Consequences and Control Measures of Workplace Violence among Nurses

Background: The exposure to violence at workplace can result in post-traumatic stress disorder symptoms, anger, anxiety, shame, guilt, and self-blame among nurses. Workplace violence is associated with nurse absenteeism, medical errors, decreased job satisfaction and burnout. Aim: To examine the workplace violence, its negative consequences and the measures used to control it among nurses. Methods: A descriptive research design using selfadministered questionnaire was employed. A convenient sample of 107 nurses from three hospitals completed the study. In order to assess negative consequences of violence at workplace and measures used to control it, an instrument was adopted for the purpose of this study. Results: About half of the participants were subjected to workplace violence in the last 12 months. About 39% of the participants reported that no action was taken to investigate the causes of violence. In addition, the most frequently reported consequence of violence was "verbal warring". Overall, most of the participants were not satisfied in the way in which the violence was handled. Only thirty percent of the participants who witnessed incident of violence in workplace reported it. The most commonly reason for not reporting violence is because it is "useless" which was reported by 26.2% of the participants. The most frequently reported measure performed to decrease the violence incidences was increasing staff number. Conclusion: Policy makers should develop specific policies to report violent incidences. Using specific security measures to decrease the violent incidences is also highly recommended.


Introduction
Workplace violence against nurses and health care professionals leads to serious negative consequences for nurses, patients, and the health care organization (International Labour Organization, International Council of Nurses, World Health Organization, and Public Services International [1]. Workplace violence might include aggression, assault, abuse, or threatening of health care providers at work or in circumstances related to their work [2]. In recent years, violence at workplace has gained special attention and is now a major concern in both developing and developed countries [3].
Workplace violence is very costly, with estimated costs of billions of dollars yearly [4], and result in hundreds of workplace homicides each year [5]. Violence at workplace might also be associated with serious personal, emotional, physical, professional consequences. Workplace violence against nurses and health care professionals might result in absenteeism from work or leaving nursing altogether [6].
The exposure to violence at workplace can result in posttraumatic stress disorder (PTSD) symptoms, anger, anxiety or fear, shame, guilt, and self-blame among nurses [7,8]. In addition, it is associated with nurse absenteeism, medical errors, decreased job satisfaction and burnout [9]. In some situations, violence at workplace might result in severe physical health consequences include injuries and disabilities [10].
Literature suggested that nurses are at a higher risk of experiencing violence in the workplace compared to other healthcare providers [7,8]. Some studies found that up to 80% of nurses have reported experiencing violence by the patients [7,8,11]. In addition, many of violence incidences are underreported.
To date there are limited studies in the Middle East Region regarding the negative consequences of violence at workplace and the measures used to control it. To develop effective intervention programs to control violence at workplace in the Middle East Region, baseline data investigating various factors related to workplace violence among nurses are needed. Subsequently, the purpose of this study was to examine the workplace violence, its negative consequences and the measures used to control it among Jordanian nurses.

Research design
A descriptive design was used for this study employing a survey method to investigate the workplace violence, its negative consequences and the measures used to control it among Jordanian nurses. Data regarding the sociodemographic variables and measures to control violence at workplace were obtained from the participants.

Data collection
For the purpose of this study, the researchers collected the data from three hospitals located in Amman, the capital city of Jordan. The researchers targeted three settings including psychiatric and mental health settings, the emergency departments, and one elderly home in which care is provided by nurses. Nurses employed in these settings are providing care for patients from all over the country.

Ethical considerations
An approval of the study protocol was obtained from the Institutional Research Board (IRB) committee in Zarqa University. The researchers have also obtained the IRB for the ethical approval form the three hospitals where data were collected. Data collection was started in June, 2015 and completed in January, 2016. The inclusion criteria for the current study are: being a Jordanian nurse, who is able to read and write in Arabic language; having experience of at least one year, and currently working in a Jordanian hospital. The purpose of selecting these criteria is to assure that the participants are able to complete the study questionnaires and to guarantee that they could have experienced violence at workplace. Nurses who met the inclusion criteria were invited to complete the study. Data were collected by the original researchers who provided a description about the study protocol to all nurses who completed the study. The researchers explained the purpose of the study to all participants and assured the confidentiality for their data; the researchers informed them that the data would be used for the research purpose only. Completing all the questionnaires in the study took 15 minutes.

Participants
A convenient sample of 107 nurses completed the study including 49 males (45.8%) and 58 females (54.2%). Most participants have bachelor degree in nursing (n=84, 78.5%). About half of the participants have experience of less than 5 years in nursing practice. Most participants were employed in the emergency departments (n=73, 68.2%), followed by psychiatric and mental health care settings (n=26, 24.3%), and elderly home (n=8, 7.5%). The sample characteristics are presented in Table 1.

Instruments
The current study used two instruments to investigate the workplace violence, its negative consequences and the measures used to control it among Jordanian nurses. These instruments include the demographic questionnaire and the modified scale about the negative consequences and the measures used to control it.

The modified scale about the negative consequences of violence at workplace and the measures used to control it
In order to assess negative consequences of violence at workplace and the measures used to control it, an instrument was adapted for the purpose of this study. The instrument was originally developed by the Public Services International (PSI) and the International Council of Nurses [12]. In addition, the instrument was finalized in collaboration with the World Health Organization (WHO) and the International Labor Office (ILO). This measure focuses on various problems and complaints nurses experienced after attack, the consequences of violence to attacker, the reasons of not reporting violence incidents, policies on various aspects associated with workplace, the measures to deal with workplace violence, and changes occurred in the workplace in the last two years.

