Violence and unsafety in Italian hospitals: Experience and perceptions of nursing students

Abstract

BACKGROUND:

Assessment of workplace violence towards healthcare workers represents a challenge for healthcare organizations worldwide. Workers’ experience and perceived risk of violence may have a serious impact on job satisfaction and retention of workers. To date, no studies have been conducted on nursing students.

OBJECTIVES:

To assess the prevalence of physical and non-physical violence among nursing students during their clinical experiences and to analyze the perceived risk of violence.

METHODS:

Multicentre, cross-sectional survey. We enrolled a convenience sample of nursing students of the bachelor’s degree in Nursing of the University of Milan (Italy). The students completed a structured questionnaire prepared in accordance with the available literature on violence in healthcare settings.

RESULTS:

Out of 1185 questionnaires sent, 603 were collected (50.89%). 35.1% had experience of verbal violence during the clinical internship training period, while 8.1% were victims of physical violence. 202 students (33.5%) reported unsafety, which was related to experience of physical or psychological violence, witnessed episodes of violence, gender, hospital structure and efficacy of the safety policies.

CONCLUSIONS:

Our findings highlight that nursing students are exposed to the risk of violence which influences their perception of risk.

Keywords

Physical assault verbal assault feeling of unsafety

1 Introduction

Workplace violence has been defined by the National Institute of Occupational Safety and Health (NIOSH) as “any physical assault, threatening behavior, verbal abuse or any other criminal event that occurs in the workplace” [1]. It is a public health problem of seriousness importance and progressively expanding worldwide [2 –4].

In the specific case of violence against health workers, the aggressions are both physical and psychological. It is alarming that aggressive behavior performed by patients and/or their families is considered as part of the regular health professional load or is tolerated with acceptance, justifying the aggressive subject. Attacks during the work of healthcare personnel include physical and psychological violence,mobbing, bullying, racial harassment, sexual harassment, and any other type of abuse by senior colleagues, patient and their family members, visitors, and others [5]. The international literature emphasized how violence represents the main expression of insecurity in health care settings [6, 7], compromising the professionals’ health, particularly the nursing and medical categories [8, 9]. Among the consequences of physical, sexual and verbal abuses, there are also feelings of shock, disbelief, shame, guilt, anger, fear and sexual impotence that may result in anxiety and depression [10 –13]. Violent aggression can have destructive and negative impacts on those who attend the violent event, be it the victims and/or their relatives [14, 15]. In this case, violence against health care personnel can have a destructive impact on the care and safety of the patient. These manifestations may affect the worker’s perception of safety in the context of daily activities affecting job satisfaction, productivity, and involvement within the organization [16]. Moreover, an aggressive event can adversely affect the operator’s problem-solving skills and increase the risk of making a mistake or being distracted, because healthcare providers tend to pay less attention to aggressive patients.

Although the true dimensions of the phenomenon are difficult to be defined [17, 18], a recent systematic review and meta-analysis reported 61.9% rates of verbal violence in the past year and physical violence rates of 24.4% [19]. Many studies conducted in Italy already confirmed the prevalence of this phenomenon [13, 20] The perception of a safe environment is an important factor in job satisfaction, performance, and worker turnover [21]. Many studies investigated this complex phenomenon in the social context [22], highlighting how this can play an important role in the perception of well-being and health status of the population [23]. Recently, Terzoni et al. [5] showed how more than 50% of health care workers included in the study reported feeling of insecure about their personal safety in the context of their daily activities and how this feeling was related to the professional role. Among healthcare workers, nursing student spent more than 2000 hours/year of clinical internship in hospital. During this professional experience, also this healthcare categories may be victims of aggressive conduct, spectators or victims of violence’s episodes. However, to our knowledge, very few data are available [24] regarding the perception of their safety. The aim of this study was to investigate the prevalence of episodes of physical and non-physical violence suffered by the nursing student and their perception of safety in a universityHospital.

2 Methods

A cross-sectional study was conducted by the administration of a structured questionnaire to all students of the Bachelor of Science in Nursing of the University of Milan (UniMi), in Northern Italy.

The inclusion criteria were: being registered in the Bachelor of Science in Nursing during the academic year 2018/2019 and having at least one internship experience. The overall number of eligible participants was 1185 from the 16 degreee course in Nursing of UniMi.

The SurveyMonkey™ software was used to collect the questionnaire answers between 31 August to 30 September 2019. The questionnaire was similar to a previous one already published [5]. It was anonymous and self-administered, and it was adapted creating a tool consisting of 27 multiple-choice questions, prepared in accordance with the available literature on violence in healthcare settings. It was then composed by four sections with several items per section:

Section 1: (7 items) sociodemographic (gender, age) and academic characteristics (University centre, years, number of internship experiences), interest in the topic, training received.

