The Prevalence of Workplace Violence Against Nurses in Healthcare Facilities and its Associated Factors in a Selected Area of Dhaka

Background: Workplace violence in healthcare settings is a growing concern internationally, particularly affecting nurses due to their frontline role in patient care. The escalating instances of such violence compromise not only the well-being of healthcare workers but also the quality of care provided to patients. Objective: The primary objective of this study was to evaluate the prevalence and factors associated with workplace violence against nurses in selected healthcare facilities in Dhaka and to assess the impact of such violence on the nursing workforce. Methods: A descriptive cross-sectional study design was employed, with a sample size of 507 nurses chosen through random sampling from various healthcare facilities in Dhaka. Data were collected via face-to-face interviews using a pretested interview schedule, following which the respondents’ verbal consent was obtained. Ethical considerations were addressed in line with the Helsinki Declaration, ensuring confidentiality and voluntary participation. Data analysis was conducted using SPSS version 25.0, utilizing descriptive and inferential statistics, including frequency, percentage, mean, standard deviation, and the Chi-Square test. Results: The majority of respondents (55.8%) were below 30 years, with a mean age of 32.7 ± 8.5 years. Females comprised 91.1% of the sample. A significant 51.9% had encountered workplace violence, with verbal abuse being the most prevalent at 33.9%. The emergency department was the most common setting for violence (40.3%). Notably, 88.2% of nurses had received training on workplace safety. Conclusion: The study concludes that workplace violence against nurses is a significant issue in healthcare facilities in Dhaka, with a high prevalence of verbal abuse. The findings suggest the need for targeted interventions to enhance workplace safety and improve healthcare delivery.


INTRODUCTION
Workplace violence (WPV) is increasingly recognized as a significant occupational hazard for health professionals globally, emerging as a pressing concern that undermines the quality of healthcare delivery (1).The multifaceted nature of violence within healthcare settings, encompassing physical, sexual, psychological, and verbal forms, not only deteriorates the patient-care provider relationship but also adversely impacts the effectiveness of healthcare services (2).This violence is dichotomized into internal sourcesemanating from within the organization through interactions between employers and employees-and external sources, involving external individuals such as clients and criminals (3).The World Health Organization categorizes WPV into physical and psychological violence, highlighting its prevalence in both hospital and pre-hospital settings and underlining the escalating nature of WPV across all healthcare environments (5).The inherent risks associated with the healthcare profession, exacerbated by factors such as night shifts, high-stress levels, resource constraints, gender imbalances, and insufficient security measures, render healthcare workers, particularly nurses, highly susceptible to WPV (5,6).Nurses, constituting the largest segment of the healthcare workforce at 2.7 million, frequently encounter violence in the form of verbal abuse, physical assault, and sexual harassment, placing them second only to direct patient care providers in terms of vulnerability to workplace violence (7).The adverse effects of WPV on healthcare workers are profound, negatively correlating with job satisfaction and performance levels, which in turn compromises patient care and the overall efficacy of the healthcare system (8).Despite the high prevalence of WPV in healthcare settings, reported to exceed 50% in numerous studies, the ratification of the International Labour Organization's Convention No. 190 (C190) in June 2019 marked a significant step towards establishing a global standard for a violence and harassment-free workplace (9,10).This convention, which came into force on 25 June 2021, underscores the necessity of enacting legal and policy measures to prevent and address violence and harassment, with a particular focus on gender-based violence and the protection of women, who are disproportionately affected by such incidents due to various physical, social, cultural, and traditional constraints (10,11).The fundamental right to safety for healthcare providers within their workplace underscores the urgency of evaluating the current landscape of WPV against nurses.Such an assessment is critical for informing policymakers in the development and implementation of strategies aimed at enhancing the working conditions for nurses, thereby ensuring a safer and more conducive environment for both healthcare workers and patients.Through a comprehensive understanding of the factors contributing to WPV and its pervasive effects on healthcare delivery, this study endeavors to pave the way for substantive improvements in the health sector's approach to protecting its workforce, ultimately contributing to the optimization of healthcare services.

