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 Table of Contents  
Year : 2020  |  Volume : 7  |  Issue : 1  |  Page : 15-22

Prevalence and patterns of psychological and physical violence among nurses in a public tertiary health facility in Enugu, southeast Nigeria

1 Department of Community Medicine, Enugu State University College of Medicine, Enugu, Nigeria
2 Department of Community Medicine, College of Medicine, University of Nigeria Enugu Campus, Nsukka, Nigeria
3 Department of Community Medicine, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu State, Nigeria

Date of Submission09-Dec-2019
Date of Acceptance03-Jul-2020
Date of Web Publication18-Aug-2020

Correspondence Address:
Dr. Olanike Rebecca Agwu-Umahi
Department of Community Medicine, College of Medicine, University of Nigeria Enugu Campus, Nsukka, Enugu State
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJAMR.IJAMR_143_19

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Background: Workplace violence (WPV) is a significant and persistent occupational health hazard and constitutes a major concern for employers and employees. While there is increasing evidence on the prevalence of WPV in the health-care settings, nurses have been shown to be disproportionately affected. Although widely researched globally, there is scarcity of data on this phenomenon in Nigeria. This study aimed to determine the prevalence of physical and psychological violence among nurses in a tertiary health institution. Subjects and Methods: A descriptive cross-sectional study using a questionnaire adapted from WPV in the Health Sector Country Case Study Questionnaire. This study was carried out among nurses at the University of Nigeria Teaching Hospital Enugu, Southeast Nigeria. Proportionate sampling method was used to select 301 respondents. Results: Majority (219, 72.2%) of the participants were aged above 35 years, were female (283, 94%) and were married (249, 82.7%). About half (152, 50.5%) of the respondents had spent 10 years or more in practice. Verbal abuse was the most prevalent form of psychological violence experienced (129, 42.9%) followed by bullying/mobbing (21, 7.0%) while sexual abuse was reported by a few (7, 2.3%). Physical violence, on the other hand, was experienced by 46 (15.3%). Majority of the physical violence was carried out with a weapon (39, 84.8%) and in most of the cases the attacker was patient's relative (35, 76%). Patients' relatives were mostly responsible for the verbal abuse (78, 60.5%) and bullying (10, 47.6%) while sexual assault was mostly carried out by a coworker (4, 57.1%). Conclusion: Psychological violence was commonly experienced by nurses in Enugu and physical violence was often carried out with a weapon. Policies should put in place to ensure safety of nurses.

Keywords: Enugu, nurses, violence, workplace

How to cite this article:
Arinze-Onyia SU, Agwu-Umahi OR, Chinawa AT, Ndu AC, Okwor TJ, Chukukasi KW, Ogugua IJ, Aguwa EN, Theodore AO. Prevalence and patterns of psychological and physical violence among nurses in a public tertiary health facility in Enugu, southeast Nigeria. Int J Adv Med Health Res 2020;7:15-22

How to cite this URL:
Arinze-Onyia SU, Agwu-Umahi OR, Chinawa AT, Ndu AC, Okwor TJ, Chukukasi KW, Ogugua IJ, Aguwa EN, Theodore AO. Prevalence and patterns of psychological and physical violence among nurses in a public tertiary health facility in Enugu, southeast Nigeria. Int J Adv Med Health Res [serial online] 2020 [cited 2023 Apr 2];7:15-22. Available from: https://www.ijamhrjournal.org/text.asp?2020/7/1/15/292397

  Introduction Top

Violence toward health-care providers is a common problem and exposure of health-care personnel to violent behavior while at work is increasingly becoming a public concern.[1],[2] Evidence has shown that workplace violence (WPV) in health-care settings constitutes about one quarter of total violence reported in all workplaces.[3] In 2013, the Bureau of Labour Statistics in the USA reported that between 23,540 and 25,630 WPV cases were reported yearly from which more than a third of these were in health care and social service settings. Furthermore, health care and social service workers are almost four times likely to be injured as a result of violence as the average private sector worker.[4]