Section 2: (13 items) personal experiences of violence (category, frequency, perpetrator, consequences, reporting, motivations to under reporting).

Section 3: (4 items) perception of unsafety (1 item); the remaining three were used to detail such information (Hospital perceived as unsafe regarding intrusions, vandalism, and lack of light).

Section 4: (3 items) efficacy of the safety policies adopted by the hospital management, intention to leave the academic course, impact of violence experience and unsafety on intention to leave.

Prior to the administration of the questionnaire, it was administered to five experts in the subject (three tutor nurse and nurse coordinator with experience in risk management) asking them how relevant each question was (on Likert scale 1- not relevant at all- to 10- very relevant). Based on the answers provided, we assessed the Content Validity Index of each item (CVI-I) and the Content Validity Index of the scale as a whole (CVI-S). The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement guideline was used for reporting of the research.

2.1 Ethics

Data were collected anonymously. The survey was conducted according to the principles of the Declaration of Helsinki and the current Italian law regarding data privacy. We complied with the rules of the local Ethical committee, which at the time of data collection did not require approval for educational studies on students. The coordinator of the bachelor’s degree course of the University of Milan and all the directors of the sixteen Nursing schools affiliated with the University approved the study.

The results of this survey will be presented according to the structure of the four sections of the tool.

2.2 Statistics

We analyzed the experiences of psychological and physical violence during clinical training, as well as the level of unsafety perceived, in relation to gender, age and number of experiences in training. Perceived safety was also studied in relation with previous education in this field, perceived effectiveness of the safety policies adopted by the hospital, episodes of direct (both physical and psychological) and indirect violence, perceptions regarding areas of poor lighting in the hospital, vandalism, and intrusions.

Normality was tested by the Shapiro-Wilk test. Normally distributed data are indicated as mean±SD, while median and interquartile range are used to report non-normally distributed variables. The Kolmogorov-Smirnov test was to assess data normality.

The associations between the feeling of unsafety or violence episodes and the single variables were evaluated by calculation of odds ratios and 95% confidence intervals. For all analyses, the significance level was set to 0.05. Analysis was conducted using SPSS®.

Post-hoc power analysis on our sample revealed an actual power of all statistical tests between 82% and 85%, which can be considered satisfactory.

3 Results

3.1 Validity of the tool

The CVI-S score obtained was 96.8%, indicating satisfactory content validity.

3.2 Sociodemographic and academic characteristics

Out of 1185 questionnaires sent, 603 were collected (50.89%). All 16 schools of nursing of University of Milan participated in the survey, with no significant differences in the response rates.

Most students were female (n = 464, 77.08%); mean age was 22±2 years; 187 students were in their first year of course, 183 in their second, and 233 in their third and final. All students had at least one internship experience at the time of the survey. The median number of clinical internship experiences was 3, IQR [3, 4].

Regarding the topic of violence and insecurity in health care, the majority of the sample (n = 472, 78.28%) reported received no specific education on the topic, while 101 had learned about violence during theoretical classes. 469 (77.78%) reported to be very interested, 81 (13.43%) to be rather interested and 53 (8.79%) considered the topic of minor interest for the profession.

3.2 Episodes of violence

322 students (53.40%) reported experiencing episodes of indirect victimization, such as witnessing or becoming aware of incidents of violence regarding other individuals during the various clinical internship experiences.

Regarding the student’s personal experiences during the clinical internship, 35.16% (n = 212) reported experiences of verbal aggression such as threats, intimidation, or bullying. Almost 40% were victims in more than one occasion.

The aggressor was primarily a patient (38.21%), followed by another healthcare professional (25.47%), a relative or visitor (20.28%), a non-healthcare professional (10.38%) and another student (5.66%).

166 victims never reported the incident despite 68.87% (n = 146) reported emotional consequences. The most common feeling was frustration (n = 50), anger (n = 44), fear (n = 32), and anxiety (n = 20). The main reasons for non-reporting the incident were the feeling of no matter (30.12%, n = 50), the idea that nothing would change (26.50%, n = 44) but also the fear of consequences on their academic path (25.30%, n = 42). 21 subjects motivated their choice not to report with the intent to defend for themselves. 9 did not motivated the behavior.

