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Workplace violence against nurses: a narrative review

Background and Aim: Any harmful act Physical, sexual, or psychological committed against the nurses in the workplace by a patient or visitor is called workplace violence (WPV) against nurses. WPV is directly related to decreasing job satisfaction, burnout, humiliation, guilt, emotional stress, intention to quit a job, and increased staff turnover. The purpose of this narrative review is to explore the concept of WPV, its prevalence, consequences, influence on nursing, and strategies developed to prevent such incidences. WPV is not acceptable and, regardless of the culprit’s physical or psychological status, should be held responsible for such a heinous crime. WPV can have a vastly negative impact on nurses. Unfortunately, violence in the workplace has become so common that it is now considered an unpleasant part of the job and ignored instead of being reported. Nurses should be educated appropriately on hospital policies against WPV and be encouraged to report any incidence. Relevance for Patients: WPV is detrimental to nurse and patient’s relationship which negatively affects patient care.


Background
Violence against nurses has been a pandemic. According to the World Health Organization (WHO), "between 8 and 38% of nurses suffer from health-care violence at some point of their career" [1]. Compared to other workplaces, health care workers have a higher risk of getting physically, sexually, or psychologically injured. Incidents where staff is abused, threatened, or assaulted in the circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being, or health are Workplace Violence (WPV) [2]. The WPV is divided into two main groups: Physical and psychological, including racial abuse, bullying, verbal abuse, and mobbing, which may overlap in both groups [3]. WPV can be directly related to increased job stress, decreased job satisfaction, absenteeism, burnout, sleep disorder, fatigue, post-traumatic stress disorder, fear, and suicide. Overall, WPV negatively affects a nurse's working life, resulting in decreased productivity and quality of care. There is a paucity of information regarding WPV against nurses in the literature. A few publications available discuss WPV aggregately in the health-care profession [4][5][6]. A recent systematic literature review on WPV against nurses discussed the antecedent factors surrounding WPV [7]. However, articles written from the perspective of a nurse discussing exclusively WPV against nurses and the mental and professional implications of such WPV incidents are very rare to none. In this narrative review, we intend to exclusively discuss WPV against nurses and its implications.

Purpose
The purpose of this paper is to explore the concept and prevalence of WPV, its trend, consequences, influence on nursing, and strategies developed to prevent such incidences.

Issue
The prevalence of WPV is very high. Different research suggests variable prevalence but undoubtedly remains high. According to Cheung et al., in 2017, among 25,630 incidences of WPV occurred in the United States, of which 74% occurred in healthcare settings. Similarly, the same study shows that medical occupation group represents 10.2% of all WPV [2]. Health-care professionals, and in particular, nurses, are most exposed to WPV [3]. Similarly, Liu et al. in their study reported that 62% of participants reported exposure to any form of WPV, 43% reported exposure to non-physical violence, and 24% reported experiencing physical violence in the past year [5]. Nurses are the frontline workers, and patients spend more time with nurses in care facilities than other health-care providers, automatically increasing the risk of violence. Other factors that increase the risk of violence in health-care settings include increased workplace stress, novice nurses, shift jobs, and understaffing. These situations can lead to delayed care for patients and they might take these situations as negligence of nurses causing the violence [3]. Similarly, other important components of violence are a patient's viewpoint regarding the nurse and their role. They have a specific role for a nurse and violence occurs when those roles are not played out as the patient wishes. Similarly, WPV depends on the workplace environment because nurses are abused by patients and visitors and by coworkers, supervisors, or administrators.
Being a female dominant profession also puts nurses at risk of WPV. We live in a patriarchal society and nurses have been subject to violence since the beginning of time [3]. According to one study conducted in Iran, 90% of nurses who reported being victims of violence at the workplace were female [8]. Furthermore, according to Cheung et al., engaging in direct patient care seems to correlate significantly with WPV. The incidence of WPV is very high in elderly units (63.8%), pediatrics (22.1%), maternity units (15.3%), psychiatric units (14.7%), and emergency rooms (<10%) [2]. The patients in these departments need high-level and direct care from nurses. Patients may feel powerless and lose control over their life and simultaneously may be in pain and under the influence of drugs or alcohol with no proper way to vent. The accumulation of anger, frustration, and powerlessness is often directed toward the nurses in verbal abuse or physical violence, which ultimately causes psychological problems. Ironically, the professional who helps the injured and abused toward better health is at the highest risk of getting abused and forgotten.

