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WORKPLACE VIOLENCE AGAINST NURSES WORKING IN EMERGENCY DEPARTMENTS AT PUBLIC HOSPITALS LAHORE Submitted by M Salman Ijaz SUPERVISOR

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WORKPLACE VIOLENCE AGAINST NURSES WORKING IN EMERGENCY DEPARTMENTS AT PUBLIC HOSPITALS LAHORE

Submitted by
M Salman Ijaz

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SUPERVISOR: AFSAR ALI
CO-SUPERVISOR: Ms. Naseem Rooman

______________________________________________________________________________
NATIONAL COLLEGE OF NURSING AFFILIATED WITH
THE UNIVERSITY OF LAHORE
ACADEMIC YEAR 2016-18

Table of Contents
Abstract 1
1. Introduction 2
1.1. Background 2
1.2. Problem Statement……………….………………………………………………………..3

1.3. Research Significance 4
1.4. Research Purpose 5
1.5. Research Objectives 5
1.6. Research Question 5
1.7. Operational definitions 6
Chapter 2 7
2. Literature Review 7
Chapter 3. Methodology 11
3.1. Research Design 11
3.2. Site 11
3.3. Setting 11
3.4. Population 12
3.5. Inclusion criteria 12
3.6. Exclusion criteria 12
3.7. Sampling method 15
3.8. Sample size 15
3.9. Data collection 13
3.10. Data Analysis 13
3.11. Ethical considerations 13
4. Results…………………………………………………………………………………………………..14
5. Discussion……………………………………………………………………………………………..35

6. Conclusion……………………………………………………………………………….…………….37

7. References 39
8.Inform consent and questionnaire 41

Dedication:

I would like to thank ALLAH supporting and helping me to complete this study.

This project work is dedicated to my parents and Teachers for their endless love, support and encouragement.

I am eternally grateful to my parents, who have supported and encouraged me to continue my studies. I appreciate the encouragement from my brothers sisters friends and my group members especially Anam khadim, Dilnesheen safdar, Sumera Rehman, Sehar Shabir and Kiran Akhter for their constant support.

Professionally I would like to extend my thanks for all assistance and support provided to me by my principal Naseem Roman my principal supervisor Afsar Ali my program coordinator Nosheen Noruddin the whole National College of nursing team and management and to the participants of research for their contribution and cooperation.

Acknowledgement:
I am highly thankful to Allah for giving me the strength and knowledge to carry out this research work. Without Allah’s blessings and providence it would not be possible to complete this research project successfully. After that I am grateful to my parents and family members who gave me enough courage and support to complete this work.
I am highly thankful to my supervisor (sir. Afsar Ali) and Co supervisor Ms. Naseem Rooman (the principal college of nursing NH ; MC) for their guidance and support
I am thankful to the entire Management of National college and hospital Lahore
I am thankful to the Management of UOL, Lahore school of nursing for their guidance in my studies
I am thankful to All Faculty of National CON

M Salman ijaz
Senior Elective Management
National College of Nursing
The University of Lahore

Abstract:
Work place violence is an alarming and devastating issue worldwide particularly in the emergency departments. Incident of work place violence is common towards nurses in health care settings. Nurses are more prone to workplace violence due to lack of respect towards nursing profession in Pakistani society and the nature of work performed by the nurses.
The main purpose of this study was to assess the prevalence of work place violence including physical and non physical and bring awareness about work place violence among nurses at the emergency departments of health care systems.
A cross sectional descriptive survey was performed to assess the prevalence of work place violence at tertiary care hospitals of Lahore. A convenient sample of n=147 was used to collect the data. A structured standardized adopted questionnaire was used to collect data. The questionnaire consisted demographic, physical and non physical variables. The data was collected from Jinnah and services hospital Lahore. The data was analyzed on SPSS version 21.
It was found that 77.55% stated that they are not exposed to physical violence last 12 months, 13.6% said once, 7.48% said 2-3 times and 1.3% stated they have been exposed 4-5 times during last year. On the other hand the participants exposed to Nonphysical violence in last 12 months,12.93% stated that they are not exposed to physical violence last 12 months, 25.85% said once, 40.82% said 2-3 times and 19.73% stated they have been exposed 4-5 times during last year.
Most recent physical incident in which 10.20% of incidents were happened at resuscitation room 2.04% at waiting room and 10.20% in treatment room. The most recent nonphysical incident in which 38.10% of incidents were happened at resuscitation room 0.68% in triage 12.24% at waiting room and 37.41% in treatment room 0.68% in other places.
It was also found that 2.04% incidents happened at morning shift 9.52% at evening 8.84% at night shift. Where as in nonphysical violence 11.56% incidents happened at morning shift 42.86% at evening 30.61% at night shift 3.40% participants was not sure about timing of the incident.

CHAPTER I: INTRODUCTION
1.1. Background:
Many countries of the world are encountered by Workplace physical violence almost in every field of employment which is a real matter of concern for (Blanchar, 2011). The prevalence of work place violence becomes a threat to employees’ safety, their dignity and causes lower wellbeing and thus the workers tend to become unhappy. Workplace violence appears among the leading threats to life and is considered as leading work place deaths among Us women workers. The lethal consequences of work place violence such as severe injuries have greater impact on life and cannot be underestimated by any state or country of the world (Boafo & Hancock, 2017).
Occupations such as Health care professions have even more severe consequences from work place violence which appears as a global phenomenon in terms of violence against health professionals at work place. It mainly encompasses verbal threats or abuse, physical assault among health care workers and sexual harassment etcetera. The verbal violence is reported the highest of all work place violence. Moreover, the Nurses face the work place violence more than any other health care discipline because they remain in more contact with patients and their families (Alameddine, Mourad, & Dimassi, 2015).
Some highlighted areas at the hospital are at greater risk of work place violence. These areas include the Psychiatric wards, emergency departments of the hospital, and sometimes high dependency units of health care systems. The occurrence of violence in the psychiatric wards and the emergency departments are reported in almost 100% in hospitals which is more than any other department in the hospital (Somani, 2012).
Workplace violence among nurses is defined as occurrence of some form of aggression such as physical aggression, sexual aggression, emotional or psychological threats against nurses, where the nurses are abused, assaulted, and threats in their work place circumstances. It is also claimed that workplace violence has very bad impact on the cost of any hospital in terms of increasing the financial burden which might reach up to 4.2 billion dollars annually(Somani, 2012).
It may also be defined as “Incidents of activities where the nurses are abused verbally, harassed sexually,or might face assaulted in their work place environment. This may challenge their safety and security, their health and wellbeing (Baydin & Erenler, 2014).The effects of work place violence is not limited to nurses only, rather it also have equal impact on doctors and other health care workers (Kowalenko, Hauff, Morden, & Smith, 2012).
Thls is recognized as high risk occupation which gaining more attention due to high occurrence of violent attacks on the working nurses. It was found by National Crime Victimization thatnon-fatal violence is about 21.9 per 1,000 among the nurses which is less in average than other profession (12.6 per 1,000 workers). The nurses of the emergency departments are the primary target of work place violence at every health care setup. In a previous study, conducted at the emergency departments, 82% of the nurses indicated that they have been assaulted in the last 12 months(May & Grubbs, 2002).
It is suggested that the incidence of verbal abuse is rising day by day and reaching almost 100% nurses at the emergency departments of many hospitals. The American Nurses Association found very few nurses are safe from the work place violence (Less than 20%). There is no support from the institutions to prevent violence among nurses which contributes to more dissatisfaction among them (Gacki-Smith et al., 2010).
Work place violence is very common everywhere in every hospital against nurses but it is on the top in low socioeconomic developing countries of the world. Pakistan is one of such countries having high incidence of work place violence among nurses at work environment. There is also another issue of poor reporting, lack of documentation and un- published status of such violence in the health care setups. Such high incidences of work place violence among nurses put the managements of different organizations in the challenging situations(Somani, 2012)
Health care workers’ especially nurses of the emergency departments may experience lots of workplace violence which may cause low satisfaction and poor performance among them (Hesketh et al., 2003). If there is no full performance of nurses due to unsafe environment, it will have direct impact on patients care outcomes and ultimately leads to ineffective and poor services of the hospitals (Kwok et al., 2006).
Despite of so many bad consequences of work place violence among nurses, it is still under reported and under rated issue. This lack of reporting may be because of fear, stigma and blame of being harassed. More seriously, the society might think that the nurses are made to bear such violence as part of their care that is why they are expected to tolerate it (Alameddine et al., 2015)
This paper presents workplace violence towards nurses as a major issue in the context of health care settings in Pakistan. Heresome characteristics of violence against the emergency nurses will be highlighted; some problems will be analyzed from different ethical professional and legal perspectives.Here some physical and psychological consequences of work place violence will be highlighted too.
1.2. Problem Statement:
Workplace violence among nurses is known to affect their job working environment, which may lead to decrease in their services at the emergency departments. Furthermore, the work place violence might be associated with physical and emotional imbalances among nurses at their duty. If the nurses are not balance physically and mentally, their care will not be according to standards, therefore there is need to identify the prevalence of violence, the types of violence at work place and also the measures to eliminate the high occurrence of work place violence among nurses.
1.3. Research Question:
1. What is the prevalence of violence against nurses working in the emergency departments of public tertiary hospitals Lahore?
2. What are the types of violence against nurses working in the emergency departments of public tertiary hospitals Lahore?
3. What are the contributing factors for workplace violence against nurses working in the emergency departments of public tertiary hospitals Lahore?
1.4. Significance:
Workplace violence is an issue of international health care among the workers at all departments of the health care systems but more sever at the emergency departments. Direct violence or indirect violence which may be physical or non-physical violence among nurses at the emergency departments might cause negative consequences in the future of nurses. If nurses of emergency department be aware of the types and causes of violence they can decrease the bad consequences and will avoid negative effect on the quality of health care providers and patients. The decrease in the productivity of nursing care will be minimized, negative impact on nurses whether it is physically or psychologically will be controlled. This may help the nurses to resolve violence related issues and continue a peaceful job life ahead.
1.5. Research Purpose:
The aim of this study is to bring awareness about work place violence among nurses at the emergency departments of health care systems. It will further reveal the issue of workplace violence after finding the prevalence at the emergency departments.
1.6. Objectives:
1. To assess the prevalence of violence against nurses working in the emergency departments of public tertiary hospitals Lahore
2. To identify the types of violence against nurses working in the emergency departments of public tertiary hospitals Lahore
3. To determine the contributing factors for workplace violence against nurses working in the emergency departments of public tertiary hospitals Lahore
1.7. Definitions:
a) Workplace Violence
Incidents where staff are abused, threatened or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being or health.
b) Physical violence:
It occurs when an employee is exposed to the deliberate use of force such as beating, pushing, slapping, and kicking, biting, pinching, stabbing, shooting by the patient and/or their families, a colleague or any others. Physical violence may lead to physical harm or emotional or sexual harm to the abused employee.
c) Verbal violence:
This happen when someone such as (patient, patients’ relatives, visitors, and coworkers) shout, curses or use other words to verbally insult the employee without an intention to bodily harm. For example someone yells at you. This includes any behavior towards an employee based on age, disability, gender, race, poverty, richness, or any other unwanted status which negatively influence the dignity of employee.
d) Sexual violence:
Any unwanted, unwelcomed and non-reciprocal sexual attention. It may include sexist remarks, behavior or sexual advances which results in a tense and unproductive environment. These forms of harassments/ abuse threaten the employees and cause them to feel humiliated.
1.8. Variables
Independent variable
Personal characteristic such as Gender, age, Marital status, experience and place of violence etcetera.
Dependent variables:
Prevalence of violence and Types of violence

Chapter II: Literature Review
Different literature studies are available regarding workplace violence among nurses. Here also some studies were found about workplace violence among nurses, workplace aggression of patients and families against nurses, violence against nurses at the emergency department and nurse’s perception of workplace violence at the emergency departments.
Workplace violence is the act which involves physical and nonphysical threats of assault affecting the nurses at their work places. Even verbal violence such as threats and verbal abuse against nurses, hostility for nurses, harassment against them can cause equal mental and psychological trauma to physical work place violence (Gomaa et al., 2015).
Study conducted by the Emergency Nurses Association (ENA), found that in the united states every year about nine hundred deaths occurs due to work place violence and around 1.7 million less life threatening assaults occur annually. This is still an unclear estimate of the severity of the work place violence. Further the Bureau of Labor and Statistic’s Survey conducted about the Occupational Injuries and violence found that the violence at work place among the health care workers is much higher than other profession (Albashtawy, 2013).
Emergency departments are working for 24 hours and have risks of much violence. Some situations like the lack of adequate training, physical security, lack of visible security guards and increased stress in the department make nurses of the emergency department more prone to work place violence. In a study 25% of the study participants at the emergency departments experience physical violence and around 20% stated verbal violence experience during last three years (Gacki-Smith et al., 2009).
Prevalence of Violence among nurses of Emergency Department:
A study assessed the prevalence of work place violence among the emergency nurses which was found that 44.6% nurses during the last year have experienced work place violence. Furthermore verbal abuse was found the most common work place violence. The physical and sexual assault were less in number as compare to verbal violence. Many nurses have experienced a combination of physical and nonphysical violence both. The work place violence was mostly caused by the patients, then the relatives and colleagues while least violence was recorded from supervisors’ side. Almost half of the nurses said that the violence they have experienced was preventable with proper care. Moreover all the nurses mentioned few management techniques for work place violence such as discussing with colleagues, reporting to the immediate supervisors, and confronting to the perpetrator of violence etcetera (Cheung ; Yip, 2017).
Another study also conducted among health care workers to assess the work place violence among them. It was found that about 60% of the study participants, who were working at the emergency departments exposed to violence during their duty in the last one year. A total of 65.7% nurses exposed to verbal violence at their work place. Majority of the HCW 61% were females who got affected by violence. The occurrence of violence was found different in different individuals. Some experienced work place violence very frequently, other faced it once a month etcetera. The violence from patients relative was found at the top (89.7% of verbal violence) and for 90.5% of physical violence. Verbal violence mostly found in the evening shift (Abdellah ; Salama, 2017).
Types of Violence among ER Nurses:
Some commonest physical violence types were experienced by more than 50% nurses were, they were being spit on, pushed by patients or relatives, scratched and being kicked. Among the verbal violence, the most common (70%) was yelling from patients and their families, intimidated and being harassed with sexually abusive language. The perception of safety was found very low and about 70% participants showed less than 50% safety perception. About 33% participants were in favor of leaving emergency department due to increased work place violence (Gacki-Smith et al., 2010).
Findings of another study reveals that incidence of verbal violence was (63.9%), which was almost five times more than physical violence (11.9%) at the emergency department among nurses in the last 12 months of period. Verbal violence at the emergency department was mainly by the patients against nurses then secondly by their family members and relatives. The rate of physical violence was also high from patients and their family members. Afternoon shift was found to have more work place violence at the emergency departments due to increased patients inflow (Albashtawy, 2013).
According to another study verbal violence was found among the 86% of nurses at the emergency departments. Threats were also found high among the (35%) of the study participants. Physical abuse was also found among the nurses from the patients and their families but it was lower than that of verbal assault. No difference of violence exposure was found between males and females or based on the specialty such as medical and surgical. However very few respondents were from emergency to have a meaningful comparison (Imran, Pervez, Farooq, ; Asghar, 2013).
Contributing factors for Work Place violence:
Patients relatives were overall the most common source of work place violence among the emergency department nurses (71%) followed by patients (30.5%). Results also showed that there are other various aspects of work place violence caused by colleagues, supervisors also (Imran et al., 2013).It is observed that there are under reported may be due to feeling of uncomforted and lack of support from the organization. There is also lack of a well-structured reporting system for work place violence in many health care organizations. It is very important to identify the contributing factors for work place violence (Somani, 2012).
It is very clear from previous studies that the major contributor of workplace violence among nurses at the emergency department was found patients which is followed by the relatives of the patients. Along with patients and their relatives, the nursing colleagues, senior nurses, the manager nurses, and on duty doctors also are the contributing factors for work place violence among the emergency department nurses (Kwok et al., 2006).
According to another study, workplace physical violence against the emergency department nurses was perpetrated mainly by patients followed by their relatives and then by other nurses. The results of the study found that relatives of patients were the most frequent contributors of physical violence against the emergency department nurses. They were responsible for a large number of cases (58.5%)(Boafo ; Hancock, 2017).

CHAPTER III: METHODOLOGY
3.1. Research Design:
A descriptive cross-sectional study design was used to conduct this study. Data about the violence against emergency department nurses was collected at one point in time with the help of a questionnaire.
3.2. Time Period:
This study was conducted from February 2018 to May 2018 for about 4 months period of time.
3.3. Site and setting of the study:
This study was conducted among the nurses at the Emergency Departments of two public tertiary care hospitals Lahore. They are the Jinnah Hospital Lahore and Services Hospital Lahore.
3.4. Population:
The study was conducted among the nurses. The population for this study was all nurses who are working in emergency departments of the selected hospitals, the Jinnah Hospital and the Services Hospital Lahore.
3.5. Sample size Determination
The minimum sample required is calculated using the single proportion formula which is given below.
? = ?2(1 ? ?) /?2
d= Acceptable margin of error (precision of measurement) = 5%
z= Standard variant (1.96) which correspond to 95% confidence level
p= Overall prevalence of workplace violence among nurses in public health facilities in
Nazish Imran2013 (73%).
(1.96)2 0.73 (1?0.73) /(0.05)2 =
(1.96)2 0.73 (1?0.73) /(0.05)2 =
3.8416* 0.73 (0.27) /(0.0025)=
2.804* 108 = 302
Since the total number of study population is ; 10,000 (N=400) using the correction formula the final sample size will benf = ???/ ?+?
400?302 /400+302 = 147
120,800 /702 = 147
3.6. Sampling procedure
Sampled will be selected from the emergency departments of two public hospitals through convenient sampling methods. N=75 will be selected from Jinnah Hospital while remaining 72 nurses will be selected from services hospital emergency department.
3.7. Inclusion criteria
All nurses from the emergency departments were recruited who were:
1. Willing to participate in the study
2. Working in emergency department at least one year
3. Registered with Pakistan Nursing council
3.8. Exclusion criteria
Those nurses will not be recruited who are:
1. All nurses who were not at work place during data collection period
2. Those who were not willing and not registered
3.9. Data collection tool
A self-administered standardized adopted questionnaire was used to collect the data. The questionnaire adopted from a study ‘Work place violence against nurses working in the emergency department of in Saudi Arabia’ by Fuaad Ali Alshehri(Albashtawy, 2013).
The first section of the questionnaire consisted off the demographic information about the age, gender, education and working experience of the participants. The second and third parts of the questionnaire discussed the physical and nonphysical violence among nurses at the emergency departments. The participants of the study were asked to fill the questionnaire of work place violence.
3.10. Data processing, Analysis and presentation
The data was put into the SPSS version 21. The results were processed and analyzed with the help of graphs, tables in the form of frequencies, averages and percentages.
3.11. Ethical Consideration
An approval was taken from the committee of national college of nursing. Then permission was taken from the heads of the study setting such as Head of Jinnah hospital and Head of the services Hospital. A written permission was taken from each individual participant of the study. Each participant was provided with the questionnaire with an informed consent which was explained the purposes and significance of the study. The study participants were assured that their names will be kept confidential. Their participation was fully volunteer and can withdraw at any time.

CHAPTER IV: RESULTS

4.1 Demographic data analysis and results

The below table shows about the gender of participants that were 6.80% were male and 93.20% was female. Result also shows the age of the participants of study from which 10.20% were less than 25 years ; 53.06% were between 26 to 30 years 27.89% were between the age of 31 to 35 years 6.12% were between the age of 36 to 40 years and 2.72% participants of study were more than 40 years of age. It was also found that the education level of the study participants from which 19.05% were only have general nursing diploma 40.14% of study participants having specialization as well 40.82% have the degree of generic BSN and post RN BSN degree.
Table 1: Frequency and percentage of demographics data

Variables Number (n) Per cent
Gender
Male
Female
10
137
6.8
93.2
Age:
Less than 25 years
26-30 years
31-35 years
36-40 years
Above 40 years
15
78
41
9
4
10.2
53.1
27.9
6.1
2.7
Education:
Nursing Diploma
Diploma plus specialization
BSN/PRN BSN
MSN/MPH
28
59
60

19.0
40.1
40.8

Experience
77
51
15
4

52.4
34.7
10.2
2.7

1-5 years
6-10 years
11-15 years
Above 15years

4.2: DESCRIPTIVE ANALYSIS OF PHYSICAL AND NONPHYSICAL VIOLENCE
Below Table 2 shows that in response for how many times the participants exposed to physical violence in last 12 months. It was found that 77.55% stated that they are not exposed to physical violence last 12 months, 13.6% said once, 7.48% said 2-3 times and 1.3% stated they have been exposed 4-5 times during last year. On the other hand the participants exposed to Nonphysical violence in last 12 months,12.93% stated that they are not exposed to physical violence last 12 months, 25.85% said once, 40.82% said 2-3 times and 19.73% stated they have been exposed 4-5 times during last year. The type of physical assault the study participants was asked and 4.08% of participants had experience beating, 9.52% experience pushing, 6.12% of study participants had experience slapping, 1.36% pinching, 1.36% shooting, and not applicable for 77.55% of study participants. Similarly about types of nonphysical assault the study participants were exposed to, 50.34% of participants had experience threats, 36.05% experience verbal abuse and 2.04% of study participants had experience sexual harassment/abuse. Regarding the physical assaulters to staff from which 8.16% were patients, 13.61% were relatives of patients, 0.68% were coworkers of the staff and not applicable for 77.55% participants. About the assaulters of nonphysical at staff from which 19.73% were patients, 63.27% were relatives of patients, 5.44% were coworkers of the staff and not applicable for 11.56% participants. It was also found that 2.04% incidents happened at morning shift 9.52% at evening 8.84% at night shift and not applicable for 77.55% of study participants in terms of physical violence. Where as in nonphysical violence 11.56% incidents happened at morning shift 42.86% at evening 30.61% at night shift 3.40% participants was not sure about timing of the incident and not applicable for 11.56% of study participants.

Most recent physical incident in which 10.20% of incidents were happened at resuscitation room 2.04% at waiting room and 10.20% in treatment room and this question was not applicable for 77.55% of participants. The most recent nonphysical incident in which 38.10% of incidents were happened at resuscitation room 0.68% in triage 12.24% at waiting room and 37.41% in treatment room 0.68% in other places and this question was not applicable for 10.88% of participants.
Furthermore to physical violence 1.36% said yes received treatment, 12.24% not need, 2.04% not received and 6.80% self-treated and this question was not applicable for 77.55% of study participants. Similarly in nonphysical violence, 0.68% said yes received treatment, 68.71% no need, 3.40% not received and 15.65% self-treated. Result also shows that percentage by whom physical violence victim was treated 6.12% was treated by nurse 16.33% not treated and not applicable for 77.55% of study participants. It was also found in nonphysical violence that victim was treated 10.20 % was treated by nurse, 0.68% by psychiatrist, 0.68% by others 76.87% not treated and not applicable for 11.56% of study participants. The Findings also show the percentage of the cause of most recent incident from which 12.93% of participants said that it was due to waiting for services 5.44% was unable to meet patients desire 2.72% was due to unavailability of services 1.36 % was due to lack of preventive tools and not applicable for 77.55% of study participants. The cause of most recent nonphysical incidents from which 24.49% of participants said that it was due to waiting for services 13.61% was unable to meet patients desire 6.12% was due to mental illness 1.36% was due to way of dealing with patients 29.25% was due to unavailability of services 8.84 % was due to lack of preventive tools 4.76% said that it was due to impact of disease or pain and not applicable for 11.56% of study participants.

(Table 2) Frequency and percentage of the Violence

Variables Physical Violence Non-Physical Violence

Number of Time Being exposed Number(n) Percent Number(n) Percent
Never
Once
2-3 Times
4-5 times
6 times 114
20
11
2
00 77.6
13.6
7.5
1.4
00 19
38
60
29
01 12.9
25.9
40.8
19.7
.7
Who Assaulted
Patients
Visitors/Patients’ relatives
Co-workers
Not applicable 12
20
1
114 8.2
13.6
.7
77.6 29
93
8
17 19.7
63.3
5.4
11.6
When the Incidence Happened?
Morning
Afternoon
Night
Unsure
Not applicable 3
14
13
3
114 2.0
9.5
8.8
2.0
77.6 17
63
45
5
17 11.6
42.9
30.6
3.4
11.6
Where the incidence happened?
Resuscitation
Waiting Room
Triage
Treatment
Hallway
Not applicable 15
3
0
15
0
114 10.2
2.0
0
10.2
0
77.6 56
18
1
55
0
18 38.1
12.2
.7
37.4
0
10.9
Receiving treatment after the incident
Yes, received
There was no need
Needed but did not received
Self treated
Not applicable 2
18
3
10
114 1.4
12.2
2.0
6.8
77.6 1
101
5
23
17 .7
68.7
3.4
15.6
11.6
Who treated?
Doctors
Psychiatrist
Nurse
Not treated
Not applicable 0
0
9
24
114 0
0
6.1
16.3
77.6 0
1
15
113
17 0
.7
10.2
76.9
11.6
The causes of most Recent Incident
Waiting for receiving services
Failure to meet patients’ desire
Mental illness
Way of dealing the patients
Unavailability of the services
Fear stress
Lack of preventive tools
Impact of disease or pain
Not applicable 19
8
0
0
4
0
2
0
114 12.9
5.4
0
0
2.7
0
1.4
0
77.6 36
20
9
2
43
0
13
7
17 24.5
13.6
6.1
1.4
29.3
0
8.8
4.8
11.6

4.3: Summary of Physical and Nonphysical Violence:

The following Table 3 suggests that 4.1% of the study participants had Beating experience, 9.5% experienced pushing, 6.9% faced slapping, no kicking or biting was found, pinching and shooting was 1.4% each, while the rest of 77% had no experienced of physical violence.

Table 3: Summary of Physical Violence

Variable Category
Type of physical Violence N %
Beating
Pushing
Slapping
Kicking
Biting
Pinching
Shooting
Stabbing
Not applicable 6
14
9
0
0
2
2
0
114 4.1
9.5
6.1
0
0
1.4
1.4
0
77.6

The following Table 4 findings indicate thatabout 50.3% of the study participants had faced threats as nonphysical violence, 36.1% experienced Verbal abuse/Harassment, while 2% have experience Sexual Abuse/Harassment and 11.6% faced no any nonphysical violence during last 1 year.

Table 4: Summary of Nonphysical Violence

Variable Category
Type of Nonphysical Assault N %
Threats
Verbal abuse/Harassment
Sexual Abuse/Harassment
Not applicable 74
53
3
17 50.3
36.1
2.0
11.6

4.3.2: Descriptive analysis of Physical Violence
How many times have you been exposed to physical violence during the last 12 months?
Frequency Percent Valid Percent Cumulative Percent
Valid Never 114 77.6 77.6 77.6
Once 20 13.6 13.6 91.2
2-3times 11 7.5 7.5 98.6
4-5 times 2 1.4 1.4 100.0
Total 147 100.0 100.0

The above table and Graph shows that in response for how many times the participants exposed to physical violence in last 12 months. It was found that 77.55% stated that they are not exposed to physical violence last 12 months, 13.6% said once, 7.48% said 2-3 times and 1.3% stated they have been exposed 4-5 times during last years.

What type of physical assault were you exposed to during the most recent incidence?
Frequency Percent Valid Percent Cumulative Percent
Valid Beating 6 4.1 4.1 4.1
Pushing 14 9.5 9.5 13.6
Slaping 9 6.1 6.1 19.7
Pinching 2 1.4 1.4 21.1
Shooting 2 1.4 1.4 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph shows the type of physical assault the study participants were exposed to in which 4.08% of participants had experience beating 9.52% experience pushing 6.12% of study participants had experience slapping 1.36% pinching 1.36% shooting and not applicable for 77.55% of study participants.

In the most recent physical incident who assault you?
Frequency Percent Valid Percent Cumulative Percent
Valid Patients 12 8.2 8.2 8.2
Relatives 20 13.6 13.6 21.8
Co-Workers 1 .7 .7 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph show the percentage of physical assaulters to staff from which 8.16% were patients 13.61% were relatives of patients 0.68% were coworkers of the staff and not applicable for 77.55% participants.

In the most recent physical incident when did the incident happened?
Frequency Percent Valid Percent Cumulative Percent
Valid Morning 3 2.0 2.0 2.0
Afternoon 14 9.5 9.5 11.6
Night 13 8.8 8.8 20.4
Not sure 3 2.0 2.0 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph show the timing of physical incident from which 2.04% incidents happened at morning shift 9.52% at evening 8.84% at night shift and not applicable for 77.55% of study participants.

In the most recent physical incident where did the incident happened?
Frequency Percent Valid Percent Cumulative Percent
Valid Resuscitation 15 10.2 10.2 10.2
Waiting room 3 2.0 2.0 12.2
Treatment room 15 10.2 10.2 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph shows the location of most recent incident in which 10.20% of incidents were happened at resuscitation room 2.04% at waiting room and 10.20% in treatment room and this question was not applicable for 77.55% of participants.

Did you receive treatment after the most recent incident?
Frequency Percent Valid Percent Cumulative Percent
Valid Yes received 2 1.4 1.4 1.4
No need 18 12.2 12.2 13.6
Not received 3 2.0 2.0 15.6
Self treated 10 6.8 6.8 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph shows the percentage of study participants who receive or didn’t receive the treatment after most recent physical incident in which 1.36% said yes received 12.24% no need 2.04% not received and 6.80% self treated and this question was not applicable for 77.55% of study participants.

If yes who treated You?
Frequency Percent Valid Percent Cumulative Percent
Valid Nurse 9 6.1 6.1 6.1
Not treated 24 16.3 16.3 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph shows the percentage by whom physical violence victim was treated 6.12% was treated by nurse 16.33% not treated and not applicable for 77.55% of study participants.

What do you think was the cause of the most recent incidence?
Frequency Percent Valid Percent Cumulative Percent
Valid Waiting for services 19 12.9 12.9 12.9
not meeting patients' desire 8 5.4 5.4 18.4
Unavailability of the services 4 2.7 2.7 21.1
Lack of preventive tools 2 1.4 1.4 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph shows the percentage of the cause of most recent incident from which 12.93% of participants said that it was due to waiting for services 5.44% was unable to meet patients desire 2.72% was due to unavailability of services 1.36 % was due to lack of preventive tools and not applicable for 77.55% of study participants.

4.3.2: Descriptive analysis of Nonphysical Violence:

How many times have you been exposed to Non-physical violence during the last 12 months?

Frequency Percent Valid Percent Cumulative Percent
Valid Never 19 12.9 12.9 12.9
Once 38 25.9 25.9 38.8
2-3times 60 40.8 40.8 79.6
4-5 times 29 19.7 19.7 99.3
6 or more times 1 .7 .7 100.0
Total 147 100.0 100.0

The above table and Graph shows that in response for how many times the participants exposed to physical violence in last 12 months. It was found that 12.93% stated that they are not exposed to physical violence last 12 months, 25.85% said once, 40.82% said 2-3 times and 19.73% stated they have been exposed 4-5 times during last year.

What type of non-physical assault were you exposed to during the most recent incidence?

Frequency Percent Valid Percent Cumulative Percent
Valid Threats 74 50.3 50.3 50.3
Verbal abuse/Harassment 53 36.1 36.1 86.4
Sexual abuse 3 2.0 2.0 88.4
Not applicale 17 11.6 11.6 100.0
Total 147 100.0 100.0

The above table and graph shows the type of non physical assault the study participants were exposed to in which 50.34% of participants had experience threats 36.05% experience verbal abuse and 2.04% of study participants had experience sexual harassment/abuse and not applicable for 11.56% of study participants.

In the most recent nonphysical incident who assault you?
Frequency Percent Valid Percent Cumulative Percent
Valid Patients 29 19.7 19.7 19.7
Relatives 93 63.3 63.3 83.0
Co-Workers 8 5.4 5.4 88.4
Not applicable 17 11.6 11.6 100.0
Total 147 100.0 100.0

The above table and graph show the percentage of non physical assaulters to staff from which 19.73% were patients 63.27% were relatives of patients 5.44% were coworkers of the staff and not applicable for 11.56% participants.

In the most recent nonphysical incident when did the incident happened?
Frequency Percent Valid Percent Cumulative Percent
Valid Morning 17 11.6 11.6 11.6
Afternoon 63 42.9 42.9 54.4
Night 45 30.6 30.6 85.0
Not sure 5 3.4 3.4 88.4
Not applicable 17 11.6 11.6 100.0
Total 147 100.0 100.0

The above table and graph show the timing of physical incident from which 11.56% incidents happened at morning shift 42.86% at evening 30.61% at night shift 3.40% participants was not sure about timing of the incident and not applicable for 11.56% of study participants.

In the most recent nonphysical incident where did the incident happened?
Frequency Percent Valid Percent Cumulative Percent
Valid Resuscitation 56 38.1 38.1 38.1
Triage 1 .7 .7 38.8
Waiting room 18 12.2 12.2 51.0
Treatment room 55 37.4 37.4 88.4
Others 1 .7 .7 89.1
Not applicable 16 10.9 10.9 100.0
Total 147 100.0 100.0

The above table and graph shows the location of most recent incident in which 38.10% of incidents were happened at resuscitation room 0.68% in triage 12.24% at waiting room and 37.41% in treatment room 0.68% in other places and this question was not applicable for 10.88% of participants.

Did you receive treatment after the most recent incident?

Frequency Percent Valid Percent Cumulative Percent
Valid Yes received 1 .7 .7 .7
No need 101 68.7 68.7 69.4
Not received 5 3.4 3.4 72.8
Self treated 23 15.6 15.6 88.4
Not applicable 17 11.6 11.6 100.0
Total 147 100.0 100.0

The above table and graph shows the percentage of study participants who receive or didn’t receive the treatment after most recent non physical incident in which 0.68% said yes received 68.71% no need 3.40% not received and 15.65% self treated and this question was not applicable for 11.56% of study participants.

If yes who treated You?

Frequency Percent Valid Percent Cumulative Percent
Valid Nurse 15 10.2 10.2 10.2
Psychiatristist 1 .7 .7 10.9
Others 1 .7 .7 11.6
Not treated 113 76.9 76.9 88.4
Not applicable 17 11.6 11.6 100.0
Total 147 100.0 100.0

The above table and graph shows the percentage by whom physical violence victim was treated 10.20 % was treated by nurse 0.68% by psychiatrist 0.68% by others 76.87% not treated and not applicable for 11.56% of study participants.

