Journal of Transcultural Nursing

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Physical Violence in the Workplace Among Jordanian Hospital Nurses Raeda Fawzi AbuAlRub and Ali Hasan Al-Asmar J Transcult Nurs 2011 22: 157 originally published online 10 February 2011 DOI: 10.1177/1043659610395769 The online version of this article can be found at: http://tcn.sagepub.com/content/22/2/157

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Physical Violence in the Workplace Among Jordanian Hospital Nurses

Journal of Transcultural Nursing 22(2) 157–165 © The Author(s) 2011 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043659610395769 http://tcn.sagepub.com

Raeda Fawzi AbuAlRub, PhD, RN1, and Ali Hasan Al-Asmar, MSN, RN2

Abstract Purpose: Lack of policies and assertive legislations on workplace violence has placed Jordanian nurses at frequent risk for workplace violence. The purposes of this research were to (a) investigate the level of physical violence and the complaints and responses of Jordanian hospital nurses to such violence and (b) describe workplace policies that deal with violence and recommend policy directions. Design: A descriptive exploratory survey was used to investigate physical workplace violence among a convenience sample of 420 Jordanian nurses. Data were collected by a self-administered questionnaire that was developed in 2003 by the International Labour Organization, International Council of Nurses, World Health Organization, and Public Services International. Results: The findings indicated that 22.5% of the participants were exposed to physical workplace violence. The contributing factors as indicated by the participants were related to the administration, staff, security, patients and families, and the public. Discussion/Conclusion: Participants who had experienced workplace violence were very dissatisfied with the manner in which the incidents were handled. Implications: It is important to investigate consequences of workplace violence on the satisfaction of employees and the quality of heath care service. Instituting appropriate policies and legislations would minimize workplace violence. Keywords physical violence, policies, nurses, Jordan, management, survey design, workplace violence

Introduction Violence is a universal problem that tears the structure of communities and threatens the well-being and happiness of all. Each year, more than 1.6 million people worldwide lose their lives because of violence and many more are injured and suffer from physical, sexual, and mental health problems (International Labour Organization [ILO], International Council of Nurses [ICN], World Health Organization [WHO], & Public Services International [PSI], 2002a). Interpersonal violence is the third leading cause of death for people aged 15 to 44 years worldwide, accounting for almost 14% of deaths among males and 7% of deaths among females (ILO, ICN, WHO, & PSI, 2002b). Workplace violence is defined as “incidents where staff are abused, threatened or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being or health” (ILO, ICN, WHO, & PSI, 2002a). Workplace violence including physical and psychological violence has dramatically gained attention in recent years and is now a priority concern in both developed and developing countries (Di Martino, 2002). Physical violence is the use of physical force against others that may result in physical, sexual, or psychological harm. Examples of physical violence are beating, kicking, slapping,

stabbing, shooting, pushing, and biting (Di Martino, 2002). Health care workers are known to be particularly at risk for workplace violence, with almost one quarter of all violent incidents at work occurring in this sector (Di Martino, 2002). According to the Bureau of Labor Statistics, health care and social service workers have the highest rate of nonfatal assault injuries in the workplace (U.S. Bureau of Labor Statistics, 2004). Although anyone working in a hospital may become a victim of violence, nurses and aides, who have the most direct contact with patients, are at higher risk (Centers for Disease Control and Prevention [CDC], 2002). Nurses are three times more likely to experience violence than other professionals (U.S. Bureau of Labor Statistics, 2004). Violence in the workplace negatively affects the moral of workers and increases stress, absenteeism, turnover, mistrust of administration, and hostility (CDC, 2002). Violence in the health sector threatens the delivery of effective patient services

1

Jordan University of Science and Technology, Irbid, Jordan Al Salt Hospital, Amman, Jordan

2

Corresponding Author: Raeda Fawzi AbuAlRub, College of Nursing, PO Box 1894, Jordan University of Science and Technology, Irbid, Jordan Email: [email protected]


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and patient safety. Equal access to primary health care will be threatened if health care workers have to abandon their profession because of the threat of violence (ILO, ICN, WHO, & PSI, 2002a). The International Council of Nurses indicates that governments fail to collect accurate data or information about the incidence rate of violence against nurses in health care settings, which is considered as the main reason for governments being unsuccessful in formulating sound policies to tackle the problem (International Council of Nurses, 2000). Jordanian nurses, like elsewhere in the world, suffer from workplace violence and its consequences. Lack of policies and assertive legislations on workplace violence has placed Jordanian nurses at frequent risk for workplace violence. Little research, if any, has been devoted to this issue in Jordan. This study provides implications to hospital and nursing administrators with regard to the level of physical workplace violence among Jordanian hospital nurses and the factors that may contribute to this problem. Thus, the purposes of the study are to (a) assess the level and frequency of physical violence among Jordanian hospital nurses, (b) explore the complaints and the reactions of nurses to such violence, (c) describe the policies and supportive interventions that exist in the workplace to deal with violence and recommend policy directions, and (d) identify the factors that contribute to the workplace violence and propose strategies to prevent them from the Jordanian nurses’ point of view.

