Department of Community Health Sciences, College of Applied Medical
Sciences, King Saud University, Riyadh, Saudi Arabia.

Corresponding author email: malmomani@ksu.edu.sa

Article Publishing History

INTRODUCTION

One of the top worldwide health issues that has recently gotten more attention is the mistreatment of nurses in the workplace. Workplace violence is defined by the World Health Organization (WHO) as any occurrence where workers are abused, intimidated, or assaulted due to their work-related activities, such as commuting to and from work. Many national organizations and other relevant organizations, including the National Council on Workplace Violence (WPV), consider both physical and psychological trauma, including attacks, verbal abuse, bullying, and both sexual and racial harassment, to be workplace violence (Stephens, 2019).

WPV is defined as a pattern of episodes in which employees are abused, threatened, or assaulted at work, with explicit or implicit threats to their safety, well-being, or health (Anderson and Stamper, 2001). For certain registered nurses, over 25% of incidents of patient or family member physical violence result in injuries, but over 50% result in exposure to verbal abuse or bullying (Al‐Qadi, 2021). Other professionals who work in mental and emergency facilities can also be among the casualties (Bordignon and Monteiro, 2021).

This description encompasses all instances, from small assaults to intentional murder (Hegney et al., 2003). The vast majority of WPV research have been dedicated to healthcare workers and nurses, whereas nursing students worldwide have received a lack of attention. The vast majority of academic time in nursing programs is spent in clinical settings. Younger age, less clinical abilities, and less communication skills put them at an elevated risk of WPV. Students at risk of violence may be victims in both clinical and academic environments (Normohammadi et al., 2021).

The International Council of Nurses (ICN) acknowledged WPV as a significant issue in nursing and asked that priority be given to concerns of clinical competence and WPV treatment. The frequency of WPV in the Saudi population was estimated to be between 50-86% (Alkorashy and Al Moalad, 2016). The WPV varies among countries, with the UK documenting 19.6%, while China and Korea confirm 77.1% and 78.6%, respectively (Liao et al., 2010; Park et al., 2017; Tee et al., 2016). Physical abuse against health care professionals has been connected to job exhaustion, customer demands, and decreasing patient-staff interactions (Phillips, 2016). About 80% of all significant violence in healthcare settings stems from encounters between nurses and patients, according to Occupational Safety and Health Administration (Wyatt et al., 2016).

When it came to psychological violence and bullying, Asia had the highest prevalence, with the US following just after. Meanwhile, Africa had the lowest percentage of non-physical violence, Europe had the second lowest percentage of physical violence, bullying, and sexual harassment, and Asia was placed worst for all three types of violence. Although it revealed that US nurses had the highest overall exposure to physical WPV, Asian nurses had the least exposure to that specific type of WPV. In Europe and Africa, the nurses were exposed to low levels of physical violence and high levels of nonphysical violence. Men reported the most experiences of physical WPV, accounting for the lower reported rate of physical WPV (Mobaraki et al., 2020).

A recent systematic review study carried out in the Saudi Arabia indicated that pediatric employees who work in a healthcare setting may face an increased risk of WPV. Parents or caregivers of the attending children can exhibit a range of forms of aggression against pediatric doctors and nurses due to the stress the child’s condition can produce. Hospital personnel must be given explicit instructions on how to handle violent occurrences and how to report them (Albalwei et al., 2021).

According to El-Hneiti et al studies, about 60% of participants reported being victims of violence or facing threats of violence in the workplace (El‐Hneiti et al., 2020). There is a lack of accurate data on abuse in Saudi Arabia, thus we decided to explore this phenomenon in Saudi Arabia and its culture. In order to determine the prevalence of WPV among nurses working in public health facilities, this study will examine the relevant factors. The nurses’ workplace also has mechanisms in place to cope with workplace violence.

MATERIAL AND  METHODS

Settings: During the period of 5 September 2020 to 10 January 2021, this descriptive cross-sectional study was undertaken in two public hospitals in Saudi Arabia. As part of the study (n=550), all full-time licensed nurses with at least one prior hospital experience were included. A random sample of 275 nurses from each hospital was taken.

Study Instrument: The questionnaires (English version) developed by the International Labour Office (ILO), ICN, WHO, and Public Services International (PSI) in 2003 (ICN, 2003) served as the basis for the study instrument. The questionnaire was written in English at first, then translated to Arabic to suit local language requirements, and finally back to English to verify conceptual consistency. Non-Arabic speakers could fill out surveys in English. To minimize confusion, the definition of workplace violence was given with both questionnaire versions (English and Arabic).

