Encouraging employees to report verbal violence in primary health care in Serbia: A cross-sectional study

Workplace violence is a serious and multidimensional problem that adversely affects professional and personal lives of employees (1, 2). Violence appears as physical violence or as psychological violence in different forms. Psychological violence (Emotional abuse) is “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” (3, 4). It includes verbal abuse, bullying/mobbing, harassment and threats. Verbal violence is behaviour that humiliates, degrades or otherwise indicates the lack of respect for the dignity and worth of an individual. Psychological violence should be considered more deeply, because results of studies indicate a high prevalence of this kind of violence (5-7).

Psychological workplace violence can lead to a decrease in job satisfaction, quality of life and productivity (8, 9). It might, consequently, lead to an increase in medical errors, the reduction of patient care quality, and it might have negative effects on the employee-patient communication (10, 11). Employees in health care institutions are at the top of the list of occupations with a high level of stress and the risk of workplace violence (12).

Studies from twenty years ago showed that verbal violence was the most frequent type of violence, but the true prevalence of it is unknown and varies from country to country (4, 13, 14). Verbal violence against healthcare workers ranges from 23.2% to 97.8% (7, 15, 16).

Globalization and intense transition are expected to increase the number of victims of violence in the workplace (4, 17). In the last two decades, Serbia faced different challenges. It was a period of transition and reforms in all social and economic areas, including health care system. In the period from 2005 to 2010, an increase of workplace violence from 48.7% to 64.2% was recorded, which was reported by non-governmental organizations or trade unions (18). In Serbia, there is a legal basis for the prevention of abuse at work, which should provide greater security for employees: The Constitution of the Republic of Serbia, Labour Law, Law on the Prevention of Workplace Harassment, Discrimination Law, Law on Safety and Health at Work (19). In spite of this, there is no sufficient social and media attention given to this problem because of the lack of information about the types of assistance available, the procedures to report violence, and the lack of strategies which might reduce or prevent verbal violence.

The aim of this study was to assess the prevalence and characteristics of verbal violence as a part of psychological violence among employees in primary health care in Belgrade, and to identify contributing factors of verbal violence in the workplace.

A general response rate was 86.8% (1526/1757). The final analysis included 1526 employees, 243 men (15.9%) and 1280 women (83.9%). There was no significant association between the exposure to workplace verbal violence and gender, age, marital status and years of work experience. However, the prevalence of verbal violence was significantly higher among employees who interacted with patients, worked in shifts, and worked between 6pm and 7am (P<0.001; see Table 1). Furthermore, verbal violence was more prevalent among employees who had more education (Table 1). 48% of employees reported that they had been subjected to verbal violence at the workplace. Verbal attacks occurred most often sometimes (82.0%) and inside health organizations (97.4%). The main source of verbal violence was the patient/client (52.1%) (Table 2).

Out of all participants who experienced verbal violence, 45,7% told to a colleague and 55.6% of employees did not report the incident. Among those who did not report the incident, 74.9% believed that reporting violence was useless (Table 3). Participants could mark more than one answer to questions related to reactions toward violence and reasons for not reporting the incident.

Many of employees who have experienced verbal violence had disturbing memories, thoughts, or images of the abuse (69.3%) (Table 4).

Multiple logistic regression analyses (Table 5) indicated that nurses, as a professional group (OR=2.57, 95% CI: 1.59-4.13), who work between 6pm and 7am (OR=1.34, 95% CI: 1.07-1.68), interact with patients during work (OR=1.77, 95% CI: 1.26-2.47), with less than 20 employees in the same work setting (OR=1.43, 95% CI: 1.10-1.85) and with no encouragement to report workplace violence (OR=1.56, 95% CI: 1.28-1.96), were predictors of verbal violence.

The results indicated that 47.8% of employees had been exposed to verbal violence. Workplace violence has increased in countries worldwide (4, 24). The prevalence rates of verbal violence were from 29.8% to over 82% in the previous studies (15, 25). According to our knowledge, there is not a lot of research on workplace violence and mobbing conducted in Bosnia and Herzegovina, and 76% of physicians self-reported one or more types of mobbing behaviour (26). In Slovenia, the study was conducted on health care workers in emergency departments in primary and secondary health care, and it showed that 74.2% of them experienced verbal or other forms of indirect verbal violence at the workplace (27). These results confirm that verbal violence against healthcare workers is a serious problem (7, 16, 28).

Our study showed that patients were the main source of verbal violence. In most other studies, patients are attackers, followed by their relatives or employees (25, 29). In our study, verbal violence is 1.5 times more common among employees who interact with patients during work. This finding might indicate the miscommunication between patients and healthcare workers, especially nurses. Nurses are the group of health professionals who are at risk for workplace violence in our study and most other studies (9-11, 29). The studies showed that workplace violence among nurses, compared to other professional groups, is a frequent problem, and has negative effects on nurses’ health, work, and therefore on the quality of care (1, 10, 11, 30). Nurses are the first to come into contact with patients and their relatives. It is necessary to improve the quantity and quality of their communication with patients (14). Patients my either feel that they did not receive an appropriate treatment or what they deserved, or that they did not receive the treatment in time (16, 31). It is possible that patients are impatient because of the nature of a disease or because of a crowd. Besides illness, it is possible that many of them are under the influence of alcohol, drugs, or possessing weapons (4, 25).

Working in night shifts is considered to be a high-risk factor for the exposure to violence, which is confirmed by other and our research findings, while working between 6pm and 7am, according to our study, is about 1.3 times more frequent to be a risk factor for the exposure to violence among employees. Higher rates of violence during night shifts can be attributed to personnel who are required to work alone, and are under stress caused by patients’ selfassessment that the need for care was urgent, long waiting times for procedures, the failure to obtain necessary services promptly, or poor work and working conditions (25, 32). In our study, the exposure to verbal violence occurred more often in the work settings with 20 and more employees. It is known that workers in medium- and largesized organisations experienced workplace violence more often than those in small-sized organisations (33).

In the current study, more than half of the participants did not report violence. In other studies, despite a high prevalence of verbal violence, participants also did not report violence (7, 28, 30). The encouragement to report workplace violence and increased awareness and information on the occurrence of workplace violence are measures that contribute to better reporting and combating violence (29, 34, 36). In our study, the encouragement to report workplace violence was 53.3%.

In this study, participants considered reporting useless (74.9%), because they were concerned that they may suffer another assault by reporting it, or feared losing their jobs (36). The lack of reporting could be due to the lack of proper feedback from officials and the lack of proper guidelines for violence reporting. Moreover, this might indicate that health care workers do not trust legal institutions (37, 38).

The strength of this study is a better understanding of workplace violence, because the real size of the problem is still unknown, and this study provides the data about it. One of strengths is that the prevalence of workplace verbal violence is determined. Another strength of this study is that it explains the relationship between predictors of verbal violence and verbal violence itself, and provides the ability for planning measures against workplace violence as well as the basis for future research.

There were some limitations in the present study. First, the data were collected retrospectively, and self-reports may cause recall bias and underreporting. Second, the findings of this study cannot be generalized and are limited to the workplaces in the study. Also, the results may suffer from a misunderstanding of the workplace violence definition or the lack of willingness to share private information.

In conclusion, the results are indicative of a high prevalence of verbal violence against employees in primary health centres, which could have undesirable consequences. Contributing factors of verbal violence include the interaction with patients during work, a large number of staff in the same work setting, and working between 6pm and 7am. The majority of the participants were not inclined to report verbal violence because they thought it would have been useless and due to the lack of encouragement to do so. Conducting better organizational measures and encouraging reporting workplace violence could reduce the prevalence of verbal violence.