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. 2021 Mar 24;30(13-14):2036–2047. doi: 10.1111/jocn.15760

Nurses' exposure to violence and their professional commitment during the COVID‐19 pandemic

Sultan Özkan Şat 1,, Pınar Akbaş 2, Şengül Yaman Sözbir 1
PMCID: PMC8251095  PMID: 33761158

Abstract

Aims and Objectives

This study aimed to determine the relationship between nurses' exposure to violence and their professional commitment during the COVID‐19 pandemic.

Background

Violence against nurses is a common problem that persists worldwide.

Design

This was a descriptive cross‐sectional study.

Methods

An online questionnaire form and the Nursing Professional Commitment Scale were used to collect the data. The study was carried out online during the COVID‐19 pandemic between October–December 2020. A total of 263 nurses agreed to participate in the study. The STROBE checklist was followed for observational studies.

Results

During the COVID‐19 pandemic, 8.4% of the nurses stated that they were exposed to physical violence, 57.8% to verbal violence, 0.8% to sexual violence and 61.6% to mobbing. 52.1% of the nurses stated that they thought of quitting the profession during the COVID‐19 pandemic. The mean total Nursing Professional Commitment Scale score was 71.33 ± 15.05.

Conclusions

This study revealed that nurses' exposure to physical, verbal and sexual violence during the COVID‐19 pandemic decreased compared to before the pandemic. Nurses' exposure to mobbing during the pandemic was found to increase. A statistically significant difference was found between the status of the nurses' exposure to physical violence, verbal violence, and mobbing, working hours, number of patients given care, and their thoughts of quitting the profession. It was found that the status of exposure to physical violence, thinking of quitting the profession and working hours decreased professional commitment.

Relevance to clinical practice

In the light of these results, it is recommended that measures to prevent violence should be addressed in a multifaceted way. In managing the pandemic process, the decisions and practices should not be left to the managers' initiative to prevent mobbing. Initiatives that will increase nurses' professional commitment during the pandemic process should be planned and implemented.

Keywords: COVID‐19, exposure to violence, intention to quit nursing, nursing, professional commitment, workplace violence


What does this paper contribute to the wider global clinical community?

  • This study demonstrated that working conditions of nurses are getting worse during the pandemic process.

  • This study revealed that nurses' exposure to all type of violence except for mobbing during the pandemic was found to decrease.

  • Our results showed that especially exposure to physical violence among the type of violence decreased professional commitment.

1. INTRODUCTION

Many areas of life, from health systems to the economy, working life, and daily life in Turkey, as well as the world, have been adversely impacted by the COVID‐19 pandemic, declared by the World Health Organization (WHO) (Nakışci Kavas & Develi, 2020). Following the first case's appearance on 11 March 2020, in Turkey, as of 7 December 2020, the total number of patients infected with COVID‐19 reached 545.711, with the death toll increasing to 15.103 (T.R. Ministry of Health, 2020). One of the issues that the pandemic has negatively affected, exacerbated and made visibly is violence against health professionals. During the COVID‐19 pandemic process in Turkey, healthcare professionals have been more often commissioned in the home care of the individuals aged 65 or older, who make up the risk group for COVID‐19, 112 emergency care services, COVID‐19 intensive care units, and filiation teams. Consequently, other health services provided in health institutions have been interrupted. In addition to intense working conditions, long shifts and lack of protective equipment, healthcare professionals have occasionally had to enter quarantine due to testing positive for COVID‐19. Also, patients and their relatives cannot receive adequate health care due to pandemic regulations such as limited polyclinic services, the transition to an appointment system and subsequent patient failure to make an appointment for an examination or postponement of the appointment date to later days, need for disinfecting the rooms after each examination, waiting time of at least 20 min between examinations, and cancellation of non‐urgent operations. All these experiences and fear of death/loss of relatives due to the COVID‐19 have led to extreme tension and anger in patients and their relatives.

