Opinions of nurse managers on impact of domestic violence on work life: a qualitative study

Abstract

Background

Domestic violence is a pervasive issue that affects women regardless of language, religion, race, geography, culture or social structure.

Objective

This study aimed to explore the perspectives of nurse managers on how domestic violence impacts employees’ work lives.

Method

This research was conducted in design by using the qualitative research method. The necessary permissions from institutions and ethical committee approval have been obtained. The sample of the research was determined by maximum diversity method, one of the purposeful sampling methods. The sample of the research consists of 52 female nurse managers who work in different managerial positions, different experience and training, from three different hospital groups (a university hospital, a ministry of health hospital, and two private hospitals) in Turkey. The data collection process was terminated when data saturation was reached. The data were collected using a semi-structured interview form. Interviews were conducted face-to-face with nurse managers in hospitals. The interviews lasted for 63 min on average. The collected data were analyzed by content analysis method, and theme, sub-themes and codes were created.

Results

This study was presenting results related to the theme of “reflections of domestic violence on work life.” The results under this theme were explored through three subthemes: “how it is noticed that the employee is subjected to violence,” “how domestic violence is reflected on work life,” and “how the nurse manager approaches the employee who is subjected to domestic violence”.

Conclusion

In interviews conducted with nurse managers, it was observed that employees often hesitated to disclose that they were subjected to domestic violence; some only revealed their situation when they felt compelled to do so or when it was noticed by the nurse manager. The effects of domestic violence on work life were stated to have included absenteeism, physical inability to work, reduced team cohesion, performance decline, and difficulty adhering to work schedules. Nurse managers adopted several strategies to support employees affected by domestic violence, including managing other employees’ attitudes, adjusting work arrangements, removing her from the environment, providing support (legal, psychological, sociological, and temporary accommodation), and ensuring security measures. The findings show that the necessity of developing institutional policies and protocols on domestic violence within healthcare settings, establishing early note and intervention mechanisms, and implementing structured training programs for nurse managers and healthcare professionals on this issue. Moreover, it is of great importance to integrate domestic violence prevention strategies into national health, family, and social policies.

Clinical trial number

Not applicable.

Introduction

Violence against women is a significant public health concern and a violation of human rights of women. The World Health Organization (WHO) states that intimate partner violence, also referred to as domestic violence, is one of the most prevalent forms of violence against women [1]. The United Nations Entity for Gender Equality and the Empowerment of Women (UNWOMEN) defines domestic or intimate partner violence as encompassing all physical, sexual, emotional, economic, and psychological acts or threats of acts aimed at gaining or maintaining power and control over an intimate partner [2].

Women may experience one or more forms of domestic violence, irrespective of language, religion, race, geography, culture, and social structure. The estimates of the WHO reveal that approximately 1 in 3 (30%) women globally have been subjected physical and/or sexual violence by an intimate partner or non-partner sexual violence or both during their lifetime [1]. According to the study grouped by 21 regions used in the 2010 Global Burden of Disease (GBD) report; it is indicated that the prevalence of partner violence is the highest in sub-Saharan Africa (65.6%), while rates in Central Asia (22.9%), Southern Latin America (23.7%), North America (21.3%), and Western Europe (19.3%) were below the global average, with the lowest rates in East Asia (16.3%) [3]. Acording to the Organization for Economic Co-operation and Development (OECD), Turkey ranks first with a rate of 32%, rate of women (in 15–49 ages) experiencing physical and/or sexual violence by their intimate partners at over the lifetime [4]. “As cited in the Combating Violence Against Women IV National Action Plan (2021–2025), research conducted by the General Directorate of Women’s Status in 2008 and 2014 revealed that approximately 4 out of every 10 women in Turkey have been subjected to physical and/or sexual violence by their partner at some point in their lives [5].

A woman, who should feel most secure physically and mentally within her family, is subjected to domestic violence for various causes. Studies exploring this subject revealed the following general causes of domestic violence against women: unemployment, a higher education level of the woman and a lower education level of the man, duration of the marriage, employment status of the spouses, younger age of the woman, witnessing of domestic violence, patriarchal belief, physical or mental health issues in one of the spouses, sex discrimination, alcohol and substance abuse, family type, and the inability of the family to maintain a balance between income and expenses [6–10].

As a result of being subjected to violence, women may suffer from physical and sexual health problems such as lip–nose injuries, broken teeth, chewing difficulties, bone fractures, brain injury, chronic pain and internal organ injuries, miscarriages, giving birth to low-birth-weight babies, pelvic pain, bleeding, menstrual cycle disorders and infection [11–17]. These women may also suffer from mental health problems such as anxiety, post-traumatic stress disorder, sleep disorders, depression, suicidal ideation or attempt, and substance abuse [18–20]. Violence has effects not only on health but also on women’s participation in the workforce. Intimate partner violence may create problems such as absenteeism, lost productivity, missing work, workplace accidents, starting late or leaving early, fear of being injured and being stalked by the partner or ex-partner, concentration problems, and turnover [21, 22].

