INTRODUCTION:

Nursing is a highly stressful profession. Everyday nurses are dealing with patients and their relatives in different clinical setting. Because of many reasons patient and their relatives become aggressive and violent toward healthcare professionals. The most serious incidents of aggression and violence are reported in healthcare facilities.

The effects and consequences of verbal abuse can be devastating and long-lasting. Research that has focused on its consequences has found that it is both physiologically and psychologically damaging.¹ Violence is mainly due to several reasons, such as unwilling to report incidents, peer pressure, limited support from supervisors and a dearth of funding for research into aggression against healthcare professionals.

Unfortunately there is evidence that the levels of violence among inpatients is increasing. Violent behaviour is an important obstacle among patients undergoing effective rehabilitation. A hope and help can be offered to patients, staffs and families.²

Nurses who work in the setting, such as emergency rooms, critical care areas and trauma centre often care for people who respond to events with angry and aggressive behaviour that can pose a significant risk to themselves, other patients and health care providers. Thus preventing and managing behaviour are important skills for all nurses to have.

Raeda Fawzi (2011)studied on physical violence in the workplace in a Jordanian Hospital Nurses among 420 nurses and found that 22.5% of the participants were exposed to physical workplace violence.³

D Jackson (2002)⁴ stated that in a climate of a declining nursing workforce where violence and hostility is a part of the day-to-day lives of most nurses, it is timely to name violence as a major factor in the recruitment and retention of registered nurses in the health system. Workplace violence takes many forms, such as aggression, harassment, bullying, intimidation and assault. Violent acts are perpetrated against nurses from various quarters including patients, relatives, other nurses and other professional groups. Research suggests that nurse managers are implicated in workplace violence and bullying. Furthermore, there may be a direct link between episodes of violence and aggression towards nurses and sick leave, burnout and poor recruitment and retention rates.

Workplace violence is acknowledged as a major problem in healthcare settings and affects staff morale, recruitment, retention and direct healthcare budgets. Staff training is advocated as the appropriate managerial response, but identifying appropriate training and trainers is difficult and there is little published evidence of training effectiveness. Student nurses are frequent targets of aggression but are less likely to receive specific training.⁵

PROBLEM STATEMENT:

A descriptive study to assess the prevalence of violence by patients and their relatives towards staff nurses with respect to their knowledge and utilization of safety resources in a selected hospital of Amritsar, Punjab.

OBJECTIVES OF THE STUDY:

1. To assess the prevalence of violence by patients and their relatives towards staff nurses.

2. To assess the knowledge and utilization of safety resources among staff nurses regarding violence.

3. To assess the relationship between prevalence of violence towards staff nurses and their knowledge and utilization of safety resources.

4. To determine the relationship between prevalence of violence by patients and their relatives towards staff nurses with selected socio-demographic variables such as age, gender, marital status, professional qualification, total professional experience and present ward experience.

5.To determine the relationship of knowledge and utilization of safety resources by patients and their relatives towards staff nurses with selected sociodemographic variables such as age, gender, marital status, professional qualification, total professional experience and present ward experience.

6. To prepare the guidelines regarding prevention and management of violence among staff nurses.

Assumption

Staff nurses are victims of violence in various clinical settings.

Delimitation

Study is restricted to staff nurses who are having minimum 1 year of working experience.

OPERATIONAL DEFINITIONS:

1. Safety Resources: Preventive measures used by staff nurses against violence.

2. Patients: Clients admitted for some medical/surgical reasons.

3. Relatives: Persons who are staying with admitted patients in the selected hospital.

4. Staff Nurses: The nursing personnels having minimum 1 year of working experience in the various departments of selected hospital.

5. Knowledge of Safety Resources: Adequate information regarding the safety resources in response to violence.

6. Utilization of safety resources: Use of safety resources during or after violent attacks.

MATERIAL AND METHODS:

Total 100 staff nurses of Guru Nanak Dev Hospital, Amritsar (Punjab) using convenient sampling technique. The research tool consisted of socio-demographic data, prevalence of violence, Knowledge of safety resources regarding violence and utilization of safety resources regarding violence. The socio-demographic data consisted of items for obtaining information about age, education, age, gender, marital status, professional qualification, total professional experience, and present ward experience. Prevalence of violence was a self structured questionnaire. Knowledge of safety resources regarding violence was a self-structured questionnaire. It consisted of 24 items. Each question carried 1 mark. Total score was 24 marks. There is a provision of three types of responses for each individual item i.e. Good (>16), Average (9-16) and Poor (<9). Higher the score, more knowledge of safety resources regarding violence.

