Experience of workplace violence against emergency nurses: Suggesting managerial policies and control measures

Article history: Received 25 January 2020 Received in revised form 2 May 2020 Accepted 19 May 2020 The occupational health and safety duty act requires employers to provide a safe and healthy workplace for all of their responsible nursing staff and to gross rational steps to avoid or decline the risk of workplace violence. The aim of the study was to investigate workplace violence against emergency nurses: Suggesting managerial policies and measures used to control it. Descriptive methodological approach was used to fulfillment study aim. The study was conducted at emergency hospital of Zagazig University Hospitals. A purposive sample of 135 nurses working in emergency hospital and fulfilled the inclusion criteria and Jury committee sample (30 experts). An adjusted self-administered questionnaire which comprised of three parts: Socio-demographic of the nurses, Workplace violence and opinionative sheet. The findings clear that 39.3% of the nurses were aged from 20-30 years, with a mean age 35.61±10.67years. The majority of them (89.6%) were females. More than half of them (53.3%) were reported very worried, while only onequarter (25.9%) of them reported that they didn't worried at all. All the studied nurses (100%) exposed to workplace violence, and 63.0% of them exposed to physical workplace violence. two-thirds of them (68.1%) were very dissatisfied with the manner in which the incident was handled. (97.0%) nurses reported their hospital did not develop any policies related workplace violence. Suggesting managerial policies and control measures should be applied and practiced at Emergency hospital, disseminated by the hospital administration to all departments, reviewed, revised and updated periodically as appropriate and as necessary.


Introduction
*The occupational health and safety duty act requires employers to provide a safe and healthy workplace for all of their responsible nursing staff and to gross rational steps to avoid or decline the risk of workplace violence. Workplace violence, a major occupational health, and safety concern arises once nurses experience: Verbal abuse, physical threat, physical assault, sexual assault, and/or homicide (Ncube and Kanda, 2018). OSHA (2017) was defined workplace-violence as any abuse, assault, or else threats directed towards employees at work. The assault can be physical, verbal, plus sexual and will lead to physical and emotional harm of persons (Guay et al., 2014). Workplace violence is an underreported professional risk that has several influences on numerous healthcare personnel (HCWs). The reasons behind violence in the workplace differ (Al Ubaidi, 2018).
Violence can be classified based on the nature of the behavior, which includes physical, sexual, psychological, and verbal violence. It can also be separated according to the sources of violence: a) internal which is performed by employers and employees of the same institute; and b) external, which is performed by outsiders including clients and criminals (Lippel, 2016). In addition, workplace violence is branded into two main groups: Physical and non-physical or psychological, including verbal abuse, bullying, and mobbing as well as sexual and racial abuse that may overlap both groups (Whelan, 2008). Earlier, consideration has always been given to workplace physical violence, but recently, the harm caused by non-physical violence, including verbal and psychological at the workplace gained more attention (Chappell and Di Martino, 2006).
As a consequence of experiencing violence in the workplace, workplace violence is one of the reasons which can strongly decrease job satisfaction (Teymourzadeh et al., 2014). Besides, workplace violence affects nurses' job performance and nursing care. Also, the exposure to violence at the workplace can result in increased absenteeism, influencing nurses' personal and professional lives, increasing stress besides, distrusting of administration, and increasing burnout and staff turnover (Algwaiz and Alghanim, 2012). Generally, a high level of abuse among nursing staff considered a vital cause for losses from the workforce and an incapability to invite new staff (Alyaemni and Alhudaithi, 2016;Blanchar, 2011). In brief, violence in the emergency department has been usually accepted as part of the job (Stene et al., 2015).
Emergency department (ED) is the entering access to all other hospital wards where emergency nurses are working on the forward-facing line of patient care (Fute et al., 2015). In fact, the emergency department provides actual vital services for the life bullying circumstances, and the number of patients with the emergency department is growing each day (Esmaeili et al., 2015). Amongst healthcare sets, emergency departments are at the maximum hazard of violence where nurses are three times further possible to experience violent proceedings in comparison with other workers (Jabbari-Bairami et al., 2013). Generally, the literature suggested that nurses are at a greater risk of experiencing violence in the workplace compared to other healthcare providers (Arnetz et al., 2015).
For effectively managing violence in the workplace, managers need to identify that not only working situations are essential, but individual differences from personal characters can often play a role, and individual reactivity can affect perceptions. Management can act to report the reason and pay distinct attention to the demands (Rodwell and Demir, 2012). Furthermore, the management of violent incidents and its subsequent interventions result in reducing the risk of psychological and physical side effects of violence among nurses. As follows, providing a safe working environment for their employees is the responsibility of healthcare managers (Hemati-Esmaeili et al., 2018). The active participation of managers in policies to prevent and combat violence at work is a preponderant factor for the use of knowledge, skills, and attitudes that allow the appropriate decision making regarding violence management (Sousa et al., 2018).