What do you think was the cause of the most recent incidence?

Frequency Percent Valid Percent Cumulative Percent
Valid Waiting for services 36 24.5 24.5 24.5
not meeting patients' desire 20 13.6 13.6 38.1
Mental illness 9 6.1 6.1 44.2
Way of dealing the patients 2 1.4 1.4 45.6
Unavailability of the services 43 29.3 29.3 74.8
Lack of preventive tools 13 8.8 8.8 83.7
Impact of disease or pain 7 4.8 4.8 88.4
Not appicable 17 11.6 11.6 100.0
Total 147 100.0 100.0

The above table and graph shows the percentage of the cause of most recent incident from which 24.49% of participants said that it was due to waiting for services 13.61% was unable to meet patients desire 6.12% was due to mental illness 1.36% was due to way of dealing with patients 29.25% was due to unavailability of services 8.84 % was due to lack of preventive tools 4.76% said that it was due to impact of disease or pain and not applicable for 11.56% of study participants.

Chapter 5: Discussion
This current study found that physical violence was about 22.5% where 4.1% of the study participants had Beating experience, 9.5% experienced pushing, 6.9% faced slapping and pinching and shooting was 1.4% each, while the rest of 77.5% had not experienced of physical violence. The prevalence of nonphysical violence was found about 88.4% where 50.3% of the study participants had faced threats as nonphysical violence, 36.1% experienced Verbal abuse/Harassment, while 2% have experience Sexual Abuse/Harassment and 11.6% faced no any nonphysical violence during last 1 year.
According to a previous study the verbal violence was found among the 86% of nurses at the emergency departments. Physical abuse was also found among the nurses from the patients and their families but it was lower than that of verbal assault. No difference of violence exposure was found between males and females or based on the specialty such as medical and surgical. However very few respondents were from emergency to have a meaningful comparison (Imran et al., 2013).
Similarly Findings of another study reveals that incidence of verbal violence was (63.9%), which was almost five times more than physical violence (11.9%) at the emergency department among nurses in the last 12 months of period (Albashtawy, 2013).
A previous study found some similar findings where nonphysical abuse was found the most common work place violence. The physical and sexual assault were less in number as compare to verbal violence (Cheung ; Yip, 2017). According to another study, a total of 65.7% nurses exposed to nonphysical violence at their work place (Abdellah ; Salama, 2017).
During my study the physical violence was mainly 13.61% were from relatives of patients (out of 22%), which becomes almost half the violence.
Similarly, in a previous study, violence from patients relative was found at the top (89.7% of verbal violence) and for 90.5% of physical violence. Verbal violence mostly found in the evening shift (Abdellah ; Salama, 2017).
According to this study most common violence were 4.08% of participants had experience beating, 9.52% experience pushing, 6.12% of study participants had experience slapping, 1.36% pinching, 1.36% shooting and not applicable for 77.55% of study participants.
According to previous study some commonest physical violence types were experienced by more than 50% nurses were, they were being spit on, pushed by patients or relatives, scratched and being kicked (Gacki-Smith et al., 2010).
According to this current study, the type of nonphysical assault the study participants were exposed to in which 50.34% of participants had experience threats 36.05% experience verbal abuse and 2.04% of study participants had experience sexual harassment/abuse and not applicable for 11.56% of study participants. Previously, among the verbal violence, the most common (70%) was yelling from patients and their families, intimidated and being harassed with sexually abusive language. (Gacki-Smith et al., 2010). According to another study, threats were also found high among the (35%) of the study participants (Imran et al., 2013).

Chapter 6: Conclusion

Conclusion
The purpose of this study was to assess the prevalence of work place violence and types of physical and non physical violence in the public hospitals of Lahore. The emergency nurses during study indicated that violence was a common occurrence.
It was found that 77.55% stated that they are not exposed to physical violence last 12 months, 13.6% said once, 7.48% said 2-3 times and 1.3% stated they have been exposed 4-5 times during last year. On the other hand the participants exposed to Nonphysical violence in last 12 months,12.93% stated that they are not exposed to physical violence last 12 months, 25.85% said once, 40.82% said 2-3 times and 19.73% stated they have been exposed 4-5 times during last year.
Most recent physical incident in which 10.20% of incidents were happened at resuscitation room 2.04% at waiting room and 10.20% in treatment room. The most recent nonphysical incident in which 38.10% of incidents were happened at resuscitation room 0.68% in triage 12.24% at waiting room and 37.41% in treatment room 0.68% in other places.
It was also found that 2.04% incidents happened at morning shift 9.52% at evening 8.84% at night shift. Where as in nonphysical violence 11.56% incidents happened at morning shift 42.86% at evening 30.61% at night shift 3.40% participants was not sure about timing of the incident.

Recommendations
This study addressed several areas requiring further research. There is a shortage of violence research among emergency nurses in Lahore. Further research is needed to develop strategies for preventing violence against emergency nurses, which would need to consider the local culture and findings of this study. Further in depth research is needed to assess the impact of violence on the perception and professional life of emergency nurses.

Limitations
This was my first research study so due to lack of expertise there are some limitations.it may be better if I can relate different kind of professional, environmental and cultural factors affecting work place violence in my study, but due to lack of time and less expertise I was unable to do that. Hopefully it will be better in my next studies.

REFERENCES:
Abdellah, R. F., ; Salama, K. M. (2017). Prevalence and risk factors of workplace violence against health care workers in emergency department in Ismailia, Egypt. Pan African Medical Journal, 26(1), 1-8.
Al Shameri, F. Critical Care Nurse’s Knowledge of Ventilator-Associated Pneumonia Prevention in Selected Hospitals, Khartoum.
Alameddine, M., Mourad, Y., & Dimassi, H. (2015). A national study on nurses’ exposure to occupational violence in Lebanon: prevalence, consequences and associated factors. PLoS ONE, 10(9), e0137105.
Albashtawy, M. (2013). Workplace violence against nurses in emergency departments in Jordan. International nursing review, 60(4), 550-555.
Baydin, A., ; Erenler, A. K. (2014). Workplace violence in emergency department and its effects on emergency staff. Int J Emerg Ment Health, 16(2), 288-290.
Blanchar, Y. (2011). Violence in the health care sector: a global issue. World Medical Journal, 57(3), 87-89.
Boafo, I. M., ; Hancock, P. (2017). Workplace violence against nurses: a cross-sectional descriptive study of Ghanaian nurses. SAGE Open, 7(1), 2158244017701187.
Cheung, T., ; Yip, P. S. (2017). Workplace violence towards nurses in Hong Kong: prevalence and correlates. BMC Public Health, 17(1), 196.
Gacki-Smith, J., Juarez, A. M., Boyett, L., Homeyer, C., Robinson, L., ; MacLean, S. L. (2009). Violence against nurses working in US emergency departments. Journal of Nursing Administration, 39(7/8), 340-349.
Gacki-Smith, J., Juarez, A. M., Boyett, L., Homeyer, C., Robinson, L., ; MacLean, S. L. (2010). Violence against nurses working in US emergency departments. Journal of healthcare protection management: publication of the International Association for Hospital Security, 26(1), 81-99.
Gomaa, A. E., Tapp, L. C., Luckhaupt, S. E., Vanoli, K., Sarmiento, R. F., Raudabaugh, W. M., . . . Sprigg, S. M. (2015). Occupational traumatic injuries among workers in health care facilities—United States, 2012–2014. MMWR. Morbidity and mortality weekly report, 64(15), 405.
Hesketh, K. L., Duncan, S. M., Estabrooks, C. A., Reimer, M. A., Giovannetti, P., Hyndman, K., ; Acorn, S. (2003). Workplace violence in Alberta and British Columbia hospitals. Health policy, 63(3), 311-321.
Imran, N., Pervez, M. H., Farooq, R., ; Asghar, A. R. (2013). Aggression and violence towards medical doctors and nurses in a public health care facility in Lahore, Pakistan: A preliminary investigation. Khyber Medical University Journal, 5(4), 179-184.
Kowalenko, T., Hauff, S. R., Morden, P. C., ; Smith, B. (2012). Development of a data collection instrument for violent patient encounters against healthcare workers. Western journal of emergency medicine, 13(5), 429.
Kwok, R., Law, Y., Li, K., Ng, Y., Cheung, M., Fung, V., . . . Leung, W.-C. (2006). Prevalence of workplace violence against nurses in Hong Kong. Hong Kong Medical Journal.
May, D. D., ; Grubbs, L. M. (2002). The extent, nature, and precipitating factors of nurse assault among three groups of registered nurses in a regional medical center. Journal of emergency nursing, 28(1), 11-17.
Somani, R. K. (2012). Workplace violence towards nurses: A reality from the Pakistani context. Journal of Nursing Education and Practice, 2(3), 148.

Informed consent:

Workplace violence against nurses working in emergency departments at a public hospital Lahore

Dear participants,
I am Salman Ijaz, want to conduct a research on “Workplace violence against nurses working in emergency departments at a public hospital Lahore”. As this Research project work for the fulfillment of my Post RN BSN degree from National College of Nursing, affiliated with the University of Lahore. The purpose of this research study is to assess the Workplace violence against nurses working in emergency departments at a public hospital Lahore.A questionnaire will be distributed for data collection, for which your cooperation is required. The questionnaire will take about 20-30 minutes to complete. Your participation will be very helpful for me to complete my study. Your valued information will be kept confidential. You are allowed to withdraw at any time from research study.
I have read all the terms and voluntarily consent to participate in the research study.

Participant's Signature:………………………..
Date: ………………………….

Questionnaire:

Workplace Violence against nurses working in emergency departments at a Public Hospital Lahore
Section 1: Demographic Data:

1. Gender:

1. Male ( ) 2. Female ( )

2. Age in Years:

1.Below 25 ( ) 2. 26-30 ( ) 3. 31-35 ( ) 4. 36-40 ( ) 5. above 40 ( )

3. Education:

1. Diploma GN ( ) 2. Specialization ( ) 3. BSN/Post RN ( ) 4.MSN ( )

4. Experience:

1.1-5 years ( ) 2. 6-10 years ( ) 3. 11-15 Years ( ) 4. Above 15 years ( )

Section 2: Physical Violence:

s. No Statement Options
1 How many times have you been exposed to physical violence during the last 12 months? Never
Once

2-3
4-5

6 or more times
2 What type of physical assault were you exposed to during the most recent incidence? Beating
Pushing
Slapping

Kicking
Biting
Pinching

Shooting
Stabbing
Others

3 In the most recent physical incident who assault you? Patients
Relatives

Coworkers
Others ______

4 In the most recent physical incident when did the incident happened? Morning
Afternoon

Night
Not sure

5 Where did the most recent incident happen? Resuscitation
Triage

Waiting Room
Treatment room

Other specify ______

6 Did you receive treatment after the most recent incident? Yes received
No Need

Did Not receive
Self-treated

7 If yes who treated You? Doctors
Nurse

Psychiatrist
Others

Not treated

8 What do you think was the cause of the most recent incidence? Waiting for receiving services

Failure to meet patients’ desire

Mental illness

Way of dealing the patients

Unavailability of the services

Fear stress

Lack of preventive tools

Impact of disease or pain

Section 3: Non Physical Violence:

s. No Statement Options
1 How many times have you been exposed to Non-physical violence during the last 12 months? Never
Once

2-3
4-5

6 or more times
2 What type of physical assault were you exposed to during the most recent incidence? Threats

Verbal abuse/Harassment

Sexual abuse Harassment

3 In the most recent physical incident who assault you? Patients
Relatives

Coworkers
Others ______

4 In the most recent physical incident when did the incident happened? Morning
Afternoon

Night
Not sure

5. Where did the most recent incident happen? Resuscitation
Triage

Waiting Room
Treatment room

Other specify ______

6. Did you receive treatment after the most recent incident? Yes received
No Need

Did Not receive
Self-treated

7. If yes who treated You? Doctors
Nurse

Psychiatrist
Others

Not treated

8. What do you think was the cause of the most recent incidence? Waiting for receiving services

Failure to meet patients’ desire

Mental illness

Way of dealing the patients

Unavailability of the services

Fear stress

Lack of preventive tools

Impact of disease or pain

Section 4: Preventing/managing procedures for Assault reports:

S. No Statement Yes No Don’t Know
9. Are there enough methods to prevent violence on staff (Guard, Security, Camera, warning devices ) in the departments
10. Are there enoughpolicies systems and instructions to prevent violence on workers in the hospitals?
11. Are there reporting procedures for the reporting violence in the hospitals?
12. Did you receive training or educational programs by the hospital to prevent and deal with violence?
13. In the most recent incidence did you write report to your administrator or any other third party authority?
14. Has any action been taken against the assaulter?
15. Does the violence have Negative impact on you?
16. Do you think stop working in the coming 1-3 years due to violence in the work area?

WORKPLACE VIOLENCE AGAINST NURSES WORKING IN EMERGENCY DEPARTMENTS AT PUBLIC HOSPITALS LAHORE

Submitted by
M Salman Ijaz

SUPERVISOR: AFSAR ALI
CO-SUPERVISOR: Ms. Naseem Rooman

______________________________________________________________________________
NATIONAL COLLEGE OF NURSING AFFILIATED WITH
THE UNIVERSITY OF LAHORE
ACADEMIC YEAR 2016-18

Table of Contents
Abstract 1
1. Introduction 2
1.1. Background 2
1.2. Problem Statement……………….………………………………………………………..3

1.3. Research Significance 4
1.4. Research Purpose 5
1.5. Research Objectives 5
1.6. Research Question 5
1.7. Operational definitions 6
Chapter 2 7
2. Literature Review 7
Chapter 3. Methodology 11
3.1. Research Design 11
3.2. Site 11
3.3. Setting 11
3.4. Population 12
3.5. Inclusion criteria 12
3.6. Exclusion criteria 12
3.7. Sampling method 15
3.8. Sample size 15
3.9. Data collection 13
3.10. Data Analysis 13
3.11. Ethical considerations 13
4. Results…………………………………………………………………………………………………..14
5. Discussion……………………………………………………………………………………………..35

6. Conclusion……………………………………………………………………………….…………….37

7. References 39
8.Inform consent and questionnaire 41

Dedication:

I would like to thank ALLAH supporting and helping me to complete this study.

This project work is dedicated to my parents and Teachers for their endless love, support and encouragement.

I am eternally grateful to my parents, who have supported and encouraged me to continue my studies. I appreciate the encouragement from my brothers sisters friends and my group members especially Anam khadim, Dilnesheen safdar, Sumera Rehman, Sehar Shabir and Kiran Akhter for their constant support.

Professionally I would like to extend my thanks for all assistance and support provided to me by my principal Naseem Roman my principal supervisor Afsar Ali my program coordinator Nosheen Noruddin the whole National College of nursing team and management and to the participants of research for their contribution and cooperation.

Acknowledgement:
I am highly thankful to Allah for giving me the strength and knowledge to carry out this research work. Without Allah's blessings and providence it would not be possible to complete this research project successfully. After that I am grateful to my parents and family members who gave me enough courage and support to complete this work.
I am highly thankful to my supervisor (sir. Afsar Ali) and Co supervisor Ms. Naseem Rooman (the principal college of nursing NH & MC) for their guidance and support
I am thankful to the entire Management of National college and hospital Lahore
I am thankful to the Management of UOL, Lahore school of nursing for their guidance in my studies
I am thankful to All Faculty of National CON

M Salman ijaz
Senior Elective Management
National College of Nursing
The University of Lahore

Abstract:
Work place violence is an alarming and devastating issue worldwide particularly in the emergency departments. Incident of work place violence is common towards nurses in health care settings. Nurses are more prone to workplace violence due to lack of respect towards nursing profession in Pakistani society and the nature of work performed by the nurses.
The main purpose of this study was to assess the prevalence of work place violence including physical and non physical and bring awareness about work place violence among nurses at the emergency departments of health care systems.
A cross sectional descriptive survey was performed to assess the prevalence of work place violence at tertiary care hospitals of Lahore. A convenient sample of n=147 was used to collect the data. A structured standardized adopted questionnaire was used to collect data. The questionnaire consisted demographic, physical and non physical variables. The data was collected from Jinnah and services hospital Lahore. The data was analyzed on SPSS version 21.
It was found that 77.55% stated that they are not exposed to physical violence last 12 months, 13.6% said once, 7.48% said 2-3 times and 1.3% stated they have been exposed 4-5 times during last year. On the other hand the participants exposed to Nonphysical violence in last 12 months,12.93% stated that they are not exposed to physical violence last 12 months, 25.85% said once, 40.82% said 2-3 times and 19.73% stated they have been exposed 4-5 times during last year.
Most recent physical incident in which 10.20% of incidents were happened at resuscitation room 2.04% at waiting room and 10.20% in treatment room. The most recent nonphysical incident in which 38.10% of incidents were happened at resuscitation room 0.68% in triage 12.24% at waiting room and 37.41% in treatment room 0.68% in other places.
It was also found that 2.04% incidents happened at morning shift 9.52% at evening 8.84% at night shift. Where as in nonphysical violence 11.56% incidents happened at morning shift 42.86% at evening 30.61% at night shift 3.40% participants was not sure about timing of the incident.

CHAPTER I: INTRODUCTION
1.1. Background:
Many countries of the world are encountered by Workplace physical violence almost in every field of employment which is a real matter of concern for (Blanchar, 2011). The prevalence of work place violence becomes a threat to employees’ safety, their dignity and causes lower wellbeing and thus the workers tend to become unhappy. Workplace violence appears among the leading threats to life and is considered as leading work place deaths among Us women workers. The lethal consequences of work place violence such as severe injuries have greater impact on life and cannot be underestimated by any state or country of the world (Boafo ; Hancock, 2017).
Occupations such as Health care professions have even more severe consequences from work place violence which appears as a global phenomenon in terms of violence against health professionals at work place. It mainly encompasses verbal threats or abuse, physical assault among health care workers and sexual harassment etcetera. The verbal violence is reported the highest of all work place violence. Moreover, the Nurses face the work place violence more than any other health care discipline because they remain in more contact with patients and their families (Alameddine, Mourad, ; Dimassi, 2015).
Some highlighted areas at the hospital are at greater risk of work place violence. These areas include the Psychiatric wards, emergency departments of the hospital, and sometimes high dependency units of health care systems. The occurrence of violence in the psychiatric wards and the emergency departments are reported in almost 100% in hospitals which is more than any other department in the hospital (Somani, 2012).
Workplace violence among nurses is defined as occurrence of some form of aggression such as physical aggression, sexual aggression, emotional or psychological threats against nurses, where the nurses are abused, assaulted, and threats in their work place circumstances. It is also claimed that workplace violence has very bad impact on the cost of any hospital in terms of increasing the financial burden which might reach up to 4.2 billion dollars annually(Somani, 2012).
It may also be defined as “Incidents of activities where the nurses are abused verbally, harassed sexually,or might face assaulted in their work place environment. This may challenge their safety and security, their health and wellbeing (Baydin & Erenler, 2014).The effects of work place violence is not limited to nurses only, rather it also have equal impact on doctors and other health care workers (Kowalenko, Hauff, Morden, & Smith, 2012).
Thls is recognized as high risk occupation which gaining more attention due to high occurrence of violent attacks on the working nurses. It was found by National Crime Victimization thatnon-fatal violence is about 21.9 per 1,000 among the nurses which is less in average than other profession (12.6 per 1,000 workers). The nurses of the emergency departments are the primary target of work place violence at every health care setup. In a previous study, conducted at the emergency departments, 82% of the nurses indicated that they have been assaulted in the last 12 months(May & Grubbs, 2002).
It is suggested that the incidence of verbal abuse is rising day by day and reaching almost 100% nurses at the emergency departments of many hospitals. The American Nurses Association found very few nurses are safe from the work place violence (Less than 20%). There is no support from the institutions to prevent violence among nurses which contributes to more dissatisfaction among them (Gacki-Smith et al., 2010).
Work place violence is very common everywhere in every hospital against nurses but it is on the top in low socioeconomic developing countries of the world. Pakistan is one of such countries having high incidence of work place violence among nurses at work environment. There is also another issue of poor reporting, lack of documentation and un- published status of such violence in the health care setups. Such high incidences of work place violence among nurses put the managements of different organizations in the challenging situations(Somani, 2012)
Health care workers’ especially nurses of the emergency departments may experience lots of workplace violence which may cause low satisfaction and poor performance among them (Hesketh et al., 2003). If there is no full performance of nurses due to unsafe environment, it will have direct impact on patients care outcomes and ultimately leads to ineffective and poor services of the hospitals (Kwok et al., 2006).
Despite of so many bad consequences of work place violence among nurses, it is still under reported and under rated issue. This lack of reporting may be because of fear, stigma and blame of being harassed. More seriously, the society might think that the nurses are made to bear such violence as part of their care that is why they are expected to tolerate it (Alameddine et al., 2015)
This paper presents workplace violence towards nurses as a major issue in the context of health care settings in Pakistan. Heresome characteristics of violence against the emergency nurses will be highlighted; some problems will be analyzed from different ethical professional and legal perspectives.Here some physical and psychological consequences of work place violence will be highlighted too.
1.2. Problem Statement:
Workplace violence among nurses is known to affect their job working environment, which may lead to decrease in their services at the emergency departments. Furthermore, the work place violence might be associated with physical and emotional imbalances among nurses at their duty. If the nurses are not balance physically and mentally, their care will not be according to standards, therefore there is need to identify the prevalence of violence, the types of violence at work place and also the measures to eliminate the high occurrence of work place violence among nurses.
1.3. Research Question:
1. What is the prevalence of violence against nurses working in the emergency departments of public tertiary hospitals Lahore?
2. What are the types of violence against nurses working in the emergency departments of public tertiary hospitals Lahore?
3. What are the contributing factors for workplace violence against nurses working in the emergency departments of public tertiary hospitals Lahore?
1.4. Significance:
Workplace violence is an issue of international health care among the workers at all departments of the health care systems but more sever at the emergency departments. Direct violence or indirect violence which may be physical or non-physical violence among nurses at the emergency departments might cause negative consequences in the future of nurses. If nurses of emergency department be aware of the types and causes of violence they can decrease the bad consequences and will avoid negative effect on the quality of health care providers and patients. The decrease in the productivity of nursing care will be minimized, negative impact on nurses whether it is physically or psychologically will be controlled. This may help the nurses to resolve violence related issues and continue a peaceful job life ahead.
1.5. Research Purpose:
The aim of this study is to bring awareness about work place violence among nurses at the emergency departments of health care systems. It will further reveal the issue of workplace violence after finding the prevalence at the emergency departments.
1.6. Objectives:
1. To assess the prevalence of violence against nurses working in the emergency departments of public tertiary hospitals Lahore
2. To identify the types of violence against nurses working in the emergency departments of public tertiary hospitals Lahore
3. To determine the contributing factors for workplace violence against nurses working in the emergency departments of public tertiary hospitals Lahore
1.7. Definitions:
a) Workplace Violence
Incidents where staff are abused, threatened or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being or health.
b) Physical violence:
It occurs when an employee is exposed to the deliberate use of force such as beating, pushing, slapping, and kicking, biting, pinching, stabbing, shooting by the patient and/or their families, a colleague or any others. Physical violence may lead to physical harm or emotional or sexual harm to the abused employee.
c) Verbal violence:
This happen when someone such as (patient, patients’ relatives, visitors, and coworkers) shout, curses or use other words to verbally insult the employee without an intention to bodily harm. For example someone yells at you. This includes any behavior towards an employee based on age, disability, gender, race, poverty, richness, or any other unwanted status which negatively influence the dignity of employee.
d) Sexual violence:
Any unwanted, unwelcomed and non-reciprocal sexual attention. It may include sexist remarks, behavior or sexual advances which results in a tense and unproductive environment. These forms of harassments/ abuse threaten the employees and cause them to feel humiliated.
1.8. Variables
Independent variable
Personal characteristic such as Gender, age, Marital status, experience and place of violence etcetera.
Dependent variables:
Prevalence of violence and Types of violence

Chapter II: Literature Review
Different literature studies are available regarding workplace violence among nurses. Here also some studies were found about workplace violence among nurses, workplace aggression of patients and families against nurses, violence against nurses at the emergency department and nurse’s perception of workplace violence at the emergency departments.
Workplace violence is the act which involves physical and nonphysical threats of assault affecting the nurses at their work places. Even verbal violence such as threats and verbal abuse against nurses, hostility for nurses, harassment against them can cause equal mental and psychological trauma to physical work place violence (Gomaa et al., 2015).
Study conducted by the Emergency Nurses Association (ENA), found that in the united states every year about nine hundred deaths occurs due to work place violence and around 1.7 million less life threatening assaults occur annually. This is still an unclear estimate of the severity of the work place violence. Further the Bureau of Labor and Statistic’s Survey conducted about the Occupational Injuries and violence found that the violence at work place among the health care workers is much higher than other profession (Albashtawy, 2013).
Emergency departments are working for 24 hours and have risks of much violence. Some situations like the lack of adequate training, physical security, lack of visible security guards and increased stress in the department make nurses of the emergency department more prone to work place violence. In a study 25% of the study participants at the emergency departments experience physical violence and around 20% stated verbal violence experience during last three years (Gacki-Smith et al., 2009).
Prevalence of Violence among nurses of Emergency Department:
A study assessed the prevalence of work place violence among the emergency nurses which was found that 44.6% nurses during the last year have experienced work place violence. Furthermore verbal abuse was found the most common work place violence. The physical and sexual assault were less in number as compare to verbal violence. Many nurses have experienced a combination of physical and nonphysical violence both. The work place violence was mostly caused by the patients, then the relatives and colleagues while least violence was recorded from supervisors’ side. Almost half of the nurses said that the violence they have experienced was preventable with proper care. Moreover all the nurses mentioned few management techniques for work place violence such as discussing with colleagues, reporting to the immediate supervisors, and confronting to the perpetrator of violence etcetera (Cheung & Yip, 2017).
Another study also conducted among health care workers to assess the work place violence among them. It was found that about 60% of the study participants, who were working at the emergency departments exposed to violence during their duty in the last one year. A total of 65.7% nurses exposed to verbal violence at their work place. Majority of the HCW 61% were females who got affected by violence. The occurrence of violence was found different in different individuals. Some experienced work place violence very frequently, other faced it once a month etcetera. The violence from patients relative was found at the top (89.7% of verbal violence) and for 90.5% of physical violence. Verbal violence mostly found in the evening shift (Abdellah & Salama, 2017).
Types of Violence among ER Nurses:
Some commonest physical violence types were experienced by more than 50% nurses were, they were being spit on, pushed by patients or relatives, scratched and being kicked. Among the verbal violence, the most common (70%) was yelling from patients and their families, intimidated and being harassed with sexually abusive language. The perception of safety was found very low and about 70% participants showed less than 50% safety perception. About 33% participants were in favor of leaving emergency department due to increased work place violence (Gacki-Smith et al., 2010).
Findings of another study reveals that incidence of verbal violence was (63.9%), which was almost five times more than physical violence (11.9%) at the emergency department among nurses in the last 12 months of period. Verbal violence at the emergency department was mainly by the patients against nurses then secondly by their family members and relatives. The rate of physical violence was also high from patients and their family members. Afternoon shift was found to have more work place violence at the emergency departments due to increased patients inflow (Albashtawy, 2013).
According to another study verbal violence was found among the 86% of nurses at the emergency departments. Threats were also found high among the (35%) of the study participants. Physical abuse was also found among the nurses from the patients and their families but it was lower than that of verbal assault. No difference of violence exposure was found between males and females or based on the specialty such as medical and surgical. However very few respondents were from emergency to have a meaningful comparison (Imran, Pervez, Farooq, & Asghar, 2013).
Contributing factors for Work Place violence:
Patients relatives were overall the most common source of work place violence among the emergency department nurses (71%) followed by patients (30.5%). Results also showed that there are other various aspects of work place violence caused by colleagues, supervisors also (Imran et al., 2013).It is observed that there are under reported may be due to feeling of uncomforted and lack of support from the organization. There is also lack of a well-structured reporting system for work place violence in many health care organizations. It is very important to identify the contributing factors for work place violence (Somani, 2012).
It is very clear from previous studies that the major contributor of workplace violence among nurses at the emergency department was found patients which is followed by the relatives of the patients. Along with patients and their relatives, the nursing colleagues, senior nurses, the manager nurses, and on duty doctors also are the contributing factors for work place violence among the emergency department nurses (Kwok et al., 2006).
According to another study, workplace physical violence against the emergency department nurses was perpetrated mainly by patients followed by their relatives and then by other nurses. The results of the study found that relatives of patients were the most frequent contributors of physical violence against the emergency department nurses. They were responsible for a large number of cases (58.5%)(Boafo & Hancock, 2017).

CHAPTER III: METHODOLOGY
3.1. Research Design:
A descriptive cross-sectional study design was used to conduct this study. Data about the violence against emergency department nurses was collected at one point in time with the help of a questionnaire.
3.2. Time Period:
This study was conducted from February 2018 to May 2018 for about 4 months period of time.
3.3. Site and setting of the study:
This study was conducted among the nurses at the Emergency Departments of two public tertiary care hospitals Lahore. They are the Jinnah Hospital Lahore and Services Hospital Lahore.
3.4. Population:
The study was conducted among the nurses. The population for this study was all nurses who are working in emergency departments of the selected hospitals, the Jinnah Hospital and the Services Hospital Lahore.
3.5. Sample size Determination
The minimum sample required is calculated using the single proportion formula which is given below.
? = ?2(1 ? ?) /?2
d= Acceptable margin of error (precision of measurement) = 5%
z= Standard variant (1.96) which correspond to 95% confidence level
p= Overall prevalence of workplace violence among nurses in public health facilities in
Nazish Imran2013 (73%).
(1.96)2 0.73 (1?0.73) /(0.05)2 =
(1.96)2 0.73 (1?0.73) /(0.05)2 =
3.8416* 0.73 (0.27) /(0.0025)=
2.804* 108 = 302
Since the total number of study population is < 10,000 (N=400) using the correction formula the final sample size will benf = ???/ ?+?
400?302 /400+302 = 147
120,800 /702 = 147
3.6. Sampling procedure
Sampled will be selected from the emergency departments of two public hospitals through convenient sampling methods. N=75 will be selected from Jinnah Hospital while remaining 72 nurses will be selected from services hospital emergency department.
3.7. Inclusion criteria
All nurses from the emergency departments were recruited who were:
1. Willing to participate in the study
2. Working in emergency department at least one year
3. Registered with Pakistan Nursing council
3.8. Exclusion criteria
Those nurses will not be recruited who are:
1. All nurses who were not at work place during data collection period
2. Those who were not willing and not registered
3.9. Data collection tool
A self-administered standardized adopted questionnaire was used to collect the data. The questionnaire adopted from a study ‘Work place violence against nurses working in the emergency department of in Saudi Arabia’ by Fuaad Ali Alshehri(Albashtawy, 2013).
The first section of the questionnaire consisted off the demographic information about the age, gender, education and working experience of the participants. The second and third parts of the questionnaire discussed the physical and nonphysical violence among nurses at the emergency departments. The participants of the study were asked to fill the questionnaire of work place violence.
3.10. Data processing, Analysis and presentation
The data was put into the SPSS version 21. The results were processed and analyzed with the help of graphs, tables in the form of frequencies, averages and percentages.
3.11. Ethical Consideration
An approval was taken from the committee of national college of nursing. Then permission was taken from the heads of the study setting such as Head of Jinnah hospital and Head of the services Hospital. A written permission was taken from each individual participant of the study. Each participant was provided with the questionnaire with an informed consent which was explained the purposes and significance of the study. The study participants were assured that their names will be kept confidential. Their participation was fully volunteer and can withdraw at any time.

CHAPTER IV: RESULTS

4.1 Demographic data analysis and results

The below table shows about the gender of participants that were 6.80% were male and 93.20% was female. Result also shows the age of the participants of study from which 10.20% were less than 25 years & 53.06% were between 26 to 30 years 27.89% were between the age of 31 to 35 years 6.12% were between the age of 36 to 40 years and 2.72% participants of study were more than 40 years of age. It was also found that the education level of the study participants from which 19.05% were only have general nursing diploma 40.14% of study participants having specialization as well 40.82% have the degree of generic BSN and post RN BSN degree.
Table 1: Frequency and percentage of demographics data

Variables Number (n) Per cent
Gender
Male
Female
10
137
6.8
93.2
Age:
Less than 25 years
26-30 years
31-35 years
36-40 years
Above 40 years
15
78
41
9
4
10.2
53.1
27.9
6.1
2.7
Education:
Nursing Diploma
Diploma plus specialization
BSN/PRN BSN
MSN/MPH
28
59
60

19.0
40.1
40.8

Experience
77
51
15
4

52.4
34.7
10.2
2.7

1-5 years
6-10 years
11-15 years
Above 15years

4.2: DESCRIPTIVE ANALYSIS OF PHYSICAL AND NONPHYSICAL VIOLENCE
Below Table 2 shows that in response for how many times the participants exposed to physical violence in last 12 months. It was found that 77.55% stated that they are not exposed to physical violence last 12 months, 13.6% said once, 7.48% said 2-3 times and 1.3% stated they have been exposed 4-5 times during last year. On the other hand the participants exposed to Nonphysical violence in last 12 months,12.93% stated that they are not exposed to physical violence last 12 months, 25.85% said once, 40.82% said 2-3 times and 19.73% stated they have been exposed 4-5 times during last year. The type of physical assault the study participants was asked and 4.08% of participants had experience beating, 9.52% experience pushing, 6.12% of study participants had experience slapping, 1.36% pinching, 1.36% shooting, and not applicable for 77.55% of study participants. Similarly about types of nonphysical assault the study participants were exposed to, 50.34% of participants had experience threats, 36.05% experience verbal abuse and 2.04% of study participants had experience sexual harassment/abuse. Regarding the physical assaulters to staff from which 8.16% were patients, 13.61% were relatives of patients, 0.68% were coworkers of the staff and not applicable for 77.55% participants. About the assaulters of nonphysical at staff from which 19.73% were patients, 63.27% were relatives of patients, 5.44% were coworkers of the staff and not applicable for 11.56% participants. It was also found that 2.04% incidents happened at morning shift 9.52% at evening 8.84% at night shift and not applicable for 77.55% of study participants in terms of physical violence. Where as in nonphysical violence 11.56% incidents happened at morning shift 42.86% at evening 30.61% at night shift 3.40% participants was not sure about timing of the incident and not applicable for 11.56% of study participants.

