healthcareArticleWorkplace Violence among British Columbia NursesAcross Different Roles and ContextsFarinaz Havaei 1,*, Maura MacPhee 1 and Andy Ma 21 School of Nursing, The University of British Columbia, Vancouver, BC V6T 2B5, Canada;Maura.MacPhee@ubc.ca2 School of Educational and Counselling Psychology and Special Education, The University of British Columbia,Vancouver, BC V6T 1Z4, Canada; andytfma@mail.ubc.ca* Correspondence: farinaz.havaei@ubc.ca; Tel.: +1-604-827-4732Received: 23 March 2020; Accepted: 9 April 2020; Published: 14 April 2020



Abstract: Workplace violence in healthcare settings is on the rise, particularly against nurses.Most healthcare violence research is in acute care settings. The purpose of this paper is to presentdescriptive findings on the prevalence of types and sources of workplace violence among nursesin different roles (i.e., direct care, leader, educator), specialties, care sectors (i.e., acute, community,long-term care) and geographic contexts (i.e., urban, suburban, rural) within the province of BritishColumbia (BC), Canada. This is a province-wide survey study using a cross-sectional descriptive,correlational design. An electronic survey was emailed by the provincial union to members acrossthe province in Fall 2019. A total of 4462 responses were analyzed using descriptive and chi-squarestatistics. The most common types of workplace violence were emotional abuse, threats of assault andphysical assault for all nursing roles and contexts. Findings were similar to previous BC research fromtwo decades ago except for two to ten times higher proportions of all types of violence, includingverbal and physical sexual assault. Patients were the most common source of violence towards nurses.Nurses should be involved in developing workplace violence interventions that are tailored to workenvironment contexts and populations.Keywords: workplace violence; types; sources; roles; sector; geographical region; specialty; nursing;patients; family; visitors1. IntroductionCompared to employees in other industries, healthcare workers have a four-fold higher rateof exposure to workplace violence [1]. As the largest healthcare workforce and an overwhelminglyfemale dominant profession, nurses are more prone to workplace violence, particularly inconstrained healthcare environments where workload management and staffing inadequacies are dailychallenges [1,2]. Although the long-term consequences of workplace violence for providers, patients,the healthcare organization and the society at large have been relatively well studied [3], there is a gapin our understanding of different typologies and sources of workplace violence towards nurses across avariety of roles, specialties, sectors and geographical areas. To date, the majority of workplace violenceresearch has been conducted with direct care nurses from urban acute care settings [4–7], with limitedresearch on the state of workplace violence among non-direct care providers, such as nursing leadersand educators, and nurses in long-term care or community care sectors and/or healthcare settings acrossgeographical areas (e.g., urban, rural). For example, violence rates in acute care settings have alsobeen attributed to the close, frequent contact direct care nurses have with patients and families [2,4,6].Less is known about violence rates in other healthcare sectors with nurses in roles that require lessfrequent, direct contact with patients and families. Moreover, previous healthcare violence researchHealthcare 2020, 8, 98; doi:10.3390/healthcare8020098 www.mdpi.com/journal/healthcareHealthcare 2020, 8, 98 2 of 14used simplistic operational definitions of workplace violence [5,8,9] or was conducted with datacollected over two decades ago [4,6,9]. Because the consequences of workplace violence vary forvictims depending on its type and source [10], describing workplace violence with respect to themultiple factors associated with nursing care delivery is an urgent undertaking. The purpose ofthis study was to examine the prevalence of workplace violence, in terms of typologies and sources,towards nurses in different roles and care delivery contexts in British Columbia (BC), Canada.Workplace violence encompasses the full range of acts and threats of physical violence againstemployees, from threatening or intimidating behaviors, harassment and verbal abuse to physicalassaults at the worksite [11]. Workplace violence is a complex phenomenon with nuanced distinctionsthat have been difficult to isolate and measure. The World Health Organization, for instance, classifiesworkplace violence into two categories of physical and emotional violence [12]. Physical violence isdescribed as the use of physical force that causes physical and psychological harm and emotionalviolence refers to the use of non-physical means that result in psychological harm [12]. These broadclassifications fail to effectively capture the range of types of violence, particularly non-physical typesof violence, such as emotional abuse. Hence, more research is needed on the prevalence of specifictypes of workplace violence among nurses.One of the most recent comprehensive reviews of nurse exposure to workplace