Bronfenbrenner’s Ecological Systems Theory was adopted as the theoretical framework in order to strengthen the analytical basis of the study. This theory has made it possible to understand how domestic violence affects nurses’ individual lives, their relationships in the workplace, and their interactions with institutional/social structures at multiple levels [23]. Intense workload, shift-work system, length and irregularity of working hours, inadequate hospital resources, urgent work demands in health services, emotionally exhausting work, etc., many situations can cause burnout in nurses and problems affecting their quality of work life. Nurses, especially female nurses, may face difficulties in balancing home and work life while coping with the aforementioned negative working conditions [24–27], which may increased the likelihood of experiencing domestic violence. In a study involving 471 female doctors, nurses, and healthcare professionals, 45% of the participants reported that they have experienced either violence from a partner or family member during their lifetime, and one-third reported being exposed to intimate partner violence since the age of 16 years [28]. In another study, 25% of female nurses and nursing personnel were found to experience physical or sexual intimate partner violence and 22.8% emotional abuse by intimate partners [29]. According to a report by Cavell Nurses Trust (2016) [30], nurses are 3 times more likely to have experienced domestic abuse than the average person in the UK in the last year and one in 50 respondents (2.2%) was injured by a partner or ex-partner.

In the healthcare sector, particularly in nursing due to the high number of female employees, it is of great importance to examine how nurse managers notice cases of domestic violence among nurses, their approach to employees who are exposed to violence, the effects of violence on working life, institutional support provided to nurses in such situations. Although awareness of domestic violence among healthcare workers is increasing, there is a limited number of studies examining how nurse managers identify and intervene in such cases. In this regard, the study aims to make original contributions to the national and international literature in the fields of human resource management and nursing management. Additionally, it aims to provide also important contributions to the development of institutional support structures against domestic violence in healthcare institutions.

Aim

This study aimed to assess the perspectives of nurse managers on how domestic violence affects work life.

Methods

Design

This study was conducted using a Husserl-based descriptive phenomenological research method aimed at defining the essence of participants’ experiences [31]. The phenomenological analysis aimed to capture the experiences and perceptions of participants regarding the phenomenon of violence. In essence, the researchers explored the profound meanings of participants’ experiences and encounters related to the subject, considering their relationships with different times, places, and backgrounds. This approach involved immersing the researcher in a detailed, sensitive, and probing research process [31]. The study aimed to answer the following questions:

• How do nurse managers notice that employees are subjected to domestic violence?

• What are the reflections of domestic violence on work life?

• How do nurse managers approach employees being subjected to domestic violence?

Participants and settings

To determine the sample size in this study, the researchers employed the maximum variation method, one of the purposeful sampling methods that allows for in-depth analysis of cases expected to yield rich information [32]. The study involved nurse managers in different managerial positions (nursing services managers and assistants, supervisor nurses, and service responsible nurses) with varying levels of experience and education from different hospital groups (a university hospital, a Ministry of Health hospital, and two private hospitals) in Turkey.

In the research, the decision to stop data collection were based on reaching data saturation. Data saturation is reached when new information can’t be obtained, the answers to research questions become repetitive, and when further coding is no longer feasible [33]. In this study, data collection was concluded after 52 interviews (26 in university hospitals, 11 in private hospitals and, 15 in Ministry of Health hospitals) as the data were deemed to have reached saturation.

Data collection

The data were collected using a semi-structured interview form (Table 1). The interview form addressed the multidimensional effects of domestic violence on working life. Participants were asked about how violence reflects on work life, how do women who experience violence fight against domestic violence, practices implemented by organization/hospital to fight violence, approach of nurse manager and employees towards employees who are experiencing domestic violence. Interviews were conducted face-to-face with nurse managers in hospitals. Interviews were conducted in environments where the participants thought they would be less disturbed and would ensure confidentiality, such as the manager’s office, meeting room, etc., as decided jointly with the participants. In the interviews, a voice recorder was used with the permission of the participants in order to collect the data completely. At the beginning of the form, the participants were asked to introduce themselves (give information about their age, education level, unit of employment, total working time in the profession, total working time in the organization, and total working time in the managerial position). The remaining part of the form included questions prepared by the researchers, taking into account the scientific literature and expert opinions on domestic violence against women and working life [22].

Table 1.

Semi-structured interview form

Opinions of Nurse Managers on Impact of Domestic Violence on Work Life
1. Could you briefly introduce yourself professionally (age, education level, years of civil service, professional/institutional experience, managerial experience, etc.)?
2…………
3………….
4…………
5…………
6. How is domestic violence reflected in work life?
7. How do women who experience violence fight against domestic violence?
8. What kind of work is being done at this organization/hospital to fight violence?
9. What is the attitude of the organisation’s employees towards women who experience violence?
10. As a manager, how do you approach employees who are experiencing domestic violence?
11………

A pilot study was conducted before the data collection phase. Three people in the nurse manager group were interviewed on different days and the interview questions and flow were checked. These interviews were excluded from the sample. Based on feedback from the three nurse managers who participated in the pilot study, some questions were rephrased to make them clearer, and the order of the questions was rearranged to improve the flow. These changes improved the suitability and comprehensiveness of the interview form.

In this study, since three participants did not allow audio recording, the interviews were recorded by taking notes. In addition, the notes taken immediately after the interview were reviewed and tried to be completed.

Data analysis

The interviews lasted for 63 min on average. Data transcription was carried out at the same time as the interviews were conducted. The interview reports were read several times by the researchers to get a general perspective and identify meaning units. Codes were developed through inductive content analysis by identifying units of meaning in the interview transcripts. Similar codes were grouped to form sub-themes. The researchers attempted to describe the experiences of nurse managers in an impartial manner by consciously suspending their own biases (bracketing) during the data collection and analysis process. Nvivo 2012 (qualitative) software was also used to assist with data organization and coding.

