The epidemic of workplace violence against nurses: a narrative review

INTRODUCTION

Nurses enter the profession with the hope of finding great job opportunities, a decent pay scale, and a sense of serving society. However, they are often less aware of the hidden side of nursing, such as the violence they may face in the workplace. We will start this paper by sharing some information you might already know, but it's important to understand how severe and widespread the current violence against nurses has become.

Violence against nurses is a global issue affecting nearly every country, making an already tough job even harder.¹ The United States records approximately 900 deaths and 1.7 million incidents of WPV annually and 74% of these incidents occur in healthcare settings.² Nurses are the primary victims in WPV in healthcare settings.³ The WHO reported that globally 8-38% of nurses face some form of violence in their careers.⁴

WPV affect to healthcare professionals five times more than in other jobs, but there is not a single agreed-upon definition for it.⁵ WPV was described by the WHO as incidents where employees are abused, threatened, assaulted, or subject to other offensive acts or behaviors in circumstances related to their work.⁴

Any form of WPV is unacceptable. It's crucial to identify essential interventions to prevent violence and creating a safe work environment for healthcare workers, including nurses.

LITERATURE SEARCH

A comprehensive literature search was conducted to examine the characteristics, risk factors, and mitigation strategies for WPV against nurses. The electronic databases PubMed, Scopus and Google Scholar was utilized to searched. The combination of keywords such as "nurses," "workplace violence," "health care," "female profession," and "emergency department. Articles published in English language between 1995 and 2023 were identified and included in the study. The findings were combined into a narrative review. Both quantitative and qualitative studies focusing on violence or aggression against nurses were considered eligible. The researchers cross-checked data and held multiple meetings to resolve any disagreements or discrepancies. In total, over 130 articles were initially screened based on the search strategy across PubMed and Scopus, with 61 articles selected after removing duplicates. Ultimately, 37 of these articles were included in the review.

THE GLOBAL AND LOCAL IMPACT OF WPV

Nurses are the majority of health care professionals constitute 50% of the global healthcare workforce, totaling approximately 29 million nurses worldwide.⁵ Indian nurses make up a significant proportion of 2.34 million among their total healthcare workforce of 5.76 million.⁶ An Indian study reported approximately 87% of nurses have experienced some form of WPV during their careers.⁷

Nowadays acts of violence against nurses appear to have become increasingly common.⁸ A study from Taiwan estimated the prevalence of WPV against nurses varies widely, ranging from 24.7% to 88.9%.⁹ Similarly Italian hospitals reported frequent WPV against nurses (67%).¹⁰ Another study from Ethiopia shows that 51.4% of nurses have faced incidents of WPV.¹¹ A study from China reported WPV against nurses was 46% likewise, a study from Australia revealed 60% of nurses experiencing some form of violence in the past year.^12,13 According to the international labor office (ILO) report nurses faced more violence than other health care workers.¹⁴ Nurses provide direct care to individuals experiencing serious traumas, life-threatening events, and infectious diseases. Despite their critical role, they often face unprovoked attacks.⁷

DIFFERENT FORMS OF VIOLENCE

WPV is primarily divided into two categories verbal and physical violence.4 The majority of nurses experience verbal violence, which includes threats, heated arguments personal comments, aggression, abusive language, obscene gestures, bullying, and intimidation.¹¹

Verbal abuse is identified as the most common form of violence.¹⁵ Despite the fact that verbal abuse does not cause physical harm, the emotional scars can last a long time, damaging the victim's confidence and dignity.⁴ A study conducted by Mishra et al revealed that 97% of nurses in India have experienced verbal abuse.¹⁶ Additionally, international studies consistently identify verbal abuse as the most prevalent form of WPV.^11,12,14 A systematic review and meta-analysis study reported that verbal abuse (57.6%) is the most common form of nonphysical violence among nurses.⁹ Studies from Melbourne, Southeast Queensland, and New South Wales indicate that 60-90% of nurses frequently experience verbal abuse at work.¹⁷

Secondly direct attack such as hitting, holding, twisting arms or necks, stabbing, kicking, slapping, and even fatal incidents are all considered forms of physic al violence.^8,9 According to a study by Byon et al on workplace health and safety, 44.4% of nurses had ever experienced physical aggression whether with or without weapons.¹⁸

A systematic review reported that 24.4% of nurses experienced physical violence in the past year.¹⁹ Another study from Jordan reported that 52.8% of nurses were physically attacked, with 26.5% of these incidents involving a weapon.²⁰ WPV is a significant concern in every country, with unique contributing factors such as local law enforcement practices, socioeconomic and behavioral characteristics, government policies, and the intention to take action. How these incidents are handled afterward is crucial in preventing such crimes.

