Introduction

Workplace violence (WPV) among nurses refers to incidents of mistreatment, intimidation, or assault of nurses while they are at work, which directly or indirectly threaten their safety, well-being, or health [1]. Due to their frontline roles, nurses are three times more likely to experience WPV than other health workers [2–5]. The prevalence of WPV among nurses varies widely across contexts [6–15]. Although patients and their relatives are the most prevalent people engaged in violent behaviours against nurses, coworkers, and other professional groups also perpetrate workplace violence against nurses [1,3,9,16–18]. Nonetheless, most nurses do report WPV due to lack of support, a lack of hospital reporting protocols, unclear reporting channels, increased workload, insufficient staffing, a poorly implemented visitor policy, and unfulfilled expectations [4,16,19–21]. Therefore, healthcare organizations need to enact occupational safeguarding legislation, enforce zero-tolerance policies, and adopt strategies to improve patient-nurse relationships and prevent WPV among nurses.

WPV contributes to the global nursing shortage of around 9 million and reduces the efficiency of healthcare organizations [2,22]. WPV reduces nurses’ work engagement and task performance [23], autonomy [22,24–26], and motivation and causes them to withdraw from co-workers and experience anxiety [10,16,27,28]. WPV predisposes nurses to burnout, long-term dissatisfaction, resentment, and the intention to leave their jobs [5,28,29]. WPV among nurses results in substance misuse, increased sick leave, absenteeism, reduced hospital effectiveness and efficiency, and career or death loss [2,3,10,19], and physical and mental injuries [23]. Additionally, WPV increases patients’ wait time and medication errors [22,24–26], and causes anger toward patients, a lack of empathy, and disengagement with patients [28,29].

Categories of WPV include verbal violence, physical violence, and sexual violence [8,30]. Verbal violence is an intentional use of devaluing or humiliating words, manners, or tone that significantly harms another person’s psychological integrity through coercion, threats, insulting, bullying, and emotional, psychological, and non-physical violence, causing harm to one’s mental well-being [6,9,12]. Globally, the prevalence of verbal violence ranged from 49.4% to 71.4% in Asian countries [20,21,25,31–33] 93.4% of nurses in Tunisia [11], 54% of European nurses [16], 52.6% to 94.3% in Middle-East countries [17,18,34]. In Nigeria, about 54.6% to 85.7% of nurses experienced verbal abuse, mainly in Outpatient Departments (OPD) and emergency units [3,12,27,35]. Determinants of verbal violence include insufficient lighting and a poor organizational culture [21], working in public hospitals and a lack of training on how to deal with workplace violence [33], nurses with work experience of 5–10 years compared to more junior nurses [20], and being a female nurses [6,9,10,27,29].

Physical violence refers to intentional acts to cause bodily harm to another individual, including beating, kicking, slapping, stabbing, shooting, pushing, biting, pinching, punching, hurling objects, strangling, dragging, pushing against walls, and threatening with weapons [9,12,17,32]. The prevalence of physical violence ranges from 9.1% to 78.30% among nurses in low-and-middle-income countries [5,17,18,20,21,23,31–33,36]. In African countries, the prevalence of physical violence against nurses were 6.7% to 42.9% [8–11,34]. In Nigeria, 12.6% to 34.3% of nurses experienced physical violence [19,27,35,37]. Determinants of physical violence include working in emergency rooms, outpatient clinics, or psychiatric units [21,33], inadequate skills to deal with workplace violence, working long hours and high workloads [33], working in acute and psychiatric ward [38], and direct contact with patients [1,39].

Sexual violence is a forceful sexual relation, threat of blackmail, offering gifts in exchange for sex, assault, and unwelcome behaviour that humiliates, threatens, or embarrasses the victim [9,18,32]. The prevalence of sexual violence among nurses ranged from 4.7 to 19.7% in Asia [5,23,31,32]. In Africa, the prevalence of sexual harassment ranges from 2.1% to 18.1% [8–10,34]. In Southwest Nigeria, the prevalence of sexual harassment among nurses was 6% in a general hospital in Osun state [12]. Direct patient contact is a risk factor for sexual violence [27]. Nurses who are appealing, amiable, and easygoing nurses are likelier to experience sexual harassment than other nurses [32].