During the content analysis process, not only the manifest content of participants’ statements were considered, but also their latent content. For example, underlying phenomena such as fear, helplessness, lack of institutional support were identified through in-depth analysis beneath surface-level statements like absenteeism, sleep problems, or refusal to provide explanations. The Consolidated Criteria for Reporting Qualitative Research (COREQ) Checklist was used to report this study [34].

Rigor

In qualitative research, the concepts of validity and reliability are replaced by the concept of trustworthiness. Trustworthiness is defined through the criteria of credibility, transferability, dependability and confirmability [35, 36]. To ensure credibility in the study, the researchers read the written transcripts of each interview, and all interviews were consistently conducted by the same researcher. The researcher who has received qualitative research training and is an expert in nursing management, adopted a reflective attitude and applied the bracketing method throughout the data collection and analysis processes. Diversity was ensured by involving nurse managers from different institutions, units, and positions. All interviews were conducted using the same semi-structured interview form, which was developed with input from three academics specializing in nursing. Transferability was ensured by conducting interviews using a purposive sampling method, and durability was ensured by recording and preserving the interviews. Finally, the data obtained from the study were examined by a social scientist to establish confirmability.

Ethical considerations

Approval (number: 59491012/604.01.02) was obtained from Istanbul University Cerrahpaşa Medical Faculty Clinical Research Ethics Committee and the necessary official written permissions were obtained from the institutions where the participants were working to conduct the study. Each participant was informed about the purpose, rationale, design, and methodology of the study before the commencement of the interviews. Participants were assured that their information would be exclusively used for this study, and they had the right to withdraw from the study at any time. Permission for audio recording was obtained before recording, and participants’ consent was documented. Participants’ identities were kept confidential, and descriptors such as numbers, which did not directly reveal their identity, were used in the quoted excerpts presented in the Results section.

Result

Demographic information

In this study, 52 female nurse managers were interviewed. Their professional experience ranged between 9 and 36 years (mean = 22.5), and their managerial experience ranged between 1 year and 26 years (mean = 13.5). Their educational status was distributed as follows: 2 with a vocational health school degree, 5 with an associate degree, 15 with a bachelor’s degree, 20 with a master’s degree, and 10 with a doctorate.

This study was produced from a comprehensive doctoral thesis. The published part of the research; presents findings on the theme of the “reflections of domestic violence on working life” which is theme the most dominant. The results under this theme were explored through three subthemes: “how it is noticed that the employee is subjected to violence,” “how domestic violence is reflected on work life,” and “how the nurse manager approaches the employee who is subjected to domestic violence” (Fig. 1).

Fig. 1.

Theme, Subtheme, Code. This figure shows the theme, sub-themes and related codes created based on the qualitative findings obtained in the study. The authors created this figure, and it does not require permission for reproduction

Subtheme 1: How it is noticed that the employee is subjected to violence

During interviews with nurse managers, it was observed that women generally hesitated to disclose that they were subjected to domestic violence, and the impact of domestic violence became evident in later stages of work life. The findings regarding this subtheme are illustrated in Fig. 2, encompassing codes such as “performance decline,” “self-disclosure when insisted,” “sharing with colleagues,” and “being noticed by the manager.”

Fig. 2.

Codes of the subtheme “how it is noticed that the employee is subjected to violence". This figure shows how nurse managers noticed when an employee is subjected to domestic violence. The authors created this figure, and it does not require permission for reproduction

Code 1: Performance decline

The nurse managers indicated that they identified female employees who were subjected to domestic violence by observing signs such as a decrease in their job performance, a general decline in their work effectiveness, an inability to work harmoniously with the team, and noncompliance with work rules, all of which suggested personal challenges in their lives (Table 2).

Table 2.

Codes of the subtheme “how it is noticed that the employee is subjected to violence” and description from interviewees

Theme	Subtheme	Code	Description from interviewees
Reflections of Domestic Violence on Work Life	How it is noticed that the employee is subjected to violence	Performance decline	“… the employee who was subjected to domestic violence didn’t say anything, but when she started avoiding work, not doing the tasks I assigned, and when I asked ‘Why are you doing this?’…I mean, she had not come and explained anything before I asked her about the situation. When I asked what was wrong with her as she did not do her work, she told me. She opened her arm and showed me the bite mark on her arm… I just guessed that something was going on because of her work performance and asked her about it.…” (Participant 2).
		self-disclosure when insisted	“… She hadn’t told anyone; when her arm was broken, and she had to get a medical report, she had to explain the situation out of necessity … Otherwise, she had never made any statement about it before …” (Participant 14).
			“… She never said it. She didn’t tell us that she was being subjected to violence. She has to said because we saw her in the dressing room. We saw the bruises on her shoulder.” (Participant 28).
			“…She had been beaten, there were bruises on her face that she was trying to cover up, then she shared it with me…” (Participant 52).
		Sharing with colleagues	“… She shared it with her close friends in the ward, but she didn’t share it with me directly as her manager. She had shared that she had problems with her husband and was not happy at home, but she had not directly shared with me that she was subjected to domestic violence …” (Participant 12).
			“…I didn’t see it, but others were saying it. The nurse was subjected to physical violence… she did not tell me either, she was ashamed.” (Participant 27).
			“…No one tells us one-on-one, but I have a nurse friend from my staff. Of course. Some things stay within the family, of course, a friend of hers told me about it… She says that she has been subjected to such violence from her husband, that is, she has problems with her husband…” (Participant 38).
		Being noticed by the manager	“… She came to the work with injuries to her face and eyes; when I asked her what happened, she denied it. She insisted that her husband loved her very much, but I understood when her nose was broken one day …” (Participant 40).
			“… There was a nurse colleague here; in fact, her husband came here, pointed a gun at her, and said, ‘I will kill you.’ The incident happened. He threatened the woman …” (Participant 34).
			‘…I look at her and I say, “You’re make-up today, what’s wrong?” do you understand what I mean…’ (Participant 7)