Problem identification
According to the report of the United States of America in 2012, which stated that the rate of violence against health care workers is increasing and has turn into a pandemic (ANA, 2019). The incidence of workplace violence in healthcare settings rests inadmissibly great. Employees in health care settings are at advanced threat of verbal and physical abuse than any further occupational set (Rayan et al., 2016). Workplace violence became a universal concern and perceived as an actual serious safety and health risk, particularly in a healthcare setting (Zainal et al., 2018).
Clearly, violence against nurses is a compound and insistent professional experience challenged by the nursing profession (Sharma and Sharma, 2016). Despite the significance of the problem, there has been very little regular research converging on the matter in hospital EDs in the Middle East region, and Egypt is no exception (Abou-ElWafa et al., 2015). So the aim of the study is to investigate the workplace violence against emergency nurses: Suggesting managerial policies and measures used to control it.

1.
What is the level of anxiety regarding workplace violence among emergency nurses? 2. Is there an experience of workplace violence against emergency nurses? What is the exposure type? 3. Why do emergency nurses not report the incidences of violence? 4. Are they satisfied with the manner in which the incident is handled? 5. Has their hospital manger been developed specific policies on workplace violence? 6. What are managerial policies and control measures to deal with workplace violence?

Research design
The descriptive methodological design was used to examine workplace violence against emergency nurses: Suggesting managerial policies and control measures. Setting: This study was conducted at the emergency hospital of Zagazig University Hospitals, which includes two sectors involving 8 hospitals are: New surgery, emergency, general medicine, delivery, and premature, cardiothoracic, pediatric, el-Salam and economical treatment hospital.

Study sample
A purposive sample of 135 nurses working in an emergency hospital and fulfilled the inclusion criteria. The inclusion criteria: Defined for sample choice were as follows: (Nurses were working in the previously mentioned settings for as a minimum one year constantly with fulltime work and approve to join in the study). The sample moreover involved: Jury committee sample (30 experts). The included hospital director, hospital matron, members of crisis and disaster management unit Faculty of Medicine, doctors, nursing, and academic staff to assess the content and face validity of designed managerial policies and control measures.

Sample size for studied nurses
The ideal sample size was calculated using this formula (Israel, 2013) where, n is the sample size; N is the total population number (155 nurses); e is margin error (0.05).
They were 121 female and 14 male nurses (39.3%) of the nurses were aged from 30-30 years. The majority of them (89.6%) were females. Most participants (77.0%) of them were staff nurses. Most of them (65.9%) were married, more half of them (53.3%) had a diploma degree. 32.6% of the nurses had an experience of 6-10 years. The sample personal characteristics are obtainable in Table 1.

Tool of data collections
An adjusted self-administered questionnaire of The International Labour Organization, Internal Council of Nurses, the World Health Organization, and the Public Services International's (ILO/ICN/WHO/PSI, 2003). The health sector workplace violence questionnaire was adapted and used to collect data which comprised of three parts: a) socio-demographic of the nurses: Which include: "age, gender, position, social status, educational qualification and years of experience." b) Workplace violence includes: Their exposure of workplace violence, its type, the reason for not reporting, the perpetrator of violence, and the frequency of incidents in the last year. Information on the perpetrator of violence was collected by choosing one of the following: Violence by patients, by visitors, by physicians, by nurses, and by others. Questions relating to the experience of violence were with a yes/no format, their satisfaction regarding the manner in which the incident was handled rated on 5-point Likert scale ranged from 1 (strongly disagree) to 5 (strongly agree). c) Opinionative Sheet: The sheet was developed to assess the content validity of managerial policies on various aspects associated with workplace violence, and measures used to control workplace violence. It involved the opinions of the experts for each item were recorded on a two-point scale: Relevant or not relevant.

Validity the study tools were translated into Arabic
The adjusted questionnaires were then pre-tested and modified for face and content validity by a panel of experts in the field. They were then revised on the basis of the results of a pilot study of 14 emergency staff nurses who were excluded from the final analysis of this study, clarity, and consistency of the tool and to determine the time needed to fill each tool. Modification needed being done included rephrasing some questions, rearrangement of the questions, and omission.

Reliability
Test-retest reliability was done using Cronbach's alpha coefficient test. The total consistency for all items was 0.80.

Pilot study
A pilot study was carried out on ten nurses who were not included in the study to assess the simplicity and applicability of the questionnaire sheet. Based on its result, modifications and omissions of some details were done, and then the final forms were developed.

Procedure of data collection
Data collection from participants was carried out through distribution of the questionnaire sheet to the subjects and handed back to the researcher upon completion after an official agreement was obtained from the hospitals' directors and oral permission of study participants. They were given an occasion to reject or to participate, and certain that the information would be utilized confidentially. This study was executed in two months, started in March 2018 and was completed by the end of April 2018.

