Abstract: Workplace violence is still a problem that nurses may be exposed to in clinical wards. A psychiatric ward is among the most probable one confronting this violence. This study determined the workplace violence in psychiatric wards in Tehran, Iran. Nurses working in Razi Psychiatric Center, Tehran, Iran were enrolled using the International Workplace Violence questionnaire. Among 385 nurses of this ward, 200 subjects completed the questionnaire using a simple random sampling method with a response rate of 91.5%. The prevalence of workplace violence was 71% including mental (93.4%) and physical violence (71.6%). Verbal and sexual violence occurred in 19.1 and 5.5% of subjects, respectively. The 62.3% of the nurses did not report violence because they considered it useless (55.3%) or did not believe to be important (42.1%). The 61.2% believed to the necessity of training courses while 72.7% had completed these courses and 59.6% believed to a reporting system. The need to security guard (56.8%), taking security actions in wards (67.8%) and training of staffs (68.9%) were the most important preventive measures reported to be effective for workplace violence. It seems that training courses, establishing rules to prevent workplace violence, reporting systems, compensating losses from violence, increasing the security at workplace, increasing the number of nurses and providing especial guiding protocols against any workplace violence would promote the wards to control the workplace violence against nurses.
INTRODUCTION
Violence may be visible in different situations and concepts such as violence against women, children and young people and street violence were previously studied. Workplace violence is one of the commonest ones that the staffs of an organization may confront with. OSHA (2004) has defined workplace violence as any kind of assault, threatening or verbal abuse that can occur in or out of a workplace either temporary or permanent (OSHA, 2004). NIOSH (2006) has another definition on workplace violence as physical or threatening attacks against staffs in a workplace during working time (NIOSH, 2006; Atai-Otong, 2001). WHO (2008) has divided the workplace violence into 4 types of physical, mental, sexual and verbal violences.
International Council of Nursing has reported that workplace violence is still a common and major problem in health sector (WHO, 2008). The reports of Occupational Administration of America showed that in US, 2 millions nonlethal workplace violence had occurred annually and they were the third reason of mortality reports. Nurses in different occupational settings such as outpatient and inpatient wards and in especial departments like psychiatric and emergency wards reported presence of workplace violence (Findorff et al., 2005). Violence at work is of great importance for nurses working in mental health services. American Psychiatric Nursing Association (APNA) reported that safety is a major concern for nurses working in psychiatric wards. Nurses are the front line of care providers who are responsible for people suffering from an illness, trauma or pain. So they may face people, patients or their relatives having unusual behaviors (APNA, 2008).
In one study on workplace violence, 1400 subjects from 17 countries who were working in hospitals including USA, Saudi Arabia, Afghanistan and Taiwan were enrolled and 74% of respondents reported a violence at workplace (Hader, 2008). In other studies, the prevalence of workplace violence against nurses was 62% in Taiwan (Lin and Liu, 2005) and 95% in Australia (O’Connell et al., 2000) while verbal abuse against nurses in public hospitals of UK was 68% (Winstanley and Whittington, 2004).
There are some reports on workplace violence in Iran. Among 160 nurses working in Emergency Ward of Tabriz hospitals, western Iran, during a one year period, 37.7% of nurses reported violence at their workplace (Rahmani et al., 2008). In Arak, Central Iran, 71.7% of 205 medical personnel and students reported exposure to workplace violence (Yusefi et al., 2008). In East Azerbaijan, Iran, workplace violence was studied among 486 nurses while 46% had experienced physical violence and 72% mental violence (Zamanzadeh et al., 2009).
Among 82 nursing students of Zanjan School of Nursing and Midwifery, Iran, 18% reported physical violence, 9% a kind of threat and 23% verbal abuse (Aghajanloo et al., 2010). In Baghiatallah Hospital, Tehran, Iran among 450 nurses, 21.3% had experienced physical violence during a period of one year (Ghasemi et al., 2007). In Babol University of Medical Sciences hospitals, Northern Iran; among 302 nurses (61 men (20.2%) and 238 women (78.8%) working in hospitals affiliated to the university, 70.2% of nurses were exposed to verbal violences and 12.6% to physical behaviors (Zabihi, 2009).
