Workplace Violence Directed at Nursing Staff at a General Hospital in Southern Thailand

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1 J Occup Health 2008; 50: Journal of Occupational Health Field Study Workplace Violence Directed at Nursing Staff at a General Hospital in Southern Thailand Chalermrat KAMCHUCHAT 1, Virasakdi CHONGSUVIVATWONG 2, Suparnee ONCHEUNJIT 3, Teem Wing YIP 4 and Rassamee SANGTHONG 2 1 Department of Community Medicine, 2 Epidemiology Unit, Faculty of Medicine, 3 Department of Public Health Nursing, Faculty of Nursing, Prince of Songkla University, Thailand and 4 School of Medicine, Flinders University, Australia Abstract: Workplace Violence Directed at Nursing Staff at a General Hospital in Southern Thailand: Chalermrat KAMCHUCHAT, et al. Department of Community Medicine, Faculty of Medicine, Prince of Songkla University, Thailand This study aimed to document the characteristics of workplace violence directed at nursing staff, an issue which has rarely been studied in a developing country. Two study methods, a survey and a key informant interview, were conducted at a general hospital in southern Thailand. A total of 545 out of 594 questionnaires sent were returned for statistical analysis (response rate=91.7%). The 12- month prevalence of violence experience was 38.9% for verbal abuse, 3.1% for physical abuse, and 0.7% for sexual harassment. Psychological consequences including poor relationships with colleagues and family members were the major concerns. Patients and their relatives were the main perpetrators in verbal and physical abuse while co-workers were the main perpetrators in cases of sexual harassment. Common factors to incidents of violence were psychological setting, illness of the perpetrators, miscommunication, and alcohol use. Logistic regression analysis showed younger age to be a personal risk factor. Working in the out-patient unit, trauma and emergency unit, operating room, or medical or surgical unit increased the odds of violence by 80%. Training related to violence prevention and control was found to be effective and decreased the risk of being a victim of violence by 40%. We recommend providing training to high risk groups as a means of controlling workplace violence directed at nursing staff. (J Occup Health 2008; 50: ) Received Feb 7, 2007; Accepted Nov 21, 2007 Correspondence to: R. Sangthong, Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Thailand ( rassamee_sangthong@yahoo.com) Key words: Occupational hazard, Workplace violence, Verbal abuse, Physical abuse, Nursing staff Violence is one of the leading causes of morbidity and mortality. The International Council of Nurses (ICN), the World Health Organization (WHO), the International Labor Organization and Public Services International have advocated nurses to unite against violence 1). Subsequently, WHO initiated a global campaign for violence prevention. Nurses and healthcare personnel are most vulnerable to violence in the workplace. The Bureau of Labor Statistics, Census of Fatal Occupational Injuries 2) reported that healthcare workers are 16 times at greater risk of violence than other service workers. Among them, nursing staff are most at risk of suffering workplace violence. Nursing staff in developed countries experience workplace violence on average at least once during their professional careers 2). In Thailand, there has been an increase in the number of reports of violence, especially on women and children in the community. Workplace violence directed at nurses has become an occupational health problem despite nursing being one of the professions that has high authority and respect in Thai society. Violence in the health care environment has been well studied in developed countries 3 9) ; advice on prevention and control of violence has been offered and established 1, 2, 10, 11). Workplace violence directed at nurses, however, has rarely been researched in developing countries including Thailand. Working conditions such as workload, background of the patients, personnel-patient relationship are expected to be different between developed and developing countries. An understanding of the problem would enable appropriate modification of existing practices. This study was conducted to document the characteristics of workplace violence directed at nursing