violence examined136 international studies with prevalence rates for physical and non-physical violence, bullying, andsexual harassment in an aggregated sample of 151,347 nurses [7]. This review found that 32% of nursesworldwide were exposed to physical violence, 63% to non-physical violence, 48% to bullying, and18% to sexual harassment. Nurses had the highest violence exposure rates in emergency departments(physical = 50%, non-physical = 81), mental health (physical = 55%, non-physical = 73%) and long-termcare settings (physical = 46%, non-physical = 34%). The highest prevalence of sexual harassmentwas in psychiatric settings (30%), followed by nurses working in hospitals (19%). Despite importantknowledge gleaned from this quantitative review, the study failed to differentiate between nursingroles (e.g., direct and non-direct care); nurses were classified by world regions (i.e., Anglo, Asia,Europe, Middle East); and prevalence rates were based on considerable variation in how violencewas operationalized and measured across studies. The most common types of violence reported inthe review papers were physical violence, non-physical violence, bullying and sexual harassment.The review, therefore, ‘fit’ data into these four violence categories, acknowledging differences in howviolence was defined and assessed.In this study’s country context, Canada, workplace violence seems to be particularly prevalent inBC. A 2005 national survey on the work and health of nurses found that BC nurses reported exposureabove national averages for physical (33% vs. 29%) and emotional violence (50% vs. 44%). This researchonly used two categories of violence [9]. Two earlier Canadian studies used five specific categories ofviolence, but these studies were conducted with data collected over two decades ago [4,6].In addition to the factors mentioned above that influence prevalence rates of workplace violenceagainst nurses, violence research needs to include the source of violence and work environment factorsassociated with violence. Workplace violence is classified based the source or the instigator of violence.Instigators are categorized as: clients of the victim (e.g., patients, families), other employees workingin the same organization as the victim (e.g., nursing colleagues, management), individuals who havepersonal relations with the victim (e.g., spouse), and individuals with no relation to the victims or theorganization (e.g., stranger) [13]. According to previous research, the majority of workplace violencein healthcare is attributed to patients and their families/visitors. For example, the aforementionedinternational review reported that a majority of physical and non-physical workplace violence wasrespectively instigated by patients (64% and 54%) and families/visitors (30% and 47%) followed byorganizational staff such as nursing colleagues, physicians and supervisors (2%–6% and 22%–39%) [7].Workplace characteristics, such as lack of resources, inadequate staffing, heavy workload andlong wait times are often the root causes of patient aggression towards healthcare providers [5,14–16].A recent study, for example, found associations between nurses’ heavy workloads, patient/familyHealthcare 2020, 8, 98 3 of 14complaints and violence escalation [5]. Other research has established differences in adequacy of nursestaffing and workload management between healthcare sectors (e.g., acute care, long-term care) [17]and geographical regions (e.g., urban, rural) [18–20]. Violence research with nurses, therefore, needs toconsider the variety of contexts that may influence acts of violence against them.To summarize, the majority of previous workplace violence research was conducted with directcare nurses from urban acute care settings. There is limited evidence on the prevalence of workplaceviolence among nurses in non-direct care roles, working outsides of hospitals in different healthcaresectors and urban/rural regions. This study addressed previous research limitations and includedother workplace factors related to violence, specifically the source or instigator of violence and workenvironment characteristics. Therefore, the purpose of this study was to establish a comprehensivebaseline of workplace violence in a Canadian province with some of the highest reported violencerates against nurses. Baseline descriptive data will serve as a foundation for further exploration of thecausal relationships most predictive of different types of violence against nurses based on their roles,specialties, healthcare sectors and urban/rural contexts.2. Materials and MethodsThis was a province-wide study of BC nurses using a cross-sectional descriptive and correlationaldesign. A weblink to an electronic survey was emailed by the provincial union to about membersacross the province inviting them to participate in a study of psychological health and safety in theworkplace. To increase response rates, the survey was open for two months and email reminderswere sent through the union e-news every week. The study was also advertised through the union’ssocial media and print advertisements. Additionally, respondents were included in a raffle draw fortwo Apple Watches. Respondents