Data analysis
The collected data were organized, categorized, tabulated, and analyzed using the Statistical Package for Social Sciences (SPSS) windows version 20. For qualitative data, tables use numbers and percentages. For quantitative data, the table use means, range, and standard deviation. An independent samples-test was used to find the association between variables. Correlation between variables was evaluated using Pearson's correlation coefficient (r). Significance was adopted at p≤0.05. Table  1 illustrates the demographic characteristics of the studied sample. It was clear that 39.3% of the nurses were aged from 30-30 years, with a mean age of 35.61±10.67 years. The majority of them (89.6%) were females. More than three-quarters of them (77.0%) were staff nurses. Regarding their social status, 65.9% of them were married. As regards their educational qualification, 53.3% of them had diploma degrees. In addition, 32.6% of the nurses had experience of6-10 years with a mean of 11.54±6.89 years. Table 2 indicates the distribution of the studied sample according to their current workplace characteristics. It was found that 85.9% of the nurses had direct physical contact with patients/clients. Furthermore, 48.1% of the nurses were most frequently worked with both sexes (males and females). More than three-quarters of them (71.1%) were reported the availability of reporting procedures. Moreover, 79.2% of them confirmed the presence of encouragement to report workplace violence. In addition, near half (47.7%) of the nurses had referred to the role of the management in encouraging to report workplace violence.   Fig. 1 shows the distribution of the studied sample according to their level of anxiety regarding workplace violence. More than half of them (53.3%) were reported very worried, while only one-quarter (25.9%) of them reported that they didn't worry at all.  Table 3 portrays the distribution of the studied sample according to their experience of workplace violence. It is clear from the table that all the studied nurses (100%) exposed to workplace violence, and 63.0% of them exposed to physical workplace violence. The patient/client relatives were responsible for 83% of workplace violence. As regards the place of incidents, inside health institution or facility was the most reported (97.0%). Regarding the work schedule, workplace violence was more prevalent in the morning shift from 7.00 AM.-before 1.PM. (38.5%). Finally, 45.2% of them didn't remember the day of the week, which the incidents most happen.  Table 4 displays that among those who reported workplace violence, 34.8% tried to defend themselves physically. Moreover, less than one-third (31.1%) of them reported no consequences for the attacker. As regards the reasons for not report the incident, useless and afraid of negative consequences were the most reported 46.7%, 20.7%, respectively. In addition, 40.7% of them reported that they experienced workplace violence once in the last year, and 13.3% experienced5-10 times in the last year. Fig. 2 reflects the distribution of the studied nurses according to their satisfaction regarding the manner in which the incident was handled. More than two-thirds of them (68.1%) were very dissatisfied with the manner in which the incident was handled, while about one-quarter (26.7%) of them reported very satisfied.

Fig. 2:
Distribution of the studied sample according to their satisfaction regarding the manner in which the incident was handled Table 5 states the distribution of the studied sample about policies and measures to deal with workplace violence. It is declaring from the table that (97.0%) nurses reported their hospital did not develop any policies related to workplace violence. As regards the measures to deal with workplace violence, all the studied nurses (100%) reported in their hospital did not apply security measures, improve surroundings, restrict public access, patient screening, patient protocols also, training, and investment in human resource development.

Discussion
In the latest years, workplace violence (WPV) against healthcare workers and nursing staff have developed a global problem (Morken et al., 2015). Violence in the healthcare setting can have severe individual consequences for nursing staff, such as a loss of consciousness, need for medical treatment, disability, also even death. In addition to lost workdays and absenteeism, enlarged work-related tension, employment termination, or turnover. Moreover, WPV has serious both patients and the facilities since violence is related to adverse patient outcomes due to the minor quality of care besides treatment provided (Roche et al., 2010).