Literature Review Sources, Contributing Factors, and Consequences of Physical Violence Physical violence in health care settings is more likely to occur in psychiatric settings, emergency rooms, waiting rooms, and geriatric units (CDC, 2002; Nolan, Soaresb, Dallendera, Thomsenc, & Arnetzd, 2001; O’Connell, Young, Brooks, Hutchings, & Lofthouse, 2000). The most common types of physical violence are grabbing, punching, pushing, pinching, scratching, kicking, and hitting with an object (Astrom et al., 2004; O’Connell et al., 2000). A descriptive study was conducted in Iraq to explore the incidence and frequency of physical violence among 116 Iraqi hospitals. The results indicated that 42.2% of nurses were exposed to physical violence and 14.3% of them were exposed to lethal weapons. About 65.3% of physical violence incidents were committed by patients’ family or relatives (AbuAlRub, Khalifa, & Habbib, 2007). In Kuwait, 7% of 5,876 nurses were exposed to physical violence and 10% had witnessed violent incidents (Adib, Al-Shatti, Kamal, ElGerges, & Al-Raqem, 2002). On the other hand, the results of a study conducted among a random sample of 300 nurses in the United Kingdom indicated that 9.1% of participants

were never exposed to physical violence, 57.6% was rarely exposed to physical violence, 31.6% was sometime exposed to physical violence, and 2% was often exposed to physical violence (Schnieden & Marren-Bell, 1995). The most frequent sources of abuse against nurses are patients, patients’ family members, visitors, physicians, and other health care personnel (Celik, Celik, Agirbas, & Ugurluoglu, 2007; Lin & Liu, 2005). The main source of abuse against nurses is patients and their relatives (Kwok, Law, & Li, 2006; O’Connell et al., 2000). Work conditions in the health sector place nursing and other health personnel at a greater risk for violence. Examples of such work conditions are (a) staffing patterns, for example, inadequate staffing levels and heavy workloads; (b) commuting to and from workplace at night for shift workers; (c) poor security measures in health facilities; (d) interventions demanding close physical contact with the patients; (e) demanding workload in an emotionally charged environment; and (f) highly accessible work settings with little or no privacy (ICN, 2000, 2007). Lin and Liu (2005) reported that the main source of physical violence was related to patients’ mental disorders and that the incidence of violence was highest in evening shifts. Gates, Ross, and McQueen (2006) conducted a study to describe the violence initiated by patients and visitors against 242 workers in an emergency department. The results indicated that the following factors contributed to workplace violence: (a) patients’ and visitors’ alcohol use and psychiatric diseases, (b) lack of adequate staff and working shift between 7 p.m. and 7 a.m., and (c) long hours of waiting for patients and lack of security measures for the nurses. The dramatic consequences of workplace violence are deterioration of the quality of care, a destructive impact on employees’ health, abandonment of the profession, difficulty in the recruitment of health care professionals, increasing health care costs, perpetuation of unacceptable societal behaviors, high rate of turnover, high stress levels, and increased number of errors at work (ICN, 2000, 2003). Moreover, physical and psychological violence may result in death, loss of workdays, loss of consciousness, restriction of motion or wok, termination of employment, transfer to another job, or health problems (U.S. Bureau of Labor Statistics, 2004). In their study to determine the reaction to mob behaviors, Yildirim and Yildirim (2006) found that nurses’ reactions included feeling tired, sad, and stressed and having gastrointestinal complaints.