UNDER-REPORTING OF WPV

The trend of violence against nurses is growing dangerously. Surprisingly, more than 80% of WPV incidents among nurses are not formally reported.²¹ Under-reporting of WPV remains a global issue in the nursing profession.¹⁸ A survey from Slovenia shows formal written reports of violence by nurses ranged from just 6.5% to 10.9%. ²² A similar pattern was observed in Israel, where nearly 72% of nurses experienced violent incidents, but only 26.6% filed formal written reports and that also in physical violence cases.²³ Whereas an Indian study found that while 74.6% of violent incidents were reported verbally, only 15.4% were formally reported.²⁴

Barriers to reporting violence

Globally over 70% of incidents of WPV against nurses go unreported.^19,23 In most cases nurses are reluctant to report the incidents, often considering them a part of their daily work life.¹⁶ The lack of support from supervisors and colleagues, fear of being blamed, and lack of support from management discourage their reporting behavior.^3,4 Nurses feel reporting would not change anything but a waste of time. Moreover, those who speak out about such incidents in public or in the media are sometimes reprimanded or even fired by management.¹⁵ Nurses are more likely to formally report violence if they are physically hurt or if they receive support from colleagues and management.²⁵

The nursing profession, known for its nature of caring, and empathy, often supports a culture of tolerance that endures verbal abuse, rather than reporting them.⁷ Motivating nurses to report all incidences of violence could avoid future mishaps and can help to get a better idea about the real magnitude of the problem.

FACTORS CONTRIBUTING TO VIOLENCE AGAINST NURSES

As professionals, nurses take on various responsibilities, including but not limited to being caregivers, researchers, and instructors. They are more exposed to violence because they directly communicate with patients and their families while providing care.⁹ However, the public often perceives nurses as attending to patient’s needs and following instructions by doctors rather than as independent profession.²⁶ This perception of a lower-status role contributes to factors that make nurses more vulnerable to violence.

Patient-related factors

Studies have identified patients and their attendants, particularly partners and siblings, as the primary sources of WPV.^16,21,22 A study conducted by Spector et al found that 90% of violent behavior originated from patients and their families.²⁷ The American nurses association reported that about 25% of nurses experience physical assaults by patients and their families, while over 50% are subjected to verbal abuse.²⁸

Incidents are more common among patients with mental health disorders, those under the influence of substances, or suffering from chronic illnesses. Unrealistic expectations from patient’s family about personalized care, along with a lack of information about patient’s conditions and hospital visiting hours, contribute to aggressive reactions toward nurses.

The attitudes and behaviors of patients and their families, influenced by their socioeconomic and political positions, often lead to conflicts with hospital staff. Cultural or language barriers further increase the risk.¹⁶

Organizational factors

Most studies identified patients and their families as the primary perpetrators of violence against nurses. However, WPV also involves colleagues, supervisors, fellow nurses, and doctors as perpetrators.^7,10 A study conducted by Banda et al reported that 43% of perpetrators of violence against nurses were fellow nurses, doctors, and other health professionals.²⁹

Another study from Iran reported that 46.1% of violent acts against nurses were perpetrated by colleagues, seniors, and doctors.³⁰ Conflicts among nurses and other team members primarily stem from disagreements over work responsibilities, treatment decisions, and authority, which contribute to aggression and violence.²⁹ Studies have observed that doctors sometimes seen aggressive against nurses to assert their hierarchical power, pressurizing them to comply with established norms by misusing their authority. Generally, unequal power dynamics contribute to violence against nurses.³¹

Institutional shortcomings

The institute's operational management practices are crucial for ensuring a safe and violence-free work environment.¹² Shortage of experienced nurses, delay in treatment, and long waiting times for patient admission contribute to violent incidents.²³ Overcrowding is also a worsening issue, especially in tertiary care centers with limited resources, leading to patient frustration and outbursts of anger.⁹ Nurses are under paid member of health care team. Low pay enumerations affect new recruitment and deficiency of skilled nurses.

Professional factors

Professional factors, such as nurse’s experience, age, and communication skills, contribute to the risk of violence.²² Studies indicate that younger, less experienced nurses are more vulnerable to such incidents possibly due to a lower threshold for tolerance.³² Demographic factors, including the profession's female-dominated nature, and shift duties, especially night shifts, are significant predictors of risk.²⁰

Power of communication

Good communication is an essential factor in conflict management. Informing patient’s health status and progress on time can avoid any unwanted confusion and arguments. Violence is more likely to occur if the families are not being informed about prognosis and outcomes do not meet their expectations.²³ When nurses communicate poorly or use harsh language, patients and their families might use violence in frustration and emotional response.³³

Moreover, it has been observed that when nurses on rotating shifts take short breaks for tea or food, it is often perceived by the patient’s family as negligence and lack of concern.²⁷

Organizational attitude

Patients are clients of hospitals and contribute to their revenue. In case violence happens, management often prioritizes calming the patient rather than supporting their employees. This makes healthcare workers lose trust in management and fear being blamed. The study also found that organizations often ignore to acknowledge reports of verbal abuse, which contributes to the problem's ongoing nature.^24,26

