Keywords: Violence, nurses, workplace, healthcare, Pakistan.

INTRODUCTION

Living in an Islamic country that condemns any form of violence is a blessing (Wiktorowicz & Kaltner, 2017) [1]. However, the prevailing socio-cultural practices and norms including negative attitudes towards the nurses and considering subordinates may lead to non-compliance with the teachings of Islam and its translation into actions, like workplace violence in healthcare, which is a significant issue and has gained considerable focus in recent years in Pakistan.

Workplace violence is defined as any act or threat of abuse aimed toward someone at work, varying from exploitative language to physical abuse (Vijayakumar & Rajagopal, 2023) [2]. Workplace violence in healthcare, especially against nurses is more prevalent, in the form of physical, verbal, or sexual harassment or coercion that results in potentially disruptive behaviour to target or abuse the nurse at their workplace (Al-Qadi, 2021) [3]. Workplace violence is the most critical concern affecting the healthcare industry and is a common issue around the globe, which is evident by a study conducted in the United States of America (USA) that, 78% of emergency department healthcare workers are a victim of workplace violence (Vrablik et al., 2020) [4]. Similarly, in Pakistan, research conducted in Khyber Pakhtunkhwa, found that 50% of nurses have experienced physical assault, while 74% have experienced verbal abuse and in the previous six months, 74.4% of nurses witnessed workplace violence (Khan et al., 2015) [5]. In addition, a study conducted in Lahore, Pakistan reported that 73.1% of 309 nurse participants reported at least one type of violence in the previous 12 months, with physical violence accounting for 53.4%, verbal violence accounting for 57.3%, and sexual violence accounting for 26.7% (Jafree, 2017) [6]. Furthermore, a study carried out in Karachi, Pakistan, showed that 85.2% of nurses had experienced at least one type of violence, with 41.1% experiencing physical abuse and 79.6% experiencing verbal abuse, while 15.9% were subjected to sexual harassment (Maaari et al., 2017) [7].

There are commonly three types of violence that are verbal, physical, and sexual violence (Ayasneh & Hayajneh, 2021) [8].

Verbal Violence

Verbal violence, also known as verbal abuse, is a type of violence that includes a wide range of actions such as blaming, discrediting, verbal threatening, pressuring, trivializing, continual ignoring, bullying, spreading of offensive rumours, silencing, shaming, name-calling, and publicly criticizing (Keller et al., 2018) [9], which is experienced by about 100% of nurses some time in their careers, and it is becoming more common (Shahzad & Malik, 2014) [10]. Moreover, it has been reported that verbal aggression is more prevalent during the morning shift and physical violence during the night shift (Bernardes et al., 2020) [11]. Words matter a lot, and a few inappropriate words may cause nurses to get emotionally disturbed, eventually, compromising healthcare delivery and patient care (Shahzad & Malik, 2014) [10].

Physical Violence

Physical violence is any act that attempts to cause or results in suffering or injury, such as kicking, slapping, biting, hitting, pushing, homicide, and punching. It has been reported that physical violence is more prevalent during the night shift (Bernardes et al., 2020) [11]. Nurses are not, by any means to be subjected to physical assault, but needed to be respected. Literature shows that it is less reported in other healthcare workers as compared to nurses (Dafny & Beccaria, 2020) [12].

Sexual Violence

Sexual violence is an undesired sex-based behaviour that undermines an individual's dignity It includes overly pleasant and sexual attitudes, sexual jokes, finger-pointing and offering unwanted sex, and revealing genital parts and sexual materials (Desai & Mandal, 2022) [13]. Female nurses are more likely to be sexually harassed, with most of them being unmarried, inexperienced, and novice nurses (Somani et al., 2015) [14]. Evidence indicated that 64.5% of nurses reported some violence in their workplace in Pakistan. Verbal violence at 65%, physical violence at 15% and sexual violence at 15% respectively (Pandey et al., 2017) [15].

IMPACTS OF WORKPLACE VIOLENCE

Workplace violence can have negative impacts on patients, staff, and healthcare services. For instance, nurses spend much of their time with patients and provide direct care to their patients. Nurses play an important role in patient safety and contribute to providing high-quality care, which may compromise with workplace violence and can result in emotional (fear, anger humiliation), psychological (depression and flashbacks), and physical injuries (Cabilan et al., 2021) [16]. Moreover, It can also lead to decreased nurses' professional performances and may contribute to dissatisfaction and work burnout among the nurses, which will eventually negatively impact the personal well-being of the staff (Liu et al., 2019) [17].

