Abstract
BACKGROUND:
One of the significant issues in health studies is violence. Although violence against nurses has been recognized as a major occupational problem, its magnitude and extent is not clearly defined. The aim of this study was to determine the extent and types of violence during clinical training of nursing students.
METHODS:
In this descriptive and cross-sectional study, 180 sophomores, juniors and seniors of Shahid Beheshti, Tehran and Iran Medical Universities were selected by quota sampling method. A questionnaire was used for collecting data regarding violence over the past year. Content and test-retest methods were used for evaluating its validity and reliability, respectively.
RESULTS:
Findings showed that 6.7%, 8.3% and 39.4% of the students experienced physical assault, physical menace and insult, respectively, over the past year. Most cases of the assaults (66.7%) were done by patients, most menaces by staff as well as patients’ attendants (18.1%) and most insults by staff (33.7%) and patients (31%). No significant relation was found between the sex as well as the educational year of the students and the experience of insult. 41.6% of the assaults were due to the effects of disease in assailants. However, no specific reason was found for physical menace and insult in most cases. 66.65%, 26.6% and 39.4% of the students reported physical assault, menace and insult to their tutors, respectively.
CONCLUSIONS:
Nursing students are subject to more violence because of young age and inadequate experience. Therefore, devising educational programs regarding occupational violence as well as its prevention and providing necessary support and consultation following violence are essential.
KEY WORDS: Violence, training, nursing students
One of the critical issues in health studies is violence influencing individuals throughout their lives.1 In the US, over 600 cases of work-related homicide occurred in 2002 and it is estimated that almost 1.7 million nonfatal violence cases have taken place annually between 1993 and 1999. Staff in certain professions such as nursing is at high risk of nonfatal violence at work. Currently, there are no regulations in this regard; however, Occupational Safety and Health Administration (OSHA) has only proposed some recommendations regarding prevention of violence at work.2
A critical event is described as one perceived as an emotional stress and overcomes coping mechanisms of an individual involved. One of the significant resources of occupational harms for healthcare workers in addition to numerous fatal events is the experience of violence by patients.3 Ayranci (2005) defines violence as any event that puts healthcare workers at risk and includes insult, threatening conduct, invasion by patient or significant others.4 Stilling (1992) describes invasion of patients as any verbal, nonverbal and physical conduct that threatens themselves, others and devices.5
Healthcare workers are subject to the highest risk of violence particularly nonfatal type. Nurses comprise a significant proportion of healthcare personnel. Although violence has been considered as a primary problem in nursing occupation, its extent and related risk factors are still unknown.6
According to Fernandes et al. (1999), violence at work is a familiar experience for healthcare personnel, which is mostly done by patients and less frequently by patients’ visitors. Drug abuse and mental disorders are of important factors leading to violence at hospital wards such as emergency departments. Incidents like violence have significant long-term impacts such as low morale, anger, lack of self-confidence, burn out, work leave, incapability and change in working condition on healthcare workers.7
Littrell and Littrell (1998) did contend that common risk factors in assault include youngness, masculinity, low socioeconomic status, significant psychiatric conditions such as hyperactivity syndrome as well as noncompliance to treatment, and such personality disorders as dependence on caregiver, history of misconduct or hospitalization for assault, familial history of assault, carrying gun and social isolation.8
Preventing occupational violence requires planning to identify its extent and related factors. Studies of occupational violence have been mostly conducted on healthcare workers and no research is found on nursing students. The aim of this study was to determine the extent and types of violence over one year among nursing students of Shahid Beheshti, Tehran and Iran Medical Universities during their clinical training in 2006. Occupational violence consisted of physical assault, physical menace and insult.
Methods
This descriptive and cross-sectional study was carried out on 180 sophomores, juniors and seniors in Tehran city. Inclusion criteria included no work experience, studying nursing in Shahid Beheshti, Tehran or Iran Medical Universities and one year experience of clinical training. Samples were selected by quota sampling method according to number of students in three schools. After taking verbal informed consent from the students, they were asked to complete a questionnaire following being informed about it and assured about confidentiality matters. They reported types of violence in previous years during 2006.
