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ORIGINAL ARTICLE
Year : 2020  |  Volume : 23  |  Issue : 1  |  Page : 103-109

Prevalence of psychological workplace violence among employees of a public tertiary health facility in Enugu, Southeast Nigeria


1 Department of Community Medicine, College of Medicine, Enugu State University; Department of Community Medicine, Enugu State University Teaching Hospital, Enugu, Nigeria
2 Department of Community Medicine, College of Medicine, University of Nigeria; Department of Community Medicine, University of Nigeria Teaching Hospital, Ituku/Ozalla, Enugu, Nigeria
3 Department of Community Medicine, University of Nigeria Teaching Hospital, Ituku/Ozalla, Enugu, Nigeria
4 Department of Community Medicine, College of Medicine, University of Nigeria, Enugu, Nigeria

Date of Submission22-Oct-2019
Date of Acceptance30-Sep-2019
Date of Web Publication10-Jan-2020

Correspondence Address:
Dr. I J Ogugua
Department of Community Medicine, University of Nigeria Teaching Hospital, Ituku/Ozalla, Enugu
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_160_19

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   Abstract 


Background: Psychological violence is the most common form of workplace violence (WPV) that can affect job performance and health of the workers. Aims: This study sought to determine the prevalence of psychological WPV among employees working in a tertiary health institution in a South-eastern state of Nigeria. Methods: A descriptive cross-sectional study done in 2018 among healthcare workers at the University of Nigeria Teaching Hospital Enugu State using a pretested self-administered questionnaire adapted from Workplace Violence in the Health Sector Country Case Study Questionnaire. Proportionate sampling method was used to select 412 respondents. Data were analyzed with SPSS version 23 using Chi-square test of significance and P value set at 0.05. Results: Prevalence of psychological violence among the participants was 49.7%. Verbal abuse was the most form of psychological violence experienced 168 (40.8%) followed by bullying 29 (7.0%) while sexual abuse was reported by 8 (1.9%). Majority 114 (55.6%) of the perpetrators of the psychological violence were patient's relative, whereas 48 (23.4%) were staff members. In response to the violence, 58 (28.6%) of the healthcare workers took no action, while only 2 (1%) completed incident/accident form. Bullying was statistically significantly higher in healthcare workers who have spent less than 10 years (χ2 = 3.978 P = 0.046). There was a significant association between verbal abuse and frequent interaction with patients (χ2 = 4.757, P = 0.029). Conclusion: This study has shown that the prevalence of psychological WPV was high among healthcare workers in University of Nigeria Teaching Hospital, Enugu State. Therefore, there is need for the hospital management to develop policy interventions specific to psychological WPV.

Keywords: Enugu, healthcare workers, psychological, workplace violence


How to cite this article:
Chinawa A T, Ndu A C, Arinze-Onyia S U, Ogugua I J, Okwor T J, Kassy W C, Agwu-Umahi N, Aguwa E N, Okeke T A. Prevalence of psychological workplace violence among employees of a public tertiary health facility in Enugu, Southeast Nigeria. Niger J Clin Pract 2020;23:103-9

How to cite this URL:
Chinawa A T, Ndu A C, Arinze-Onyia S U, Ogugua I J, Okwor T J, Kassy W C, Agwu-Umahi N, Aguwa E N, Okeke T A. Prevalence of psychological workplace violence among employees of a public tertiary health facility in Enugu, Southeast Nigeria. Niger J Clin Pract [serial online] 2020 [cited 2020 Aug 8];23:103-9. Available from: http://www.njcponline.com/text.asp?2020/23/1/103/275611




   Introduction Top


Workplace violence (WPV) is defined as exerting intentional physical and psychological force and pressure on individuals to harm, threaten, or insult them in the workplace.[1] WPV can be classified into two broad categories: physical and psychological violence.[1] Physical violence is the use of physical force against another person or group, which results in physical, sexual, or psychological harm.[1] It includes among others, beating, kicking, slapping, stabbing, shooting, pushing, biting, and pinching.[1] Psychological violence is the intentional use of power, including threat of physical force, against another person or group, that can result in harm to physical, mental, spiritual, moral, or social development.[1] It includes verbal abuse, bullying/mobbing, harassment, and threats.[1]

