Is violence against nurses a global problem What are the statistics for violence against nurses. Do nurses report it? JOH2-63-e12226.pdf

J Occup Health. 2021;63:e12226. | 1 of 11 https://doi.org/10.1002/1348-9585.12226

wileyonlinelibrary.com/journal/joh2

1 | INTRODUCTION

Violence against nurses in their workplace is a major global problem that has received increased attention in recent years.1 Approximately 25% of registered nurses report being physi- cally assaulted by a patient or family member, while over 50% reported exposure to verbal abuse or bullying.2 Nurses, who are primarily responsible for providing life- saving care to pa- tients are victimized at a significantly higher rate than other health- care professionals,3 and it is estimated that workplace violence causes 17.2% of nurses to leave their job every year.4

In the United States, workplace violence increased by 23% to become the second most common fatal event in 2016,5 accounting for 1.7 million nonfatal assaults and 900 workplace homicides each year.6 In addition, there has been an increase in workplace violence in US hospitals, increasing from 2 events per 100 beds in 2012 to 2.8 events per 100 beds

in 2015.5 In 2016, hospitals and health- care facilities invested $1.1 billion in security and training to prevent violence and had to spend $429 million on insurance, staffing, and medical care due to workplace violence.7

The absence of a universal definition for workplace vi- olence within health- care settings and the ambiguity about what constitutes a violent event currently compromise re- search on the prevalence and magnitude of this phenomenon. Furthermore, varying definitions and unclear criteria may lead to nurses failing to identify their experience as a form of workplace violence, which prevents it from being reported.

Applying the concept analysis method to better under- stand the violence to which nursing staff are subjected in the workplace will demystify the factors at play, with the under- lying intention of preventing such violence. Using concept analysis to address the theoretical background to such vio- lence will aid the development of an operational definition

Received: 9 December 2020 | Revised: 15 March 2021 | Accepted: 5 April 2021

DOI: 10.1002/1348-9585.12226

R E V I E W A R T I C L E

Workplace violence in nursing: A concept analysis

Mahmoud Mustafa Al- Qadi RN, MSN, MHA

This is an open access article under the terms of the Creative Commons Attribution- NonCommercial- NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non- commercial and no modifications or adaptations are made. © 2021 The Authors. Journal of Occupational Health published by John Wiley & Sons Australia, Ltd on behalf of The Japan Society for Occupational Health

University of Connecticut School of Nursing, Storrs, CT, USA

Correspondence University of Connecticut School of Nursing, 231 Glenbrook Rd., Unit 4026, Storrs, CT 06269- 4026, USA. Email: [email protected]

Abstract Objectives: To clarify the concept of workplace violence in nursing and propose an operational definition of the concept. Methods: The review method used was Walker and Avant's eight- step method. Results: Identification of the key attributes, antecedents, consequences, and empiri- cal referents of the concept resulted in an operational definition of the concept. The proposed operational definition identifies workplace violence experienced by nurses as any act or threat of verbal or physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the worksite with the intention of abus- ing or injuring the target. Conclusions: Developing insights into the concept will assist in the design of new research scales that can effectively measure the underlying issues, provide a frame- work that facilitates nursing interventions, and improve the validity of future studies.

K E Y W O R D S

concept analysis, harassment, health and safety, nurses and violence, occupational health nursing, workplace violence

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that increases the validity of the concept. This study aims to elucidate the nature and form of workplace violence experi- enced by nurses and develop a precise operational definition of the concept in conjunction with a set of criteria that can be used to identify the phenomenon.

2 | BACKGROUND AND SIGNIFICANCE

Violence is defined by the World Health Organization in the World Report on Violence and Health as “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either result in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or dep- rivation.”8 This definition emphasizes that a person or group must intend to use force or power against another person or group for an act to be classified as violent.

University of Iowa Injury Prevention Research Center9 classified workplace violence into four basic types: Type I, Type II, Type III, and Type IV. Type I involves “criminal in- tent.” In this type of workplace violence, “individuals with criminal intent have no relationship to the business or its em- ployees.” Type II involves a customer, client, or patient. In this type, an “individual has a relationship with the business and becomes violent while receiving services.” Type III in- volves a “worker- on- worker” relationship and includes “em- ployees who attack or threaten another employee.” Type IV involves personal relationships. It includes “individuals who have interpersonal relationships with the intended target but no relationship to the business.” Types II and III are the most common in the health- care industry.