The questionnaire was divided into five portions, each with 39 questions. The first segment (7 questions) included questions about the participants’ sociodemographic data, the second section (7 questions) included questions about workplace characteristics, and the third section covered physical workplace violence encountered by nurses in the previous 12 months (14 questions). This part evaluated the instance, location, time, and perpetrator type. Participants were asked how frequently they had encountered physical violence, how they responded to the occurrence, and how they dealt with the abuse. The fourth section (9 questions) had similar questions to the third section. The final portion includes two questions about the reasons for the instances of violence that happened with nurses, as well as the steps and policies that the employer implemented to deal with workplace violence.

Five experts evaluated the instrument’s content validity. They were asked to review and rate the instrument based on its clarity, relevance, comprehensiveness, translation correctness, and cultural sensitivity. Following the suggestions of the experts, certain improvements were suggested. After that, the redesigned questionnaire was pilot tested with 25 participants, who were then eliminated from the study population. As a result, several changes were made. Cronbach alpha values ranged from 0.71-0.87 for all subscales.

IRB and consent : Ethical approval was obtained for this study from our institutional premises. The 550 participants involved in this study has signed the informed consent to participate in this study. Participation in the study was entirely optional, and individuals who were unwilling or desired to withdraw at any time were advised that they could do so without limitation. The hospital’s central nursing department delivered a self-administered questionnaire along with a cover letter to 550 nurses. The nurses were given a two-week time frame to respond. Confidentiality was maintained throughout this study

Statistical analysis:The information gathered data was uploaded and analyzed using the Statistical Package for Social Sciences (SPSS Inc., software version 21 Chicago, IL, USA). Demographic and occupational violence factors were described in descriptive statistics. The Chi-square test was used to examine the relationship between socio-demographic data and kinds of violence. The logistic regression was used to predict the relationship between the participants’ demographic data among the violation of nurses. The 95% confidence interval (CI) was used to examine the crude odds ratio. A P value of 0.05 was deemed statistically significant.

RESULTS AND DISCUSSION

This is a cross-sectional study conducted at Public Hospitals following the COVID-19 pandemic, and 550 nurses took part in it after signing an informed consent form. Table 1 lists the clinical characteristics of nurses. The nurses’ ages were classified into three groups, with 36.3% being under 30 years old, 48.1% between 31-45 years old, and 15.6% being above 45 years old. Male and female participation rates were discovered to be 19.6% and 80.4%, respectively. Almost 65% of nurses were married, while 31.6% were single. The proportion of nurses with a bachelor’s degree was determined to be 72.1%, while 18.6% of subjects were documented with a diploma and 9.3% were post-graduated. Only 20.5% of the nurses had more than a decade of experience, 47.9% of the nurses had experience between the ages of 6-10, and 31.6% of the nurses had experience less than five years.

Table 1. characteristics of participants (n=526)

Variables	Frequency	Percentage
The age    ≤ 30 31-45 >45	191 253 82	36.3 48.1 15.6
Gender Male Female	103 423	19.6 80.4
Marital status   Single Married Others	166 344 16	31.6 65.4 3.0
Educational status  Diploma 2 years  Bachelor (BSC) Graduate studies	98 379 49	18.6 72.1 9.3
Years of experience ≤ 5 6-10 >10	166 252 108	31.6 47.9 20.5
Shift work    Day Evening Night Rotation	130 9 12 375	24.7 1.7 2.3 71.3
Clinical setting Medical/surgical Emergency Intensive care Pediatric Obstetric and Gynecology Orthopedic ENT/ Ophthalmology Operating room/Recovery Dialysis	181 68 69 56 51 48 18 22 13	34.4 12.9 13.1 10.6 9.7 9.1 3.4 4.2 2.6

The rotation shifting nurses accounted for 71.3% of the total, while the day shifting nurses accounted for 24.7%. The evening and night shift nurses were found to be 1.7% and 2.3%, respectively. One-third (34.4%) of the nurses worked in the medical and surgical departments, while 12.9%, 13.1%, and 10.6% worked in the emergency, intensive care, and pediatric departments, respectively. The percentages of nurses working in obstetrics/gynecology, orthopedics, ENT, operating rooms, and dialysis were 9.7%, 9.1%, 3.4%, 4.2%, and 2.6%, respectively.