2. BACKGROUND

The World Health Organization (WHO) defines violence as “the intentional threat or actual use of physical force or power against another person, which either results in or has a likelihood of resulting in injury, death, or psychological harm” (Krug et al., 2002). Violence against healthcare workers, on the other hand, is defined as situations consisting of behavioural or verbal threats, physical assault, or sexual assault coming from the patient, patient relatives, or any other persons and posing a risk to the healthcare worker (Annagür, 2010; Catlette, 2005). Studies reveal that violence against healthcare professionals has increased in recent years. The 2015 report of the American Nurses Association (ANA) states that 43% of nurses and nursing students have been subjected to verbal or physical violence by patients and their relatives and that this rate is more than 70% among emergency department nurses (Potera, 2016). According to a study conducted in Italy, 49% of nurses were subjected to violence within a year, and 82% of this was verbal violence (Zampieron et al., 2010). There are many studies carried out in Turkey in which violence against healthcare workers varies by the department (99.7% for 112 employees, 90.4% for emergency service workers, 43.4% for paediatric service workers, 73.8% for inpatient services, 65% for primary care workers, etc.), the type of violence that is exerted (physical violence at varying rates, such as 9.6% 16.7%, 20% and 23.2%; verbal violence at varying rates, such as 78.3%, 82%, 95.7% and 99.7%) and the profession (85% towards nurses, 69.4% towards research assistant doctors and 54.5% towards specialists) (Akbaş et al., 2016; Cerit et al., 2018; Coşkun & Karahan, 2019; Çuvadar & Ekuklu, 2020; Demirci & Uğurluoğlu, 2020; Oğuz et al., 2020; Şahin & Yıldırım, 2020; Yücens & Oğuzhanoğlu, 2020). It has been reported that nurses, who are in close contact with patients and patient relatives while giving care, are exposed to violence by patients and patient relatives due to factors, such as long waiting times in health institutions, an inadequate number of healthcare workers, lack of security personnel, lack of information about the responsibilities of healthcare professionals by patients and their relatives, poor working conditions, lack of professional experience, and working in the night shift (Angland et al., 2014; Fallahi Khoshknab et al., 2015; Park et al., 2015).

Nurses are the leading healthcare professionals, who are at the forefront in the fight against COVID‐19, risk their own lives, and are exposed to dangers. Although health professionals in many countries have been declared heroes in the fight against COVID‐19 and are given applauses, violence towards healthcare professionals has increased during the pandemic process. In the literature, it was reported that during the COVID‐19 pandemic, healthcare professionals in Mexico were attacked with eggs and subjected to physical violence, and those in India were beaten, despised, stoned, spat on their faces, and evacuated from their homes (Semple, 2020; Withnall, 2020). Similarly, it has been reported that in many places, like Europe, the USA and Australia, violence towards healthcare professionals has kept increasing during the pandemic period (McKay et al., 2020). Besides, health professionals have experienced stigma and exclusion due to the concerns that they may be COVID‐19 carriers (Chew et al., 2020). Similarly, we learn from the news or social media that incidents of violence have increased or become visible in Turkey, too (Özgüç & Toprak Ergönen, 2020).

Exposure to all forms of violence can lead to the low quality of life, decreased job satisfaction, decreased productivity, anxiety and depression, anger, confusion, increased occupational burnout, decreased quality of patient care, post‐traumatic stress disorder, decreased professional commitment, and quitting the profession (Bernaldo‐De‐Quiros et al., 2015; Heckemann et al., 2015). Therefore, this study aimed to determine the relationship between nurses' exposure to violence and their professional commitment during the COVID‐19 pandemic process.

2.1. Research questions

Has the COVID‐19 pandemic process affected the status of nurses' exposure to violence?

Has the COVID‐19 pandemic process affected the types of violence towards nurses?

Has the COVID‐19 pandemic process affected nurses' level of professional commitment?

Is there a relationship between nurses' exposure to violence and their level of professional commitment during the COVID‐19 pandemic process?

3. METHOD

3.1. Research design

The study used a descriptive cross‐sectional design. The STROBE (STrengthening the Reporting of OBservational studies in Epidemiology) checklist was followed to guide this article (see Appendix S1).

3.2. Study population and sample

The study population consisted of nurses working actively in public, private or university health institutions in Turkey. Since the number of nurses actively involved in the COVID‐19 process was not known, the sample size was calculated using the sampling unknown universe formula (n = t 2 pq/d 2), where p = .85 q = 0.15, d = 0.05, and t = 1.96 based on the study of Çuvadar and Ekuklu (2020). Accordingly, it was found that the sample size (n) should consist of 196 participants. The study was completed with a total of 263 nurses who resided within the boundaries of the Republic of Turkey, worked as a nurse in one of the public, private, or university health institutions, and volunteered to participate in the study.

3.3. Data collection tools

The study data were collected using a questionnaire form created by the researchers and the “Nursing Professional Commitment Scale” to determine the level of participants' professional commitment.

3.3.1. The online questionnaire form

The form consists of 39 items that collect information about participants' socio‐demographic characteristics (i.e. age, education level) and status of exposure to violence during the COVID‐19 pandemic process (Demirci & Uğurluoğlu, 2020; Şahin & Yıldırım, 2020).

3.3.2. The Nursing Professional Commitment Scale (NPCS)

This scale was developed by Lu et al. (2000) to determine nurses' professional commitment. The scale has 26 items, three sub‐dimensions (willingness to make an effort, maintaining as professional membership, belief in goals and values) and a four‐point Likert‐type rating structure. Nine items of the scale are reversed (items 14, 15, 16, 17, 18, 19, 20, 21 and 25). The scores that can be obtained from the total scale range between 26–104. The scores that can be obtained from the sub‐dimensions range between 13–52 for “willingness to make an effort,” 8–32 for “maintaining as a professional membership,” and 5–20 for “belief in goals and values.” Increased scores from the overall scale and sub‐dimensions indicate that individuals' professional commitment is high. The Turkish validity and reliability study of the scale was conducted by Çetinkaya et al. (2015), and the internal consistency of the scale was found as 0.90. Cronbach's α coefficient from the original scale's validity and reliability study was reported to be 0.94 (Lu et al., 2000). Cronbach's α coefficient of the scale in our study was found as 0.91.