MATERIAL AND METHODS
In this descriptive cross-sectional study, a total of 507 nurses were selected through random sampling from various healthcare facilities in Dhaka.The selection of study locations was done based on convenience to ensure a wide representation of the nursing workforce within the area.Prior to data collection, each participant was informed about the objectives and scope of the study, following which verbal consent was obtained, thereby adhering to ethical standards of research conduct.The ethical considerations of this study were guided by the principles of the Helsinki Declaration, emphasizing respect for the autonomy, privacy, and dignity of all participants.Participants were assured of the confidentiality of their responses and were informed that they had the right to withdraw from the study at any time without providing a reason, ensuring voluntary participation.Data were gathered through face-to-face interviews conducted by the principal investigator, utilizing a pretested interview schedule.This method facilitated a comprehensive understanding of the workplace violence experienced by nurses, allowing for the collection of nuanced and detailed data.To maintain the highest standard of data integrity, each questionnaire was meticulously reviewed for completeness, consistency, correctness, and to identify any discrepancies immediately following the interview.This rigorous approach ensured that the data collected were of the highest quality and reliability.The analysis of the collected data was carried out using the Statistical Package for Social Sciences (SPSS) version 25.0, a decision that underscores the study's commitment to employing robust and sophisticated statistical methods.Descriptive statistics, including frequency, percentage, mean, and standard deviation, were employed to summarize the data effectively.These measures provided a clear overview of the prevalence and characteristics of workplace violence against nurses in the selected area.Additionally, inferential statistics, specifically the Chi-Square test, were applied to explore the associations between workplace violence and various factors, offering insights into potential predictors of such incidents.The results were presented in tables and diagrams to facilitate ease of understanding and interpretation of the findings.

RESULTS
In this study, the categorization of workplace violence perpetrators revealed that the highest frequency of violence against nurses was committed by patients' relatives, accounting for 170 cases (64.7%).Patients themselves were the source of violence in 63 instances (23.9%), while hospital staff or management were responsible for 30 cases (11.4%) of the total 263 reported incidents.These numbers underline the primary role that individuals closely associated with patients play in the occurrence of workplace violence within healthcare settings.The association between workplace violence and job duration was statistically significant (p < 0.000).Among nurses with less than 5 years of job tenure, 129 (72.9%) experienced workplace violence, whereas, for those with more than 5 years of tenure, 134 (40.6%) faced violence.This suggests that less experienced nurses are more likely to be victims of workplace violence.The chi-square test yielded a value of 48.072 with 1 degree of freedom, strongly indicating that the observed distribution of workplace violence across different job durations is unlikely to be due to chance.
The bar chart presents the distribution of workplace violence causation as reported by the respondents.The leading cause, cited by 179 respondents, was dissatisfaction with the expected quality of management.This was closely followed by prolonged waiting, noted by 137 individuals.The cost of availing services and dissatisfaction with healthcare services were identified by 92 and 116 respondents, respectively, as contributors to workplace violence.Interestingly, the death of a patient was the reason for 162 respondents, while 47 respondents cited other reasons.The data suggests that administrative and service-related issues are pivotal in the genesis of workplace violence.

