key: cord-0890321-bmru115z authors: Özkan Şat, Sultan; Akbaş, Pınar; Yaman Sözbir, Şengül title: Nurses' exposure to violence and their professional commitment during the COVID‐19 pandemic date: 2021-03-24 journal: J Clin Nurs DOI: 10.1111/jocn.15760 sha: 03d43c3409426a0e40c5d5c51e0b8686ad3addf6 doc_id: 890321 cord_uid: bmru115z AIMS AND OBJECTIVES: This study aimed to determine the relationship between nurses' exposure to violence and their professional commitment during the COVID‐19 pandemic. BACKGROUND: Violence against nurses is a common problem that persists worldwide. DESIGN: This was a descriptive cross‐sectional study. METHODS: An online questionnaire form and the Nursing Professional Commitment Scale were used to collect the data. The study was carried out online during the COVID‐19 pandemic between October–December 2020. A total of 263 nurses agreed to participate in the study. The STROBE checklist was followed for observational studies. RESULTS: During the COVID‐19 pandemic, 8.4% of the nurses stated that they were exposed to physical violence, 57.8% to verbal violence, 0.8% to sexual violence and 61.6% to mobbing. 52.1% of the nurses stated that they thought of quitting the profession during the COVID‐19 pandemic. The mean total Nursing Professional Commitment Scale score was 71.33 ± 15.05. CONCLUSIONS: This study revealed that nurses' exposure to physical, verbal and sexual violence during the COVID‐19 pandemic decreased compared to before the pandemic. Nurses' exposure to mobbing during the pandemic was found to increase. A statistically significant difference was found between the status of the nurses' exposure to physical violence, verbal violence, and mobbing, working hours, number of patients given care, and their thoughts of quitting the profession. It was found that the status of exposure to physical violence, thinking of quitting the profession and working hours decreased professional commitment. RELEVANCE TO CLINICAL PRACTICE: In the light of these results, it is recommended that measures to prevent violence should be addressed in a multifaceted way. In managing the pandemic process, the decisions and practices should not be left to the managers' initiative to prevent mobbing. Initiatives that will increase nurses' professional commitment during the pandemic process should be planned and implemented. Many areas of life, from health systems to the economy, working life, and daily life in Turkey, as well as the world, have been adversely impacted by the COVID-19 pandemic, declared by the World Health Organization (WHO) . Following the first case's appearance on 11 March 2020, in Turkey, as of 7 December 2020, the total number of patients infected with COVID-19 reached 545.711, with the death toll increasing to 15.103 (T.R. Ministry of Health, 2020) . One of the issues that the pandemic has negatively affected, exacerbated and made visibly is violence against health professionals. During the COVID-19 pandemic process in Turkey, healthcare professionals have been more often commissioned in the home care of the individuals aged 65 or older, who make up the risk group for COVID-19, 112 emergency care services, COVID-19 intensive care units, and filiation teams. Consequently, other health services provided in health institutions have been interrupted. In addition to intense working conditions, long shifts and lack of protective equipment, healthcare professionals have occasionally had to enter quarantine due to testing positive for COVID-19. Also, patients and their relatives cannot receive adequate health care due to pandemic regulations such as limited polyclinic services, the transition to an appointment system and subsequent patient failure to make an appointment for an examination or postponement of the appointment date to later days, need for disinfecting the rooms after each examination, waiting time of at least 20 min between examinations, and cancellation of non-urgent operations. All these experiences and fear of death/loss of relatives due to the COVID-19 have led to extreme tension and anger in patients and their relatives. The World Health Organization (WHO) defines violence as "the intentional threat or actual use of physical force or power against another person, which either results in or has a likelihood of resulting in injury, death, or psychological harm" (Krug et al., 2002) . Violence against healthcare workers, on the other hand, is defined as situations consisting of behavioural or verbal threats, physical assault, or sexual assault coming from the patient, patient relatives, or any other persons and posing a risk to the healthcare worker (Annagür, 2010; Catlette, 2005) . Studies reveal that violence against healthcare professionals has increased in recent years. The 2015 report of the American Nurses Association (ANA) states that 43% of nurses and nursing students have been subjected to verbal or physical violence by patients and their relatives and that this rate is more than 70% among emergency department nurses (Potera, 2016) . According to a study conducted in Italy, 49% of nurses were subjected to violence within a year, and 82% of this was verbal violence (Zampieron et al., 2010) . There are many studies carried out in Turkey in which violence against healthcare workers varies by the department (99.7% for 112 employees, 