hajar, Kashani, and Social Security hospitals of Shahrekord. Nurses were excluded from the study if they did not want to participate.

Questionnaire of Data Collection

The data collection tool includes a multiple-selection questionnaire with 58 questions derived from a comprehensive and standardized questionnaire established with the cooperation of the International Labour Organization (ILO), the WHO, the ICN, and the PSI in 2003. This questionnaire asks for background information of the participants and about workplace violence in health care environments to provide data on how to develop preventive programs. In this regard, the questionnaire has been used in several studies in various countries, and it has even been used in Iran, where it has been translated and used by various researchers (Qodsbin et al., 2009; Rafati et al., 2012).

The two main parts of this questionnaire include demographics and working information and exposure to violence. The scientific definition of workplace physical and psychological violence in this study was as follows: Physical violence is defined as at least once the nurse faced physical aggression during the past year by clients, partners, or colleagues such as beating, flogging, punching, kicking, slapping, hooliganism, pushing, biting, or tweaking. Psychological violence includes the nurse dealing with defamation, intimidation or bullying, invasion or violation of chastity, or race-based slander during the last year by clients or coworkers as shown in conflicts, verbal abuse, lack of courtesy, disrespect to ethnic or minority status of the nurse, and coercion or violation of chastity and sexual privacy.

Possible factors associated with the type of violence that was evaluated included age, gender, work experience, work shift, marital status, as well as nurses’ race and ethnicity.

Procedure

To conduct this research and the validation of the questionnaire, the entire text of the questionnaire was translated into Persian and the Farsi text was translated back into English (double translation).

Every part of this dual translation was done by two people who have lived in English-speaking countries and were university educated in the field of medical sciences. After revision of the translations by a number of specialists in the field of nursing, social medicine, and health, their opinions were applied. The reliability was calculated using Cronbach’s alpha as .81.

After approval of the questionnaire by the expertise, all of the ethical rules were obeyed, such as obtaining permission from the Ethical Committee of Isfahan University of Medical Sciences and providing the hospital president and nursing management with an ethics agreement.

After ensuring privacy to the participants, the researcher distributed the questionnaires randomly (with a dictionary for the definition of violence) along with the consent forms to participants in Hajar, Kashani, and Social Security hospitals of Shahrekord. Participants were not asked to include their name or provide other identifying characteristics as part of the survey.

Statistical Analyses

Finally, data were analyzed using SPSS software (Version 19) with the use of chi-square and Fisher’s exact test considering a significance level of less than 5%.

Results

Out of 100 nurses in the present study, 76% were female and 24% were male with the mean age of 35.60 ± 11.24 years and 56% of the participants were in the mean age of 30.39 years. Both groups were comprised of racial minorities (Lor or Turk) and racial majorities, and their mean working experience was 9.87 ± 10.03 years; the most frequently reported work duration was 6 to 10 years with 43%. The participants reported interacting with patients in the distribution of either female (15%) or male (14%) or with both genders (71%); the most nurses (84%) have communicated with teens (10-18 years), adults, and the elderly, and the lowest age range included newborns (12%) and children below the age of 10 years (26%)(Table 1).

Table 1.

Demographic Characteristics’ Frequency of Nurses and Patients.

Factors	n (%) or M ± SD
Sex
Male	24 (24%)
Female	76 (76%)
Age (years)	35.60 ± 11.24
20-29	19 (19%)
30-39	56 (56%)
40-49	20 (20%)
50-59	5 (5%)
Work experience (years)	9.87 ± 10.03
<1	3 (3%)
1-5	21 (21%)
6-10	43 (43%)
11-15	14 (14%)
16-20	11 (11%)
>20	8 (8%)
Group age of patient
Babies	12 (12%)
Children	26 (26%)
Adult	84 (84%)
Elderly	84 (84%)
Racial status
Racial minorities^a	38 (38%)
The majority of racial	62 (62%)
Marital status
Single	27 (27%)
Married	63 (63%)
Divorced	3 (3%)
Widow	7 (7%)
Night shift of 20:00 p.m. to 8:00 a.m. of the next day
Yes	87 (87%)
No	13 (13%)
Sex of patient
Female	15 (15%)
Male	14 (14%)
Both sexes	71 (71%)

Ethnic minorities mean a member of Lor tribe or Turk tribe.