Code 2: Self-disclosure when insisted

When women experience domestic violence, they often blame themselves and fear a potential loss of status in both society and the workplace. A tendency to conceal the violence is found due to traditional societal and familial perspectives and pressures. The study found that female employees who individually struggle with incidents of domestic violence on their own tended to share their situations out of necessity, such as seeking permission, obtaining a report, or experiencing health issues (physical marks caused by violence) that prevented them from coming to work (Table 2).

Code 3: Sharing with colleagues

The nurse managers stated that some female employees who experienced domestic violence only confided in their close coworkers (Table 2).

Code 4: Being noticed by the manager

The nurse managers stated that they themselves identified instances of violence when they either witnessed the incident or observed physical, psychological, and sociological symptoms of violence in their employees (Table 2).

Subtheme 2: How domestic violence is reflected on work life

The findings regarding this subtheme are illustrated in Fig. 3, encompassing codes such as “Inability to work”, “inability to work harmoniously with the team”, “having problematic staff behaviors”, “noncompliance with working hours and schedule”, and “performance decline”.

Fig. 3.

Codes of the subtheme “how domestic violence is reflected on work life”. This figure shows the reflect of domestic violence on the working lives of employees. The authors created this figure, and it does not require permission for reproduction

Code 1: Inability to work

In the study, when the views of the nurse managers on the code “inability to work” were analysed, it was stated that the employee could not come to work and was unable to work due to reasons such as bruising on the face due to violence, safety concerns and fear, distraction. The views of nurse managers were analysed under four headings: nurses’ attention decreased, they could not be absent from work due to assault, were prevented from coming to work due to violence, and they experienced safety concerns/fear. These themes are outlined in Table 3.

Table 3.

Codes of the subtheme “how domestic violence is reflected on work life” and description from interviewees

Theme	Subtheme	Code	Description from interviewees
Reflections of Domestic Violence on Work Life	How domestic violence is reflected on work life	Inabilityto work	Decreased attention: “… she was already spending the night sleepless because there was a problem at home, she had no peaceful sleep.When you don’t sleep well, when you’re unhappy…But those who are not peaceful in their home life can make excuses such as distraction, I was not aware, I forgot. The happier you are outside, the more peacefully you at work …” (Participant 44). Absence from work due to assault: “… I know that the man broke the woman’s arm; she couldn’t come to work and took sick leave…” (Participant 23). “… She took leave because her nose was broken, couldn’t come to work … then she got a medical report …” (Participant 47). “… she left. Because there were times when she could not come to work. She came with a bruised eye … during the incident when her eye was bruised; she mentioned not hearing from one ear for a few days …” (Participant 1). Being prevented from coming to work: “… when the fight escalated, my friend who was subjected to violence wanted to leave home, but her husband locked her in the house … she couldn’t come to work …” (Participant 29). “…he locked her out in the morning (She means that the nurse’s husband locked the door of the house) so she wouldn’t come to work… the woman couldn’t come to work…” (Participant 22). Safety concerns/fear: “…She was afraid of being assaulted because of her husband, she was afraid to come on shift…” (Participant 22). “… even at night, he was harassing her a lot on the phone, calling her inside line repeatedly, 50 times, 30 times. He was constantly making an effort to reach her (referring to the nurse). The man (referring to the nurse’s husband) was basically questioning us, asking about his wife whether she came to work, whether she was there, when she left, etc. …” (Participant 12). ‘…one day she called me and said, “I can’t come to work today, my husband beat me.” She said she had been physically abused by her husband, that her face was badly hurt and she couldn’t come to work, and that even if she did, he would follow her. She said she was afraid he would cause a bigger scandal here…’ ((Participant 19).
		Inabilityto work harmoniously with the team	“… the nurse being subjected to violence affected all of us. Because the nurse subjected to violence suddenly becomes passive, and since she is removed from her duties and work, who will do that job? Because she works in an important position and has a key role in the clinic, so if she’s not there, the work stops, (Participant 17). “… the employee subjected to violence did not participate in social activities; for example, she never invited us to her home, nor did she attend any of the social events we organized, the institution’s meals, celebrations, she did not participate in anything …” (Participant 13). “…She does not get along well with her colleagues and treats them badly…”((Participant 29).
		Having problematic staff behaviors	“…but she reflects this to work a lot, her psychological state seriously impacts her job performance. She’s constantly tense and irritable… she acts very impulsively, gets angry quickly, and starts complaining. For example, when we ask something, she gets irritated very easily, gives sharp responses, raises her voice, and when you talk to her, it feels like you’re arguing because she’s always in defense mode, always tense and irritable… She lacks self-confidence… she says, ‘I’m not in the right state of mind, I might make a mistake,’ and she keeps double-checking everything all the time. Of course, this also affects her colleagues around her.” (Participant 19). “…An employee who experienced psychological violence, can’t get along with her team, and can’t control her tone of voice. She acts aggressively, speaks in a commanding way, and I’ve warned her about it a couple of times—I have to warn her because I hear complaints from her coworkers. Then, she also ends up insulting people…” (Participant 50).
		Noncompliance with working hoursand schedule	“…the female employee who was experiencing abuse, she wanted priority rights over things like shift hours, coming and going for shifts, shift end times, and holiday duty schedules compared to her other colleagues… she was trying to shape her work around her personal life so that it wouldn’t cause any problems or issues at home. But of course, when she tried to adjust her work to fit her personal life, her relationships with her coworkers deteriorated… she wasn’t very suited for teamwork, she would sometimes come to work late, and she wanted to leave her shifts early. She always had these tendencies, and there were issues with her adaptability…” (Participant 42). “…she didn’t want to work shifts… she would say, ‘My children are alone at home,’ or ‘My children are suffering because of this…’ I had issues with her regarding shifts.” (Participant 33). “…does not want to be on shift (referring to night shift) (Participant 48). “…She was running late… she wanted to leave early… (Participant 15). “…and that’s when the absences began. (Participant 2).
		Performance decline	“…she acts as if she’s not there, because her mind is always on her family, her spouse, and the problems she’s experiencing. Since she’s constantly caught up in chaos with them, her motivation is disrupted. That person can’t fully focus on her work… she becomes disconnected from her job, her performance drops, and sometimes she doesn’t even process what you’re saying. Her motivation completely plummets, and her performance decline.” (Participant 20). “…her performance declined, she didn’t want to work…she couldn’t focus on her job… (Participant 36). ‘…performance was completely declining… for example, a phone would ring and she would leave her work. Her concentration was completely gone, and her colleagues and team were constantly watching her…’ (Participant 34).