Verbal abuse is the most common type of abuse directed toward nurses in health- care settings. It is three times more likely to occur than physical violence.10 In one study, 82% of nurses reported verbal abuse as being the most common type of abuse,11 while 63.9% of nurses had been subjected to some form of verbal abuse by patients.12 Behaviors such as swearing, shouting, or cursing have been identified as the most common form of verbal abuse13 and have also been re- ported as the most violent type of verbal aggression.14 Data collected from 349 nurses indicated that 79.5% had been sub- jected to verbal violence, while 28.6% had been exposed to physical violence.15 Physical abuse often co- exists with ver- bal abuse, suggesting that the latter might act as a predictor for potential physical abuse.10 Of these behaviors, “being pushed or hit” has been identified as the most common type of physical abuse,13 while the use of lethal weapons has been shown to occur mostly during night hours.16

Many studies indicate that violence against nurses is under- reported.17 Emergency departments have been highlighted as locations where violent incidents are likely to be significantly

underreported; the reasons given are: (a) nurses are not satis- fied with how their previous violent events were handled as some cases were not treated with appropriate seriousness15; (b) nurses’ belief that violence is part of the job18; (c) nurses are discouraged from reporting such events as even if they do, there are no policies guaranteeing justice19; (d) insufficient time20; (e) nurses' belief that no harm was inflicted on them and they can handle it21; and (f) nurses' ability to defend them- selves by changing how they treat that particular patient.12

Previous studies have reported that nurses consider the absence of assertive legislation, poor management of violent incidents, a lack of resources, such as insufficient equipment, medical errors, and a poor environment to contribute signifi- cantly to workplace violence.22 Also, a lack of proper com- munication skills, lack of experience, lack of quality care, and shortage of nursing staff can also lead to workplace vio- lence.15 The shortage of nursing staff is a pertinent issue that has affected the majority of countries. The reviewed literature underlines how health- care settings have witnessed high turn- over rates among nurses.23

The experience of workplace violence has physical, per- sonal, emotional, professional, and organizational conse- quences that impact individuals and organizations. We argue that a definition to aid the recognition of workplace violence and the understanding of its attributes, antecedents, and con- sequences will assist in optimizing recognition and facilitate the formation of strategies to address the problem.

3 | CONCEPT ANALYSIS METHOD

This study used Walker and Avant's24 eight- step method, which is commonly applied in the nursing context (see Table 1). The concept analysis process helps to validate current nursing un- derstanding, as well as support strategies for nursing interven- tions. Hence, this approach was utilized to analyze the current understanding of the workplace violence to which nurses are subjected as it offers an interactive process that can facilitate the development of an operational definition of a concept.

4 | DATA SOURCES

Walker and Avant24 suggest that all data sources should be fully utilized to ensure a thorough inventory of the relevant characteristics and variables is compiled. Studies were iden- tified via a search of four key databases: Cumulative Index of Nursing and Allied Health Literature (CINAHL), PubMed, PsycINFO, and Scopus using the following single and/or combined keywords: “nurses”; “nursing”; “nurse”; “vio- lence”; “workplace violence”; “abuse”; and “assault.”

The eligibility of the studies was assessed based on the aims of the concept analysis. The following inclusion criteria

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were utilized: (a) studies published in peer- reviewed journals between 2000 and 2020; (b) studies that are relevant to the topic and fit with the content of the analysis; (c) studies that included nurses experience of workplace violence; and (d) studies published in English. Papers were excluded if the study primarily focused on violence against nurses working in mental health settings on the basis that these had different and unique considerations (see Figure 1).

Initially, 383 papers were identified. Once duplicates were removed, the titles and abstracts of the papers were re- viewed. This resulted in 227 papers, which were reviewed in full against the inclusion criteria, after which a further 193 papers were excluded. Thus, a total of 34 papers met the in- clusion criteria and were included in the concept analysis; see Figure 1 for a Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) flow diagram of the process.25

5 | RESULTS

The results of the concept analysis are presented according to the eight steps of Walker and Avant's24 method.