3.4. Procedure

The study was carried out online between October–December 2020. In this context, data collection tools were turned into an online survey using Google Forms®. The study was carried out by sending the online link to nurses through social networking sites such as Facebook®, WhatsApp®, Instagram® and Twitter®. Besides, researchers shared the link on forums and blogs on the Internet. As people are mostly active on social networking sites, these sites were used for circulating the questionnaire. “Allow only one response per user” option in Google Forms was used to identify potential duplicate entries from the same user. The questionnaire included a short explanation that stated only nurses who worked actively in public, private and university health institutions could participate in the study. It is estimated that completing the online questionnaire took approximately 10–15 min for each participant. The incomplete submission of the questionnaire was not possible due to the function in Google Forms which prevents submission of partially answered or unfilled questions.

3.5. Data analysis

The data collected in the study were analysed on spss 23.0 (Statistical Package for Social Sciences, version 23.0, for Windows) software package. Descriptive statistics, such as numbers and percentages, and t‐test and chi‐square tests, were employed to analyse the data.

3.6. The ethical aspect of the study

At the outset, the approval of the Scientific Research Platform of the Turkish Republic Ministry of Health was obtained to carry out a study related to the pandemic process (Research No: 2020‐10‐15T20_18_20). In addition, the ethical approval of the Gazi University Ethics Committee was obtained (Research Code No: 2020‐606). In the study's application phase, the participants were informed about the study, and their informed consent was obtained on the first page of the questionnaire form. After the participants checked the checkbox showing they agreed to participate in the study, they could see the questionnaire items. No personal information was requested from the participants, and their responses reached the researchers anonymously. All information obtained from the participants was kept confidential and stored in an e‐mail address accessible only to researchers.

4. RESULTS

4.1. Socio‐demographic characteristics of the participants and findings regarding their working life

The nurses' mean age in our study was 31.26 ± 7.17, 88.2% of them were female, and 63.9% had an undergraduate degree. The participants were from the seven regions of Turkey, and most of them were found to work in the Central Anatolia region (38.8%). 43.7% of nurses had a working period of 0–5 years. Also, 22.1% of the nurses were in intensive care units, 20.9% in internal medicine units, 16.7% in special nursing units (wound care, infection control and breastfeeding), 16% in the emergency departments, 13.7% in surgical units and 10.6% in other units. As for the nurses' positions, 77.2% were service nurses, 14.4% were charge nurses and 8.4% were polyclinic nurses. While 27% of the nurses worked only in the day shift, 73% worked in day‐night/mixed shifts (Table 1).

TABLE 1.

Characteristics of nurses' socio‐demographic and working life during the COVID‐19 pandemic

Socio‐demographic characteristics X¯ + SD Min/Max
Age 31.26 ± 7.17 22–52
Number (n = 263) %
Sex
Female 232 88.2
Male 31 11.8
Education level
High school 40 15.2
Undergraduate 168 63.9
Postgraduate 55 20.9
Working region
Central Anatolia region 102 38.8
Black Sea region 70 26.6
Marmara region 43 16.3
Aegean region 26 9.9
Eastern Anatolia region 10 3.8
Mediterranean region 7 2.7
Southeastern Anatolia region 5 1.9
Working period as a nurse
0–5 years 115 43.7
5–10 years 58 22.1
10 years and more 90 34.2
Working department
Intensive care units 58 22.1
Internal medicine units 55 20.9
Special nursing units 44 16.7
Emergency departments 42 16.0
Surgical units 36 13.7
Other units 28 10.6
Working position
Service nurse 203 77.2
Charge nurse 38 14.4
Polyclinic nurse 22 8.4
Working shift
Day shift 71 27.0
Day‐night/mixed shift 192 73.0
Changes in the department worked during the pandemic
No. There was no change 141 53.6
Yes, I started working in COVID‐19‐related units 82 30.9
Yes, I started working in the filiation team 11 4.3
Yes, I started working in a unit other than the one I usually work in 29 11.2
Changes in the working hours during the pandemic
No. There was no change 113 43.0
Yes. Increased 118 44.8
Yes. Decreased 32 12.2
Changes in the number of patients given care during the pandemic
No. There was no change 70 26.6
Yes. Increased 96 36.5
Yes. Decreased 97 36.9
X¯ + SD Min/Max
Average number of patients giving daily care before pandemic 52.12 ± 154.73 0–1600
Average number of patients given daily care during pandemic 41.46 ± 111.93 0–1000

This article is being made freely available through PubMed Central as part of the COVID-19 public health emergency response. It can be used for unrestricted research re-use and analysis in any form or by any means with acknowledgement of the original source, for the duration of the public health emergency.

