Have you ever been slapped, clothing pulled, or bitten by a patient? Has a patient, a relative or even a health care professional used abusive language, or threatened you if you tried to enforce a hospital policy or did not comply with a demand?

If your answer is “no,” consider yourself one of the few nurses escaped verbal and physical abuse at the hands of patients, family members, colleague, or visitors in the course of your duties.

Violence has been recognized as a major problem crosses all boundaries, become global, and has clear implications in the current and future projected shortage of nurses, as well as proficiency, the safety and quality of patient care, and negative impact on nurse retention and quality of life, as well as on organizations (ANA, 2009; CENTER, 2008; CDNM, 2005; ICN, 2008; JC, 2007; NACNEP, 2007).

The hospital has been viewed as a safe haven, a place where anyone can go and, be protected and cared for, now it lost that view. Moreover, as patient protected since they became a one why health care worker are not treating same as they preserving life and provide care.

Health care workers have been found to be at high risk for violence than workers in any other sector, particular non- fatal violence. However, nurses are at the most likely to be assaulted (Bureau of Labor Statistics, 2005; Gerberich, Church, McGovern, Hansen, Geisser, Ryan, &Watt, 2004; Hegney, Plank, Buikstra &Parker 2006; Nancy, 2007; Wieclaw, Agerbo, Mortensen& Bonde 2006).

Nurses are facing a whole range of problems and challenges due to issues around professional autonomy, abuse and violence imposed organizational change , occupational health and safety issues and constant restructuring, the working environment could be experienced as hostile abusive or unrewarding (Bradley,& Moore,2004;Jackson, Firtko& Edenborough,2007).

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Aim

The purpose of this paper to review the contemporary literature regarding the violence toward nurses at work place and identify the current strategies followed to prevent such issues.

Definition and types of workplace violence

Workplace violence has defined as “the intentional use of physical force or power, threatened or actual, against oneself, another person or against a group or community that either results in or has a high likelihood of resulting in injury, death, psychological harm, mal-development or deprivation occurring in the workplace” (NIOSH,2004;WHO,2003).

Violence can take many forms, including verbal and emotional abuse (which is humiliates, degrades or indicates a lack of respect for the dignity and worth of an individual); physical assault; threats of physical violence; unwanted sexual advances; and harassment (ICN, 2008; ILO, 2003; WHO, 2003).

(Bartholomew, 2006; Griffin, 2004; Rowell, 2007; Stanley, Martin, Michel, Welton & Nemeth, 2007), they explore that horizontal violence is the physical, verbal, or emotional abuse of an employee. Moreover, within nursing, lateral violence has been defined as nurse to nurse aggression it can be manifested in verbal or nonverbal behaviors which interferes with effective communication among health care providers and negatively impact performance and outcomes. Furthermore, verbal abuse is a way of abuser” bullies” attempt to coerce their victims (Sullivan, &Decker, 2009).

According too many researcher the non-physical violence (verbal) is more frequently and prevalence than physical on. Which can include: silence backbiting, gossip, and passive aggressive behavior.

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How committed violence

(Ferns, 2007; Rayan, & Maguire, 2006; Sofield, & Salmond, 2003), associates the most frequent source of verbal abuse and toward nurses was primarily physicians, and in descending order patients, families and peers, supervisors and subordinates. However, the reasons behinds such behavior from patients are anger, frustration, pain, anxiety, loss of control, long wait-times and disorientations with perceived lack of care or communication from staff.

(Sofield. et al, 2003), conclude that the patients are the most frequent source of sexual harassment and physical assault; over half of the sexual assaults are committed by physicians. Furthermore, the physical assaults by patients, the majority of whom are impaired (Farrell, & Cubit, 2005; Gerberich, et al, 2005).

(Rowe, & Sherlock, 2005), reported that the nurses were the most frequent source of verbal abuse towards other nurses. Patients` families were the second, followed by physicians and then patients.

(El-Gilany, El-Wehady, & Amr, 2010), recognize that the perpetrators were mostly Saudi, males, of middle age, patients’ relatives, low socioeconomic status and with lower education or young illiterate males.