Despite the growing literature on workplace violence, significant knowledge gap exists on the predictors of workplace violence against nurses in Nigeria [15,40]. Most studies in Nigeria have described the prevalence, patterns, causes, consequences, and factors associated with workplace violence broadly, often including nurses and other healthcare workers [3,12–14,27,35,37,41,42]. These studies were methodologically limited to test of association and did not include predictive analysis [3,12–14,27,35,37,41,42]. Furthermore, WPV studies involving nurses in tertiary hospitals were either limited to single centers or included lower-level hospitals [13,19,35,37,41,42]. To our knowledge, no research has investigated the predictors of verbal, physical, and sexual violence distinctively among nurses from many tertiary hospitals in Nigeria. The present study addresses this gap by examining the prevalence and determinants of the different dimensions of workplace violence among nurses in public tertiary hospitals in Enugu State, Nigeria. Such information will inform the development of context-specific policies to minimize violence and create a safe work environment for nurses in Nigeria.

Methods and materials

Results

Socio-demographic characteristics of nurses

Almost 50% of the nurses in this study are over 40 years of age. Most nurses are female and married. About 68% of nurses have a Bachelor of Nursing degree. Approximately 58% of nurses have worked for more than 10 years as nurse (Table 1). About 9% of nurses in this study worked in the Neuropsychiatric hospital. About 50% of nurses work in special clinics and outpatient departments.

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Table 1. Socio-demographic characteristics of nurses.

https://doi.org/10.1371/journal.pone.0349187.t001

Prevalence and characteristics of workplace violence among nurses

Overall, 92.4% of nurses experienced at least one form of workplace violence in the 12 months preceding the study. The prevalence of verbal violence, physical violence, and sexual violence are 91.1%, 13.3%, and 2.0% correspondingly (Fig 1).

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Fig 1. Prevalence of workplace violence among nurses in public tertiary hospitals in Enugu State.

https://doi.org/10.1371/journal.pone.0349187.g001

Relatives of patients accounted for 56% of verbal abuse, 78% of physical violence, and 33% of sexual violence among nurses in this study (Table 2). The leading reasons for verbal and physical violence were long waiting time, anxiety, unmet expectations, pain, and unavailability of needed services and medicine.

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Table 2. Characteristics of workplace violence among nurses in public tertiary hospitals in Enugu State.

https://doi.org/10.1371/journal.pone.0349187.t002

Factors associated with any workplace violence and its dimensions

No socio-demographic and organizational factor was significantly associated with workplace violence (Table 3).

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Table 3. Socio-demographic and organizational factors associated with any workplace violence.

https://doi.org/10.1371/journal.pone.0349187.t003

Gender was the only demographic and job-related factor significantly associated with verbal violence (p = 0.027). Marital status (p = 0.007), educational qualifications (p = 0.008), years worked as a nurse (p = 0.026), direct patient contact (p < 0.001), and current unit (p < 0.001) were significantly associated with physical violence (Table 4). Highest educational qualifications (p = 0.023), direct patient contact (p < 0.001), current unit (p = 0.023), and clients worked with (p = 0.002) had significant association with sexual violence (Table 4).

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Table 4. Socio-demographic factors associated with any workplace violence.

https://doi.org/10.1371/journal.pone.0349187.t004

Predictors of verbal, physical, and sexual violence

The predictors of verbal, physical and sexual violence are shown in Table 5. We reported the unadjusted, crude odd ratio (COR) for gender, since gender was the only demographic and job-related factor associated with verbal violence included in binary regression for verbal violence. Female nurses were more likely to experience verbal abuse than male nurses (COR = 2.84, 95%CI: 1.09–7.42, p = 0.002).