90.4% for emergency service workers, 43.4% for paediatric service workers, 73.8% for inpatient services, 65% for primary care workers, etc.), the type of violence that is exerted (physical violence at varying rates, such as 9.6% 16.7%, 20% and 23.2%; verbal violence at varying rates, such as 78.3%, 82%, 95.7% and 99.7%) and the profession (85% towards nurses, 69.4% towards research assistant doctors and 54.5% towards specialists) (Akbaş et al., 2016; Cerit et al., 2018; Coşkun & Karahan, 2019; Çuvadar & Ekuklu, 2020; Demirci & Uğurluoğlu, 2020; Oğuz et al., 2020; Şahin & Yıldırım, 2020; Yücens & Oğuzhanoğlu, 2020) . It has been reported that nurses, who are in close contact with patients and patient relatives while giving care, are exposed to violence by patients and patient relatives due to factors, such as long waiting times in health institutions, an inadequate number of healthcare workers, lack of security personnel, lack of information about the responsibilities of healthcare professionals by patients and their relatives, poor working conditions, lack of professional experience, and working in the night shift (Angland et al., 2014; Fallahi Khoshknab et al., 2015; Park et al., 2015) . Nurses are the leading healthcare professionals, who are at the forefront in the fight against COVID-19, risk their own lives, and are exposed to dangers. Although health professionals in many countries have been declared heroes in the fight against COVID-19 and are given applauses, violence towards healthcare professionals has increased during the pandemic process. In the literature, it was reported that during the COVID-19 pandemic, healthcare professionals in Mexico were attacked with eggs and subjected to physical violence, and those in India were beaten, despised, stoned, spat on their faces, and evacuated from their homes (Semple, 2020; Withnall, 2020) . Similarly, it has been reported that in many places, like Europe, the USA and Australia, violence towards healthcare professionals has kept increasing during the pandemic period (McKay et al., 2020) . Besides, health professionals have experienced stigma and exclusion due to the concerns that they may be COVID-19 carriers (Chew et al., 2020) . Similarly, we learn from the news or social media that incidents of violence have increased or become visible in Turkey, too (Özgüç & Toprak Ergönen, 2020) . • This study demonstrated that working conditions of nurses are getting worse during the pandemic process. • This study revealed that nurses' exposure to all type of violence except for mobbing during the pandemic was found to decrease. • Our results showed that especially exposure to physical violence among the type of violence decreased professional commitment. Exposure to all forms of violence can lead to the low quality of life, decreased job satisfaction, decreased productivity, anxiety and depression, anger, confusion, increased occupational burnout, decreased quality of patient care, post-traumatic stress disorder, decreased professional commitment, and quitting the profession (Bernaldo-De-Quiros et al., 2015; Heckemann et al., 2015) . Therefore, this study aimed to determine the relationship between nurses' exposure to violence and their professional commitment during the COVID-19 pandemic process. Has the COVID-19 pandemic process affected the status of nurses' exposure to violence? Has the COVID-19 pandemic process affected the types of violence towards nurses? Has the COVID-19 pandemic process affected nurses' level of professional commitment? Is there a relationship between nurses' exposure to violence and their level of professional commitment during the COVID-19 pandemic process? 3 | ME THOD The study used a descriptive cross-sectional design. The STROBE (STrengthening the Reporting of OBservational studies in Epidemiology) checklist was followed to guide this article (see Appendix S1). The study population consisted of nurses working actively in public, private or university health institutions in Turkey. Since the number of nurses actively involved in the COVID-19 process was not known, the sample size was calculated using the sampling unknown universe formula (n = t 2 pq/d 2 ), where p = .85 q = 0.15, d = 0.05, and t = 1.96 based on the study of Çuvadar and Ekuklu (2020) . Accordingly, it was found that the sample size (n) should consist of 196 participants. The study was completed with a total of 263 nurses who resided within the boundaries of the Republic of Turkey, worked as a nurse in one of the public, private, or university health institutions, and volunteered to participate in the study. The study data were collected using a questionnaire form created by the researchers and the "Nursing Professional Commitment Scale" to determine the level of participants' professional commitment. The form consists of 39 items that collect information about participants' socio-demographic characteristics (i.e. age, education level) and status of exposure to violence during the COVID-19 pandemic process (Demirci & Uğurluoğlu, 2020; Şahin & Yıldırım, 2020 ). This scale was developed by Lu et al. (2000) to determine nurses' professional commitment. The scale has 26 items, three subdimensions (willingness to make an effort, maintaining as professional membership, belief in goals and values) and a four-point Likert-type rating