5.1 | Select a concept

According to Walker and Avant,24 before a concept is selected its significance should be scrutinized across a variety of set- tings. The selected concept should reflect the area of interest

T A B L E 1 Walker and Avant's24 eight- step method

Step # Walker and Avant's step

1 Select a concept.

2 Determine the purpose of analysis.

3 Identify all uses of the concept.

4 Determine the defining attributes.

5 Construct a model case.

6 Construct borderline and contrary cases.

7 Identify antecedents and consequences.

8 Define empirical referents.

F I G U R E 1 PRISMA diagram of search strategy adapted for use from Moher et al25

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addressed in the research question. Workplace violence experi- enced by nurses is the selected concept for this analysis.

5.2 | Purpose of the analysis

The aims of the current analysis were to (a) clarify the con- cept of workplace violence experienced by nurses by defin- ing its essential attributes, antecedents, consequences, and empirical referents; and (b) propose an operational definition of workplace violence.

5.3 | Identifying uses of the concept

Under the next step in Walker and Avant's24 method, the available literature is searched to outline the primary attrib- utes of the concept and identify how it is used. Reviewing the existing studies generates an evidence base in relation to the essential attributes underpinning the concept; hence, it facili- tates and validates the outcomes of the analysis.

5.3.1 | Literature definitions

Violence in health care has been defined “as any incidents where the staff are abused, threatened, or assaulted in circum- stances relating to their work involving an explicit or implicit challenge to their safety, well- being, or health.”26 This defini- tion includes “any threatening statement or behavior which gives a worker reasonable cause to believe they are at risk.”27 It also encompasses a broad range of behaviors28 from physical assault or direct violence to nonphysical forms of violence such as verbal abuse and sexual harassment.29 Workplace violence can be defined as any physical assault, threatening behavior, or verbal abuse that occurs in a work setting.30

The Center for Disease Control and Prevention,31 World Health Organization,32 and Occupational Safety and Health Administration33 define workplace violence as any act occur- ring in the workplace with the intention to harm someone physically or psychologically including attacks, verbal abuse, and both sexual and racial harassment.34 Also, 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.”31- 33

5.4 | Defining attributes

The defining attributes are those critical qualities and charac- teristics that often emerge within a concept. Such attributes

differentiate the concept from closely related notions, and elucidate its meaning. The literature review revealed that the three distinguishing qualities of the workplace violence expe- rienced by nursing staff can be classed in distinct categories: (a) working relationship; (b) power and powerlessness; and (c) behavior.

5.4.1 | Working relationship

One of the considered attributes is the working relationship, which is one of the contributors to violence against nurses. It involves the relationship between nurses and patients, nurses and the patient's family, physician and nurses, management and nurses, and nurses and other nurses, any of which can trigger violence.35 Human beings differ in their response to emotions,36 and dealing with them requires a certain level of discipline.

5.4.2 | Power and powerlessness

Power is another defining factor. In any normal working en- vironment, there should be someone superior who guides and directs the normal operations of the day.37 However, misuse of this power can result in conflicts within the organiza- tion.38,39 For example, conflicts tend to arise when multiple people want to wield power or when a superior rule in an unjust manner. Similarly, there may be others within the or- ganization who intend to disempower the one bestowed with power. Such an intention results in organizational politics, which can have serious consequences for workplace perfor- mance.40 Moreover, when members of one gender believe that they should rule over others, this destabilizes the unity within a health facility. In general, unequal power relation- ships contribute to violence against nurses.41

5.4.3 | Behavior

The final attribute is the behavior of the perpetrator. Behavior is defined as how a person acts or does things, whereby in this context the causative agent of the violence comes from an outside source. It can be in the form of physical or emo- tional violence.42

6 | CONSTRUCTED CASES

The defining attributes identified within the concept analy- sis can also be narrowed down through the identification of model, borderline, contrary, illegitimate, and invented cases.24 The constructed cases facilitate efforts to delineate

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between the characteristics that represent key attributes and those that do not.

7 | MODEL CASE

The model case should be a real example that, ideally, pre- sents all the critical attributes.24 Sarah went to see Julia, the charge nurse in her unit. Sarah reported that the workload in her assignment was becoming unsafe and unacceptable for practice and quality of care. Julia became defensive saying that Sarah was over- dramatic and her noncompli- ance with following policies and procedures in the unit contributed to unsafe practice within the unit. This case is an example containing all the defining attributes of work- place violence: That is, a formal working relationship ex- ists between Sarah and Julia, with Julia in a position of power. Julia's response to verbal abuse and horizontal vio- lence professionally degraded Sarah and is again consistent with workplace violence.