According to the US National Institute for Occupational Safety and Health, WPV can be defined by as any violent acts, threatening behavior, or assault happening in an employment place.[5] It can be classified into two broad categories to include physical and psychological violence.[6] Physical violence or abuse include those events that lead to major injury, require medical assistance or first aid, assault, and murder. Psychological violence on the other hand involves threat, verbal abuse, bullying, harassment, intimidation, and among others.[6]

Evidence from many studies across the world has demonstrated the fact that abuse is experienced more commonly among nurses than other health-care professionals with some studies suggesting up to three times higher prevalence among nurses.[7],[8],[9],[10],[11],[12],[13],[14] A review by Spector et al.[8] revealed that about a third of nurses worldwide indicated exposure to physical violence and bullying, about a third reported injury, about a quarter experienced sexual harassment, and about two-thirds indicated nonphysical violence. In Nigeria, a study conducted to find out the prevalence of WPV against nurses working at Katsina General Hospital, Nigeria, revealed that all the nurses (100%) had experienced some form of violence in their work place.[15] In addition, in a multicenter survey carried out in Nigeria by Ogundipe et al. about 88.6% of respondents had witnessed violence in the emergency department while 65% had been direct victims, nurses being the usual victims.[11] Another cross-sectional survey carried out among 242 health-care professionals in Osogbo, Southwestern Nigeria, revealed that the highest prevalence was among the nurses (53.5%) followed by the doctors/dentists (21.5%).[14]

The most common forms of violence against nurses reported by many authors were verbal abuse, closely followed by physical violence,[6],[8],[12],[14],[16],[17],[18] even though the physical violence has been shown to be most prevalent in in some cases. According to Spector et al., physical violence and sexual harassment were more common in Anglo countries, while nonphysical violence and bullying were most prevalent in the Middle East.[8] In another study, which compared WPV in primary care and psychiatry service, verbal violence was more common in primary care, while physical violence was more frequently experienced in the psychiatry service.[19] In addition, a study conducted in three community hospitals in Saudi Arabia, the prevalence of physical violence was higher than verbal abuse.[20] Sexual assault, on the other hand, was not commonly reported as the other forms of violence.[17],[20]

The perpetrators of the WPV reported by authors have been shown to differ from country to country and vary with the type of violence. In their review, Spector et al. reported that patients accounted for most physical violence in the Anglo region and Europe, and patient family and friends accounted for the most in the Middle East.[8] However, most studies carried out locally revealed that the perpetrators were patient's relatives or patients.[11],[14],[15] As much as, 87.2% of the perpetrators in a study carried out in Katsina, Nigeria, were patient relations while working colleagues were identified in only 5.1% of cases of violence against nurses.[15] In Saudi Arabia, patients were the major perpetrators of the violence (76.0%) followed by the patient's family members (24.0%).[20]

Although much work has been done on health-care WPV globally, there is relative paucity of literature on the subject matter in a country like Nigeria. There is therefore need to increase awareness on the phenomenon while adding to the growing body of literature available. This study sought to determine the prevalence of WPV against nurses, describing the manner in which they occur as well as ascertaining the factors associated with this social ill.

  Subjects and Methods Top

Study design

This was a descriptive cross-sectional survey involving all nurses at the University of Nigeria Teaching Hospital (UNTH), Enugu, Southeast Nigeria.

Study area

Enugu is the capital of Enugu State located in the south East geo-political zone of Nigeria. There are 2 public tertiary (teaching hospitals), 492 primary health-care facilities, 47 secondary health-care facilities and in the state. Participants were selected from UNTH, a public tertiary facility which has 21 clinical departments and 6 care centers and a total population of 780 nurses.


The sample size was calculated using the formula for proportion for a single population size of <10,000, using a 95% confidence interval (CI), 5% degree of error tolerated and prevalence of WPV of 88% obtained from a previous study by Ogbonnaya et al. in a similar setting[17] as follows:

n = Z2P (1−P)/d2

Where n = Sample size,

Z = 1.96 at 95% confidence limit

p = prevalence from a previous study (88.1%)[17]

d = margin of error tolerated, usually 5%

A minimum sample size of 162 was calculated and this was multiplied by 2 to increase the power of the study and rounded off to 320.