Data analysis
Data were analyzed using SPSS program (version 22). Descriptive statistics including frequencies and percentages were used to describe the sample characteristics. Descriptive statistics were also used to describe the problems and complaints nurses experienced after violence, the consequences to attacker, reasons for not reporting the incidences of violence, and the policies and measures used to control workplace violence.

Results
The experience of violence, its types, and its preparators A total of 51 (47.7%) participants were attacked in the last 12 months. A total of 28 (26.2%) participants took time off from work after attack. Thirty nine percent of them reported that no action was taken to investigate the causes of incident. About 38.3% of the investigations were conducted by the employer, while 9.3% were conducted by police.

The consequences of violence to attacker
The consequences to attacker are reported in Figure 1. No action was taken for 32.7% of the violence incidences. The most frequently reported consequence of violence was "verbal warring issued", which was reported in 32.7 of the violence incidences. Only 10% of the participants were satisfied in the way in which the incident was handled.

Figure 1
The consequences to attacker.

The reasons of not reporting violence incidents
A total of 42 (39.3 %) of the participants witnessed incident of violence in workplace in the last year. However, only 33 (30.8%) of the participants have reported the incident of workplace violence that they witnessed or experienced in the last year. Table 3 presents the reasons of not reporting violence incidents as reported by the participants who did not report the incidences of violence. The most commonly reason for not reporting violence is because it is "not important" and "useless" which was reported by (28% &26.2%) of the participants respectively.

Policies on various aspects associated with workplace
Presence of specific policies on various aspects associated with workplace violence is presented in Table 4. These aspects include safety, physical workplace violence, bullying/mobbing, and threat. As shown by Table 5, the percent of participants who reported presence of specific policies for all of these aspects was less than 50%.

The measures to deal with workplace violence
The measures to deal with workplace violence in workplace are presented in Table 5. These measures are security measures, improve surroundings, restrict public access, patient screening, patient protocols, increased staff numbers, changed shift or rotates, reduced periods of work alone, training, and investment in human resource development. Only 4.7% of the participants reported absence of all of these measures in their workplace. As presented by Table 6, the most helpful measure to control workplace violence was "Restrict public access" which was reported by 95.3% of the participants.

Changes occurred in the workplace in the last 2 years
To decrease the violence incidences, many changes have occurred in the workplace. The most frequently reported change was "Increased staff numbers " which was reported by 25 participants (23.4%). However, it is noteworthy to mention that about 27.1 % of participants who experienced violence incidences reported "None" of these changes occurred in the workplace in the last 2 years ( Table 7).

Discussion
The purpose of the current study was to examine the workplace violence, its negative consequences and the measures used to control it among Jordanian nurses. Although the prevalence and sources of workplace among Jordanian nurses were reported in literature [13], data regarding the consequences of workplace violence and the measures used to control it have yet to be established.
About half of the participants were subjected to workplace violence in the last 12 months. This percent is consistent with the previous literature in this area of investigation [13]. Nurses who were exposed to workplace violence had various psychological disturbances after attack, including disturbing memories, thoughts, or images, being super alert, avoid thinking or talking about the attack, and feeling everything, they did was an effort. Unsurprisingly, violence at workplace was reported to cause serious consequences on nurses [6].
About 39% of the participants reported that no action was taken to investigate the causes of violence. In addition, the most frequently reported consequence of violence was "verbal warring". Overall, most of the participants were not satisfied in the way in which the violence was handled. In addition, this could be due to the absence of specific policies regarding workplace violence in the selected setting [14].
Only 33 (30.8%) of the participants who witnessed incident of violence in workplace reported it. The most commonly reason for not reporting violence is because it is "useless" which was reported by 26.2% of the participants.
Subsequently, there is a need to establish a specific and uniform reporting system for all incidents of violence at workplace.
The security measures (i.e. prevent unwanted visitors, establish clear policies regarding access to sensitive areas, and video surveillance) were the most frequently reported measures to deal with workplace violence. Excellent security measures might enhance working conditions for nurses and alleviate the risks of violence at workplace. Previous research has emphasized on the role of these measures to reduce workplace violence in health care facilities [15].
The most frequently reported change to decrease the violence incidences was "Increasing staff number". Increasing nurse-to-patient ratios was found to be a significant predictor of violence among nurses [15]. However, it is noteworthy to mention that about 27.1 % of participants who experienced violence incidences reported "No" changes at workplace to decrease violence. This indicates a need for taking specific actions to control violence at workplace.

Conclusion
The current study concluded that most of the participants were not satisfied in the way violence was handled, the most commonly reason for not reporting violence is because it is "useless", and the most frequently reported measure performed to decrease the violence incidences was increasing staff number. Therefore, future research may want to examine the effectiveness of specific interventions to control violence at workplace. In addition, using the qualitative approach to explore the lived experiences of nurses who were exposed to various types of violence is recommended. Additionally, Policy makers may want to develop specific policies to report violent incidences. Using specific security measures to decrease the violent incidences is also highly recommended as it was reported by most of the participants.

Limitation of the Study
The most important limitation of the current study is using a convenience and relatively small sample. A future research with a larger and more representative sample is recommended.