Utilization of Safety Resources regarding Violence was a self structured check list to identify utilization of safety resources regarding violence among staff nurses. This check list was made of 15 items. Items were scored dichotomously i.e. Yes/no means Yes (01) and No (00). There was a provision of two types of responses for each individual item i.e. Favourable (≥8) and Unfavourable (<8). Negative items were reversely scored. The reliability of knowledge of safety resources regarding violence was r’=0.7 and utilization of safety resources regarding violence was r’=0.73.

RESULTS:

It shows that maximum (29%) staff nurses were in the 26-30 years of age, followed by above 40 (27%), 21-25 years (20%) and 31-35 years (17%). Very few (7%) were between 36-40 years of age. As per gender, most of the staff nurses were females (99%). Only one (1%) was male nurse. More than three-fourths (78%) were married whereas remaining (21%) were unmarried, none was widow. Most of the staff nurses (90%) were diploma holders. Maximum (39%) of the staff nurses were having experience of 1-5 years followed by those who had 6-10 years (25%), above 20 (23%), 11-15 (8%) and 16-20 (5%) years of experience.

On the basis of present ward experience, 68% of staff nurses were having 0-5 years of present ward experience. On the other hand, the study subjects with 6-10, 11-15 and above 15 years were found to be almost equal in number i.e. 11, 11, 10 respectively.

All subjects (100%) have experienced assault. It reveals that most of the subjects (97%) experienced assault 1-5 times during their present ward experience whereas none of the subjects were found to be never being assaulted by the patient and their family/relatives. About 99% of the staff nurses experienced verbal assault and only one had experienced physical assault. Out of 100, 91% of the subjects experienced violence in the wards as followed by 5% and 4% who experienced violence in duty room and outside the ward respectively. Most of the subjects (52%) experienced violence in the morning shift as followed by those (30%) who experienced violence in night shift. On the other hand, only 18% of the subjects experienced violence in the evening shift.

Almost equal number of subjects (49% and 51%) experienced violence by patients and their family/relatives respectively. Maximum of the staff nurses (68%) were having average (13.15) knowledge as compared to those who were having good knowledge (28%) about safety resources (Table 1)

Maximum mean score of utilization of safety resources among staff nurses was 8.93 (14%) under favorable cases as compared to those staff nurses who came under unfavorable cases i.e. 4.31(86%). There was positive correlation between utilization of safety resources and knowledge of safety resources with assault experienced. Most of the subjects (99%) has 14.15 mean knowledge score of safety resources who have experienced verbal assault and only 1 subject who has experienced physical assault have 18 knowledge score of safety resources.

DISCUSSION:

Violence was found to be a significant problem affecting the majority of nurses. The findings showed that all subjects experienced 100% assault. A study by Laura Sofield (2003)⁶revealed that 24% of the subjects experienced assault. A study by Yu-Hua Lin (2004)⁷suggested that 62% of the nurses experienced workplace violence. But findings by Michael Privitera (2006)⁸ reported that 43% of the respondents reported being threatened and 25% being assaulted.

Out of total, 99% of the staff nurses experienced verbal assault as compared to only 1% of those who experienced physical assault. A study by Jessica Gacki (2009)⁹ reported that approximately 25% of respondents reported experiencing physical violence more than 20 times in the past 20 years and almost 20% reported experiencing verbal abuse more than 200 times during the same period.

On the basis of hospital area of violence experienced, it showed that 91% of the subjects experienced violence in the ward as followed by 5%, 4% who experienced violence in duty room and outside the ward respectively. According to Leung (2006)¹⁰ revealed that most of the violence occurred in male wards, in certain specialties, such as the Orthopedics and Traumatology Departments. The findings from Gulten Sucu (2007)¹¹ reported that most common violence occurred in the intervention room (42.4%), patient observation unit (36.9%) and the venue (33.3%).

On the basis of time of incident, it was shown that most of the subjects (52%) experienced in the morning shift as followed by those who have experienced violence in night shift. On the other hand, only 18% of the subjects experienced violence in the evening shift. A study by Cathy Owen (2008)¹² reported that most of the incidents occurred in morning (424 incidents, or 33%) or (460 incidents, or 36%) and fewer incidents occurred at lunch (275 incidents, or 21%). The findings from Thomas J Rippon (2000)¹³ found that nurses working in night shifts had experienced more violence than those working in day shifts.

IMPLICATIONS:

Nursing Education

In the revised curriculum of basic nursing education, much emphasis is laid on psychiatric nursing regarding aggression and violence as it is period of transition, causing much turmoil and stress adjust new situation.

Teaching learning activities should include health education on assessment and prevention of violence and promotion of use of safety measures among staff nurses.

Provide a framework for contracts between patients and their families, and health care providers regarding their conduct.