Moreover, whereas violence was most common or once primarily limited to nursing homes, long-term care facilities, intensive care units, emergency, and psychiatric units, it has inched its way into the rest of the facility so “No one is immune”(Gacki-smith , Juarez, Boyett, Homeyer, Robinson, & MacLean, 2009; Trinkoff, Geiger-Brown, & Caruso, 2008).

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Overview of the problem through literature

In Turkey the nurses are facing the verbal abused more often than physical violence with the highest rates in ICU, following by out-patient clinic, and EDs staff with no formal system for reporting abuse (Ergun, & Karadokovan, 2005; Oztunc, 2006).

In Japan, nurses in psychiatric units were more suffering from severe psychological distress after experience violence, verbal abuse, and a high level of sexual harassment (Inoue, Tsukano, Muraoka , Kaneko, & Okamura, 2006; Hibino, Ogino, & Inagaki, 2006).

In Iraq about 42% of nurses were facing physical abuse committed usually the patient`s family and 14.3% attacked with a lethal weapon (Abu Al Rub, Khalifa, & Habbib, 2007), the area of study not shown. (Adib, Al-Shatti, Kamal, El-Gerges, & Al-Raqem, 2002), Kuwait nurses experience verbal abuse about 36% and 10% of physical violence study done among all healthcare facilities.

In Canada a study done to examine the violence in pediatric ward it show about 94% of pediatric nurses’ experienced verbal abuse in duration of 3 month prior to study (Pejic, 2005). Other study done to assess the affect of violence on nursing intervention found that a higher in incidence of delayed nursing interventions when individual nurses experienced violence (Obrien, Thomson, McGillis, Pink, & Wang, 2004).

(Roche, Diers, Duffield, & Catting-Paull, 2010), assess the cause of violence in medical- surgical ward conclude that violence is related to deficiencies in nursing practice and negative patient out-comes , emphasizing that violence does not be “just a part of the job for nursing but can actually managed.

(El-Gilany, et al 2010), examine the primary health care workers in Saudi Arabia, as they were the first line of close contact with the population, the PHC staff witnessed emotional violence more frequent about 92% especially the verbal abuse is 54.2%, emphasizing that the Saudi culture has its own unique characteristics of segregation of both genders in public places and its conservative society based on Islamic rules that discourage violence.

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(Esmaeilpour, Salsali, & Ahmadi, 2011), first study done in Iran on violence among EDs staff conclude that the verbal violence was much more frequent than physical assault, the patient relatives were the most common source of both violence .also all physical violence was without weapon, relay on the strict Iranian judiciary system`s. (Di-Martino, 2003), emphasize the importance while assessing the workplace violence, must take into considerations the general culture of that workplace.

What the causes of violence

(Di-Martino,2003,Esmaeilpour,et.al.,2011;Findroff,McGovern,Wall,Gerberich, &,Alexander,2004;Pawlin,2008),they suggested that increasing in patient interaction that involves close personal contact such as performing personal care, changing positions and lifting is a risk factor for physical violence, unmet service demand, and lack of penalty for perpetrators. Furthermore the causes in EDs could be due to inadequate safety measures, vulnerability of nurses and a high level of pressure in this particular area (Catlette, 2005; Johnson, 2009; Roll, 2005).

Interestingly, customer services initiatives (e.g., minimizing the physical barriers between staff and patients, encouraging nurses to be chamber to customers) taking priority over organizations` concern on protecting the staff from aggressive patients (Homeyer, 2005).

Particularly, in gulf region, low opinion held by large segments of population toward the nursing profession (Adib, et.al, 2002; El-Gilany, et al., 2010).

Moreover ,increasing number of handguns, and other weapons ,increasing diagnosis of mental illnesses among populations, unrestricted movement of the public in hospitals, lack of or poorly controlled visitor policies, long waits in EDs or clinics and crowded, uncomfortable waiting rooms, high numbers of drug or alcohol abusers ,and trauma victims; misperceptions by patients or visitors of staff behavior;

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low staffing levels at certain times, working alone in areas of hospital without backup or alarm systems, lack of staff training in recognizing and managing escalating hostile behavior (El-Gilany,et .al,2010;Franz, Zeh, Schablon, Kuhnert, & Nienhaus, 2010 ; Luck, ,Jackson, &Usher , 2007 ;May,& Grubbs, 2002; Pirro,& Bruen , 2010; Shields,&, Wilkins,2009).