49 subjects (8.13%) affirmed to have experienced physical aggression during their internship experiences. Similar to verbal experiences, the perpetrator was primarily a patient (48.08%), followed by a relative or visitor (34.62%), another healthcare professional (5.77%), a non-healthcare professional (3.85%), and another student (3.85%). 2 did not report the category of the aggressor. In 75.0% (n = 39) of the events, the victim reported consequences, primarily emotional (fear n = 11, frustration n = 7, anger = 7, anxiety n = 5); 9 subjects reported physical consequences that did not, however, require health care. Also in this case under-reporting is confirmed: in 61.54 % (n = 32) of the situation students did not report the event; the reasons are in line with that emerged with respect to verbal violence (the incident was unimportant for 15 subjects, “nothing would change” for 9, fear of consequences for 8.

The number of experiences of victimization, both verbal and physical violence, is higher in third-year students as well as in the female gender (Table 1).

Table 1
Victims of psychological and physical violence

n Number of victims of psychological violence (%) Chi-square test p Number of victims of physical violence (%) Chi-square test p

Gender

Male 139 31(22.30%) 0.02 7 (5.06%) 0.040

Female 464 181 (39.01%) 42 (9.05%)

Year of course

1° 187 51 (27.27%) 0.009 6 (3.21%) 0.015

2° 183 64 (34.97%) 14 (7.65%)

3° 233 97 (41.63%) 29 (12.45%)

Total 603 212 49

	n	Number of victims of psychological violence (%)	Chi-square test p	Number of victims of physical violence (%)	Chi-square test p
Gender
Male	139	31(22.30%)	0.02	7 (5.06%)	0.040
Female	464	181 (39.01%)		42 (9.05%)
Year of course
1°	187	51 (27.27%)	0.009	6 (3.21%)	0.015
2°	183	64 (34.97%)		14 (7.65%)
3°	233	97 (41.63%)		29 (12.45%)
Total	603	212		49

Students with more than one internship experience had more episodes of violence, both physical (OR 0.5 [0.4–0.8], p = 0.015) and verbal (OR 0.7 [0.5–0.9], p = 0.018).

3.3 Perceived unsafety

202 students (33.50%) reported feelings of unsafety (“totally unsafe” or “not very safe”) during the clinical internship experience. Regarding hospital security where the internship experiences are conducted, 323 (53.57%) declared having seen vandalism, 311 (51.78%) darkness areas in the absence of light, and 400 (66.33%) frequent intrusion. 52.74% (n = 318) perceived the safety policies adopted by the hospital to protect workers and practitioners as “un-effective”.

Perception of unsafety was related to female gender, witnessing vandalism, intrusion or hospital areas with poor light, having seen episodes of violence and personal experience of violence (Table 2). Age, year of study course, classroom education and number of clinical experiences, were not significantly related to unsafety (p > 0.05 for all variables).

Table 2
Perception of unsafety

Variable p % feeling unsafe (n) OR [95% CI]

Having seen episodes of violence <0.001 YES n = 322 46.89 (151) 4.9[3.1;6.9]

NO n = 281 18.15 (51)

Having received psychological violence <0.001 YES n = 212 46.23 (212) 7.2[5.8;8.5]

NO n = 391 26.60 (104)

Having received physical violence <0.001 YES n = 49 69.39 (34) 4.5[3.6;5.3]

NO n = 554 30.32 (168)

Having seen vandalism 0.010 YES n = 323 39.94 (129) 1.8[1.0;2.9]

NO n = 280 26.07 (73)

Hospital perceived as unsafe: intrusions 0.010 YES n = 400 37.25 (149) 2.5[1.9;3.1]

NO n = 203 26.11 (53)

Ward perceived as unsafe: lack of light 0.031 YES 311 40.84 (127) 2.3[1.5;3.1]

NO 292 25.68 (75)

Efficacy of the safety policies 0.001 YES n = 318 28.62% (91) 1.9[1.5;2.3]

NO n = 285 38.95 (111)

Gender 0.001 Male n = 139 20.86 (29) 3.3[2.7;3.9]

Female n = 464 37.28(173)

Variable	p		% feeling unsafe (n)	OR [95% CI]
Having seen episodes of violence	<0.001	YES n = 322	46.89 (151)	4.9[3.1;6.9]
		NO n = 281	18.15 (51)
Having received psychological violence	<0.001	YES n = 212	46.23 (212)	7.2[5.8;8.5]
		NO n = 391	26.60 (104)
Having received physical violence	<0.001	YES n = 49	69.39 (34)	4.5[3.6;5.3]
		NO n = 554	30.32 (168)
Having seen vandalism	0.010	YES n = 323	39.94 (129)	1.8[1.0;2.9]
		NO n = 280	26.07 (73)
Hospital perceived as unsafe: intrusions	0.010	YES n = 400	37.25 (149)	2.5[1.9;3.1]
		NO n = 203	26.11 (53)
Ward perceived as unsafe: lack of light	0.031	YES 311	40.84 (127)	2.3[1.5;3.1]
		NO 292	25.68 (75)
Efficacy of the safety policies	0.001	YES n = 318	28.62% (91)	1.9[1.5;2.3]
		NO n = 285	38.95 (111)
Gender	0.001	Male n = 139	20.86 (29)	3.3[2.7;3.9]
		Female n = 464	37.28(173)

Finally, the level of motivation regarding the choice of academic career was investigated, as well as the influence of victimization and perceived feelings of insecurity on the intention to leave the academic career (Table 3).