The characteristics of the nurses related to their working life during the pandemic process are shown in Table 1. During the pandemic process, the departments of the 46.4% of the nurses in our study had changed, 30.9% had started working in units where COVID‐19 patients were given care, the working hours of the 44.8% increased, and 36.5% had an increased number of patients (Table 1).

4.2. Findings related to participants' exposure to violence and the status of thinking of quitting the profession

Table 2 shows the status of nurses' exposure to violence before and during the pandemic. Nurses' exposure to physical, verbal–emotional–psychological, and sexual violence during the pandemic was found to decrease compared to the case before the pandemic period, and a statistically significant difference was determined (p ≤ .05). Nurses' exposure to mobbing during the pandemic was found to increase, and the difference between pre‐ and during pandemic status was statistically significant (p ≤ .05).

TABLE 2.

Status of nurses' exposure to violence before and during the pandemic

Status of nurses' exposure to violence Before the COVID‐19 pandemic During the COVID‐19 pandemic

Number

(n = 263)

%

Number

(n = 263)

%
Exposure to physical violence
Yes 47 17.9 22 8.4
No 216 82.1 241 91.6
Statistics χ 2 = 41.405 p = .000*
Types of physical violence exposed a
Scratching/pinching/biting 11 25.6 6 30.0
Pushing 21 48.8 10 50.0
Hitting/punching 13 30.3 4 20.0
Use of object 7 16.3 5 25.0
Person who perpetrated the violence a
Patients 25 54.3 12 54.5
Patient relatives 31 67.4 15 68.2
Colleagues (i.e. nurse, doctor, security personnel) 4 8.6 1 4.5
Exposure to verbal–emotional–psychological violence
Yes 181 68.8 152 57.8
No 82 31.2 111 42.2
Statistics χ 2 = 81.000 p = .000*
Types of verbal–emotional–psychological violence exposed a
Shouting 128 71.1 101 67.3
Verbal threat 94 52.2 73 48.7
Rebuke 93 51.7 81 54.0
Swearing 34 18.9 30 20.0
Insult 84 46.7 69 46.0
Humiliation 78 43.3 73 48.7
Gossip 28 15.6 25 16.7
Person who perpetrated the violence a
Patients 114 63.0 93 61.6
Patient relatives 138 76.2 101 66.9
Colleagues (i.e. nurse, doctor, security personnel) 42 23.3 50 33.3
Exposure to sexual violence
Yes 9 3.4 2 0.8
No 254 96.6 261 99.2
Statistics χ 2 = 56.877 p = .001*
Types of sexual violence exposed a
Jokes, questions or sayings about sex 3 42.9 1 50.0
Implicit eyebrow, eye, hand and facial movements 4 57.1
Exposing a certain part of a person's body in a meaningful way 3 42.9 1 50.0
Person who perpetrated the violence a
Patients 4 57.1 2 100.0
Patient relatives 2 28.6 1 50.0
Colleagues (i.e. nurse, doctor,security personnel) 3 42.9
Exposure to mobbing
Yes 149 56.7 162 61.6
No 114 43.3 101 38.4
Statistics χ 2 = 100.685 p = .000*
a

Only those who stated that they were subjected to the mentioned types of violence responded. n is replicated as nurses can choose more than one statement.

*

p ≤ .05.

This article is being made freely available through PubMed Central as part of the COVID-19 public health emergency response. It can be used for unrestricted research re-use and analysis in any form or by any means with acknowledgement of the original source, for the duration of the public health emergency.

Table 2 shows whether the nurses were subjected to violence. The participants were asked about their opinions on the change in the frequency of violence against healthcare professionals during the COVID‐19 pandemic process (Table 3). Table 3 shows nurses' thoughts on the change in the frequency of violence, whether they were exposed to violence or not. Although nurses are not exposed to violence themselves, they think that violence against nurses (especially physical violence,verbal–emotional–psychological violence, and mobbing) has increased throughout the country during the pandemic period. Accordingly, 57.4% of the nurses stated that there was an increase in the frequency of physical violence during the COVID‐19 pandemic, and according to 62.7%, the frequency of verbal–emotional–psychological violence increased. Also, 86.3% of the nurses thought there was no change in the frequency of sexual violence, and 66.5% thought an increase in mobbing frequency during the pandemic process. The nurses were also asked whether they thought of quitting the profession during the COVID‐19 pandemic process. Accordingly, 52.1% of the nurses stated that they wanted to, and the primary reason was stated to be severe working conditions (Table 3).

TABLE 3.