structure. Nine items of the scale are reversed (items 14, 15, 16, 17, 18, 19, 20, 21 and 25) . The scores that can be obtained from the total scale range between 26-104. The scores that can be obtained from the sub-dimensions range between 13-52 for "willingness to make an effort," 8-32 for "maintaining as a professional membership," and 5-20 for "belief in goals and values." Increased scores from the overall scale and sub-dimensions indicate that individuals' professional commitment is high. The Turkish validity and reliability study of the scale was conducted by Çetinkaya et al. (2015) , and the internal consistency of the scale was found as 0.90. Cronbach's α coefficient from the original scale's validity and reliability study was reported to be 0.94 (Lu et al., 2000) . Cronbach's α coefficient of the scale in our study was found as 0.91. The study was carried out online between October-December 2020. In this context, data collection tools were turned into an online survey using Google Forms ® . The study was carried out by sending the online link to nurses through social networking sites such as Facebook ® , WhatsApp ® , Instagram ® and Twitter ® . Besides, researchers shared the link on forums and blogs on the Internet. As people are mostly active on social networking sites, these sites were used for circulating the questionnaire. "Allow only one response per user" option in Google Forms was used to identify potential duplicate entries from the same user. The questionnaire included a short explanation that stated only nurses who worked actively in public, private and university health institutions could participate in the study. It is estimated that completing the online questionnaire took approximately 10-15 min for each participant. The incomplete submission of the questionnaire was not possible due to the function in Google Forms which prevents submission of partially answered or unfilled questions. The data collected in the study were analysed on SPSS 23.0 (Statistical Package for Social Sciences, version 23.0, for Windows) software package. Descriptive statistics, such as numbers and percentages, and t-test and chi-square tests, were employed to analyse the data. At the outset, the approval of the Scientific Research Platform of the Turkish Republic Ministry of Health was obtained to carry out a study related to the pandemic process (Research No: 2020-10-15T20_18_20). In addition, the ethical approval of the Gazi University Ethics Committee was obtained (Research Code No: 2020-606) . In the study's application phase, the participants were informed about the study, and their informed consent was obtained on the first page of the questionnaire form. After the participants checked the checkbox showing they agreed to participate in the study, they could see the questionnaire items. No personal information was requested from the participants, and their responses reached the researchers anonymously. All information obtained from the participants was kept confidential and stored in an e-mail address accessible only to researchers. The nurses' mean age in our study was 31.26 ± 7.17, 88.2% of them were female, and 63.9% had an undergraduate degree. The participants were from the seven regions of Turkey, and most of them were found to work in the Central Anatolia region (38.8% Table 2 shows the status of nurses' exposure to violence before and during the pandemic. Nurses' exposure to physical, verbalemotional-psychological, and sexual violence during the pandemic was found to decrease compared to the case before the pandemic period, and a statistically significant difference was determined (p ≤ .05). Nurses' exposure to mobbing during the pandemic was found to increase, and the difference between pre-and during pandemic status was statistically significant (p ≤ .05). Table 2 shows whether the nurses were subjected to violence. The participants were asked about their opinions on the change in the frequency of violence against healthcare professionals during the COVID-19 pandemic process (Table 3) . Table 3 shows nurses' thoughts on the change in the frequency of violence, whether they were exposed to violence or not. Although nurses are not exposed to violence themselves, they think that violence against nurses pandemic process. Accordingly, 52.1% of the nurses stated that they wanted to, and the primary reason was stated to be severe working conditions (Table 3) . A statistically significant difference was found between the status of the nurses' exposure to physical violence, verbal-emotionalpsychological violence, and mobbing and their thoughts of quitting the profession (p ≤ .05). There was also a statistically significant difference between the nurses who stated that their working hours and the number of patients they provided care had increased and the nurses whose department had changed during the pandemic process in terms of their thoughts of quitting the profession (p ≤ .05) ( In our study, it was found that the mean scores of the nurses who stated they were exposed to physical violence during the pandemic process from the total and "willingness to make an effort" subdimension of the Nursing Professional Commitment Scale were lower than those of the nurses who were not exposed to physical violence (p ≤ .05). There was no statistically significant difference between