were informed that participation was completely voluntary, andsurvey completion indicated informed consent.Overall, 5512 surveys were returned, reflecting an estimated response rate of 12%. Nurses wereincluded in this study if they were actively working and fully completed the workplace violencequestions. The final sample size was 4462. Ethics approval was obtained from the University BehavioralResearch Ethics Board (approval number: H18-02724).2.1. MeasuresWorkplace violence typologies were measured by a single question that asked about the frequency ofexposure to five different types of workplace violence over the last year. This question was previouslycontent validated and used in research with BC nurses [6]. The types of workplace violence were:(i) physical assault (e.g., being spit on, bitten, hit, pushed), (ii) threat of assault (e.g., verbal or writtenthreats intending harm, aggressive behavior), (iii) emotional abuse (e.g., insults, gestures, humiliation,coercion), (iv) verbal sexual harassment (e.g., unwanted intimate questions or remarks of a sexualnature) and (iv) sexual assault (e.g., any forced physical sexual contact including forcible touching andfondling and forced sexual acts including forcible intercourse). The response options were rated on aseven-point scale ranging from never (0) to everyday (6). Response options were recoded to never (0)versus ever (1).Workplace violence sources were measured by asking a check-all-apply question from respondentswho reported exposure to workplace violence. Respondents were asked to identify the source from alist of seven response options for each type of workplace violence they had experienced: (i) patients,(ii) family/visitors, (iii) physicians, (iv) nursing co-workers, (v) allied health, (vi) management, and (vii)other. This question was coded and analyzed in two ways: (a) to differentiate between respondentsthat identified a single source versus multiple sources and (b) to explore nurses’ responses in eachsource. For the former, nurses that identified more than one source for each type of workplace violencewere recoded into a multiple source category. For the latter, nurses’ responses were maintained in theiroriginal form. This question was previously content validated and used in research with BC nurses [6].Healthcare 2020, 8, 98 4 of 14Workplace characteristics were measured by a series of questions that asked nurses to identifytheir primary workplace in terms of healthcare sector (acute care, community care, long-term care)and geographical region (urban, suburban and rural). Acute care nurses were asked to identifythe primary nursing specialty of their workplace using a check-all-apply question with 17 responseoptions. As per previous nurse workplace violence research, response options were recoded intomedical/surgical, critical care, emergency, psychiatry, and other specialties [6]. Nurses that identifiedmore than one specialty were recoded into a multi-specialty category. These questions were contentvalidated in previous research with BC nurses [21].Demographic characteristics were measured using a series of questions that asked nurses to identifytheir age, gender (female, male, prefer not to describe), professional designation (licensed practicalnurse, registered nurses, registered psychiatric nurses and dually registered nurses), education(diploma/certificate, undergraduate degree, graduate degree, other), years of nursing experience androle (direct care provider, nurse leader, nurse educator).2.2. Data AnalysisData were analyzed using descriptive statistics such as frequencies, percentages and cross tabs.Chi square analysis was used to examine the difference in workplace violence across nursing roles,healthcare sectors, geographical areas and nursing specialties. Chi square analysis was not conductedfor variables that resulted in cross tabs with empty cells, as empty cells violate an important assumptionof this test statistic. The Statistical Package for Social Sciences for Windows 25.0 (SPSS Inc., Chicago, IL,USA) was used for data analysis.3. ResultsTable 1 shows respondents’ demographic and workplace characteristics. An overwhelmingmajority of the respondents were female (91%) registered nurses (RNs) (78%) with an age range of25–54 years old (80%). About 50% of the respondents had an undergraduate degree with less than11 years of nursing experience. Most nurses held a direct care role (90%) in urban (63%) acute care(74%) settings. A majority of acute care nurses worked in medical/surgical (35%), other (22%) andcritical care specialties (18%).Table 2 shows the prevalence of the types of workplace violence among BC nurses and acrossdifferent nursing roles, healthcare sectors and geographical areas. The most common types of workplaceviolence were respectively emotional abuse (83%), threat of assault (78%), physical assault (67%),verbal sexual harassment (55%) and sexual assault (11%) among BC nurses. On average, BC nursesreported exposure to emotional abuse (M = 2.0, SD = 1.7) and threat of assault (M = 1.9, SD = 1.7) oncea month, physical assault (M = 1.3, SD = 1.4) and verbal sexual harassment (M = 1.0, SD = 1.3) a fewtimes a year; and sexual assault (M = 