This article has Open Peer Review reports available.
High prevalence of workplace violence among nurses working at public health facilities in Southern Ethiopia
- Mathewos Fute†1,
- Zelalem Birhanu Mengesha†2,
- Negash Wakgari†3 and
- Gizachew Assefa Tessema†2Email author
© Fute et al.; licensee BioMed Central. 2015
Received: 2 September 2014
Accepted: 20 February 2015
Published: 3 March 2015
The rising rate of workplace violence in health care facilities has become a major problem for health care providers including nurses. However, evidences are lacking in Ethiopia particularly in the study area. The aim of this study is to assess the prevalence and associated factors of workplace violence among nurses working at health care facilities in Hawassa City Administration, Southern Ethiopia.
An institution-based cross-sectional study was conducted on 660 randomly selected nurses working at public health facilities in Hawassa City Administration in April 2014. A pre-tested and structured questionnaire was used to collect the data. Data were entered using EPI-Info and exported to SPSS for further analysis. Descriptive statistics were done. Logistic regression analyses were used to see the association between different variables and the outcome variable. Odds ratios with 95% Confidence Interval (CI) were computed to determine the presence and strength of the association.
In this study, the prevalence of workplace violence was 29.9% [95% CI: 26.5, 33.5)] of which physical violence accounted for 36 (18.22%), verbal abuse for 172 (89.58%) and sexual harassment for 25 (13.02%). Female sex [AOR=2.00, 95% CI: (1.28, 2.39)], short work experience [AOR=8.86, 95% CI: (3.47, 22.64)], age group of 22–25 [AOR=4.17, 95% CI: (2.46, 7.08)], age group of (26–35) [AOR=1.9, 95% CI (1.16, 3.1)], work in emergency [(AOR=4.28, 95% CI: (1.39, 4.34)] and work in the Inpatient Department [(AOR=2.11, 95% CI: (1.98, 2.64)] were the factors positively associated with workplace violence.
A significant proportion of nurses faced violence while providing care at in public health facilities. Being female, younger age, short work experience, and assignment in emergency and inpatient departments were positively associated with workplace violence. Policy makers and stakeholders should focus on workplace violence prevention strategies.
Workplace violence against health care workers is a common and widespread phenomenon. According to the World Health Organization (WHO), workplace violence where staffs are abused, threatened, or assaulted in circumstances related to their work and while commuting to and from work, involved explicit or implicit challenges to their safety, well-being, or health. The violence affects all work categories and takes place at various settings [1-3]. About 25% of violent accidents at work occur in the health sector, and more than 50% of health workers have already experienced violence [4,5]. Each year, more than 1.6 million people worldwide lose their lives in relation to violence, and many more are injured and suffer from physical and non-physical health problems . Violence related injury is the second leading cause of occupational injury and accounts for 16% of the more than 6.5 million acts of violence experienced by individuals .
According to the International Labour Office (ILO) report, nurses faced more violence than other health care workers [7,8]. Nurses as front-line care providers serve in a wide variety of settings caring for individuals who face all types of trauma, suffering, and life-altering events [9-11].
Exposure to violence while carrying out duties adversely affect nurses and may lead to loss of concentration, inattention to ethical guidelines, commuting mistakes, absence from shifts, repeated absenteeism, inattention to patients, reduction in job satisfaction, dislike of job, and refusal to work in stressful wards. As a consequence of experiencing violence in the workplace, a nurse may decide to transfer to another section with in the same health care facility, or may give up nursing altogether. This may result in significant additional costs on treatment centers and the community [6,12,13]. Moreover, the consequences of workplace violence in the health sector have a significant impact on the effectiveness of health systems, especially in developing countries.
However, there is a lack of evidence to support this concern due to the absence of information on the prevalence of workplace violence among nurse professionals in developing countries, like Ethiopia. Therefore, this study is meant to assess the prevalence and associated factors of workplace violence among nurses working at public health facilities in Hawassa City administration, Southern Ethiopia.