Policies and Management of Workplace Violence A campaign for zero tolerance for violence at the workplace needs to address the following contributing factors of violence: working in isolation; inadequate staff coverage; lack of staff training; poor interrelationships within the work


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AbuAlRub and Al-Asmar environment, for example, managers’ disinterest; and difficulty dealing with people who have been taking drugs and are stressed, frustrated, and violent (ICN, 2000). AbuAlRub et al. (2007) found that small percentages of employers have policies in the workplace against violence. Astrom et al. (2004) conducted a study among 848 nurses to describe, among other things, the management of violent incidents. The results indicated that discussion with colleagues was the most common strategy reported by participants to manage emotions and other consequences of violent incidents. Another cross-sectional survey study was conducted among a sample of 40 National Health Service Trusts in the United Kingdom to examine the content of Trust policies concerning the prevention and management of violence. Three Trusts (8%) stated that they had no current policy related to the management of violence. Most policies (76%) gave a definition of violence, which referred to both psychological and physical harm; and 67% stated clear aims for their policies. Almost 39% of the policies identified who was responsible for ratifying, monitoring, and evaluating the policy (Noak et al., 2002). The literature shows that workplace violence against nurses is a real problem. Its negative consequences concerning nurses as well as patients in terms of depression, absenteeism, turnover, and poor quality care call for attention from nurse administrators and policy makers. Thus, it is most important to investigate the level and frequency of such violent incidents and its contributing factors and the management modalities in order to formulate sound polices that deal with such an alarming phenomenon.

Methodology Design A quantitative research design using a survey method was used to explore physical workplace violence in Jordan.

Sample and Setting The sample of the study was a convenience sample, which consisted of hospital staff nurses from four public hospitals. Any nurse who was employed in the targeted hospitals and provided direct care to patients and could understand and comprehend Arabic language was eligible to participant in the study. All heads of departments in the targeted hospitals were informed about the study and its purpose and significance. All nurses were invited to participate in the study through their managers. The participants were selected from different departments and during different shifts with the help of departments’ managers. A total of 422 nurses completed the questionnaires, with a response rate of 84.4%. The data were collected between June 2008 and August 2008.

Human Subjects Approval The approvals of the Institutional review Board of Jordan University of Science and Technology and the Ministry of Health were obtained before the data collection was started. It was indicated in the cover letter that participation was confidential and voluntary. Participants were asked to seal the completed questionnaire in the enclosed envelope and to drop it in a box in the manger’s office. The questionnaires were collected personally by one of the researchers. The anonymity of participants and confidentiality of their responses were ensured by not reporting participants’ identities, reporting the findings in aggregates, and destroying the raw data after the analysis process was completed.

Instrument The questionnaire that was used to measure physical workplace violence was developed in 2003 by the ILO, ICN, WHO, and PSI. The questionnaire was constructed based on the feedback of hospital nurses. It has the following five sections: (a) 21 items about personal and workplace data; (b) 17 items about physical workplace violence; (c) 37 items about psychological workplace violence (emotional abuse), including verbal abuse, bullying, mobbing, and sexual harassment; (d) 8 items about the health sector; and (e) 3 open-ended questions to ascertain participants’ opinions on workplace violence. Data about the third part (psychological violence) will not be reported here because of the extensive amount of data and tables involved. Permission was obtained from the WHO to use the questionnaire for data collection. The questionnaire was translated from English to Arabic by an individual who was proficient in both languages and then back-translated from Arabic to English by another individual who was also proficient in both languages. A committee of three persons who had experience in the research topic and competent in both Arabic and English assessed the content validity of the translated versions. The committee considered the equivalence of terms, clarity, and sensitivity to the culture of Jordan. Modifications were made according to the committee’s recommendations. The questionnaire was also pilot tested with 30 nurses. Further minor modifications were made according to the feedback of the participants.

Method of Analysis The Statistical Package of Social Sciences, Version 14, was used to analyze the quantitative data, and the content analysis procedure was used for the open-ended questions. Descriptive statistics (means, standard deviations, and frequencies) were used to describe the sample as well as other variables of the study. Multiple examinations, categorizations, and


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interpretation of the data were performed for analyzing the open-ended questions.