0.2, SD = 0.5) rarely.While the most common types of workplace were respectively emotional abuse, threat of assaultand physical assault, the least common types of workplace violence were sexual assault and verbalsexual harassment across all three nursing roles, healthcare sectors and geographical areas. With respectto nursing role, all types of workplace violence were more predominantly reported by direct care nurses(Range = 12%–84%) and nurse leaders (Range = 10%–79%) compared to educators (Range = 0%–60%)(χ2 (24,462) = 50.3–89.8, p < 0.001). With respect to healthcare sector, all types of workplace violencewere more predominantly reported by acute care (Range = 13%–85%) and long-term care nurses(Range = 16%–84%) compared to community care nurses (Range = 4%–72%) (χ2 (24,462) = 57.1–591.1,p < 0.001). With respect to geographical area, there were no statistically significant differences infour types of workplace violence across urban, suburban and rural areas (χ2 (24,443) = 0.6–5.7,p > 0.05). An exception includes verbal sexual harassment that was most commonly reported bynurses in rural areas (61%) compared to their counterparts in urban (52%) and suburban (57%) areas(χ2 (24,443) = 22.5, p < 0.001).Healthcare 2020, 8, 98 5 of 14Table 1. Demographic and workplace characteristics (n = 4462).Characteristics n %AgeUnder 25 190 4.325 to 34 1465 33.035 to 44 1123 25.345 to 54 961 21.755 and above 697 15.7GenderFemale 4071 91.3Male 379 8.5Prefer to describe 9 0.2Professional Designation 1LPN 722 16.2RN 3467 77.7RPN 276 5.7Dually registered (RN/RPN) 17 0.4EducationDiploma/Certificate 1365 30.6Undergraduate degree 2132 47.8Graduate degree 905 20.3Other 57 1.3Overall nursing experience5 years or less 1307 29.46 to 10 years 957 21.511 to 15 years 777 17.516 to 20 years 364 8.221 years or more 1044 23.5Nursing RoleDirect care provider 3995 89.5Nurse leader 351 7.9Nurse educator 116 2.6SectorAcute care 3277 73.5Community care 780 17.5Long-term care 400 9.0Geographical AreaUrban 2777 62.5Suburban 781 17.6Rural 885 19.9Acute Care Nursing Specialty (n = 3260)Medical/Surgical 1142 35.0Critical care 578 17.7Emergency 468 14.4Psychiatry 272 8.3All other units 710 21.8Multiple units 90 2.81 LPN, licensed practical nurses; RN, registered nurses; RPN, registered psychiatric nurses.Table 3 shows the prevalence of the types of workplace violence among acute care nursesby nursing specialty. There were statistically significant differences in the prevalence of all typesof workplace violence across acute care nursing specialties (χ2 (53,260) = 140.5–424.1, p < 0.001).Overall, workplace violence was most commonly reported by acute care nurses that worked inemergency departments (Range = 17%–97%), psychiatric (Range = 8%–96%) and medical/surgical(Range = 20%–91%) specialties. Nurses in critical care and other specialties were less commonlyexposed to all types of workplace violence.Healthcare 2020, 8, 98 6 of 14Table 2. Percentage of nurses who reported workplace violence by nursing role, healthcare sector andgeographical area.Key Variables PhysicalAssaultThreat ofAssaultEmotionalAbuseVerbal SexualHarassmentSexualAssaultOverall sample 2971 (66.6%) 3497 (78.4%) 3693 (82.8%) 2448 (54.9%) 503 (11.3%)Nursing RoleDirect care provider 2724 (68.2%) 3180 (79.6%) 3347 (83.8%) 2248 (56.3%) 468 (11.7%)Nurse leader 214 (61.0%) 267 (76.1%) 277 (78.9%) 171 (48.7%) 35 (10.0%)Nurse educator 33 (28.4%) 50 (43.1%) 69 (59.5%) 29 (25.0%) 0 (0%)χ2(24,462) 85.4 *** 89.8 *** 50.6 *** 50.3 *** −1SectorAcute care 2393 (73.0%) 2692 (82.1%) 2795 (85.3%) 1907 (58.2%) 412 (12.6%)Community care 234 (30.0%) 463 (59.4%) 560 (71.8%) 317 (40.6%) 29 (3.7%)Long-term care 340 (85.0%) 337 (84.3%) 334 (83.5%) 222 (55.5%) 62 (15.5%)χ2(24,457) 591.1 *** 201.9 *** 80.6 *** 78.5 *** 57.1 ***Geographical AreaUrban 1824 (65.7%) 2148 (77.3%) 2297 (82.7%) 1453 (52.3%) 304 (10.9%)Suburban 536 (68.6%) 613 (78.5%) 641 (82.1%) 444 (56.9%) 86 (11.0%)Rural 595 (67.2%) 718 (81.1%) 739 (83.5%) 541 (61.1%) 111 (12.5%)χ2(24,443) 2.6 5.7 0.6 22.5 *** 1.81 No test statistic is provided because a χ2 assumption is violated. *** p < 0.001.Table 3. Percentage of acute care nurses who reported workplace violence by nursing specialty.Acute CareNursing SpecialtyPhysicalAssaultThreat ofAssaultEmotionalAbuseVerbal SexualHarassmentSexualAssaultMedical/Surgical 987 (86.4%) 1039 (91%) 1021 (89.4%) 808 (70.8%) 228 (20.0%)Critical care 349 (60.4%) 418 (72.3%) 454 (78.5%) 245 (42.4%) 31 (5.4%)Emergency 419 (89.5%) 449 (96%) 452 (96.6%) 369 (78.8%) 81 (17.3%)Psychiatry 210 (77.2%) 261 (96%) 254 (93.4%) 193 (71.0%) 22 (8.1%)All other units 357 (50.3%) 443 (62.4%) 521 (73.4%) 232 (32.7%) 33 (4.6%)Multiple specialties 62 (68.9%) 71 (78.9%) 78 (86.7%) 54 (60.0%) 15 (16.7%)X2 (53,260) 406.4 *** 386.0 *** 178.4 *** 424.1 *** 140.5 ****** p < 0.001.Table 4 shows the prevalence of the types of workplace violence by its sources (single vs.multiple) across nursing roles, healthcare sectors and geographical areas. A similar pattern was notedacross all nursing roles and most healthcare sectors and geographical areas. While physical assault(Range: 70%–84%), verbal sexual harassment (Range: 64%–74%), and sexual assault (Range: 66%–78%),were