Code 2: Inability to work harmoniously with the team

The participants stated that the absence of employees subjected to violence, particularly in specialized units, disrupted work and necessitated the redistribution of their workload to other colleagues. Additionally, it was emphasized that female employees subjected to violence might manifest symptoms such as, closed communication, introverted mood. The perspectives of nurse managers on this issue are outlined in Table 3.

Code 3: Having problematic staff behaviors

The nurse managers observed that employees subjected to violence were more unconfident, tense and irritable. This state was reflected to other colleagues in the work environment and the individuals they served.The perspectives of the participants on this issue are detailed in Table 3.

Code 4: Noncompliance with working hours and schedule

The nurse managers stated that female employees who subjected to domestic violence came to work late in the morning when they had problems at night, wanted to leave early, did not come to work at all when they were unable to work, did not want to be on duty at night shift, wanted to begiven privileges on holidays, and asked for leave because they took care of their children alone. The views of the participants are given in Table 3.

Code 5: Performance decline

The nurse managers stated that the performance of the victims of violence was generally lower because they could not pay full attention to their work and this situation negatively affected the health service provided. The statements of the managers are shown in Table 3.

Subtheme 3: How the nurse manager approaches the employee who is subjected to domestic violence

The findings related to the sub-theme of how the nurse manager approached the employee who is subjected to domestic violence are as follows; ‘managing the attitudes of other employees toward those subjected to domestic violence’, ‘organizing the work style’, ‘trying to remove her from the environment’, ‘providing support’, ‘taking security measures’ (Fig. 4).

Fig. 4.

Codes of the subtheme “how the nurse manager approaches the employee who is subjected to domestic violence”. This figure shows the approach of nurse managers to employees who are subjected to domestic violence. The authors created this figure, and it does not require permission for reproduction

Code 1: Managing the attitudes of other employees toward those subjected to domestic violence

When the views of nurse managers on the attitudes of other employees towards survivors of domestic violence were analysed, it was determined that women victims of violence generally disturbed other employees, exhibited problematic personality traits and were perceived as people who had harmony problems with the team. It was also emphasised that some employees were more understanding towards battered women and tried to support them. The findings related to this code were analysed under two headings: experiencing discomfort and providing support. The statements of the managers regarding this code are shown in Table 4.

Table 4.

Codes of the subtheme “how the nurse manager approaches the employee who is subjected to domestic violence” and description from interviewees