Study design, sample, sampling technique and setting
Data collection instrument
The data were collected using a structured, pretested, and self-administered questionnaire that was adapted from the International Labour Office (ILO), International Council of Nurses (ICN), World Health Organization (WHO), and Public Services International (PSI) . It was reviewed to suit the local condition. The questionnaire was initially prepared in English, then translated to the working language (Amharic) and back to English in order to ensure conceptual consistency. The questionnaire consisted of 4 parts: Part I enquired about the socio-demographic characteristics of the nurses; part II assessed the most recent physical abuse and nurses’ reaction for such episodes in the past 6 months prior to the study period. Part III focused on verbal abuse and the nurses’ reactions to these events Part IV, the last section, enquired about the sexual harassment and nurses’ reaction at that scene. Workplace Violence (WPV) was regarded when the study participants experienced at least one type of violence such as physical violence, verbal abuse, or sexual harassment in circumstances related to their work in the past six month.
Verbal abuse was defined as shouting at, degrading and showing lack of respect for someone’s worth and dignity; hence, nurses were asked to check whether, they had experienced any of the verbally abusive behaviors listed from 4 different sources (co-workers, patients, and patients’ relatives). Physical violence was defined as hitting, biting, throwing objects, strangling, pushing around, kicking, dragging on the floor, pushing against the wall, beating with a stick, threatening an individual with a gun, a knife, or any kind of weapon. Sexual harassment involved attempts to establish or force sexual relations, to threaten someone into having sex (sexual blackmail), and to offering money, gifts, or privileges in exchange for sexual favors. Pretesting of the study tool was conducted on 20 nurses working at Yirgalem Hospital. Finally, the necessary modifications and adjustments were made on the tool prior to the actual study. Twelve data facilitators watched over by three supervisors were involved in the data collection.
The collected copies of the questionnaire were checked manually for its completeness, coded and entered into the EPI-Info version 7 statistical packages, and exported to SPSS version 20.0 for further analysis. Descriptive statistics were done. Both bivariate and multivariate logistic regression analyses were used to determine the association of each independent variable with the dependent variable. Odds ratio with their 95% confidence intervals were computed to identify the presence and strength of association, and statistical significance was declared if p < 0.05.
Ethical clearance was obtained from the Research and Ethical Review Committee of the Institute of Public Health, College of Medicine and Health Sciences at the University of Gondar. Official letters were also submitted to respective public health facilities. The purpose and importance of the study were explained and written consent was secured from each participant. Confidentiality was maintained at all levels of the study. Participant involvement in the study was voluntary and those who were unwilling and wanted to quit their participation at any stage were informed to do so without any restriction.
Socio-demographic characteristics of respondents
Socio-demographic characteristics of nurses working at public health facilities in Hawassa city, Southern Ethiopia, April, 2014 (n=642)
Workplace characteristics of nurses
Organizational and work characteristics of nurses working at public health facilities in Hawassa city administration, Southern Ethiopia, April, 2014 (n=642)
Prevalence of workplace violence
Factors associated with workplace violence
The bivariate analysis showed that there was a statically significant association between workplace violence and sex, age, work experience, clinical setting (department), and shifts. However, in the multivariate logistic regression analysis, sex, age, experience and clinical setting (department) remained to be significant. Those who had 1–5 years of experience had about 9 times higher odds of experiencing workplace violence than those who had 5 or more years of work experience (AOR=8.9, 95% (3.47, 22.63)). Female nurses had two times higher odds of experiencing workplace violence compared to male nurses [AOR=2.0, 95% CI: (1.28, 3.12)].