Workplace violence can lead to financial loss for the organization as well as for the affected professional in terms of physical injuries and other psychological problems and can compromise his/his income and output in terms of services and products (Cabilan et al., 2021) [16].

POLICIES FOR VIOLENCE AGAINST NURSES

Laws are already set to protect healthcare workers from workplace violence. For example, as per the Pakistan Penal Code, Section 509: Insulting modesty or causing sexual harassment. Ensuring to prevent sexual violence, it states that if a man insults a woman, utters a bad word, or makes a dirty gesture in a public place, transportation, street, private gathering, workplace, or private, the offender will face three years in prison or a fine of up to five hundred thousand rupees, or both in a serious case. This clause also protects women against sexual favours sought by the person (Article 509-Pakistan Penal Code, 2010) [18]. A solid initiative was taken in Khyber Pakhtunkhwa in collaboration with the International Committee of the Red Cross (ICRC) for Healthcare Service Providers and Facilities (Prevention of Violence and Damage to Property) Act, 2020. However, the government authorities are looking unserious to comply with the said law and report workplace violence or they do not take it seriously to implement strategies or handle it efficiently.

ACTION PLAN AND STRATEGIES AT THE POLICY LEVEL

Workplace violence can be prevented by using the following framework and ensuring a safe environment for healthcare workers and better patient care. There are three recommended actions for nurses to prevent workplace violence: prevention, response, and recovery strategies (Fig. 1) (Cabilan et al., 2021) [16].

Prevention

It focuses on training and education of nurses to assess and reduce workplace violence before it occurs.

Strategies

1. Active participation in designing the program to avoid workplace violence.

2. Recognize the organization's workplace violence prevention and response policies and practices and participate actively in creating pertinent policies, developing administrative tools such as panic buttons or use of code to alert, and developing the reporting system.

3. Actively engage in programs that promote workplace violence prevention and learn more about preventing violence, look for options for continuing education regarding violence.

4. Nurses are needed to understand situational awareness promptly and actively learn how to respond to a crisis.

5. Policies must be implemented to deal with such behaviour.

Amir Rahman et al.

Response

It focuses on interventions intended to deal with workplace violence once it has occurred.

Strategies

1. Take part in the overall workplace violence program's implementation.

2. To analyze, organize, and take actions to lessen the likelihood of workplace violence, use crisis intervention, and management tactics.

3. Make use of current administrative measures to confront workplace violence.

4. Environmental safety measures (e.g., visitor access, code alert, panic alarms, and call security).

5. Employ the authorized reporting method.

Recovery

An intervention designed to minimize the effects of workplace violence.

Strategies

1. Take part in post-incident meetings, hurdles, and debriefing sessions.

2. Critically analyze the situation and remodel action plans if required.

3. Provision of counselling services.

CONCLUSION

It is concluded that workplace violence is a common phenomenon, for which effective strategies are needed to be implemented for better healthcare outcomes. A nurse can bring change to protect and ensure a safe healthcare environment and better patient care by implementing such laws, policies, frameworks, and strategies to reduce workplace violence.

FUNDING

None.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

ACKNOWLEDGEMENTS

Declared none.

AUTHORS' CONTRIBUTION

Conception of the manuscript: Amir Rahman

Designing and collection of materials: Sabeen Moosani

Writer and formatting: Kiran Karim

Critical Review: Dr. Saleema Gulzar

REFERENCES

1. Wiktorowicz Q, Kalmer J. Killing in the name of Islam: Al-Qaeda's justification for September 11. In: Insurgent Terrorism 2017: pp. 417-433. Routledge. DOI: http://dx.doi.org/10.4324/9781351155564-16

2. Vijayakumar G, Rajagopal S. Addressing Workplace Bullying: Protecting Human Rights in the Modern Workplace. J Law Sustain Develop 2023; 11(10): e750. DOI: http://dx.doi.org/10.55908/sdgs.v11i10.750