In Hormozgan University of Medical Sciences hospitals, southern Iran; among 88 nurses in Bandar Abbas, 72% reported verbal abuse and 9% physical violence during a period of 6 months (Ghodsbin et al., 2008). In Imam Khomeini, Shariati and Sina hospitals affiliated to Tehran University of Medical Sciences hospitals, Tehran, Iran; among 136 nurses in emergency wards, 97% reported workplace violence while physical violences was visible in 39% and non-physical ones in 86% (Salimi et al., 2006). In Tehran, Iran among 413 nurses, psychological violence was noticed among 69% of nurses during a period of one year (Teymoorzadeh et al., 2009).
Considering the few cases in public hospitals and emergency wards in these studies and absence of reports on workplace violence in psychiatry wards, this study was performed to evaluate workplace violence against nurses in psychiatric wards, Tehran, Iran.
MATERIALS AND METHODS
From March to September 2011 using simple random sampling method, 200 nurses working in psychiatric wards with at least one year work experience in Razi Psychiatric Center in Shahre Ray, Tehran, Iran were enrolled. A written consent was provided from each participant. The study was approved in university Ethics Committee (801/4/89/1286). First in a pilot study done twice on 20 nurses with a time interval of 15 days, the correlation coefficient was determined as 73% (r = 0.73).
Data was collected through two questionnaires containing demographics and International Workplace Violence questionnaire of the World Health Organization, International Labor Organization and International Council of Nursing. The reliability and validity of the questionnaire were previously confirmed by several researchers in Iran. Data were analyzed by SPSS software (Version 18, Chicago, IL, USA) using Chi-Square and student independent t-tests. A p value less than 0.05 was statistically considered significant.
RESULTS
One hundreds and eighty three questionnaires were completed by nurses (response rate = 91.5%) while 59.6% were male 40.4% were female. The age of nurses was 36.15±6.58 years. 85.8% of subjects were married and had children and 48.6% were married without any child. 96.7% of nurses were Shia religion, 61.2% were Persian speaking, 48.1% had a bachelor degree and 45.9% were college nurse assistants. 52.5% reported daytime work shifts, 67.2% were permanent governmental employees with 11.78±5.6 years work experience. 50.3% of survey population worked in chronic and 49.7% in acute psychiatric wards, 76.5% were full-time or even overtime employees and 95.6% did not report for security guards in their ward to protect them against any kind of violence. 59.6% of nurses believed in presence of violence at their workplace and 50.8% were always worried about these violent behaviors.
In Razi Psychiatric wards, the prevalence of workplace violence was 71%. Mental and physical violence in these wards occurred with the frequency of 71.6 and 93.4%, respectively. The least type of workplace violence was verbal (5.5%) followed by sexual violence (19.1%) (Table 1).
| Table 1: | Type of violence and the groups exposed to in Razi psychiatric ward |
Violent behaviors were done by the patients as 65.7, 79.5, 93.9 and 100% for sexual, physical, mental and verbal violence, respectively (Table 1). Self-defense and asking for help were reported 27.9 and 23%, respectively (Table 2).
62.3% of the nurses did not report violence because they believed that any report was useless (55.3%) or was not considered important (42.1%). 55.2% mentioned that they did not receive any order from the head nurse to report any kind of workplace violence. 72.7% of nurses believed that no action was taken by the head nurses to identify the reason for the violent behaviors and in 52% of the reported violences; follow-up actions by managers did not satisfy them (68.3%). The main reasons for occurrence of workplace violence were reported to be (i) Low number of nurses in the wards, lack of security guards, consumption of psychotropic drugs and patient’s judicial and legal issues with the frequency of 78.7, 53, 39.9 and 35%, respectively (Table 3).
| Table 2: | Type of nurses’ reaction to violence in psychiatry wards |
The 72.7% of participants mentioned to training courses that they spent on control of workplace violence. 61.2% of them believed that these courses and 59.6% reported that good management systems to report workplace violence are necessary. Besides, presence of security guards (56.8%), security actions in wards (67.8%) and training courses (68.9%) were the most important preventive measure to control workplace violence (Table 4).