2 202 J Occup Health, Vol. 50, 2008 staff, namely magnitude, perpetrator, sources and determinants, consequences and reactions, and potential recommendations for prevention of violence and its control. Materials and Methods The study was composed of two parts, a survey and a key informant interview. The survey was conducted among all head nurses, registered nurses, vocational nurses, and nurse assistants at a 500-bed general hospital in southern Thailand in The definition of workplace violence was modified from the Occupational Safety and Health Administration (OSHA) and workplace violence prevention programs 11). It was defined as any incident where employees were abused, threatened, assaulted or subjected to other offensive behavior 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. Three main types of violence that nurses may encounter in the workplace are verbal abuse, physical violence, and sexual harassment 11). Verbal abuse refers to the use of vexatious comments that are known, or that ought to be known, to be unwelcome, embarrassing, offensive, threatening or degrading to another person including swearing, insults or condescending language. Physical violence is the use of physical force against another person or group, that results in physical, sexual or psychological harm and includes beating, kicking, slapping, stabbing, shooting, pushing, biting, and pinching, among others. Sexual harassment was defined as any unwanted, unreciprocated and unwelcome behavior of a sexual nature that is offensive to the person involved, and causes that person to be threatened, humiliated or embarrassed. These definitions were incorporated in the first part of the questionnaire and the respondent was requested to answer whether he or she had experienced it ( yes or no ) in the previous one year and during their nursing career. The numbers of questions on verbal abuse, physical violence, and sexual harassment were 13, 16, and 15, respectively. The hospital where we conducted the study has regularly offered various training and education courses to nursing staff every 1 2 months to improve healthcare quality. Some parts of the Excellent Service Behavior (ESB) course were considered to be relevant to violence prevention. They were communication skills, service psychology understanding clients needs, service behavior how to respond appropriately to clients needs and personality improvement, and safety training handling aggression and defusing hostile situations. Each topic took 3 hours and was offered annually. The course was not mandatory but all nursing staff were encouraged to attend. In the questionnaire, respondents were asked if they had received training in any of these four topics as a background characteristic. An anonymous, self-administered questionnaire was developed based on a literature review and modified from the questionnaire developed by the Joint Program on Workplace Violence in the Health Sector 12). Content validity was examined by six experts including one associate professor of psychiatry, one assistant professor of occupational health, two assistant professors of nursing, one assistant professor of law, and one faculty member of management in public administration (content validity index=0.93). The questionnaire was then pre-tested. Cronbach alpha coefficients were 0.75 and 0.85 on consequences and perception of violence, respectively. After receiving subjects informed consent, the questionnaire was distributed to all eligible participants with a request to return it in an envelope within a twoweek period. The head nurses provided a list of key informants who had experienced violence. Only seventeen key informants agreed to participate in the interview. They were requested to provide detailed descriptions of the violence such as locale and time of the events, perpetrators, causes, consequences, and potential solutions. All information was kept confidential and used for research purposes only. The study was approved by the ethics committee, Faculty of Medicine, Prince of Songkla University. Data from the survey were entered in EpiData ), and analysed with R version statistical software 14). Chi-square test and multi-level logistic regression with a test for the trend were used to determine significant risk factors of violence. The first-level determinants included age and receiving ESB training. Since the number of wards was too numerous to put into the model, each ward was classified as either high risk or low risk. High risk wards were characterized by increasing care of acutely disturbed, violent individuals, unrestricted movement of the public in clinics and hospitals, and long waits 11). Moreover, they were also determined by having a high incidence of violence reported by previous studies 4, 6, 7, 15). High risk wards eventually included the outpatient unit, emergency unit, operating room, medical and surgical units. Low risk wards were ICU, pediatrics unit, post-partum unit, labor room, ophthalmological unit, and private room. The variable of high and low risk ward was thus a contextual determinant of two levels. Data from the interviews were analysed qualitatively and presented as selective case studies. Results A total of 545 out of the 594 questionnaires sent were returned (response rate=91.7%) from 13 head nurses, 294 registered nurses, 100 vocational nurses, and 138 nurse assistants. Baseline characteristics of the respondents are shown in Table 1. Ninety seven percent of the respondents were female and almost half of them were below 30 yr of age. More than half of them were