The tool consisted of two parts. Demographic data including age, sex, marital status, and educational year and questions related to occupational violence including physical assault, physical menace and insult. Content and test-retest methods were used for evaluating validity and reliability (r = 0.89) of the questionnaire, respectively. The data was analyzed using descriptive (mean and standard deviation) and analytic (chi-square) models employing version 11 of SPSS software.
Results
Most subjects (78.9%) were below 22 and 21.1% above 22 years. Mean age of the students was 21.94 (SD = ±1.95). 72.2% of them were female. 90% of the subjects were single and only 10% were married
6.7% experienced physical assaults, of whom 66.7% were done by patients, 16.7% by nursing staff, and 16.7% by others. Nobody suffered from physical injury or needed any treatment. Most assailants (66.7%) were male.
8.3% of the students faced with physical menace mostly by nursing staff (36.3%), patients’ visitors (18.1%), clinicians (13.6%), patients (9%), aides (9%) and others (13.6%). The students were menaced mostly by females (66.66%).
39.4% of the students experienced insults largely by nursing staff (33.7%), patients (31%), clinicians (9.4%), patients’ visitors (8.1%), aides (8.1%) and others (9.4%). Most insulters (50.05%) were female.
No significant relation was found between students’ sex and the frequency of insult by chi-square test (p = 0.051). The same result was found between educational years and insult frequency (p = 0.86). No statistical test was used for physical assault and menace because of the low number of cases.
With respect to the physical assault, 41.6%, 25%, 16.6% and 16.6% were due to disease effects, without any specific problem, emotional problems, and with no known disorder, respectively. Regarding the physical menace, 60% of attackers had no specific problem, 26.7% suffered from mental disorders and 13.3% had no known disease. Concerning insult, 32.3% of insulters had no specific problem, 28.1% suffered from an unknown disorder, 22.5% were affected by a disease and 11.3% suffered from mental disorders. 66.7, 26.6 and 39.4% of the students reported physical assault, physical menace and insult to their tutors, respectively.
Discussion
Different studies have been conducted regarding occupational violence in healthcare professionals but no related research was found in nursing students. 6.7%, 8.3%, and 39.4% of the students experienced physical assaults, physical menace and insults, respectively. Whittington et al. (1996) reported 25% physical assaults and 50% insults in their study, which was higher than in our study.9 Lin and Liu (2005), identified two types of violence in their study. They reported 12.7% physical assaults only by patients and 53.9% insults mostly by patients and their visitors, which were similar to our findings.10
Gerberich et al. (2004) found 13.2% physical assaults, 17% physical menaces and 34% insults in their study similar to those of our study.6 Similarly, most physical assaults (90%) were committed by patients but findings regarding nonphysical violence differed and included clinicians, visitors, other staff and supervisors.
Ayranci (2005) performed a study on health-care personnel in emergency wards of Turkey. 8.5% physical assaults, 53.2% physical menaces, and 69.5% insults were reported.4 These figures were higher than ones of our study, which may be attributed to the diversity of participants including nurses, clinicians, guards and most physical assaults were committed by patients and their visitors.
Our findings showed no significant relation between two sexes as well as educational years and the occurrence of insult, i.e., sex and educational year of the students had no effect on insult frequency. No statistical test was applied to find a relation between sex as well as educational year and physical assault as well as menace due to few number of cases. Whittington et al. (1996) found a significant relation between duration of service delivery and occupational violence as new staff experienced violence more frequently, which may indicate the effects of increased age, experience and skill in communicating with patients and staff.9
In this study, most assailants were affected by their diseases. Gerberich et al. also found that 80% of the assailants were affected by their diseases or drugs while nonphysical violence occurred less due to diseases (41%) or drugs (12%).6 Most cases of physical and nonphysical violence were committed by males while, in our study, most physical assaults were committed by males but nonphysical assaults by females. Mental problems, certain conditions and substances can lead to occupational violence but most assailants or insulters in the current research had no specific problem contrary to other studies.