DISCUSSION
Our findings showed that the prevalence of mental and physical violence during a period of 12 months was 71.6 and 93.4%, respectively. The most prevalent violence was verbal (95.5%) and the least was sexual violence (19.1%). Other authors in Iran also noticed verbal and physical violence (72.7 and 9.1%, respectively) which are close to our findings (Ghodsbin et al., 2008). Another study in Iran also indicated that verbal violence was the most and that sexual violence was the least similar to our results (Zamanzadeh et al., 2009). It seems that physical violence occurs simultaneously or after a verbal violence.
Our findings showed that most of the violence occurred by patients. Zamanzadeh et al. (2009) demonstrated that most of the verbal and physical violence happened by patients and most of them had verbal and sexual violence to doctors and nurses.
| Table 3: | View of nurses on predisposing factors of workplace violence in Razi psychiatric center, Tehran, Iran |
| Table 4: | View of nurses on preventive factors affecting workplace violence in Razi psychiatric center, Tehran, Iran |
Yusefi et al. (2008) found that 25.85% of violence were done by patients and their relatives. Their findings are different with our results. High rate of violence by patients may be due to mental disorders on one hand and indifference of the patients’ relatives in psychiatric wards on the other hand.
In this study, the patients were requested to be calm and quiet and self-defense and asking for help were the most common reactions done against violence. Rahmani et al. (2008) and Teymoorzadeh et al. (2009) showed that the most common reactions of nurses were asking the patients to be calm and in peace identical to our findings. So it seems that most of the participants accepted the workplace violence as part of their occupational hazard.
Most of the subjects did not report the violence since they believed that any reporting would be useless. Teymoorzadeh et al. (2009) also revealed that in most cases, nurses did not report the events because of considering it useless to be reported identical to our results. This belief may be due to absence of follow-ups in an organization for reporting violence and lack of a good management system. Most of nurses reported absence of an acceptable management to follow up workplace violence and even if reported, no especial action was taken by the managers to overcome the problem.
The main causes of workplace violence in our study were the low number of nurses (78.7%), lack of security guards (53%), consumption of psychoactive drugs (39.9%) and patients’ judicial affairs (35%). Another study indicated that 90.9% of nurses believed that continuous training courses can be one of the ways to deal with the workplace violence (Ergun and Karadakovan, 2005).
Our findings were identical to many studies denoting to the lack of enough human resources and lack of security guards as important factors affecting workplace violence (Aghajanloo et al., 2010; Ghasemi et al., 2007; Zabihi, 2009; Ghodsbin et al., 2008; Salimi et al., 2006). Most of the patients referring to psychiatric wards were those who had a history of drug-abuse. It should be emphasized that consumption of psychoactive drugs may lead to delusion and hallucination as main causes of workplace violence in these patients which may explain the presence of workplace violence.
Our findings showed that presence of security guards (56.8%), taking security measures in wards (67.8%) and training courses of staffs (68.9%) were the important factors leading to workplace violence. In this regard, the findings of Zamanzadeh et al. (2009) were similar to our results. Therefore, it is very important to prevent violence against nurses as violence can affect nurses, services in patient care and would influence the relation between nurses and the patients (Salimi et al., 2006).
The 50.8% of our subjects were always worried about their workplace violence and probable risks. Ghasemi et al. (2007) indicated that 16% of their cases were anxious about their workplace violence; however, in Gates et al. (2006) study, 26% of their subjects were worried about workplace violence and did not feel secure and confident about their workplace while the extent of their anxiety was dependent on the situation. It seems that feeling insecure at workplace not only decreased the satisfaction but also increased the stresses too.
One of the limitations of this research was absence of evaluation of other staffs in psychiatric wards such as psychiatrists, social workers, occupational therapists and psychologists. So it would be beneficial to evaluate workplace violence in these groups too. Based on our findings, it seems that training of staff is necessary to control any workplace violence. Establishing rules to prevent workplace violence, helping management systems to report violence and to compensate physical and mental damages, increasing the security of workplace by employing security guards or policemen, increase in number of nurses at workplace and finally providing especial protocols for training courses of nurses would be beneficial.
ACKNOWLEDGMENTS
We are grateful to the Vice Chancellor of Research and the staff of research of Welfare and Rehabilitation University. Especial thanks also to the president and all of the nursing staff of psychiatric wards of Razi Psychiatric Center who helped us in conducting this research.