Most recent physical incident in which 10.20% of incidents were happened at resuscitation room 2.04% at waiting room and 10.20% in treatment room and this question was not applicable for 77.55% of participants. The most recent nonphysical incident in which 38.10% of incidents were happened at resuscitation room 0.68% in triage 12.24% at waiting room and 37.41% in treatment room 0.68% in other places and this question was not applicable for 10.88% of participants.
Furthermore to physical violence 1.36% said yes received treatment, 12.24% not need, 2.04% not received and 6.80% self-treated and this question was not applicable for 77.55% of study participants. Similarly in nonphysical violence, 0.68% said yes received treatment, 68.71% no need, 3.40% not received and 15.65% self-treated. Result also shows that percentage by whom physical violence victim was treated 6.12% was treated by nurse 16.33% not treated and not applicable for 77.55% of study participants. It was also found in nonphysical violence that victim was treated 10.20 % was treated by nurse, 0.68% by psychiatrist, 0.68% by others 76.87% not treated and not applicable for 11.56% of study participants. The Findings also show the percentage of the cause of most recent incident from which 12.93% of participants said that it was due to waiting for services 5.44% was unable to meet patients desire 2.72% was due to unavailability of services 1.36 % was due to lack of preventive tools and not applicable for 77.55% of study participants. The cause of most recent nonphysical incidents from which 24.49% of participants said that it was due to waiting for services 13.61% was unable to meet patients desire 6.12% was due to mental illness 1.36% was due to way of dealing with patients 29.25% was due to unavailability of services 8.84 % was due to lack of preventive tools 4.76% said that it was due to impact of disease or pain and not applicable for 11.56% of study participants.

(Table 2) Frequency and percentage of the Violence

Variables Physical Violence Non-Physical Violence

Number of Time Being exposed Number(n) Percent Number(n) Percent
Never
Once
2-3 Times
4-5 times
6 times 114
20
11
2
00 77.6
13.6
7.5
1.4
00 19
38
60
29
01 12.9
25.9
40.8
19.7
.7
Who Assaulted
Patients
Visitors/Patients’ relatives
Co-workers
Not applicable 12
20
1
114 8.2
13.6
.7
77.6 29
93
8
17 19.7
63.3
5.4
11.6
When the Incidence Happened?
Morning
Afternoon
Night
Unsure
Not applicable 3
14
13
3
114 2.0
9.5
8.8
2.0
77.6 17
63
45
5
17 11.6
42.9
30.6
3.4
11.6
Where the incidence happened?
Resuscitation
Waiting Room
Triage
Treatment
Hallway
Not applicable 15
3
0
15
0
114 10.2
2.0
0
10.2
0
77.6 56
18
1
55
0
18 38.1
12.2
.7
37.4
0
10.9
Receiving treatment after the incident
Yes, received
There was no need
Needed but did not received
Self treated
Not applicable 2
18
3
10
114 1.4
12.2
2.0
6.8
77.6 1
101
5
23
17 .7
68.7
3.4
15.6
11.6
Who treated?
Doctors
Psychiatrist
Nurse
Not treated
Not applicable 0
0
9
24
114 0
0
6.1
16.3
77.6 0
1
15
113
17 0
.7
10.2
76.9
11.6
The causes of most Recent Incident
Waiting for receiving services
Failure to meet patients’ desire
Mental illness
Way of dealing the patients
Unavailability of the services
Fear stress
Lack of preventive tools
Impact of disease or pain
Not applicable 19
8
0
0
4
0
2
0
114 12.9
5.4
0
0
2.7
0
1.4
0
77.6 36
20
9
2
43
0
13
7
17 24.5
13.6
6.1
1.4
29.3
0
8.8
4.8
11.6

4.3: Summary of Physical and Nonphysical Violence:

The following Table 3 suggests that 4.1% of the study participants had Beating experience, 9.5% experienced pushing, 6.9% faced slapping, no kicking or biting was found, pinching and shooting was 1.4% each, while the rest of 77% had no experienced of physical violence.

Table 3: Summary of Physical Violence

Variable Category
Type of physical Violence N %
Beating
Pushing
Slapping
Kicking
Biting
Pinching
Shooting
Stabbing
Not applicable 6
14
9
0
0
2
2
0
114 4.1
9.5
6.1
0
0
1.4
1.4
0
77.6

The following Table 4 findings indicate thatabout 50.3% of the study participants had faced threats as nonphysical violence, 36.1% experienced Verbal abuse/Harassment, while 2% have experience Sexual Abuse/Harassment and 11.6% faced no any nonphysical violence during last 1 year.

Table 4: Summary of Nonphysical Violence

Variable Category
Type of Nonphysical Assault N %
Threats
Verbal abuse/Harassment
Sexual Abuse/Harassment
Not applicable 74
53
3
17 50.3
36.1
2.0
11.6

4.3.2: Descriptive analysis of Physical Violence
How many times have you been exposed to physical violence during the last 12 months?
Frequency Percent Valid Percent Cumulative Percent
Valid Never 114 77.6 77.6 77.6
Once 20 13.6 13.6 91.2
2-3times 11 7.5 7.5 98.6
4-5 times 2 1.4 1.4 100.0
Total 147 100.0 100.0

The above table and Graph shows that in response for how many times the participants exposed to physical violence in last 12 months. It was found that 77.55% stated that they are not exposed to physical violence last 12 months, 13.6% said once, 7.48% said 2-3 times and 1.3% stated they have been exposed 4-5 times during last years.

What type of physical assault were you exposed to during the most recent incidence?
Frequency Percent Valid Percent Cumulative Percent
Valid Beating 6 4.1 4.1 4.1
Pushing 14 9.5 9.5 13.6
Slaping 9 6.1 6.1 19.7
Pinching 2 1.4 1.4 21.1
Shooting 2 1.4 1.4 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph shows the type of physical assault the study participants were exposed to in which 4.08% of participants had experience beating 9.52% experience pushing 6.12% of study participants had experience slapping 1.36% pinching 1.36% shooting and not applicable for 77.55% of study participants.

In the most recent physical incident who assault you?
Frequency Percent Valid Percent Cumulative Percent
Valid Patients 12 8.2 8.2 8.2
Relatives 20 13.6 13.6 21.8
Co-Workers 1 .7 .7 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph show the percentage of physical assaulters to staff from which 8.16% were patients 13.61% were relatives of patients 0.68% were coworkers of the staff and not applicable for 77.55% participants.

In the most recent physical incident when did the incident happened?
Frequency Percent Valid Percent Cumulative Percent
Valid Morning 3 2.0 2.0 2.0
Afternoon 14 9.5 9.5 11.6
Night 13 8.8 8.8 20.4
Not sure 3 2.0 2.0 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph show the timing of physical incident from which 2.04% incidents happened at morning shift 9.52% at evening 8.84% at night shift and not applicable for 77.55% of study participants.

In the most recent physical incident where did the incident happened?
Frequency Percent Valid Percent Cumulative Percent
Valid Resuscitation 15 10.2 10.2 10.2
Waiting room 3 2.0 2.0 12.2
Treatment room 15 10.2 10.2 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph shows the location of most recent incident in which 10.20% of incidents were happened at resuscitation room 2.04% at waiting room and 10.20% in treatment room and this question was not applicable for 77.55% of participants.

Did you receive treatment after the most recent incident?
Frequency Percent Valid Percent Cumulative Percent
Valid Yes received 2 1.4 1.4 1.4
No need 18 12.2 12.2 13.6
Not received 3 2.0 2.0 15.6
Self treated 10 6.8 6.8 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph shows the percentage of study participants who receive or didn’t receive the treatment after most recent physical incident in which 1.36% said yes received 12.24% no need 2.04% not received and 6.80% self treated and this question was not applicable for 77.55% of study participants.

If yes who treated You?
Frequency Percent Valid Percent Cumulative Percent
Valid Nurse 9 6.1 6.1 6.1
Not treated 24 16.3 16.3 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph shows the percentage by whom physical violence victim was treated 6.12% was treated by nurse 16.33% not treated and not applicable for 77.55% of study participants.

What do you think was the cause of the most recent incidence?
Frequency Percent Valid Percent Cumulative Percent
Valid Waiting for services 19 12.9 12.9 12.9
not meeting patients' desire 8 5.4 5.4 18.4
Unavailability of the services 4 2.7 2.7 21.1
Lack of preventive tools 2 1.4 1.4 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph shows the percentage of the cause of most recent incident from which 12.93% of participants said that it was due to waiting for services 5.44% was unable to meet patients desire 2.72% was due to unavailability of services 1.36 % was due to lack of preventive tools and not applicable for 77.55% of study participants.

4.3.2: Descriptive analysis of Nonphysical Violence:

How many times have you been exposed to Non-physical violence during the last 12 months?

Frequency Percent Valid Percent Cumulative Percent
Valid Never 19 12.9 12.9 12.9
Once 38 25.9 25.9 38.8
2-3times 60 40.8 40.8 79.6
4-5 times 29 19.7 19.7 99.3
6 or more times 1 .7 .7 100.0
Total 147 100.0 100.0

The above table and Graph shows that in response for how many times the participants exposed to physical violence in last 12 months. It was found that 12.93% stated that they are not exposed to physical violence last 12 months, 25.85% said once, 40.82% said 2-3 times and 19.73% stated they have been exposed 4-5 times during last year.

What type of non-physical assault were you exposed to during the most recent incidence?

Frequency Percent Valid Percent Cumulative Percent
Valid Threats 74 50.3 50.3 50.3
Verbal abuse/Harassment 53 36.1 36.1 86.4
Sexual abuse 3 2.0 2.0 88.4
Not applicale 17 11.6 11.6 100.0
Total 147 100.0 100.0

The above table and graph shows the type of non physical assault the study participants were exposed to in which 50.34% of participants had experience threats 36.05% experience verbal abuse and 2.04% of study participants had experience sexual harassment/abuse and not applicable for 11.56% of study participants.

In the most recent nonphysical incident who assault you?
Frequency Percent Valid Percent Cumulative Percent
Valid Patients 29 19.7 19.7 19.7
Relatives 93 63.3 63.3 83.0
Co-Workers 8 5.4 5.4 88.4
Not applicable 17 11.6 11.6 100.0
Total 147 100.0 100.0

The above table and graph show the percentage of non physical assaulters to staff from which 19.73% were patients 63.27% were relatives of patients 5.44% were coworkers of the staff and not applicable for 11.56% participants.

In the most recent nonphysical incident when did the incident happened?
Frequency Percent Valid Percent Cumulative Percent
Valid Morning 17 11.6 11.6 11.6
Afternoon 63 42.9 42.9 54.4
Night 45 30.6 30.6 85.0
Not sure 5 3.4 3.4 88.4
Not applicable 17 11.6 11.6 100.0
Total 147 100.0 100.0

The above table and graph show the timing of physical incident from which 11.56% incidents happened at morning shift 42.86% at evening 30.61% at night shift 3.40% participants was not sure about timing of the incident and not applicable for 11.56% of study participants.

In the most recent nonphysical incident where did the incident happened?
Frequency Percent Valid Percent Cumulative Percent
Valid Resuscitation 56 38.1 38.1 38.1
Triage 1 .7 .7 38.8
Waiting room 18 12.2 12.2 51.0
Treatment room 55 37.4 37.4 88.4
Others 1 .7 .7 89.1
Not applicable 16 10.9 10.9 100.0
Total 147 100.0 100.0

The above table and graph shows the location of most recent incident in which 38.10% of incidents were happened at resuscitation room 0.68% in triage 12.24% at waiting room and 37.41% in treatment room 0.68% in other places and this question was not applicable for 10.88% of participants.

Did you receive treatment after the most recent incident?

Frequency Percent Valid Percent Cumulative Percent
Valid Yes received 1 .7 .7 .7
No need 101 68.7 68.7 69.4
Not received 5 3.4 3.4 72.8
Self treated 23 15.6 15.6 88.4
Not applicable 17 11.6 11.6 100.0
Total 147 100.0 100.0

The above table and graph shows the percentage of study participants who receive or didn’t receive the treatment after most recent non physical incident in which 0.68% said yes received 68.71% no need 3.40% not received and 15.65% self treated and this question was not applicable for 11.56% of study participants.

If yes who treated You?

Frequency Percent Valid Percent Cumulative Percent
Valid Nurse 15 10.2 10.2 10.2
Psychiatristist 1 .7 .7 10.9
Others 1 .7 .7 11.6
Not treated 113 76.9 76.9 88.4
Not applicable 17 11.6 11.6 100.0
Total 147 100.0 100.0

The above table and graph shows the percentage by whom physical violence victim was treated 10.20 % was treated by nurse 0.68% by psychiatrist 0.68% by others 76.87% not treated and not applicable for 11.56% of study participants.

What do you think was the cause of the most recent incidence?

Frequency Percent Valid Percent Cumulative Percent
Valid Waiting for services 36 24.5 24.5 24.5
not meeting patients' desire 20 13.6 13.6 38.1
Mental illness 9 6.1 6.1 44.2
Way of dealing the patients 2 1.4 1.4 45.6
Unavailability of the services 43 29.3 29.3 74.8
Lack of preventive tools 13 8.8 8.8 83.7
Impact of disease or pain 7 4.8 4.8 88.4
Not appicable 17 11.6 11.6 100.0
Total 147 100.0 100.0

The above table and graph shows the percentage of the cause of most recent incident from which 24.49% of participants said that it was due to waiting for services 13.61% was unable to meet patients desire 6.12% was due to mental illness 1.36% was due to way of dealing with patients 29.25% was due to unavailability of services 8.84 % was due to lack of preventive tools 4.76% said that it was due to impact of disease or pain and not applicable for 11.56% of study participants.

Chapter 5: Discussion
This current study found that physical violence was about 22.5% where 4.1% of the study participants had Beating experience, 9.5% experienced pushing, 6.9% faced slapping and pinching and shooting was 1.4% each, while the rest of 77.5% had not experienced of physical violence. The prevalence of nonphysical violence was found about 88.4% where 50.3% of the study participants had faced threats as nonphysical violence, 36.1% experienced Verbal abuse/Harassment, while 2% have experience Sexual Abuse/Harassment and 11.6% faced no any nonphysical violence during last 1 year.
According to a previous study the verbal violence was found among the 86% of nurses at the emergency departments. Physical abuse was also found among the nurses from the patients and their families but it was lower than that of verbal assault. No difference of violence exposure was found between males and females or based on the specialty such as medical and surgical. However very few respondents were from emergency to have a meaningful comparison (Imran et al., 2013).
Similarly Findings of another study reveals that incidence of verbal violence was (63.9%), which was almost five times more than physical violence (11.9%) at the emergency department among nurses in the last 12 months of period (Albashtawy, 2013).
A previous study found some similar findings where nonphysical abuse was found the most common work place violence. The physical and sexual assault were less in number as compare to verbal violence (Cheung & Yip, 2017). According to another study, a total of 65.7% nurses exposed to nonphysical violence at their work place (Abdellah & Salama, 2017).
During my study the physical violence was mainly 13.61% were from relatives of patients (out of 22%), which becomes almost half the violence.
Similarly, in a previous study, violence from patients relative was found at the top (89.7% of verbal violence) and for 90.5% of physical violence. Verbal violence mostly found in the evening shift (Abdellah & Salama, 2017).
According to this study most common violence were 4.08% of participants had experience beating, 9.52% experience pushing, 6.12% of study participants had experience slapping, 1.36% pinching, 1.36% shooting and not applicable for 77.55% of study participants.
According to previous study some commonest physical violence types were experienced by more than 50% nurses were, they were being spit on, pushed by patients or relatives, scratched and being kicked (Gacki-Smith et al., 2010).
According to this current study, the type of nonphysical assault the study participants were exposed to in which 50.34% of participants had experience threats 36.05% experience verbal abuse and 2.04% of study participants had experience sexual harassment/abuse and not applicable for 11.56% of study participants. Previously, among the verbal violence, the most common (70%) was yelling from patients and their families, intimidated and being harassed with sexually abusive language. (Gacki-Smith et al., 2010). According to another study, threats were also found high among the (35%) of the study participants (Imran et al., 2013).

Chapter 6: Conclusion

Conclusion
The purpose of this study was to assess the prevalence of work place violence and types of physical and non physical violence in the public hospitals of Lahore. The emergency nurses during study indicated that violence was a common occurrence.
It was found that 77.55% stated that they are not exposed to physical violence last 12 months, 13.6% said once, 7.48% said 2-3 times and 1.3% stated they have been exposed 4-5 times during last year. On the other hand the participants exposed to Nonphysical violence in last 12 months,12.93% stated that they are not exposed to physical violence last 12 months, 25.85% said once, 40.82% said 2-3 times and 19.73% stated they have been exposed 4-5 times during last year.
Most recent physical incident in which 10.20% of incidents were happened at resuscitation room 2.04% at waiting room and 10.20% in treatment room. The most recent nonphysical incident in which 38.10% of incidents were happened at resuscitation room 0.68% in triage 12.24% at waiting room and 37.41% in treatment room 0.68% in other places.
It was also found that 2.04% incidents happened at morning shift 9.52% at evening 8.84% at night shift. Where as in nonphysical violence 11.56% incidents happened at morning shift 42.86% at evening 30.61% at night shift 3.40% participants was not sure about timing of the incident.

Recommendations
This study addressed several areas requiring further research. There is a shortage of violence research among emergency nurses in Lahore. Further research is needed to develop strategies for preventing violence against emergency nurses, which would need to consider the local culture and findings of this study. Further in depth research is needed to assess the impact of violence on the perception and professional life of emergency nurses.

Limitations
This was my first research study so due to lack of expertise there are some limitations.it may be better if I can relate different kind of professional, environmental and cultural factors affecting work place violence in my study, but due to lack of time and less expertise I was unable to do that. Hopefully it will be better in my next studies.

REFERENCES:
Abdellah, R. F., & Salama, K. M. (2017). Prevalence and risk factors of workplace violence against health care workers in emergency department in Ismailia, Egypt. Pan African Medical Journal, 26(1), 1-8.
Al Shameri, F. Critical Care Nurse’s Knowledge of Ventilator-Associated Pneumonia Prevention in Selected Hospitals, Khartoum.
Alameddine, M., Mourad, Y., & Dimassi, H. (2015). A national study on nurses’ exposure to occupational violence in Lebanon: prevalence, consequences and associated factors. PLoS ONE, 10(9), e0137105.
Albashtawy, M. (2013). Workplace violence against nurses in emergency departments in Jordan. International nursing review, 60(4), 550-555.
Baydin, A., & Erenler, A. K. (2014). Workplace violence in emergency department and its effects on emergency staff. Int J Emerg Ment Health, 16(2), 288-290.
Blanchar, Y. (2011). Violence in the health care sector: a global issue. World Medical Journal, 57(3), 87-89.
Boafo, I. M., & Hancock, P. (2017). Workplace violence against nurses: a cross-sectional descriptive study of Ghanaian nurses. SAGE Open, 7(1), 2158244017701187.
Cheung, T., & Yip, P. S. (2017). Workplace violence towards nurses in Hong Kong: prevalence and correlates. BMC Public Health, 17(1), 196.
Gacki-Smith, J., Juarez, A. M., Boyett, L., Homeyer, C., Robinson, L., & MacLean, S. L. (2009). Violence against nurses working in US emergency departments. Journal of Nursing Administration, 39(7/8), 340-349.
Gacki-Smith, J., Juarez, A. M., Boyett, L., Homeyer, C., Robinson, L., & MacLean, S. L. (2010). Violence against nurses working in US emergency departments. Journal of healthcare protection management: publication of the International Association for Hospital Security, 26(1), 81-99.
Gomaa, A. E., Tapp, L. C., Luckhaupt, S. E., Vanoli, K., Sarmiento, R. F., Raudabaugh, W. M., . . . Sprigg, S. M. (2015). Occupational traumatic injuries among workers in health care facilities—United States, 2012–2014. MMWR. Morbidity and mortality weekly report, 64(15), 405.
Hesketh, K. L., Duncan, S. M., Estabrooks, C. A., Reimer, M. A., Giovannetti, P., Hyndman, K., & Acorn, S. (2003). Workplace violence in Alberta and British Columbia hospitals. Health policy, 63(3), 311-321.
Imran, N., Pervez, M. H., Farooq, R., & Asghar, A. R. (2013). Aggression and violence towards medical doctors and nurses in a public health care facility in Lahore, Pakistan: A preliminary investigation. Khyber Medical University Journal, 5(4), 179-184.
Kowalenko, T., Hauff, S. R., Morden, P. C., & Smith, B. (2012). Development of a data collection instrument for violent patient encounters against healthcare workers. Western journal of emergency medicine, 13(5), 429.
Kwok, R., Law, Y., Li, K., Ng, Y., Cheung, M., Fung, V., . . . Leung, W.-C. (2006). Prevalence of workplace violence against nurses in Hong Kong. Hong Kong Medical Journal.
May, D. D., & Grubbs, L. M. (2002). The extent, nature, and precipitating factors of nurse assault among three groups of registered nurses in a regional medical center. Journal of emergency nursing, 28(1), 11-17.
Somani, R. K. (2012). Workplace violence towards nurses: A reality from the Pakistani context. Journal of Nursing Education and Practice, 2(3), 148.

Informed consent:

Workplace violence against nurses working in emergency departments at a public hospital Lahore

Dear participants,
I am Salman Ijaz, want to conduct a research on “Workplace violence against nurses working in emergency departments at a public hospital Lahore”. As this Research project work for the fulfillment of my Post RN BSN degree from National College of Nursing, affiliated with the University of Lahore. The purpose of this research study is to assess the Workplace violence against nurses working in emergency departments at a public hospital Lahore.A questionnaire will be distributed for data collection, for which your cooperation is required. The questionnaire will take about 20-30 minutes to complete. Your participation will be very helpful for me to complete my study. Your valued information will be kept confidential. You are allowed to withdraw at any time from research study.
I have read all the terms and voluntarily consent to participate in the research study.

Participant's Signature:………………………..
Date: ………………………….

Questionnaire:

Workplace Violence against nurses working in emergency departments at a Public Hospital Lahore
Section 1: Demographic Data:

1. Gender:

1. Male ( ) 2. Female ( )

2. Age in Years:

1.Below 25 ( ) 2. 26-30 ( ) 3. 31-35 ( ) 4. 36-40 ( ) 5. above 40 ( )

3. Education:

1. Diploma GN ( ) 2. Specialization ( ) 3. BSN/Post RN ( ) 4.MSN ( )

4. Experience:

1.1-5 years ( ) 2. 6-10 years ( ) 3. 11-15 Years ( ) 4. Above 15 years ( )

Section 2: Physical Violence:

s. No Statement Options
1 How many times have you been exposed to physical violence during the last 12 months? Never
Once

2-3
4-5

6 or more times
2 What type of physical assault were you exposed to during the most recent incidence? Beating
Pushing
Slapping

Kicking
Biting
Pinching

Shooting
Stabbing
Others

3 In the most recent physical incident who assault you? Patients
Relatives

Coworkers
Others ______

4 In the most recent physical incident when did the incident happened? Morning
Afternoon

Night
Not sure

5 Where did the most recent incident happen? Resuscitation
Triage

Waiting Room
Treatment room

Other specify ______

6 Did you receive treatment after the most recent incident? Yes received
No Need

Did Not receive
Self-treated

7 If yes who treated You? Doctors
Nurse

Psychiatrist
Others

Not treated

8 What do you think was the cause of the most recent incidence? Waiting for receiving services

Failure to meet patients’ desire

Mental illness

Way of dealing the patients

Unavailability of the services

Fear stress

Lack of preventive tools

Impact of disease or pain

Section 3: Non Physical Violence:

s. No Statement Options
1 How many times have you been exposed to Non-physical violence during the last 12 months? Never
Once

2-3
4-5

6 or more times
2 What type of physical assault were you exposed to during the most recent incidence? Threats

Verbal abuse/Harassment

Sexual abuse Harassment

3 In the most recent physical incident who assault you? Patients
Relatives

Coworkers
Others ______

4 In the most recent physical incident when did the incident happened? Morning
Afternoon

Night
Not sure

5. Where did the most recent incident happen? Resuscitation
Triage

Waiting Room
Treatment room

Other specify ______

6. Did you receive treatment after the most recent incident? Yes received
No Need

Did Not receive
Self-treated

7. If yes who treated You? Doctors
Nurse

Psychiatrist
Others

Not treated

8. What do you think was the cause of the most recent incidence? Waiting for receiving services

Failure to meet patients’ desire

Mental illness

Way of dealing the patients

Unavailability of the services

Fear stress

Lack of preventive tools

Impact of disease or pain

Section 4: Preventing/managing procedures for Assault reports:

S. No Statement Yes No Don’t Know
9. Are there enough methods to prevent violence on staff (Guard, Security, Camera, warning devices ) in the departments
10. Are there enoughpolicies systems and instructions to prevent violence on workers in the hospitals?
11. Are there reporting procedures for the reporting violence in the hospitals?
12. Did you receive training or educational programs by the hospital to prevent and deal with violence?
13. In the most recent incidence did you write report to your administrator or any other third party authority?
14. Has any action been taken against the assaulter?
15. Does the violence have Negative impact on you?
16. Do you think stop working in the coming 1-3 years due to violence in the work area?

WORKPLACE VIOLENCE AGAINST NURSES WORKING IN EMERGENCY DEPARTMENTS AT PUBLIC HOSPITALS LAHORE

Submitted by
M Salman Ijaz

SUPERVISOR: AFSAR ALI
CO-SUPERVISOR: Ms. Naseem Rooman

______________________________________________________________________________
NATIONAL COLLEGE OF NURSING AFFILIATED WITH
THE UNIVERSITY OF LAHORE
ACADEMIC YEAR 2016-18

Table of Contents
Abstract 1
1. Introduction 2
1.1. Background 2
1.2. Problem Statement……………….………………………………………………………..3

1.3. Research Significance 4
1.4. Research Purpose 5
1.5. Research Objectives 5
1.6. Research Question 5
1.7. Operational definitions 6
Chapter 2 7
2. Literature Review 7
Chapter 3. Methodology 11
3.1. Research Design 11
3.2. Site 11
3.3. Setting 11
3.4. Population 12
3.5. Inclusion criteria 12
3.6. Exclusion criteria 12
3.7. Sampling method 15
3.8. Sample size 15
3.9. Data collection 13
3.10. Data Analysis 13
3.11. Ethical considerations 13
4. Results…………………………………………………………………………………………………..14
5. Discussion……………………………………………………………………………………………..35

6. Conclusion……………………………………………………………………………….…………….37

7. References 39
8.Inform consent and questionnaire 41

Dedication:

I would like to thank ALLAH supporting and helping me to complete this study.

This project work is dedicated to my parents and Teachers for their endless love, support and encouragement.

I am eternally grateful to my parents, who have supported and encouraged me to continue my studies. I appreciate the encouragement from my brothers sisters friends and my group members especially Anam khadim, Dilnesheen safdar, Sumera Rehman, Sehar Shabir and Kiran Akhter for their constant support.

Professionally I would like to extend my thanks for all assistance and support provided to me by my principal Naseem Roman my principal supervisor Afsar Ali my program coordinator Nosheen Noruddin the whole National College of nursing team and management and to the participants of research for their contribution and cooperation.

Acknowledgement:
I am highly thankful to Allah for giving me the strength and knowledge to carry out this research work. Without Allah's blessings and providence it would not be possible to complete this research project successfully. After that I am grateful to my parents and family members who gave me enough courage and support to complete this work.
I am highly thankful to my supervisor (sir. Afsar Ali) and Co supervisor Ms. Naseem Rooman (the principal college of nursing NH & MC) for their guidance and support
I am thankful to the entire Management of National college and hospital Lahore
I am thankful to the Management of UOL, Lahore school of nursing for their guidance in my studies
I am thankful to All Faculty of National CON

M Salman ijaz
Senior Elective Management
National College of Nursing
The University of Lahore

Abstract:
Work place violence is an alarming and devastating issue worldwide particularly in the emergency departments. Incident of work place violence is common towards nurses in health care settings. Nurses are more prone to workplace violence due to lack of respect towards nursing profession in Pakistani society and the nature of work performed by the nurses.
The main purpose of this study was to assess the prevalence of work place violence including physical and non physical and bring awareness about work place violence among nurses at the emergency departments of health care systems.
A cross sectional descriptive survey was performed to assess the prevalence of work place violence at tertiary care hospitals of Lahore. A convenient sample of n=147 was used to collect the data. A structured standardized adopted questionnaire was used to collect data. The questionnaire consisted demographic, physical and non physical variables. The data was collected from Jinnah and services hospital Lahore. The data was analyzed on SPSS version 21.
It was found that 77.55% stated that they are not exposed to physical violence last 12 months, 13.6% said once, 7.48% said 2-3 times and 1.3% stated they have been exposed 4-5 times during last year. On the other hand the participants exposed to Nonphysical violence in last 12 months,12.93% stated that they are not exposed to physical violence last 12 months, 25.85% said once, 40.82% said 2-3 times and 19.73% stated they have been exposed 4-5 times during last year.
Most recent physical incident in which 10.20% of incidents were happened at resuscitation room 2.04% at waiting room and 10.20% in treatment room. The most recent nonphysical incident in which 38.10% of incidents were happened at resuscitation room 0.68% in triage 12.24% at waiting room and 37.41% in treatment room 0.68% in other places.
It was also found that 2.04% incidents happened at morning shift 9.52% at evening 8.84% at night shift. Where as in nonphysical violence 11.56% incidents happened at morning shift 42.86% at evening 30.61% at night shift 3.40% participants was not sure about timing of the incident.