Nurses should be trained for early identification of potentially violent behavior, including looking for aggressive body language and facial expressions, threats or gestures, refusal to communicate and the identification of previously violent patients. The use of various techniques may reduce the risk or severity of violence and aggression.

Nursing research

First, it has been considered a part of the job and as a result, certain administrations have not supported initiatives to prevent incidents or to mitigate the impact.

Second, some health care professionals have been unwilling to report incidents of aggression and violence due to peer pressure and limited support from supervisors.

Further work needs to be done to develop a comprehensive instrument that can accurately measures all types and severity of aggression. Only then will nurses be better able to accurately report the magnitude of the problem, and administrators better able to allocate appropriate resources to help prevent incidents, intervene and mitigate the impact.

Nursing Practice

Active measures to set zero tolerance policies and develop skills in preventing and responding to violence are needed.

Instituting appropriate policies and legislations would minimize workplace violence.

Practical measures to reduce violence should be started such as identify hazards, evaluate the risks and whether the existing precautions are adequate, set parameters for course training standards and modify the physical environment.

Provide guidance to deal with the problems commonly arising. A nurse counselor/nurse specialist in the violence management and prevention is the priority need for proper guidance and directing the staff nurses regarding the violence.

RECOMMENDATIONS:

1. A comparative study can be conducted to assess the prevalence of violence among male and female staff nurses in hospitals.

2. A descriptive study can be conducted to assess violence exposure and burn-out among nursing home staffs.

3. A comparative study can be conducted to assess physical violence and verbal violence among staff nurses.

4. An evaluative study can be conducted to assess violence among staff nurses by psychiatric patients.

5. Study can be conducted to evaluate the policies and procedures available in hospital regarding violence and their effectiveness.

6. An exploratory study can be conducted to assess the various factors responsible for violence and their management.

7. A comparative study can be conducted to assess prevalence of violence between hospital staff and community health staff.

8. An observational study to assess associations between nurse behavior and violence in psychiatric hospital

REFRENCES:

1. M Michelle Rowe, Holly Sherlock. Stress and verbal abuse in nursing: Do burned out nurses eat their young? Journal of Nursing Management. 2005; 13(3): 242-248.

2. Thomas J Rippon. Aggression and violence in healthcare professions. J Adv Nurs. 2000; 31(2): 452-460

3. Raeda Fawzi. Physical violence in workplace among Jordanian Hospital Nurses.J Transcult Nurs. 2011; 22(2):157-165.

4. D Jackson. Who would want to be a nurse? Violence in workplace-a factor in recruitment and retention. J Nurs Management.

5. Bernard Beech. Evaluating a management of aggression unit for student nurses. J Adv Nurs. 2003; 44(6): 603-612.

6. Laura Sofield, Salmond Susan W. Workplace violence: A focus on verbal abuse and intent to leave the organization. J Orthopaed Nurs. 2003; 22: 274-283.

7. Yu-Hua Lin, Hsueh-Erh Liu. The impact of workplace violence in nurses in South Taiwan. J Psych Ser. 2004; 49(11): 207-229.

8. Michael Privitera. Violence toward mental health staff and safety in the work environment. 2005; 56(6): 480-486.

9. Jessica Gacki. Violence against nurses working in US Emergency Department. J Nurs Adminis. 2009; 39: 342-349.

10. Leung WC. Prevalence of workplace violence against nurses in Hong Kong. Hong Kong Medical Journal. 2006; 12(1): 6-9.

11. Gulten Sucu, Fatma Cebeci, Erbu Karazeybek. Violence by patient and relatives against emergency service personnel. Turkish Journal of Emergency Medicine. 2007; 7(4): 207-219.

12. Cathy Owen. Violence and aggression in Psychiatric Units. J Psych Serv. 1998; 49(11): 1452-1457.

13. Thomas J Rippon. Aggression and violence in healthcare professions. J Adv Nurs. 200; 31(2): 452-460.

Received on 10.09.2014 Modified on 17.09.2014

Asian J. Nur. Edu. and Research 5(1): Jan.-March 2015; Page124-127

DOI: 10.5958/2349-2996.2015.00027.0

Levels of Knowledge	Knowledge of Safety resources				t	df
Levels of Knowledge	n	%	Mean	SD	t	df
(a) Good (>16)	28	28	17.86	0.85	(a,b)12.24^NS	94
(b) Average (9-16)	68	68	13.15	1.96	(b,c)6.94^NS	70
(c) Poor (<9)	4	4	6.25	1.26	(a,c)24.19^NS	30

Prevalence of Violence towards Staff Nurses and their Knowledge and Utilization of Safety Resources