Globally healthcare workers (HCWs) are at high risk of psychological violence mostly perpetrated by patients and visitors, although many cases go unreported.[2],[3] Evidence has shown that people who experience psychological violence are seven times as likely to be victims of physical violence.[4] Violence among HCWs is associated with negative impact on the HCW, the organization, and the patient. Such impacts include increase in perception of burnout, decreased job performance and job satisfaction, poor mental health, and these results in the suboptimal care to patients.[5],[6]

While the existence of personal physical violence at the workplace has always been recognized, the existence of psychological violence has been long under-estimated and only now receives due attention.[1] Most studies done in Nigeria were on WPV in general without particular emphasis on psychological violence. Therefore, to fill this gap in literature and because of the documented negative health impacts of psychological violence, this study aims at highlighting the prevalence and factors associated with psychological violence among HCWs in a tertiary health facility in Enugu State. The findings from this study might be useful in understanding the source of psychological violence among HCW as well as developing effective strategies and policies to reduce psychological WPV.


   Materials and Methods Top


The study was carried out in 2018 at University of Nigeria Teaching Hospital (UNTH) Enugu, South East Nigeria. Enugu State has an estimated population of 3,267.837, (1,596,042-males and 1,671,795-females) according to 2006 census.[7] University of Nigeria Teaching Hospital is located at Ituku/Ozalla, Nkanu East Local government Area of Enugu State.[8] There are 2 public tertiary, 47 secondary healthcare facilities, and 492 primary healthcare facilities in the state. This cross-sectional study was conducted among doctors and nurses in UNTH who have at least one year of professional experience. Based on prevalence of WPV of 59.5% from a previous study,[6] a minimum sample size of 370 participants was calculated using a power of 80%, 95% confidence interval, and 5% degree of error.

Using a list of doctors and nurses from their respective departments, proportional allocation to size was used to select the respondents.

Data were collected using a self-administered semi-structured questionnaire on “workplace violence in the health sector”, adapted from the International Labor Organization, International Council of Nurses, World Health Organization, and Public Services International (ILO/WHO/PSI).[9] Information was obtained on sociodemographic and workplace characteristics of participants. Responses were also elicited on participants' experiences of psychological violence including verbal abuse, bullying/mobbing, and sexual harassment as well as their experience in the preceding year. Abuse is any behavior that humiliates, degrades, or otherwise indicates a lack of respect for the dignity and worth of an individual.[9] Bullying (or mobbing) is “repeated and long-term offensive behaviours involving vindictive, cruel, or malicious attempts to humiliate or undermine an individual or groups of employees.”[9] Sexual harassment is any unwanted, unreciprocated and unwelcome behavior of a sexual nature that is offensive to the person involved, and causes that person to feel threatened, humiliated or embarrassed.[9] Data were entered and analyzed using Statistical Package for Social Sciences (SPSS) version 23 (IBM Corporation, Chicago, IL, USA). Continuous variables were expressed as means and standard deviation (SD) and compared using the student's t-test. Categorical variables were expressed as frequencies and compared using the Chi-square test. A P value < 0.05 was considered significant for all comparisons.

Ethical considerations

The Health research and ethics committee of the University of Nigeria Teaching Hospital approved the study (No. NHREC/05/01/200BB-FWA00002458-IRB00002323). All of the participants were briefed on the study objectives, assured about the anonymity of the questionnaire and voluntary nature of participation in the study, and also signed a written informed consent.


   Results Top


A total of 412 doctors and nurses participated in the study. [Table 1] shows the sociodemographic and workplace characteristics of the participants. Majority 262 (63.6%) of them were aged above 35 years, were females 310 (75.2%), were married 310 (75.2%), and were nurses 301 (73.1%). More than half 240 (58.3%) of the participants had spent less than 10 years in practice, whereas 172 (41.7) had spent 10 years and more. Majority of the participants work in shift 299 (72.6%) and have routine direct contact with patients 364 (88.3%). Majority of the participants work with adults 316 (76.7%) and with both male and female patients 320 (77.7%). Majority also have their duty posts on the ward 319 (77.4%).
Table 1: Respondents demographic and workplace characteristics

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[Table 2] shows the prevalence of psychological violence. A total 205 (49.7%) of the HCWs were exposed to psychological WPV during the past year. Majority 168 (40.8%) were exposed to verbal violence, 29 (7.0%) were exposed to bullying/mobbing, while 8 (1.9%) were exposed to sexual violence.