Table 1. Demographic and Work Characteristics (N = 422) Variable

Age Years of work experience

Results Demographic and Work Characteristics

Variable

The mean age of the participants was 29 years, ranging form 21 to 61 years. Most of the participants were females (n = 221; 52.4%) and were married (n = 241; 57.1%). The majority of participants were registered nurses (n = 215; 50.9%), followed by associate nurses (n = 132; 31.3%). The mean work experience was 6.8 years. The majority of the participants reported that they worked between 7 p.m. and 7 a.m. (n = 309; 73.2%) and had contact with patients during their work (n = 370; 87.7%). The majority of the participants reported that they worked with both females and males (n = 317; 75.1%). The participants worked in different units of the hospitals, such as emergency departments (n = 102; 24.2%), surgical units (n = 80; 19.0%), medical units (n = 73; 17.3%), intensive care units (n = 56; 13.3), pediatrics departments (n = 41; 9.7%), newborns unit (n = 14; 3.3%), operating room (n = 28; 6.6%), orthopedics units (n = 16; 3.8%), burn units (n = 9; 2.1%), and renal units (n = 3; 0.7%). A total of 152 participants reported that they were very worried about violence in their workplace (n = 152; 36.0%). The majority of the participants reported that there were procedures for reporting violence incidents in their workplace (n = 269; 63.7%) and that they know how to use them (n = 210; 78.1%). More than half of the participants reported that they were encouraged to report workplace violence (n = 227; 53.8%) and received encouragement from their colleagues (n=135; 59.8%). Data about demographic and work characteristics are presented in Table 1.

Physical Violence and Responses of Nurses Ninety-five of the 422 participants (22.5%) reported that they had been physically attacked; 15 of them with a lethal weapon (15.8%). The majority of violent incidents were caused by relatives of patients (n = 75; 79%). Almost all the physical incidents occurred inside the hospitals (n = 94; 98.9%). Forty-one of the 95 incidents occurred between 3 p.m. and 11 p.m. (43.1%). A total of 248 of the 422 participants reported that they witnessed incidents of physical violence in their workplace (58.8%). Concerning the reactions of nurses toward physical violence, (a) 43 of the 95 participants who were attacked tried to defend themselves physically (45.2%), (b) 35 participants thought that these incidents could have been prevented (36.8%), (c) 53 participants were injured because of the violent incidents (55.8%), (d) 32 participants who reported that they were injured because of the violent incidents required formal treatment for the injury

Gender Female Male Marital status Single Married Divorced/separated Widow/widower Category of present position Head nurse Supervisor Registered nurse Associate nurse Practical nurse Work between 7 p.m. and 7 a.m. Yes No Direct contact with patients during work Yes No Sex of the patients nurses most frequently work with Male Female Male and female Unit Emergency department Surgical units Medical units Pediatrics Orthopedics Newborns Burn Renal units Intensive care units Operating room Presence of procedures for reporting of workplace violence Yes No Knowing how to use procedures for reporting violence incidents Yes No Encouragement to report workplace violence Yes No Source of encouragement to report workplace violence Management Colleagues Union Family/friends


Mean (SD)

29.58 (5.97) 6.8 (5.5) n (%) 201 (47.6) 221 (52.4) 169 (40.0) 241 (57.1) 11 (2.6) 1 (0.02) 18 (4.3) 6 (1.4) 215 (50.9) 132 (31.3) 51 (12.1) 309 (73.2) 113 (26.8) 370 (87.7) 52 (12.3) 49 (13.3) 56 (11.6) 317 (75.1) 102 (24.2) 80 (19.0) 73 (17.3) 41 (9.7) 16 (3.8) 14 (3.3) 9 (2.1) 3 (0.7) 56 (13.3) 28 (6.6) 269 (63.7) 153 (36.3) 210 (78.1) 59 (21.9) 227 (53.8) 195 (46.2) 51 (22.6) 135 (59.8) 16 (7.00) 24 (10.6)

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AbuAlRub and Al-Asmar (60.4%), and (e) 57 participants who were injured took time off from work after being attacked (49.5%). Sixty-eight of the 95 participants (71.5%) reported that they were very dissatisfied with the manner in which the incident was handled. The incidence of workplace violence and reactions of nurses are presented in Table 2. For dealing with physical violence, 44 of the 95 participants (46.4%) who had been attacked reported that there was action taken to investigate the causes of the incident; the police took action in 29 cases (66%). Nineteen of the 44 participants (43.1%) reported that there were no consequences for the attacker. Thirty of the 44 participants (68.2%) reported that their employers or supervisors provided them with an opportunity to speak or report about the violent incident. The majority of the participants indicated that they did not report the incident to others since it was useless to do so (n = 69; 72.6%). Data about dealing with workplace violence are presented in Table 3. The problems and complaints reported by the participants as a result of physical violence incidents were the following: (a) 27 of the 95 participants (28.5%) who had been attacked reported that they were quite bothered by repeated, disturbing memories, thoughts, or images of the attack; (b) 32 of the 95 participants (33.7%) had been bothered moderately by avoiding talking about the attack or avoiding having feelings related to it; (c) 35 of the 95 participants (36.8%) had been bothered extremely by being “super-alert” or watchful and on guard; and (d) 30 of the 95 participants (31.6%) had been bothered quite a bit by feeling that every thing they did was an effort. Data about problems because of workplace violence are presented in Table 4.