Crude and adjusted odds ratios (OR) and 95% (CI) of factors associated with workplace violence at public health facilities in Hawassa City Administration, April, 2014 (n=642)
OR (95% CI)
COR (95% CI)
AOR (95% CI)
2.3 (1.56, 3.32)
2.0 (1.28, 3.12)
7.0 (4.41, 11.18)
4.2 (2.46, 7.08)
2.6 (1.66, 3.96)
1.9 (1.16, 3.11)
Years of experience
11.1 (4.60, 26.6)
3.6 (1.36, 8.27)
3.2 (1.49, 9.10)
3.3 (1.67, 11.44)
2.1 (1.36, 3.22)
2.1 (1.98, 3.42)
5.8 (3.55, 9.51)
This study was the first of its kind to report WPV against nurses working at health care facilities in Ethiopia. Currently, it is among the priority concerns of both industrialized and developing countries .
The prevalence of workplace violence on nurses working at public health facilities was 29.9% [95% CI: 26.5, 33.5)]. This finding is similar to findings in USA (30%)  and Egypt (27.7%) . However, it is lower than that of a study conducted in Palestine (80%) . This could be due to lack of violence preventing strategies, such as policy/procedures, training, adequate safety measures in Palestinian public health facilities.
In the present study there was a statistically significant relation between age and workplace violence, as the age of health workers increased, the violence committed against them decreased. Young nurses had higher odds of experiencing workplace violence compared to their older counterparts. This finding is in line with those of studies conducted in Saudi Arabia and Taiwan [17,18]. This might be due to young nurses’ lack of ability or experience in dealing with violence, and inadequate safety measures. In addition, this might partly be explained by the fact that older people including health care providers receive due respect in the Ethiopian culture and perhaps elsewhere.
The sex of the study participants had a significant association with workplace violence; females had higher odds of being exposed to workplace violence than males. This is in line with studies conducted in Egypt and Palestine [15,19]. This might be due to traditional thinking that dictates that men are at the top of the hierarchical structure and superior to females. This traditional thinking may explain the more common occurrence of violence on females.
The other finding of this study showed that nurses who had less than six years of service had more odds of experiencing workplace violence than nurses who served sixteen or more years. This result is consistent with the finding in Southern Taiwan . This might be due to the fact that nurses with shorter service years had less experience in dealing or preventing various types of clashes and could not dissolve the possibility of an abuse incident promptly, so they experienced more counts of verbal and physical abuse.
Clinical setting was also associated with workplace violence. Nurses working at emergency departments were facing higher odds of violence compared to those serving in outpatient departments. This finding is similar to that of a study conducted in USA . This might be happened due to as emergency departments are open twenty four hours in the absence of security guards. The other possible justification could be that attendants of patient at emergency clinics were are tempered to aggress due to the stressful environment.
The possible limitation of this study was lack of willingness of the study participants to disclose private information. Recall bias and lack of research in Ethiopian context made comparison difficult.
A significant proportion of nurses at Hawassa city health care facilities had experienced different forms of violence. The results of the study suggested that violence was a major occupational hazard and public health concern. Female sex, youth age, and short years of work experience had a positive association with the incidence of workplace violence. Policy makers and other stakeholders should focus on the provision of appropriate strategies on workplace violence prevention. The health facilities should also establish health and safety programs for the prevention and management of workplace violence. It is also advisable to provide priority attention to female, and young nurses.
We are grateful to the University of Gondar for the technical and financial support. We would also like to thank the Hawassa City Health Bureau and the Sidama Labor and Social Affairs Bureau for their collaboration and guidance in the conduct of this study. We would also thank the participants of the study for their time to involvement in the study.
