Magnitude of workplace violence and its associated factors against nurses working in public hospitals of Western Ethiopia: a cross-sectional study

The national institute for occupational safety and health administration (OSHA) defines WPV as a situation in which employees are harassed, intimidated, or assaulted at work or while commuting to and from work, causing physical and psychological suffering [1]. All health professionals in general and nurses in particular are vulnerable to any type of workplace violence as they are first-line care providers and have close contact both with the patient and attendants [2].Workplace violence not only affects the lives of those who are victims of violence, but it also affects the people around them and health care institutions indirectly through the decreasing quality of healthcare systems [3]. Although patients are the most common perpetrators of WPV against nurses, their family or attendants, coworkers, physicians, administrators, supervisors, and security guards are also common perpetrators of WPV against nurses [4].

Workplace violence among nurses and other health professionals perpetrated by patients or others in the health sector is becoming a problem in both developing and developed countries. WPV against nurses has the potential to change their attitudes toward nursing and lower their motivation, quality of care, psychological harm, deformity, or death. Furthermore, WPV can affect the organization through cost of manpower, absenteeism, and an increase in clinical and therapeutic errors [2, 5].

Globally, workplace violence has a multifaceted impact. In the United States, WPV is the third major cause of death and the second most common cause of female death at the workplace [2, 6]. Study conducted in Canada shows that 32% of nurses were exposed to physical violence, 63% to verbal violence, 48% to bullying, and 18% to sexual harassment [7]. In the same vein, health care providers in Africa are also more at risk due to a poorly built health-care system, with the hazards escalating every year [8].

Evidence indicates a high magnitude of workplace violence (WPV) in Africa, with the highest rates observed in Egypt and South Africa. In Egypt, verbal abuse was reported at 78.1%, physical violence at 27.2%, and sexual abuse at 4.6%. In South Africa, verbal abuse accounts for 45%, physical violence for 20%, and sexual violence for 9.8% [9]. The magnitude of WPV is also notable in Addis Ababa (29.9%) and Harar (64.0%) [10, 11]. Various factors contribute to WPV, including the approach of care providers and patients or attendants, the relationship between caregiver and receiver, and institutional factors. WPV is associated with several determinants, including nurse-related factors (such as clinical competence, job stress, and reporting of violence), organizational factors (such as the level of the hospital, working department, and reporting procedures), and patient-related factors (such as unmet needs, substance use, and the nature of the disease) [12].

Evidence indicates that incidents of WPV against nurses occur most frequently in the emergency department (17%–97%) and the psychiatry department (8%–96%), followed by the intensive care unit (17%–92%) and surgical and medical units (20%–91%) [7]. Strategies to address WPV include pre-incident measures such as legislation and management interventions (e.g., education and training), as well as post-incident measures like incident reporting and zero-tolerance policies [13, 14]. Additionally, the Omega program is another preventive and management measure aimed at addressing violence against healthcare professionals [15, 16].

Despite the high prevalence and common occurrence of workplace violence (WPV) in the health sector, it often goes unreported and overlooked. It has received insufficient attention from both researchers and administrators, particularly in terms of prevention and management [8]. Moreover, previous studies conducted in Ethiopia have primarily focused on specific departments within hospitals, often overlooking the heterogeneity of these institutions [11, 17‐19]. Unlike these studies, the present research is not limited to specific hospital departments and encompasses various hospital levels. This approach aims to address the generalizability gap and provide insights into the causes and prevention mechanisms of workplace violence (WPV). Therefore, the objective of this study was to assess the magnitude of workplace violence and its associated factors affecting nurses working in public hospitals in Western Ethiopia.

Of all those (396), 383 nurses took part in the study and had a response rate of 96.7%.

The mean age of the participants was 31.5 (SD = 5.16), with the minimum and maximum ages of the respondents being 21 and 54 years, respectively. From the total respondents, 120 (31.3%) were between the 25–29 and 30–34 age groups. Of the total respondents, 220 (57.4%) were female. Regarding marital status, 267 (69.7%) of them were married. The predominant religion and ethnicity among the participants were protestant (285 (74.4%) and Oromo (340 (88.8%), respectively), and 353 (92.2%) participants were BSc holders. When we saw the work experience of the nurses, 215 (56.1%) had served for more than five years (Table 1).

Workplace violence among nurses gained little attention, regardless of recognizing its consequences for the quality of health care. The results of the study revealed that the proportion of workplace violence among nurses was about 42.8%, with a 95% CI. This result signifies a significant public health concern. In terms of public health designations and policy implications, such a high prevalence indicates the need for urgent attention and robust interventions. The need for a multi-faceted approach involving policy development, comprehensive prevention strategies, and a public health framework to effectively address this issue to create safer and healthier work environments for all employees and improve the quality of health service delivery. This finding is nearly like that of the studies conducted in Gamo Gofa, 43.1% [19]. However, this finding is much higher than the study findings from Japan, 18.5% [22]. This variation could be attributed to different socio-cultural, demographic, and organizational policies or strategies. Since the study in Japan includes registered nurses, home care nurses, and those with additional qualifications. In contrast, our study focuses solely on unregistered nurses and those working in hospital settings.