CHAPTER I: INTRODUCTION
1.1. Background:
Many countries of the world are encountered by Workplace physical violence almost in every field of employment which is a real matter of concern for (Blanchar, 2011). The prevalence of work place violence becomes a threat to employees’ safety, their dignity and causes lower wellbeing and thus the workers tend to become unhappy. Workplace violence appears among the leading threats to life and is considered as leading work place deaths among Us women workers. The lethal consequences of work place violence such as severe injuries have greater impact on life and cannot be underestimated by any state or country of the world (Boafo & Hancock, 2017).
Occupations such as Health care professions have even more severe consequences from work place violence which appears as a global phenomenon in terms of violence against health professionals at work place. It mainly encompasses verbal threats or abuse, physical assault among health care workers and sexual harassment etcetera. The verbal violence is reported the highest of all work place violence. Moreover, the Nurses face the work place violence more than any other health care discipline because they remain in more contact with patients and their families (Alameddine, Mourad, & Dimassi, 2015).
Some highlighted areas at the hospital are at greater risk of work place violence. These areas include the Psychiatric wards, emergency departments of the hospital, and sometimes high dependency units of health care systems. The occurrence of violence in the psychiatric wards and the emergency departments are reported in almost 100% in hospitals which is more than any other department in the hospital (Somani, 2012).
Workplace violence among nurses is defined as occurrence of some form of aggression such as physical aggression, sexual aggression, emotional or psychological threats against nurses, where the nurses are abused, assaulted, and threats in their work place circumstances. It is also claimed that workplace violence has very bad impact on the cost of any hospital in terms of increasing the financial burden which might reach up to 4.2 billion dollars annually(Somani, 2012).
It may also be defined as “Incidents of activities where the nurses are abused verbally, harassed sexually,or might face assaulted in their work place environment. This may challenge their safety and security, their health and wellbeing (Baydin ; Erenler, 2014).The effects of work place violence is not limited to nurses only, rather it also have equal impact on doctors and other health care workers (Kowalenko, Hauff, Morden, ; Smith, 2012).
Thls is recognized as high risk occupation which gaining more attention due to high occurrence of violent attacks on the working nurses. It was found by National Crime Victimization thatnon-fatal violence is about 21.9 per 1,000 among the nurses which is less in average than other profession (12.6 per 1,000 workers). The nurses of the emergency departments are the primary target of work place violence at every health care setup. In a previous study, conducted at the emergency departments, 82% of the nurses indicated that they have been assaulted in the last 12 months(May ; Grubbs, 2002).
It is suggested that the incidence of verbal abuse is rising day by day and reaching almost 100% nurses at the emergency departments of many hospitals. The American Nurses Association found very few nurses are safe from the work place violence (Less than 20%). There is no support from the institutions to prevent violence among nurses which contributes to more dissatisfaction among them (Gacki-Smith et al., 2010).
Work place violence is very common everywhere in every hospital against nurses but it is on the top in low socioeconomic developing countries of the world. Pakistan is one of such countries having high incidence of work place violence among nurses at work environment. There is also another issue of poor reporting, lack of documentation and un- published status of such violence in the health care setups. Such high incidences of work place violence among nurses put the managements of different organizations in the challenging situations(Somani, 2012)
Health care workers’ especially nurses of the emergency departments may experience lots of workplace violence which may cause low satisfaction and poor performance among them (Hesketh et al., 2003). If there is no full performance of nurses due to unsafe environment, it will have direct impact on patients care outcomes and ultimately leads to ineffective and poor services of the hospitals (Kwok et al., 2006).
Despite of so many bad consequences of work place violence among nurses, it is still under reported and under rated issue. This lack of reporting may be because of fear, stigma and blame of being harassed. More seriously, the society might think that the nurses are made to bear such violence as part of their care that is why they are expected to tolerate it (Alameddine et al., 2015)
This paper presents workplace violence towards nurses as a major issue in the context of health care settings in Pakistan. Heresome characteristics of violence against the emergency nurses will be highlighted; some problems will be analyzed from different ethical professional and legal perspectives.Here some physical and psychological consequences of work place violence will be highlighted too.
1.2. Problem Statement:
Workplace violence among nurses is known to affect their job working environment, which may lead to decrease in their services at the emergency departments. Furthermore, the work place violence might be associated with physical and emotional imbalances among nurses at their duty. If the nurses are not balance physically and mentally, their care will not be according to standards, therefore there is need to identify the prevalence of violence, the types of violence at work place and also the measures to eliminate the high occurrence of work place violence among nurses.
1.3. Research Question:
1. What is the prevalence of violence against nurses working in the emergency departments of public tertiary hospitals Lahore?
2. What are the types of violence against nurses working in the emergency departments of public tertiary hospitals Lahore?
3. What are the contributing factors for workplace violence against nurses working in the emergency departments of public tertiary hospitals Lahore?
1.4. Significance:
Workplace violence is an issue of international health care among the workers at all departments of the health care systems but more sever at the emergency departments. Direct violence or indirect violence which may be physical or non-physical violence among nurses at the emergency departments might cause negative consequences in the future of nurses. If nurses of emergency department be aware of the types and causes of violence they can decrease the bad consequences and will avoid negative effect on the quality of health care providers and patients. The decrease in the productivity of nursing care will be minimized, negative impact on nurses whether it is physically or psychologically will be controlled. This may help the nurses to resolve violence related issues and continue a peaceful job life ahead.
1.5. Research Purpose:
The aim of this study is to bring awareness about work place violence among nurses at the emergency departments of health care systems. It will further reveal the issue of workplace violence after finding the prevalence at the emergency departments.
1.6. Objectives:
1. To assess the prevalence of violence against nurses working in the emergency departments of public tertiary hospitals Lahore
2. To identify the types of violence against nurses working in the emergency departments of public tertiary hospitals Lahore
3. To determine the contributing factors for workplace violence against nurses working in the emergency departments of public tertiary hospitals Lahore
1.7. Definitions:
a) Workplace Violence
Incidents where staff are abused, threatened or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being or health.
b) Physical violence:
It occurs when an employee is exposed to the deliberate use of force such as beating, pushing, slapping, and kicking, biting, pinching, stabbing, shooting by the patient and/or their families, a colleague or any others. Physical violence may lead to physical harm or emotional or sexual harm to the abused employee.
c) Verbal violence:
This happen when someone such as (patient, patients’ relatives, visitors, and coworkers) shout, curses or use other words to verbally insult the employee without an intention to bodily harm. For example someone yells at you. This includes any behavior towards an employee based on age, disability, gender, race, poverty, richness, or any other unwanted status which negatively influence the dignity of employee.
d) Sexual violence:
Any unwanted, unwelcomed and non-reciprocal sexual attention. It may include sexist remarks, behavior or sexual advances which results in a tense and unproductive environment. These forms of harassments/ abuse threaten the employees and cause them to feel humiliated.
1.8. Variables
Independent variable
Personal characteristic such as Gender, age, Marital status, experience and place of violence etcetera.
Dependent variables:
Prevalence of violence and Types of violence

Chapter II: Literature Review
Different literature studies are available regarding workplace violence among nurses. Here also some studies were found about workplace violence among nurses, workplace aggression of patients and families against nurses, violence against nurses at the emergency department and nurse’s perception of workplace violence at the emergency departments.
Workplace violence is the act which involves physical and nonphysical threats of assault affecting the nurses at their work places. Even verbal violence such as threats and verbal abuse against nurses, hostility for nurses, harassment against them can cause equal mental and psychological trauma to physical work place violence (Gomaa et al., 2015).
Study conducted by the Emergency Nurses Association (ENA), found that in the united states every year about nine hundred deaths occurs due to work place violence and around 1.7 million less life threatening assaults occur annually. This is still an unclear estimate of the severity of the work place violence. Further the Bureau of Labor and Statistic’s Survey conducted about the Occupational Injuries and violence found that the violence at work place among the health care workers is much higher than other profession (Albashtawy, 2013).
Emergency departments are working for 24 hours and have risks of much violence. Some situations like the lack of adequate training, physical security, lack of visible security guards and increased stress in the department make nurses of the emergency department more prone to work place violence. In a study 25% of the study participants at the emergency departments experience physical violence and around 20% stated verbal violence experience during last three years (Gacki-Smith et al., 2009).
Prevalence of Violence among nurses of Emergency Department:
A study assessed the prevalence of work place violence among the emergency nurses which was found that 44.6% nurses during the last year have experienced work place violence. Furthermore verbal abuse was found the most common work place violence. The physical and sexual assault were less in number as compare to verbal violence. Many nurses have experienced a combination of physical and nonphysical violence both. The work place violence was mostly caused by the patients, then the relatives and colleagues while least violence was recorded from supervisors’ side. Almost half of the nurses said that the violence they have experienced was preventable with proper care. Moreover all the nurses mentioned few management techniques for work place violence such as discussing with colleagues, reporting to the immediate supervisors, and confronting to the perpetrator of violence etcetera (Cheung & Yip, 2017).
Another study also conducted among health care workers to assess the work place violence among them. It was found that about 60% of the study participants, who were working at the emergency departments exposed to violence during their duty in the last one year. A total of 65.7% nurses exposed to verbal violence at their work place. Majority of the HCW 61% were females who got affected by violence. The occurrence of violence was found different in different individuals. Some experienced work place violence very frequently, other faced it once a month etcetera. The violence from patients relative was found at the top (89.7% of verbal violence) and for 90.5% of physical violence. Verbal violence mostly found in the evening shift (Abdellah & Salama, 2017).
Types of Violence among ER Nurses:
Some commonest physical violence types were experienced by more than 50% nurses were, they were being spit on, pushed by patients or relatives, scratched and being kicked. Among the verbal violence, the most common (70%) was yelling from patients and their families, intimidated and being harassed with sexually abusive language. The perception of safety was found very low and about 70% participants showed less than 50% safety perception. About 33% participants were in favor of leaving emergency department due to increased work place violence (Gacki-Smith et al., 2010).
Findings of another study reveals that incidence of verbal violence was (63.9%), which was almost five times more than physical violence (11.9%) at the emergency department among nurses in the last 12 months of period. Verbal violence at the emergency department was mainly by the patients against nurses then secondly by their family members and relatives. The rate of physical violence was also high from patients and their family members. Afternoon shift was found to have more work place violence at the emergency departments due to increased patients inflow (Albashtawy, 2013).
According to another study verbal violence was found among the 86% of nurses at the emergency departments. Threats were also found high among the (35%) of the study participants. Physical abuse was also found among the nurses from the patients and their families but it was lower than that of verbal assault. No difference of violence exposure was found between males and females or based on the specialty such as medical and surgical. However very few respondents were from emergency to have a meaningful comparison (Imran, Pervez, Farooq, & Asghar, 2013).
Contributing factors for Work Place violence:
Patients relatives were overall the most common source of work place violence among the emergency department nurses (71%) followed by patients (30.5%). Results also showed that there are other various aspects of work place violence caused by colleagues, supervisors also (Imran et al., 2013).It is observed that there are under reported may be due to feeling of uncomforted and lack of support from the organization. There is also lack of a well-structured reporting system for work place violence in many health care organizations. It is very important to identify the contributing factors for work place violence (Somani, 2012).
It is very clear from previous studies that the major contributor of workplace violence among nurses at the emergency department was found patients which is followed by the relatives of the patients. Along with patients and their relatives, the nursing colleagues, senior nurses, the manager nurses, and on duty doctors also are the contributing factors for work place violence among the emergency department nurses (Kwok et al., 2006).
According to another study, workplace physical violence against the emergency department nurses was perpetrated mainly by patients followed by their relatives and then by other nurses. The results of the study found that relatives of patients were the most frequent contributors of physical violence against the emergency department nurses. They were responsible for a large number of cases (58.5%)(Boafo & Hancock, 2017).

CHAPTER III: METHODOLOGY
3.1. Research Design:
A descriptive cross-sectional study design was used to conduct this study. Data about the violence against emergency department nurses was collected at one point in time with the help of a questionnaire.
3.2. Time Period:
This study was conducted from February 2018 to May 2018 for about 4 months period of time.
3.3. Site and setting of the study:
This study was conducted among the nurses at the Emergency Departments of two public tertiary care hospitals Lahore. They are the Jinnah Hospital Lahore and Services Hospital Lahore.
3.4. Population:
The study was conducted among the nurses. The population for this study was all nurses who are working in emergency departments of the selected hospitals, the Jinnah Hospital and the Services Hospital Lahore.
3.5. Sample size Determination
The minimum sample required is calculated using the single proportion formula which is given below.
? = ?2(1 ? ?) /?2
d= Acceptable margin of error (precision of measurement) = 5%
z= Standard variant (1.96) which correspond to 95% confidence level
p= Overall prevalence of workplace violence among nurses in public health facilities in
Nazish Imran2013 (73%).
(1.96)2 0.73 (1?0.73) /(0.05)2 =
(1.96)2 0.73 (1?0.73) /(0.05)2 =
3.8416* 0.73 (0.27) /(0.0025)=
2.804* 108 = 302
Since the total number of study population is < 10,000 (N=400) using the correction formula the final sample size will benf = ???/ ?+?
400?302 /400+302 = 147
120,800 /702 = 147
3.6. Sampling procedure
Sampled will be selected from the emergency departments of two public hospitals through convenient sampling methods. N=75 will be selected from Jinnah Hospital while remaining 72 nurses will be selected from services hospital emergency department.
3.7. Inclusion criteria
All nurses from the emergency departments were recruited who were:
1. Willing to participate in the study
2. Working in emergency department at least one year
3. Registered with Pakistan Nursing council
3.8. Exclusion criteria
Those nurses will not be recruited who are:
1. All nurses who were not at work place during data collection period
2. Those who were not willing and not registered
3.9. Data collection tool
A self-administered standardized adopted questionnaire was used to collect the data. The questionnaire adopted from a study ‘Work place violence against nurses working in the emergency department of in Saudi Arabia’ by Fuaad Ali Alshehri(Albashtawy, 2013).
The first section of the questionnaire consisted off the demographic information about the age, gender, education and working experience of the participants. The second and third parts of the questionnaire discussed the physical and nonphysical violence among nurses at the emergency departments. The participants of the study were asked to fill the questionnaire of work place violence.
3.10. Data processing, Analysis and presentation
The data was put into the SPSS version 21. The results were processed and analyzed with the help of graphs, tables in the form of frequencies, averages and percentages.
3.11. Ethical Consideration
An approval was taken from the committee of national college of nursing. Then permission was taken from the heads of the study setting such as Head of Jinnah hospital and Head of the services Hospital. A written permission was taken from each individual participant of the study. Each participant was provided with the questionnaire with an informed consent which was explained the purposes and significance of the study. The study participants were assured that their names will be kept confidential. Their participation was fully volunteer and can withdraw at any time.

CHAPTER IV: RESULTS

4.1 Demographic data analysis and results

The below table shows about the gender of participants that were 6.80% were male and 93.20% was female. Result also shows the age of the participants of study from which 10.20% were less than 25 years & 53.06% were between 26 to 30 years 27.89% were between the age of 31 to 35 years 6.12% were between the age of 36 to 40 years and 2.72% participants of study were more than 40 years of age. It was also found that the education level of the study participants from which 19.05% were only have general nursing diploma 40.14% of study participants having specialization as well 40.82% have the degree of generic BSN and post RN BSN degree.
Table 1: Frequency and percentage of demographics data

Variables Number (n) Per cent
Gender
Male
Female
10
137
6.8
93.2
Age:
Less than 25 years
26-30 years
31-35 years
36-40 years
Above 40 years
15
78
41
9
4
10.2
53.1
27.9
6.1
2.7
Education:
Nursing Diploma
Diploma plus specialization
BSN/PRN BSN
MSN/MPH
28
59
60

19.0
40.1
40.8

Experience
77
51
15
4

52.4
34.7
10.2
2.7

1-5 years
6-10 years
11-15 years
Above 15years

4.2: DESCRIPTIVE ANALYSIS OF PHYSICAL AND NONPHYSICAL VIOLENCE
Below Table 2 shows that in response for how many times the participants exposed to physical violence in last 12 months. It was found that 77.55% stated that they are not exposed to physical violence last 12 months, 13.6% said once, 7.48% said 2-3 times and 1.3% stated they have been exposed 4-5 times during last year. On the other hand the participants exposed to Nonphysical violence in last 12 months,12.93% stated that they are not exposed to physical violence last 12 months, 25.85% said once, 40.82% said 2-3 times and 19.73% stated they have been exposed 4-5 times during last year. The type of physical assault the study participants was asked and 4.08% of participants had experience beating, 9.52% experience pushing, 6.12% of study participants had experience slapping, 1.36% pinching, 1.36% shooting, and not applicable for 77.55% of study participants. Similarly about types of nonphysical assault the study participants were exposed to, 50.34% of participants had experience threats, 36.05% experience verbal abuse and 2.04% of study participants had experience sexual harassment/abuse. Regarding the physical assaulters to staff from which 8.16% were patients, 13.61% were relatives of patients, 0.68% were coworkers of the staff and not applicable for 77.55% participants. About the assaulters of nonphysical at staff from which 19.73% were patients, 63.27% were relatives of patients, 5.44% were coworkers of the staff and not applicable for 11.56% participants. It was also found that 2.04% incidents happened at morning shift 9.52% at evening 8.84% at night shift and not applicable for 77.55% of study participants in terms of physical violence. Where as in nonphysical violence 11.56% incidents happened at morning shift 42.86% at evening 30.61% at night shift 3.40% participants was not sure about timing of the incident and not applicable for 11.56% of study participants.

Most recent physical incident in which 10.20% of incidents were happened at resuscitation room 2.04% at waiting room and 10.20% in treatment room and this question was not applicable for 77.55% of participants. The most recent nonphysical incident in which 38.10% of incidents were happened at resuscitation room 0.68% in triage 12.24% at waiting room and 37.41% in treatment room 0.68% in other places and this question was not applicable for 10.88% of participants.
Furthermore to physical violence 1.36% said yes received treatment, 12.24% not need, 2.04% not received and 6.80% self-treated and this question was not applicable for 77.55% of study participants. Similarly in nonphysical violence, 0.68% said yes received treatment, 68.71% no need, 3.40% not received and 15.65% self-treated. Result also shows that percentage by whom physical violence victim was treated 6.12% was treated by nurse 16.33% not treated and not applicable for 77.55% of study participants. It was also found in nonphysical violence that victim was treated 10.20 % was treated by nurse, 0.68% by psychiatrist, 0.68% by others 76.87% not treated and not applicable for 11.56% of study participants. The Findings also show the percentage of the cause of most recent incident from which 12.93% of participants said that it was due to waiting for services 5.44% was unable to meet patients desire 2.72% was due to unavailability of services 1.36 % was due to lack of preventive tools and not applicable for 77.55% of study participants. The cause of most recent nonphysical incidents from which 24.49% of participants said that it was due to waiting for services 13.61% was unable to meet patients desire 6.12% was due to mental illness 1.36% was due to way of dealing with patients 29.25% was due to unavailability of services 8.84 % was due to lack of preventive tools 4.76% said that it was due to impact of disease or pain and not applicable for 11.56% of study participants.

(Table 2) Frequency and percentage of the Violence

Variables Physical Violence Non-Physical Violence

Number of Time Being exposed Number(n) Percent Number(n) Percent
Never
Once
2-3 Times
4-5 times
6 times 114
20
11
2
00 77.6
13.6
7.5
1.4
00 19
38
60
29
01 12.9
25.9
40.8
19.7
.7
Who Assaulted
Patients
Visitors/Patients’ relatives
Co-workers
Not applicable 12
20
1
114 8.2
13.6
.7
77.6 29
93
8
17 19.7
63.3
5.4
11.6
When the Incidence Happened?
Morning
Afternoon
Night
Unsure
Not applicable 3
14
13
3
114 2.0
9.5
8.8
2.0
77.6 17
63
45
5
17 11.6
42.9
30.6
3.4
11.6
Where the incidence happened?
Resuscitation
Waiting Room
Triage
Treatment
Hallway
Not applicable 15
3
0
15
0
114 10.2
2.0
0
10.2
0
77.6 56
18
1
55
0
18 38.1
12.2
.7
37.4
0
10.9
Receiving treatment after the incident
Yes, received
There was no need
Needed but did not received
Self treated
Not applicable 2
18
3
10
114 1.4
12.2
2.0
6.8
77.6 1
101
5
23
17 .7
68.7
3.4
15.6
11.6
Who treated?
Doctors
Psychiatrist
Nurse
Not treated
Not applicable 0
0
9
24
114 0
0
6.1
16.3
77.6 0
1
15
113
17 0
.7
10.2
76.9
11.6
The causes of most Recent Incident
Waiting for receiving services
Failure to meet patients’ desire
Mental illness
Way of dealing the patients
Unavailability of the services
Fear stress
Lack of preventive tools
Impact of disease or pain
Not applicable 19
8
0
0
4
0
2
0
114 12.9
5.4
0
0
2.7
0
1.4
0
77.6 36
20
9
2
43
0
13
7
17 24.5
13.6
6.1
1.4
29.3
0
8.8
4.8
11.6

4.3: Summary of Physical and Nonphysical Violence:

The following Table 3 suggests that 4.1% of the study participants had Beating experience, 9.5% experienced pushing, 6.9% faced slapping, no kicking or biting was found, pinching and shooting was 1.4% each, while the rest of 77% had no experienced of physical violence.

Table 3: Summary of Physical Violence

Variable Category
Type of physical Violence N %
Beating
Pushing
Slapping
Kicking
Biting
Pinching
Shooting
Stabbing
Not applicable 6
14
9
0
0
2
2
0
114 4.1
9.5
6.1
0
0
1.4
1.4
0
77.6

The following Table 4 findings indicate thatabout 50.3% of the study participants had faced threats as nonphysical violence, 36.1% experienced Verbal abuse/Harassment, while 2% have experience Sexual Abuse/Harassment and 11.6% faced no any nonphysical violence during last 1 year.

Table 4: Summary of Nonphysical Violence

Variable Category
Type of Nonphysical Assault N %
Threats
Verbal abuse/Harassment
Sexual Abuse/Harassment
Not applicable 74
53
3
17 50.3
36.1
2.0
11.6

4.3.2: Descriptive analysis of Physical Violence
How many times have you been exposed to physical violence during the last 12 months?
Frequency Percent Valid Percent Cumulative Percent
Valid Never 114 77.6 77.6 77.6
Once 20 13.6 13.6 91.2
2-3times 11 7.5 7.5 98.6
4-5 times 2 1.4 1.4 100.0
Total 147 100.0 100.0

The above table and Graph shows that in response for how many times the participants exposed to physical violence in last 12 months. It was found that 77.55% stated that they are not exposed to physical violence last 12 months, 13.6% said once, 7.48% said 2-3 times and 1.3% stated they have been exposed 4-5 times during last years.

What type of physical assault were you exposed to during the most recent incidence?
Frequency Percent Valid Percent Cumulative Percent
Valid Beating 6 4.1 4.1 4.1
Pushing 14 9.5 9.5 13.6
Slaping 9 6.1 6.1 19.7
Pinching 2 1.4 1.4 21.1
Shooting 2 1.4 1.4 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph shows the type of physical assault the study participants were exposed to in which 4.08% of participants had experience beating 9.52% experience pushing 6.12% of study participants had experience slapping 1.36% pinching 1.36% shooting and not applicable for 77.55% of study participants.

In the most recent physical incident who assault you?
Frequency Percent Valid Percent Cumulative Percent
Valid Patients 12 8.2 8.2 8.2
Relatives 20 13.6 13.6 21.8
Co-Workers 1 .7 .7 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph show the percentage of physical assaulters to staff from which 8.16% were patients 13.61% were relatives of patients 0.68% were coworkers of the staff and not applicable for 77.55% participants.

In the most recent physical incident when did the incident happened?
Frequency Percent Valid Percent Cumulative Percent
Valid Morning 3 2.0 2.0 2.0
Afternoon 14 9.5 9.5 11.6
Night 13 8.8 8.8 20.4
Not sure 3 2.0 2.0 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph show the timing of physical incident from which 2.04% incidents happened at morning shift 9.52% at evening 8.84% at night shift and not applicable for 77.55% of study participants.

In the most recent physical incident where did the incident happened?
Frequency Percent Valid Percent Cumulative Percent
Valid Resuscitation 15 10.2 10.2 10.2
Waiting room 3 2.0 2.0 12.2
Treatment room 15 10.2 10.2 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph shows the location of most recent incident in which 10.20% of incidents were happened at resuscitation room 2.04% at waiting room and 10.20% in treatment room and this question was not applicable for 77.55% of participants.

Did you receive treatment after the most recent incident?
Frequency Percent Valid Percent Cumulative Percent
Valid Yes received 2 1.4 1.4 1.4
No need 18 12.2 12.2 13.6
Not received 3 2.0 2.0 15.6
Self treated 10 6.8 6.8 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph shows the percentage of study participants who receive or didn’t receive the treatment after most recent physical incident in which 1.36% said yes received 12.24% no need 2.04% not received and 6.80% self treated and this question was not applicable for 77.55% of study participants.

If yes who treated You?
Frequency Percent Valid Percent Cumulative Percent
Valid Nurse 9 6.1 6.1 6.1
Not treated 24 16.3 16.3 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph shows the percentage by whom physical violence victim was treated 6.12% was treated by nurse 16.33% not treated and not applicable for 77.55% of study participants.

What do you think was the cause of the most recent incidence?
Frequency Percent Valid Percent Cumulative Percent
Valid Waiting for services 19 12.9 12.9 12.9
not meeting patients' desire 8 5.4 5.4 18.4
Unavailability of the services 4 2.7 2.7 21.1
Lack of preventive tools 2 1.4 1.4 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph shows the percentage of the cause of most recent incident from which 12.93% of participants said that it was due to waiting for services 5.44% was unable to meet patients desire 2.72% was due to unavailability of services 1.36 % was due to lack of preventive tools and not applicable for 77.55% of study participants.

4.3.2: Descriptive analysis of Nonphysical Violence:

How many times have you been exposed to Non-physical violence during the last 12 months?

Frequency Percent Valid Percent Cumulative Percent
Valid Never 19 12.9 12.9 12.9
Once 38 25.9 25.9 38.8
2-3times 60 40.8 40.8 79.6
4-5 times 29 19.7 19.7 99.3
6 or more times 1 .7 .7 100.0
Total 147 100.0 100.0

The above table and Graph shows that in response for how many times the participants exposed to physical violence in last 12 months. It was found that 12.93% stated that they are not exposed to physical violence last 12 months, 25.85% said once, 40.82% said 2-3 times and 19.73% stated they have been exposed 4-5 times during last year.

What type of non-physical assault were you exposed to during the most recent incidence?

Frequency Percent Valid Percent Cumulative Percent
Valid Threats 74 50.3 50.3 50.3
Verbal abuse/Harassment 53 36.1 36.1 86.4
Sexual abuse 3 2.0 2.0 88.4
Not applicale 17 11.6 11.6 100.0
Total 147 100.0 100.0

The above table and graph shows the type of non physical assault the study participants were exposed to in which 50.34% of participants had experience threats 36.05% experience verbal abuse and 2.04% of study participants had experience sexual harassment/abuse and not applicable for 11.56% of study participants.

In the most recent nonphysical incident who assault you?
Frequency Percent Valid Percent Cumulative Percent
Valid Patients 29 19.7 19.7 19.7
Relatives 93 63.3 63.3 83.0
Co-Workers 8 5.4 5.4 88.4
Not applicable 17 11.6 11.6 100.0
Total 147 100.0 100.0

The above table and graph show the percentage of non physical assaulters to staff from which 19.73% were patients 63.27% were relatives of patients 5.44% were coworkers of the staff and not applicable for 11.56% participants.

In the most recent nonphysical incident when did the incident happened?
Frequency Percent Valid Percent Cumulative Percent
Valid Morning 17 11.6 11.6 11.6
Afternoon 63 42.9 42.9 54.4
Night 45 30.6 30.6 85.0
Not sure 5 3.4 3.4 88.4
Not applicable 17 11.6 11.6 100.0
Total 147 100.0 100.0

The above table and graph show the timing of physical incident from which 11.56% incidents happened at morning shift 42.86% at evening 30.61% at night shift 3.40% participants was not sure about timing of the incident and not applicable for 11.56% of study participants.

In the most recent nonphysical incident where did the incident happened?
Frequency Percent Valid Percent Cumulative Percent
Valid Resuscitation 56 38.1 38.1 38.1
Triage 1 .7 .7 38.8
Waiting room 18 12.2 12.2 51.0
Treatment room 55 37.4 37.4 88.4
Others 1 .7 .7 89.1
Not applicable 16 10.9 10.9 100.0
Total 147 100.0 100.0

The above table and graph shows the location of most recent incident in which 38.10% of incidents were happened at resuscitation room 0.68% in triage 12.24% at waiting room and 37.41% in treatment room 0.68% in other places and this question was not applicable for 10.88% of participants.

Did you receive treatment after the most recent incident?

Frequency Percent Valid Percent Cumulative Percent
Valid Yes received 1 .7 .7 .7
No need 101 68.7 68.7 69.4
Not received 5 3.4 3.4 72.8
Self treated 23 15.6 15.6 88.4
Not applicable 17 11.6 11.6 100.0
Total 147 100.0 100.0

The above table and graph shows the percentage of study participants who receive or didn’t receive the treatment after most recent non physical incident in which 0.68% said yes received 68.71% no need 3.40% not received and 15.65% self treated and this question was not applicable for 11.56% of study participants.

If yes who treated You?

Frequency Percent Valid Percent Cumulative Percent
Valid Nurse 15 10.2 10.2 10.2
Psychiatristist 1 .7 .7 10.9
Others 1 .7 .7 11.6
Not treated 113 76.9 76.9 88.4
Not applicable 17 11.6 11.6 100.0
Total 147 100.0 100.0

The above table and graph shows the percentage by whom physical violence victim was treated 10.20 % was treated by nurse 0.68% by psychiatrist 0.68% by others 76.87% not treated and not applicable for 11.56% of study participants.

What do you think was the cause of the most recent incidence?

Frequency Percent Valid Percent Cumulative Percent
Valid Waiting for services 36 24.5 24.5 24.5
not meeting patients' desire 20 13.6 13.6 38.1
Mental illness 9 6.1 6.1 44.2
Way of dealing the patients 2 1.4 1.4 45.6
Unavailability of the services 43 29.3 29.3 74.8
Lack of preventive tools 13 8.8 8.8 83.7
Impact of disease or pain 7 4.8 4.8 88.4
Not appicable 17 11.6 11.6 100.0
Total 147 100.0 100.0

The above table and graph shows the percentage of the cause of most recent incident from which 24.49% of participants said that it was due to waiting for services 13.61% was unable to meet patients desire 6.12% was due to mental illness 1.36% was due to way of dealing with patients 29.25% was due to unavailability of services 8.84 % was due to lack of preventive tools 4.76% said that it was due to impact of disease or pain and not applicable for 11.56% of study participants.

Chapter 5: Discussion
This current study found that physical violence was about 22.5% where 4.1% of the study participants had Beating experience, 9.5% experienced pushing, 6.9% faced slapping and pinching and shooting was 1.4% each, while the rest of 77.5% had not experienced of physical violence. The prevalence of nonphysical violence was found about 88.4% where 50.3% of the study participants had faced threats as nonphysical violence, 36.1% experienced Verbal abuse/Harassment, while 2% have experience Sexual Abuse/Harassment and 11.6% faced no any nonphysical violence during last 1 year.
According to a previous study the verbal violence was found among the 86% of nurses at the emergency departments. Physical abuse was also found among the nurses from the patients and their families but it was lower than that of verbal assault. No difference of violence exposure was found between males and females or based on the specialty such as medical and surgical. However very few respondents were from emergency to have a meaningful comparison (Imran et al., 2013).
Similarly Findings of another study reveals that incidence of verbal violence was (63.9%), which was almost five times more than physical violence (11.9%) at the emergency department among nurses in the last 12 months of period (Albashtawy, 2013).
A previous study found some similar findings where nonphysical abuse was found the most common work place violence. The physical and sexual assault were less in number as compare to verbal violence (Cheung & Yip, 2017). According to another study, a total of 65.7% nurses exposed to nonphysical violence at their work place (Abdellah & Salama, 2017).
During my study the physical violence was mainly 13.61% were from relatives of patients (out of 22%), which becomes almost half the violence.
Similarly, in a previous study, violence from patients relative was found at the top (89.7% of verbal violence) and for 90.5% of physical violence. Verbal violence mostly found in the evening shift (Abdellah & Salama, 2017).
According to this study most common violence were 4.08% of participants had experience beating, 9.52% experience pushing, 6.12% of study participants had experience slapping, 1.36% pinching, 1.36% shooting and not applicable for 77.55% of study participants.
According to previous study some commonest physical violence types were experienced by more than 50% nurses were, they were being spit on, pushed by patients or relatives, scratched and being kicked (Gacki-Smith et al., 2010).
According to this current study, the type of nonphysical assault the study participants were exposed to in which 50.34% of participants had experience threats 36.05% experience verbal abuse and 2.04% of study participants had experience sexual harassment/abuse and not applicable for 11.56% of study participants. Previously, among the verbal violence, the most common (70%) was yelling from patients and their families, intimidated and being harassed with sexually abusive language. (Gacki-Smith et al., 2010). According to another study, threats were also found high among the (35%) of the study participants (Imran et al., 2013).

Chapter 6: Conclusion

Conclusion
The purpose of this study was to assess the prevalence of work place violence and types of physical and non physical violence in the public hospitals of Lahore. The emergency nurses during study indicated that violence was a common occurrence.
It was found that 77.55% stated that they are not exposed to physical violence last 12 months, 13.6% said once, 7.48% said 2-3 times and 1.3% stated they have been exposed 4-5 times during last year. On the other hand the participants exposed to Nonphysical violence in last 12 months,12.93% stated that they are not exposed to physical violence last 12 months, 25.85% said once, 40.82% said 2-3 times and 19.73% stated they have been exposed 4-5 times during last year.
Most recent physical incident in which 10.20% of incidents were happened at resuscitation room 2.04% at waiting room and 10.20% in treatment room. The most recent nonphysical incident in which 38.10% of incidents were happened at resuscitation room 0.68% in triage 12.24% at waiting room and 37.41% in treatment room 0.68% in other places.
It was also found that 2.04% incidents happened at morning shift 9.52% at evening 8.84% at night shift. Where as in nonphysical violence 11.56% incidents happened at morning shift 42.86% at evening 30.61% at night shift 3.40% participants was not sure about timing of the incident.

Recommendations
This study addressed several areas requiring further research. There is a shortage of violence research among emergency nurses in Lahore. Further research is needed to develop strategies for preventing violence against emergency nurses, which would need to consider the local culture and findings of this study. Further in depth research is needed to assess the impact of violence on the perception and professional life of emergency nurses.

Limitations
This was my first research study so due to lack of expertise there are some limitations.it may be better if I can relate different kind of professional, environmental and cultural factors affecting work place violence in my study, but due to lack of time and less expertise I was unable to do that. Hopefully it will be better in my next studies.

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Informed consent:

Workplace violence against nurses working in emergency departments at a public hospital Lahore

Dear participants,
I am Salman Ijaz, want to conduct a research on “Workplace violence against nurses working in emergency departments at a public hospital Lahore”. As this Research project work for the fulfillment of my Post RN BSN degree from National College of Nursing, affiliated with the University of Lahore. The purpose of this research study is to assess the Workplace violence against nurses working in emergency departments at a public hospital Lahore.A questionnaire will be distributed for data collection, for which your cooperation is required. The questionnaire will take about 20-30 minutes to complete. Your participation will be very helpful for me to complete my study. Your valued information will be kept confidential. You are allowed to withdraw at any time from research study.
I have read all the terms and voluntarily consent to participate in the research study.

Participant's Signature:………………………..
Date: ………………………….

Questionnaire:

Workplace Violence against nurses working in emergency departments at a Public Hospital Lahore
Section 1: Demographic Data:

1. Gender:

1. Male ( ) 2. Female ( )

2. Age in Years:

1.Below 25 ( ) 2. 26-30 ( ) 3. 31-35 ( ) 4. 36-40 ( ) 5. above 40 ( )

3. Education:

1. Diploma GN ( ) 2. Specialization ( ) 3. BSN/Post RN ( ) 4.MSN ( )

4. Experience:

1.1-5 years ( ) 2. 6-10 years ( ) 3. 11-15 Years ( ) 4. Above 15 years ( )

Section 2: Physical Violence:

s. No Statement Options
1 How many times have you been exposed to physical violence during the last 12 months? Never
Once

2-3
4-5

6 or more times
2 What type of physical assault were you exposed to during the most recent incidence? Beating
Pushing
Slapping

Kicking
Biting
Pinching

Shooting
Stabbing
Others

3 In the most recent physical incident who assault you? Patients
Relatives

Coworkers
Others ______

4 In the most recent physical incident when did the incident happened? Morning
Afternoon

Night
Not sure

5 Where did the most recent incident happen? Resuscitation
Triage

Waiting Room
Treatment room

Other specify ______

6 Did you receive treatment after the most recent incident? Yes received
No Need

Did Not receive
Self-treated

7 If yes who treated You? Doctors
Nurse

Psychiatrist
Others

Not treated

8 What do you think was the cause of the most recent incidence? Waiting for receiving services

Failure to meet patients’ desire

Mental illness

Way of dealing the patients

Unavailability of the services

Fear stress

Lack of preventive tools

Impact of disease or pain

Section 3: Non Physical Violence:

s. No Statement Options
1 How many times have you been exposed to Non-physical violence during the last 12 months? Never
Once

2-3
4-5

6 or more times
2 What type of physical assault were you exposed to during the most recent incidence? Threats

Verbal abuse/Harassment

Sexual abuse Harassment

3 In the most recent physical incident who assault you? Patients
Relatives

Coworkers
Others ______

4 In the most recent physical incident when did the incident happened? Morning
Afternoon

Night
Not sure

5. Where did the most recent incident happen? Resuscitation
Triage

Waiting Room
Treatment room

Other specify ______

6. Did you receive treatment after the most recent incident? Yes received
No Need

Did Not receive
Self-treated

7. If yes who treated You? Doctors
Nurse

Psychiatrist
Others

Not treated

8. What do you think was the cause of the most recent incidence? Waiting for receiving services

Failure to meet patients’ desire

Mental illness

Way of dealing the patients

Unavailability of the services

Fear stress

Lack of preventive tools

Impact of disease or pain

Section 4: Preventing/managing procedures for Assault reports:

S. No Statement Yes No Don’t Know
9. Are there enough methods to prevent violence on staff (Guard, Security, Camera, warning devices ) in the departments
10. Are there enoughpolicies systems and instructions to prevent violence on workers in the hospitals?
11. Are there reporting procedures for the reporting violence in the hospitals?
12. Did you receive training or educational programs by the hospital to prevent and deal with violence?
13. In the most recent incidence did you write report to your administrator or any other third party authority?
14. Has any action been taken against the assaulter?
15. Does the violence have Negative impact on you?
16. Do you think stop working in the coming 1-3 years due to violence in the work area?