Reporting violence was not ideal in this study but slightly more than that in other studies. In the study of Fernandes et al. (1999), 54% of occupational menace and 44% of physical menace with damage had never or rarely been reported. Most participants (91%) thought that occupational violence was not reported.7 Gerberich et al. found that, in physical violence, verbal, written, and both verbal and written reports were 39, 15, and 15% but, in nonphysical violence, verbal, written, and both verbal and written reports were 47, 6, and 18%, respectively.6
According to these findings, the complete omission of occupational violence is impossible. Thus, the best way is to determine the extent and causative factors of violence and minimize it by planning. Since students are more vulnerable, they may face many short- and long-term problems. Therefore, they should be supported from the beginning of violence to reduce its complications by necessary follow-ups and consultations. Nursing colleges can develop educational programs regarding communication with staff as well as patients and dealing with occupational violence to prepare students for clinical training as much as possible.
The authors declare no conflict of interest in this study.
Acknowledgments
We express our gratitude toward all participant students and all professors helping us to conduct this study.
References
- 1.Nies MA, McEwen M. Community health nursing: promoting the health of populations. 3rd ed. Philadelphia: Elsevier Health Sciences; 2001. [Google Scholar]
- 2.Nachreiner NM, Gerberich SG, McGovern PM, Church TR, Hansen HE, Geisser MS, et al. Relation between policies and work related assault: Minnesota Nurses’ Study. Occup Environ Med. 2005;62(10):675–81. doi: 10.1136/oem.2004.014134. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Paterson B, Leadbetter D, Bowie V. Supporting nursing staff exposed to violence at work. Int J Nurs Stud. 1999;36(6):479–86. doi: 10.1016/s0020-7489(99)00046-2. [DOI] [PubMed] [Google Scholar]
- 4.Ayranci U. Violence toward health care workers in emergency departments in west Turkey. J Emerg Med. 2005;28(3):361–5. doi: 10.1016/j.jemermed.2004.11.018. [DOI] [PubMed] [Google Scholar]
- 5.Stilling L. The pros and cons of physical restraints & behavior controls. J Psychosoc Nurs Ment Health Serv. 1992;30(3):18–20. doi: 10.3928/0279-3695-19920301-07. [DOI] [PubMed] [Google Scholar]
- 6.Gerberich SG, Church TR, McGovern PM, Hansen HE, Nachreiner NM, Geisser MS, et al. An epidemiological study of the magnitude and consequences of work related violence: the Minnesota Nurses’ Study. Occup Environ Med. 2004;61(6):495–503. doi: 10.1136/oem.2003.007294. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Fernandes CM, Bouthillette F, Raboud JM, Bullock L, Moore CF, Christenson JM, et al. Violence in the emergency department: a survey of health care workers. CMAJ. 1999;161(10):1245–8. [PMC free article] [PubMed] [Google Scholar]
- 8.Littrell KH, Littrell SH. Current understanding of violence and aggression: assessment and treatment. J Psychosoc Nurs Ment Health Serv. 1998;36(12):18–24. doi: 10.3928/0279-3695-19981201-18. [DOI] [PubMed] [Google Scholar]
- 9.Whittington R, Shuttleworth S, Hill L. Violence to staff in a general hospital setting. J Adv Nurs. 1996;24(2):326–33. doi: 10.1046/j.1365-2648.1996.18114.x. [DOI] [PubMed] [Google Scholar]
- 10.Lin YH, Liu HE. The impact of workplace violence on nurses in South Taiwan. Int J Nurs Stud. 2005;42(7):773–8. doi: 10.1016/j.ijnurstu.2004.11.010. [DOI] [PubMed] [Google Scholar]