3. Al-Qadi MM. Workplace violence in nursing: A concept analysis. J Occup Health 2021; 63(1): e12226. DOI: https://doi.org/10.1002/1348-9585.12226 PMID: 33960074

4. Vrablik MC, Lawrence M, Ray JM, Moore M, Wong AH. Addressing workplace safety in the emergency department: a multi-institutional qualitative investigation of health worker assault experiences. J Occup Environ Med 2020; 62(12): 1019-28. DOI: https://doi.org/10.1097/jom.0000000000002031 PMID: 32991380

5. Khan A, Said AB, Shah BA, Aurangzeb, Islam F. Violence against nurses at public sector hospital of Peshawar, Pakistan. Int J Inovat Res Dev 2015; 4(5): 4-7.

6. Jafree SR. Workplace violence against women nurses working in two public sector hospitals of Lahore, Pakistan. Nurs Outlook 2017; 65(4): 420-7. DOI: https://doi.org/10.1016/j.outlook.2017.01.008 PMID: 28343713

7. Maaari KH, Amjad CM, Ansari MI, Burir NA, Aurangzaib. Workplace violence towards nurses of intensive care areas and emergencies at Civil Hospital Karachi. J Univ Med Dent Coll 2017; 8(4): 36-45.

8. Ayasreh IR, Hayajneh FA. Workplace violence against emergency nurses: a literature review. Crit Care Nurs Q 2021; 44(2): 187-202. DOI: https://doi.org/10.1097/cnq.0000000000000333 PMID: 33595966

9. Keller R, Krainovich-Miller B, Budin W, Djukic M. Predictors of nurses' experience of verbal abuse by nurse colleagues. Nurs Outlook 2018; 66(2): 190-203. DOI: https://doi.org/10.1016/j.outlook.2017.10.006 PMID: 29685794

10. Shahzad A, Malik R. Workplace violence: an extensive issue for nurses in Pakistan: a qualitative investigation. J Interpers Violence 2014; 29(11): 2021-34. DOI: https://doi.org/10.1177/0886260513516005 PMID: 24390355

11. Bernardes MLG, Karino ME, Martins JT, Okubo CVC, Galdino MIQ, Moreira AAO. Workplace violence among nursing professionals. Rev Bras Med Trab 2020; 18(3): 250-7. DOI: https://doi.org/10.47626/1679-4435-2020-531 PMID: 33597974

12. Dafny HA, Beccaria G. I do not even tell my partner: Nurses' perceptions of verbal and physical violence against nurses working in a regional hospital. J Clin Nurs 2020; 29(17-18): 3336-48. DOI: https://doi.org/10.1111/jocn.15362 PMID: 32497347

13. Desai BH, Mandal M. Sexual and Gender-Based Violence in International Law: Making International Institutions Work 2022. Springer Singapore. DOI: https://doi.org/10.1007/978-981-19-0894-1

14. Somani R, Karmaliani R, Mc Farlane J, Asad N, Hirani S. Sexual harassment towards nurses in Pakistan: Are we safe. Int J Nurs Edu 2015, 7(2), 286-289. DOI: http://dx.doi.org/10.5958/0974-9357.2015.00120.8

15. Pandey M, Bhandari TR, Dangal G. Workplace violence and its associated factors among nurses. J Nepal Health Res Counc 2018, 15(3), 235-241. DOI: https://doi.org/10.3126/jnhrc.v15i3.18847 PMID: 29353895

16. Cabilan CJ, Eley R, Snoswell CL, Johnston ANB. What can we do about occupational violence in emergency departments? A survey of emergency staff. J Nurs Manag 2022; 30(6): 1386-95. DOI: https://doi.org/10.1111/jonm.13294 PMID: 33723863

17. Liu J, Zheng J, Liu K, Liu X, Wu Y, Wang J, et al. Workplace violence against nurses, job satisfaction, burnout, and patient safety in Chinese hospitals. Nurs Outlook 2019, 67(5), 558-66. DOI: https://doi.org/10.1016/j.outlook.2019.04.006 PMID: 31202444

18. Article 509-Pakistan Penal Code. The Pakistan Penal Code, 1860 and The Code of Criminal Procedure, 1898-Amendments. The Gazette of Pakistan 2010. Retrieved from https://na.gov.pk/uploads/documents/1300927775_931.pdf