The study of different types of violence against nurses showed that nurses were subject to physical violence in 57% of incidences, and all of the participants reporting violence were exposed to acts of mental violence such that 84% faced verbal violence, 3% with outrage, 12% with racial violence, and 91% with coercion and menace. Physical, verbal, and outrage attacks were most frequently reported as caused by the patient’s attendant (family, etc.), and in coercion and menace, the highest frequency with 38 cases (41%) was related to the patient themselves while racial violence was reportedly done by other personnel, doctors, and colleagues of the reporting nurses (Figure 1).

Figure 1.

Bar chart of the frequency percentage of violence and aggression against nurses.

Concerning the reaction to physical violence, in most cases (18 out of 57 [31.6%] nurses who reported experiencing physical violence), the nurse requested that the person stop his or her behavior and did not ask for help from any other individual. In cases of verbal violence, the nurses have largely shown no reaction (57 out of 84 [67.6%] nurses who reported verbal violence), and the most frequent reaction against racial violence (6 out of 12 [50%]) has been discussing it with their own colleagues. The nurses have shown no reaction against coercion or mentioned it to colleagues or family members, and in three cases of desecration, legal proceedings have been undertaken (Table 2).

Table 2.

Reaction of Nurses in the Face of Violence.

Nurse Reaction	Physical (n = 57)	Verbal Abuse (n = 84)	Racial Abuse (n = 12)	Bullying and Mobbing (n = 91)	Sexual (n = 3)
No action was done	5 (8.8)	57 (67.6)	5 (41.7)	46 (50.5)	0 (0)
The person wanted to stop trespassing	18 (31.6)	13 (15.5)	4 (33.3)	14 (15.4)	0 (0)
I talked about it with my family/friends	2 (3.6)	8 (9.5)	4 (33.3)	36 (39.6)	0 (0)
I talked about it to my colleagues	4 (7)	16 (19)	6 (50)	38 (41.7)	0 (0)
I referred to another	0 (0)	5 (5.9)	0 (0)	0 (0)	0 (0)
The Association asked for help	4 (7)	0 (0)	0 (0)	0 (0)	0 (0)
I claim compensation	0 (0)	0 (0)	0 (0)	0 (0)	0 (0)
I tried to pretend that nothing was happened	4 (7)	10 (11.9)	3 (25)	23 (25.3)	0 (0)
I tried to defend myself physically	8 (14)	0 (0)	0 (0)	0 (0)	0 (0)
I went to seek advice	3 (5.3)	16 (19)	2 (16.7)	18 (19.8)	0 (0)
I reported to the higher authorities	8 (14)	8 (9.5)	0 (0)	0 (0)	0 (0)
I complained compensation	1 (1.7)	0 (0)	0 (0)	0 (0)	3 (100)

Data shown are n (%) values; each nurse may show more than one reaction in the face of violence.

The study of factors affecting prevalence of violence showed that physical and verbal violence, coercion and menace, and desecration have been more evidenced in females, and racial violence has been more prevalent in males who are perpetrators of the violence. Statistically, the gender of nurse has just had a significant role in racial violence (p < .05). Age and working experience have been effective in dividing up types of violence except for racial violence (p > .05) such that the nurses of age above 50 years with more than 15 years of working experience have had the least confrontations and 30- to 39-year-old nurses with working experience of 1 to 5 years have been confronted with the most violence (p < .05). On the contrary, nurses of age below 50 years with working experience of 8 to 20 years have been confronted with physical violence, verbal violence, and menace and coercion (p < .05). And finally, the racial status of nurses has not had a role in the emergence of violence (p > .05) except for racial violence where all nurses were of racial minorities (p < .05; Table 3).

Table 3.

Demographic Factors of Nurses in Terms of Any Type of Violence.