Nurses' thoughts regarding the change in the frequency of violence during the COVID‐19 pandemic and intention to leave profession

Number (n = 263) %
Changes in the frequency of physical violence during the COVID‐19 pandemic
Increased 151 57.4
Decreased 12 4.6
There was no change 100 38.0
Changes in the frequency of verbal–emotional–psychological violence during the COVID‐19 pandemic
Increased 165 62.7
Decreased 8 3.0
There was no change 90 34.2
Changes in the frequency of sexual violence during the COVID‐19 pandemic
Increased 23 8.7
Decreased 13 4.9
There was no change 227 86.3
Changes in the frequency of mobbing during the COVID‐19 pandemic
Increased 175 66.5
Decreased 6 2.3
There was no change 82 31.2
Intention to leave profession during the COVID‐19 pandemic
Yes 137 52.1
No 126 47.9
Reasons for intention to leave the profession a
Severe working conditions 50 22.0
Economic dissatisfaction 37 16.2
Feeling worthless 29 12.7
Burnout 28 12.3
Lack of professional prestige (to think that the profession does not see the value it deserves) 24 10.5
Fear of getting infected with the coronavirus and infecting relatives 20 8.8
Mobbing 19 8.3
Psychological changes due to the pandemic (stress, irritability, intolerance, the feeling of inadequacy, anxiety) 7 3.0
Managerial misconduct 6 2.6
Verbal and physical violence by patients and their relatives 3 1.3
Shortage of personal protective equipment 2 0.8
Others 2 0.8
a

Only those who stated that they wanted to leave the profession responded. n is replicated as nurses can choose more than one statement.

This article is being made freely available through PubMed Central as part of the COVID-19 public health emergency response. It can be used for unrestricted research re-use and analysis in any form or by any means with acknowledgement of the original source, for the duration of the public health emergency.

A statistically significant difference was found between the status of the nurses' exposure to physical violence, verbal–emotional–psychological violence, and mobbing and their thoughts of quitting the profession (p ≤ .05). There was also a statistically significant difference between the nurses who stated that their working hours and the number of patients they provided care had increased and the nurses whose department had changed during the pandemic process in terms of their thoughts of quitting the profession (p ≤ .05) (Table 4).

TABLE 4.

Analyses the effects of some variables on intention to leave profession

Intention to Leave Profession
Yes No Statistics
n % n % Chi‐Square p
Exposure to physical violence during the COVID‐19 pandemic
Yes 17 12.4 5 4.0 χ 2 = 6.100 .011*
No 120 87.6 121 96.0
Exposure to verbal–emotional–psychological violence during the COVID‐19 pandemic
Yes 91 66.4 61 48.4 χ 2 = 8.728 .002*
No 46 33.6 65 51.6
Exposure to sexual violence during the COVID‐19 pandemic
Yes 2 1.5 0 0.0 χ 2 = 1.854 .270
No 135 98.5 126 100.0
Exposure to mobbing during the COVID‐19 pandemic
Yes 107 78.1 55 43.7 χ 2 = 32.932 .000*
No 30 21.9 71 56.3
Changes in the department worked during the COVID‐19 pandemic
Yes 66 48.2 75 59.5 χ 2 = 3.399 .043*
No 71 51.8 51 40.5
Changes in the working hours during the COVID‐19 pandemic
There was no change 46 33.6 67 53.2 χ 2 = 16.834 .000*
Decreased 13 9.5 19 15.1
Increased 78 56.9 40 31.7
Changes in the number of patients given care during the COVID‐19 pandemic
Increased 63 46.0 33 26.2 χ 2 = 11.096 .004*
Decreased 43 31.4 54 42.9
There was no change 31 22.6 39 31.0
*

p ≤ .05.

This article is being made freely available through PubMed Central as part of the COVID-19 public health emergency response. It can be used for unrestricted research re-use and analysis in any form or by any means with acknowledgement of the original source, for the duration of the public health emergency.

4.3. Participants' mean scores from the Nursing Professional Commitment Scale and findings regarding the variables affecting the scores

Table 5 presents the mean Nursing Professional Commitment Scale (NPCS) scores. The mean total score obtained from the scale was 71.33 ± 15.05.

TABLE 5.

The Nursing Professional Commitment Scale (NPCS) mean scores

NPCS X¯ + SD Minimum Maximum
Sub‐dimensions
Willingness to make an effort 34.70 ± 8.43 13 52
Maintaining as professional membership 21.34 ± 6.15 8 32
Belief in goals and values 15.28 ± 2.73 6 20
Total scale score 71.33 ± 15.05 31 104

This article is being made freely available through PubMed Central as part of the COVID-19 public health emergency response. It can be used for unrestricted research re-use and analysis in any form or by any means with acknowledgement of the original source, for the duration of the public health emergency.