3 Chalermrat KAMCHUCHAT, et al.: Workplace Violence Directed at Nursing Staff 203 Table 1. Demographic characteristics of respondents (N=545) Characteristics n % Sex Female Male Age (x=34.9, SD=8.9, range=18 60) Education Secondary school High school Diploma Bachelor s degree Master s degree Position Head nurse Registered nurse Vocational nurse Nurse assistant Type of ward Surgical ICU Medical Out-patient Pediatrics Post-partum Emergency Operating room Labor room Ophthalmological Private room Training course No Yes Communication skills Service behavior Service psychology Safety training registered nurses with a bachelor s degree. Almost sixty percent of the respondents had attended at least one of the four ESB courses. Verbal abuse was the most common type of violence, followed by physical assault and sexual harassment. Table 2 suggests that most of the violence may recur relatively frequently with the same person as victim. Nonmutually exclusive types of verbal abuse experienced were: shouting (68.4%), blaming (66.5%), disrespect (56.5%), and using condescending language (50.9%). Pushing (52.9%), kicking (47.1%), and slapping/hitting (41.2%) were the most common types of physical assault. Patients and their relatives were the main perpetrators of verbal and physical abuse whereas three out of the four sexual harassment events were committed by coworkers (Table 3). Miscommunication, anger, emergency situation, anxiety, and symptoms of illness were the most common causes of verbal abuse whereas patients illnesses and alcohol or drug use were the most common causes of physical abuse (Table 4). Logistic regression (Table 5) showed that older age had decreased odds of experiencing verbal violence with a significant linear trend (p=0.020). Training related to violence prevention and control could decrease odds of experiencing verbal violence by approximately 40%. High risk wards, such as the outpatient unit, trauma and emergency unit, operating room, medical and surgical unit, increased the risk of verbal violence by 80%. Immediate consequences to mental health such as distress, anger, and loss of self-confidence were commonly found. A handful of victims (n=7) felt sympathy for the perpetrator. Seventy-three percent of the victims preferred to keep the problem to themselves. Absence from work was reported for 1 out of 17 physical abuse events in the previous year and none for the other types of violence. Due to verbal abuse, almost 50% reported loss of good relationship among co-workers and 5% reported a decreased family relationship. Sixty-nine percent tried to avoid violence at their workplace after experiencing the event. Most events were not time-dependent; thirty-five percent occurred in the morning shift (8 a.m. 4 p.m.). Nurses who experienced violence could determine the potential cause of the violence; only 4% could not. Table 2. Prevalence of violence (N=545) Violence type During nursing career During past 12 months n % n % Verbal abuse Physical violence Sexual harassment More than one type of abuse

4 204 J Occup Health, Vol. 50, 2008 Table 3. Perpetrators of Violence (can be more than one choice) Perpetrator Verbal abuse (n=212) Physical violence (n=17) Sexual harassment (n=4) Patient 111 (52.4) 15 0 Patient s relative 110 (51.9) 0 1 Other nurse 76 (35.8) 2 3 Physician 74 (34.9) 0 0 Supervisor 53 (25.0) 2 0 Outside contractor 23 (10.8) 0 0 Staff of other departments 10 (4.7) 0 0 Table 4. Perceived causes of the violence reported by the victims (can be more than one choice) Perceived causes of violence Verbal abuse (n=212) Physical violence (n=17) Sexual harassment (n=4) Miscommunication 118 (55.7) 3 0 Anger 109 (51.4) 4 0 Stressful emergency situation 107 (50.5) 3 0 Anxiety 91 (42.9) 2 0 Symptoms of illness 91 (42.9) 11 0 Alcohol/drug abuse 61 (28.8) 9 0 No reason 8 (3.8) 0 0 Other Table 5. Multi-level modeling of verbal violence in the past 12 months Variable Odds ratio 95% CI p-value Individual level Age (yr)* Training course No 1 Yes Contextual level Ward type Low risk 1 High risk *p-value for linear trend of age=0.02. Case study From seventeen key informant interviews, short verbatim descriptions of five case studies were selected to present different situations of different types of violence by different perpetrators. Case 1. Verbal abuse by a doctor The doctor asked a senior vocational nurse, who stood closest to the patient, to inject a prescribed medicine into the critically ill patient s vein. The nurse informed the doctor that she was not qualified to do that procedure. The doctor under the stress yelled at her angrily: If you can t inject then get out of here! If this patient