Employers’ Policies and Measures for Violence Management The majority of the participants indicated that their employers had not placed specific polices against physical workplace violence (n = 292; 69.2%). Only 26 participants indicated that their employers had specific polices against physical workplace violence (6.2%). The other 104 participants indicated that they did not know if their employers had specific polices against physical workplace violence (24.6%). With regard to the measures that exist in the workplace to deal with workplace violence, the responses of participants were as follows: (a) security measures (n = 196; 46.4%), (b) restricted public access (n = 173; 41%), (c) patient screening (n = 112; 26.5%), (d) training existed in the workplace to deal with workplace violence (n = 89; 21.1%), (e) patient protocols (n = 78; 18.5%), (f) improved surroundings (n = 69; 16.4%), (g) increasing staff numbers (n = 85; 20.1%), (h) changing shifts or rotating (n = 70; 16.6%), (i) investment in human resource development (n = 59; 14%), (j) special equipment or clothing (n =56; 13.3%), and (k) reduced periods of working alone (n = 65; 15.4%). A total

Table 2. Frequency of Physical Workplace Violence and Reactions of Nurses (N = 422) Variable Exposure to violent incidents in the past 12 months Yes No Nurses consider this to be a typical incident of violence in their workplace Yes No Responsible persons for violent incidents Patient Relatives of patients/clients Staff members Management/supervisor External colleague/worker General public Place of violence occurrence Inside hospital At patient’s home Outside (on way to work) Time of violent incident occurrence 07.00 a.m.-3.00 p.m. 3.00 p.m.-11.00 p.m. 11.00 p.m.-07.00 a.m. Don’t remember The incident could have been prevented Yes No Injuries as a result of the physical violence Yes No Formal treatment for the injury Yes No Time taken off from work after being attacked Yes No Witnessing incidents of physical violence in the workplace (in the past 12 months) Yes No Reactions of nurses toward physical violence Took no action Tried to pretend it never happened Told the person to stop Tried to defend themselves physically Told friends/family Sought counseling Told a colleague Reported it to a senior staff member Transferred to another position Pursued prosecution Sought help from union Completed incident/accident form Completed a compensation claim


n (%)

95 (22.5) 327 (77.5) 76 (80) 19 (20) 10 (10.5) 75 (79) 2 (2.1) 0 (0) 0 (0) 8 (8.4) 94 (98.9) 1 (1.1) 0 (0) 21 (21.1) 41 (43.1) 20 (21.1) 13 (13.7) 35 (36.8) 60 (63.2) 53 (55.8) 42 (44.2) 32 (60.4) 21 (39.6) 47 (49.5) 48 (50.5) 248 (58.8) 174 (41.2) 14 (14.7) 4 (4.2) 23 (24.2) 43 (45.2) 15 (15.8) 6 (6.3) 12 (12.6) 20 (21.0) 2 (2.1) 22 (23.1) 6 (6.3) 6 (6.3) 2 (2.1) (continued)

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Table 2. (continued) Variable Action taken to investigate the causes of the incident Yes No Don’t know The source for taking the action Management Union Police Nurse’s satisfaction with the manner in which the incident was handled Very dissatisfied Dissatisfied Moderately satisfied Satisfied Very satisfied

n (%)

44 (46.4) 35 (36.8) 16 (16.8) 10 (22.7) 5 (11.3) 29 (66) 68 (71.5) 8 (8.5) 11 (11.6) 4 (4.2) 4 (4.2)

Table 3. Dealing With Violent Incidents (N = 44) Variable Consequences for the attacker None Verbal warning issued Care discontinued Reported to police Aggressor prosecuted Don’t know Interventions taken by employer or supervisora Counseling Opportunity to speak about/report it Other support Reasons for not reporting the incidenta It was not important Felt ashamed Felt guilty Afraid of negative consequences Useless Did not know who to report to

n (%) 19 (43.1) 4 (9.1) 1 (2.3) 5 (11.4) 11 (25) 4 (9.1) 20 (45.5) 30 (68.2) 14 (31.8) 9 (9.5) 21 (22.1) 0.0 (0.0) 6 (6.3) 69 (72.6) 3 (3.1)

a. Each participant can provide more than one answer.

of 126 participants indicated that none of these measures existed in their workplace (29.9%).

