INTRODUCTION

The increasing number of incidents of violence in the workplace internationally has only recently been recognized as a serious safety and health hazard be­cause of the many horrific incidents that have been reported in the media lately. (International Labor Organization 2000). Many people were aware of the exis­tence of violence but only a few voiced out their concerns until the Inter­national Labor Organization started pub­lishing its reports about violence. Work­place vio­lence is a substantial contributor to occu­pational injury and death and is increas­ingly causing concern to govern­ment bo­dies, health and safety profes­sionals, employers and employees in many countries. This is the second leading cause of fatal occupational injury in the United States (McDonald 2001). Ac­cord­ing to Summers (1999), for non­fatal as­saults, the highest risk occupa­tions are those pertaining to service-ori­ented or­ganizations such as hospitals, nursing homes, residential facilities and social service agencies.

In the healthcare setting, workplace vi­olence has brought to light the real threat that these personnel face in their daily working lives, and employees within the hospital setting are potential victims of any form of workplace violence by pa­tients, visitors or colleagues, causing them to suffer from extreme mental and physical stress. Surveys carried out by healthcare staff, especially nurses worldwide, have demonstrated that vio­lence in the healthcare workplace is widespread and nurses as front line caregivers are often involved in dealing with victims of violence and the perpe­trators of violent acts (Worthington 2000).  According to Jackson et al. (2002), the health sector is also facing serious prob­lems in the recruitment of students into nursing, and new graduates into the workforce, and retaining experienced nurses especially in specialized areas such as critical care, emergency and mental health to name a few because of workplace violence.

Workplace violence in the healthcare setting in Malaysia is also a serious problem (Department of Statistics 2002) but there has been very limited amount of research done to bring this matter to light. Nurses are said to be more likely to sustain injuries at work compared to any other professional group and a substan­tial number of these injuries are the result of assaults or aggression (Carter 2000).  According to May & Grubbs (2002), nurse assault or abuse reduces confi­dence on the job, the ability to function and cope and has also brought about conflicts with patients, family members, visitors and co-workers. DelBel (2003) found that 42 per cent of nurses felt that verbal abuse had a great impact on the turnover of nurses while 36 per cent be­lieved that it contributed to absenteeism to a great extent. 

This study was carried out to determine the prevalence of workplace violence and to obtain more information on workplace violence experienced by nurses in the Universiti Kebangsaan Malaysia Medical Centre (UKMMC). It was also carried out to determine the category of perpetrators and the common types of workplace vio­lence.

MATERIALS AND METHODS

The study was conducted in UKMMC over a three month period from January till March 2004, using the descriptive cross-sectional design.  Approval to con­duct the study was obtained from the Medical Research and Ethics Committee (Project Code No. FF/001/2004, dated 8th January, 2004).  

The definition of workplace violence adopted in this study was according to the United States National Institute for Occupational Safety and Health (NIOSH) (1996), which was  “Any physical assault, threatening behavior or verbal abuse oc­curring in the work setting,  it includes but is not limited to beatings, stabbing, sui­cides, shootings, rapes, near homicides, psychological trauma such as threats, obscene phone calls, an intimidating presence, and harassment of any nature such as being followed, sworn at or shouted at” (NIOSH 1996).

Recruitment of participants was done through poster advertisements inviting all nurses who had experienced workplace violence during the study period to par­ticipate and it was on a totally voluntary basis. Only nurses who had experi­enced workplace violence during this three month period were allowed to par­ticipate in this study. Confidentiality was main­tained throughout the study. A total of 59 nurses participated in the study but only 55 questionnaires were completely ans­wered and could be used. The re­spon­dents comprised of staff nurses, nursing students and male nurses. All 55 had experienced workplace violence from various disciplines and areas of work in UKMMC.

Data was collected via self prepared questionnaires which had been tested for validity and reliability. The Cronbach’s Alpha obtained on the questionnaire was 0.872. The self administered question­naire comprised two parts, Part A and Part B. Part A collected the personal data from the participants such as age, gen­der, ethnic background, marital status, professional status, the place of work and years of experience. Part B collected the data about the violent inci­dent itself such as when, where and what form of vio­lence that had taken place and who was the perpetrator. 

Data entry and analysis was done using the Statistical Package for Social Science (SPSS) software version 11.

RESULTS

The total number of nursing staff in UKMMC at the time of the study was 1502 and of this 55 (3.7%) reported workplace violence experienced during the three month study period. Therefore, an average of 18.3 (1.2%) of the nursing staff had experienced workplace violence per month.

The majority of the victims were within the age group of 23-27 years (n=36 or 65.5%) and of Malay ethnicity (n=44 or 80.0%). This was followed by Indians (n=10 or 18.2%) and ‘others’ (n=1 or 1.8%) who was a foreign nurse from In­dia. There were no Chinese respon­dents. The majority of the nurses who took part in this study were females (n=53 or 96.4%) and the largest group of partici­pants were the staff nurses (n=45 or 81.8%) (Table 1).

According to place of work, the most respondents were from the surgical wards (n=11 or 20.0%) followed by the emergency department (n=10 or 18.2%) and critical care areas (n=10 or 18.2%). The medical wards and psychiatric de­partment recorded the same number of respondents (n=9 or 16.4% each), fol­lowed by the operating theatre (n=4 or 7.2%) and Obstetrics & Gynecology De­partment (n=2 or 3.6%). Forty-seven (85.5%) of the respondents had between 1-5 years, five (9.1%) 6-10 years, one (1.8%) 11-15 years and 2 (3.6%) more than or equal to 21 years of work expe­rience (Table 2).