How can affect new graduate

The phrase ”nurses eat their young” has been use to describe the negative impact of destructive behavior on new graduate nurses, they emphasize on the vulnerability of newly nurses specially the verbal violence which affected their perception and the ability to remain in their current position, which lead to more shortage in nursing profession, this stage is critical and can compromise the new graduate as they feel incompetent, invisible, and inferior (Rowe&Sherlock,2005;Griffin,2004;JC2007).

As gender

”Ninety- five percent of nurses around the world are women. Also, they are targets of violence more often than men. Attitudes towards women are often reflected in interactions with the profession. Nurses are the health care workers most at risk, with female nurses considered the most vulnerable (International Council of Nurses, n.d, 2009; Wieclaw, et. al, 2006).

On other hands (Gerberich, et. al, 2004), conclude that males were more likely than females to experience violence, may be due to differences in exposures.(Adib,et.al 2002; Esmaeilpour, et. al,2011), male nurses were the victim of physical violence more than the female staff the rational is based on religious context, which not allowing males to touch female.

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(Wieclaw, et. al, 2006), men working in these typically female professions have the highest risk of depression and stress disorder due to suffer from high conflicting job demands, and display a high degree of over commitment.(Sripichyakan, Thungpunkum,& Supavititpatana,2003), prevalence of violence among male worker were high among staff in Thailand.

Why not reported

Feeling safe at work should be at the top of the list. If nurses don`t feel secure, and if they believe that their employer accepts violence, loss of trust will follow and most of the time the nurses are blaming by the managers. Nurses must be empowered to explore alternative methods of managing episodes of violence and feel safe and supported in the workplace.

A lot of literatures suggest that nurses experience blame from superiors and this could influence a nurse`s decision not to report unacceptable behavior, moreover, the most verbal abuse was not referred to authorities. (Findorff, et .al, 2005) conclude that nurses who experienced aggression from physician 43% did not report the incident and if reported was only verbally.

(Erikson, &, Williams, &, Tenn, 2000; Franz, et.al 2010; Stanley, et.al, 2007), explore that the poor transparency of the reporting procedures and lack of support and action taken by superiors and acceptance of certain aggressive behavior as a part of nursing work.

The reasons behind that as suggested could be that nurses felt reporting was an empty gesture, with a general lack of support, feeling that it is wrong to be seen to need support as professional, some see that violence in a particular area such as psychiatric ward it`s part of the job (Ferns & Chojnacka, 2005; Royal College of Psychiatrists, 2007).

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Nurses who felt that their managers were not able to improve the situation felt powerless and influence a nurse`s decision not to report unacceptable behavior (Duxbury, 2003; Jackson, et.al, 2002). (Homeryer, 2005), nurses are discouraged from taking legal actions because they realize that hospital administration may want to avoid the publicity when sue patients.

(El-Gilany, et.al, 2010), reasoned that women`s fear of reporting violence particularly sex harassment due to culture and strict Islamic roles. Furthermore, violence in Saudi Arabia could be worse due to discrimination as the majority of healthcare workers are expatriates.

The consequences of violence on nurses

Work related violence has most destructive consequences affect the employee, the employer, others in the work setting. Workplace violence has been associated with reduced productivity, increased absenteeism, burnout, turnover, and financial losses (Gates,Fitzwater,&,Succop,2003),decreased staff morale, reduced quality of life (Gerberich, et al ,2005),decreased job satisfaction (Hesketh,2003;Shadar, Broome, West,& Nash,2001),changes in relationship with the co-worker and family as well as feeling incompetence and guilt (Kamchuchat,2008), leaving the profession (Dellasega,2009;Salmond, et.al, 2003 ,and direct /indirect financial burdens for the health economy and society as a whole(Lee,2006).