All departments in the hospital were included in the study and using the list of all the 780 nurses from the hospital, proportionate sampling technique was employed to select samples from each of the 21 different departments based on the population of nurses in each department.

Eligibility criteria

Inclusion criteria were all nurses who had been employed for up to a year and more while student nurses and nurses who were on leave were excluded from the study. A total of 320 questionnaires were distributed to respondents, 308 were returned, and 301 were included in the analysis.

Data collection

Data were collected using a pretested, semi-structured, self-administered questionnaire adapted from the International Labour Organization/International Council of Nurses/WHO/Public Services International WPV in the Health Sector Country Case Study Questionnaire.[21] Data were obtained on respondents' sociodemographic and workplace characteristics. Responses were also elicited on respondents' experiences of physical and psychological violence including verbal abuse, bullying/mobbing and sexual abuse as well as their experience in the preceding year. Physical violence referred to the use of physical force against another person that results in physical harm, sexual or psychological harm including beating, kicking, slapping, stabbing, shooting, pushing, biting, and/or pinching, among others. Psychological abuse is intentional use of power, including threat of physical force, against another person that can result in harm to physical, mental, spiritual, moral, or social development. It includes verbal abuse, bullying/mobbing, harassment, and threats. Bullying/mobbing is repeated and over time offensive behavior through vindictive, cruel, or malicious attempts to humiliate or undermine an individual or groups of employees. Sexual violence is any unwanted, unreciprocated, and unwelcome behavior of a sexual nature that is offensive to the person involved, and causes that person to be threatened, humiliated, or embarrassed.[21]

Data analysis

Data were entered and analyzed with Epi-Info version 3.5.3, Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia (US). Frequencies were generated for the respondents' sociodemographics and prevalence of the different types of violence experienced by the nurses in the past 1 year. Further frequencies were generated for the patterns of the violence experienced to show the rates of occurrence of the attacks, the timing, perpetrators and if there was any consequences to the perpetrators. Finally, the relationships between sociodemographics and occurrence of WPV were determined by cross tabulation of the variables and carrying out chi-square test of association. Discrete variables were presented as proportions and percentages while continuous variables were expressed as means (± standard deviation). Chi-square test of significance was used to determine association with statistical significance level at P = 0.05.

Ethical approval

Ethical approval was obtained from the Ethics Review Board of the UNTH, Enugu, Nigeria. Informed written consent was obtained from each respondent while confidentiality was ensured by not including any self-identifying characteristics.

  Results Top

A total of 301 nurses participated in the study giving a response rate of 94.1%. [Table 1] shows the sociodemographic and workplace characteristics of the respondents. The mean age of the respondents was 41.8 ± 8.6. Majority (219, 72.2%) of them were aged above 35 years, were female (283, 94%) and were married (249, 82.7%). About half (152, 50.5%) of the respondents had spent 10 years or more in practice while the remaining half had <10 years work experience. Majority of the nurses work in shift (277, 92.0%) and have routine direct contact with patients (260, 86.4%). Most of the respondents work with adults (243, 72.1%) and with both male and female patients (243, 80.7%). Majority also have their duty posts on the ward (234, 77.7%).
Table 1: Respondents' demographic and workplace characteristics

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[Figure 1] shows the prevalence of WPV experienced among the respondents. Verbal abuse was the most common form of violence experienced (129, 42.9% [CI = 37.0–48.1]) followed by physical abuse (46, 15.3% [CI = 11.5–19.7]) while the sexual abuse was reported by a few (7, 2.3% [CI = 0.9–4.3]).
Figure 1: The prevalence of workplace violence among University of Nigeria Teaching Hospital nurses

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Respondents' description of the psychological violence they experienced is shown in [Table 2]. Majority of the respondents that experienced verbal violence affirmed that it happened only sometimes (85, 65.9%), bullying happened sometimes in 12 (57.1%) of those who reported bullying while majority of those who were sexually assaulted experienced it sometimes. Patients' relative was responsible for the verbal abuse in most of the cases (78, 60.5%) as well as for bullying (10, 47.6%) while sexual assault was carried out by a member of staff in majority of cases of sexual violence (4, 57.1%). In most of the cases of psychological violence, respondents usually reported to a senior for verbal (39, 30.2%), bullying (5, 23.8%), and sexual (2/7, 28.6%) violence. While a few sought help from the union for verbal (4, 3.1%), bullying (1, 14.8%), and sexual (1, 14.3%) violence, incident form was completed in only 2 (1.6%) cases of verbal violence. There was no consequence suffered by the aggressor in almost a third of cases of verbal abuse (37, 28.7%), over half of the bullying cases (11, 52.4%) and about a third of the sexual abuse (2, 28.6%).
Table 2: Respondents' description of their experience of psychological violence