Contributing Factors to Physical Workplace Violence In response to the open-ended question regarding the contributing factors to violence in the workplace, the responses of the participants were analyzed using content analysis. Relevant statements were organized from each survey for comparison and derivation of final categories. Multiple

examinations, categorizations, and interpretation of the data were performed. The responses were classified as (1) factors related to administration, such as (a) absence of assertive legislations (n = 93; 22%), (b) ineffective management of violent incidents (n = 31; 7.3%), (c) lack of resources such as insufficient equipments and instruments (n = 63; 14.9%), (d) medical errors (n = 24; 5.7%), and (e) inappropriate environment for providing health care services (n = 22; 5.2%); (2) factors related to staff, such as (a) inadequate staffing leading to increased workload (n = 129; 30.5%), (b) unfair assignments (n = 36; 8.5%), (c) being inconsiderate of the feelings of patients’ families (n = 13; 3.1%), (d) lack of communication skills (n = 51; 12.1%), and (e) lack of religious and ethical values when dealing with others (n = 10; 2.3%); (3) factors related to patients and their families, such as (a) increased levels of anxiety and tension (n = 73; 17.3), (b) lack of cultural and social awareness (n = 56; 13.2), and (c) having previous impressions about poor quality of health care (n = 24; 5.7%); (4) factors related to the public, such as (a) the negative image of nursing profession (n = 16; 3.8%), (b) the negative portray of health professions by the mass media (n = 13; 3.0%), and (c) lack of religious beliefs in fate (n = 16; 3.8); and (5) factors related to security, such as (a) inexperienced and unqualified security staff (n = 122; 28.9%) and (b) increased public and visitors access and uncontrolled visiting time (n = 56; 13.2%).

Strategies for Reducing Workplace Violence In response to the open-ended question about the strategies that might reduce violence in the workplace, the responses of participants were classified as (a) factors related to staff, such as ensuring adequate staffing and providing training programs; (b) factors related to the workplace setting, such as ensuring adequate resources, encouraging team work and providing fair assignments, and restricting public access during providing care for patients; (c) factors related to security, such as improving security systems, restricting public access, and controlling visiting times; and (d) factors related to the administration, such as enforcing appropriate policies and legislations.

Discussion and Conclusions Physical Violence The study showed that 22.5% of the participants were exposed to physical violence. Different exposure rates were reported by researchers. Adib et al. (2002) reported that 7% of the participants in Kuwait were exposed to physical violence. Kwok et al. (2006) reported that 18% of participants in Hong Kong were exposed to physical violence. On the other hand, AbuAlRub et al. (2007) found that the incidence rate of physical violence in Iraq was 42%.


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AbuAlRub and Al-Asmar Table 4. Problems and Complaints as a Result of Violent Incidents (N = 95) Problems and Complaints

Not At All, n (%)

A Little Bit, n (%)

Moderately, n (%)

Quite a Bit, n (%)

Extremely, n (%)

Repeated disturbing memories, thoughts, or images of the attack Avoid thinking about or talking about the attack or avoiding having feelings related to it Being “super-alert” or watchful and on guard Feeling like everything you did was an effort

12 (12.6)

18 (18.9)

23 (24.2)

27 (28.5)

15 (15.8)

5 (5.2)

15 (15.8)

32 (33.7)

27 (28.5)

16 (16.8)

4 (4.2)

10 (10.5)

16 (16.8)

30 (31.7)

35 (36.8)

5 (5.3)

12 (12.6)

22 (23.1)

30 (31.6)

26 (27.4)