Table 3

Impact of violence and unsafety on students’ perception

Would you re-enroll in a nursing degree?	n (%)	Does violence and feelings of unsafety influence your idea of leaving?	n (%)
Definitely NO	17 (2.82)	Definitely NO	39 (6.47)
Probably NO	130 (21.56)	Probably NO	132 (21.89)
Probably YES	190 (31.51)	Probably YES	192 (31.84)
Definitely YES	266 (44.11)	Definitely YES	240 (39.80)

4 Discussion

In Italy, unfortunately, the phenomenon of violence against healthcare professionals has recently caught attention and little research works on this issue are totally inadequate to describe in depth the size of the problem. Therefore, there is an evident need to extend the studies on the spread of violence against healthcare personnel, in order to deepen the characteristics of the risk factors and the consequences on their health and well-being, identifying forms of prevention and early intervention for the victims. In the present study, the prevalence of workplace violence, both verbal and physical, over the entire period of clinical practice, was similar to the data reported in literature on healthcare workers [25], in particular when compared to other Italian studies [26]. However, it is difficult to compare the results to each other because the studies were conducted in different clinical scenarios and the researchers did not clearly define and explain the concept of violence by using different methods of data collection.

The fact that the main perpetrator is a patient suggests even more the necessity to design within the academic training an intervention aimed at enabling the student to know how to prevent violent behavior. Methods such as the development of personal safety skills and de-escalation techniques, or institutional policies and environmental design, might be useful. Moreover, raising awareness of event reporting since the tendency to under report seems to be widespread even among the students.

It is not surprising that episodes of violence are more frequent among third-year students because this student category are required to attend departments with a high intensity of care and emotionality peculiar (such as Mental Health and Intensive Care Unit). Women have higher risk of both verbal and physical violence. However, our results did not highlight such gender difference.

The perception of a safe environment is a fundamental characteristic of individual and social well-being [27]. It is an important component of job satisfaction and job performance. An aggressive event can adversely affect the operator’s problem-solving skills and increase the risk of making a mistake or being distracted, because healthcare providers tend to pay less attention to aggressive patients. In our study almost one third of the sample felt unsafe during clinical internship. Factors associated with such perception were experiences of victimization, both direct and indirect, the perception of a safe hospital structure, the perception of the efficacy of the safety policies and gender. Women were found to be more unsafe than men, probably because they are more susceptible to victimization. The experience of unsafety can arise from a single episode or by the perception of working in an unsafe setting as suggested by the fact that the Course year and the number of internship experiences did not generated a significant difference. The role of the hospital management in creating a safety culture as been already pointed out [5]. These aspects deserve further investigation for developing a strategy that should include collaboration between healthcare workers and the forces of law and order.

Worryingly, almost a quarter of the students reported they would probably not sign up in the nursing degree program again. This data is comparable with the intention to leave the nursing profession [28] but seems alarming if reported by a sample of subjects who still have to finish their bachelor. Violence and the student’s perceived feelings of safety seem to be crucial factors influencing students’ choices.

Our study was limited to a single facility and we do not know the characteristics of the non responders, so the results do not necessarily reflect the whole Italian setting. However, our findings are similar to previous reported studies [29], and no evidence currently suggest that the situation might be different in other Italian hospital. Notwithstanding these limitations, our study conducted on a large sample indicates that the problem is real and suggests that prevention is essential needing both student education and management interventions.

5 Conclusion

This study can be a starting point for further developments on the topic, taking into consideration a larger reference sample. Indeed, in order to reduce and/or eliminate the phenomenon of violence against nursing students as compared to other healthcare staff and improving their safety and health [30], it is necessary to increase the studies on the phenomenon to further extend risk factors and to identify forms of prevention and early intervention in the sake of the victims.

Footnotes

Acknowledgments

The authors would like to thank all the students and the directors of the bachelor schools of nursing involved in the study.

Conflict of interest

The authors have no conflict of interest to report.

Funding

No funding was received for the study.

Author contributions

Conceptualization: PF, MM; Data curation: ST,PF; Formal analysis: ST, PF; Investigation: PF, ES; Methodology: ST, AD; Supervision: FR, AD; Roles/Writing - original draft: PF, MM; Writing - review & editing: ST.

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