Themes	Sub- theme	Code	Description from interviewees
Reflections of Domestic Violence on Work Life	How the nurse manager approaches the employee who is subjected to domestic violence	Managing the attitudes of other employees toward those subjected to domestic violence	Discomfort Experienced: “…it inevitably affects her communication with her colleagues as well… for example, if she needs to take blood from a patient, instead of saying, ‘Could you take it?’ she responds with, ‘Take it.’ The other colleagues, inevitably, feel that this situation reflects on her performance, and none of them want to work with her, openly and clearly…” (Participant 48). Providing Support: “…when everyone on the ward tries to support her,…that process affected her performance, but there were team members who could help her recover from that situation…” (Participant 52). “…They showed understanding for the situation, did not make any problems, and tried to empathise as much as possible… (Participant 24). “But the friends also supported her as much as they could…” (Participant 29).
		Organizing the work style	Giving leave or report-adjusting shifts,: “…during periods when she experienced a lot of violence and had bruises, she would take medical leave. She was already a very good nurse, so we tried to adjust the work schedules… and find suitable times for her… I didn’t create any issues when she took medical leave. I arranged her working hours according to her child’s caregiver’s schedule, and she also has a daughter in school, so I adjusted her hours to fit her daughter’s school schedule as well…” (Participant 21). “…we don’t have night shifts…” (Participant 8). “…if necessary, I would give permission, whether it was to go to the lawyer or to court…’ (Participant 36). “…what is being done in this situation? Tasks are being divided up. The work is being distributed among other people. When there is shift work, shifts are being handed over and arranged…’ (Participant 17). “… we arranged a lot of leave for the nurse who was subjected to domestic violence, allowing her to use accumulated leave, annual leave, excuse leave, and made her receive medical reports … we managed her for three or four months, but we did these officially …” (Participant 20). “… I never scheduled the nurse being subjected to violence for night shifts …” (Participant 35). Changing the unit: “…she recently submitted a request for a changce the unit. Because this is truly a challenging unit with complex patients, and I’m also worried that one day we might face a negative situation. She works night shifts… This really isn’t a place that just anyone can manage.” (Participant 19). “…she doesn’t want to work shifts… After that, we even moved her to day shifts for a while and assigned her to the … unit…” (Participant 1).
			Granting a transfer/arranging a reassignment: “…But she left here and was appointed…(Participant 17). Allowing her to work in a way that enables her to take on additional jobs: “…the nurse needed to take care of her children, so we didn’t schedule her for night shifts and had her work during the day instead. She had financial needs, so we adjusted her work schedule to allow her to take on extra jobs, and we supported her in this way for a long time…” …” (Participant 13). Employing in passive tasks.: “…we already kept the nurse experiencing violence in more passive roles; we didn’t assign her to direct patient care in the forefront…” Participant 27). “…my employee came in with bruises on her face, but I covered them up with foundation because even if she took leave, she had nowhere to go. I’m having her work in a way that minimizes her interaction with patients. I grant her leave, I let her take medical reports if she can, but let’s say I couldn’t do any of that because I also have superiors or couldn’t adjust the schedule. I would camouflage the situation and assign her tasks that didn’t require much interaction with people…” (Participant 40).
		Trying to remove her from the environment	“…We had a colleague who separated from her spouse. For example, she shared the difficulties she was going through with us, and we provided her with all the support we could. …for instance, we didn’t grant her leave for a period, we planned this ourselves so she wouldn’t be alone—we had her work during the day, she stayed by our side, and we supported her. …so she wouldn’t be alone and grieve, we visited her at home, helped her arrange her house, and even rented a place for her. She had separated from her spouse, we took her to another conference, and we always supported her so she wouldn’t feel alone. We always welcomed her with a smile and included her in our circle, supporting her in this way…” (Participant 13).
		Providing Support	Providing psychological and sociological support: “…one of my colleagues got divorced recently, she was subjected to verbal violence, she had two children. For example, she would come and tell me about it, she would feel relieved, I was listening to her, guiding her, helping her. …but they got divorced…” (Participant 36). “‘…if you make her feel that you are going through this process with her and that you are with her. This process is easier to overcome, even happy and motivated. She says “Even if I have problems at home, I am peaceful at work” and focuses on her work …” (Participant 52). Providing accommodation support: “…I spoke to the directorate of nursing. I organised a place for her, she stayed in a lodging house for fifteen to twenty days.” (Participant 25). “…once there was a nurse friend who was thrown out. she had been thrown out of her house and was on the street. She asked if she could stay in the lodgings, I had arranged such a place for her…she came early in the morningI was surprised, the woman was dishevelled. The man put her at the door with her belongings…” (Participant 15). Providing legal support: “in both cases (referring to two different nurses who were subjected to violence), I told them that this should not go unrequited, that they should get a battering report, that they could use it if and when neededthat they should seek their rights, that this was their right. Both of them got these reports and they were not subjected to violence after that.” (Participant 46).
		Taking security measures	“…when that happens, when they change their places, when there is something going on between the two services, they inform and direct each other by phone. …somehow everyone supports each other. We tell the night guards about the incident. we tell the staff to be careful, don’t let anyone in from outside, keep the doors locked, don’t give the password to anyone. ” (Participant 1). “… For example, that friend was working in the outpatient clinic, where everyone could easily reach her. We transferred her to … (said the name of a safer clinic) and informed the nurse manager in that department …” (Participant 7). (the researchers did not disclose the safety assurance methods used by nurses to protect people’s safety)

Code 2: Organizing the work style

When the opinions of the nurse managers regarding the code of organizing the working style of the employees subjected to violence were examined, it was seen that in case of violence, they gave leave when the female employees needed it, arranged the shift lists to be suitable for the nurse, changed their units, transferred them to other institutions in order to ensure the safety of the person, tried to help the nurse when she found additional work in order to support her economically, and kept her away from critical tasks in order to prevent her from making mistakes. Statements related to this code were analysed under five headings: giving leave or report-adjusting shifts, changing the unit, granting a transfer/arranging a reassignment, allowing her to work in a way that enables her to take on additional jobs, and employing in passive tasks. The statements related to this code are given in Table 4.

Code 3: Trying to remove from the environment

Participants stated that they prioritise female employees who have been subjected to domestic violence to attend trainings such as congresses and courses in order to distract them from the environment and invite them to social environments with their friends. The opinion of a nurse manager on the subject is shown in Table 4.

Code 4: Providing support

In cases where female employees are subjected to violence, nurse managers try to provide social support to help them cope with their problems and try to harmonise them with the team. Managing nurses stated that they provide temporary accommodation support in the lodgings of the institution when their employees are threatened by their spouses, when they have nowhere to go, or when they cannot meet their rental expenses during or after the divorce process. The nurse managers stated that when their female employees were subjected to violence, they tried to help them get a battering report, document the violence, and initiate legal processes such as finding a lawyer. The statements related to this code were analysed under three headings: providing psychological and sociological support, providing accommodation support and providing legal support (Table 4).