WORKPLACE VIOLENCE AGAINST NURSES WORKING IN EMERGENCY DEPARTMENTS AT PUBLIC HOSPITALS LAHORE

Submitted by
M Salman Ijaz

SUPERVISOR: AFSAR ALI
CO-SUPERVISOR: Ms. Naseem Rooman

______________________________________________________________________________
NATIONAL COLLEGE OF NURSING AFFILIATED WITH
THE UNIVERSITY OF LAHORE
ACADEMIC YEAR 2016-18

Table of Contents
Abstract 1
1. Introduction 2
1.1. Background 2
1.2. Problem Statement……………….………………………………………………………..3

1.3. Research Significance 4
1.4. Research Purpose 5
1.5. Research Objectives 5
1.6. Research Question 5
1.7. Operational definitions 6
Chapter 2 7
2. Literature Review 7
Chapter 3. Methodology 11
3.1. Research Design 11
3.2. Site 11
3.3. Setting 11
3.4. Population 12
3.5. Inclusion criteria 12
3.6. Exclusion criteria 12
3.7. Sampling method 15
3.8. Sample size 15
3.9. Data collection 13
3.10. Data Analysis 13
3.11. Ethical considerations 13
4. Results…………………………………………………………………………………………………..14
5. Discussion……………………………………………………………………………………………..35

6. Conclusion……………………………………………………………………………….…………….37

7. References 39
8.Inform consent and questionnaire 41

Dedication:

I would like to thank ALLAH supporting and helping me to complete this study.

This project work is dedicated to my parents and Teachers for their endless love, support and encouragement.

I am eternally grateful to my parents, who have supported and encouraged me to continue my studies. I appreciate the encouragement from my brothers sisters friends and my group members especially Anam khadim, Dilnesheen safdar, Sumera Rehman, Sehar Shabir and Kiran Akhter for their constant support.

Professionally I would like to extend my thanks for all assistance and support provided to me by my principal Naseem Roman my principal supervisor Afsar Ali my program coordinator Nosheen Noruddin the whole National College of nursing team and management and to the participants of research for their contribution and cooperation.

Acknowledgement:
I am highly thankful to Allah for giving me the strength and knowledge to carry out this research work. Without Allah's blessings and providence it would not be possible to complete this research project successfully. After that I am grateful to my parents and family members who gave me enough courage and support to complete this work.
I am highly thankful to my supervisor (sir. Afsar Ali) and Co supervisor Ms. Naseem Rooman (the principal college of nursing NH ; MC) for their guidance and support
I am thankful to the entire Management of National college and hospital Lahore
I am thankful to the Management of UOL, Lahore school of nursing for their guidance in my studies
I am thankful to All Faculty of National CON

M Salman ijaz
Senior Elective Management
National College of Nursing
The University of Lahore

Abstract:
Work place violence is an alarming and devastating issue worldwide particularly in the emergency departments. Incident of work place violence is common towards nurses in health care settings. Nurses are more prone to workplace violence due to lack of respect towards nursing profession in Pakistani society and the nature of work performed by the nurses.
The main purpose of this study was to assess the prevalence of work place violence including physical and non physical and bring awareness about work place violence among nurses at the emergency departments of health care systems.
A cross sectional descriptive survey was performed to assess the prevalence of work place violence at tertiary care hospitals of Lahore. A convenient sample of n=147 was used to collect the data. A structured standardized adopted questionnaire was used to collect data. The questionnaire consisted demographic, physical and non physical variables. The data was collected from Jinnah and services hospital Lahore. The data was analyzed on SPSS version 21.
It was found that 77.55% stated that they are not exposed to physical violence last 12 months, 13.6% said once, 7.48% said 2-3 times and 1.3% stated they have been exposed 4-5 times during last year. On the other hand the participants exposed to Nonphysical violence in last 12 months,12.93% stated that they are not exposed to physical violence last 12 months, 25.85% said once, 40.82% said 2-3 times and 19.73% stated they have been exposed 4-5 times during last year.
Most recent physical incident in which 10.20% of incidents were happened at resuscitation room 2.04% at waiting room and 10.20% in treatment room. The most recent nonphysical incident in which 38.10% of incidents were happened at resuscitation room 0.68% in triage 12.24% at waiting room and 37.41% in treatment room 0.68% in other places.
It was also found that 2.04% incidents happened at morning shift 9.52% at evening 8.84% at night shift. Where as in nonphysical violence 11.56% incidents happened at morning shift 42.86% at evening 30.61% at night shift 3.40% participants was not sure about timing of the incident.

CHAPTER I: INTRODUCTION
1.1. Background:
Many countries of the world are encountered by Workplace physical violence almost in every field of employment which is a real matter of concern for (Blanchar, 2011). The prevalence of work place violence becomes a threat to employees’ safety, their dignity and causes lower wellbeing and thus the workers tend to become unhappy. Workplace violence appears among the leading threats to life and is considered as leading work place deaths among Us women workers. The lethal consequences of work place violence such as severe injuries have greater impact on life and cannot be underestimated by any state or country of the world (Boafo & Hancock, 2017).
Occupations such as Health care professions have even more severe consequences from work place violence which appears as a global phenomenon in terms of violence against health professionals at work place. It mainly encompasses verbal threats or abuse, physical assault among health care workers and sexual harassment etcetera. The verbal violence is reported the highest of all work place violence. Moreover, the Nurses face the work place violence more than any other health care discipline because they remain in more contact with patients and their families (Alameddine, Mourad, & Dimassi, 2015).
Some highlighted areas at the hospital are at greater risk of work place violence. These areas include the Psychiatric wards, emergency departments of the hospital, and sometimes high dependency units of health care systems. The occurrence of violence in the psychiatric wards and the emergency departments are reported in almost 100% in hospitals which is more than any other department in the hospital (Somani, 2012).
Workplace violence among nurses is defined as occurrence of some form of aggression such as physical aggression, sexual aggression, emotional or psychological threats against nurses, where the nurses are abused, assaulted, and threats in their work place circumstances. It is also claimed that workplace violence has very bad impact on the cost of any hospital in terms of increasing the financial burden which might reach up to 4.2 billion dollars annually(Somani, 2012).
It may also be defined as “Incidents of activities where the nurses are abused verbally, harassed sexually,or might face assaulted in their work place environment. This may challenge their safety and security, their health and wellbeing (Baydin & Erenler, 2014).The effects of work place violence is not limited to nurses only, rather it also have equal impact on doctors and other health care workers (Kowalenko, Hauff, Morden, & Smith, 2012).
Thls is recognized as high risk occupation which gaining more attention due to high occurrence of violent attacks on the working nurses. It was found by National Crime Victimization thatnon-fatal violence is about 21.9 per 1,000 among the nurses which is less in average than other profession (12.6 per 1,000 workers). The nurses of the emergency departments are the primary target of work place violence at every health care setup. In a previous study, conducted at the emergency departments, 82% of the nurses indicated that they have been assaulted in the last 12 months(May & Grubbs, 2002).
It is suggested that the incidence of verbal abuse is rising day by day and reaching almost 100% nurses at the emergency departments of many hospitals. The American Nurses Association found very few nurses are safe from the work place violence (Less than 20%). There is no support from the institutions to prevent violence among nurses which contributes to more dissatisfaction among them (Gacki-Smith et al., 2010).
Work place violence is very common everywhere in every hospital against nurses but it is on the top in low socioeconomic developing countries of the world. Pakistan is one of such countries having high incidence of work place violence among nurses at work environment. There is also another issue of poor reporting, lack of documentation and un- published status of such violence in the health care setups. Such high incidences of work place violence among nurses put the managements of different organizations in the challenging situations(Somani, 2012)
Health care workers’ especially nurses of the emergency departments may experience lots of workplace violence which may cause low satisfaction and poor performance among them (Hesketh et al., 2003). If there is no full performance of nurses due to unsafe environment, it will have direct impact on patients care outcomes and ultimately leads to ineffective and poor services of the hospitals (Kwok et al., 2006).
Despite of so many bad consequences of work place violence among nurses, it is still under reported and under rated issue. This lack of reporting may be because of fear, stigma and blame of being harassed. More seriously, the society might think that the nurses are made to bear such violence as part of their care that is why they are expected to tolerate it (Alameddine et al., 2015)
This paper presents workplace violence towards nurses as a major issue in the context of health care settings in Pakistan. Heresome characteristics of violence against the emergency nurses will be highlighted; some problems will be analyzed from different ethical professional and legal perspectives.Here some physical and psychological consequences of work place violence will be highlighted too.
1.2. Problem Statement:
Workplace violence among nurses is known to affect their job working environment, which may lead to decrease in their services at the emergency departments. Furthermore, the work place violence might be associated with physical and emotional imbalances among nurses at their duty. If the nurses are not balance physically and mentally, their care will not be according to standards, therefore there is need to identify the prevalence of violence, the types of violence at work place and also the measures to eliminate the high occurrence of work place violence among nurses.
1.3. Research Question:
1. What is the prevalence of violence against nurses working in the emergency departments of public tertiary hospitals Lahore?
2. What are the types of violence against nurses working in the emergency departments of public tertiary hospitals Lahore?
3. What are the contributing factors for workplace violence against nurses working in the emergency departments of public tertiary hospitals Lahore?
1.4. Significance:
Workplace violence is an issue of international health care among the workers at all departments of the health care systems but more sever at the emergency departments. Direct violence or indirect violence which may be physical or non-physical violence among nurses at the emergency departments might cause negative consequences in the future of nurses. If nurses of emergency department be aware of the types and causes of violence they can decrease the bad consequences and will avoid negative effect on the quality of health care providers and patients. The decrease in the productivity of nursing care will be minimized, negative impact on nurses whether it is physically or psychologically will be controlled. This may help the nurses to resolve violence related issues and continue a peaceful job life ahead.
1.5. Research Purpose:
The aim of this study is to bring awareness about work place violence among nurses at the emergency departments of health care systems. It will further reveal the issue of workplace violence after finding the prevalence at the emergency departments.
1.6. Objectives:
1. To assess the prevalence of violence against nurses working in the emergency departments of public tertiary hospitals Lahore
2. To identify the types of violence against nurses working in the emergency departments of public tertiary hospitals Lahore
3. To determine the contributing factors for workplace violence against nurses working in the emergency departments of public tertiary hospitals Lahore
1.7. Definitions:
a) Workplace Violence
Incidents where staff are abused, threatened or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being or health.
b) Physical violence:
It occurs when an employee is exposed to the deliberate use of force such as beating, pushing, slapping, and kicking, biting, pinching, stabbing, shooting by the patient and/or their families, a colleague or any others. Physical violence may lead to physical harm or emotional or sexual harm to the abused employee.
c) Verbal violence:
This happen when someone such as (patient, patients’ relatives, visitors, and coworkers) shout, curses or use other words to verbally insult the employee without an intention to bodily harm. For example someone yells at you. This includes any behavior towards an employee based on age, disability, gender, race, poverty, richness, or any other unwanted status which negatively influence the dignity of employee.
d) Sexual violence:
Any unwanted, unwelcomed and non-reciprocal sexual attention. It may include sexist remarks, behavior or sexual advances which results in a tense and unproductive environment. These forms of harassments/ abuse threaten the employees and cause them to feel humiliated.
1.8. Variables
Independent variable
Personal characteristic such as Gender, age, Marital status, experience and place of violence etcetera.
Dependent variables:
Prevalence of violence and Types of violence

Chapter II: Literature Review
Different literature studies are available regarding workplace violence among nurses. Here also some studies were found about workplace violence among nurses, workplace aggression of patients and families against nurses, violence against nurses at the emergency department and nurse’s perception of workplace violence at the emergency departments.
Workplace violence is the act which involves physical and nonphysical threats of assault affecting the nurses at their work places. Even verbal violence such as threats and verbal abuse against nurses, hostility for nurses, harassment against them can cause equal mental and psychological trauma to physical work place violence (Gomaa et al., 2015).
Study conducted by the Emergency Nurses Association (ENA), found that in the united states every year about nine hundred deaths occurs due to work place violence and around 1.7 million less life threatening assaults occur annually. This is still an unclear estimate of the severity of the work place violence. Further the Bureau of Labor and Statistic’s Survey conducted about the Occupational Injuries and violence found that the violence at work place among the health care workers is much higher than other profession (Albashtawy, 2013).
Emergency departments are working for 24 hours and have risks of much violence. Some situations like the lack of adequate training, physical security, lack of visible security guards and increased stress in the department make nurses of the emergency department more prone to work place violence. In a study 25% of the study participants at the emergency departments experience physical violence and around 20% stated verbal violence experience during last three years (Gacki-Smith et al., 2009).
Prevalence of Violence among nurses of Emergency Department:
A study assessed the prevalence of work place violence among the emergency nurses which was found that 44.6% nurses during the last year have experienced work place violence. Furthermore verbal abuse was found the most common work place violence. The physical and sexual assault were less in number as compare to verbal violence. Many nurses have experienced a combination of physical and nonphysical violence both. The work place violence was mostly caused by the patients, then the relatives and colleagues while least violence was recorded from supervisors’ side. Almost half of the nurses said that the violence they have experienced was preventable with proper care. Moreover all the nurses mentioned few management techniques for work place violence such as discussing with colleagues, reporting to the immediate supervisors, and confronting to the perpetrator of violence etcetera (Cheung ; Yip, 2017).
Another study also conducted among health care workers to assess the work place violence among them. It was found that about 60% of the study participants, who were working at the emergency departments exposed to violence during their duty in the last one year. A total of 65.7% nurses exposed to verbal violence at their work place. Majority of the HCW 61% were females who got affected by violence. The occurrence of violence was found different in different individuals. Some experienced work place violence very frequently, other faced it once a month etcetera. The violence from patients relative was found at the top (89.7% of verbal violence) and for 90.5% of physical violence. Verbal violence mostly found in the evening shift (Abdellah ; Salama, 2017).
Types of Violence among ER Nurses:
Some commonest physical violence types were experienced by more than 50% nurses were, they were being spit on, pushed by patients or relatives, scratched and being kicked. Among the verbal violence, the most common (70%) was yelling from patients and their families, intimidated and being harassed with sexually abusive language. The perception of safety was found very low and about 70% participants showed less than 50% safety perception. About 33% participants were in favor of leaving emergency department due to increased work place violence (Gacki-Smith et al., 2010).
Findings of another study reveals that incidence of verbal violence was (63.9%), which was almost five times more than physical violence (11.9%) at the emergency department among nurses in the last 12 months of period. Verbal violence at the emergency department was mainly by the patients against nurses then secondly by their family members and relatives. The rate of physical violence was also high from patients and their family members. Afternoon shift was found to have more work place violence at the emergency departments due to increased patients inflow (Albashtawy, 2013).
According to another study verbal violence was found among the 86% of nurses at the emergency departments. Threats were also found high among the (35%) of the study participants. Physical abuse was also found among the nurses from the patients and their families but it was lower than that of verbal assault. No difference of violence exposure was found between males and females or based on the specialty such as medical and surgical. However very few respondents were from emergency to have a meaningful comparison (Imran, Pervez, Farooq, ; Asghar, 2013).
Contributing factors for Work Place violence:
Patients relatives were overall the most common source of work place violence among the emergency department nurses (71%) followed by patients (30.5%). Results also showed that there are other various aspects of work place violence caused by colleagues, supervisors also (Imran et al., 2013).It is observed that there are under reported may be due to feeling of uncomforted and lack of support from the organization. There is also lack of a well-structured reporting system for work place violence in many health care organizations. It is very important to identify the contributing factors for work place violence (Somani, 2012).
It is very clear from previous studies that the major contributor of workplace violence among nurses at the emergency department was found patients which is followed by the relatives of the patients. Along with patients and their relatives, the nursing colleagues, senior nurses, the manager nurses, and on duty doctors also are the contributing factors for work place violence among the emergency department nurses (Kwok et al., 2006).
According to another study, workplace physical violence against the emergency department nurses was perpetrated mainly by patients followed by their relatives and then by other nurses. The results of the study found that relatives of patients were the most frequent contributors of physical violence against the emergency department nurses. They were responsible for a large number of cases (58.5%)(Boafo ; Hancock, 2017).

CHAPTER III: METHODOLOGY
3.1. Research Design:
A descriptive cross-sectional study design was used to conduct this study. Data about the violence against emergency department nurses was collected at one point in time with the help of a questionnaire.
3.2. Time Period:
This study was conducted from February 2018 to May 2018 for about 4 months period of time.
3.3. Site and setting of the study:
This study was conducted among the nurses at the Emergency Departments of two public tertiary care hospitals Lahore. They are the Jinnah Hospital Lahore and Services Hospital Lahore.
3.4. Population:
The study was conducted among the nurses. The population for this study was all nurses who are working in emergency departments of the selected hospitals, the Jinnah Hospital and the Services Hospital Lahore.
3.5. Sample size Determination
The minimum sample required is calculated using the single proportion formula which is given below.
? = ?2(1 ? ?) /?2
d= Acceptable margin of error (precision of measurement) = 5%
z= Standard variant (1.96) which correspond to 95% confidence level
p= Overall prevalence of workplace violence among nurses in public health facilities in
Nazish Imran2013 (73%).
(1.96)2 0.73 (1?0.73) /(0.05)2 =
(1.96)2 0.73 (1?0.73) /(0.05)2 =
3.8416* 0.73 (0.27) /(0.0025)=
2.804* 108 = 302
Since the total number of study population is ; 10,000 (N=400) using the correction formula the final sample size will benf = ???/ ?+?
400?302 /400+302 = 147
120,800 /702 = 147
3.6. Sampling procedure
Sampled will be selected from the emergency departments of two public hospitals through convenient sampling methods. N=75 will be selected from Jinnah Hospital while remaining 72 nurses will be selected from services hospital emergency department.
3.7. Inclusion criteria
All nurses from the emergency departments were recruited who were:
1. Willing to participate in the study
2. Working in emergency department at least one year
3. Registered with Pakistan Nursing council
3.8. Exclusion criteria
Those nurses will not be recruited who are:
1. All nurses who were not at work place during data collection period
2. Those who were not willing and not registered
3.9. Data collection tool
A self-administered standardized adopted questionnaire was used to collect the data. The questionnaire adopted from a study ‘Work place violence against nurses working in the emergency department of in Saudi Arabia’ by Fuaad Ali Alshehri(Albashtawy, 2013).
The first section of the questionnaire consisted off the demographic information about the age, gender, education and working experience of the participants. The second and third parts of the questionnaire discussed the physical and nonphysical violence among nurses at the emergency departments. The participants of the study were asked to fill the questionnaire of work place violence.
3.10. Data processing, Analysis and presentation
The data was put into the SPSS version 21. The results were processed and analyzed with the help of graphs, tables in the form of frequencies, averages and percentages.
3.11. Ethical Consideration
An approval was taken from the committee of national college of nursing. Then permission was taken from the heads of the study setting such as Head of Jinnah hospital and Head of the services Hospital. A written permission was taken from each individual participant of the study. Each participant was provided with the questionnaire with an informed consent which was explained the purposes and significance of the study. The study participants were assured that their names will be kept confidential. Their participation was fully volunteer and can withdraw at any time.

CHAPTER IV: RESULTS

4.1 Demographic data analysis and results

The below table shows about the gender of participants that were 6.80% were male and 93.20% was female. Result also shows the age of the participants of study from which 10.20% were less than 25 years ; 53.06% were between 26 to 30 years 27.89% were between the age of 31 to 35 years 6.12% were between the age of 36 to 40 years and 2.72% participants of study were more than 40 years of age. It was also found that the education level of the study participants from which 19.05% were only have general nursing diploma 40.14% of study participants having specialization as well 40.82% have the degree of generic BSN and post RN BSN degree.
Table 1: Frequency and percentage of demographics data

Variables Number (n) Per cent
Gender
Male
Female
10
137
6.8
93.2
Age:
Less than 25 years
26-30 years
31-35 years
36-40 years
Above 40 years
15
78
41
9
4
10.2
53.1
27.9
6.1
2.7
Education:
Nursing Diploma
Diploma plus specialization
BSN/PRN BSN
MSN/MPH
28
59
60

19.0
40.1
40.8

Experience
77
51
15
4

52.4
34.7
10.2
2.7

1-5 years
6-10 years
11-15 years
Above 15years

4.2: DESCRIPTIVE ANALYSIS OF PHYSICAL AND NONPHYSICAL VIOLENCE
Below Table 2 shows that in response for how many times the participants exposed to physical violence in last 12 months. It was found that 77.55% stated that they are not exposed to physical violence last 12 months, 13.6% said once, 7.48% said 2-3 times and 1.3% stated they have been exposed 4-5 times during last year. On the other hand the participants exposed to Nonphysical violence in last 12 months,12.93% stated that they are not exposed to physical violence last 12 months, 25.85% said once, 40.82% said 2-3 times and 19.73% stated they have been exposed 4-5 times during last year. The type of physical assault the study participants was asked and 4.08% of participants had experience beating, 9.52% experience pushing, 6.12% of study participants had experience slapping, 1.36% pinching, 1.36% shooting, and not applicable for 77.55% of study participants. Similarly about types of nonphysical assault the study participants were exposed to, 50.34% of participants had experience threats, 36.05% experience verbal abuse and 2.04% of study participants had experience sexual harassment/abuse. Regarding the physical assaulters to staff from which 8.16% were patients, 13.61% were relatives of patients, 0.68% were coworkers of the staff and not applicable for 77.55% participants. About the assaulters of nonphysical at staff from which 19.73% were patients, 63.27% were relatives of patients, 5.44% were coworkers of the staff and not applicable for 11.56% participants. It was also found that 2.04% incidents happened at morning shift 9.52% at evening 8.84% at night shift and not applicable for 77.55% of study participants in terms of physical violence. Where as in nonphysical violence 11.56% incidents happened at morning shift 42.86% at evening 30.61% at night shift 3.40% participants was not sure about timing of the incident and not applicable for 11.56% of study participants.

Most recent physical incident in which 10.20% of incidents were happened at resuscitation room 2.04% at waiting room and 10.20% in treatment room and this question was not applicable for 77.55% of participants. The most recent nonphysical incident in which 38.10% of incidents were happened at resuscitation room 0.68% in triage 12.24% at waiting room and 37.41% in treatment room 0.68% in other places and this question was not applicable for 10.88% of participants.
Furthermore to physical violence 1.36% said yes received treatment, 12.24% not need, 2.04% not received and 6.80% self-treated and this question was not applicable for 77.55% of study participants. Similarly in nonphysical violence, 0.68% said yes received treatment, 68.71% no need, 3.40% not received and 15.65% self-treated. Result also shows that percentage by whom physical violence victim was treated 6.12% was treated by nurse 16.33% not treated and not applicable for 77.55% of study participants. It was also found in nonphysical violence that victim was treated 10.20 % was treated by nurse, 0.68% by psychiatrist, 0.68% by others 76.87% not treated and not applicable for 11.56% of study participants. The Findings also show the percentage of the cause of most recent incident from which 12.93% of participants said that it was due to waiting for services 5.44% was unable to meet patients desire 2.72% was due to unavailability of services 1.36 % was due to lack of preventive tools and not applicable for 77.55% of study participants. The cause of most recent nonphysical incidents from which 24.49% of participants said that it was due to waiting for services 13.61% was unable to meet patients desire 6.12% was due to mental illness 1.36% was due to way of dealing with patients 29.25% was due to unavailability of services 8.84 % was due to lack of preventive tools 4.76% said that it was due to impact of disease or pain and not applicable for 11.56% of study participants.

(Table 2) Frequency and percentage of the Violence

Variables Physical Violence Non-Physical Violence

Number of Time Being exposed Number(n) Percent Number(n) Percent
Never
Once
2-3 Times
4-5 times
6 times 114
20
11
2
00 77.6
13.6
7.5
1.4
00 19
38
60
29
01 12.9
25.9
40.8
19.7
.7
Who Assaulted
Patients
Visitors/Patients’ relatives
Co-workers
Not applicable 12
20
1
114 8.2
13.6
.7
77.6 29
93
8
17 19.7
63.3
5.4
11.6
When the Incidence Happened?
Morning
Afternoon
Night
Unsure
Not applicable 3
14
13
3
114 2.0
9.5
8.8
2.0
77.6 17
63
45
5
17 11.6
42.9
30.6
3.4
11.6
Where the incidence happened?
Resuscitation
Waiting Room
Triage
Treatment
Hallway
Not applicable 15
3
0
15
0
114 10.2
2.0
0
10.2
0
77.6 56
18
1
55
0
18 38.1
12.2
.7
37.4
0
10.9
Receiving treatment after the incident
Yes, received
There was no need
Needed but did not received
Self treated
Not applicable 2
18
3
10
114 1.4
12.2
2.0
6.8
77.6 1
101
5
23
17 .7
68.7
3.4
15.6
11.6
Who treated?
Doctors
Psychiatrist
Nurse
Not treated
Not applicable 0
0
9
24
114 0
0
6.1
16.3
77.6 0
1
15
113
17 0
.7
10.2
76.9
11.6
The causes of most Recent Incident
Waiting for receiving services
Failure to meet patients’ desire
Mental illness
Way of dealing the patients
Unavailability of the services
Fear stress
Lack of preventive tools
Impact of disease or pain
Not applicable 19
8
0
0
4
0
2
0
114 12.9
5.4
0
0
2.7
0
1.4
0
77.6 36
20
9
2
43
0
13
7
17 24.5
13.6
6.1
1.4
29.3
0
8.8
4.8
11.6

4.3: Summary of Physical and Nonphysical Violence:

The following Table 3 suggests that 4.1% of the study participants had Beating experience, 9.5% experienced pushing, 6.9% faced slapping, no kicking or biting was found, pinching and shooting was 1.4% each, while the rest of 77% had no experienced of physical violence.

Table 3: Summary of Physical Violence

Variable Category
Type of physical Violence N %
Beating
Pushing
Slapping
Kicking
Biting
Pinching
Shooting
Stabbing
Not applicable 6
14
9
0
0
2
2
0
114 4.1
9.5
6.1
0
0
1.4
1.4
0
77.6

The following Table 4 findings indicate thatabout 50.3% of the study participants had faced threats as nonphysical violence, 36.1% experienced Verbal abuse/Harassment, while 2% have experience Sexual Abuse/Harassment and 11.6% faced no any nonphysical violence during last 1 year.

Table 4: Summary of Nonphysical Violence

Variable Category
Type of Nonphysical Assault N %
Threats
Verbal abuse/Harassment
Sexual Abuse/Harassment
Not applicable 74
53
3
17 50.3
36.1
2.0
11.6

4.3.2: Descriptive analysis of Physical Violence
How many times have you been exposed to physical violence during the last 12 months?
Frequency Percent Valid Percent Cumulative Percent
Valid Never 114 77.6 77.6 77.6
Once 20 13.6 13.6 91.2
2-3times 11 7.5 7.5 98.6
4-5 times 2 1.4 1.4 100.0
Total 147 100.0 100.0

The above table and Graph shows that in response for how many times the participants exposed to physical violence in last 12 months. It was found that 77.55% stated that they are not exposed to physical violence last 12 months, 13.6% said once, 7.48% said 2-3 times and 1.3% stated they have been exposed 4-5 times during last years.

What type of physical assault were you exposed to during the most recent incidence?
Frequency Percent Valid Percent Cumulative Percent
Valid Beating 6 4.1 4.1 4.1
Pushing 14 9.5 9.5 13.6
Slaping 9 6.1 6.1 19.7
Pinching 2 1.4 1.4 21.1
Shooting 2 1.4 1.4 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph shows the type of physical assault the study participants were exposed to in which 4.08% of participants had experience beating 9.52% experience pushing 6.12% of study participants had experience slapping 1.36% pinching 1.36% shooting and not applicable for 77.55% of study participants.

In the most recent physical incident who assault you?
Frequency Percent Valid Percent Cumulative Percent
Valid Patients 12 8.2 8.2 8.2
Relatives 20 13.6 13.6 21.8
Co-Workers 1 .7 .7 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph show the percentage of physical assaulters to staff from which 8.16% were patients 13.61% were relatives of patients 0.68% were coworkers of the staff and not applicable for 77.55% participants.

In the most recent physical incident when did the incident happened?
Frequency Percent Valid Percent Cumulative Percent
Valid Morning 3 2.0 2.0 2.0
Afternoon 14 9.5 9.5 11.6
Night 13 8.8 8.8 20.4
Not sure 3 2.0 2.0 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph show the timing of physical incident from which 2.04% incidents happened at morning shift 9.52% at evening 8.84% at night shift and not applicable for 77.55% of study participants.

In the most recent physical incident where did the incident happened?
Frequency Percent Valid Percent Cumulative Percent
Valid Resuscitation 15 10.2 10.2 10.2
Waiting room 3 2.0 2.0 12.2
Treatment room 15 10.2 10.2 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph shows the location of most recent incident in which 10.20% of incidents were happened at resuscitation room 2.04% at waiting room and 10.20% in treatment room and this question was not applicable for 77.55% of participants.

Did you receive treatment after the most recent incident?
Frequency Percent Valid Percent Cumulative Percent
Valid Yes received 2 1.4 1.4 1.4
No need 18 12.2 12.2 13.6
Not received 3 2.0 2.0 15.6
Self treated 10 6.8 6.8 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph shows the percentage of study participants who receive or didn’t receive the treatment after most recent physical incident in which 1.36% said yes received 12.24% no need 2.04% not received and 6.80% self treated and this question was not applicable for 77.55% of study participants.

If yes who treated You?
Frequency Percent Valid Percent Cumulative Percent
Valid Nurse 9 6.1 6.1 6.1
Not treated 24 16.3 16.3 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph shows the percentage by whom physical violence victim was treated 6.12% was treated by nurse 16.33% not treated and not applicable for 77.55% of study participants.

What do you think was the cause of the most recent incidence?
Frequency Percent Valid Percent Cumulative Percent
Valid Waiting for services 19 12.9 12.9 12.9
not meeting patients' desire 8 5.4 5.4 18.4
Unavailability of the services 4 2.7 2.7 21.1
Lack of preventive tools 2 1.4 1.4 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph shows the percentage of the cause of most recent incident from which 12.93% of participants said that it was due to waiting for services 5.44% was unable to meet patients desire 2.72% was due to unavailability of services 1.36 % was due to lack of preventive tools and not applicable for 77.55% of study participants.

4.3.2: Descriptive analysis of Nonphysical Violence:

How many times have you been exposed to Non-physical violence during the last 12 months?

Frequency Percent Valid Percent Cumulative Percent
Valid Never 19 12.9 12.9 12.9
Once 38 25.9 25.9 38.8
2-3times 60 40.8 40.8 79.6
4-5 times 29 19.7 19.7 99.3
6 or more times 1 .7 .7 100.0
Total 147 100.0 100.0

The above table and Graph shows that in response for how many times the participants exposed to physical violence in last 12 months. It was found that 12.93% stated that they are not exposed to physical violence last 12 months, 25.85% said once, 40.82% said 2-3 times and 19.73% stated they have been exposed 4-5 times during last year.

What type of non-physical assault were you exposed to during the most recent incidence?

Frequency Percent Valid Percent Cumulative Percent
Valid Threats 74 50.3 50.3 50.3
Verbal abuse/Harassment 53 36.1 36.1 86.4
Sexual abuse 3 2.0 2.0 88.4
Not applicale 17 11.6 11.6 100.0
Total 147 100.0 100.0

The above table and graph shows the type of non physical assault the study participants were exposed to in which 50.34% of participants had experience threats 36.05% experience verbal abuse and 2.04% of study participants had experience sexual harassment/abuse and not applicable for 11.56% of study participants.

In the most recent nonphysical incident who assault you?
Frequency Percent Valid Percent Cumulative Percent
Valid Patients 29 19.7 19.7 19.7
Relatives 93 63.3 63.3 83.0
Co-Workers 8 5.4 5.4 88.4
Not applicable 17 11.6 11.6 100.0
Total 147 100.0 100.0

The above table and graph show the percentage of non physical assaulters to staff from which 19.73% were patients 63.27% were relatives of patients 5.44% were coworkers of the staff and not applicable for 11.56% participants.

In the most recent nonphysical incident when did the incident happened?
Frequency Percent Valid Percent Cumulative Percent
Valid Morning 17 11.6 11.6 11.6
Afternoon 63 42.9 42.9 54.4
Night 45 30.6 30.6 85.0
Not sure 5 3.4 3.4 88.4
Not applicable 17 11.6 11.6 100.0
Total 147 100.0 100.0

The above table and graph show the timing of physical incident from which 11.56% incidents happened at morning shift 42.86% at evening 30.61% at night shift 3.40% participants was not sure about timing of the incident and not applicable for 11.56% of study participants.

In the most recent nonphysical incident where did the incident happened?
Frequency Percent Valid Percent Cumulative Percent
Valid Resuscitation 56 38.1 38.1 38.1
Triage 1 .7 .7 38.8
Waiting room 18 12.2 12.2 51.0
Treatment room 55 37.4 37.4 88.4
Others 1 .7 .7 89.1
Not applicable 16 10.9 10.9 100.0
Total 147 100.0 100.0

The above table and graph shows the location of most recent incident in which 38.10% of incidents were happened at resuscitation room 0.68% in triage 12.24% at waiting room and 37.41% in treatment room 0.68% in other places and this question was not applicable for 10.88% of participants.

Did you receive treatment after the most recent incident?

Frequency Percent Valid Percent Cumulative Percent
Valid Yes received 1 .7 .7 .7
No need 101 68.7 68.7 69.4
Not received 5 3.4 3.4 72.8
Self treated 23 15.6 15.6 88.4
Not applicable 17 11.6 11.6 100.0
Total 147 100.0 100.0

The above table and graph shows the percentage of study participants who receive or didn’t receive the treatment after most recent non physical incident in which 0.68% said yes received 68.71% no need 3.40% not received and 15.65% self treated and this question was not applicable for 11.56% of study participants.

If yes who treated You?

Frequency Percent Valid Percent Cumulative Percent
Valid Nurse 15 10.2 10.2 10.2
Psychiatristist 1 .7 .7 10.9
Others 1 .7 .7 11.6
Not treated 113 76.9 76.9 88.4
Not applicable 17 11.6 11.6 100.0
Total 147 100.0 100.0

The above table and graph shows the percentage by whom physical violence victim was treated 10.20 % was treated by nurse 0.68% by psychiatrist 0.68% by others 76.87% not treated and not applicable for 11.56% of study participants.

What do you think was the cause of the most recent incidence?