Current trends
WPV is increasing at an alarming rate. According to Arnetz et al. [9], hospital WPV-related injuries are four times greater than in other sectors. Similarly, according to the same study, one out of every five nurses had to experience WPV at some point in their career. Among the health care workers, nurses have been affected mainly by violence and nothing much has changed since the pioneering research of Marilyn Lanza in 1985 [3]. The rate of violence against nurses seems to be increasing rather than decreasing. In the health-care setting, nurses follow orders from doctors, which is perceived by many as a low hierarchy job, which is another reason for the incivility of the patient toward the nurses. Nurses are the backbone of the health-care system but often go unnoticed. Despite the disturbingly increasing rate of violence, very few things to none have been done to prevent it. Violence is taken as one of the ugly parts of the job and it is being ignored by the administrators and supervisors. Similarly, nothing much has been done by the federal or state governments to protect nurses. According to the American Nursing Association, only 36 states have established penalties for assault of nurses. Among those 36 states, seven states apply if the assaults have occurred in an emergency or mental institute only. In general, in a WPV case, the law only helps if severe bodily injuries are inflicted on nurses. There are no laws for emotional abuse or any other form of nonphysical abuse [10].

Significance of issue
WPV creates constant fears in the mind of the nurses. WPV not only affects the health care worker like nurses and doctors but also the organization like hospitals or mental health institutions. Nurses and the health-care setting have an intimate and interdependent relationship; the deterioration of one leads to the ultimate deterioration of the other. More than 70% of nurses are constantly worried about being a victim of WPV. These stresses decrease job satisfaction and increase the constant psychological stress, which negatively affects nurses' work and personal life. All forms of violence result in psychological distress. According to Li et al., among all types of violence, nurses face verbal abuse and physical abuse the most [4]. In another study, verbal abuse (57.6%) was the most common form of non-physical violence reported, followed by threats (33.2%) and sexual harassment (12.4%) [5]. Physical abuse includes but is not limited to kicking, shooting, biting, beating, slapping, pinching, stabbing, and pushing. Constant physical and verbal abuse emotionally scares nurses.
WPV has a significant negative impact on nurses and has been categorized into four subgroups: Biophysiological, cognitive, emotional, and social [3]. Fear, anxiety, headache, and irritability fall under the biophysiological category, which physically interferes with the quality of care provided by a nurse. Similarly, disbelief, a threat to personal integrity, and transformed perception fall under the cognitive category, which causes decreased job satisfaction, increased staff turnover, burnout, and absenteeism. Anger, guilt, apathy, and helplessness fall under the emotional category, which causes sleeplessness. Likewise, insecurity and antisocial fall under the social category, which hampers coworkers' relations and creates a toxic working environment [3]. All these humiliations and violence, in the long run, can cause severe emotional distress such as post-traumatic stress disorder, depression, and suicide [8]. Hence, it is vital to address these issues as fast as possible. WPV is constantly pushing the nursing profession backward.

Influence on nursing practice
WPV significantly hampers nursing professionals. Constant fear and anxiety dramatically decrease the quality of care provided by a nurse. WPV negatively affects the therapeutic relationship between nurse and patient. Violence results in humiliation and guilt, which negatively affects the psyche of a nurse. In the long run, this phenomenon causes burnout, decreased job satisfaction, and reduced attraction to the nursing profession. Living in constant fear of unavoidable violence causes physical exhaustion, increased stress, insomnia, and post-traumatic stress disorder. According to Escribano et al., 1.4% of total homicide in the United States is related to WPV in the health-care system. It is a great irony that the group of people responsible for the well-being of others is being abused [3].
WPV creates a toxic working environment for nurses. Trust toward the administration, supervisor, and coworker diminishes, creating a hostile working environment. Furthermore, it creates significant consequences for victims, coworkers, and organizations.