In most cases of physical violence, the perpetrator was one of the patient’s relatives. This is also congruent with the findings of AbuAlRub et al. (2007), O’Connell et al. (2000), Kwok et al. (2006), and Uzun (2003). A possible explanation for such results might be because of the instability of the psychological status of the family members when their loved ones are hospitalized, especially if the patient is seriously ill. Almost 43% of the physical violent cases happened between 3:00 p.m. and 11:00 p.m. at night. The work pressure, inadequate staffing, and the increased access of public during this time might have enhanced the probability of committing violent incidents. Such a result was consistent with the results of Lin and Liu (2005), AbuAlRub et al. (2007), and Adib et al. (2002), who found that violent incidents were highest in the evening shift. The reactions of the nurses with regard to physical violence differ from “physical self-defense” to “taking no actions.” Although 45% of them tried to defend themselves physically, only 21% reported the incidents to the administration. Such a result was inconsistent with Celik et al. (2007), who found that reporting the incidents to administrators was the most frequently used action. The attempt of participants to defend themselves physically might indicate that there was no adequate security staff to act promptly and protect nurses. The highest percentage of participants who were physically abused indicated that they became very alert and watchful as a result of the incident. Most of the participants were exposed to injury as a result of the violent incidents and received formal treatment and had taken time off after the incident. Such a result was consistent with Senuzun and Karadakovan (2005), who reported that all the participants who were exposed to injury as a result of violence received formal treatment and had taken time off after the violent incident had occurred. Taking time off as a result of the violence might indicate the occurrence of severe injury that needed medical attention. Although the police investigated 66% of the physical violence incidents, the administration only investigated 22.7%

of the cases. Almost half of the participants indicated that there were no consequences for the perpetrator who committed physical violence. This indicates the lack of workplace policies with regard to violence. The majority of participants indicated that they were very dissatisfied about the way in which the violent acts were dealt with. Such results were consistent with the results of Senuzun and Karadakovan (2005), who also showed that the majority of the incidents were not reported because the participants felt that the legal procedures were not accomplished. Losing trust in the administration and the nursing associations would lead to frustration and poor motivation and commitment, which eventually might affect negatively the quality of care provided to consumers.

Employer’s Polices for Violence Management The majority of the participants reported that the decision makers have not placed policies concerning physical workplace violence, which is consistent with AbuAlRub et al. (2007). The absence of clear policies concerning the violent acts enhanced the increase of the phenomenon. If the reasons behind recurring violent acts are identified and necessary policies are established, it is possible to minimize the reoccurrence of this phenomenon. Only 196 of the 422 participants indicated that security measures existed in the workplace to deal with violence. However, most participants indicated that having security measures, restricting public access, and providing training programs for staff in the workplace would be helpful in dealing with the workplace violence.

Opinions of Nurses Regarding Workplace Violence With regard to the factors that contributed to workplace violence, the participants indicated that these factors were related to administration, staff, patients and families, public, and security. Such results were congruent with the results


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Gates et al. (2006), who found that the factors that contributed to workplace violence were related to (a) patients and visitors, (b) staff, (c) hospital and environment. Concerning the factors that contributed to minimizing the workplace violence, the participants indicated that these factors were also related to staff, workplace setting, security, and administration. Such results were supported by the study of AbuAlRub et al. (2007), who also found that instituting polices against workplace violence and improving security measures and workplace conditions were important factors to deal with workplace violence form nurses’ points of view. The limitations of the study were the following: (a) using a convenience sample from only four public hospitals and (b) the instrument that was used for data collection relied on the recall of the participants, which might create a reporting bias.

Implications for Further Research and Clinical Practice Implications for further research indicate (a) the importance of investigating the consequences of workplace violence on the quality of care and satisfaction of employees and (b) the significance of conducting qualitative research to examine why workplace policies are limited concerning violence. However, implications for practice point to the importance of (a) instituting policies that subject judicial punishment on the perpetrators; (b) improving security measures such as restricting number of patients’ visitors, establishing alarm and monitoring systems, and increasing number of security staff; (c) developing training programs for nurses with regard to anger management, conflict management, and communication skills; (d) providing treatment, support, and counseling services for nurses who are exposed to violent acts; (e) ensuring adequate staffing; (f) providing quality services; (g) directing mass media toward increasing public awareness concerning the nurses’ roles as part of the health care team; and (h) integrating nursing curriculum with one or more courses that focus on workplace violence, its causes, sources, consequences, and its management and prevention.

Summary Workplace violence is a serious issue and an alarming phenomenon against hospital nurses in Jordan. Almost a quarter of the participants in the present study had experienced workplace violence and were very dissatisfied with the manner in which the incidents were handled. Moreover, most of the participants indicated that they did not report the violent acts because they believed it was useless. Few employers have established specific policies with regard to workplace violence. Providing training programs on how to avoid workplace violence, increasing the number of staff, enforcing security measures, improving quality of care, and instituting appropriate policies and legislations in the workplace

were some of the measures indicated by the participants to minimize workplace violence. Acknowledgment The authors thank all nurses who provided information necessary for the completion of the study.

Declaration of Conflicting Interests The author(s) declared no conflicts of interest with respect to the authorship and/or publication of this article.