the status of these two groups' exposure to verbal-emotionalpsychological violence, sexual violence and mobbing (p ≥ .005). A statistically significant difference was found between the status of thinking of quitting the profession during the COVID-19 pandemic process and all subscale and total scores of the Nursing Professional Commitment Scale and the professional commitment of those who thought of quitting the profession was found lower (p ≤ .05). Besides, as the working hours increased during the pandemic process, the mean scores from the maintaining as a professional membership and belief in goals and values sub-dimensions and that of the total scale were found to decrease, and there was a statistically significant difference between working hours and the mean Nursing Professional Commitment Scale score (p ≤ .05) ( Table 6 ). Violence is common in healthcare institutions, and nurses are the primary victims of violence in the workplace (Chapman et al., 2010; Pich et al., 2010) . Violence against nurses is a common problem that persists worldwide (Yang et al., 2012) . Our study revealed that nurses were exposed to violence both before and during the pandemic and that the most common type of violence was verbalemotional-psychological violence. Studies conducted in Turkey reported that 68% of the nurses were subjected to verbal violence and 33.6% to threat/psychological violence (Bahar et al., 2015) , 60.8% of the nurses working in emergency departments, intensive care units, and psychiatry clinics were subjected to verbal or physical violence (Ünsal Atan et al., 2013), and 78.3% of the nurses experienced verbal violence (Çuvadar & Ekuklu, 2020) . Our study is similar to the literature regarding the type of violence that nurses are frequently exposed to. Our study indicated that the verbal-emotionalpsychological violence that the nurses were exposed to before and during the pandemic was approximately four times the physical violence they were subjected to. The reasons why verbal violence was more common than other types of violence were that perpetrators usually thought that they would not be subjected to any legal sanctions, healthcare professionals continued to do their jobs unless there was a physical assault, and there were no legal notifications regarding verbal violence, all of which lead to the persistence of violence. In our study, nurses reported that they were exposed to physical and verbal-emotional-psychological violence most often by patients' relatives and to sexual violence most frequently by patients before and during the pandemic. According to studies conducted in Turkey, 60.2% of the nurses were subjected to violence by patient relatives, and 33.6% by patients (Bahar et al., 2015) , and 44.3% of the violence was found to come from patient relatives (Çuvadar & Ekuklu, 2020 Nursing is one of the professional groups that have been most negatively affected by the COVID-19 pandemic. Nurses in this process faced risks, such as intensive and long-term work, increased workload, stress due to new working styles because of the pandemic, getting infected and transmitting the infection to their relatives, disruption of family responsibilities, postponement of plans, mental traumas, permanent health deterioration, and death (Hiçdurmaz & Üzar Özçetin, 2020) . The phenomenon of violence towards healthcare workers that existed before the pandemic also persists in this process. We found exposure to physical, verbalemotional-psychological, and sexual violence types were determined to decrease during the pandemic. However, the nurses in our study thought that the prevalence of physical violence and verbalemotional-psychological violence increased during this period. It has been reported that the incidence of violence towards health professionals in the world and Turkey during the pandemic period continues (Devi, 2020; McKay et al., 2020; Oğan, 2020; Semple, 2020; Withnall, 2020) . Some studies have shown that healthcare workers are exposed to violence because they are accused of spreading the virus and that some patients and their relatives deliberately cough towards or spit in healthcare workers' faces (Rodríguez-Bolaños et al., 2020) . The decrease in the incidence of violence found in our study may have resulted from the reduction in patient admissions other than COVID-19 cases, people's staying away from hospitals due to their fears of COVID-19 transmission, and non-admission of patient relatives to hospitals. Despite all these, nurses were found to perceive an increased level of violence towards themselves, which suggests experiencing burnout. It was thought that the image of the nursing profession in Turkey changed in the first months of the COVID-19 pandemic and that the profession became more visible in this process. During the pandemic period, the nursing profession has been on the agenda both in the media and on social media and has been attributed values related to courage, sacrifice, and humanity. Besides, giving a huge round of applause to healthcare workers across the country at the beginning of the pandemic process to appreciate them and raise their morale has increased the attention towards them. However, as the pandemic process progressed, this increasing interest in healthcare personnel decreased, and they were exposed to social stigma and exclusion