- Needham I, Mireille K, Nico O. Third International Conference on Violence in the Health Sector: Linking local initiatives with global learning. Vancouver, Canada, 2012Google Scholar
- ILO ICN, WHO PSI. Joint programme on workplace violence in the health sector. Geneva, Switzerland: ILO, ICN, WHO, PSI; 2003.Google Scholar
- Khoshknab M. Prevalence of workplace violence in psychiatric wards, Tehran, Iran. Pak J Biol Sci. 2012;15(14):680–4.View ArticlePubMedGoogle Scholar
- Marziale M. Violence in the health sector. Rev Latino-am Enfermagem. 2004;12(2):149–50.View ArticleGoogle Scholar
- Hahn S. Patient and visitor violence in the general hospital, occurrence, staff interventions and consequences: a cross-sectional survey. J Adv Nurs. 2012;68(12):2685–99.View ArticlePubMedGoogle Scholar
- Abbas MA, Fiala LA, Abdel Rahman AG, Fahim AE. Epidemiology of workplace violence against nursing staff in Ismailia Governorate, Egypt. J Egypt Public Health Assoc. 2010;85(1–2):29–43.PubMedGoogle Scholar
- Jacquelyn C et al. Workplace violence prevalence and risk factors in the safe at work study. J Occup Environ Med. 2011;53(1):82–9.View ArticleGoogle Scholar
- Melek S, Semra K, Selma A. A survey of violence against staff working in the emergency department in Ankara. Turkey Asian Nursing Research. 2011;5:197–203.View ArticleGoogle Scholar
- Moustafa MS, Gewaifel GI. Work-related violence among female employees in a university hospital in Alexandria: an epidemiologic study. J Am Sci. 2013;9(3):243–50.Google Scholar
- Balamurugan G, Tessy T, Nandakumar P. Patients’ violence towards nurses: a questionnaire survey. International Journal of Nursing. 2012;1(1):1–7.View ArticleGoogle Scholar
- Kamchuchat C, Chongsuvivatwong V, Oncheunjit S, Yip TW, Sangthong R. Workplace violence directed at nurseing staff at general hospital in Southern Thailand. J Occup Health. 2008;50:201–7.View ArticlePubMedGoogle Scholar
- Constance J, Newman CJ, H de Vries D, Kanakuze J, Ngendahimana G. Workplace violence and gender discrimination in Rwanda's health workforce: increasing safety and gender equality. Hum Resour Health. 2011;9:19.View ArticleGoogle Scholar
- Samir N. Nurses’ attitudes and reactions to workplace violence in obstetrics and gynaecology departments in Cairo hospitals. East Mediterr Health J. 2012;18(3):198–204.PubMedGoogle Scholar
- ILO ICN, WHO. Workplace violence in the health sector country case studies research instruments. ILO/ICN/WHO/PSI; 2003.Google Scholar
- Ahmed A. Verbal and physical abuse against Jordanian nurses in the work environment. East Mediterr Health J. 2012;18(4):318–24.PubMedGoogle Scholar
- Kitaneh M, Hamdan M. Workplace violence against physicians and nurses in Palestinian public hospitals: a cross-sectional study. BMC Health Serv Res. 2012;12:469.View ArticlePubMedPubMed CentralGoogle Scholar
- El-Gilany AH, El-Wehady A, Amr M. Violence against primary health care workers in Al-Hassa. Journal of Interpersonal Violence and Victims: Saudi Arabia; 2010;25:716–34.View ArticleGoogle Scholar
- Chen WC, Kung SM, Chiu HJ. Prevalence and deteriminant of work place violencce of health care in a psychaitaric hospital in Taiwan. J Occup Health. 2008;50:288–93.View ArticlePubMedGoogle Scholar
- Kitaneh M, Hamdan M. Workplace violence against physicians and nurses in Palestinian public hospitals: a cross- sectional study. BMC Health Serv Res. 2002;12:469.View ArticleGoogle Scholar
- Tang JS, Chen CL, Zhang ZR, Wang L. Incidence and related factors of violence in emergency departments—a study of nurses in southern Taiwan. J Formos Med Assoc. 2007;106(9):748–58.View ArticlePubMedGoogle Scholar
- Jacquelyn C, Campbell J, Agnew JK, Sheila F, Cathleen L, Jo D, et al. Workplace violence against emergency nurses remains high. Am Nurse. 2011;43(6):7.Google Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.