And due to the socio-economic level difference between the wealthy and developing countries,

The result of this study is lower than the study findings from Kenya (77.8%) [23]. Likewise, the possible explanation for the gap might be due to the working setting, department, and level of the hospital in which the latter is conducted at a tertiary hospital among emergency nurses only. Similarly, the findings of this study are much lower than those of the study in Egypt, where the prevalence of WPV was 86.1% [9]. This difference might be due to the Egyptian survey over the past six months. This might result in higher prevalence due to a lower recall bias. Our finding is also lower than the study finding from South Africa by 100% [9]. The reason might be due to a different study design, as their study design was pure qualitative.

The result of this study is lower than the study conducted in Harar, 64.0% [11]. This gap might be due to the use of khat for entertainment, for more serious businesses like religion and work, and they accepted it as an integral part of their culture in the study area. In addition, the result of this study is higher than the study done in the Amhara region (26.7%). The gap might be due to the number and level of hospitals at which the study was conducted, since the Amhara region study was conducted only at three referral hospitals and our study was at five public hospitals [17].

The high prevalence of verbal violence (73.8%) in our study is consistent with the results of studies from Iran, which are 74% (30). In contrast, our finding is higher than the study findings of Jordan (67.8%) [12], Nigeria (60.7%) [24] and Amhara Regional State (39.8%) [17]. The reason for the difference between this finding and Jordan might be because of the difference between developed and developing countries towards human rights assertiveness and the recording of violence. Additionally, the Jordan study was conducted in three private hospitals only among nurses who care for older people. On the other hand, the possible explanations for the gap between our findings and those of Nigeria might be due to the homogeneity of the hospital since the Nigerian study was conducted at a general hospital only among registered nurses and the Amhara regional state study was done at the same hospital level. Regarding the prevalence of physical violence, our study findings revealed that it accounts for 18.2%, which is similar to the findings from Hawassa (18.22%) [18] and Gambia (17.4%) [25]. On the other hand, our finding of physical violence is much lower than the finding reported by nurses working in psychiatric hospitals in China, which is 57.9% [26]. And also, lower than the study done at Addis Ababa Amanuel Mental Specialized Hospital (36.8%) [10]. The possible explanation for the difference between these study findings and those of those two countries might be due to the study setting, which can cause a great prevalence of physical violence due to the patients’ disease processes, since the study was conducted among nurses working in the psychiatry unit in which mentally ill patients are treated.

In this study, factors significantly associated with workplace violence were age group between 25–29 and 30–34, marital status, work experience, working between 6:30 and 7:30 o’clock, availability of reporting guidelines, encouragement to report, substance use, and job stress.

The findings of this study revealed that workplace violence was significantly influenced by the age of the respondents. The age category between 25–29 and 30–34 (31.3%) was four times more likely to experience workplace violence than other age categories. This finding is inconsistent with the study findings conducted at Hawassa [18]. The possible explanation for the age group of 25–29 might be due to less work experience, whereas age categories ranging between 30 and 34 were the dominant age group of nurses in the context of our study.

The present study showed that married nurses (69.7%) were less likely to experience workplace violence as compared to single nurses. This finding is inconsistent with a study conducted in Gamo Gofa, where single nurses were more likely to suffer from workplace violence [19]. This inconsistence might be because the number of married nurses is greater than that of single nurses.

The findings of this study showed that nurses who had less or equal to five years’ experience were about 2.2 times more likely to suffer from workplace violence as compared to those nurses who had greater than five years’ experience. This finding is supported by a study in Congo [9]. This could be accounted for by the fact that nurses with less work experience might have less clinical skills and fewer prevention methods for workplace violence. This finding revealed that nurses who work between 6:30 pm-7:30 pm were 3.4 times more likely to suffer from workplace violence as compared to those nurses who didn’t work between. This finding is inversely related to the Pokhara [27]. In our context, this difference might be attributable to the number of nurses and patients present between 6:30 pm—7:30 pm and the disease nature of the patient at this time.

The likelihood of workplace violence was four times higher among nurses who weren’t encouraged to report workplace violence than those who were encouraged to do so. The findings are consistent with those of studies in Indonesia. The possible explanation for this could be that encouragement might be absent because of the absence of a reporting system, or it might be due to the absence of proper measures taken towards reported violence [20]. The results of this study showed that nurses who use substances were four times more likely to experience violence than those who didn’t use them. The finding is consistent with the research the research conducted in Gamo Gofa Zone, where those nurses who use substances are more likely to suffer from workplace violence in public health facilities [19]. The justification for this might be the fact that those nurses who use substances remark themselves as being at risk for violence due to the nature of the substance they use.

This study also revealed that the odds of workplace violence were 3.66 times higher among nurses who reported job stress to suffer from WPV than who did not. This finding was in line with studies done in Jordan [12]. The possible explanation for this could be that nurses might take this job stress as part of their job, the managers might not be aware of nurses’ job stress, and there might be a few nurses present at the same time.

The findings of this study revealed that workplace violence was significantly influenced by the absence of reporting guidelines. Nurses who reported "the availability of reporting procedures were two times (AOR = 2.58, 95% CI: 1.04, 6.4) more likely to be exposed to WPV than those who reported the presence of reporting procedures. This finding agrees with a study conducted in Nigeria [28]. In the same way, the finding is supported by a study done in Harar, which stated that the availability of reporting procedures was the main reason for WPV [11].