because they thought they were carriers of the disease. Mobbing, which is a behaviour type applied in many different ways, such as psychological violence, emotional abuse, humiliation, exclusion, damaging the employee's self-confidence, breaking motivation, and restricting powers, is frequently seen in health institutions. Our study determined that the rate of nurses' exposure to mobbing increased in the pandemic period. In a study conducted on female health workers in Turkey during the pandemic period, four out of 10 female healthcare workers were reported to have faced the repressive attitudes of senior workers or administrators (Nakışci et al., Nurses' thoughts regarding the change in the frequency of violence during the COVID-19 pandemic and intention to leave profession 2020). Forced department changes and applications of severe shift systems without healthcare workers' consent are among the pressure methods applied to them (Oğan, 2020) . We found that many nurses were assigned to units related to COVID-19, and their working hours had increased. Our study is similar to the literature in this respect. It is thought that conflicts emerging during the pandemic process due to increased workload and work stress increase mobbing incidents. In this extraordinary process, which is challenging for all healthcare professionals and requires complying with new protocols for pandemic management for both managers and nurses, it is recommended that the pandemic management should be done in accordance with transparent procedures to minimise exposure to mobbing. Professional commitment and professional identity are concepts that are created by the members of the profession over time as of school years and continuously change with the effect of various factors (Johnson et al., 2012) . Extraordinary processes such as pandemics can lead to a decrease in professional commitment and an increase in intention to leave the profession in occupational groups that have a role and importance in healthcare (Kim et al., 2019) . We found that more than half of the nurses wanted to quit the profession during the pandemic process, and it was related to violence exposure and low professional commitment. Also, it was found that the professional commitment of them was decreased during the COVID-19 pandemic process. There were a limited number of studies in the literature investigating to leave the nursing profession. It was reported that working more than 40 h a week and working more than three nightshifts a week increased the intention to leave the nursing profession (Said & El-Shafei, 2021) . Some studies in the literature revealed that violence towards healthcare professionals reduced job satisfaction and productivity, reduced the quality of care, and decreased professional commitment (Bahar et al., 2015; Hıdıroğlu et al., 2019; Najafi et al., 2018) . There is a strong relationship between professional commitment and the idea of quitting the profession (Cowin et al., 2008) . Our study is similar to the literature in this respect. It is thought that it is necessary to develop and implement effective policies and procedures to prevent violence, which is one of the factors that negatively affect professional commitment among nurses and can play an important role in increasing nurses' professional commitment. This study, which was carried out in Turkey, discussed the status of nurses' exposure to violence and their professional commitment during the COVID-19 pandemic process, and the relationship between the two. In conclusion, it was found that nurses were exposed to various forms of violence during the pandemic process and that their exposure to physical, verbal-emotionalpsychological, and sexual violence decreased compared to the pre-pandemic period. Another result of our study was that nurses were exposed to mobbing during the pandemic process more frequently. According to our study results, exposure to physical violence, verbal-emotional-psychological violence, mobbing, increased working hours and a multiplying number of patients provided care during the pandemic process affected nurses' thoughts of quitting the profession. Besides, as the nurses' exposure to physical violence, their thoughts of quitting the profession, and working hours increased during the pandemic process, their professional commitment decreased. Based on these results, we recommend the following points: • Measures to prevent violence towards healthcare professionals should be addressed multifaceted (regarding political, legal and cultural aspects). • Society should be informed to create an anti-violence culture. • Training programmes should be planned for patients and their relatives. • In managing the pandemic process, the decisions and practices taken to prevent mobbing in hospitals should not be left to the managers' initiative. • Initiatives that will increase nurses' professional commitment during the pandemic process should be planned and implemented (i.e. employment of more personnel, appropriate working conditions). • To minimise the thought of quitting the nursing profession, strategies should be developed to control the factors that are thought to increase nurses' work stress during the pandemic process, and nurses should be provided with psychological support. 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