In our study, it was found that the mean scores of the nurses who stated they were exposed to physical violence during the pandemic process from the total and “willingness to make an effort” sub‐dimension of the Nursing Professional Commitment Scale were lower than those of the nurses who were not exposed to physical violence (p ≤ .05). There was no statistically significant difference between the status of these two groups' exposure to verbal–emotional–psychological violence, sexual violence and mobbing (p ≥ .005). A statistically significant difference was found between the status of thinking of quitting the profession during the COVID‐19 pandemic process and all subscale and total scores of the Nursing Professional Commitment Scale and the professional commitment of those who thought of quitting the profession was found lower (p ≤ .05). Besides, as the working hours increased during the pandemic process, the mean scores from the maintaining as a professional membership and belief in goals and values sub‐dimensions and that of the total scale were found to decrease, and there was a statistically significant difference between working hours and the mean Nursing Professional Commitment Scale score (p ≤ .05) (Table 6).

TABLE 6.

Results related to The Nursing Professional Commitment Scale (NPCS)

Variables Willingness to make an effort Maintaining as professional membership Belief in goals and values Total scale score
Exposure to physical violence during the COVID‐19 pandemic
Yes (n = 22) 31.13 ± 8.03 19.40 ± 6.03 14.63 ± 3.30 65.18 ± 13.83
No (n = 241) 35.02 ± 8.40 21.51 ± 6.14 15.34 ± 2.68 71.89 ± 15.06
Statistics

t = −2.086

p = .038*

t = −1.543

p = .124

t = −1.161

p = .247

t = −2.013

p = .045*

Exposure to verbal–emotional–psychological violence during the COVID‐19 pandemic
Yes (n = 152) 34.41 ± 8.88 21.05 ± 6.21 15.17 ± 2.72 70.65 ± 15.71
No (n = 111) 35.09 ± 7.78 21.72 ± 6.07 15.43 ± 2.75 72.26 ± 14.12
Statistics

t = −0.663

p = .508

t = −0.872

p = .384

t = −0.744

p = .457

t = −0.856

p = .393

Exposure to sexual violence during the COVID‐19 pandemic
Yes (n = 2) 24.00 ± 15.55 28.00 ± 5.65 12.50 ± 6.36 64.50 ± 16.26
No (n = 261) 34.78 ± 8.35 21.29 ± 6.13 15.30 ± 2.71 71.38 ± 15.06
Statistics

t = −1.810

p = .071

t = 1.540

p = .125

t = −0.623

p = .645

t = −0.643

p = .521

Exposure to mobbing during the COVID‐19 pandemic
Yes (n = 162) 34.06 ± 8.42 20.80 ± 6.13 15.30 ± 2.75 70.17 ± 14.89
No (n = 101) 35.72 ± 8.37 22.19 ± 6.12 15.25 ± 2.72 73.17 ± 15.20
Statistics

t = −1.552

p = .122

t = −1.788

p = .075

t = 0.129

p = .897

t = −1.575

p = .116

Intention to leave profession during the COVID‐19 pandemic
Yes (n = 137) 32.07 ± 8.48 19.10 ± 6.05 14.88 ± 2.92 66.06 ± 14.93
No (n = 126) 37.56 ± 7.40 23.76 ± 5.29 15.72 ± 2.46 77.05 ± 12.99
Statistics

t = −5.570

p = .000*

t = −6.617

p = .000*

t = −2.524

p = .012*

t = −6.340

p = .000*

Changes in the department worked during the COVID‐19 pandemic
Yes (n = 122) 34.85 ± 7.03 21.04 ± 5.89 15.18 ± 2.47 71.09 ± 13.22
No (n = 141) 34.57 ± 9.49 21.59 ± 6.38 15.36 ± 2.95 71.53 ± 16.52
Statistics

t = −0.272

p = .786

t = 0.718

p = .474

t = 0.538

p = .591

t = 0.244

p = .807

Changes in the working hours during the COVID‐19 pandemic
Decreased (n = 32) 37.06 ± 8.91 24.03 ± 6.65 16.43 ± 2.79 77.53 ± 16.62
Increased (n = 118) 34.27 ± 7.92 20.20 ± 6.04 15.09 ± 2.56 69.56 ± 13.78
There was no change (n = 113) 34.48 ± 8.76 21.76 ± 5.87 15.15 ± 2.84 71.41 ± 15.52
Statistics

F = 1.450

p = .236

F = 5.533

p = .04*

F = 3.298

p = .039*

F = 3.593

p = .029*

Changes in the number of patients given care during the COVID‐19 pandemic
Increased (n = 96) 34.41 ± 8.14 21.22 ± 6.45 14.79 ± 2.62 70.43 ± 14.64
Decreased (n = 97) 34.31 ± 8.87 21.74 ± 5.67 15.46 ± 2.87 71.52 ± 15.42
There was no change (n = 70) 35.62 ± 8.22 20.94 ± 6.41 15.71 ± 2.62 72.28 ± 15.24
Statistics

F = 0.576

p = .563

F = 0.367

p = .693

F = 2.657

p = .072

F = 0.316

p = .729

*

p ≤ .05.