Table 2 shows the WPV of the individuals in the study. In this research, 77.6% of nurses reported being violated on the job in the previous 12 months. The nurses have suffered the most verbal abuse (90.4%) and the least physical violence (9.6%). However, 12.7% of nurses have had to deal with both of them. The highest percentage of violations was collected from a patient’s relative (66.7%), followed by a patient (16.9%), a staff nurse (9.1%), a manager (4.2%), a colleague (2.2%), and 0.9% was unknown. The biggest violation was discovered to be 45.6% in the afternoon, followed by 36.9% in the morning, and the lowest violation was discovered to be 17.5% during the night shift. The patient room has seen the most violence, with 46.8%, followed by reception (19.4%), waiting room (17.2%), corridor (10.2%), and treatment room (6.4%).

Table-2. Violations among nurses during their WPV

Variable	Frequency	Percentage
Exposure to violent incidents in the last 12 months Yes No	408 118	77.6 22.4
Types of violence Physical violence Verbal Abuse Both (physical and verbal)	39 369 51	9.6 90.4 12.7
Identity of perpetrator Patient Relatives of patient Staff nurse Manager or supervisor External colleague Unknown	69 272 37 17 9 4	16.9 66.7 9.1 4.2 2.2 0.9
Time of violent incidence Morning shift (7 am – 2.30 pm) Evening shift (2.30pm – 10.30pm) Night shift    (10.30pm-7am)	151 186 71	36.9 45.6 17.5
Violence place Patient room Waiting room Treatment room Nursing station/reception Corridor	191 70 26 79 42	46.8 17.2 6.4 19.4 10.2
Reasons of violence Intense workload High level of stress related to patient illness Pain High patient expectation Long waiting time Lack of communication Inadequate security	364 210   132 173 77 22	89.2 51.5   32.4 42.4 18.9 5.4
Initial reaction to the incident Took no action Tried to pretend it never happened Told the person to stop Told friends and family Told a colleague Reported to senior staff	127 39 50 35 70 87	31.2 9.5 12.2 8.5 17.2 21.4

The high degree of patient stress during treatment was discovered to be one of the main reasons for the violation, with 51.5% and 89.2% for the intensive workload. The patient expectation was documented to be 32.4%, the long waiting time was 42.4%, the lack of communication was 18.9%, and the inadequate security was 5.4%. In this study, 31.2% were found to be for no action, 9.5% for pretending not to happen, 12.2% for stopping the person, 8.5% for informing family members, 17.2% for informing a coworker, and 21.4% reported to senior staff.

Table 3 defines the nurses who report the occurrence of workplace violations. In this study, 21.4% of nurses reported the occurrence, while 78.6% did not disclose the occurrence of the violation. The majority of nurses, 38.5%, believed there was no use in complaining about a file, while 31.7% believed it was unimportant. 13.1% and 12.4% of nurses were embarrassed and worried of unfavorable consequences, respectively. Only 4.3% of the nurses felt guilty. The method in which the incident was handled was extremely satisfactory to 5.3% of the nurses. Nonetheless, 54.8% of nurses were moderately happy. Both 31.3% and 8.6% of the nurses were dissatisfied or very dissatisfied with their jobs.

Table 3. Details of nurses and their role in complaining about their violation during WPV

Reporting incident  Yes No	87 321	21.4 78.4
Reasons for not reporting the incident  It was not important Felt a shamed Felt guilty Afraid of negative consequences Useless	102     42     14     40     123	31.7 13.1 4.3 12.4 38.5
Nurse’s satisfaction with the manner  In which the incident was handled  Very dissatisfied Dissatisfied Moderately satisfy Very satisfy	35 128 224 21	8.6 31.3 54.8 5.3
Opinion of nurses with the measures used to deal with workplace violence exist in their workplace (n=408)   Security measures (e.g. guards, alarms, portable telephones, cameras) Improve surroundings (e.g. lighting, noise, heat, access to food, cleanliness, privacy) Restrict public access Waiting room should be comfortable Increased staff numbers Changed shifts or rotas (i.e. working times) Reduced periods of working alone Training (e.g. workplace violence, coping strategies, communication skills, conflict resolution, self- defense)	221            88             202          128         239         79         72         162	54.2   21.5   49.6 31.4 58.7 19.4 17.6 39.7

Table 4 describes the multivariate logistic regression analysis among the baseline characteristics such as gender, age, marital status, education, work experience, and working shifts, and the study results confirmed that age (p=0.001), education (p=0.01), and work experience (p=0.001) were statistically associated.