most commonly initiated by patients, multiple perpetuators were most commonly reported foremotional abuse (Range: 60%–77%), and threats of assault (Range: 33%–53%). Exceptions includedthreats of assault in community and long-term care settings as well as rural areas where patients alonewere identified as the most common single instigators of these types of violence.Table 5 similarly shows the prevalence of the types of workplace violence by sources across nursingroles, sectors and geographical areas, but without the grouping of responses that reported multiplesources of a workplace violence type. Therefore, the percentages in Table 5 report the prevalence ofworkplace violence for each source individually. Overall, patients were overwhelmingly the mostcommon source of workplace violence for physical assault (Range: 94%–99%), verbal sexual harassment(Range: 76%–91%), and sexual assault (Range: 80%–89%) across roles, sectors, and geographicalareas. For threats of assault, most commonly reported sources were patients (Range: 78%–96%)followed by family/visitors (Range: 33%–57%). Similarly, emotional abuse was often most commonlyperpetrated by patients (Range: 46%–84%) and family/visitors (Range: 39%–69%) across nursing rolesand contexts. An exception includes emotional abuse experienced by nurse educators who identifiednursing co-workers as the most common source of this type of violence (58%).Healthcare 2020, 8, 98 7 of 14Table 4. Percentage of workplace violence that is reported compared by single and multiple sources ofworkplace violence.Nursing Role PhysicalAssaultThreat ofAssaultEmotionalAbuseVerbal SexualHarassmentSexualAssaultDirect care provider n = 2718 n = 3173 n = 3339 n = 2242 n = 465Patients 72.1% 45.5% 16.9% 65.1% 76.1%Family/visitors 0.5% 4.3% 3.1% 1.7% 0.4%Physicians 0.1% 0.3% 0.9% 0.8% 0.6%Nursing co-workers 0.2% 0.3% 3.3% 1.1% 0.4%Allied health 0% 0.1% 0.1% 0.3% 0.2%Management 0% 0.1% 2.0% 0% 0.2%Other 0.7% 0.6% 1.0% 7.3% 10.1%Multiple sources 26.5% 48.9% 72.6% 23.8% 11.8%Nurse leader n = 214 n = 267 n = 277 n = 171 n = 35Patients 71.5% 43.8% 11.6% 66.1% 77.1%Family/visitors 0% 3.7% 3.2% 1.8% 0%Physicians 0% 0.4% 0.7% 2.3% 0%Nursing co-workers 0% 0.7% 4.3% 1.8% 2.9%Allied health 0% 0% 0% 0.6% 0%Management 0% 0% 3.6% 0% 0%Other 0.9% 1.1% 1.4% 9.9% 17.1%Multiple sources 27.6% 50.2% 75.1% 17.5% 2.9%Nurse educator n = 33 n = 50 n = 69 n = 29 n = 0Patients 69.7% 38.0% 7.2% 69.0% -Family/visitors 0% 8.0% 1.4% 3.4% -Physicians 3.0% 2.0% 2.9% 3.4% -Nursing co-workers 0% 4.0% 20.3% 6.9% -Allied health 0% 0% 0% 0% -Management 0% 2.0% 4.3% 0% -Other 0% 4.0% 1.4% 6.9% -Multiple sources 27.3% 42.0% 62.3% 10.3% -SectorAcute care n = 2389 n = 2687 n = 2789 n = 1904 n = 409Patients 70.0% 41.6% 14.8% 63.8% 77.3%Family/visitors 0.5% 4.3% 2.8% 1.9% 0.2%Physicians 0.1% 0.4% 1.1% 1.2% 0.5%Nursing co-workers 0.1% 0.3% 2.8% 1.0% 0%Allied health 0% 0% 0% 0.2% 0.2%Management 0% 0.1% 1.7% 0.1% 0.2%Other 0.5% 0.3% 0.8% 7.7% 10.0%Multiple sources 28.8% 53.0% 75.9% 24.1% 11.5%Community care n = 233 n = 462 n = 559 n = 315 n = 29Patients 76.0% 53.9% 18.4% 67.6% 65.5%Family/visitors 0.4% 6.1% 2.9% 1.3% 3.4%Physicians 0% 0% 0.5% 0.3% 0%Nursing co-workers 0.4% 0.4% 7.9% 0.6% 0%Allied health 0% 0.6% 0.7% 1.0% 0%Management 0% 0.2% 4.3% 0% 0%Other 0.9% 2.2% 2.5% 5.7% 13.8%Multiple sources 22.3% 36.6% 62.8% 23.5% 17.2%Long-term care n = 339 n = 336 n = 333 n = 221 n = 62Patients 83.8% 62.8% 25.5% 73.8% 74.2%Family/visitors 0% 2.1% 5.7% .5% 0%Physicians 0.3% 0% .3% 0% 1.6%Nursing co-workers 0.3% 1.2% 3.9% 3.6% 4.8%Allied health 0% 0% 0% 0% 0%Management 0% 0% 2.7% 0% 0%Other 2.1% .9% 1.5% 7.7% 12.9%Multiple sources 13.6% 33.0% 60.4% 14.5% 6.5%Healthcare 2020, 8, 98 8 of 14Table 4. Cont.Nursing Role PhysicalAssaultThreat ofAssaultEmotionalAbuseVerbal SexualHarassmentSexualAssaultGeographical areaUrban n = 1822 n = 2145 n = 2293 n = 1451 n = 302Patients 71.1% 45.0% 17.6% 65.1% 77.5%Family/visitors 0.7% 4.8% 3.2% 2.1% 0.3%Physicians 0.1% 0.3% 0.8% 0.9% 0%Nursing co-workers 0.2% 0.4% 3.9% 1.3% 0.3%Allied health 0% 0.1% 0.2% 0.3% 0%Management 0% 0.2% 2.0% 0.1% 0.3%Other 0.7% 0.7% 1.0% 7.7% 11.6%Multiple sources 27.3% 48.4% 71.3% 22.5% 9.9%Suburban n = 534 n = 611 n = 639 n = 442 n = 85Patients 69.7% 42.4% 13.6% 64.3% 72.9%Family/visitors 0.4% 3.6% 3.0% 0.9% 1.2%Physicians 0.2% 0% 0.3% 1.1% 0%Nursing co-workers 0% 0.3% 3.1% 0.9% 2.4%Allied health 0% 0% 0% 0.2% 1.2%Management 0% 0.2% 1.7% 0% 0%Other 0.4% 0.3% 1.1% 8.1% 9.4%Multiple sources 29.4% 53.2% 77.2% 24.4% 12.9%Rural n = 593 n = 716 n = 737 n = 539 n = 111Patients 77.1% 48.0% 14.8% 66.0% 74.8%Family/visitors 0% 3.5% 2.8% 1.1% 0%Physicians 0.2% 0.6% 1.9% 0.9% 2.7%Nursing co-workers 0.2% 0.3% 3.5% 1.1% 0%Allied health 0% 0.1% 0.1% 0.4% 0%Management 0% 0% 3.1% 0% 0%Other 1.0% 0.6% 1.2% 6.3% 9.0%Multiple sources 21.6% 46.9% 72.5% 24.1% 13.5%Table 5. Percentage of workplace violence compared individually by source.Nursing Role PhysicalAssaultThreat ofAssaultEmotionalAbuseVerbal SexualHarassmentSexualAssaultDirect care provider n = 2718 n = 3173 n = 3339 n = 2242 n = 465Patients 98.5% 94.2% 82.8% 88.4% 88.0%Family/Visitors 25.9% 52.3% 64.1% 22.3% 10.8%Physicians 2.0% 1.7% 23.7% 3.5% 1.1%Nursing co-workers 