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Table 5. Predictor of verbal violence among nurses in public hospitals in Enugu State.

https://doi.org/10.1371/journal.pone.0349187.t005

Although marital status, highest qualification, years worked as a nurse, direct patient contact, and current unit had significant association with physical violence, marital status and years worked as a nurse were not significant in the unadjusted binary regression. Being a registered nurse (AOR = 2.06, 95%CI: 1.13–3.78, p = 0.019), direct contact with patients (AOR = 21.04, 95%CI: 3.17–139.82, p = 0.002), working in accident and emergency units (AOR = 6.91, 95%CI: 2.82–16.93, p < 0.001) increased the likelihood of physical violence against nurses.

Regarding sexual violence, highest qualification, direct patient contact, and current unit were included in the binary regression, but only direct patient contact remained significant in the unadjusted model. Direct contact with patients (AOR = 20.71, 95%CI: 3.54–121.12, p = 0.001) increased the likelihood of sexual violence.

Discussion

The study found a high prevalence of workplace violence in public tertiary hospitals in Enugu metropolis, which is higher than results from previous Nigerian and African studies [7–13,27,35,37,42]. One reason for this variation is that some previous studies included nurses in secondary health care and private health facilities, unlike the current study, which focused on nurses in publicly owned tertiary hospitals. It might also be that nurses in secondary and private hospitals underreported their experiences of workplace violence, given that WPV is an unpleasant part of the nursing profession, but reporting is unimportant [12,20]. Underreporting accounts for the low prevalence in Ethiopia [9]. Consistent with prior evidence [12,17], verbal violence is the most significant driver of the high prevalence of WPV in the current study

The high prevalence of verbal violence found in the current study is consistent with evidence from other countries [11,17,18,20,33,36]. Nevertheless, other studies found a lower prevalence of verbal violence [8,12,16,21,25,31,32,34]. The mixed findings on verbal violence across different settings indicate a need for evidence-informed, context-specific responses to reduce verbal violence. In the current study, patients’ relatives and patients were the most significant people perpetrating verbal violence against nurses. Prior studies also found that the perpetrators of verbal abuse are primarily patients and their relatives [9,10,18,20,35]. In our study, the critical reasons for verbal violence were long waiting times, unmet expectations of patients, influence of sickness or pain, and unavailability of needed services/medicines. Addressing these causes of WPV would be a meaningful change to reduce verbal violence among nurses in tertiary hospitals.

The study found that female nurses were likelier to experience verbal violence than male nurses in this study. This finding is consistent with the evidence from existing studies indicating that violence against nurses is more common among female nurses [6,9,10,27,29]. One possible cause of verbal violence against female nurses is the higher proportion of female nurses compared with male nurses in the nursing profession, given that the nursing profession is more accessible to women [29]. Another reason might be the negative community attitude toward female power and ability, where males are superior to women, and women are often subject to derogatory comments [9,10].

The prevalence of physical violence in the current study is consistent with evidence from previous studies [9,19,31,35,37,39]. While our prevalence is lower than the findings from other studies [5,11,16,17,27,32,33,36], the present study found higher a prevalence than evidence from Rwanda [8]. The variations in prevalence result from methodological differences: sampling exclusively mental health or emergency nurses and a mix of public and private nurses. Also, underreporting physical violence varies across settings depending on the availability of WPV prevention policies and reporting systems in the hospitals. Because of lower rates of reports, infrequent incidents of physical violence, which serve as warning signs of future physical violence, are tolerated [6,29]. The most frequently abusive persons are patients’ relatives. Long waiting times, anxiety, unmet expectations of patients and families, and the influence of pain were the leading reasons for physical violence. Evidence shows that many patients daily may overwhelm hospital staff, leading to long waiting periods and making patients and their relatives irritable [39].