This article is being made freely available through PubMed Central as part of the COVID-19 public health emergency response. It can be used for unrestricted research re-use and analysis in any form or by any means with acknowledgement of the original source, for the duration of the public health emergency.

5. DISCUSSION

Violence is common in healthcare institutions, and nurses are the primary victims of violence in the workplace (Chapman et al., 2010; Pich et al., 2010). Violence against nurses is a common problem that persists worldwide (Yang et al., 2012). Our study revealed that nurses were exposed to violence both before and during the pandemic and that the most common type of violence was verbal–emotional–psychological violence. Studies conducted in Turkey reported that 68% of the nurses were subjected to verbal violence and 33.6% to threat/psychological violence (Bahar et al., 2015), 60.8% of the nurses working in emergency departments, intensive care units, and psychiatry clinics were subjected to verbal or physical violence (Ünsal Atan et al., 2013), and 78.3% of the nurses experienced verbal violence (Çuvadar & Ekuklu, 2020). Our study is similar to the literature regarding the type of violence that nurses are frequently exposed to. Our study indicated that the verbal–emotional–psychological violence that the nurses were exposed to before and during the pandemic was approximately four times the physical violence they were subjected to. The reasons why verbal violence was more common than other types of violence were that perpetrators usually thought that they would not be subjected to any legal sanctions, healthcare professionals continued to do their jobs unless there was a physical assault, and there were no legal notifications regarding verbal violence, all of which lead to the persistence of violence.

In our study, nurses reported that they were exposed to physical and verbal–emotional–psychological violence most often by patients' relatives and to sexual violence most frequently by patients before and during the pandemic. According to studies conducted in Turkey, 60.2% of the nurses were subjected to violence by patient relatives, and 33.6% by patients (Bahar et al., 2015), and 44.3% of the violence was found to come from patient relatives (Çuvadar & Ekuklu, 2020). Our study results are similar to those of the literature. During the pandemic process, the patients' relatives cannot see their relatives after the patients are hospitalised and have a fear of death, which can be shown as the source of verbal violence. It is thought that planning should be made to include patients and their relatives while planning violence prevention.

Nursing is one of the professional groups that have been most negatively affected by the COVID‐19 pandemic. Nurses in this process faced risks, such as intensive and long‐term work, increased workload, stress due to new working styles because of the pandemic, getting infected and transmitting the infection to their relatives, disruption of family responsibilities, postponement of plans, mental traumas, permanent health deterioration, and death (Hiçdurmaz & Üzar Özçetin, 2020). The phenomenon of violence towards healthcare workers that existed before the pandemic also persists in this process. We found exposure to physical, verbal–emotional–psychological, and sexual violence types were determined to decrease during the pandemic. However, the nurses in our study thought that the prevalence of physical violence and verbal–emotional–psychological violence increased during this period. It has been reported that the incidence of violence towards health professionals in the world and Turkey during the pandemic period continues (Devi, 2020; McKay et al., 2020; Oğan, 2020; Semple, 2020; Withnall, 2020). Some studies have shown that healthcare workers are exposed to violence because they are accused of spreading the virus and that some patients and their relatives deliberately cough towards or spit in healthcare workers' faces (Rodríguez‐Bolaños et al., 2020). The decrease in the incidence of violence found in our study may have resulted from the reduction in patient admissions other than COVID‐19 cases, people's staying away from hospitals due to their fears of COVID‐19 transmission, and non‐admission of patient relatives to hospitals. Despite all these, nurses were found to perceive an increased level of violence towards themselves, which suggests experiencing burnout.

It was thought that the image of the nursing profession in Turkey changed in the first months of the COVID‐19 pandemic and that the profession became more visible in this process. During the pandemic period, the nursing profession has been on the agenda both in the media and on social media and has been attributed values related to courage, sacrifice, and humanity. Besides, giving a huge round of applause to healthcare workers across the country at the beginning of the pandemic process to appreciate them and raise their morale has increased the attention towards them. However, as the pandemic process progressed, this increasing interest in healthcare personnel decreased, and they were exposed to social stigma and exclusion because they thought they were carriers of the disease. Mobbing, which is a behaviour type applied in many different ways, such as psychological violence, emotional abuse, humiliation, exclusion, damaging the employee's self‐confidence, breaking motivation, and restricting powers, is frequently seen in health institutions. Our study determined that the rate of nurses' exposure to mobbing increased in the pandemic period. In a study conducted on female health workers in Turkey during the pandemic period, four out of 10 female healthcare workers were reported to have faced the repressive attitudes of senior workers or administrators (Nakışci et al., 2020). Forced department changes and applications of severe shift systems without healthcare workers' consent are among the pressure methods applied to them (Oğan, 2020). We found that many nurses were assigned to units related to COVID‐19, and their working hours had increased. Our study is similar to the literature in this respect. It is thought that conflicts emerging during the pandemic process due to increased workload and work stress increase mobbing incidents. In this extraordinary process, which is challenging for all healthcare professionals and requires complying with new protocols for pandemic management for both managers and nurses, it is recommended that the pandemic management should be done in accordance with transparent procedures to minimise exposure to mobbing.