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

References AbuAlRub, R., Khalifa, M., & Habbib, M. (2007). Workplace violence among Iraqi hospital nurses. Journal of Nursing Scholarship, 39, 281-288. Adib, S., Al-Shatti, A., Kamal, S., El-Gerges, N., & Al-Raqem, M. (2002). Violence against nurses in health care facilities in Kuwait. International Journal of Nursing Studies, 39, 469-478. Astrom, S., Karlsson, S., Sandvide, A., Bucht, G., Eisemann, M., Norberg, A., & Saveman, B. (2004). Staffs experiences and the management of violent incidents in elderly care. Scandinavian Journal of Caring Sciences, 18, 410-416. Celik, S., Celik, Y., Agirbas, I., & Ugurluoglu, O. (2007). Verbal and physical abuse against nurses in Turkey. International Nursing Review, 54, 359-366. Centers for Disease Control and Prevention. (2002). The changing organization of work and the safety and health of working people: Knowledge gaps and research directions. Washington, DC: Author. Di Martino, V. (2002). Workplace violence in the health sector: Country case studies Brazil, Bulgaria, Lebanon, Portugal, South Africa, Thailand, plus an additional Australian study: Synthesis report. Geneva, Switzerland: ILO/ICN/WHO/PSI Joint Programme on Workplace Violence in the Health Sector. Gates, D., Ross, C., & McQueen, L. (2006). Violence against emergency department workers. Journal of Emergency Medicine, 31, 331-337. International Council of Nurses. (2000). ICN position statement: Abuse and violence against nursing personnel. Retrieved from http://www.icn.ch/images/stories/documents/publications/position_statements/C01_Abuse_Violence_Nsg_Personnel.pdf International Council of Nurses. (2003). International perspectives. International Nursing Review, 50, 196-200. International Council of Nurses. (2007). Guidelines on coping with violence in the work place. Geneva, Switzerland: Author. International Labour Office, International Council of Nurses, World Health Organization, & Public Services International. (2002a). Framework guidelines for addressing workplace violence in the health sector. Joint programme on workplace violence in the health sector. Geneva, Switzerland: Author.


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AbuAlRub and Al-Asmar International Labour Organization, International Council of Nurses, World Health Organization, & Public Services International. (2002b). World report on violence and health. Geneva, Switzerland: Author. International Labor Office, International Council of Nurses, World Health Organization, & Public Services International. (2003). Workplace violence in the health sector: Country case studies, research instruments, survey questionnaire, English. Geneva, Switzerland: Author. Kwok, R., Law, Y., & Li, K. (2006). Prevalence of workplace violence against nurses in Hong Kong. Hong Kong Medical Journal, 12, 6-9. Lin, Y., & Liu, H. (2005). The impact of workplace violence on nurses in south Taiwan. International Journal of Nursing Studies, 42, 773-778. Noak, J., Wright, S., Sayer, J., Parr, A., Gray, R., Southern, D., & Gournay, K. (2002). The content of management of violence policy documents in United Kingdom acute inpatient mental health services. Health and Nursing Policy Issues, 37, 394-401. Nolan, P., Soaresb, J., Dallendera, J., Thomsenc, S., & Arnetzd, B. (2001). A comparative study of experiences of violence of English

and Swedish mental health nurses. International Journal Nursing Studies, 38, 419-426. O’Connell, B., Young, J., Brooks, J., Hutchings, J., & Lofthouse, J. (2000). Nurses perception of the nature and frequency of aggression in general ward settings and high dependency areas. Journal of Clinical Nursing, 9, 602-610. Schnieden, V., & Marren-Bell, U. (1995). Violence in the accident and emergency department. Accident and Emergency Nursing, 3, 74-78. Senuzun, F., & Karadakovan, A. (2005). Violence towards nursing staff in emergency departments in one Turkish city. International Nursing Review, 52, 145-160. U.S. Bureau of Labor Statistics. (2004). Occupational and illnesses in the U.S. by industry (Bulletin No. 2399). Washington, DC: Author. Uzun, O. (2003). Perceptions and experiences of nurses in Turkey about verbal abuse in settings. Journal of Nursing Scholarship, 35, 81-85. Yildirim, A., & Yildirim, D. (2007). Mobbing in the workplace by peers and managers: Mobbing experienced by nurses working in healthcare facilities in Turkey and its effect on nurses. Journal of Clinical Nursing, 16, 1444-1453.