The largest number of violent incidents took place in the surgical areas (n=12 or 21.8%) followed by the Emergency De­partment, Psychiatric Department and critical care areas each experiencing ten (18.2%) incidents. The Medical wards had eight (14.5%) incidents, Operating Theatre three (5.5%) and Obstetrics & Gy­necology two (3.6%) incidents. The total number of perpetrators was 64 of whom 26 (40.6%) were females and 38 (59.4%) were males. The greatest number of vio­lent incidents perpetrated against nurses was by patients (n=26 or 40.6%) followed by patients’ relatives (n=24 or 37.5%).  Eight (12.5%) were doctors (n=4), head nurses (n=2) and nurse managers (n=2). Four (6.3%) of the perpetrators were peers and two (3.1%) were non-relative visitors.

There were altogether 64 perpetrators for the 55 victims.  Eight nurses had ex­pe­rienced violence from two perpetrators at one time and one nurse from three per­petrators at the same time (Table 3).

The 55 respondents experienced different forms of violence 97 times during the study period. This is be­cause some respondents experienced two or three forms of violence at the same time.

The most common form of violence was verbal abuse (n=31 or 31.9%) followed by verbal threat (n=23 or 23.7%). The most common form of physical violence was ‘being pushed’ (n=15 or 15.5%); other forms included being ‘slapped’ (n=2), ‘pinched’ (n=4), ‘scratched’ (n=3) and ‘spat at’ (n=2), which totaled 11.3% (n=11); hit with an object (n=6 or 6.2%); kicked (n=3 or 3.1%); grabbed (n=3 or 3.1%); bitten (n=2 or 2.1%); sexually as­saulted (stroked thigh) (n=2 or 2.1%) and strangled (n=1 or 1.0%). There were no incidents of being hit with a fist or cut by a knife (Table 4).

DISCUSSION

The main objective of this study was to determine the incidence of workplace violence in UKMMC, which to our know­ledge has not been studied earlier. During the study period of three months (90 days), 55 nurses (3.7%) expe­rienced workplace violence which trans­lates to an average of 18.3 (1.2%) nurses per month and 0.6 nurses each day. This means that approximately one nurse is being abused every other day in UKMMC. 

Forty-five (4.1%) out of 1091 staff nurses experienced workplace violence during the 90-day period. In other words, in every two days, one staff nurse is abused.

Therefore, according to the findings of this study, staff nurses experienced the most number of violent incidents. Anderson & Stamper (2001) found that 90% of staff nurses experience at least one inci­dent a year of abusive anger, conde­s­cension or being ignored by a physician and every two to three months 30% ex­perience sexual abuse, ranging from lewd remarks to inappropriate touching.

The majority of the victims in the pre­sent study were in the relatively younger age group of 23-27 years (36 or 65.5%) followed by the age group of 18-22 years (9 or 16.4%).  Astrom et al. (2002), also found that more of the younger staff (less than 40 years) reported exposure to vio­lence than older staff (more than 40 years). Female victims (53 or 96.4%) outnumbered the male victims (2 or 3.6%). This could be explained by the fact that in UKMMC there are only 43 male nurses compared to 1459 female nurses which gives a female to male ratio of 34:1. When the percentage is calcu­lated by gender, 3.6% of the female nurses and 4.6% of the male nurses re­ported violence during the study period. 

The male nurses in UKMMC are mostly posted to the emer­gency department and the psychiatric areas. This could be the main reason why the male nurses have reported more exposure to workplace violence. Senu­zun & Karadakovan (2005) indi­cated that nurses working in these areas are more exposed to work­place violence.

The majority (85.5%) of the respon­dents who experienced workplace vio­lence were those with 1-5 years of work experience. This may be because they are still new in their jobs and they are much less experienced. This observation was also made by Astrom et al. (2002), who found that inexperienced young staffs were most likely to be exposed to vio­lence than those who had been work­ing for a long time.

Our study revealed that workplace vio­lence was widespread and not confined to any particular area. O’Connell et al. (2000), also reported that violent inci­dents are not confined to the commonly acknowledged high-risk areas such as the emergency and psychiatric settings but also occur at a high frequency in the general wards. In our study some of the perpetrators were peers and other pro­fessionals, comprising colleagues such as doctors, nurse managers and head nurses. O’Connell et al. (2000) found that medical staff and nurses themselves were one of the most frequent causes for the intimidation of nurses. Dalphond et al. (2000) and O’Connell et al. (2000) found that patients and their relatives are the most common source of verbal and physical aggression to nurses, which was also a feature in our study.

Verbal abuse and threat was the most common form of violence in our study.  Lee (2001) also reported that nurses ex­perienced verbal abuse more commonly than physical violence. The types of physical violence in this study were simi­lar with those reported by O’Connell et al. (2000), who also found that physical vio­lence included being chased, stabbed with scissors, being urinated or defecated on and having their hair pulled.

Our results were obtained only through those respondents who had willingly taken part in this study. It could not be confirmed that all the nurses who had experienced workplace violence during this study period had participated in this study. However, the low prevalence rate at UKMMC could be due to the general unwillingness of nurses to participate in this study.

CONCLUSION

This study confirms that workplace vio­lence remains an important issue among nurses, which calls for more effective measures to overcome this problem.  It is also high time that nurses demand a safe working environment for themselves so that quality nursing care can be provided to patients. As mentioned earlier in rela­tion to difficulty in retaining nurses in this profession, a safe working environment can be an encouraging factor for nurses to remain in this profession. 

The main limitation of our study was that it relied only on voluntary reporting by the victims. The reported prevalence of violence is probably an underestima­tion of the true violence prevalence.