Professional commitment and professional identity are concepts that are created by the members of the profession over time as of school years and continuously change with the effect of various factors (Johnson et al., 2012). Extraordinary processes such as pandemics can lead to a decrease in professional commitment and an increase in intention to leave the profession in occupational groups that have a role and importance in healthcare (Kim et al., 2019). We found that more than half of the nurses wanted to quit the profession during the pandemic process, and it was related to violence exposure and low professional commitment. Also, it was found that the professional commitment of them was decreased during the COVID‐19 pandemic process. There were a limited number of studies in the literature investigating nurses' professional commitment and their thoughts on quitting the profession during the COVID‐19 pandemic process. A study in the literature reported that the fear of COVID‐19 reduced job satisfaction and increased the intention to quit the institution and the profession among nurses (Labrague & de Los Santos, 2020). In another study, it was revealed that 24.8% of the nurses intended to leave the nursing profession. It was reported that working more than 40 h a week and working more than three nightshifts a week increased the intention to leave the nursing profession (Said & El‐Shafei, 2021). Some studies in the literature revealed that violence towards healthcare professionals reduced job satisfaction and productivity, reduced the quality of care, and decreased professional commitment (Bahar et al., 2015; Hıdıroğlu et al., 2019; Najafi et al., 2018). There is a strong relationship between professional commitment and the idea of quitting the profession (Cowin et al., 2008). Our study is similar to the literature in this respect. It is thought that it is necessary to develop and implement effective policies and procedures to prevent violence, which is one of the factors that negatively affect professional commitment among nurses and can play an important role in increasing nurses' professional commitment.

5.1. Strengths and limitations of the study

Our findings should be interpreted within the context of the limitations and strengths of the study. One of our study's strengths is that the first study investigating the status of nurses' exposure to violence in the COVID‐19 pandemic in Turkey. Our study reveals that even in such an extraordinary situation, although there is a small decrease, violence continues its existence. For this reason, our study is important in understanding the situation of nurses and drawing attention to this issue. Bringing to the literature the thoughts of nurses working in the field under pandemic conditions on both the violence they experience, their commitment to the profession, and leaving the profession has an important place in developing strategies, plans and solutions for the future. Another strength of the study is that our study reflects nationwide data on nurses as the study was conducted online. On the other hand, as our study design is cross‐sectional, we cannot offer definitive evidence about findings. Due to this reason, causality in this study cannot be explained definitively. Although our study sample consists of nationwide participants, there was a small sample of male nurses. Besides, our study findings cannot be generalised to nurses not using smartphones and social media.

6. CONCLUSIONS

This study, which was carried out in Turkey, discussed the status of nurses' exposure to violence and their professional commitment during the COVID‐19 pandemic process, and the relationship between the two. In conclusion, it was found that nurses were exposed to various forms of violence during the pandemic process and that their exposure to physical, verbal–emotional–psychological, and sexual violence decreased compared to the pre‐pandemic period. Another result of our study was that nurses were exposed to mobbing during the pandemic process more frequently.

6.1. Relevance to clinical practice

According to our study results, exposure to physical violence, verbal–emotional–psychological violence, mobbing, increased working hours and a multiplying number of patients provided care during the pandemic process affected nurses' thoughts of quitting the profession. Besides, as the nurses' exposure to physical violence, their thoughts of quitting the profession, and working hours increased during the pandemic process, their professional commitment decreased.

Based on these results, we recommend the following points:

  • Measures to prevent violence towards healthcare professionals should be addressed multifaceted (regarding political, legal and cultural aspects).

  • Society should be informed to create an anti‐violence culture.

  • Training programmes should be planned for patients and their relatives.

  • In managing the pandemic process, the decisions and practices taken to prevent mobbing in hospitals should not be left to the managers' initiative.

  • Initiatives that will increase nurses' professional commitment during the pandemic process should be planned and implemented (i.e. employment of more personnel, appropriate working conditions).

  • To minimise the thought of quitting the nursing profession, strategies should be developed to control the factors that are thought to increase nurses' work stress during the pandemic process, and nurses should be provided with psychological support.

CONFLICT OF INTEREST

None.

AUTHOR CONTRIBUTIONS

Conception and design, analysis and interpretation of data, and drafting the article: Sultan Özkan Şat, Pınar Akbaş; conception and design, analysis and interpretation of data, drafting the article, and revising it critically for important intellectual content: Şengül Yaman Sözbir.

Supporting information

Appendix S1

ACKNOWLEDGEMENT

We would like to thank all the nurses who participated in this study.

DATA AVAILABILITY STATEMENT

Data available on request from the authors.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Appendix S1

Data Availability Statement

Data available on request from the authors.


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