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Respondents' experience of physical violence is described in [Table 3]. Majority of the physical violence was carried out with a weapon (39, 84.8%) and in most of the cases the attacker was patients relative (35, 76%) although in a few cases respondents were attacked by a staff member (4, 8.7%) or a supervisor (1, 2.2%). Attacks were more frequent in the morning (20, 43.5%) than at night (6, 13.0%). In about one quarter of cases verbal warning was issued to the attacker (16, 34.8%) while the aggressor was prosecuted in only two (4.3%) of cases. In the preceding 12 months, about one-third (84, 28.0%) respondents witnessed physical violence and in majority of them, they experienced it about 2–4 times (53, 63.1%). The incident was reported in only 12.6% (38) of cases.
Table 3: Respondents' description of their experience of physical violence

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The relationship between WPV and respondents' sociodemographic characteristics is described in [Table 4]. While bullying was statistically significantly higher in nurses aged 35 years or less (χ2 = 4.729 P = 0.041), physical violence, verbal abuse, or sexual assault were not associated with the age group of respondents. Gender and length of practice did not significantly influence the occurrence of physical or psychological violence.
Table 4: Association between nurses' sociodemographics and workplace characteristics and workplace violence

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As shown in [Table 4], associations between respondents' workplace characteristics and occurrence of violence are described. Working in shifts is not associated with physical or psychological violence, however, physical violence was experienced more commonly among nurses that work with newborns compared with those that work with children and adults (χ2 = 18.066, P = 0.000) just as verbal abuse was highest among respondents who frequently worked with newborns (χ2 = 6.765 P <0.001). Sex of the patients frequently seen or respondents' present duty post was not associated with WPV.

  Discussion Top

This study has described the occurrence and patterns in which WPV occurs among nurses. One of the factors identified by previous studies as a risk factor for WPV is female gender of the workers.[22] The fact that most of the respondents in this study were female may have an implication for a high level of WPV among them.

Verbal abuse was by far the most common form of abuse experienced in this study, with nearly half (43%) of the respondents experiencing it. This prevalence is comparable to what was obtained in many other studies[8],[14],[16],[18] even though some studies reported higher prevalence.[17] In Ethiopia, Fute et al. reported up to 90%[12] while in Australia, the prevalence of verbal violence against emergency department workers was reported as 88.1%.[23] In a few studies, however, verbal abuse occurrence was found to be low, for instance in a study carried out in Saudi Arabia, only 23% of the nurses experienced verbal abuse[20] probably due to cultural factors which might restrict people from expressing outrage.

The prevalence of bullying/mobbing observed in this study was 7% which is much lower compared to a prevalence of 82.6% obtained from a survey carried out in four hospitals in Enugu by Nwaneri et al.[24] The disparity in the values obtained might be as a result of a different tool used by the authors which was a modified 22-item Negative Acts Questionnaire for measuring bullying behaviors in the workplace, where the constructs included gossiping, backbiting, excessive workload without supervision, failure to respect privacy and humiliating someone in front of others including patients. Nonetheless, it has been said that the prevalence of workplace bullying might be underreported, due to the embarrassment that victims have to endure, or because of fear. Bambi et al. in their review found that bullying prevalence among nurses varies between 2.4% and 81%.[25] Workplace bullying can have dire consequences including anger, low self-esteem, and strained social and work relationships as well leading to inefficiency at work.[26],[27] It has been identified as a major cause of attrition from the profession.[27],[28]