2.7% 2.4% 31.4% 3.9% 1.1%Allied health 0.6% 0.8% 4.9% 1.1% 0.6%Management 1.4% 1.3% 23.1% 0.8% 0.4%Other 0.9% 1.0% 1.9% 7.9% 11.0%Nurse leader n = 214 n = 267 n = 277 n = 171 n = 35Patients 98.1% 93.3% 76.2% 83.6% 80.0%Family/Visitors 24.3% 52.1% 63.5% 15.8% 2.9%Physicians 1.4% 3.0% 26.0% 5.3% 0%Nursing co-workers 3.7% 6.4% 41.9% 5.3% 2.9%Allied health 0.5% 1.9% 8.7% 1.2% 0%Management 2.8% 4.1% 30.0% 0.6% 0%Other 0.9% 1.5% 2.5% 9.9% 17.1%Nurse educator n = 33 n = 50 n = 69 n = 29 n = 0Patients 93.9% 78.0% 46.4% 75.9% 0%Family/visitors 24.2% 48.0% 39.1% 10.3% 0%Physicians 12.1% 6.0% 36.2% 6.9% 0%Nursing co-workers 9.1% 8.0% 58.0% 10.3% 0%Allied health 0% 0% 8.7% 0% 0%Management 3.0% 2.0% 26.1% 0% 0%Other 0% 6.0% 4.3% 6.9% 0%Healthcare 2020, 8, 98 9 of 14Table 5. Cont.Nursing Role PhysicalAssaultThreat ofAssaultEmotionalAbuseVerbal SexualHarassmentSexualAssaultSectorAcute care n = 2389 n = 2687 n = 2789 n = 1904 n = 409Patients 98.7% 94.3% 83.8% 87.5% 88.8%Family/Visitors 28.0% 56.7% 67.5% 23.1% 10.5%Physicians 2.1% 1.7% 27.8% 4.0% 1.0%Nursing co-workers 2.7% 1.9% 31.4% 3.5% 0.2%Allied health 0.5% 0.6% 4.6% 0.9% 0.5%Management 1.3% 1.3% 22.3% 0.7% 0.5%Other 0.6% 0.6% 1.5% 8.0% 10.5%Community care n = 233 n = 462 n = 559 n = 315 n = 29Patients 97.9% 90.5% 71.7% 90.5% 82.8%Family/Visitors 21.0% 40.3% 48.5% 20.6% 17.2%Physicians 2.6% 2.8% 14.5% 2.9% 0%Nursing co-workers 3.4% 5.2% 37.7% 3.2% 3.4%Allied health 1.3% 2.4% 7.2% 2.2% 3.4%Management 2.1% 2.8% 30.4% 1.3% 0%Other 1.7% 3.7% 3.9% 8.6% 17.2%Long-term care n = 339 n = 336 n = 333 n = 221 n = 62Patients 97.1% 95.2% 80.5% 88.2% 80.6%Family/Visitors 12.7% 33.0% 56.2% 11.3% 4.8%Physicians 1.5% 1.2% 10.2% 1.8% 1.6%Nursing co-workers 3.8% 6.2% 35.1% 10.0% 6.5%Allied health 1.2% 1.2% 8.1% 0.9% 0%Management 2.4% 1.8% 22.8% 1.4% 0%Other 2.1% 1.5% 3.3% 7.7% 14.5%Geographical areaUrban n = 1822 n = 2145 n = 2293 n = 1451 n = 302Patients 98.3% 93.1% 81.3% 86.9% 87.4%Family/Visitors 26.7% 52.3% 62.7% 21.0% 9.6%Physicians 2.0% 2.1% 23.9% 4.0% 0.3%Nursing co-workers 3.0% 2.8% 32.8% 5.0% 1.0%Allied health 0.6% 0.8% 5.9% 1.3% 0.3%Management 1.4% 1.6% 22.8% 0.9% 0.3%Other 0.9% 1.2% 2.0% 8.4% 12.3%Suburban n = 534 n = 611 n = 639 n = 442 n = 85Patients 98.7% 95.6% 83.9% 88.7% 85.9%Family/Visitors 27.7% 56.0% 68.9% 23.5% 11.8%Physicians 3.0% 0.7% 25.4% 2.9% 0%Nursing co-workers 3.4% 2.5% 31.6% 2.5% 2.4%Allied health 0.6% 0.8% 3.8% 1.1% 2.4%Management 2.6% 1.5% 24.3% 0.5% 0%Other 0.4% 0.5% 2.3% 8.6% 10.6%Rural n = 593 n = 716 n = 737 n = 539 n = 111Patients 98.7% 94.8% 80.6% 90.2% 88.3%Family/Visitors 20.9% 49.4% 61.6% 22.1% 10.8%Physicians 1.3% 2.1% 24.2% 3.5% 3.6%Nursing co-workers 2.2% 2.9% 33.5% 3.0% 0.9%Allied health 0.7% 1.1% 4.5% 0.6% 0%Management 0.8% 1.4% 25.6% 0.9% 0.9%Other 1.2% 1.1% 1.9% 6.7% 9.9%4. DiscussionWe found differences in the prevalence of various types and sources of workplace violence amongnurses across a variety of nursing roles and contexts. The most common types of workplace violencereported by BC nurses were emotional abuse, threats of assault and physical assault respectively.Previous research with BC nurses showed similar findings in that emotional abuse (37%), threatsof assault (22%) and physical assault (21%) were the most common types of workplace violenceHealthcare 2020, 8, 98 10 of 14respectively [4]. However, our data showed two to ten times higher proportions of all kinds of violencethan proportions reported by previous research. For example, while we found 85% of acute care nursesand 84% of direct care nurses reported exposure to emotional abuse in the last year, previous researchfound 37% of direct care nurses in acute care settings reported this type of workplace violence over thelast five shifts [4]. This difference is also notable among less common types of workplace violence suchas verbal sexual harassment (this study = 56%–58% vs. previous research = 8%) and sexual assault(this study = 12%–13% vs. previous research = 0.8%) [4].These data may represent actual increases in workplace violence against BC nurses since twodecades ago [4]. While different time frames were used to explore workplace violence in these studies,increased trends over time may also represent better detection and reporting. The provincial nurses’union started a province-wide campaign in 2017 with a view to battle the culture of normalization andraise awareness that violence is NOT part of nurses’ jobs [22].There were differences in the prevalence of workplace violence primarily across nursing roles andsectors. Compared to nurse educators, a higher proportion of direct care nurses and nurse leadersreported exposure to all types of workplace violence. This finding is interpreted in light of the studyfinding that identified patients and their families/visitors as the most common instigators of workplaceviolence. Direct care nurses are at the forefront of healthcare delivery providing the majority of patientcare with respect to care delivery hours and proximity. Accordingly, these nurses are a primary target ofpatient and family/visitor frustration when their needs are not met. A recent study found a link betweendirect care nurses’ heavy workloads and more frequent patient and family