Code 5: Taking security measures

The nurse managers stated that when the employees who were subjected to violence were threatened by their spouses, they assigned them to more sheltered wards, had security at the door of the ward, took precautions to prevent the sharing of information about the nurse’s personal and working order with other people, and asked for help from the police when necessary. The opinions of the participants on the subject are given in Table 4.

The findings of this study reveal that nurse managers require formal and structured training programmes to identify domestic violence and address such situations. Furthermore, the importance of establishing institutional policies to support employees exposed to violence while maintaining team performance and service continuation is emphasised. In this context, nurse managers and healthcare organisation managers should adopt a comprehensive approach that includes individual awareness as well as systematic and sustainable intervention mechanisms at the organisational level.

Discussion

The findings of this study on the impact of domestic violence on work life were examined within three subthemes: (1) “how it is noticed that the employee is subjected to violence,” (2) “how domestic violence is reflected on work life,” and (3) “how the nurse manager approaches the employee who is subjected to domestic violence”.

The nurse managers mentioned that female employees subjected to violence struggled to perform their jobs adequately, had a general decline in their performance, did not work in harmony with the team, and did not comply with work rules. The employees also mentioned that they generally dealt with violence alone, but they had to share their situation with their managers or close colleagues when taking leave, having health problems, or getting a report because of being subjected to violence. According to a global study, less than 40% of women subjected to violence sought help of any sort and a majority of women seeking help shared their experiences with family and friends [37]. Turkey, the “Domestic Violence Against Women Survey” revealed that 36% of married women experienced physical violence, 12% faced sexual violence, 44% endured emotional violence, and 30% encountered economic violence throughout their lives. Alarmingly, 44% of women did not disclose the violence they experienced to anyone. Women who share that they have been subjected to violence first tell about the violence to their own families, relatives, or friends [38]. The reports of 2014 and 2019, focusing on the impact of domestic violence on the work life of white-collar female employees, indicated that only 21% of women in 2014 and 28% in 2019 witnessed or knew about a colleague, an employee, or a manager experiencing violence at the workplace. In contrast, the corresponding figures for male employees were 15% and 19%, respectively. These findings highlighted that the issue of domestic violence remained a sensitive topic for many white-collar employees to share at work, even within companies participating in the project. Additionally, the reports revealed that the percentage of women subjected to violence who believed they could seek support from “colleagues at work,” “their manager at work,” and “human resources department employees of the company” increased from 7 to 8% in 2014 to 10% − 12% in 2019 [39].

The nurse managers emphasized that female employees subjected to domestic violence often faced sleep problems due to turmoil at home. They also observed that these employees experienced difficulty concentrating at work because of the unrest at home, which negatively affected the health services they provided. Other studies revealed psychological effects such as depression, sleep disorders, anxiety, and attention disturbances related to post-traumatic stress disorder in women subjected to domestic violence [20, 40, 41]. In a study involving 1715 participants, employees reported depression (28%) and anxiety and fear (19.1%) as signs of partner violence observed by colleagues at work [22].

The nurse managers observed that female employees subjected to domestic violence were tense and irritable during such periods. They might attempt to avoid work, show a tendency to constantly control everything due to attention disturbances, have low self-confidence, and disturb their team members with aggressive and disruptive behavior. A study on the relationship between domestic violence, self-esteem, and interpersonal relationships found that empathy scores decreased as physical violence increased. Individuals with high self-esteem were reported to be more successful in establishing interpersonal relationships because they perceived themselves as worthy of forming connections. In contrast, individuals with low self- esteem were thought to be less willing to express themselves remain in the background and alone in their own environment, and encounter difficulties in their relationships for these reasons [42]. A study by Güngör & Harmancı (2023) [43] also showed that women experiencing violence had lower levels of anger control compared with those who had not experienced violence.

The nurse managers mentioned that female employees subjected to domestic violence were threatened with death by their spouses, who sometimes came to the workplace armed. They did not want to come to work due to frequent harassment through phone calls, and primarily due to concerns about their safety. According to a study by Tiesman et al. (2012) [44] on women killed in the workplace, the rate at which women were killed by a former or current intimate partner (26%) was as high as the rate at which they were killed during event such as a robbery, theft, or other criminal activity (39%). Intimate partner violence also possibly affects the safety of other employees at the workplace [45]. The workplace is often seen as an access point for a husband or boyfriend to reach their female partners. A partner who closely monitors the victim knows that the victim’s workplace is a location where they can regularly and predictably access and confront the victim [46]. According to a study by Korkodeilou (2017) [47] reported that many participants changed their workplaces or stopped working because of being disturbed by persistent stalkers. Most of the attackers use weapons to intimidate the victim [48].

The nurse managers stated that female employees subjected to violence sometimes could not come to work or a shift because their spouses intentionally locked the doors of their homes after the violence. Researches suggests that intentional acts by the perpetrator, such as deliberately not providing childcare to prevent the woman from going to work, manipulating the woman’s physical appearance by cutting her hair, intentionally hiding or damaging the woman’s clothes, having car keys or other work items hidden, preventing the woman from getting enough rest, and changing or turning off alarm clocks, also impacted women’s ability to attend work [46, 49, 50].