Frequency Percent Valid Percent Cumulative Percent
Valid Waiting for services 36 24.5 24.5 24.5
not meeting patients' desire 20 13.6 13.6 38.1
Mental illness 9 6.1 6.1 44.2
Way of dealing the patients 2 1.4 1.4 45.6
Unavailability of the services 43 29.3 29.3 74.8
Lack of preventive tools 13 8.8 8.8 83.7
Impact of disease or pain 7 4.8 4.8 88.4
Not appicable 17 11.6 11.6 100.0
Total 147 100.0 100.0

The above table and graph shows the percentage of the cause of most recent incident from which 24.49% of participants said that it was due to waiting for services 13.61% was unable to meet patients desire 6.12% was due to mental illness 1.36% was due to way of dealing with patients 29.25% was due to unavailability of services 8.84 % was due to lack of preventive tools 4.76% said that it was due to impact of disease or pain and not applicable for 11.56% of study participants.

Chapter 5: Discussion
This current study found that physical violence was about 22.5% where 4.1% of the study participants had Beating experience, 9.5% experienced pushing, 6.9% faced slapping and pinching and shooting was 1.4% each, while the rest of 77.5% had not experienced of physical violence. The prevalence of nonphysical violence was found about 88.4% where 50.3% of the study participants had faced threats as nonphysical violence, 36.1% experienced Verbal abuse/Harassment, while 2% have experience Sexual Abuse/Harassment and 11.6% faced no any nonphysical violence during last 1 year.
According to a previous study the verbal violence was found among the 86% of nurses at the emergency departments. Physical abuse was also found among the nurses from the patients and their families but it was lower than that of verbal assault. No difference of violence exposure was found between males and females or based on the specialty such as medical and surgical. However very few respondents were from emergency to have a meaningful comparison (Imran et al., 2013).
Similarly Findings of another study reveals that incidence of verbal violence was (63.9%), which was almost five times more than physical violence (11.9%) at the emergency department among nurses in the last 12 months of period (Albashtawy, 2013).
A previous study found some similar findings where nonphysical abuse was found the most common work place violence. The physical and sexual assault were less in number as compare to verbal violence (Cheung ; Yip, 2017). According to another study, a total of 65.7% nurses exposed to nonphysical violence at their work place (Abdellah ; Salama, 2017).
During my study the physical violence was mainly 13.61% were from relatives of patients (out of 22%), which becomes almost half the violence.
Similarly, in a previous study, violence from patients relative was found at the top (89.7% of verbal violence) and for 90.5% of physical violence. Verbal violence mostly found in the evening shift (Abdellah ; Salama, 2017).
According to this study most common violence were 4.08% of participants had experience beating, 9.52% experience pushing, 6.12% of study participants had experience slapping, 1.36% pinching, 1.36% shooting and not applicable for 77.55% of study participants.
According to previous study some commonest physical violence types were experienced by more than 50% nurses were, they were being spit on, pushed by patients or relatives, scratched and being kicked (Gacki-Smith et al., 2010).
According to this current study, the type of nonphysical assault the study participants were exposed to in which 50.34% of participants had experience threats 36.05% experience verbal abuse and 2.04% of study participants had experience sexual harassment/abuse and not applicable for 11.56% of study participants. Previously, among the verbal violence, the most common (70%) was yelling from patients and their families, intimidated and being harassed with sexually abusive language. (Gacki-Smith et al., 2010). According to another study, threats were also found high among the (35%) of the study participants (Imran et al., 2013).

Chapter 6: Conclusion

Conclusion
The purpose of this study was to assess the prevalence of work place violence and types of physical and non physical violence in the public hospitals of Lahore. The emergency nurses during study indicated that violence was a common occurrence.
It was found that 77.55% stated that they are not exposed to physical violence last 12 months, 13.6% said once, 7.48% said 2-3 times and 1.3% stated they have been exposed 4-5 times during last year. On the other hand the participants exposed to Nonphysical violence in last 12 months,12.93% stated that they are not exposed to physical violence last 12 months, 25.85% said once, 40.82% said 2-3 times and 19.73% stated they have been exposed 4-5 times during last year.
Most recent physical incident in which 10.20% of incidents were happened at resuscitation room 2.04% at waiting room and 10.20% in treatment room. The most recent nonphysical incident in which 38.10% of incidents were happened at resuscitation room 0.68% in triage 12.24% at waiting room and 37.41% in treatment room 0.68% in other places.
It was also found that 2.04% incidents happened at morning shift 9.52% at evening 8.84% at night shift. Where as in nonphysical violence 11.56% incidents happened at morning shift 42.86% at evening 30.61% at night shift 3.40% participants was not sure about timing of the incident.

Recommendations
This study addressed several areas requiring further research. There is a shortage of violence research among emergency nurses in Lahore. Further research is needed to develop strategies for preventing violence against emergency nurses, which would need to consider the local culture and findings of this study. Further in depth research is needed to assess the impact of violence on the perception and professional life of emergency nurses.

Limitations
This was my first research study so due to lack of expertise there are some limitations.it may be better if I can relate different kind of professional, environmental and cultural factors affecting work place violence in my study, but due to lack of time and less expertise I was unable to do that. Hopefully it will be better in my next studies.

REFERENCES:
Abdellah, R. F., ; Salama, K. M. (2017). Prevalence and risk factors of workplace violence against health care workers in emergency department in Ismailia, Egypt. Pan African Medical Journal, 26(1), 1-8.
Al Shameri, F. Critical Care Nurse’s Knowledge of Ventilator-Associated Pneumonia Prevention in Selected Hospitals, Khartoum.
Alameddine, M., Mourad, Y., & Dimassi, H. (2015). A national study on nurses’ exposure to occupational violence in Lebanon: prevalence, consequences and associated factors. PLoS ONE, 10(9), e0137105.
Albashtawy, M. (2013). Workplace violence against nurses in emergency departments in Jordan. International nursing review, 60(4), 550-555.
Baydin, A., ; Erenler, A. K. (2014). Workplace violence in emergency department and its effects on emergency staff. Int J Emerg Ment Health, 16(2), 288-290.
Blanchar, Y. (2011). Violence in the health care sector: a global issue. World Medical Journal, 57(3), 87-89.
Boafo, I. M., ; Hancock, P. (2017). Workplace violence against nurses: a cross-sectional descriptive study of Ghanaian nurses. SAGE Open, 7(1), 2158244017701187.
Cheung, T., ; Yip, P. S. (2017). Workplace violence towards nurses in Hong Kong: prevalence and correlates. BMC Public Health, 17(1), 196.
Gacki-Smith, J., Juarez, A. M., Boyett, L., Homeyer, C., Robinson, L., ; MacLean, S. L. (2009). Violence against nurses working in US emergency departments. Journal of Nursing Administration, 39(7/8), 340-349.
Gacki-Smith, J., Juarez, A. M., Boyett, L., Homeyer, C., Robinson, L., ; MacLean, S. L. (2010). Violence against nurses working in US emergency departments. Journal of healthcare protection management: publication of the International Association for Hospital Security, 26(1), 81-99.
Gomaa, A. E., Tapp, L. C., Luckhaupt, S. E., Vanoli, K., Sarmiento, R. F., Raudabaugh, W. M., . . . Sprigg, S. M. (2015). Occupational traumatic injuries among workers in health care facilities—United States, 2012–2014. MMWR. Morbidity and mortality weekly report, 64(15), 405.
Hesketh, K. L., Duncan, S. M., Estabrooks, C. A., Reimer, M. A., Giovannetti, P., Hyndman, K., ; Acorn, S. (2003). Workplace violence in Alberta and British Columbia hospitals. Health policy, 63(3), 311-321.
Imran, N., Pervez, M. H., Farooq, R., ; Asghar, A. R. (2013). Aggression and violence towards medical doctors and nurses in a public health care facility in Lahore, Pakistan: A preliminary investigation. Khyber Medical University Journal, 5(4), 179-184.
Kowalenko, T., Hauff, S. R., Morden, P. C., ; Smith, B. (2012). Development of a data collection instrument for violent patient encounters against healthcare workers. Western journal of emergency medicine, 13(5), 429.
Kwok, R., Law, Y., Li, K., Ng, Y., Cheung, M., Fung, V., . . . Leung, W.-C. (2006). Prevalence of workplace violence against nurses in Hong Kong. Hong Kong Medical Journal.
May, D. D., ; Grubbs, L. M. (2002). The extent, nature, and precipitating factors of nurse assault among three groups of registered nurses in a regional medical center. Journal of emergency nursing, 28(1), 11-17.
Somani, R. K. (2012). Workplace violence towards nurses: A reality from the Pakistani context. Journal of Nursing Education and Practice, 2(3), 148.

Informed consent:

Workplace violence against nurses working in emergency departments at a public hospital Lahore

Dear participants,
I am Salman Ijaz, want to conduct a research on “Workplace violence against nurses working in emergency departments at a public hospital Lahore”. As this Research project work for the fulfillment of my Post RN BSN degree from National College of Nursing, affiliated with the University of Lahore. The purpose of this research study is to assess the Workplace violence against nurses working in emergency departments at a public hospital Lahore.A questionnaire will be distributed for data collection, for which your cooperation is required. The questionnaire will take about 20-30 minutes to complete. Your participation will be very helpful for me to complete my study. Your valued information will be kept confidential. You are allowed to withdraw at any time from research study.
I have read all the terms and voluntarily consent to participate in the research study.

Participant's Signature:………………………..
Date: ………………………….

Questionnaire:

Workplace Violence against nurses working in emergency departments at a Public Hospital Lahore
Section 1: Demographic Data:

1. Gender:

1. Male ( ) 2. Female ( )

2. Age in Years:

1.Below 25 ( ) 2. 26-30 ( ) 3. 31-35 ( ) 4. 36-40 ( ) 5. above 40 ( )

3. Education:

1. Diploma GN ( ) 2. Specialization ( ) 3. BSN/Post RN ( ) 4.MSN ( )

4. Experience:

1.1-5 years ( ) 2. 6-10 years ( ) 3. 11-15 Years ( ) 4. Above 15 years ( )

Section 2: Physical Violence:

s. No Statement Options
1 How many times have you been exposed to physical violence during the last 12 months? Never
Once

2-3
4-5

6 or more times
2 What type of physical assault were you exposed to during the most recent incidence? Beating
Pushing
Slapping

Kicking
Biting
Pinching

Shooting
Stabbing
Others

3 In the most recent physical incident who assault you? Patients
Relatives

Coworkers
Others ______

4 In the most recent physical incident when did the incident happened? Morning
Afternoon

Night
Not sure

5 Where did the most recent incident happen? Resuscitation
Triage

Waiting Room
Treatment room

Other specify ______

6 Did you receive treatment after the most recent incident? Yes received
No Need

Did Not receive
Self-treated

7 If yes who treated You? Doctors
Nurse

Psychiatrist
Others

Not treated

8 What do you think was the cause of the most recent incidence? Waiting for receiving services

Failure to meet patients’ desire

Mental illness

Way of dealing the patients

Unavailability of the services

Fear stress

Lack of preventive tools

Impact of disease or pain

Section 3: Non Physical Violence:

s. No Statement Options
1 How many times have you been exposed to Non-physical violence during the last 12 months? Never
Once

2-3
4-5

6 or more times
2 What type of physical assault were you exposed to during the most recent incidence? Threats

Verbal abuse/Harassment

Sexual abuse Harassment

3 In the most recent physical incident who assault you? Patients
Relatives

Coworkers
Others ______

4 In the most recent physical incident when did the incident happened? Morning
Afternoon

Night
Not sure

5. Where did the most recent incident happen? Resuscitation
Triage

Waiting Room
Treatment room

Other specify ______

6. Did you receive treatment after the most recent incident? Yes received
No Need

Did Not receive
Self-treated

7. If yes who treated You? Doctors
Nurse

Psychiatrist
Others

Not treated

8. What do you think was the cause of the most recent incidence? Waiting for receiving services

Failure to meet patients’ desire

Mental illness

Way of dealing the patients

Unavailability of the services

Fear stress

Lack of preventive tools

Impact of disease or pain

Section 4: Preventing/managing procedures for Assault reports:

S. No Statement Yes No Don’t Know
9. Are there enough methods to prevent violence on staff (Guard, Security, Camera, warning devices ) in the departments
10. Are there enoughpolicies systems and instructions to prevent violence on workers in the hospitals?
11. Are there reporting procedures for the reporting violence in the hospitals?
12. Did you receive training or educational programs by the hospital to prevent and deal with violence?
13. In the most recent incidence did you write report to your administrator or any other third party authority?
14. Has any action been taken against the assaulter?
15. Does the violence have Negative impact on you?
16. Do you think stop working in the coming 1-3 years due to violence in the work area?

WORKPLACE VIOLENCE AGAINST NURSES WORKING IN EMERGENCY DEPARTMENTS AT PUBLIC HOSPITALS LAHORE

Submitted by
M Salman Ijaz

SUPERVISOR: AFSAR ALI
CO-SUPERVISOR: Ms. Naseem Rooman

______________________________________________________________________________
NATIONAL COLLEGE OF NURSING AFFILIATED WITH
THE UNIVERSITY OF LAHORE
ACADEMIC YEAR 2016-18

Table of Contents
Abstract 1
1. Introduction 2
1.1. Background 2
1.2. Problem Statement……………….………………………………………………………..3

1.3. Research Significance 4
1.4. Research Purpose 5
1.5. Research Objectives 5
1.6. Research Question 5
1.7. Operational definitions 6
Chapter 2 7
2. Literature Review 7
Chapter 3. Methodology 11
3.1. Research Design 11
3.2. Site 11
3.3. Setting 11
3.4. Population 12
3.5. Inclusion criteria 12
3.6. Exclusion criteria 12
3.7. Sampling method 15
3.8. Sample size 15
3.9. Data collection 13
3.10. Data Analysis 13
3.11. Ethical considerations 13
4. Results…………………………………………………………………………………………………..14
5. Discussion……………………………………………………………………………………………..35

6. Conclusion……………………………………………………………………………….…………….37

7. References 39
8.Inform consent and questionnaire 41

Dedication:

I would like to thank ALLAH supporting and helping me to complete this study.

This project work is dedicated to my parents and Teachers for their endless love, support and encouragement.

I am eternally grateful to my parents, who have supported and encouraged me to continue my studies. I appreciate the encouragement from my brothers sisters friends and my group members especially Anam khadim, Dilnesheen safdar, Sumera Rehman, Sehar Shabir and Kiran Akhter for their constant support.

Professionally I would like to extend my thanks for all assistance and support provided to me by my principal Naseem Roman my principal supervisor Afsar Ali my program coordinator Nosheen Noruddin the whole National College of nursing team and management and to the participants of research for their contribution and cooperation.

Acknowledgement:
I am highly thankful to Allah for giving me the strength and knowledge to carry out this research work. Without Allah's blessings and providence it would not be possible to complete this research project successfully. After that I am grateful to my parents and family members who gave me enough courage and support to complete this work.
I am highly thankful to my supervisor (sir. Afsar Ali) and Co supervisor Ms. Naseem Rooman (the principal college of nursing NH & MC) for their guidance and support
I am thankful to the entire Management of National college and hospital Lahore
I am thankful to the Management of UOL, Lahore school of nursing for their guidance in my studies
I am thankful to All Faculty of National CON

M Salman ijaz
Senior Elective Management
National College of Nursing
The University of Lahore

Abstract:
Work place violence is an alarming and devastating issue worldwide particularly in the emergency departments. Incident of work place violence is common towards nurses in health care settings. Nurses are more prone to workplace violence due to lack of respect towards nursing profession in Pakistani society and the nature of work performed by the nurses.
The main purpose of this study was to assess the prevalence of work place violence including physical and non physical and bring awareness about work place violence among nurses at the emergency departments of health care systems.
A cross sectional descriptive survey was performed to assess the prevalence of work place violence at tertiary care hospitals of Lahore. A convenient sample of n=147 was used to collect the data. A structured standardized adopted questionnaire was used to collect data. The questionnaire consisted demographic, physical and non physical variables. The data was collected from Jinnah and services hospital Lahore. The data was analyzed on SPSS version 21.
It was found that 77.55% stated that they are not exposed to physical violence last 12 months, 13.6% said once, 7.48% said 2-3 times and 1.3% stated they have been exposed 4-5 times during last year. On the other hand the participants exposed to Nonphysical violence in last 12 months,12.93% stated that they are not exposed to physical violence last 12 months, 25.85% said once, 40.82% said 2-3 times and 19.73% stated they have been exposed 4-5 times during last year.
Most recent physical incident in which 10.20% of incidents were happened at resuscitation room 2.04% at waiting room and 10.20% in treatment room. The most recent nonphysical incident in which 38.10% of incidents were happened at resuscitation room 0.68% in triage 12.24% at waiting room and 37.41% in treatment room 0.68% in other places.
It was also found that 2.04% incidents happened at morning shift 9.52% at evening 8.84% at night shift. Where as in nonphysical violence 11.56% incidents happened at morning shift 42.86% at evening 30.61% at night shift 3.40% participants was not sure about timing of the incident.

CHAPTER I: INTRODUCTION
1.1. Background:
Many countries of the world are encountered by Workplace physical violence almost in every field of employment which is a real matter of concern for (Blanchar, 2011). The prevalence of work place violence becomes a threat to employees’ safety, their dignity and causes lower wellbeing and thus the workers tend to become unhappy. Workplace violence appears among the leading threats to life and is considered as leading work place deaths among Us women workers. The lethal consequences of work place violence such as severe injuries have greater impact on life and cannot be underestimated by any state or country of the world (Boafo ; Hancock, 2017).
Occupations such as Health care professions have even more severe consequences from work place violence which appears as a global phenomenon in terms of violence against health professionals at work place. It mainly encompasses verbal threats or abuse, physical assault among health care workers and sexual harassment etcetera. The verbal violence is reported the highest of all work place violence. Moreover, the Nurses face the work place violence more than any other health care discipline because they remain in more contact with patients and their families (Alameddine, Mourad, ; Dimassi, 2015).
Some highlighted areas at the hospital are at greater risk of work place violence. These areas include the Psychiatric wards, emergency departments of the hospital, and sometimes high dependency units of health care systems. The occurrence of violence in the psychiatric wards and the emergency departments are reported in almost 100% in hospitals which is more than any other department in the hospital (Somani, 2012).
Workplace violence among nurses is defined as occurrence of some form of aggression such as physical aggression, sexual aggression, emotional or psychological threats against nurses, where the nurses are abused, assaulted, and threats in their work place circumstances. It is also claimed that workplace violence has very bad impact on the cost of any hospital in terms of increasing the financial burden which might reach up to 4.2 billion dollars annually(Somani, 2012).
It may also be defined as “Incidents of activities where the nurses are abused verbally, harassed sexually,or might face assaulted in their work place environment. This may challenge their safety and security, their health and wellbeing (Baydin & Erenler, 2014).The effects of work place violence is not limited to nurses only, rather it also have equal impact on doctors and other health care workers (Kowalenko, Hauff, Morden, & Smith, 2012).
Thls is recognized as high risk occupation which gaining more attention due to high occurrence of violent attacks on the working nurses. It was found by National Crime Victimization thatnon-fatal violence is about 21.9 per 1,000 among the nurses which is less in average than other profession (12.6 per 1,000 workers). The nurses of the emergency departments are the primary target of work place violence at every health care setup. In a previous study, conducted at the emergency departments, 82% of the nurses indicated that they have been assaulted in the last 12 months(May & Grubbs, 2002).
It is suggested that the incidence of verbal abuse is rising day by day and reaching almost 100% nurses at the emergency departments of many hospitals. The American Nurses Association found very few nurses are safe from the work place violence (Less than 20%). There is no support from the institutions to prevent violence among nurses which contributes to more dissatisfaction among them (Gacki-Smith et al., 2010).
Work place violence is very common everywhere in every hospital against nurses but it is on the top in low socioeconomic developing countries of the world. Pakistan is one of such countries having high incidence of work place violence among nurses at work environment. There is also another issue of poor reporting, lack of documentation and un- published status of such violence in the health care setups. Such high incidences of work place violence among nurses put the managements of different organizations in the challenging situations(Somani, 2012)
Health care workers’ especially nurses of the emergency departments may experience lots of workplace violence which may cause low satisfaction and poor performance among them (Hesketh et al., 2003). If there is no full performance of nurses due to unsafe environment, it will have direct impact on patients care outcomes and ultimately leads to ineffective and poor services of the hospitals (Kwok et al., 2006).
Despite of so many bad consequences of work place violence among nurses, it is still under reported and under rated issue. This lack of reporting may be because of fear, stigma and blame of being harassed. More seriously, the society might think that the nurses are made to bear such violence as part of their care that is why they are expected to tolerate it (Alameddine et al., 2015)
This paper presents workplace violence towards nurses as a major issue in the context of health care settings in Pakistan. Heresome characteristics of violence against the emergency nurses will be highlighted; some problems will be analyzed from different ethical professional and legal perspectives.Here some physical and psychological consequences of work place violence will be highlighted too.
1.2. Problem Statement:
Workplace violence among nurses is known to affect their job working environment, which may lead to decrease in their services at the emergency departments. Furthermore, the work place violence might be associated with physical and emotional imbalances among nurses at their duty. If the nurses are not balance physically and mentally, their care will not be according to standards, therefore there is need to identify the prevalence of violence, the types of violence at work place and also the measures to eliminate the high occurrence of work place violence among nurses.
1.3. Research Question:
1. What is the prevalence of violence against nurses working in the emergency departments of public tertiary hospitals Lahore?
2. What are the types of violence against nurses working in the emergency departments of public tertiary hospitals Lahore?
3. What are the contributing factors for workplace violence against nurses working in the emergency departments of public tertiary hospitals Lahore?
1.4. Significance:
Workplace violence is an issue of international health care among the workers at all departments of the health care systems but more sever at the emergency departments. Direct violence or indirect violence which may be physical or non-physical violence among nurses at the emergency departments might cause negative consequences in the future of nurses. If nurses of emergency department be aware of the types and causes of violence they can decrease the bad consequences and will avoid negative effect on the quality of health care providers and patients. The decrease in the productivity of nursing care will be minimized, negative impact on nurses whether it is physically or psychologically will be controlled. This may help the nurses to resolve violence related issues and continue a peaceful job life ahead.
1.5. Research Purpose:
The aim of this study is to bring awareness about work place violence among nurses at the emergency departments of health care systems. It will further reveal the issue of workplace violence after finding the prevalence at the emergency departments.
1.6. Objectives:
1. To assess the prevalence of violence against nurses working in the emergency departments of public tertiary hospitals Lahore
2. To identify the types of violence against nurses working in the emergency departments of public tertiary hospitals Lahore
3. To determine the contributing factors for workplace violence against nurses working in the emergency departments of public tertiary hospitals Lahore
1.7. Definitions:
a) Workplace Violence
Incidents where staff are abused, threatened or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being or health.
b) Physical violence:
It occurs when an employee is exposed to the deliberate use of force such as beating, pushing, slapping, and kicking, biting, pinching, stabbing, shooting by the patient and/or their families, a colleague or any others. Physical violence may lead to physical harm or emotional or sexual harm to the abused employee.
c) Verbal violence:
This happen when someone such as (patient, patients’ relatives, visitors, and coworkers) shout, curses or use other words to verbally insult the employee without an intention to bodily harm. For example someone yells at you. This includes any behavior towards an employee based on age, disability, gender, race, poverty, richness, or any other unwanted status which negatively influence the dignity of employee.
d) Sexual violence:
Any unwanted, unwelcomed and non-reciprocal sexual attention. It may include sexist remarks, behavior or sexual advances which results in a tense and unproductive environment. These forms of harassments/ abuse threaten the employees and cause them to feel humiliated.
1.8. Variables
Independent variable
Personal characteristic such as Gender, age, Marital status, experience and place of violence etcetera.
Dependent variables:
Prevalence of violence and Types of violence

Chapter II: Literature Review
Different literature studies are available regarding workplace violence among nurses. Here also some studies were found about workplace violence among nurses, workplace aggression of patients and families against nurses, violence against nurses at the emergency department and nurse’s perception of workplace violence at the emergency departments.
Workplace violence is the act which involves physical and nonphysical threats of assault affecting the nurses at their work places. Even verbal violence such as threats and verbal abuse against nurses, hostility for nurses, harassment against them can cause equal mental and psychological trauma to physical work place violence (Gomaa et al., 2015).
Study conducted by the Emergency Nurses Association (ENA), found that in the united states every year about nine hundred deaths occurs due to work place violence and around 1.7 million less life threatening assaults occur annually. This is still an unclear estimate of the severity of the work place violence. Further the Bureau of Labor and Statistic’s Survey conducted about the Occupational Injuries and violence found that the violence at work place among the health care workers is much higher than other profession (Albashtawy, 2013).
Emergency departments are working for 24 hours and have risks of much violence. Some situations like the lack of adequate training, physical security, lack of visible security guards and increased stress in the department make nurses of the emergency department more prone to work place violence. In a study 25% of the study participants at the emergency departments experience physical violence and around 20% stated verbal violence experience during last three years (Gacki-Smith et al., 2009).
Prevalence of Violence among nurses of Emergency Department:
A study assessed the prevalence of work place violence among the emergency nurses which was found that 44.6% nurses during the last year have experienced work place violence. Furthermore verbal abuse was found the most common work place violence. The physical and sexual assault were less in number as compare to verbal violence. Many nurses have experienced a combination of physical and nonphysical violence both. The work place violence was mostly caused by the patients, then the relatives and colleagues while least violence was recorded from supervisors’ side. Almost half of the nurses said that the violence they have experienced was preventable with proper care. Moreover all the nurses mentioned few management techniques for work place violence such as discussing with colleagues, reporting to the immediate supervisors, and confronting to the perpetrator of violence etcetera (Cheung & Yip, 2017).
Another study also conducted among health care workers to assess the work place violence among them. It was found that about 60% of the study participants, who were working at the emergency departments exposed to violence during their duty in the last one year. A total of 65.7% nurses exposed to verbal violence at their work place. Majority of the HCW 61% were females who got affected by violence. The occurrence of violence was found different in different individuals. Some experienced work place violence very frequently, other faced it once a month etcetera. The violence from patients relative was found at the top (89.7% of verbal violence) and for 90.5% of physical violence. Verbal violence mostly found in the evening shift (Abdellah & Salama, 2017).
Types of Violence among ER Nurses:
Some commonest physical violence types were experienced by more than 50% nurses were, they were being spit on, pushed by patients or relatives, scratched and being kicked. Among the verbal violence, the most common (70%) was yelling from patients and their families, intimidated and being harassed with sexually abusive language. The perception of safety was found very low and about 70% participants showed less than 50% safety perception. About 33% participants were in favor of leaving emergency department due to increased work place violence (Gacki-Smith et al., 2010).
Findings of another study reveals that incidence of verbal violence was (63.9%), which was almost five times more than physical violence (11.9%) at the emergency department among nurses in the last 12 months of period. Verbal violence at the emergency department was mainly by the patients against nurses then secondly by their family members and relatives. The rate of physical violence was also high from patients and their family members. Afternoon shift was found to have more work place violence at the emergency departments due to increased patients inflow (Albashtawy, 2013).
According to another study verbal violence was found among the 86% of nurses at the emergency departments. Threats were also found high among the (35%) of the study participants. Physical abuse was also found among the nurses from the patients and their families but it was lower than that of verbal assault. No difference of violence exposure was found between males and females or based on the specialty such as medical and surgical. However very few respondents were from emergency to have a meaningful comparison (Imran, Pervez, Farooq, & Asghar, 2013).
Contributing factors for Work Place violence:
Patients relatives were overall the most common source of work place violence among the emergency department nurses (71%) followed by patients (30.5%). Results also showed that there are other various aspects of work place violence caused by colleagues, supervisors also (Imran et al., 2013).It is observed that there are under reported may be due to feeling of uncomforted and lack of support from the organization. There is also lack of a well-structured reporting system for work place violence in many health care organizations. It is very important to identify the contributing factors for work place violence (Somani, 2012).
It is very clear from previous studies that the major contributor of workplace violence among nurses at the emergency department was found patients which is followed by the relatives of the patients. Along with patients and their relatives, the nursing colleagues, senior nurses, the manager nurses, and on duty doctors also are the contributing factors for work place violence among the emergency department nurses (Kwok et al., 2006).
According to another study, workplace physical violence against the emergency department nurses was perpetrated mainly by patients followed by their relatives and then by other nurses. The results of the study found that relatives of patients were the most frequent contributors of physical violence against the emergency department nurses. They were responsible for a large number of cases (58.5%)(Boafo & Hancock, 2017).

CHAPTER III: METHODOLOGY
3.1. Research Design:
A descriptive cross-sectional study design was used to conduct this study. Data about the violence against emergency department nurses was collected at one point in time with the help of a questionnaire.
3.2. Time Period:
This study was conducted from February 2018 to May 2018 for about 4 months period of time.
3.3. Site and setting of the study:
This study was conducted among the nurses at the Emergency Departments of two public tertiary care hospitals Lahore. They are the Jinnah Hospital Lahore and Services Hospital Lahore.
3.4. Population:
The study was conducted among the nurses. The population for this study was all nurses who are working in emergency departments of the selected hospitals, the Jinnah Hospital and the Services Hospital Lahore.
3.5. Sample size Determination
The minimum sample required is calculated using the single proportion formula which is given below.
? = ?2(1 ? ?) /?2
d= Acceptable margin of error (precision of measurement) = 5%
z= Standard variant (1.96) which correspond to 95% confidence level
p= Overall prevalence of workplace violence among nurses in public health facilities in
Nazish Imran2013 (73%).
(1.96)2 0.73 (1?0.73) /(0.05)2 =
(1.96)2 0.73 (1?0.73) /(0.05)2 =
3.8416* 0.73 (0.27) /(0.0025)=
2.804* 108 = 302
Since the total number of study population is < 10,000 (N=400) using the correction formula the final sample size will benf = ???/ ?+?
400?302 /400+302 = 147
120,800 /702 = 147
3.6. Sampling procedure
Sampled will be selected from the emergency departments of two public hospitals through convenient sampling methods. N=75 will be selected from Jinnah Hospital while remaining 72 nurses will be selected from services hospital emergency department.
3.7. Inclusion criteria
All nurses from the emergency departments were recruited who were:
1. Willing to participate in the study
2. Working in emergency department at least one year
3. Registered with Pakistan Nursing council
3.8. Exclusion criteria
Those nurses will not be recruited who are:
1. All nurses who were not at work place during data collection period
2. Those who were not willing and not registered
3.9. Data collection tool
A self-administered standardized adopted questionnaire was used to collect the data. The questionnaire adopted from a study ‘Work place violence against nurses working in the emergency department of in Saudi Arabia’ by Fuaad Ali Alshehri(Albashtawy, 2013).
The first section of the questionnaire consisted off the demographic information about the age, gender, education and working experience of the participants. The second and third parts of the questionnaire discussed the physical and nonphysical violence among nurses at the emergency departments. The participants of the study were asked to fill the questionnaire of work place violence.
3.10. Data processing, Analysis and presentation
The data was put into the SPSS version 21. The results were processed and analyzed with the help of graphs, tables in the form of frequencies, averages and percentages.
3.11. Ethical Consideration
An approval was taken from the committee of national college of nursing. Then permission was taken from the heads of the study setting such as Head of Jinnah hospital and Head of the services Hospital. A written permission was taken from each individual participant of the study. Each participant was provided with the questionnaire with an informed consent which was explained the purposes and significance of the study. The study participants were assured that their names will be kept confidential. Their participation was fully volunteer and can withdraw at any time.

CHAPTER IV: RESULTS

4.1 Demographic data analysis and results

The below table shows about the gender of participants that were 6.80% were male and 93.20% was female. Result also shows the age of the participants of study from which 10.20% were less than 25 years & 53.06% were between 26 to 30 years 27.89% were between the age of 31 to 35 years 6.12% were between the age of 36 to 40 years and 2.72% participants of study were more than 40 years of age. It was also found that the education level of the study participants from which 19.05% were only have general nursing diploma 40.14% of study participants having specialization as well 40.82% have the degree of generic BSN and post RN BSN degree.
Table 1: Frequency and percentage of demographics data

Variables Number (n) Per cent
Gender
Male
Female
10
137
6.8
93.2
Age:
Less than 25 years
26-30 years
31-35 years
36-40 years
Above 40 years
15
78
41
9
4
10.2
53.1
27.9
6.1
2.7
Education:
Nursing Diploma
Diploma plus specialization
BSN/PRN BSN
MSN/MPH
28
59
60

19.0
40.1
40.8

Experience
77
51
15
4

52.4
34.7
10.2
2.7

1-5 years
6-10 years
11-15 years
Above 15years

4.2: DESCRIPTIVE ANALYSIS OF PHYSICAL AND NONPHYSICAL VIOLENCE
Below Table 2 shows that in response for how many times the participants exposed to physical violence in last 12 months. It was found that 77.55% stated that they are not exposed to physical violence last 12 months, 13.6% said once, 7.48% said 2-3 times and 1.3% stated they have been exposed 4-5 times during last year. On the other hand the participants exposed to Nonphysical violence in last 12 months,12.93% stated that they are not exposed to physical violence last 12 months, 25.85% said once, 40.82% said 2-3 times and 19.73% stated they have been exposed 4-5 times during last year. The type of physical assault the study participants was asked and 4.08% of participants had experience beating, 9.52% experience pushing, 6.12% of study participants had experience slapping, 1.36% pinching, 1.36% shooting, and not applicable for 77.55% of study participants. Similarly about types of nonphysical assault the study participants were exposed to, 50.34% of participants had experience threats, 36.05% experience verbal abuse and 2.04% of study participants had experience sexual harassment/abuse. Regarding the physical assaulters to staff from which 8.16% were patients, 13.61% were relatives of patients, 0.68% were coworkers of the staff and not applicable for 77.55% participants. About the assaulters of nonphysical at staff from which 19.73% were patients, 63.27% were relatives of patients, 5.44% were coworkers of the staff and not applicable for 11.56% participants. It was also found that 2.04% incidents happened at morning shift 9.52% at evening 8.84% at night shift and not applicable for 77.55% of study participants in terms of physical violence. Where as in nonphysical violence 11.56% incidents happened at morning shift 42.86% at evening 30.61% at night shift 3.40% participants was not sure about timing of the incident and not applicable for 11.56% of study participants.