complaints escalating intoemotional and physical violence towards nurses [5]. Future research should examine the impact of thequality of patient care on workplace violence towards nurses. In addition, more exploration is neededabout violence against nurse leaders. There is a dearth of published research on violence against nursesin non-direct care roles. We surmise that a role of nurse leaders may be intervening in situations wherepatients/families are complaining about their nursing care, placing them at bedsides when emotions,such as anxiety and frustration, are escalating. Research shows staff nurses often manage workplaceviolence through the support of a colleague and a superior [23]. More specifically, this study foundone third of nursing victims discussed incidents with a superior following workplace violence [23].We suspect, leaders’ involvement in workplace violence management explains their higher report ofexposure found in this study. Future research should further explore nurse leaders’ experiences ofworkplace violence.Although increases in all types of violence are concerning, the rise in types of sexual violence froma decade ago is particularly worrisome. A meta-analysis of 41 studies identified an organizationalculture of tolerance as one of the most important predictors of sexual harassment. This findinghighlights the important role of organizations in preventing workplace violence particularly sexualviolence towards nurses [24]. This meta-analysis also found exposure to sexual harassment is linked topoor mental and physical health, life dissatisfaction and PTSD [24].Compared to community care nurses, a higher proportion of nurses in acute care and long-termcare sectors were exposed to workplace violence. This finding can be explained by the shorter patientand family/visitors contact in community care as opposed to the other two sectors. In acute care andlong-term care sectors, patients and their families/visitors typically have length of stays long enoughto recognize changes in quality of care imposed by work environment conditions such as staffingshortages, heavy workloads and long wait times [5,17,21]. Despite, differences in the conditions ofnurses’ works environments across geographical areas [18–20], we did not find statistically significantdifferences in the prevalence of most types of workplace violence across geographical areas. That said,the raw prevalence for most types of workplace violence was slightly higher in rural areas. Accordingly,we suspect that our study did not have sufficient power to detect smaller differences in the prevalenceof workplace violence. As discussed by previous workplace violence research, even small violenceexposure may have significant, adverse consequences [3,10].Healthcare 2020, 8, 98 11 of 14We also found acute care nurses that worked in emergency departments, psychiatric andmedical/surgical specialties reported the highest prevalence of almost all types of workplaceviolence. Earlier research identified these nursing specialties as high-risk areas [7,25,26]. However,there seems to be a shift in the pattern of workplace violence across nursing specialties. In this study,while the highest prevalence of physical assault, emotional abuse and verbal sexual harassment wasreported by emergency department nurses, the highest prevalence of sexual assault was reported bymedical-surgical nurses. Threats of assault were equally reported by emergency and psychiatry nurses.Previous research with BC nurses found the most common types of workplace violence as: physicalassault in medical-surgical specialties; threats of assault, verbal sexual harassment and sexual assaultin psychiatry; and emotional abuse in emergency departments [6].One potential explanation for shifting patterns of violence by nursing specialty may be the increasein patient complexities and care needs in under-resourced healthcare environments. One Australianstudy with hospital nurses found that different combinations of workplace factors (e.g., limitedresources, job demands) were predictive of specific types of aggression by patients and by colleagues [27].For example, increased job demands were associated with patient threats of assault. The researchersproposed that when nurses are pressured by heavy workloads, for example, they have less capacity torespond to patient needs, triggering assault threats [27].As an example, The Canadian Institute of Health Information database showed that in BC between2014 to 2019, patients experienced above the national average wait times in emergency departmentswhen compared to other provincial emergency department wait times [28]. Thus, the high prevalenceof workplace violence against BC nurses in emergency departments may be associated with frustratedpatients and families who must wait long hours for assessment and treatment. Additionally, patientsliving with mental health diagnosis and substance use disorders are one of the most frequent usersof emergency services [29]. Research shows the greatest safety and security concerns in emergencydepartments are dissatisfied patients and behavior health issues [30]. We would like to note, however,that more than half of nurses from ‘low-risk’ areas, such as critical care settings, reported exposure tocertain types of workplace violence, suggesting that nurse workplace violence has become a systemicproblem across BC acute care settings [31].Finally, this study found patients and their families were the most common perpetuators of almostall types of workplace violence towards nurses. Although, to our knowledge, this is the first studyto explore the prevalence of nurse workplace violence across a variety of nursing roles and contexts,previous national and international research reported similar findings among aggregate samples ofnurses [6,7]. We also found a relatively high prevalence of horizontal violence, particularly emotionalabuse, among nurses in a variety of roles and contexts. Surprisingly, nursing co-workers were identifiedas the most prominent source of emotional abuse by nurse educators, more so than patients and theirfamilies. While previous research also pointed to the phenomenon of bullying and horizontal violenceamong nurses [7,32–34], we think its high prevalence among educators is attributed to their significantinvolvement in training and educating their nursing colleagues.The findings of this study demonstrate an urgent need for more effective workplace violenceprevention initiatives that are role and context specific. In 2019, the House of Commons StandingCommittee on Health identified nine recommendations focused on minimizing and eradicatingworkplace violence among healthcare workers [1]. While some of these recommendations focusedon addressing the root causes of workplace violence, others emphasized the importance of existinginterventions to better protect the health and safety of healthcare workers and their clients [1]. A recentstudy of BC mental health and medical-surgical nurses found several of the existing interventionsare ineffective [31]. For example, prevention training and personal protective devices, also known aspersonal alarms, despite their prevalent use, did not positively contribute to nurses’ perceptions ofworkplace safety. Strategies that enhanced nurses’ perceptions of workplace safety were conversationswith leadership and engagement in collaborative problem-solving [31]. Thus, it is essential forleadership to engage staff nurses in policies, decisions and interventions to prevent workplaceHealthcare 2020, 8, 98 12 of 14violence. Researchers, health employers, policy makers and practitioners should work togethertowards evaluating and implementing interventions that better ensure workplace safety for nursesacross a variety of roles and contexts.LimitationsThis is the first province-wide study to explore the prevalence of various typologies and sources ofworkplace violence among nearly 4500 nurses across a variety of roles, sectors, geographical areas andnursing specialties. However, there are several limitations associated with this study. First, the studyresponse rate is low which raises concerns around sampling bias and external validity. Although ahigh response rate does not ensure representation and vice versa, the findings should be cautiouslygeneralized to other samples and contexts [21]. Second, workplace violence questions asked aboutexposures over the last year, which raises the possibility of recall bias. Third, responses to workplaceviolence exposure types were recoded into a binary, ignoring the variance in exposure frequency.Finally, due to the cross-sectional nature of the data, we cannot establish cause and effect betweenstudy variables.5. ConclusionsThis study found that the most common types of workplace violence were emotional abuse,threats of assault and physical assault respectively. For most nurses, patients and their families/visitorswere the most common instigators of workplace violence. There were differences in the prevalence ofvarious types of workplace violence across nursing roles, healthcare sectors and nursing specialties.Since research with data from two decades ago that examined workplace violence against BC nurses,there have been increases in all types of violence. These shifts may signal actual increases or betterdetection and reporting. These study findings will help inform workplace interventions that mitigaterisk to nurses and other healthcare providers. A premise of this survey study is that nurses are bestplaced to know what is working for them—or not. Nurses, therefore, should be involved in the designand implementation of workplace interventions suited to their specific contexts and patient populations.Author Contributions: Conceptualization, F.H.; methodology, F.H.; formal analysis, F.H. and A.M.; writing—originaldraft preparation, F.H.; writing—review and editing, F.H., M.M., and A.M.; supervision, F.H.; project administration,F.H. and M.M.; funding acquisition, F.H. All authors have read and agreed to the published version of the manuscript.Funding: This research was funded by the Social Sciences and Humanities Research Council of Canada,ORS #F19-04340.Acknowledgments: We would like to thank the British Columbia Nurses’ Union for their in-kind support ofthe study.Conflicts of Interest: The authors declare no conflict of interest. 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