In the present study, the nurse managers emphasized that nurses subjected to violence encountered several difficulties in working as a team and fulfilling their role as team members with their colleagues and other members of their profession, which negatively affected the work environment. A violent man not only poses a risk to his intimate partner but can also have a negative impact on her work colleagues. Due to this potential risk, women may struggle to sustain employment. The employee’s ability to maintain an adequate level of work performance and productivity may be affected due to concentration difficulties and absenteeism which are related to violence [45, 46]. The productivity of the female employee exposed to violence decreases and the number of days she cannot come to work increases [51, 52].

The findings of this study are consistent with previous studies indicating that domestic violence negatively affects the work life of employees. Specifically, the decline in employee work performance is considered by nurse managers both as an indicator for identifying domestic violence and as a consequence of the violence. In the study, approximately one-quarter of employees who believed that their colleague was subjected to violence stated that they noticed decreases in their colleague’s performance; they observed behaviours such as coming to work late, absenteeism, and turnover (13%) [22]. IPV leads to increased workplace costs, with the mean annual cost of IPV lifetime victims being 2,394 $ for absenteeism and 82.84 $ for tardiness [52].

Although present studies [29, 30] investigated nurses’ levels and reasons of exposure to a partner or ex-partner violence, nursing manager approaches were not sufficiently addressed. As also suggested by Swanberg and Logan (2005) [50], this study aims to investigate in depth the attitudes of nurses and nurse managers toward domestic violence, as well as institutional policies and practices. The nursing managerial approaches presented in this study (such as giving leave or report-adjusting shifts, changing the unit and providing psychological and sociological support) are mostly individual applications. These approaches are inadequate according to the relevant legal regulations (Law on Occupational Health and Safety No. 6331 and 6284 Law to Protect Family and Prevent Violence against Woman) demonstrate the need for institutional policy development [53, 54]. Therefore, this study emphasises the importance of developing comprehensive support mechanisms that are compatible with legal obligations related to domestic violence and international occupational health and safety.

Limitations

This study had some limitations. First, this qualitative study included individual interviews with a limited number of nurses working in Turkey, and hence the results could not be generalized to the entire population. Second, despite the assurance that their personal information would remain confidential, some participants expressed reluctance and limited themselves in narrating the experiences of their colleagues. Third, the researchers were unable to identify any findings, regarding impact work lives of domestic violence only in a nursing sample and the approach of nurse managers, which significantly limited the comparability of research results. Finally, the fact that the sample consists only of nurse managers limits the possibility of triangulation with different perspectives.

Conclusions

This study aimed to investigate how nurse managers address domestic violence against nurses, their methods of recognizing and such cases, the impact of such violence on work life, the support provided that nurses subjected to domestic violence, and the measures taken in this process. Hence, the findings could be of significant importance, especially considering the rising prevalence of violence against women today.

This study explored the perspectives of nurse managers regarding the implications of domestic violence on professional life through subthemes including how nurse managers noticed when an employee was subjected to violence, the impact of domestic violence was reflected on work life, and the approach taken by nurse managers when an employee experienced domestic violence.

In interviews conducted with nurse managers, it was observed that employees often hesitated to disclose that they were subjected to domestic violence; some only revealed their situation when they felt compelled to do so or when it was noticed by the nurse manager. The study revealed that female employees subjected to domestic violence struggled to perform their duties, faced challenges in harmonizing with the team, struggled with adherence to work hours and schedules, and experienced a decline in overall performance. In terms of the managerial approach to nurses facing domestic violence, the nurse managers regulated the work patterns of such employees, sent them to conferences or training to create distance from the work environment, provided support to them, implemented safety measures, and strove to harmonize them with the team.

Implications and recommendations

This study findings indicate that individual only awareness will not be sufficient to prevent the impact of domestic violence on work life. In order to effectively address this issue, policy-based regulations and intervention strategies may be implement. Intervention strategies should be structured in the short and long term; in the short term, structured training programmes covering legal responsibilities, communication skills, guidance/consult may be implemented for nurse managers. At the same time, security measures and psychosocial support mechanisms may be developed for employees exposed to violence within the institution.

In the long term, personnel policies should be reviewed and made more sensitive to domestic violence. In addition, institutional procedures that protect employee rights should be established and the sustainability of these policies should be ensured. In this context, the roles of stakeholders (nurse managers, human resources units, policymakers, and relevant ministries) responsible from implementing the recommendations must be also clearly defined.

Considering the causes of domestic violence, it can be inferred that children particularly those who are modeling their parents play a significant role in domestic violence. Therefore, preventive programs addressing domestic violence and raising awareness in the community can be implemented under the Ministry of National Education or the Ministry of Family and Social Policies. It is recommended that the number of women’s research centres be increased and that interdisciplinary academic research on this topic be supported.

Abbreviations

COREQ

COnsolidated criteria for REporting Qualitative research

WHO

The World Health Organization

Un Women

The United Nations Entity for Gender Equality and the Empowerment of Women

Author contributions

Burcu ALAÇAM conceptualized and designed the study, undertook the data collection and analysis, and drafted and wrote the manuscript.Ülkü BAYKAL performed the drafting of the article, the critical revision and the final approval of the version to be published.

Funding

This study received no specific funding from any public, commercial, or nonprofit funding agency.

Data availability

The data that support the findings of this study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Ethics approval and consent to participate This study was performed in accordance with the Helsinki standard and was approved by the Istanbul University Cerrahpaşa Medical Faculty Clinical Research Ethics Committee (reference number number: 59491012/604.01.02). All participants were informed of the study’s objectives and provided written consent before participation. Participants’ identities were kept confidential, and descriptors such as numbers, which did not directly reveal their identity, were used in the quoted excerpts presented in the Results section.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.