Most of literature described the consequences of non-physical violence appeared to be more severe than the physical assault, (Maldonado, &,Greenland, 2002; Shaffer, Casteel,&,Kraus,2002), report that the most obvious consequences of work related violence – physical injury, disability, and other physical effects, such as sleeplessness, chronic pain, nightmares, and flashbacks.

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The psychological and emotion effects include feelings of helplessness, irritability, sadness, soreness, depression, shock, disbelief, and sympathy for who committed the assault. Other identified consequences including; family disruption, career change, and fear of recurrent (Aiken, Clarke, Sloane, Snchalski, Busse, & Clarke, 2001; Gabal, & Gerberich, 2002; Herman, Hernandez-Diaz, & Werler, 2002; Riopelle, Bourque, &Robbins, 2000).

Violence prevention

”Unfortunately, most hospitals do have a security and safety plan like the fire plan, or patient safety…Few focus on staff safety, especially from assaultive patients.”(Homeyer, 2005).

The majority of evidence emphasizes the importance to develop a strategy to prevent violence among health care workers to improve the quality of care and retain nurses. Healthcare professionals facing coercion sometimes choose to abandon their advocacy role to avoid intimidating behaviors, which impact patient safety.

Promote a culture of safety that encourages and improve open and respectful communication, interdisciplinary collaboration among all health care providers and staff, provide support , education , and counseling to the victim(Joint Commission ,2007 ;Rosenstein,2002).

The US department of Labor and OSHA produce Guidelines for preventing workplace violence for Health care and Social worker. The employers realize that if the program is successful that is means it has the following elements: management commitment and employee involvement, hazard prevention and control, safety and health training, documenting, and program evaluation. Health organizations should adapt

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a zero- tolerance policy with respect to violence in health care setting (OSHA, 2010; Trinkoff, et.al, 2008).

(Nachreine, et.al 2005), examine the effectiveness of zero- tolerance policies found that the odds of physical assault decreased among nurses working in locations which implement these policies. Additionally in the US, some hospitals have implemented a ”code” for violence (Jacobson, 2007).

Some researchers highlight the importance of advocacy of nurses and establishment of a zero-tolerance policy to protect nurses (Henderson, 2003). Others emphasize the impact of environmental factors such as use of an authoritarian nursing style as precursors to patient aggression (Duxbury, &Whittington, 2005).

According to (El-Gilany, et.al, 2010), the reaction to violence is depending on individual traits and experience to control and reacts to a conflict. Moreover, about one of third of victims did not take any coping mechanisms which are, telling a colleague, pretending it did not happen, telling family/friends, and trying to forget the event.

Other research proposed the need to promote personal growth in nurses through develop resilience because it is not possible for them to give patients what they do not themselves possess. Personal resilience may not retain nurses in the profession. It is important to assist nurses to develop skills that will help them in being more resilient and better able to cope with challenging and difficult working climate, autonomy, empowerment, emotional awareness, and self- care are important factors in developing resilience which improved well-being, lowering vulnerability and achieving high quality care (Darbyshire,&, Jackson,2005; Hodges, Keeley, &Grier,2005; Hutchinson, Vickers, Jackson, &,Wilkes ,2006; Jackson, et.al, 2007;Judkins, Arris, &,Keener,2005; McGee, 2006; Tugade ,& Fredrickson,2004).

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Conclusion

The organizations should establish a zero-tolerance policy for violence, all employees should aware about it, and maintain there is no place for violence in professional practice environments. Eliminate institutional barriers for a safe work environment by supporting a culture of open communication and reporting among nursing staff, health care personnel, and students regarding violence in the workplace.

All disruptive behaviors have a serious impact on the retention of nursing staff as well as the safety and quality of patient care accordingly damaged the organizations reputation. Violence prevention is a vital step toward improving the work environment for nurses, who may be leaving the bedside because of safety issues.

The healthcare provider should be able to recognize the signs of escalating violence to evaluate when a person is becoming violent, assured that reporting violence will not result in reprisals, and know the steps to take if a violent incident occurs (Sullivan, et al 2009).

No federal laws worldwide to protect nurses from violence in the workplace, impose penalties on the offenders, or mandate violence prevention programs. In USA antibullying legislation has been passed in few states (American Nurses Association, 2008).