What is the level of anxiety regarding workplace violence among emergency nurses?
Findings of the present study reported that more than half of the studied sample was very worried, while only one-quarter of them didn't worry at all. These results corroborate that nurses' worry about violence is a serious problem requiring a need for attention from hospital managers. These results disagree by Xing et al. (2016), which stated that 85.2% of respondents had some degree of worry about WPV, and 22.1% were either worried or very worried. As well, Gale et al. (2006)  We found that all the studied nurses exposed to workplace violence, and 63.0% of them exposed to physical workplace violence, patient relatives were the major responsible for workplace violence. This might be physical violence was also associated with high job strain, low social support, and low organizational justice among nursing staff. Likewise, in a study conducted by Warren (2011) to determine Workplace violence in hospitals: Safe havens no more, that majority of nurses who were exposed to workplace violence had various psychological disturbances after the attack. As well, Hemati-Esmaeili et al. (2018) mention that the level of occupational violence against nurses increases from 68.8 to 98.6 percent, which is a considerable rate among healthcare settings. Moreover, Magnavita and Heponiemi (2011) concluded that nurses reported more physical assaults during the previous 12 months, and nurses were mostly assaulted or harassed by patients or their relatives and friends.
Further, many kinds of research supported this result: The study in Chinese clarify that workplace violence against nurses (93.5%) in Chinese hospitals Jiao et al. (2015) and similar to the study in Saudi Arabia (71.7%) Algwaiz and Alghanim (2012) and correspondingly, a study in Iran (Esmaeilpour et al., 2011). Furthermore, in the survey, by Yoo et al. (2018) found that 67.5% of the nurses agree that they had experienced violence from their visitors (families or relatives). Verbal violence was reported more than physical ones. They showed moderate or severe responses to violence. This study is comparable to previous research that indicating relatives of the patients were the major source of violence, 86.8% in your study (Abed, 2014). Conversely, this finding disagreed with a study by (Keyvanara et al., 2015). Who points out verbal abuse was the most common type of violence experienced by 60% of participants. Besides was higher than what was reported in the previous study in Basra city (24.6%) (Abed, 2014).
3. Why do emergency nurses not report the incidences of violence?
As regards the reasons for not report the incident, useless and afraid of negative consequences were the most reported by the studied sample. The researchers thought that adequate documentation is crucial step towards addressing this issue, such as workplace violence. This finding is congruent with that of Ebrahim and Issa (2018), who carried out a study in Basra and found that the majority of those who exposed to workplace violence didn't submit violence reports. Too, supported by Esmaeili et al. (2015), who found that (76.3%) studied subjects reported the main reason for not reporting the incident of violence was they consider it of not important and useless. Above all agree with study in Egypt Abdellah and Salama (2017) than similar to Abed (2014), who concluded that 63% of nursing and physician staff at the polyclinics in Barbados reported at least one episode of violence in the past year. The previous finding is incongruent and higher than reports in the study done in Iran, Jordon, by Ahmed (2012), who performed a study investigated verbal and Physical abuse against Jordanian nurses in the work environment and in the study made in Basra.
4. Are nurses satisfied with the manner in which the incident in an emergency hospital is handled?
As regards the distribution of the studied nurses about their satisfaction with the manner in which the incident in emergency hospital was handled. More than two-thirds of them were very dissatisfied. This might be due to that nurses took the hospital as only a place to find a job safety, or because their experiences of workplace violence were only enough to dissatisfy as well could be due to the absence of specific policies regarding workplace violence in a health care setting. This finding is matching with Rayan et al. (2016), who found that most of the participants were not satisfied with the way in which the violence was handled. 5. Has their hospital manger been developed specific policies on workplace violence? Lastly, the main study finding with regard to the distribution of the studied sample about policies and measures to treaty workplace violence exists in your hospital. Nearly all nurses reported their hospital did not develop any policies related to workplace violence, and all nurses reported in their hospital did not apply security measures, improve surroundings, restrict public access, patient screening, patient protocols also, training, and investment in human resource development. This might be due to that inadequate documentation and the UN implementing clear policies and violence prevention programs in health institutions. This directs a need for taking definite actions to control violence at the workplace. In the same way with Higazee and Rayan (2017) found that study subjects reported "No" changes at workplace to decrease violence.
On the contrary, in other studies carried out by Duncan et al. (2016) who summarized that, outstanding security measures might augment working conditions for nurses and improve the risks of violence at the workplace also mention preceding research has emphasized on the role of these measures to reduce workplace violence in health care facilities. Moreover, Ebrahim and Issa (2018) recommended that legislations need to be activated to protect health staff in general and specifically the emergency unit staff. Above all this study finding is contradicting with that of Abed (2014) who concluded that advocacy, educational programs, and proper training are needed to enhance awareness of this problem between health service managers, healthcare workers, and the overall hospitals as well, paying attention to exact security concerns, such as having dedicated security personnel and panic buttons, would be supportive and Hemati- Esmaeili et al. (2018) mention that, to create a safe environment for patient care in the emergency department (ED), a comprehensive program for the prevention of violence is necessary.

Conclusion and recommendations
According to the results of this study, it could be concluded that more than half of nurses were reported very worried, while only one-quarter of them reported that they didn't worry at all. All the studied nurses exposed to workplace violence, and near two-thirds of them exposed to physical workplace violence. Two-thirds of them were very dissatisfied with the manner in which the incident was handled. , The majority of nurses, reported their hospital did not develop any policies related to workplace violence. Therefore, suggesting managerial policies and control measures should be applied and practiced at the Emergency hospital, disseminated by the hospital administration to all departments, reviewed, revised, and updated periodically as appropriate and as necessary.