Most recent physical incident in which 10.20% of incidents were happened at resuscitation room 2.04% at waiting room and 10.20% in treatment room and this question was not applicable for 77.55% of participants. The most recent nonphysical incident in which 38.10% of incidents were happened at resuscitation room 0.68% in triage 12.24% at waiting room and 37.41% in treatment room 0.68% in other places and this question was not applicable for 10.88% of participants.
Furthermore to physical violence 1.36% said yes received treatment, 12.24% not need, 2.04% not received and 6.80% self-treated and this question was not applicable for 77.55% of study participants. Similarly in nonphysical violence, 0.68% said yes received treatment, 68.71% no need, 3.40% not received and 15.65% self-treated. Result also shows that percentage by whom physical violence victim was treated 6.12% was treated by nurse 16.33% not treated and not applicable for 77.55% of study participants. It was also found in nonphysical violence that victim was treated 10.20 % was treated by nurse, 0.68% by psychiatrist, 0.68% by others 76.87% not treated and not applicable for 11.56% of study participants. The Findings also show the percentage of the cause of most recent incident from which 12.93% of participants said that it was due to waiting for services 5.44% was unable to meet patients desire 2.72% was due to unavailability of services 1.36 % was due to lack of preventive tools and not applicable for 77.55% of study participants. The cause of most recent nonphysical incidents from which 24.49% of participants said that it was due to waiting for services 13.61% was unable to meet patients desire 6.12% was due to mental illness 1.36% was due to way of dealing with patients 29.25% was due to unavailability of services 8.84 % was due to lack of preventive tools 4.76% said that it was due to impact of disease or pain and not applicable for 11.56% of study participants.

(Table 2) Frequency and percentage of the Violence

Variables Physical Violence Non-Physical Violence

Number of Time Being exposed Number(n) Percent Number(n) Percent
Never
Once
2-3 Times
4-5 times
6 times 114
20
11
2
00 77.6
13.6
7.5
1.4
00 19
38
60
29
01 12.9
25.9
40.8
19.7
.7
Who Assaulted
Patients
Visitors/Patients’ relatives
Co-workers
Not applicable 12
20
1
114 8.2
13.6
.7
77.6 29
93
8
17 19.7
63.3
5.4
11.6
When the Incidence Happened?
Morning
Afternoon
Night
Unsure
Not applicable 3
14
13
3
114 2.0
9.5
8.8
2.0
77.6 17
63
45
5
17 11.6
42.9
30.6
3.4
11.6
Where the incidence happened?
Resuscitation
Waiting Room
Triage
Treatment
Hallway
Not applicable 15
3
0
15
0
114 10.2
2.0
0
10.2
0
77.6 56
18
1
55
0
18 38.1
12.2
.7
37.4
0
10.9
Receiving treatment after the incident
Yes, received
There was no need
Needed but did not received
Self treated
Not applicable 2
18
3
10
114 1.4
12.2
2.0
6.8
77.6 1
101
5
23
17 .7
68.7
3.4
15.6
11.6
Who treated?
Doctors
Psychiatrist
Nurse
Not treated
Not applicable 0
0
9
24
114 0
0
6.1
16.3
77.6 0
1
15
113
17 0
.7
10.2
76.9
11.6
The causes of most Recent Incident
Waiting for receiving services
Failure to meet patients’ desire
Mental illness
Way of dealing the patients
Unavailability of the services
Fear stress
Lack of preventive tools
Impact of disease or pain
Not applicable 19
8
0
0
4
0
2
0
114 12.9
5.4
0
0
2.7
0
1.4
0
77.6 36
20
9
2
43
0
13
7
17 24.5
13.6
6.1
1.4
29.3
0
8.8
4.8
11.6

4.3: Summary of Physical and Nonphysical Violence:

The following Table 3 suggests that 4.1% of the study participants had Beating experience, 9.5% experienced pushing, 6.9% faced slapping, no kicking or biting was found, pinching and shooting was 1.4% each, while the rest of 77% had no experienced of physical violence.

Table 3: Summary of Physical Violence

Variable Category
Type of physical Violence N %
Beating
Pushing
Slapping
Kicking
Biting
Pinching
Shooting
Stabbing
Not applicable 6
14
9
0
0
2
2
0
114 4.1
9.5
6.1
0
0
1.4
1.4
0
77.6

The following Table 4 findings indicate thatabout 50.3% of the study participants had faced threats as nonphysical violence, 36.1% experienced Verbal abuse/Harassment, while 2% have experience Sexual Abuse/Harassment and 11.6% faced no any nonphysical violence during last 1 year.

Table 4: Summary of Nonphysical Violence

Variable Category
Type of Nonphysical Assault N %
Threats
Verbal abuse/Harassment
Sexual Abuse/Harassment
Not applicable 74
53
3
17 50.3
36.1
2.0
11.6

4.3.2: Descriptive analysis of Physical Violence
How many times have you been exposed to physical violence during the last 12 months?
Frequency Percent Valid Percent Cumulative Percent
Valid Never 114 77.6 77.6 77.6
Once 20 13.6 13.6 91.2
2-3times 11 7.5 7.5 98.6
4-5 times 2 1.4 1.4 100.0
Total 147 100.0 100.0

The above table and Graph shows that in response for how many times the participants exposed to physical violence in last 12 months. It was found that 77.55% stated that they are not exposed to physical violence last 12 months, 13.6% said once, 7.48% said 2-3 times and 1.3% stated they have been exposed 4-5 times during last years.

What type of physical assault were you exposed to during the most recent incidence?
Frequency Percent Valid Percent Cumulative Percent
Valid Beating 6 4.1 4.1 4.1
Pushing 14 9.5 9.5 13.6
Slaping 9 6.1 6.1 19.7
Pinching 2 1.4 1.4 21.1
Shooting 2 1.4 1.4 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph shows the type of physical assault the study participants were exposed to in which 4.08% of participants had experience beating 9.52% experience pushing 6.12% of study participants had experience slapping 1.36% pinching 1.36% shooting and not applicable for 77.55% of study participants.

In the most recent physical incident who assault you?
Frequency Percent Valid Percent Cumulative Percent
Valid Patients 12 8.2 8.2 8.2
Relatives 20 13.6 13.6 21.8
Co-Workers 1 .7 .7 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph show the percentage of physical assaulters to staff from which 8.16% were patients 13.61% were relatives of patients 0.68% were coworkers of the staff and not applicable for 77.55% participants.

In the most recent physical incident when did the incident happened?
Frequency Percent Valid Percent Cumulative Percent
Valid Morning 3 2.0 2.0 2.0
Afternoon 14 9.5 9.5 11.6
Night 13 8.8 8.8 20.4
Not sure 3 2.0 2.0 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph show the timing of physical incident from which 2.04% incidents happened at morning shift 9.52% at evening 8.84% at night shift and not applicable for 77.55% of study participants.

In the most recent physical incident where did the incident happened?
Frequency Percent Valid Percent Cumulative Percent
Valid Resuscitation 15 10.2 10.2 10.2
Waiting room 3 2.0 2.0 12.2
Treatment room 15 10.2 10.2 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph shows the location of most recent incident in which 10.20% of incidents were happened at resuscitation room 2.04% at waiting room and 10.20% in treatment room and this question was not applicable for 77.55% of participants.

Did you receive treatment after the most recent incident?
Frequency Percent Valid Percent Cumulative Percent
Valid Yes received 2 1.4 1.4 1.4
No need 18 12.2 12.2 13.6
Not received 3 2.0 2.0 15.6
Self treated 10 6.8 6.8 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph shows the percentage of study participants who receive or didn’t receive the treatment after most recent physical incident in which 1.36% said yes received 12.24% no need 2.04% not received and 6.80% self treated and this question was not applicable for 77.55% of study participants.

If yes who treated You?
Frequency Percent Valid Percent Cumulative Percent
Valid Nurse 9 6.1 6.1 6.1
Not treated 24 16.3 16.3 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph shows the percentage by whom physical violence victim was treated 6.12% was treated by nurse 16.33% not treated and not applicable for 77.55% of study participants.

What do you think was the cause of the most recent incidence?
Frequency Percent Valid Percent Cumulative Percent
Valid Waiting for services 19 12.9 12.9 12.9
not meeting patients' desire 8 5.4 5.4 18.4
Unavailability of the services 4 2.7 2.7 21.1
Lack of preventive tools 2 1.4 1.4 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph shows the percentage of the cause of most recent incident from which 12.93% of participants said that it was due to waiting for services 5.44% was unable to meet patients desire 2.72% was due to unavailability of services 1.36 % was due to lack of preventive tools and not applicable for 77.55% of study participants.

4.3.2: Descriptive analysis of Nonphysical Violence:

How many times have you been exposed to Non-physical violence during the last 12 months?

Frequency Percent Valid Percent Cumulative Percent
Valid Never 19 12.9 12.9 12.9
Once 38 25.9 25.9 38.8
2-3times 60 40.8 40.8 79.6
4-5 times 29 19.7 19.7 99.3
6 or more times 1 .7 .7 100.0
Total 147 100.0 100.0

The above table and Graph shows that in response for how many times the participants exposed to physical violence in last 12 months. It was found that 12.93% stated that they are not exposed to physical violence last 12 months, 25.85% said once, 40.82% said 2-3 times and 19.73% stated they have been exposed 4-5 times during last year.

What type of non-physical assault were you exposed to during the most recent incidence?

Frequency Percent Valid Percent Cumulative Percent
Valid Threats 74 50.3 50.3 50.3
Verbal abuse/Harassment 53 36.1 36.1 86.4
Sexual abuse 3 2.0 2.0 88.4
Not applicale 17 11.6 11.6 100.0
Total 147 100.0 100.0

The above table and graph shows the type of non physical assault the study participants were exposed to in which 50.34% of participants had experience threats 36.05% experience verbal abuse and 2.04% of study participants had experience sexual harassment/abuse and not applicable for 11.56% of study participants.

In the most recent nonphysical incident who assault you?
Frequency Percent Valid Percent Cumulative Percent
Valid Patients 29 19.7 19.7 19.7
Relatives 93 63.3 63.3 83.0
Co-Workers 8 5.4 5.4 88.4
Not applicable 17 11.6 11.6 100.0
Total 147 100.0 100.0

The above table and graph show the percentage of non physical assaulters to staff from which 19.73% were patients 63.27% were relatives of patients 5.44% were coworkers of the staff and not applicable for 11.56% participants.

In the most recent nonphysical incident when did the incident happened?
Frequency Percent Valid Percent Cumulative Percent
Valid Morning 17 11.6 11.6 11.6
Afternoon 63 42.9 42.9 54.4
Night 45 30.6 30.6 85.0
Not sure 5 3.4 3.4 88.4
Not applicable 17 11.6 11.6 100.0
Total 147 100.0 100.0

The above table and graph show the timing of physical incident from which 11.56% incidents happened at morning shift 42.86% at evening 30.61% at night shift 3.40% participants was not sure about timing of the incident and not applicable for 11.56% of study participants.

In the most recent nonphysical incident where did the incident happened?
Frequency Percent Valid Percent Cumulative Percent
Valid Resuscitation 56 38.1 38.1 38.1
Triage 1 .7 .7 38.8
Waiting room 18 12.2 12.2 51.0
Treatment room 55 37.4 37.4 88.4
Others 1 .7 .7 89.1
Not applicable 16 10.9 10.9 100.0
Total 147 100.0 100.0

The above table and graph shows the location of most recent incident in which 38.10% of incidents were happened at resuscitation room 0.68% in triage 12.24% at waiting room and 37.41% in treatment room 0.68% in other places and this question was not applicable for 10.88% of participants.

Did you receive treatment after the most recent incident?

Frequency Percent Valid Percent Cumulative Percent
Valid Yes received 1 .7 .7 .7
No need 101 68.7 68.7 69.4
Not received 5 3.4 3.4 72.8
Self treated 23 15.6 15.6 88.4
Not applicable 17 11.6 11.6 100.0
Total 147 100.0 100.0

The above table and graph shows the percentage of study participants who receive or didn’t receive the treatment after most recent non physical incident in which 0.68% said yes received 68.71% no need 3.40% not received and 15.65% self treated and this question was not applicable for 11.56% of study participants.

If yes who treated You?

Frequency Percent Valid Percent Cumulative Percent
Valid Nurse 15 10.2 10.2 10.2
Psychiatristist 1 .7 .7 10.9
Others 1 .7 .7 11.6
Not treated 113 76.9 76.9 88.4
Not applicable 17 11.6 11.6 100.0
Total 147 100.0 100.0

The above table and graph shows the percentage by whom physical violence victim was treated 10.20 % was treated by nurse 0.68% by psychiatrist 0.68% by others 76.87% not treated and not applicable for 11.56% of study participants.

What do you think was the cause of the most recent incidence?

Frequency Percent Valid Percent Cumulative Percent
Valid Waiting for services 36 24.5 24.5 24.5
not meeting patients' desire 20 13.6 13.6 38.1
Mental illness 9 6.1 6.1 44.2
Way of dealing the patients 2 1.4 1.4 45.6
Unavailability of the services 43 29.3 29.3 74.8
Lack of preventive tools 13 8.8 8.8 83.7
Impact of disease or pain 7 4.8 4.8 88.4
Not appicable 17 11.6 11.6 100.0
Total 147 100.0 100.0

The above table and graph shows the percentage of the cause of most recent incident from which 24.49% of participants said that it was due to waiting for services 13.61% was unable to meet patients desire 6.12% was due to mental illness 1.36% was due to way of dealing with patients 29.25% was due to unavailability of services 8.84 % was due to lack of preventive tools 4.76% said that it was due to impact of disease or pain and not applicable for 11.56% of study participants.

Chapter 5: Discussion
This current study found that physical violence was about 22.5% where 4.1% of the study participants had Beating experience, 9.5% experienced pushing, 6.9% faced slapping and pinching and shooting was 1.4% each, while the rest of 77.5% had not experienced of physical violence. The prevalence of nonphysical violence was found about 88.4% where 50.3% of the study participants had faced threats as nonphysical violence, 36.1% experienced Verbal abuse/Harassment, while 2% have experience Sexual Abuse/Harassment and 11.6% faced no any nonphysical violence during last 1 year.
According to a previous study the verbal violence was found among the 86% of nurses at the emergency departments. Physical abuse was also found among the nurses from the patients and their families but it was lower than that of verbal assault. No difference of violence exposure was found between males and females or based on the specialty such as medical and surgical. However very few respondents were from emergency to have a meaningful comparison (Imran et al., 2013).
Similarly Findings of another study reveals that incidence of verbal violence was (63.9%), which was almost five times more than physical violence (11.9%) at the emergency department among nurses in the last 12 months of period (Albashtawy, 2013).
A previous study found some similar findings where nonphysical abuse was found the most common work place violence. The physical and sexual assault were less in number as compare to verbal violence (Cheung & Yip, 2017). According to another study, a total of 65.7% nurses exposed to nonphysical violence at their work place (Abdellah & Salama, 2017).
During my study the physical violence was mainly 13.61% were from relatives of patients (out of 22%), which becomes almost half the violence.
Similarly, in a previous study, violence from patients relative was found at the top (89.7% of verbal violence) and for 90.5% of physical violence. Verbal violence mostly found in the evening shift (Abdellah & Salama, 2017).
According to this study most common violence were 4.08% of participants had experience beating, 9.52% experience pushing, 6.12% of study participants had experience slapping, 1.36% pinching, 1.36% shooting and not applicable for 77.55% of study participants.
According to previous study some commonest physical violence types were experienced by more than 50% nurses were, they were being spit on, pushed by patients or relatives, scratched and being kicked (Gacki-Smith et al., 2010).
According to this current study, the type of nonphysical assault the study participants were exposed to in which 50.34% of participants had experience threats 36.05% experience verbal abuse and 2.04% of study participants had experience sexual harassment/abuse and not applicable for 11.56% of study participants. Previously, among the verbal violence, the most common (70%) was yelling from patients and their families, intimidated and being harassed with sexually abusive language. (Gacki-Smith et al., 2010). According to another study, threats were also found high among the (35%) of the study participants (Imran et al., 2013).

Chapter 6: Conclusion

Conclusion
The purpose of this study was to assess the prevalence of work place violence and types of physical and non physical violence in the public hospitals of Lahore. The emergency nurses during study indicated that violence was a common occurrence.
It was found that 77.55% stated that they are not exposed to physical violence last 12 months, 13.6% said once, 7.48% said 2-3 times and 1.3% stated they have been exposed 4-5 times during last year. On the other hand the participants exposed to Nonphysical violence in last 12 months,12.93% stated that they are not exposed to physical violence last 12 months, 25.85% said once, 40.82% said 2-3 times and 19.73% stated they have been exposed 4-5 times during last year.
Most recent physical incident in which 10.20% of incidents were happened at resuscitation room 2.04% at waiting room and 10.20% in treatment room. The most recent nonphysical incident in which 38.10% of incidents were happened at resuscitation room 0.68% in triage 12.24% at waiting room and 37.41% in treatment room 0.68% in other places.
It was also found that 2.04% incidents happened at morning shift 9.52% at evening 8.84% at night shift. Where as in nonphysical violence 11.56% incidents happened at morning shift 42.86% at evening 30.61% at night shift 3.40% participants was not sure about timing of the incident.

Recommendations
This study addressed several areas requiring further research. There is a shortage of violence research among emergency nurses in Lahore. Further research is needed to develop strategies for preventing violence against emergency nurses, which would need to consider the local culture and findings of this study. Further in depth research is needed to assess the impact of violence on the perception and professional life of emergency nurses.

Limitations
This was my first research study so due to lack of expertise there are some limitations.it may be better if I can relate different kind of professional, environmental and cultural factors affecting work place violence in my study, but due to lack of time and less expertise I was unable to do that. Hopefully it will be better in my next studies.

REFERENCES:
Abdellah, R. F., & Salama, K. M. (2017). Prevalence and risk factors of workplace violence against health care workers in emergency department in Ismailia, Egypt. Pan African Medical Journal, 26(1), 1-8.
Al Shameri, F. Critical Care Nurse’s Knowledge of Ventilator-Associated Pneumonia Prevention in Selected Hospitals, Khartoum.
Alameddine, M., Mourad, Y., & Dimassi, H. (2015). A national study on nurses’ exposure to occupational violence in Lebanon: prevalence, consequences and associated factors. PLoS ONE, 10(9), e0137105.
Albashtawy, M. (2013). Workplace violence against nurses in emergency departments in Jordan. International nursing review, 60(4), 550-555.
Baydin, A., & Erenler, A. K. (2014). Workplace violence in emergency department and its effects on emergency staff. Int J Emerg Ment Health, 16(2), 288-290.
Blanchar, Y. (2011). Violence in the health care sector: a global issue. World Medical Journal, 57(3), 87-89.
Boafo, I. M., & Hancock, P. (2017). Workplace violence against nurses: a cross-sectional descriptive study of Ghanaian nurses. SAGE Open, 7(1), 2158244017701187.
Cheung, T., & Yip, P. S. (2017). Workplace violence towards nurses in Hong Kong: prevalence and correlates. BMC Public Health, 17(1), 196.
Gacki-Smith, J., Juarez, A. M., Boyett, L., Homeyer, C., Robinson, L., & MacLean, S. L. (2009). Violence against nurses working in US emergency departments. Journal of Nursing Administration, 39(7/8), 340-349.
Gacki-Smith, J., Juarez, A. M., Boyett, L., Homeyer, C., Robinson, L., & MacLean, S. L. (2010). Violence against nurses working in US emergency departments. Journal of healthcare protection management: publication of the International Association for Hospital Security, 26(1), 81-99.
Gomaa, A. E., Tapp, L. C., Luckhaupt, S. E., Vanoli, K., Sarmiento, R. F., Raudabaugh, W. M., . . . Sprigg, S. M. (2015). Occupational traumatic injuries among workers in health care facilities—United States, 2012–2014. MMWR. Morbidity and mortality weekly report, 64(15), 405.
Hesketh, K. L., Duncan, S. M., Estabrooks, C. A., Reimer, M. A., Giovannetti, P., Hyndman, K., & Acorn, S. (2003). Workplace violence in Alberta and British Columbia hospitals. Health policy, 63(3), 311-321.
Imran, N., Pervez, M. H., Farooq, R., & Asghar, A. R. (2013). Aggression and violence towards medical doctors and nurses in a public health care facility in Lahore, Pakistan: A preliminary investigation. Khyber Medical University Journal, 5(4), 179-184.
Kowalenko, T., Hauff, S. R., Morden, P. C., & Smith, B. (2012). Development of a data collection instrument for violent patient encounters against healthcare workers. Western journal of emergency medicine, 13(5), 429.
Kwok, R., Law, Y., Li, K., Ng, Y., Cheung, M., Fung, V., . . . Leung, W.-C. (2006). Prevalence of workplace violence against nurses in Hong Kong. Hong Kong Medical Journal.
May, D. D., & Grubbs, L. M. (2002). The extent, nature, and precipitating factors of nurse assault among three groups of registered nurses in a regional medical center. Journal of emergency nursing, 28(1), 11-17.
Somani, R. K. (2012). Workplace violence towards nurses: A reality from the Pakistani context. Journal of Nursing Education and Practice, 2(3), 148.

Informed consent:

Workplace violence against nurses working in emergency departments at a public hospital Lahore

Dear participants,
I am Salman Ijaz, want to conduct a research on “Workplace violence against nurses working in emergency departments at a public hospital Lahore”. As this Research project work for the fulfillment of my Post RN BSN degree from National College of Nursing, affiliated with the University of Lahore. The purpose of this research study is to assess the Workplace violence against nurses working in emergency departments at a public hospital Lahore.A questionnaire will be distributed for data collection, for which your cooperation is required. The questionnaire will take about 20-30 minutes to complete. Your participation will be very helpful for me to complete my study. Your valued information will be kept confidential. You are allowed to withdraw at any time from research study.
I have read all the terms and voluntarily consent to participate in the research study.

Participant's Signature:………………………..
Date: ………………………….

Questionnaire:

Workplace Violence against nurses working in emergency departments at a Public Hospital Lahore
Section 1: Demographic Data:

1. Gender:

1. Male ( ) 2. Female ( )

2. Age in Years:

1.Below 25 ( ) 2. 26-30 ( ) 3. 31-35 ( ) 4. 36-40 ( ) 5. above 40 ( )

3. Education:

1. Diploma GN ( ) 2. Specialization ( ) 3. BSN/Post RN ( ) 4.MSN ( )

4. Experience:

1.1-5 years ( ) 2. 6-10 years ( ) 3. 11-15 Years ( ) 4. Above 15 years ( )

Section 2: Physical Violence:

s. No Statement Options
1 How many times have you been exposed to physical violence during the last 12 months? Never
Once

2-3
4-5

6 or more times
2 What type of physical assault were you exposed to during the most recent incidence? Beating
Pushing
Slapping

Kicking
Biting
Pinching

Shooting
Stabbing
Others

3 In the most recent physical incident who assault you? Patients
Relatives

Coworkers
Others ______

4 In the most recent physical incident when did the incident happened? Morning
Afternoon

Night
Not sure

5 Where did the most recent incident happen? Resuscitation
Triage

Waiting Room
Treatment room

Other specify ______

6 Did you receive treatment after the most recent incident? Yes received
No Need

Did Not receive
Self-treated

7 If yes who treated You? Doctors
Nurse

Psychiatrist
Others

Not treated

8 What do you think was the cause of the most recent incidence? Waiting for receiving services

Failure to meet patients’ desire

Mental illness

Way of dealing the patients

Unavailability of the services

Fear stress

Lack of preventive tools

Impact of disease or pain

Section 3: Non Physical Violence:

s. No Statement Options
1 How many times have you been exposed to Non-physical violence during the last 12 months? Never
Once

2-3
4-5

6 or more times
2 What type of physical assault were you exposed to during the most recent incidence? Threats

Verbal abuse/Harassment

Sexual abuse Harassment

3 In the most recent physical incident who assault you? Patients
Relatives

Coworkers
Others ______

4 In the most recent physical incident when did the incident happened? Morning
Afternoon

Night
Not sure

5. Where did the most recent incident happen? Resuscitation
Triage

Waiting Room
Treatment room

Other specify ______

6. Did you receive treatment after the most recent incident? Yes received
No Need

Did Not receive
Self-treated

7. If yes who treated You? Doctors
Nurse

Psychiatrist
Others

Not treated

8. What do you think was the cause of the most recent incidence? Waiting for receiving services

Failure to meet patients’ desire

Mental illness

Way of dealing the patients

Unavailability of the services

Fear stress

Lack of preventive tools

Impact of disease or pain

Section 4: Preventing/managing procedures for Assault reports:

S. No Statement Yes No Don’t Know
9. Are there enough methods to prevent violence on staff (Guard, Security, Camera, warning devices ) in the departments
10. Are there enoughpolicies systems and instructions to prevent violence on workers in the hospitals?
11. Are there reporting procedures for the reporting violence in the hospitals?
12. Did you receive training or educational programs by the hospital to prevent and deal with violence?
13. In the most recent incidence did you write report to your administrator or any other third party authority?
14. Has any action been taken against the assaulter?
15. Does the violence have Negative impact on you?
16. Do you think stop working in the coming 1-3 years due to violence in the work area?

WORKPLACE VIOLENCE AGAINST NURSES WORKING IN EMERGENCY DEPARTMENTS AT PUBLIC HOSPITALS LAHORE

Submitted by
M Salman Ijaz

SUPERVISOR: AFSAR ALI
CO-SUPERVISOR: Ms. Naseem Rooman

______________________________________________________________________________
NATIONAL COLLEGE OF NURSING AFFILIATED WITH
THE UNIVERSITY OF LAHORE
ACADEMIC YEAR 2016-18

Table of Contents
Abstract 1
1. Introduction 2
1.1. Background 2
1.2. Problem Statement……………….………………………………………………………..3

1.3. Research Significance 4
1.4. Research Purpose 5
1.5. Research Objectives 5
1.6. Research Question 5
1.7. Operational definitions 6
Chapter 2 7
2. Literature Review 7
Chapter 3. Methodology 11
3.1. Research Design 11
3.2. Site 11
3.3. Setting 11
3.4. Population 12
3.5. Inclusion criteria 12
3.6. Exclusion criteria 12
3.7. Sampling method 15
3.8. Sample size 15
3.9. Data collection 13
3.10. Data Analysis 13
3.11. Ethical considerations 13
4. Results…………………………………………………………………………………………………..14
5. Discussion……………………………………………………………………………………………..35

6. Conclusion……………………………………………………………………………….…………….37

7. References 39
8.Inform consent and questionnaire 41

Dedication:

I would like to thank ALLAH supporting and helping me to complete this study.

This project work is dedicated to my parents and Teachers for their endless love, support and encouragement.

I am eternally grateful to my parents, who have supported and encouraged me to continue my studies. I appreciate the encouragement from my brothers sisters friends and my group members especially Anam khadim, Dilnesheen safdar, Sumera Rehman, Sehar Shabir and Kiran Akhter for their constant support.

Professionally I would like to extend my thanks for all assistance and support provided to me by my principal Naseem Roman my principal supervisor Afsar Ali my program coordinator Nosheen Noruddin the whole National College of nursing team and management and to the participants of research for their contribution and cooperation.

Acknowledgement:
I am highly thankful to Allah for giving me the strength and knowledge to carry out this research work. Without Allah's blessings and providence it would not be possible to complete this research project successfully. After that I am grateful to my parents and family members who gave me enough courage and support to complete this work.
I am highly thankful to my supervisor (sir. Afsar Ali) and Co supervisor Ms. Naseem Rooman (the principal college of nursing NH & MC) for their guidance and support
I am thankful to the entire Management of National college and hospital Lahore
I am thankful to the Management of UOL, Lahore school of nursing for their guidance in my studies
I am thankful to All Faculty of National CON

M Salman ijaz
Senior Elective Management
National College of Nursing
The University of Lahore

Abstract:
Work place violence is an alarming and devastating issue worldwide particularly in the emergency departments. Incident of work place violence is common towards nurses in health care settings. Nurses are more prone to workplace violence due to lack of respect towards nursing profession in Pakistani society and the nature of work performed by the nurses.
The main purpose of this study was to assess the prevalence of work place violence including physical and non physical and bring awareness about work place violence among nurses at the emergency departments of health care systems.
A cross sectional descriptive survey was performed to assess the prevalence of work place violence at tertiary care hospitals of Lahore. A convenient sample of n=147 was used to collect the data. A structured standardized adopted questionnaire was used to collect data. The questionnaire consisted demographic, physical and non physical variables. The data was collected from Jinnah and services hospital Lahore. The data was analyzed on SPSS version 21.
It was found that 77.55% stated that they are not exposed to physical violence last 12 months, 13.6% said once, 7.48% said 2-3 times and 1.3% stated they have been exposed 4-5 times during last year. On the other hand the participants exposed to Nonphysical violence in last 12 months,12.93% stated that they are not exposed to physical violence last 12 months, 25.85% said once, 40.82% said 2-3 times and 19.73% stated they have been exposed 4-5 times during last year.
Most recent physical incident in which 10.20% of incidents were happened at resuscitation room 2.04% at waiting room and 10.20% in treatment room. The most recent nonphysical incident in which 38.10% of incidents were happened at resuscitation room 0.68% in triage 12.24% at waiting room and 37.41% in treatment room 0.68% in other places.
It was also found that 2.04% incidents happened at morning shift 9.52% at evening 8.84% at night shift. Where as in nonphysical violence 11.56% incidents happened at morning shift 42.86% at evening 30.61% at night shift 3.40% participants was not sure about timing of the incident.

CHAPTER I: INTRODUCTION
1.1. Background:
Many countries of the world are encountered by Workplace physical violence almost in every field of employment which is a real matter of concern for (Blanchar, 2011). The prevalence of work place violence becomes a threat to employees’ safety, their dignity and causes lower wellbeing and thus the workers tend to become unhappy. Workplace violence appears among the leading threats to life and is considered as leading work place deaths among Us women workers. The lethal consequences of work place violence such as severe injuries have greater impact on life and cannot be underestimated by any state or country of the world (Boafo & Hancock, 2017).
Occupations such as Health care professions have even more severe consequences from work place violence which appears as a global phenomenon in terms of violence against health professionals at work place. It mainly encompasses verbal threats or abuse, physical assault among health care workers and sexual harassment etcetera. The verbal violence is reported the highest of all work place violence. Moreover, the Nurses face the work place violence more than any other health care discipline because they remain in more contact with patients and their families (Alameddine, Mourad, & Dimassi, 2015).
Some highlighted areas at the hospital are at greater risk of work place violence. These areas include the Psychiatric wards, emergency departments of the hospital, and sometimes high dependency units of health care systems. The occurrence of violence in the psychiatric wards and the emergency departments are reported in almost 100% in hospitals which is more than any other department in the hospital (Somani, 2012).
Workplace violence among nurses is defined as occurrence of some form of aggression such as physical aggression, sexual aggression, emotional or psychological threats against nurses, where the nurses are abused, assaulted, and threats in their work place circumstances. It is also claimed that workplace violence has very bad impact on the cost of any hospital in terms of increasing the financial burden which might reach up to 4.2 billion dollars annually(Somani, 2012).
It may also be defined as “Incidents of activities where the nurses are abused verbally, harassed sexually,or might face assaulted in their work place environment. This may challenge their safety and security, their health and wellbeing (Baydin ; Erenler, 2014).The effects of work place violence is not limited to nurses only, rather it also have equal impact on doctors and other health care workers (Kowalenko, Hauff, Morden, ; Smith, 2012).
Thls is recognized as high risk occupation which gaining more attention due to high occurrence of violent attacks on the working nurses. It was found by National Crime Victimization thatnon-fatal violence is about 21.9 per 1,000 among the nurses which is less in average than other profession (12.6 per 1,000 workers). The nurses of the emergency departments are the primary target of work place violence at every health care setup. In a previous study, conducted at the emergency departments, 82% of the nurses indicated that they have been assaulted in the last 12 months(May ; Grubbs, 2002).
It is suggested that the incidence of verbal abuse is rising day by day and reaching almost 100% nurses at the emergency departments of many hospitals. The American Nurses Association found very few nurses are safe from the work place violence (Less than 20%). There is no support from the institutions to prevent violence among nurses which contributes to more dissatisfaction among them (Gacki-Smith et al., 2010).
Work place violence is very common everywhere in every hospital against nurses but it is on the top in low socioeconomic developing countries of the world. Pakistan is one of such countries having high incidence of work place violence among nurses at work environment. There is also another issue of poor reporting, lack of documentation and un- published status of such violence in the health care setups. Such high incidences of work place violence among nurses put the managements of different organizations in the challenging situations(Somani, 2012)
Health care workers’ especially nurses of the emergency departments may experience lots of workplace violence which may cause low satisfaction and poor performance among them (Hesketh et al., 2003). If there is no full performance of nurses due to unsafe environment, it will have direct impact on patients care outcomes and ultimately leads to ineffective and poor services of the hospitals (Kwok et al., 2006).
Despite of so many bad consequences of work place violence among nurses, it is still under reported and under rated issue. This lack of reporting may be because of fear, stigma and blame of being harassed. More seriously, the society might think that the nurses are made to bear such violence as part of their care that is why they are expected to tolerate it (Alameddine et al., 2015)
This paper presents workplace violence towards nurses as a major issue in the context of health care settings in Pakistan. Heresome characteristics of violence against the emergency nurses will be highlighted; some problems will be analyzed from different ethical professional and legal perspectives.Here some physical and psychological consequences of work place violence will be highlighted too.
1.2. Problem Statement:
Workplace violence among nurses is known to affect their job working environment, which may lead to decrease in their services at the emergency departments. Furthermore, the work place violence might be associated with physical and emotional imbalances among nurses at their duty. If the nurses are not balance physically and mentally, their care will not be according to standards, therefore there is need to identify the prevalence of violence, the types of violence at work place and also the measures to eliminate the high occurrence of work place violence among nurses.
1.3. Research Question:
1. What is the prevalence of violence against nurses working in the emergency departments of public tertiary hospitals Lahore?
2. What are the types of violence against nurses working in the emergency departments of public tertiary hospitals Lahore?
3. What are the contributing factors for workplace violence against nurses working in the emergency departments of public tertiary hospitals Lahore?
1.4. Significance:
Workplace violence is an issue of international health care among the workers at all departments of the health care systems but more sever at the emergency departments. Direct violence or indirect violence which may be physical or non-physical violence among nurses at the emergency departments might cause negative consequences in the future of nurses. If nurses of emergency department be aware of the types and causes of violence they can decrease the bad consequences and will avoid negative effect on the quality of health care providers and patients. The decrease in the productivity of nursing care will be minimized, negative impact on nurses whether it is physically or psychologically will be controlled. This may help the nurses to resolve violence related issues and continue a peaceful job life ahead.
1.5. Research Purpose:
The aim of this study is to bring awareness about work place violence among nurses at the emergency departments of health care systems. It will further reveal the issue of workplace violence after finding the prevalence at the emergency departments.
1.6. Objectives:
1. To assess the prevalence of violence against nurses working in the emergency departments of public tertiary hospitals Lahore
2. To identify the types of violence against nurses working in the emergency departments of public tertiary hospitals Lahore
3. To determine the contributing factors for workplace violence against nurses working in the emergency departments of public tertiary hospitals Lahore
1.7. Definitions:
a) Workplace Violence
Incidents where staff are abused, threatened or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being or health.
b) Physical violence:
It occurs when an employee is exposed to the deliberate use of force such as beating, pushing, slapping, and kicking, biting, pinching, stabbing, shooting by the patient and/or their families, a colleague or any others. Physical violence may lead to physical harm or emotional or sexual harm to the abused employee.
c) Verbal violence:
This happen when someone such as (patient, patients’ relatives, visitors, and coworkers) shout, curses or use other words to verbally insult the employee without an intention to bodily harm. For example someone yells at you. This includes any behavior towards an employee based on age, disability, gender, race, poverty, richness, or any other unwanted status which negatively influence the dignity of employee.
d) Sexual violence:
Any unwanted, unwelcomed and non-reciprocal sexual attention. It may include sexist remarks, behavior or sexual advances which results in a tense and unproductive environment. These forms of harassments/ abuse threaten the employees and cause them to feel humiliated.
1.8. Variables
Independent variable
Personal characteristic such as Gender, age, Marital status, experience and place of violence etcetera.
Dependent variables:
Prevalence of violence and Types of violence