8 | BORDERLINE CASE

Borderline cases are those that present some, but not all, of the key attributes associated with the concept. They shed light on ideas related to the main attributes of the concept of interest by providing insights into how often it is mis- construed.24 John was due for his surgery and was observed continuously pacing throughout the corridor looking very agitated and anxious. Jessica, a nurse, asked him if he was alright. John did not say anything and went back to his room but showed signs of autonomic arousal by continuing

pacing throughout the hallway. However, while anxious and agitated, he has not acted abusively toward Jessica (the nurse), and therefore this cannot be considered workplace violence.

9 | CONTRARY CASE

A contrary case is one that does not represent the defining attributes of the concept. In addition, it represents attributes that are not features of the concept.24 A contrary case can give insights into the primary characteristics of the concept by highlighting contrary ideas.

9.1 | Antecedents

Walker and Avant24 describe antecedents as events or inci- dents that precede the concept's occurrence (see Figure 2). These can be defined as the fundamental and underlying factors that initialize violence against nurses.43 For any form of violence to occur, there must be two parties; one party is the perpetrator, who aims to harm the other party, and the other is the recipient, who is on the receiving end of the act. Other contributors are the internal factors and the external factors.

9.1.1 | Two parties (perpetrators and nurses)

Two parties must be present in order for violence to occur, namely the perpetrator and the recipient. In this study, the recipient is the nurse, while the perpetrator could be a family

F I G U R E 2 Antecedents, empirical referents, attributes, and consequences of workplace violence

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member of the patient, the patient, management, other nurses, or even a physician.

Nurses are more vulnerable to violence as they commu- nicate directly with patients and their families.44 Sometimes, physicians use violence to achieve power, maintain their prestige, and abuse nurses to force them to perform better in their handling of not only patients but also the physicians themselves.12

9.1.2 | External factors (policies and workplace environment)

Some policies that are imposed within health- care settings lead to nurses being subject to stress and can even affect pa- tients negatively. For example, in some instances, nurses are expected to work long hours without rest45; however, increas- ing the working hours impairs the performance of nurses. Similarly, restricting the visitation hours makes patients’ family members experience distress and resentment. They feel alienated and unvalued by the administration. A stressful situation also arises when patients are involved in painful in- vasive procedures.46 All these situations can precipitate vio- lence against nurses. Hence, the physical setting is important when it comes to health care, whereby the accessibility of working instruments and a good working atmosphere play a key role. If there is not enough medicine or if staffing levels are low, both nurses and patients may be negatively affected. The working environment can also discourage patients and even staff from being associated with the health facility as they feel that the quality of services is being compromised. Moreover, there is a lack of well- structured policies, which contributes significantly to the violence experienced by nurses.23 The result is conflict among different parties.

9.1.3 | Internal factors (perpetrator or recipient characteristics)

Anything that causes stress can serve as a contributor to vio- lence against nurses. These factors are not contributed ex- ternally but rather emanate from the thinking of individuals. Some of the causes for such behaviors are substance and drug abuse, feelings of powerlessness, frustration, fear, disorder, mental illness, and others.44 These can affect the minds of individuals, which in turn impairs individual judgments. A perpetrator can become directly violent toward a recipient if he or she falls into one of the identified categories. The above behaviors are associated with perpetrators, who in this context are generally patients or their relatives.47 On the other hand, the recipients, who are nurses, may display poor communication and a failure to perform, making them more vulnerable to violence.22 For example, a nurse who fails to

accomplish his or her task is prone to verbal violence from a senior nurse.

9.2 | Consequences

Walker and Avant24 refer to consequences as events or in- cidents which follow the occurrence of workplace violence. These consequences can be psychological, emotional, physi- cal, organizational, or professional.