5 Chalermrat KAMCHUCHAT, et al.: Workplace Violence Directed at Nursing Staff 205 was your mother, would you do this to her? Inject now! The intimidation was in front of several clients and co-workers. The nurse felt frustrated and disappointed, and lost her self-esteem. The incident was eventually reported to the head nurse. Case 2. Verbal abuse by a patient s relative An elderly woman presented at the hospital one day after a poisonous snake bite. While a nurse was taking care of her, her blood pressure decreased, and she became unconscious. The doctor and nurses rushed to her and gave proper treatment immediately. The patient s cousin witnessed the event and dreadfully yelled: My cousin came to the hospital with full consciousness, but look what s happened! Have you given her an overdose treatment? I was wrong to bring her to this hospital. The nurses became stressed and anxious, but did not react. Case 3. Physical abuse by a patient At around midnight, a delirious alcoholic patient screamed and attempted to leave the hospital. A nurse tried to stop him. Unexpectedly, the patient abruptly struck the nurse with a chair. Her wrist was painful and swollen. She developed post-traumatic anxiety, became paranoid, and took leave from work for one week. Case 4. Physical and verbal abuse by a co-worker As one nurse finished taking a nurse note, her peer misunderstood that she had not signed off. The nurse was blamed for incomplete work. The chart was thrown in her face and a quarrel ensued. Case 5. Sexual harassment by a patient A nurse aide was giving care to a 65-yr-old male patient in a private room in the absence of other persons. She was touched and hugged when measuring his blood pressure and bathing him. Whenever a third person was present, he would ask the nurse to postpone that routine care. The harassment also occurred with other young and attractive aides. The nurse aides felt stressful and insecure. Results of Key Informant Interview The interview found that verbal violence was associated with giving care to a critically ill patient [cases 1 and 2] and carelessness in giving care, hastiness, long waiting times, shortage of health professionals, authority, patients pain, and loss of life. Physical violence was related to alcohol use [case 3]. Miscommunication could possibly lead to verbal and physical abuse [case 4]. Sexual harassment was associated with out-of-sight locales [case 5]. The nursing staff recommended that the hospital should set up an alarm system, provide a 24-h security surveillance officer and encourage reporting of events as well as increase the number of health personnel to reduce waiting times. From individual staff, recommendations for prevention of violence included being more conscientious at work, improving healthcare knowledge and skills, reporting to the head nurse misunderstandings among co-workers, avoiding direct communication and contact when frustrated, being specially prepared when working with patients under the influence of alcohol or drugs or having pain, expressing understanding and empathy to patients and relatives for their sickness or loss, and controlling patient s pain when possible. Being accompanied by a coworker or the patients relative during close contact care was recommended to prevent sexual harassment. Discussion This study is one of the rare reports concerning workplace violence against nursing staff in Thailand. Almost half of the nursing staff in our study had encountered verbal abuse. Physical abuse and sexual harassment were also a problem. Psychological consequences were the major concern. Patients were the most common perpetrators of both verbal and physical abuse. The high risk group for workplace violence was found to be those with younger age and working in highrisk wards such as the out-patient unit, emergency unit, operating room, and medical and surgical units. Training related to violence prevention and control may reduce the chances of being a victim of workplace violence. Workplace violence is a significant problem for nursing staff 6 8, 11, 15 18) although this study reported a relatively lower magnitude than other studies from developed countries. The difference may be due to differences in setting, work load, working style and attitudes to reporting the event by the victim. Verbal abuse was the most common form of abuse among the three types of workplace violence in this study. Individual psychological consequences and poor relationships among co-workers and family members are of concern. Others reported decreased productivity levels, decreased job satisfaction, increases in errors, and shortages of nurses 9, 16, 19). Long-term effects are not yet known. Common perpetrators were patients and coworkers, a finding similar to previous reports 3, 7, 15, 19, 20). Psychological setting and illness, communication gaps, delay in service, perceived lack of caring, and long waiting times were common factors of the violence in our study and elsewhere 17). The study found significant personal determinants of verbal abuse included younger age. Younger age may be a reflection of lack of work experience and lower education, resulting in a nurse s inability to handle