Factors	Physical	p	Verbal Abuse	p	Racial Abuse	p	Bullying and Mobbing	p	Sexual	p
Sex
Male	10 (17.5)	.666	18 (21.4)	.004	9 (75)	.005	27 (29.7)	.511	1 (33.3)	.132
Female	47 (82.5)	.666	66 (78.6)	.004	3 (25)	.005	64 (70.3)	.511	2 (66.7)	.132
Age (years)
20-29	18 (31.6)	.018	19 (22.6)	.021	4 (33.3)	.568	19 (20.9)	.032	2 (66.7)	.887
30-39	35 (61.4)		53 (63.1)		3 (25)		54 (59.3)		1 (33.3)
40-49	4 (7)		11 (13.1)		4 (33.3)		16 (17.6)		0 (0)
50-59	0 (0)		1 (1.2)		1 (8.3)		2 (2.2)		0 (0)
Work experience (years)
<1	2 (3.5)	.536	3 (3.6)	.782	2 (16.7)	.556	3 (3.3)	.431	1 (33.3)	.801
1-5	36 (63.1)			46 (54.8)		1 (8.3)		46 (50.5)	2 (66.7)
6-10	11 (19.3)			20 (23.8)		2 (16.7)		21 (23.1)	0 (0)
11-15	7 (12.3)			7 (8.3)		3 (25)		9 (9.9)	0 (0)
16-20	1 (1.8)			5 (5.9)		3 (25)		8 (8.8)	0 (0)
>20	0 (0)			3 (3.6)		1 (8.3)		4 (4.4)	0 (0)
Night shift^a
Yes	52 (91.2)	.003	84 (100)	<.001	5 (41.7)	.874	83 (91.2)	.003	3 (100)	<.001
No	5 (8.8)	.003	0 (0)	<.001	7 (58.3)	.874	8 (8.8)	.003	0 (0)	<.001
Racial status
Racial minorities	15 (26.4)	.098	28 (33.3)	.189	12 (100)	<.001	26 (28.6)	.167	1 (33.3)	.132
The majority of racial	42 (73.7)	.098	56 (66.7)	.189	0 (0)	<.001	65 (71.4)	.167	2 (66.7)	.132

Note. Data are n (%) values, and chi-square and Fisher’s exact test have been used.

Working hours 20:00 p.m. to 8:00 a.m. of the next day.

Discussion

According to the results of this study, all nurses faced mental (or psychological) violence, as the most violence was related to intimidation and bullying (91%), verbal violence (84%), and physical violence (57%).

In line with this study, in many studies, verbal and physical violence had the highest incidence (Gates et al., 2011; Kamchuchat et al., 2008; Kennedy, 2005; Talas et al., 2011). For example, in a study conducted in America (Gates, Ross, & McQueen, 2006), physical violence against nurses was 67%; in Thailand, verbal violence was 45.9% and physical violence was 4.6% (Kamchuchat et al., 2008). In Iran, Tehran, Qodsbin et al. (2009) reported physical violence being 9.1% and verbal violence being 72.7%, whereas Zamanzadeh, Soleimannejad, and Abdollahzadeh (2009) found verbal violence to be the highest and sexual violence to be the lowest forms of violence against nurses. So, it seems that physical violence is almost always accompanied by or occurs after verbal violence. In other words, mental violence is more prevalent than physical violence, but it is one of the physical violence risk factors. Because of lower rates of report, these incidents, which serve as warning signs of future physical violence, go unchecked.

In many past studies, the majority of verbal and physical violence was from patients and their relatives, and the largest number of assailants in ethnic and sexual violence was related to doctors and nurses (Henderson, 2003; Jackson, Clare, & Mannix, 2002; Zamanzadeh et al., 2009). This research is in alignment with the past research. The present study showed that the most violence was committed by patients and their relatives. Ethnic violence, on the contrary, was most commonly attributed to doctors and medical staff.

The high levels of violence caused by patients can on one hand be due to their health condition and illness, and on the other hand be due to the lack of active participation by the patient’s family and relatives. The family members and relatives may also be more likely to be violent to the nurse because of poor mental state, stress, and concern for the patient.

It seems inappropriate that the atmosphere in the hospital may affect the personnel so that they are also humiliated and insulted by their supervisors or coworkers—as evidenced in scenarios where colleagues are seen as competitors (not peers seeking to work with each other to resolve the patients’ problems).

For example, verbal abuse in this study occurred between personnel in terms of ethnicity and race, which could have a negative impact on hospital efficiency over time. For nurses, in addition to the many confrontations they face with patients and their relatives, they will be frustrated by dealing with and socializing with their colleagues, leading to a reduction in their enthusiasm and diminishing their desire to serve their patients due to burnout. Studies on the causes of violence against nurses and hospital personnel by coworkers are needed to root out this issue and extinguish the predisposing factors. Teambuilding activities and sensitivity training courses could improve the working environment, supporting workers to better interact with each other so that they are able to serve together in a friendly environment and better tolerate patient problems. Furthermore, appropriate management methods and the promotion of coordination between different hospital units can significantly reduce the incidence of stress and violence in hospitals (Evers, Tomic, & Brouwers, 2002).