Chapter II: Literature Review
Different literature studies are available regarding workplace violence among nurses. Here also some studies were found about workplace violence among nurses, workplace aggression of patients and families against nurses, violence against nurses at the emergency department and nurse’s perception of workplace violence at the emergency departments.
Workplace violence is the act which involves physical and nonphysical threats of assault affecting the nurses at their work places. Even verbal violence such as threats and verbal abuse against nurses, hostility for nurses, harassment against them can cause equal mental and psychological trauma to physical work place violence (Gomaa et al., 2015).
Study conducted by the Emergency Nurses Association (ENA), found that in the united states every year about nine hundred deaths occurs due to work place violence and around 1.7 million less life threatening assaults occur annually. This is still an unclear estimate of the severity of the work place violence. Further the Bureau of Labor and Statistic’s Survey conducted about the Occupational Injuries and violence found that the violence at work place among the health care workers is much higher than other profession (Albashtawy, 2013).
Emergency departments are working for 24 hours and have risks of much violence. Some situations like the lack of adequate training, physical security, lack of visible security guards and increased stress in the department make nurses of the emergency department more prone to work place violence. In a study 25% of the study participants at the emergency departments experience physical violence and around 20% stated verbal violence experience during last three years (Gacki-Smith et al., 2009).
Prevalence of Violence among nurses of Emergency Department:
A study assessed the prevalence of work place violence among the emergency nurses which was found that 44.6% nurses during the last year have experienced work place violence. Furthermore verbal abuse was found the most common work place violence. The physical and sexual assault were less in number as compare to verbal violence. Many nurses have experienced a combination of physical and nonphysical violence both. The work place violence was mostly caused by the patients, then the relatives and colleagues while least violence was recorded from supervisors’ side. Almost half of the nurses said that the violence they have experienced was preventable with proper care. Moreover all the nurses mentioned few management techniques for work place violence such as discussing with colleagues, reporting to the immediate supervisors, and confronting to the perpetrator of violence etcetera (Cheung & Yip, 2017).
Another study also conducted among health care workers to assess the work place violence among them. It was found that about 60% of the study participants, who were working at the emergency departments exposed to violence during their duty in the last one year. A total of 65.7% nurses exposed to verbal violence at their work place. Majority of the HCW 61% were females who got affected by violence. The occurrence of violence was found different in different individuals. Some experienced work place violence very frequently, other faced it once a month etcetera. The violence from patients relative was found at the top (89.7% of verbal violence) and for 90.5% of physical violence. Verbal violence mostly found in the evening shift (Abdellah & Salama, 2017).
Types of Violence among ER Nurses:
Some commonest physical violence types were experienced by more than 50% nurses were, they were being spit on, pushed by patients or relatives, scratched and being kicked. Among the verbal violence, the most common (70%) was yelling from patients and their families, intimidated and being harassed with sexually abusive language. The perception of safety was found very low and about 70% participants showed less than 50% safety perception. About 33% participants were in favor of leaving emergency department due to increased work place violence (Gacki-Smith et al., 2010).
Findings of another study reveals that incidence of verbal violence was (63.9%), which was almost five times more than physical violence (11.9%) at the emergency department among nurses in the last 12 months of period. Verbal violence at the emergency department was mainly by the patients against nurses then secondly by their family members and relatives. The rate of physical violence was also high from patients and their family members. Afternoon shift was found to have more work place violence at the emergency departments due to increased patients inflow (Albashtawy, 2013).
According to another study verbal violence was found among the 86% of nurses at the emergency departments. Threats were also found high among the (35%) of the study participants. Physical abuse was also found among the nurses from the patients and their families but it was lower than that of verbal assault. No difference of violence exposure was found between males and females or based on the specialty such as medical and surgical. However very few respondents were from emergency to have a meaningful comparison (Imran, Pervez, Farooq, & Asghar, 2013).
Contributing factors for Work Place violence:
Patients relatives were overall the most common source of work place violence among the emergency department nurses (71%) followed by patients (30.5%). Results also showed that there are other various aspects of work place violence caused by colleagues, supervisors also (Imran et al., 2013).It is observed that there are under reported may be due to feeling of uncomforted and lack of support from the organization. There is also lack of a well-structured reporting system for work place violence in many health care organizations. It is very important to identify the contributing factors for work place violence (Somani, 2012).
It is very clear from previous studies that the major contributor of workplace violence among nurses at the emergency department was found patients which is followed by the relatives of the patients. Along with patients and their relatives, the nursing colleagues, senior nurses, the manager nurses, and on duty doctors also are the contributing factors for work place violence among the emergency department nurses (Kwok et al., 2006).
According to another study, workplace physical violence against the emergency department nurses was perpetrated mainly by patients followed by their relatives and then by other nurses. The results of the study found that relatives of patients were the most frequent contributors of physical violence against the emergency department nurses. They were responsible for a large number of cases (58.5%)(Boafo & Hancock, 2017).

CHAPTER III: METHODOLOGY
3.1. Research Design:
A descriptive cross-sectional study design was used to conduct this study. Data about the violence against emergency department nurses was collected at one point in time with the help of a questionnaire.
3.2. Time Period:
This study was conducted from February 2018 to May 2018 for about 4 months period of time.
3.3. Site and setting of the study:
This study was conducted among the nurses at the Emergency Departments of two public tertiary care hospitals Lahore. They are the Jinnah Hospital Lahore and Services Hospital Lahore.
3.4. Population:
The study was conducted among the nurses. The population for this study was all nurses who are working in emergency departments of the selected hospitals, the Jinnah Hospital and the Services Hospital Lahore.
3.5. Sample size Determination
The minimum sample required is calculated using the single proportion formula which is given below.
? = ?2(1 ? ?) /?2
d= Acceptable margin of error (precision of measurement) = 5%
z= Standard variant (1.96) which correspond to 95% confidence level
p= Overall prevalence of workplace violence among nurses in public health facilities in
Nazish Imran2013 (73%).
(1.96)2 0.73 (1?0.73) /(0.05)2 =
(1.96)2 0.73 (1?0.73) /(0.05)2 =
3.8416* 0.73 (0.27) /(0.0025)=
2.804* 108 = 302
Since the total number of study population is < 10,000 (N=400) using the correction formula the final sample size will benf = ???/ ?+?
400?302 /400+302 = 147
120,800 /702 = 147
3.6. Sampling procedure
Sampled will be selected from the emergency departments of two public hospitals through convenient sampling methods. N=75 will be selected from Jinnah Hospital while remaining 72 nurses will be selected from services hospital emergency department.
3.7. Inclusion criteria
All nurses from the emergency departments were recruited who were:
1. Willing to participate in the study
2. Working in emergency department at least one year
3. Registered with Pakistan Nursing council
3.8. Exclusion criteria
Those nurses will not be recruited who are:
1. All nurses who were not at work place during data collection period
2. Those who were not willing and not registered
3.9. Data collection tool
A self-administered standardized adopted questionnaire was used to collect the data. The questionnaire adopted from a study ‘Work place violence against nurses working in the emergency department of in Saudi Arabia’ by Fuaad Ali Alshehri(Albashtawy, 2013).
The first section of the questionnaire consisted off the demographic information about the age, gender, education and working experience of the participants. The second and third parts of the questionnaire discussed the physical and nonphysical violence among nurses at the emergency departments. The participants of the study were asked to fill the questionnaire of work place violence.
3.10. Data processing, Analysis and presentation
The data was put into the SPSS version 21. The results were processed and analyzed with the help of graphs, tables in the form of frequencies, averages and percentages.
3.11. Ethical Consideration
An approval was taken from the committee of national college of nursing. Then permission was taken from the heads of the study setting such as Head of Jinnah hospital and Head of the services Hospital. A written permission was taken from each individual participant of the study. Each participant was provided with the questionnaire with an informed consent which was explained the purposes and significance of the study. The study participants were assured that their names will be kept confidential. Their participation was fully volunteer and can withdraw at any time.

CHAPTER IV: RESULTS

4.1 Demographic data analysis and results

The below table shows about the gender of participants that were 6.80% were male and 93.20% was female. Result also shows the age of the participants of study from which 10.20% were less than 25 years & 53.06% were between 26 to 30 years 27.89% were between the age of 31 to 35 years 6.12% were between the age of 36 to 40 years and 2.72% participants of study were more than 40 years of age. It was also found that the education level of the study participants from which 19.05% were only have general nursing diploma 40.14% of study participants having specialization as well 40.82% have the degree of generic BSN and post RN BSN degree.
Table 1: Frequency and percentage of demographics data

Variables Number (n) Per cent
Gender
Male
Female
10
137
6.8
93.2
Age:
Less than 25 years
26-30 years
31-35 years
36-40 years
Above 40 years
15
78
41
9
4
10.2
53.1
27.9
6.1
2.7
Education:
Nursing Diploma
Diploma plus specialization
BSN/PRN BSN
MSN/MPH
28
59
60

19.0
40.1
40.8

Experience
77
51
15
4

52.4
34.7
10.2
2.7

1-5 years
6-10 years
11-15 years
Above 15years

4.2: DESCRIPTIVE ANALYSIS OF PHYSICAL AND NONPHYSICAL VIOLENCE
Below Table 2 shows that in response for how many times the participants exposed to physical violence in last 12 months. It was found that 77.55% stated that they are not exposed to physical violence last 12 months, 13.6% said once, 7.48% said 2-3 times and 1.3% stated they have been exposed 4-5 times during last year. On the other hand the participants exposed to Nonphysical violence in last 12 months,12.93% stated that they are not exposed to physical violence last 12 months, 25.85% said once, 40.82% said 2-3 times and 19.73% stated they have been exposed 4-5 times during last year. The type of physical assault the study participants was asked and 4.08% of participants had experience beating, 9.52% experience pushing, 6.12% of study participants had experience slapping, 1.36% pinching, 1.36% shooting, and not applicable for 77.55% of study participants. Similarly about types of nonphysical assault the study participants were exposed to, 50.34% of participants had experience threats, 36.05% experience verbal abuse and 2.04% of study participants had experience sexual harassment/abuse. Regarding the physical assaulters to staff from which 8.16% were patients, 13.61% were relatives of patients, 0.68% were coworkers of the staff and not applicable for 77.55% participants. About the assaulters of nonphysical at staff from which 19.73% were patients, 63.27% were relatives of patients, 5.44% were coworkers of the staff and not applicable for 11.56% participants. It was also found that 2.04% incidents happened at morning shift 9.52% at evening 8.84% at night shift and not applicable for 77.55% of study participants in terms of physical violence. Where as in nonphysical violence 11.56% incidents happened at morning shift 42.86% at evening 30.61% at night shift 3.40% participants was not sure about timing of the incident and not applicable for 11.56% of study participants.

Most recent physical incident in which 10.20% of incidents were happened at resuscitation room 2.04% at waiting room and 10.20% in treatment room and this question was not applicable for 77.55% of participants. The most recent nonphysical incident in which 38.10% of incidents were happened at resuscitation room 0.68% in triage 12.24% at waiting room and 37.41% in treatment room 0.68% in other places and this question was not applicable for 10.88% of participants.
Furthermore to physical violence 1.36% said yes received treatment, 12.24% not need, 2.04% not received and 6.80% self-treated and this question was not applicable for 77.55% of study participants. Similarly in nonphysical violence, 0.68% said yes received treatment, 68.71% no need, 3.40% not received and 15.65% self-treated. Result also shows that percentage by whom physical violence victim was treated 6.12% was treated by nurse 16.33% not treated and not applicable for 77.55% of study participants. It was also found in nonphysical violence that victim was treated 10.20 % was treated by nurse, 0.68% by psychiatrist, 0.68% by others 76.87% not treated and not applicable for 11.56% of study participants. The Findings also show the percentage of the cause of most recent incident from which 12.93% of participants said that it was due to waiting for services 5.44% was unable to meet patients desire 2.72% was due to unavailability of services 1.36 % was due to lack of preventive tools and not applicable for 77.55% of study participants. The cause of most recent nonphysical incidents from which 24.49% of participants said that it was due to waiting for services 13.61% was unable to meet patients desire 6.12% was due to mental illness 1.36% was due to way of dealing with patients 29.25% was due to unavailability of services 8.84 % was due to lack of preventive tools 4.76% said that it was due to impact of disease or pain and not applicable for 11.56% of study participants.

(Table 2) Frequency and percentage of the Violence

Variables Physical Violence Non-Physical Violence

Number of Time Being exposed Number(n) Percent Number(n) Percent
Never
Once
2-3 Times
4-5 times
6 times 114
20
11
2
00 77.6
13.6
7.5
1.4
00 19
38
60
29
01 12.9
25.9
40.8
19.7
.7
Who Assaulted
Patients
Visitors/Patients’ relatives
Co-workers
Not applicable 12
20
1
114 8.2
13.6
.7
77.6 29
93
8
17 19.7
63.3
5.4
11.6
When the Incidence Happened?
Morning
Afternoon
Night
Unsure
Not applicable 3
14
13
3
114 2.0
9.5
8.8
2.0
77.6 17
63
45
5
17 11.6
42.9
30.6
3.4
11.6
Where the incidence happened?
Resuscitation
Waiting Room
Triage
Treatment
Hallway
Not applicable 15
3
0
15
0
114 10.2
2.0
0
10.2
0
77.6 56
18
1
55
0
18 38.1
12.2
.7
37.4
0
10.9
Receiving treatment after the incident
Yes, received
There was no need
Needed but did not received
Self treated
Not applicable 2
18
3
10
114 1.4
12.2
2.0
6.8
77.6 1
101
5
23
17 .7
68.7
3.4
15.6
11.6
Who treated?
Doctors
Psychiatrist
Nurse
Not treated
Not applicable 0
0
9
24
114 0
0
6.1
16.3
77.6 0
1
15
113
17 0
.7
10.2
76.9
11.6
The causes of most Recent Incident
Waiting for receiving services
Failure to meet patients’ desire
Mental illness
Way of dealing the patients
Unavailability of the services
Fear stress
Lack of preventive tools
Impact of disease or pain
Not applicable 19
8
0
0
4
0
2
0
114 12.9
5.4
0
0
2.7
0
1.4
0
77.6 36
20
9
2
43
0
13
7
17 24.5
13.6
6.1
1.4
29.3
0
8.8
4.8
11.6

4.3: Summary of Physical and Nonphysical Violence:

The following Table 3 suggests that 4.1% of the study participants had Beating experience, 9.5% experienced pushing, 6.9% faced slapping, no kicking or biting was found, pinching and shooting was 1.4% each, while the rest of 77% had no experienced of physical violence.

Table 3: Summary of Physical Violence

Variable Category
Type of physical Violence N %
Beating
Pushing
Slapping
Kicking
Biting
Pinching
Shooting
Stabbing
Not applicable 6
14
9
0
0
2
2
0
114 4.1
9.5
6.1
0
0
1.4
1.4
0
77.6

The following Table 4 findings indicate thatabout 50.3% of the study participants had faced threats as nonphysical violence, 36.1% experienced Verbal abuse/Harassment, while 2% have experience Sexual Abuse/Harassment and 11.6% faced no any nonphysical violence during last 1 year.

Table 4: Summary of Nonphysical Violence

Variable Category
Type of Nonphysical Assault N %
Threats
Verbal abuse/Harassment
Sexual Abuse/Harassment
Not applicable 74
53
3
17 50.3
36.1
2.0
11.6

4.3.2: Descriptive analysis of Physical Violence
How many times have you been exposed to physical violence during the last 12 months?
Frequency Percent Valid Percent Cumulative Percent
Valid Never 114 77.6 77.6 77.6
Once 20 13.6 13.6 91.2
2-3times 11 7.5 7.5 98.6
4-5 times 2 1.4 1.4 100.0
Total 147 100.0 100.0

The above table and Graph shows that in response for how many times the participants exposed to physical violence in last 12 months. It was found that 77.55% stated that they are not exposed to physical violence last 12 months, 13.6% said once, 7.48% said 2-3 times and 1.3% stated they have been exposed 4-5 times during last years.

What type of physical assault were you exposed to during the most recent incidence?
Frequency Percent Valid Percent Cumulative Percent
Valid Beating 6 4.1 4.1 4.1
Pushing 14 9.5 9.5 13.6
Slaping 9 6.1 6.1 19.7
Pinching 2 1.4 1.4 21.1
Shooting 2 1.4 1.4 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph shows the type of physical assault the study participants were exposed to in which 4.08% of participants had experience beating 9.52% experience pushing 6.12% of study participants had experience slapping 1.36% pinching 1.36% shooting and not applicable for 77.55% of study participants.

In the most recent physical incident who assault you?
Frequency Percent Valid Percent Cumulative Percent
Valid Patients 12 8.2 8.2 8.2
Relatives 20 13.6 13.6 21.8
Co-Workers 1 .7 .7 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph show the percentage of physical assaulters to staff from which 8.16% were patients 13.61% were relatives of patients 0.68% were coworkers of the staff and not applicable for 77.55% participants.

In the most recent physical incident when did the incident happened?
Frequency Percent Valid Percent Cumulative Percent
Valid Morning 3 2.0 2.0 2.0
Afternoon 14 9.5 9.5 11.6
Night 13 8.8 8.8 20.4
Not sure 3 2.0 2.0 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph show the timing of physical incident from which 2.04% incidents happened at morning shift 9.52% at evening 8.84% at night shift and not applicable for 77.55% of study participants.

In the most recent physical incident where did the incident happened?
Frequency Percent Valid Percent Cumulative Percent
Valid Resuscitation 15 10.2 10.2 10.2
Waiting room 3 2.0 2.0 12.2
Treatment room 15 10.2 10.2 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph shows the location of most recent incident in which 10.20% of incidents were happened at resuscitation room 2.04% at waiting room and 10.20% in treatment room and this question was not applicable for 77.55% of participants.

Did you receive treatment after the most recent incident?
Frequency Percent Valid Percent Cumulative Percent
Valid Yes received 2 1.4 1.4 1.4
No need 18 12.2 12.2 13.6
Not received 3 2.0 2.0 15.6
Self treated 10 6.8 6.8 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph shows the percentage of study participants who receive or didn’t receive the treatment after most recent physical incident in which 1.36% said yes received 12.24% no need 2.04% not received and 6.80% self treated and this question was not applicable for 77.55% of study participants.

If yes who treated You?
Frequency Percent Valid Percent Cumulative Percent
Valid Nurse 9 6.1 6.1 6.1
Not treated 24 16.3 16.3 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph shows the percentage by whom physical violence victim was treated 6.12% was treated by nurse 16.33% not treated and not applicable for 77.55% of study participants.

What do you think was the cause of the most recent incidence?
Frequency Percent Valid Percent Cumulative Percent
Valid Waiting for services 19 12.9 12.9 12.9
not meeting patients' desire 8 5.4 5.4 18.4
Unavailability of the services 4 2.7 2.7 21.1
Lack of preventive tools 2 1.4 1.4 22.4
Not applicable 114 77.6 77.6 100.0
Total 147 100.0 100.0

The above table and graph shows the percentage of the cause of most recent incident from which 12.93% of participants said that it was due to waiting for services 5.44% was unable to meet patients desire 2.72% was due to unavailability of services 1.36 % was due to lack of preventive tools and not applicable for 77.55% of study participants.

4.3.2: Descriptive analysis of Nonphysical Violence:

How many times have you been exposed to Non-physical violence during the last 12 months?

Frequency Percent Valid Percent Cumulative Percent
Valid Never 19 12.9 12.9 12.9
Once 38 25.9 25.9 38.8
2-3times 60 40.8 40.8 79.6
4-5 times 29 19.7 19.7 99.3
6 or more times 1 .7 .7 100.0
Total 147 100.0 100.0

The above table and Graph shows that in response for how many times the participants exposed to physical violence in last 12 months. It was found that 12.93% stated that they are not exposed to physical violence last 12 months, 25.85% said once, 40.82% said 2-3 times and 19.73% stated they have been exposed 4-5 times during last year.

What type of non-physical assault were you exposed to during the most recent incidence?

Frequency Percent Valid Percent Cumulative Percent
Valid Threats 74 50.3 50.3 50.3
Verbal abuse/Harassment 53 36.1 36.1 86.4
Sexual abuse 3 2.0 2.0 88.4
Not applicale 17 11.6 11.6 100.0
Total 147 100.0 100.0

The above table and graph shows the type of non physical assault the study participants were exposed to in which 50.34% of participants had experience threats 36.05% experience verbal abuse and 2.04% of study participants had experience sexual harassment/abuse and not applicable for 11.56% of study participants.

In the most recent nonphysical incident who assault you?
Frequency Percent Valid Percent Cumulative Percent
Valid Patients 29 19.7 19.7 19.7
Relatives 93 63.3 63.3 83.0
Co-Workers 8 5.4 5.4 88.4
Not applicable 17 11.6 11.6 100.0
Total 147 100.0 100.0

The above table and graph show the percentage of non physical assaulters to staff from which 19.73% were patients 63.27% were relatives of patients 5.44% were coworkers of the staff and not applicable for 11.56% participants.

In the most recent nonphysical incident when did the incident happened?
Frequency Percent Valid Percent Cumulative Percent
Valid Morning 17 11.6 11.6 11.6
Afternoon 63 42.9 42.9 54.4
Night 45 30.6 30.6 85.0
Not sure 5 3.4 3.4 88.4
Not applicable 17 11.6 11.6 100.0
Total 147 100.0 100.0

The above table and graph show the timing of physical incident from which 11.56% incidents happened at morning shift 42.86% at evening 30.61% at night shift 3.40% participants was not sure about timing of the incident and not applicable for 11.56% of study participants.

In the most recent nonphysical incident where did the incident happened?
Frequency Percent Valid Percent Cumulative Percent
Valid Resuscitation 56 38.1 38.1 38.1
Triage 1 .7 .7 38.8
Waiting room 18 12.2 12.2 51.0
Treatment room 55 37.4 37.4 88.4
Others 1 .7 .7 89.1
Not applicable 16 10.9 10.9 100.0
Total 147 100.0 100.0

The above table and graph shows the location of most recent incident in which 38.10% of incidents were happened at resuscitation room 0.68% in triage 12.24% at waiting room and 37.41% in treatment room 0.68% in other places and this question was not applicable for 10.88% of participants.

Did you receive treatment after the most recent incident?

Frequency Percent Valid Percent Cumulative Percent
Valid Yes received 1 .7 .7 .7
No need 101 68.7 68.7 69.4
Not received 5 3.4 3.4 72.8
Self treated 23 15.6 15.6 88.4
Not applicable 17 11.6 11.6 100.0
Total 147 100.0 100.0

The above table and graph shows the percentage of study participants who receive or didn’t receive the treatment after most recent non physical incident in which 0.68% said yes received 68.71% no need 3.40% not received and 15.65% self treated and this question was not applicable for 11.56% of study participants.

If yes who treated You?

Frequency Percent Valid Percent Cumulative Percent
Valid Nurse 15 10.2 10.2 10.2
Psychiatristist 1 .7 .7 10.9
Others 1 .7 .7 11.6
Not treated 113 76.9 76.9 88.4
Not applicable 17 11.6 11.6 100.0
Total 147 100.0 100.0

The above table and graph shows the percentage by whom physical violence victim was treated 10.20 % was treated by nurse 0.68% by psychiatrist 0.68% by others 76.87% not treated and not applicable for 11.56% of study participants.

What do you think was the cause of the most recent incidence?

Frequency Percent Valid Percent Cumulative Percent
Valid Waiting for services 36 24.5 24.5 24.5
not meeting patients' desire 20 13.6 13.6 38.1
Mental illness 9 6.1 6.1 44.2
Way of dealing the patients 2 1.4 1.4 45.6
Unavailability of the services 43 29.3 29.3 74.8
Lack of preventive tools 13 8.8 8.8 83.7
Impact of disease or pain 7 4.8 4.8 88.4
Not appicable 17 11.6 11.6 100.0
Total 147 100.0 100.0

The above table and graph shows the percentage of the cause of most recent incident from which 24.49% of participants said that it was due to waiting for services 13.61% was unable to meet patients desire 6.12% was due to mental illness 1.36% was due to way of dealing with patients 29.25% was due to unavailability of services 8.84 % was due to lack of preventive tools 4.76% said that it was due to impact of disease or pain and not applicable for 11.56% of study participants.

Chapter 5: Discussion
This current study found that physical violence was about 22.5% where 4.1% of the study participants had Beating experience, 9.5% experienced pushing, 6.9% faced slapping and pinching and shooting was 1.4% each, while the rest of 77.5% had not experienced of physical violence. The prevalence of nonphysical violence was found about 88.4% where 50.3% of the study participants had faced threats as nonphysical violence, 36.1% experienced Verbal abuse/Harassment, while 2% have experience Sexual Abuse/Harassment and 11.6% faced no any nonphysical violence during last 1 year.
According to a previous study the verbal violence was found among the 86% of nurses at the emergency departments. Physical abuse was also found among the nurses from the patients and their families but it was lower than that of verbal assault. No difference of violence exposure was found between males and females or based on the specialty such as medical and surgical. However very few respondents were from emergency to have a meaningful comparison (Imran et al., 2013).
Similarly Findings of another study reveals that incidence of verbal violence was (63.9%), which was almost five times more than physical violence (11.9%) at the emergency department among nurses in the last 12 months of period (Albashtawy, 2013).
A previous study found some similar findings where nonphysical abuse was found the most common work place violence. The physical and sexual assault were less in number as compare to verbal violence (Cheung & Yip, 2017). According to another study, a total of 65.7% nurses exposed to nonphysical violence at their work place (Abdellah & Salama, 2017).
During my study the physical violence was mainly 13.61% were from relatives of patients (out of 22%), which becomes almost half the violence.
Similarly, in a previous study, violence from patients relative was found at the top (89.7% of verbal violence) and for 90.5% of physical violence. Verbal violence mostly found in the evening shift (Abdellah & Salama, 2017).
According to this study most common violence were 4.08% of participants had experience beating, 9.52% experience pushing, 6.12% of study participants had experience slapping, 1.36% pinching, 1.36% shooting and not applicable for 77.55% of study participants.
According to previous study some commonest physical violence types were experienced by more than 50% nurses were, they were being spit on, pushed by patients or relatives, scratched and being kicked (Gacki-Smith et al., 2010).
According to this current study, the type of nonphysical assault the study participants were exposed to in which 50.34% of participants had experience threats 36.05% experience verbal abuse and 2.04% of study participants had experience sexual harassment/abuse and not applicable for 11.56% of study participants. Previously, among the verbal violence, the most common (70%) was yelling from patients and their families, intimidated and being harassed with sexually abusive language. (Gacki-Smith et al., 2010). According to another study, threats were also found high among the (35%) of the study participants (Imran et al., 2013).

Chapter 6: Conclusion

Conclusion
The purpose of this study was to assess the prevalence of work place violence and types of physical and non physical violence in the public hospitals of Lahore. The emergency nurses during study indicated that violence was a common occurrence.
It was found that 77.55% stated that they are not exposed to physical violence last 12 months, 13.6% said once, 7.48% said 2-3 times and 1.3% stated they have been exposed 4-5 times during last year. On the other hand the participants exposed to Nonphysical violence in last 12 months,12.93% stated that they are not exposed to physical violence last 12 months, 25.85% said once, 40.82% said 2-3 times and 19.73% stated they have been exposed 4-5 times during last year.
Most recent physical incident in which 10.20% of incidents were happened at resuscitation room 2.04% at waiting room and 10.20% in treatment room. The most recent nonphysical incident in which 38.10% of incidents were happened at resuscitation room 0.68% in triage 12.24% at waiting room and 37.41% in treatment room 0.68% in other places.
It was also found that 2.04% incidents happened at morning shift 9.52% at evening 8.84% at night shift. Where as in nonphysical violence 11.56% incidents happened at morning shift 42.86% at evening 30.61% at night shift 3.40% participants was not sure about timing of the incident.

Recommendations
This study addressed several areas requiring further research. There is a shortage of violence research among emergency nurses in Lahore. Further research is needed to develop strategies for preventing violence against emergency nurses, which would need to consider the local culture and findings of this study. Further in depth research is needed to assess the impact of violence on the perception and professional life of emergency nurses.

Limitations
This was my first research study so due to lack of expertise there are some limitations.it may be better if I can relate different kind of professional, environmental and cultural factors affecting work place violence in my study, but due to lack of time and less expertise I was unable to do that. Hopefully it will be better in my next studies.

REFERENCES:
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Alameddine, M., Mourad, Y., ; Dimassi, H. (2015). A national study on nurses’ exposure to occupational violence in Lebanon: prevalence, consequences and associated factors. PLoS ONE, 10(9), e0137105.
Albashtawy, M. (2013). Workplace violence against nurses in emergency departments in Jordan. International nursing review, 60(4), 550-555.
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Blanchar, Y. (2011). Violence in the health care sector: a global issue. World Medical Journal, 57(3), 87-89.
Boafo, I. M., & Hancock, P. (2017). Workplace violence against nurses: a cross-sectional descriptive study of Ghanaian nurses. SAGE Open, 7(1), 2158244017701187.
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Informed consent:

Workplace violence against nurses working in emergency departments at a public hospital Lahore

Dear participants,
I am Salman Ijaz, want to conduct a research on “Workplace violence against nurses working in emergency departments at a public hospital Lahore”. As this Research project work for the fulfillment of my Post RN BSN degree from National College of Nursing, affiliated with the University of Lahore. The purpose of this research study is to assess the Workplace violence against nurses working in emergency departments at a public hospital Lahore.A questionnaire will be distributed for data collection, for which your cooperation is required. The questionnaire will take about 20-30 minutes to complete. Your participation will be very helpful for me to complete my study. Your valued information will be kept confidential. You are allowed to withdraw at any time from research study.
I have read all the terms and voluntarily consent to participate in the research study.

Participant's Signature:………………………..
Date: ………………………….

Questionnaire:

Workplace Violence against nurses working in emergency departments at a Public Hospital Lahore
Section 1: Demographic Data:

1. Gender:

1. Male ( ) 2. Female ( )

2. Age in Years:

1.Below 25 ( ) 2. 26-30 ( ) 3. 31-35 ( ) 4. 36-40 ( ) 5. above 40 ( )

3. Education:

1. Diploma GN ( ) 2. Specialization ( ) 3. BSN/Post RN ( ) 4.MSN ( )

4. Experience:

1.1-5 years ( ) 2. 6-10 years ( ) 3. 11-15 Years ( ) 4. Above 15 years ( )

Section 2: Physical Violence:

s. No Statement Options
1 How many times have you been exposed to physical violence during the last 12 months? Never
Once

2-3
4-5

6 or more times
2 What type of physical assault were you exposed to during the most recent incidence? Beating
Pushing
Slapping

Kicking
Biting
Pinching

Shooting
Stabbing
Others

3 In the most recent physical incident who assault you? Patients
Relatives

Coworkers
Others ______

4 In the most recent physical incident when did the incident happened? Morning
Afternoon

Night
Not sure

5 Where did the most recent incident happen? Resuscitation
Triage

Waiting Room
Treatment room

Other specify ______

6 Did you receive treatment after the most recent incident? Yes received
No Need

Did Not receive
Self-treated

7 If yes who treated You? Doctors
Nurse

Psychiatrist
Others

Not treated

8 What do you think was the cause of the most recent incidence? Waiting for receiving services

Failure to meet patients’ desire

Mental illness

Way of dealing the patients

Unavailability of the services

Fear stress

Lack of preventive tools

Impact of disease or pain

Section 3: Non Physical Violence:

s. No Statement Options
1 How many times have you been exposed to Non-physical violence during the last 12 months? Never
Once

2-3
4-5

6 or more times
2 What type of physical assault were you exposed to during the most recent incidence? Threats

Verbal abuse/Harassment

Sexual abuse Harassment

3 In the most recent physical incident who assault you? Patients
Relatives

Coworkers
Others ______

4 In the most recent physical incident when did the incident happened? Morning
Afternoon

Night
Not sure

5. Where did the most recent incident happen? Resuscitation
Triage

Waiting Room
Treatment room

Other specify ______

6. Did you receive treatment after the most recent incident? Yes received
No Need

Did Not receive
Self-treated

7. If yes who treated You? Doctors
Nurse

Psychiatrist
Others

Not treated

8. What do you think was the cause of the most recent incidence? Waiting for receiving services

Failure to meet patients’ desire

Mental illness

Way of dealing the patients

Unavailability of the services

Fear stress

Lack of preventive tools

Impact of disease or pain

Section 4: Preventing/managing procedures for Assault reports:

S. No Statement Yes No Don’t Know
9. Are there enough methods to prevent violence on staff (Guard, Security, Camera, warning devices ) in the departments
10. Are there enoughpolicies systems and instructions to prevent violence on workers in the hospitals?
11. Are there reporting procedures for the reporting violence in the hospitals?
12. Did you receive training or educational programs by the hospital to prevent and deal with violence?
13. In the most recent incidence did you write report to your administrator or any other third party authority?
14. Has any action been taken against the assaulter?
15. Does the violence have Negative impact on you?
16. Do you think stop working in the coming 1-3 years due to violence in the work area?

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