[Table 3] shows the participants' description of verbal abuse, bullying/mobbing violent incident, and sexual harassment. Ten (4.9%) of the participants reported that they experienced psychological WPV all the time, 132 (64.4%) sometimes, and 63 (30.73%) once during the past one year. Of the 205 HCWs who experienced psychological violence, 114 (55.6%) reported that the patient's relatives were the perpetrators, 48 (23.4%) reported staff members, 28 (13.7%) patient while 15 (7.3%) reported supervisors/management as perpetrators of psychological WPV.
Table 2: Prevalence of Psychological Violence

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Table 3: Respondents' description of verbal abuse, bullying/mobbing violent incident and sexual harassment

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As responses to psychological violence, 58 (28.6%) of the HCWs took no action, 8 (3.9%) sought counseling, 49 (23.9%) of the victims reported to a senior, 6 (2.9%) sought help from the union they belong to in the hospital while few 2 (1%) completed incident/accident form. In a teaching hospital, the consultants belong to Medical and Dental Consultants Association of Nigeria (MDCAN), resident doctors belong to the Association of Resident Doctors (ARD) while the nurses belong to the Joint Health Sector Union (JOHESU). Regarding the action taken by the management to investigate the cause of the abuse, 136 (66.3%) the participants reported no action was taken while 48 (19%) reported that an action was taken while 7 (3.4%) did not know if any action was taken. Concerning the consequences for the perpetrator, 80 (39%) of the victims reported that that there was no consequence for the perpetrator, 71 (34.1%) reported that verbal warning was issued to the perpetrator, 11 (5.3%) of the victims reported that the incident was reported to the police while 8 (3.9%) reported that care was discontinued while 3 (1%) reported that the aggressor was prosecuted. Forty-five (21.9%) of the participants reported that the employer/supervisor provided them with counseling while 49 (23.9%) of the respondents reported that they had opportunity to talk about the incident.

Factors associated with psychological violence are shown in [Table 4] and [Table 5]. [Table 4] shows the associations between psychological WPV and participants' sociodemographic characteristics. While bullying was statistically significantly higher in HCWs that have spent less than 10 years (χ2 = 3.978 P = 0.046), verbal abuse and sexual assault were not associated with the years of practice of respondents. Sex of the participants did not significantly influence the occurrence of psychological violence. Verbal abuse was slightly higher among participants less than 35 years while bullying and sexual abuse were slightly higher among respondents 35 years and older.
Table 4: Factors associated with psychological violence (verbal abuse, bullying, and sexual abuse)

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Table 5: Factors associated with psychological violence (verbal abuse, bullying, and sexual abuse)

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In [Table 5] associations between respondents' workplace characteristics and occurrence of violence are described. There was no association between working in shift and psychological violence. Verbal abuse was experienced more commonly among HCWs who work in children department compared with those who work with new born and adults (χ2 = 10.949, P = 0.004). There was a significant association between verbal abuse and frequency of interaction with patients (χ2= 4.757 P = 0.029) and routine direct contact with patients (χ2 = 5.680 P = 0.018). Sex of the patients frequently seen and participants' present duty post (working in the ward or clinic) were not associated with WPV.