In this study, the most common reactions of nurses against any type of violence were inviting the offender to calm down in physical violence; lack of response in verbal, intimidation, and bullying violence; talking to colleagues and family in ethnic violence; and dealing decisively and legal prosecution in sexual violence (violation of chastity). Perhaps, as in many other studies (Gates et al., 2011; Gates et al., 2006; Kamchuchat et al., 2008; Kennedy, 2005; Qodsbin et al., 2009; Talas et al., 2011; Zamanzadeh et al., 2009), as violence results in injury only in limited cases, the staff consider occupational violence as part of their job and accept this amount of violence in their work area, and only a violation of chastity has been seen as an unbearable problem for nurses. Nurses may also neglect reporting violence due to the lack of appropriate feedback (e.g., responding to it by blaming the nurse, etc.) and the lack of clear and explicit instructions on how to handle incidents of violence.

Assessing the factors affecting violence, gender had a significant correlation with verbal violence, intimidation, bullying, and ethnic violence (p < .05). In verbal violence, intimidation, and bullying the females and in ethnic violence the males experienced the most frequent incidence. Physical violence was experienced by female nurses more frequently than male nurses, which was not statistically significant (p > .05). Other studies have also found that in all hospital wards, female nurses were victims of violence more than males (Ghasemi et al., 2009; Henderson, 2003; Jackson et al., 2002). But also contrary to the present study, many studies have shown that violence against male nurses occurs more frequently than against women (McKenna, Poole, Smith, Coverdale, & Gale, 2003; Mozafari, & Tavan, 2013; Talas et al., 2011). Perhaps one of the causes of violence against women nurses in certain countries is that there is a higher density of female nurses compared with male nurses within the field of nursing because the nursing profession is more accessible to women.

Also in this study, the most probable age and work experience of nurses in the face of physical, verbal, and intimidation and bullying violence is 30 to 39 years and 1 to 5 years, respectively (p < .05). Of course, in cases such as ethnic violence and chastity violation, age and experience had no significant impact (p > .05). In New Zealand, one third of nurses were physically attacked in their first year of work (Samir, Mohamed, Moustafa, & Abou Saif, 2012). Most studies also believe that younger people with less work experience have more experience of direct confrontation with violence (Gates et al., 2011; Ghasemi et al., 2009; McKenna et al., 2003; Mozafari, & Tavan, 2013; Talas et al., 2011).

Moreover, the majority of nurses with work shifts of 8:00 a.m. to 8:00 p.m. experienced more than 50% of the violence; work shift had no significant effect in relation to sexual and ethnic violence (p > .05). But physical, verbal, intimidation, and bullying violence during the night shift were considerably higher than other shifts (p < .05). In this regard, some research findings showed more violence during night shifts (Balamurugan, Jose, & Nandakumar, 2012; Estryn-Behar et al., 2008; McCall & Horwitz, 2004). The racial status of nurses was not an effective indicator of the type of violence experienced, except for ethnic violence (p > .05). In other words, all nurses facing ethnic violence were of Turk or Lor ethnic minorities (p < .05); in this regard, no study has examined the role of nurse’s race in the face of violence.

Regarding the high levels of violence against nurses in this study, to promote the physical and mental health of nurses and patients, as well as support the relaxation, motivation, and enthusiasm of the medical staff, it is suggested to improve the work environment, increase human resources, and provide the necessary facilities for nurses to report incidents of workplace violence. Considering continuous and in-service training programs for the medical team to apply different and effective methods to cope with violence and its agents are recommended. Training novice nurses, providing clear training in violence identification and prevention to nursing students, providing a safe work environment, supporting personnel, using containment and isolation rooms for aggressive patients, offering counseling to the victim, providing a sufficient number of personnel to prevent violence, developing and training staff on the process for suing and reporting violence, and providing medical or mental care for the victim if required are other means of preventing violence (Longo, 2010).

Conclusion

According to the results, all nurses were faced with violence during their working years and intimidation and bullying violence are usually the first acts of violence to take place, with the patient being the primary agent of violence. The lack of reaction or response by the nurse whether in controlling the patients or talking to their colleagues was the most common reaction of nurses confronting these incidents of violence. Factors such as gender, age, work experience, and nursing shifts are shown to play important roles in violence.

Footnotes

Acknowledgements

The authors thank all the nurses in Shahrekord who cooperated in the implementation of this study.

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.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Sahar Dehghan-Chaloshtari, MSc, is a nurse working at a public hospital in shahrekord, Iran. Her main field of interest is research on the problems of nurses and medical staff in the hospital.

Arash Ghodousi, MD, associate professor, Forensic Medicine Specialist, works in the Department of Nursing and Forensic Medicine Research Center, Isfahan (Khorasgan) Branch, Islamic Azad University. His main field of interest is domestic violence and human identification.

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