Being a female profession

In India, female nurses are commonly called "SISTER," a term that shows respect and politeness. However, in recent years, especially during the COVID-19 pandemic, this respect has decreased, and incidents of violence against female nurses have risen compared to male nurses.¹

Globally, 67% of the health workforce is women, compared to 41% in all other job sectors.³⁴ Globally approximately 30 million are nurses and the majority of these nurses (76.91%,) are female.³⁵ In India, out of 5.76 million health workers, 2.34 million are nurses, and two-thirds of these nurses are women.³⁶

An Iranian study reported that over 90% of female nurses experienced WPV.³⁷ Nursing is a predominantly female profession, which contributes to the higher rates of violence in today’s patriarchal society. Female nurses, working under difficult and high-risk conditions, face serious threats of violence, including physical assaults.

VIOLENCE RISK AREAS OF THE HOSPITAL

Violence incidence is more common in acute and critical care units like the emergency, ICU, pediatrics, and psychiatry units.⁹ The emergency department nurses are expected to act quickly and accurately, with no time for delays. Patients often come in with pain, suffering, and sometimes economic hardships, and they direct their aggression toward nurses. The risk of violence in emergency units is between 56-75.8%.¹⁰ A survey study from the USA reported that 25% of nurses posted in emergency units face physical violence in a year.²⁸ The nurses working in emergency units are the first line of contact with patients and their families. Italy reported that 86% of WPV cases against nurses occur in psychiatry departments and 71% in emergency units, marking these areas as high-risk for nurses when dealing with patients and their families.¹⁰

In psychiatric departments, violence is seen as inevitable.²⁴ Patients in these units may experience pain, be under the influence of drugs and feel powerless with no proper way to express their emotions.¹¹ This anger and frustration is often directed at nurses through verbal abuse or physical violence.

IMPACT OF VIOLENCE ON NURSES

WPV has become the new normal for nurses, significantly impacting their physical and mental health, as well as their ability to work effectively. Early signs of the long-term effects of violence include headaches, poor sleep, mood disorders, and burnout.¹⁹

This phenomenon of WPV against nurses is a serious concern adversely affecting their self-confidence and instills fear in them, resulting in poor performance, absenteeism, and low self-esteem.³⁵

A study from Jordan found that violence and abuse are causing nurses to consider leaving their jobs and affecting the quality of their work.³⁶ Similarly, another study from Turkey reported that over 87% of nurses exposed to WPV experienced decreased job satisfaction and increased errors at work.²⁰ WPV leads to a hostile work environment severely damaging the nursing profession in the long run.² The constant fear of violence causes stress, insomnia, and post-traumatic stress disorder among nurses.²⁸

DISCUSSION

Reducing violence creates a safer and more productive working environment for nurses impacting the workplace environment. Institutions should focus on addressing internal security and taking initiatives to address issues of nurses, and health care workers, especially in emergency departments that are more vulnerable to violent incidents.

This study is a preliminary narrative review of WPV against nurses summarized from high-quality, peer-reviewed research studies. The review incorporated limitations such as recall bias, sample size discrepancy, and study designs that affect the generalizability of findings. Variability in study methods and the non availability of universally accepted definitions of violence complicate findings. WPV against nurses is identified as a significant global issue requiring more rigorous research to develop effective prevention strategies. Despite the significant prevalence of WPV, there is insufficient research data available about nurses. Particularly in the Indian setting, there is very little research available, and the majority is from single centers. The review's findings offer valuable insights for policymakers, administrative and academics.

CONCLUSION

In the era of the twenty-first century where movements like “#me too” making headlines and creating awareness about working women’s rights and safety, nurses are too expecting reforms as maximum number of nurses. Violence in any form is unacceptable. It's crucial to identify areas requiring in-depth analysis and to provide appropriate solutions. Interventions to prevent or manage violence are essential for creating a safe work environment for healthcare workers, including nurses.

Recommendations

There is a strong need to adopt a zero-tolerance policy on WPV and tough legislation. The offenders should face immediate detention and heavy fines. Inadequate security arrangements lead to more violent incidents in hospitals. Early risk assessment and preventive measures like deploying sufficient security guards, using metal detectors at entrances, thoroughly checking individuals for weapons as they enter healthcare settings, and installing cameras for reporting violence are required.

Strategies should be implemented to avoid delays in admission to emergency and critical areas.

Nursing is always a challenging profession, and working with patients from diverse cultures and locations makes it even more difficult. Poor communication can further hinder nurse’s ability to explain things correctly to patients' families. Training of nurses in communication skills can be useful. There is a significant need for organizations to raise employees' awareness of hospital policies for reporting WPV incidents.

There is a need to create more awareness among the scientific community and policymakers about WPV. Studies have shown that measures taken by countries like Australia to ensure the safety of nurses have not been effective due to a lack of in-depth investigation into the issue.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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