6 206 J Occup Health, Vol. 50, 2008 potentially difficult situations. Previous reports have shown that personal risk factors for workplace violence included gender, education, childhood abuse or previous assault experience 4, 7, 8, 18, 21 24). We did not find gender to be a significant determinant, probably due to the predominance of females in the nursing profession in Thailand. Working sites at risk in this study included the outpatient unit, emergency room, operation room, surgical ward, and medical ward. Previous studies consistently reported that nurses working in male wards and in certain specialties such as the accident and emergency department, psychiatry department, community nursing service, and the orthopedics and traumatology department experienced the highest incidence of all forms of violence 3, 7 9, 15, 19, 20, 25). These kinds of wards may need special attention in order to reduce the incidence of violence. Training is an essential element of an effective violence prevention program 26). Our study showed training could reduce the risk of verbal abuse by 40%. ESB training improved nursing staff s communication skills, helped in understanding clients needs and how to respond to them appropriately. Nursing staff could also learn to recognize hostile situations and learn how to handle aggression through safety training. The coverage of training, however, was shown by our study to be incomplete (60%). Increasing the coverage of the program is recommended. Physical assaults were less common in this study. In another study, apart from the psychological consequences, injuries sustained from physical abuse were generally bruises or abrasion, minor cuts, pain, muscle strain, and broken bones while permanent disability was found in 2.3% 9). Physical injury in this study was rare, was not serious, and did not require treatment. Common perpetrators were patients, especially those with severe symptoms caused by their disease, or from drugs and/or alcohol. Alcohol and/or drug abuse accounted for about 60% of workplace violence in one other study 9), whereas our subjects reported these perceived causes of violence in less than 30% of events. Racial tension, anger related to hospital policies and the health care system in general could also cause violence 9) but were not perceived as causes in this study. Every increase in the level of education decreases the chances that a nurse will be a victim of physical aggression 18). Perception of risk and maintenance of vigilance to prevent violence, and preparation for prompt rescue should be advocated. Sexual harassment was scarcely reported in this study, probably due to concerns of stigmatization and the psychological consequences. Nurses perceived lack of institutional support and feeling of insecurity in the workplace have been reported elsewhere 9), as has their association with low job satisfaction 19). Hospital staff (physicians, co-workers, and supervisors) were frequently cited as perpetrators of sexual harassment and this finding was also evident in other settings 3, 7, 15, 19, 20). Most studies found victims were unlikely to report the incidents 2, 3, 17) but were likely to confide in friends, family members, or colleagues. Potential reasons were having no apparent injury, being part of their job, making no difference 9). Most victims in our study, however, were hesitant to talk about the incidents to friends and family, and tended to keep their feelings to themselves. This may also be influenced by the Thai culture. A reporting and support system after the incidents in our study were obviously lacking, and thus should be set up. Nursing staff need to be encouraged to report any incidents of workplace violence. The strength of this study lies in its very high response rate (91.7%) compared to other studies. The data were obtained by both qualitative and quantitative techniques, which together provide consistent and corresponding information on the characteristics of workplace violence. Risk factors were identified both at the individual and contextual levels, which offer implications for establishing prevention and control programs. This study, however, was conducted in only one general hospital due to limited resources, and may not be representative of the whole country. A larger survey including more than one institute is needed to provide a more accurate picture of the incidence of workplace violence and the characteristics of the problem. There might be recall bias among the respondents so that only serious events could be recalled and reported. 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