Workplace violence against nurses in three different Greek healthcare settings

1 Introduction

Workplace violence (WPV) is prevalent around the world and between 8% and 38% of healthcare workers suffer physical violence at some point in their careers [1]. Among healthcare workers, nurses are at highest risk [1]. A number of studies have reported high rates of WPV against nurses [2–5]. Zampieron et al. reported that 49.4% of the participating nurses had experienced aggression in the last year [5]. Verbal violence is the predominant type of WPV, but physical violence is not a negligible type either [2, 5]. In the Minnesota Nurses’ Study the adjusted rates per 100 persons per year (95% CI) for physical and non-physical violence were 13.2 (12.2 to 14.3) and 38.8 (37.4 to 40.4) [2]. Furthermore Kamchuchat et al. reported that the 12-month prevalence of violence experience was 38.9% for verbal abuse and 3.1% for physical abuse [6]. Predominantly patients and their relatives are the perpetrators of verbal (51.9% – 67%) and physical violence (88.2% – 97%) against nursing staff [2, 6]. Furthermore it is reported that worker-on worker violence among hospital employees is not unusual with the majority (87%) of worker-on-worker incidents involving nonphysical conflict [7]. In case of sexual harassment against nurses, Kamchuchat et al. reported that three out of four cases were committed by co-workers [6].

WPV adversely affects the nurses’ psychological well-being, even up to one year after the violent incident [2, 5]. Moreover WPV has been related to adverse patient outcomes through unstable or negative qualities of the working environment [8]. Despite the high prevalence and the negative consequences of WPV, the reporting rates of violent incidents by the nurses remain suboptimal [5, 9].

Unfortunately, there are no studies in literature exploring WPV against nurses in any Greek healthcare facility. The current study represents the first attempt. The aim of this study was to assess the prevalence and the characteristics of workplace violence (WPV) encountered by nurses working in three different healthcare settings, in Greece.

2 Methods

This was a cross-sectional study, conducted in a tertiary hospital, a non-tertiary hospital and a health center. We used a convenience sampling method and our research tool was an anonymous self-completed questionnaire (available as a supplementary material). The research protocol was approved by the Committee of Research, Ethics and Deontology and the Scientific Board of the University General Hospital of Patras.

This study followed the study completed in the tertiary facility [10]. However the present study focuses on nurses and expands the research to include two more healthcare settings; namely a non-tertiary district hospital and a healthcare center. A novel questionnaire was created based on the one by the International Labour Office, the International Council of Nurses, the World Health Organization and Public Services International, while elements from other relevant studies were also included [10]. To assist the personnel in understanding the terms associated with psychological and physical violence, we translated the relevant definitions given by the World Health Organization and incorporated them into the questionnaire (10). The items were adjusted to better align with the conditions and social culture in Greek workplaces, while a pilot pre-test was performed in order to correct any ambiguities [10]. Four of the questions used a Likert response scale, but most of them required a single answer or potentially multiple answers (10).

During March to May 2013, the self-report questionnaire was distributed by the research team and completed by every eligible nurse; the participants were informed about the purposes of the study and the confidentiality and anonymity of their data. The statistical analysis was performed with SPSS 17.0 (SPSS, Chicago, IL). Correlation of each answer to age, gender, age group, healthcare setting, working experience in general and working experience in the current workplace, was assessed by multinomial logistic regression.

3 Results

Of the 120 nurses invited to participate, 80 completed the questionnaire (response rate 67%). Demographically, 53.8% of the participants belonged to the age group of 40–49 years old, 83.3% were women, 47.5% worked in a tertiary hospital, 31.3% in a non-tertiary hospital and 11.3% in a healthcare center. The mean (±standard deviation) years of work experience in general and in the particular healthcare facility were 16.5±7.6 years and 11.1±8 years respectively. Multinomial logistic regression models revealed no significant associations between each answer and the examined variables of age, gender, age group, healthcare setting, working experience in general and working experience in the current workplace. The only exception was for the question: “Have you been subjected to WPV in the last year?”, which will be explained later. Furthermore, the most frequent reasons indicated by the nurses for not participating to the study were frustration about the fact that the results of the study will not change the present situation and believing that it will be no useful.