   Discussion Top


The findings from this study showed that 205 (49.7%) of the HCWs were exposed to psychological WPV during the past year. This is similar to a study done in Canada where 56.7% of the healthcare personnel experienced psychological violence.[10] This study reported that verbal abuse was the most common type of psychological violence followed by bullying and the least, sexual abuse. This is similar to studies done in Nigeria where verbal abuse was the most prevalent type of psychological violence reported though with higher prevalence of 85.4% and 64.6% respectively.[6],[11]

The present study reported sexual harassment as the least psychological violence experienced by the victims with prevalence of 1.9%. This finding is similar to studies done in Nigeria and Hong Kong though with higher prevalence of 4.5% and 12% respectively.[11],[12] Studies on psychological WPV done among HCWs in other countries: Hong Kong, Jordan, and Egypt also reported a higher prevalence of verbal abuse than the present study, 73%, 70%, and 58.2% respectively.[12],[13],[14] The contributing factors to verbal abuse as perceived by Jordanian nurses were related to administration, staff, patients and their families, workplace setting, and security.[13] In Egypt, the most reported reasons by the respondents were waiting time and that patient and family expectations were not being met.[14] These factors might account for the higher prevalence found in those studies. The higher prevalence in those studies might also be due the cultural differences in the experience of violence and harassment.

The present study showed that patients' relatives were the main perpetrators of psychological violence. This finding is similar to a study on psychological violence done among HCWs in Egypt and Iran where patients' relatives were reported as the main source of psychological violence (89.7% and 64.5%).[14],[15] Similar studies done in Turkey reported that patients' companions (90.9%) and relatives (60.1%) were the primary perpetrators of violence.[16],[17] This finding might be as a result of communication gaps between patients' relatives and HCWs. Without proper communication, patients and their relatives will have insufficient knowledge about the diseases, costs, and effects of treatment, which may result in their misunderstanding the treatment and ultimately to violence.[18]

In this study, HCWs less than 35 years reported slightly higher occurrence of verbal abuse than those 35 years and older. This finding is similar to that done in Turkey which showed that the prevalence of verbal abuse was higher among HCWs 34 years and younger.[16]

These association between verbal abuse and younger age groups could be attributed to lower threshold for insult and pain and less maturity compared to the older age group.[14] It could also be that the younger HCWs lack the ability of dealing with violence issues.[16] A study done in China also found that HCWs 35 years and younger were at greater risk of psychological violence.[19]

The present study showed that only 23.9% of the victims reported the incident to a senior. This is comparable to a study done in Turkey where only 35.8% and 34.9% of the victims reported verbal abuse and sexual harassment respectively.[16] A study done in Jordan also showed that only 30.7% of verbal abuse incidents were reported by nurses.[20] The reason for the high rates of underreporting of WPV might be because of the absence of institutional reporting policies/protocol[21] or the perception that violence is a part of the job and reporting will not benefit them[22] or beliefs that the incident may be viewed as worker's negligence or poor job performance.[23]

Findings from this study showed that having spent less than 10 years in practice was associated with bullying. This is similar to a study done in Malaysia which showed that years of employment was significantly associated with WPV (p = 0.002) as participants with less working experience reported higher prevalence of WPV than those with more working experience.[24] This might be as due to the fact that the HCWs who have less years in practice are still anxious about their job and so more vulnerable to WPV. Also, the present study found that there was a significant association between occurrence of verbal abuse, working in children department, frequently interaction with patients, and routine direct contact with patient. This is similar to a study which showed that nurse's direct contact with their patients and their families were the main causes of verbal abuse in emergency setting.[25] This might be due to emotional stress experienced when taking care of sick children.


   Conclusion Top


Based on the results of our study, we conclude that psychological WPV is a burden faced by HCWs in tertiary health facilities. Although most violence incidents were verbal, bullying and sexual abuse were not uncommon. This result therefore highlights the need for the hospital management to develop regulations or policy interventions specific to psychological WPV. There is also need to provide appropriate workplace health education intervention to promote HCWs' mental health wellbeing. The hospital management also needs to develop a policy or protocol for reporting and dealing with WPV.

Limitation

Recall bias would have been a limitation in this study as the occurrence of psychological WPV was self-reported. However, this was overcome by limiting the experience of the violence to 12 months. This study was done in only one teaching hospital in Nigeria and therefore, the findings cannot be generalized. However, it may provide a guide for further research on WPV among HCWs in Nigeria.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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ILO, ICN, WHO, PSI. Framework Guidelines for Addressing Workplace Violence in the Health Sector 2002. Available from: http://www.who.int/violence_injury_prevention/violence/activities/workplace/en/. [Last accessed on 2018 Nov 21].  Back to cited text no. 1
    
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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