DISCUSSION
In the presented study, an analysis of workplace violence against nurses revealed that a considerable proportion of the respondents, 283 (55.8%), were under the age of 30, with an average age of 32.7 years and a standard deviation of 8.5 years.These findings align with those reported by Zainal N. et al., highlighting a youthful workforce within the nursing profession, where the majority were also less than 30 years old (3).Furthermore, the gender distribution within this study was predominantly female, echoing the gender disparities in nursing identified by Lei Z et al., wherein 89.41% of the participants were female (12).The religious demographics of the respondents reflected the national religious composition reported in the National Population and Housing Census 2011, with a majority being Muslim, followed by Hindus and Christians (13).The marital status distribution indicated that a larger proportion of nurses in this study were married compared to those in the research conducted by Jiao et al., suggesting potential cultural or regional variations influencing marital status among nurses (14).Educational attainment among respondents indicated a majority holding BSc degrees, which is consistent with findings from Bekalu YE. et al., underlining the educational qualifications prevalent within the nursing sector (15).The designation of the majority as staff nurses is corroborated by the study of Sapkota S., demonstrating a common staffing structure in healthcare facilities (16).This study also identified that over half of the participants experienced workplace violence, with verbal abuse being the most common form, a finding supported by Weldehawaryat HN. et al. (17).However, none reported sexual harassment, a divergence from the aforementioned study.The prevalence of violence inflicted by patients' relatives was particularly notable in this study and was Figure 1 Reasons for Workplace Violence higher than that reported by Paudel S., which may suggest varying interpersonal dynamics within different healthcare settings or cultural contexts (18).The distribution of violence across various departments revealed the emergency department as the most prevalent setting for such incidents.This is partially supported by Fute et al., although their findings indicated a higher proportion of workplace violence in the outpatient department (19).Interestingly, the training regarding workplace safety and prevention of workplace violence was remarkably high among respondents in contrast to the findings of Alam K. et al., where a significant number lacked such training (20).This discrepancy could reflect recent initiatives to improve workplace safety or differences in the study designs.Shift patterns emerged as a significant factor, with a notable majority of participants engaging in night shifts more than 8 times per month, diverging from the study conducted by Bhusal A. et al., in Nepal, where a lesser frequency of night shifts was reported (21).This pattern may have implications for the risk of workplace violence, suggesting a need for further investigation into the impact of shift work on nurses' well-being.The study's scope extended to examining the tenure of nurses, with a majority having more than 5 years of experience, which contrasts the findings of Warda H. et al., who reported a greater proportion of nurses with over 10 years of experience (22).The working hours per week mostly conformed to the standard workweek, similar to the distribution observed by Bhusal A. et al. (21).Perpetrator gender was predominantly male, aligning with the findings of Weldehawaryat HN. et al., reflecting a potential gender dynamic in the perpetration of workplace violence (17).Concerning nurses' perceptions of workplace violence, a wide range of sentiments was noted, from no concern to severe worry, differing from the sentiments captured by Legesse et al., which suggested that nurses' concerns about workplace violence might vary with different cultural or organizational contexts (23).Causation analysis highlighted patient death, management quality, waiting times, cost, and satisfaction with healthcare services as significant factors for violence, corroborating the diverse reasons identified by Huang et al. for such events (24).However, a considerable discrepancy was observed in the reporting behaviors of nurses when compared to the study by Noorullahi S. et al., where almost half reported incidents of violence (25).This discrepancy might indicate a potential underreporting in the current study setting or a variance in organizational culture regarding incident reporting.In conclusion, the profile of nurses affected by workplace violence included a predominance of young, married, Muslim females with a significant amount of experience, suggesting that violence in healthcare settings is a complex phenomenon influenced by a myriad of demographic and occupational factors.The study underscored the multifaceted nature of workplace violence, reflecting broader societal and systemic issues.The identification of departmental hotspots for violence, notably in the emergency department, and the intersection of professional training with the prevention of violence, point towards targeted interventions as a means to mitigate risks.The study's strength lies in its extensive sample size and the comprehensive demographic data gathered.However, limitations such as the potential for selection bias due to the convenience sampling method, and the possibility of underreporting, must be acknowledged.To address these issues, future research could incorporate a more randomized sampling approach and ensure anonymity to facilitate honest reporting.Recommendations for practice include the implementation of regular training programs focusing on conflict de-escalation and the provision of support systems for staff affected by violence.Furthermore, administrative reforms to improve patient flow and reduce waiting times could indirectly decrease the incidence of violence.The findings emphasize the need for policies that protect nurses and ensure a safe work environment, ultimately enhancing the quality of patient care.

CONCLUSION
In conclusion, the profile of nurses affected by workplace violence included a predominance of young, married, Muslim females with a significant amount of experience, suggesting that violence in healthcare settings is a complex phenomenon influenced by a myriad of demographic and occupational factors.The study underscored the multifaceted nature of workplace violence, reflecting broader societal and systemic issues.The identification of departmental hotspots for violence, notably in the emergency department, and the intersection of professional training with the prevention of violence, point towards targeted interventions as a means to mitigate risks.

Table 2 :
Association between Workplace Violence and Job Duration