The sexual abuse prevalence was expectedly, the least reported in this study as previous studies have suggested that it is often underreported. Some of the reasons for the low prevalence were thought to be differences in understanding what sexual harassment constitute between males and females as well as fear of speaking out by the victims. Nevertheless, the prevalence of 2.3% obtained in this study is lower than that obtained by Ogbonnaya et al.,[17] in a similar setting (4.5%) or Fute et al.,[12] in Ethiopia (13.02%) and Honarvar et al., in Iran (10.8%).[29]

Physical abuse was the next prevalent violence experienced by nurses in this study after verbal abuse, with about 15% of them having experienced physical violence. This prevalence also was comparable to findings from Fute et al.[12] Abodunrin et al.[14] in Southwestern Nigeria obtained a higher prevalence of 35% while lower prevalence of about 7% was obtained in the Democratic Republic of Congo.[30] In Saudi Arabia, the rate of physical violence was surprisingly higher than verbal violence.[20] In this current study, a vast majority (85%) of the respondents who experienced physical violence described it as being attacked with some form of weapon. This is contrary to the finding by Ogundipe et al.[11] who reported that only 15.8% of the nurses were ever threatened with a weapon. In addition, the incidents mostly took place in the mornings as opposed to the finding by Ogundipe et al. where it mostly took place in the evenings.[11]

With regards to the perpetrators of the violence, this study revealed that patients' relatives were responsible for the verbal abuse in most of the cases as well as physical violence. This is consistent with findings from other studies carried out in Nigeria[11],[14],[15] except Azodo et al.[31] where patients were the main culprits. In the Middle East, Anglo region, and Europe also, Spector et al. reported that patients carried out most of the physical violence.[8] Patients' relatives were also responsible for most of the bullying in this study, contrary to the findings of Onoka et al. who reported that senior female nurses were the perpetrators of bullying while junior female nurses were their targets in the same setting. This might be explained by a more encompassing definition of bullying by the said authors which is different from that used in this study. In Saudi Arabia, patients were the major perpetrators of the violence followed by patient's family members.[20] Prolonged waiting times and poor communication between health personnel and patients relatives can explain the aggression they express toward the health worker,[12],[16],[31] especially in settings with shortage of health workforce and other resources like Nigeria. In addition, nurses who have heavier workloads have been found to be more likely to be exposed to violence in their workplace.[32]

This study showed that in response to workplace psychological and physical violence the victims often reported to the senior or took no action. This might have been because the victims were ignorant of any workplace policy on violence or not being certain of the far reaching consequences even though in most of the cases this study reported there was no consequence suffered by the aggressor other than issuing of verbal warning. A study by Higazee and Rayan[33] who investigated the consequences and control measures of WPV among Jordanian Nurses showed that many participants did not think it was important or thought it pointless to report the incident. When they did report, similar to the findings of this present study, no action was taken or verbal warning was issued for majority of the violence incidents.[16],[32]

This study showed that while bullying was significantly higher in nurses aged <35 years or less, physical violence, verbal abuse, or sexual assault were not associated with the age group of respondents. Nwaneri et al.[24] had also reported younger nurses were usually the victims of workplace bullying just like other studies.[12],[20] It was surprising however, that in this study, neither gender nor length of practice significantly influenced the occurrence of physical or psychological violence as documented in previous studies.[12],[19],[20] Furthermore, though workplace characteristics such as working in shifts, in the emergency department or outpatient have been found to predispose nurses to violence,[12],[14],[16],[19] in this study, physical and verbal violence was experienced more commonly among nurses that work with newborns. This finding might be due to the fact that many individuals feel more emotional and protective of their newborns and may display more aggression when dissatisfied with services or quality of care.

  Conclusion Top

This study has been able to show that psychological and physical violence is common among the nurses. Verbal violence was the most prevalent form of violence experienced by nurses followed by physical violence which was often carried out with a weapon. Violence was mostly perpetrated by patients' relatives and in most cases the perpetrators suffered no consequences. Violence was experienced more commonly by nurses who work with newborns. The implication of these findings is that nurses may feel vulnerable and threatened at work leading to less motivation or job satisfaction. There is, therefore, need for effective policies to prevent violence against nurses at their duty posts.


This was a study based on self-reported information, recall bias might have affected the accuracy of the data collected.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]

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