The finding that nurses with lower qualifications in this study had increased odds of physical violence is consistent with the evidence that lower nursing qualifications increased the odds of physical violence among nurses [39]. In contrast, our findings differ from other preceding studies indicating that nurses were more likely to experience WPV if they held bachelor’s degrees or higher levels of education [17,32,36]. Evidence in Japan also shows that licensed nurses experienced more WPV than assistant nurses because of their role in convincing patients to take medicine or medical treatments or administer forced treatments [38]. Nurses with lower qualifications lack the experience, maturity, and ability to manage potentially violent circumstances or patients [39].

Consistent with previous studies [1,39], having direct contact with patients increased the likelihood of physical violence among nurses in public tertiary hospitals in the present study. This finding should be cautiously interpreted given the wide confidence interval of the odd ratio. In clinical settings, nurses’ work usually brings them close to the patients and their relatives, which puts them at a higher risk of being abused physically than other health professionals when patients or their relatives perceive a delay in accessing healthcare or when care expectations are not [39]. Nurses’ position exposes them to violence related to the environment as the nurses who are usually in direct contact with the patient were more apt to violence than the nursing supervisor or the nurses working in offices [1].

This study’s finding that nurses working in the accident and emergency units were more likely to experience physical violence is similar to those found by previous studies [8,35,39]. The interdependence theory of aggression explains the pathway to violence in emergency units. Interaction between patients and nurses depends on the patient’s factors, the nurse’s approach towards them, and how patients and nurses deal with stress. The accident and emergency units care for many severely ill patients who need nursing care and regular monitoring. For example, communicating poor prognoses to the patients and patient’s relatives may create unnecessary anger and anxiety, leading to violence against the nurses. Our finding highlights a need for hospital decision-makers to direct a violence prevention program to high-risk areas, such as emergency units, with patients whose behaviour can be affected by health conditions and drugs [21].

We found a considerably low prevalence of sexual violence among nurses in this study, which is consistent with evidence from Rwanda [8]. Nonetheless, our finding is low compared to studies conducted in China, Ethiopia, and Indonesia [5,9,10,31]. Sexual violence is stigmatizing and may be the reason for underreporting sexual violence in our study. The findings of this study further show that having direct contact with patients increased the likelihood of sexual violence among nurses in public tertiary hospitals in Enugu State. This finding is consistent with a previous study, which revealed that most of the nurses who experienced sexual harassment had direct patient contact [27]. However, this finding has a wide confidence interval, indicating substantial imprecision, and should be interpreted with caution.

Our study fills an important knowledge gap in literature by providing evidence of the social and organizational predictors of individual dimensions of workplace violence in public tertiary hospitals in South-East, Nigeria. Nonetheless, the findings may not be generalizable to the other geopolitical zones of Nigeria or nurses in private health facilities. Also, as with cross-sectional surveys, our study does not establish any causal inferences. Future studies may consider conducting longitudinal studies, where data is collected from nurses over time. This would allow the researchers to observe changes, understand the temporal sequence of events, and assess potential causal relationships more confidently. Moreover, the study’s findings could suffer from social desirability bias, where nurses may have presented answers that are more socially acceptable than their actual experiences, leading to the underreporting of physical and sexual violence and the over-reporting of verbal violence.

Conclusion

The study provided evidence on the prevalence and determinants of workplace violence. The burden of workplace violence among nurses is high, especially verbal and physical violence. Gender differences were significant in verbal violence. Nurses’ qualifications, direct patient contact and working in accident and emergency units significantly increase the risk of physical violence. Direct contact with patients increases the risk of sexual violence among nurses. Health policymakers, practitioners, and health facility managers need to incorporate these findings into safeguarding policies and strategies to improve nurses’ safety, intervene promptly in cases of workplace violence, and monitor interventions to eliminate workplace violence against nurses in Nigeria.

Acknowledgments

We thank the nurses who participated in this study.