9.2.1 | Emotional and psychological consequences

The emotional and psychological consequences are largely experienced by nurses, whereby psychological violence is the most common type of abuse reported by nurses in health- care facilities.48 They include, but are not limited to, stress, lack of sleep, and anger. Emotional and psychological con- sequences are more prevalent than physical consequences and represent the highest percentage of experienced conse- quences. Such consequences eventually affect the quality of work performed as a stressed nurse will not deliver as per the expected standards.49 Violence also evokes feelings of humiliation, which can lead to an increase in absenteeism.50

9.2.2 | Physical consequences

Physical consequences are the result of an assault on nurses from external sources and include broken bones, headaches, wounds, and other injuries that are associated with physical harassment.35 Nurses in the health- care setting have reported being subjected to incidents of physical abuse, including the use of weapons, whereby most of the perpetrators of these violent incidents were patients.3 Physical attacks on nurses within the health- care setting have been reported to include lethal weap- ons, and most of these attacks occur between the afternoon and night time.16 This is due to the fact that the majority of clin- ics do not accept patients after 4 PM, and the managers and administrators also finish work at that time. This results in a large number of patients visiting hospitals and requiring atten- tion from nurses.47 Pushing and hitting have been reported to be the most common forms of physical attacks.13

9.2.3 | Organizational consequences

Workplace violence is associated with a high turnover rate, lack of proper communication skills, lack of experience, and lack of quality care,15 and thus it incurs additional operating costs.7 It is expensive to replace a nurse as the new staff needs to be trained

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so that they can become acquainted with the normal operations of the health- care setting.51 The organization is thus negatively affected in terms of running costs. Furthermore, it can be dif- ficult for the administration to source new and skilled nurses.

9.2.4 | Professional consequences

The professional consequences of workplace violence are re- lated to the delivery of services, manifested through increased sick leave, decreased job satisfaction, a high turnover rate, very low productivity, and an increase in error frequency by staff.23 A nurse who feels threatened will not be inspired to work better. Instead, their motivation to work will decrease and they may opt to venture into other areas to find safety.35 In addition, violence by perpetrators disrupts teamwork, thereby reducing the efficiency of service delivery.

9.3 | Empirical referents

Empirical referents are categories of actual phenomena that may indicate the occurrence of the concept in its contextual framework and enable one to recognize or measure the defin- ing attributes of the concept.24 Although empirical referents are not themselves instruments for measuring the concept, they can be employed in the development of new measure- ment instruments or evaluation of existing ones. Empirical referents can be correlated to the theoretical foundations of the concept and contribute to the content and construct valid- ity of the new measurement tool.

These are symptoms signifying that violence has oc- curred or might occur at any time and can be combined to form a tool that is used as part of the concept under discus- sion. Such observable cues are (a) humiliation, (b) verbal abuse, (c) physical abuse, and (d) horizontal violence and bullying.23

9.3.1 | Humiliation

Humiliation is an act aiming to belittle an individual as well as a failure to acknowledge achieved success. It may be pre- sented in the form of words or actions directed at the victim. This mostly happens when a member of staff fails to appre- ciate the role of another or when someone is the subject of malicious rumors circulated by their colleagues.13

9.3.2 | Verbal abuse

Verbal abuse is also a sign of impending danger.52 Patients or other staff members can decide to use abusive language

against nurses. Family members of a patient can also become perpetrators by subjecting a nurse to verbal abuse.

9.3.3 | Physical abuse

Physical abuse refers to the use of physical force, such as wounding a nurse or inflicting other forms of injury. This indicates the presence of violence. As stated earlier, this can come from patients who are angry with the nurse or even from the family members. The worst- case scenario involves the use of weapons and the throwing of objects.20

9.3.4 | Horizontal violence and bullying

Horizontal violence can be an indicator of violence. This is mostly directed at vulnerable groups within the health- care setting,53 for example, when these are sidelined from major activities and are not consulted. Horizontal violence might involve the withholding of resources, exclusion from the or- ganization's activities, and the belittling of nurses.

10 | PROPOSED OPERATIONAL DEFINITION

The following is a proposed operational definition of work- place violence generated from the current concept analysis:

Workplace violence is any act or threat of physical vio- lence (beating, slapping, stabbing, shooting, pinching, push- ing, smashing, throwing objects, preventing individuals from leaving the room, pulling, spitting, biting or scratching, striking, or kicking; including sexual assault), harassment (unwanted behavior that affects the dignity of an individ- ual), intimidation, or other threatening disruptive behavior that occurs at the worksite with the intention of abusing or injuring the target. It ranges from threats and verbal abuse (swearing, shouting, rumors, threatening behavior, nonseri- ous threats, or sexual intimidation) to physical assaults and even homicide that creates an explicit or implicit risk to the health, well- being, and safety of an individual, multiple indi- viduals, or property.

11 | DISCUSSION AND IMPLICATIONS

It is important to keep the working environment safe, cooper- ative, and respectful.47 The relations

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