Controversies
There are not sufficient pieces of consistent literature on WPV toward nurses. Inconsistent literature regarding the concepts of WPV makes these situations more complex. It could be true that some violent acts such as verbal abuse are simply considered an unpleasant part of the job. In a setting such as psychiatric, maternity, and pediatrics, this violence is regarded as an unavoidable or average risk of the job. Similarly, some psychiatric nurses can have a positive view of aggression [3]. However, this point of view does not protect nurses' integrity and dignity. Despite the unit nurses are working, they will feel fear, humiliation, and stress in response to WPV.

Strategies
WPV has become so prevalent globally that the International Labor Office, International Council of Nurses, World Health Organization, and Public Services International in 2002 jointly issued guidelines to address WPV in the health-care sector. In 2003, the American Association of Occupational Health Nurses, Inc. signed an alliance with the Occupational Safety and Health Administration regarding WPV [11]. The health institutions have their specific strategies and workforce against WPV. Despite all the efforts, the WPV remains high, and the success data of such strategies remain elusive. Patients with dementia, schizophrenia, under the influence of alcohol or drugs, and anxiety are some of the major delinquents of WPV against the nurses [12]. However, the culprits of WPV are not limited to the above medical conditions but also patients in a lucid and normal state of consciousness. Hence, it is vital to perform a quick assessment of risk behavior. For example, according to D'Ettorre et al., this assessment can be done by following the STAMPEDAR (staring, tone, and volume of voice, assertiveness, mumbling, pacing, emotions, disease process, anxiety, and resources) technique. However, this technique does not protect against the violence itself. This risk assessment helps predict whether the patient will be violent or not down the line and gives nurses some insight to prepare for what might come next [12].
In general, the common causes of WPV are understaffing, increased stress among nurses, the demanding nature of the job, and prolonged waiting period. These causes eventually end with dissatisfied patients and visitors, causing WPV [12]. In a study, 63% of emergency department violence was reported to have occurred in the waiting room, which can be attributed to the aforementioned causes [13]. To prevent WPV, the primary interventions should be carried out at the administrative level managing the high demanding job and improving the working environment. Frequent training should be conducted on improving patient-nurse relationships, stress management, communication skills, anger-control management, and de-escalation skills [12].
Health care workers, including nurses, should be appropriately educated on the hospital/organization's policy on reporting violence. According to Escribano et al., in a study conducted in Switzerland general hospital, only 7.6% of the participants knew about their hospital policy against WPV. Similarly, as per the same article, in a study conducted in Australia, among the 37.7% of official complaints against the WPV, only 1% got a response from the administration [3]. These two studies show that WPV is most likely not being reported due to a lack of knowledge on policies, and administration/supervisors utterly ignore those reported. Hence, it creates an untrusty working climate. WPV against nurses is getting worse day by day. Hence, it is imperative to have a zero-tolerance policy against WPV.

A nurse's position
WPV is an occupational hazard that is getting uglier by the day. It is never acceptable, and no matter the culprit's physical or psychological status, they should be held responsible for such a heinous crime. Among all health care workers, nurses, especially female nurses, are more at risk of being abused at the workplace. Despite being the most ethical and caring profession, the nursing profession is still a victim in today's patriarchal society. It is disheartening to see that despite the increased violence against the nurses, nothing tangible has been done to protect them. The constant fear of being a victim of WPV makes nurses selfconscious around the patient, which hampers the nurse-patient relationship. This situation dramatically decreases the quality of care and willingness to care for a patient.
Nursing is not an easy profession. It is demanding and requires a lot of patience as the nurses work with people from different locations and cultural backgrounds. However, WPV is turning an already difficult job into an unbearable one. The nursing profession is already facing shortages due to increased life expectancy of patients and inequitable workforce distribution. Furthermore, if this WPV against nurses cannot be managed in time, we cannot DOI: http://dx.doi.org/10.18053/jctres.08.202205.010 say that the day will not come when we have a severe shortage of nurses which will eventually cause the collapse of the health-care services.

Conclusion
Any act that causes physical, psychological, or sexual harm to the nurses at the place of work is WPV against the nurses. Unfortunately, violence in the workplace has become so common that it is now considered an unpleasant part of the job and ignored instead of being reported. Nurses should be educated appropriately on hospital policies against WPV and be encouraged to report any incidence.