Table 4. Multivariate adjusted odds ratios for exposure to violence among participants

Characteristic	Adjusted		P value
	OR	95%CI
Gender Male Female	1.61 1.0	0.33-119 Reference	0.183
Age <30 ≥30	3.41 1.0	2.91-16.46 Reference	0.001
Marital status Single Married	1.39 1.0	0.79-3.85 Reference	0.176
Education <Bachelor’s degree ≥ Bachelor’s degree	4.21 1.0	4.21 1.0	0.010
Years of experience < 10 ≥ 10	7.63 1.0	7.63 1.0	0.001
Shift work Fixed Rotation	0.68 1.0	0.68 1.0	0.582

The aim of this study was to enroll WPV among the working nurses in the Saudi Arabia and the current study results indicated that 77.6% of nurses were violated at work. The majority of the violations (90.4%) were classified as verbal abuse. The relatives of the patients violated 66.7% of the nurses, and the occurrence occurred during the evening shifts of the working hours between 2.30-10.30pm. The most violations occurred in the patient room, accounting for 46.8% of all violations, with the severe workload accounting for 89.2% of all violations. However, among the violations, 21.4% of the nurses were reported to senior management. Nurses are exposed to more impolite behavior and more physical or emotional abuse under stressful situations, such as the death of a patient, the transfer of patients to another hospital, or as they wait for a doctor or nurse to arrive at the scene of an accident or trauma (Shoghi et al., 2008).

Worldwide, the prevalence of WPV were documented and majority of the nurses were very well known with their past experiences. In our study, nurses were subjected to various forms of physical aggression while at work. During the job, nurses are exposed to violence and that exposure has an impact on them, making them more likely to get exhausted, to experience sleeping disorders, to be stressed, to have spasms, to lose self-confidence, to be disappointed, to want to drink, to smoke, and to attempt suicide.

These difficulties experienced in the workplace may lead to absence from shifts, frequent absenteeism, inattention to patients, and a decrease in job satisfaction. This may result in resignation or even death. A study found that workplace violence against nurses may decrease the quality of care provided, cause greater levels of staff errors, compromise ethics, and end up costing treatment centers and the community substantially more, (Kobayashi et al., 2020).

Nursing workplace violence is likely a serious problem that has yet to be fully investigated and reported on (Jackson et al., 2002; Jones and Lyneham, 2001; Kaye, 1996). on the other hand, it has been observed that the incidence is rising (Taylor, 2000). O’Connell et al state that patients are the most frequent workplace violence perpetrators, with colleagues and managers in nursing next in line. Then, families follow (O’Connell et al., 2000). Patients were the most frequent source of violence in a previous research on mental health nurses and violence. Furthermore, in the study they observed that the risk of violent encounters with healthcare workers other than physicians or allied health professionals is greater than the risk of such encounters with medical practitioners or allied health workers (Nolan et al., 1999).

Concerning workplace violence and gender, there is contradicting information. For instance, in Queensland, it has been found that women are more likely to be harassed at work than men (Queensland Government, 2002). Rippon disagreed, saying that male nurses are more likely to face workplace violence than female nurses (Rippon, 2000). One study indicated that patient satisfaction is significantly greater in hospitals where there are fewer nurses that are disgruntled or burned out (McHugh et al., 2011).

The rate of WPV against nurses was shown to range from 10-50% (Hegney et al., 2003; Wells and Bowers, 2002), one study finding the higher incidence rate as 87% (Uzun, 2003). Our study identified a large proportion of workplace violence, particularly verbal aggressiveness, which has been documented in prior studies, ( Koohestani et al., 2011; Magnavita and Heponiemi, 2011; Samadzadeh and Aghamohammadi, 2018; Tee et al., 2016, Budden et al., 2017; Cheung et al., 2019, Normohammadi et al., 2021). A couple of systemic reviews have validated and documented the WPV among nurses with a higher incidence (Konttila et al., 2018; Spector et al., 2014).

One of the limitations of our study was we haven’t mentioned the details of foreign countries and we have enrolled only 550 participants during the pandemic crisis. The study design was cross-sectional and does not deliberate causality. The strength of our study was we have covered all types of violation and nurses came out with the WPV in our study. We haven’t incorporated the details of the patients and their relatives who have abuses the nurses to avoid the conflicts.

CONCLUSION

This study has confirmed  that  the nurses who have participated in this were mentally strong in handling the WPV during their job. It is necessary to conduct further study, which may include studies looking at the factors that increase the chance of a repeat event and those that decrease it, as well as development of an intervention program for the emotional load that accompanies WPV. To prevent workplace violence in healthcare settings, it is equally vital to implement policies that supplement the existing call to action. To help prevent workplace violence, this study recommends to consider implementing anti-bullying programs in the nursing curriculum, hospital security, and legal policies, as well as designing violence reporting and surveillance systems.

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