4 Conclusions

A high prevalence of WPV was revealed, especially verbal, among nurses working in different Greek healthcare settings. The majority of the participants had experienced WPV in general (76.3%) and in the last year (78.7%). These results are higher than those reported in a study conducted in a university and a general hospital, where 49.4% of the participating nurses reported an episode of aggression in the previous year [5]. Pai et al. reported that the prevalence of verbal abuse, physical violence and sexual harassment in a randomly selected sample from the Taiwan Nurses Association registry was 51.4% , 19.6% and 12.9% respectively [3]. The findings of the present study concerning physical violence (19.7%) and sexual harassment (15%) are in accordance with the results of Pai et al. However the prevalence of verbal violence was remarkably higher (98.3%).

In this study, greater work experience and being male correlated with lower WPV incidence. It has been suggested that senior staff is less likely to be victims of internal physical assault and external threat of assault, while the observed differences between male and female nurses may relate to the differences in exposures [2, 4]. However, violent incidents early in nurses’ careers are particularly problematic as nurses can become disillusioned with their profession [11]. In contrast to other studies, our results indicated patients’ relatives and friends as the most common perpetrators of WPV [2, 3]. This may be in part due to the patient’s current physical state, often being physically unable to engage in violent incidents. Interestingly, and in concordance with previous studies, almost four out of ten nurses reported a colleague as perpetrator [3, 6]. It is reported that co-worker violence threatens the well-being of hospital employees and therefore it should be regularly tracked with other forms of workplace violence [7].

Verbal abuse is the commonest type of WPV and it has been reported that the consequences of non-physical violence may be more severe than for physical violence, thus the effects of non-physical violence must not be neglected [2]. In this study, anger, stress, disappointment, fear and diminished quality of life were the most frequent emotional consequences of WPV reported by the nurses. Furthermore the frequent reporting loss of job satisfaction, wishing for a workplace change or poor work performance after a violent incident was a disturbing finding. Our results are in agreement with previous studies, where findings like poor relationships with colleagues and family members, quitting their jobs, or intention to leave the present position after the violent incidents also represented major concerns [2, 8].

However, it is reported that the minority of nurses ask for help after an episode of WPV, while workplaces with an absence of formal procedures for patient and visitor violence have been associated with a higher risk for WPV [5, 12]. In the present study, the majority of the nurses reported the violent incident to the hospital authorities. However, the support provided by the authorities appeared to be unsatisfactory. Furthermore, the majority of the participants who had experienced violent incidents stated that they feel lack of safety in their workplace. Nevertheless priority should be given to the development of a human-centred workplace culture based on safety and dignity, non-discrimination, tolerance, equal opportunity and cooperation [13]. The widely expressed opinion by the nurses that long waiting time and insufficient staff are possible causes of WPV might reflect a role of the ongoing financial crisis in Greece, since personnel hiring is reduced. The suggested measures of prevention reflect the deficiencies of the healthcare system. Therefore, eliciting nurses’ opinion about the causes and measures for prevention of WPV appeared appealing, since this may lead to the optimal decision-making by the respective healthcare facility’s authorities.

There are several limitations of this study. First of all, the sample size is small and the convenience sampling method used cannot allow generalization of the results. Moreover, the retrospective nature of the study and the fact that there are no formal procedures of recording WPV events in the studied healthcare facilities did not allow for checking the credibility of the reported data.

Nevertheless, the findings of this study strongly suggest the need for focusing on WPV across different healthcare settings. Unfortunately, in our country there is a lack of guidelines and a low rate of formal recording of violent incidents. This might be the reason why many nurses might consider WPV as “part of the job”. Although taking a sick leave after a violent incident seemed to be an exception, the quality of services provided in general by victimized individuals should be further examined. It is vital to work towards reducing WPV by exploring the causes and applying preventive measures. However, those causes may vary among health units and different cultures. Therefore, country and unit-specific studies, which will account for the nurses’ opinion, may provide a more comprehensive transcultural picture of the perceived WPV etiology and guide the implementation of the appropriate interventions at an international level.

5 Aknowledgements

We thank all participating nurses for their precious time.