Special Issue: Psychometrics
In this Issue
Special Issue: Psychometrics
Verbal Abuse: The Words that Divide Impact on Nurses and Their Perceived Solutions
Tanya Judkins-Cohn, R.N., MSN, MEd.
The author would like to thank Baptist Health South Florida’s Center for Nursing Excellence for sponsorship of this study.
Verbal abuse is a prominent problem for nurses and a direct threat to patient care. Verbal abuse was defined in this study as any communication via behavior, tone, or words that are intended to humiliate, degrade, or disrespect an individual, leaving the recipient feeling emotionally hurt or personally or professionally attacked or devalued, which results in a decrease in happiness and/or productivity. The purpose of this study was to determine nurses' perceptions of the characteristics, sources of, impact of, prevention of, and resolution of verbal abuse. The participants were 517 nurses in direct patient care from five hospitals and approximately ten outpatient clinics within the southeast region of the United States. The nurses completed a modified version of the Cox Verbal Abuse Survey and an open-ended question addressing solutions to verbal abuse. Findings indicated that nurses experienced verbal abuse most frequently from physicians, patients’ families, and patients. Intense negative impact of verbal abuse on nurses and patient care was a major finding. The following six themes emerged from the content analysis of the nurses’ perceived solutions to verbal abuse: accountability, communication, education, respect, support, and value.
Keywords: verbal abuse, lateral violence, nurses, impact of verbal abuse, acute care, survey, perceptions of verbal abuse
Verbal Abuse: The Words that Divide Impact on Nurses and Their Perceived Solutions
Although there is a significant amount of research on nurses’ experiences of workplace violence, such as verbal abuse, the problem continues to affect both the nurse and the care she or he provides. There is, however, little research on plausible solutions that can truly assist to change the culture of verbal abuse in nursing practice. Verbal abuse was defined in this study as any communication via behavior, tone, or words that are intended to humiliate, degrade, or disrespect an individual, leaving the recipient feeling emotionally hurt or personally or professionally attacked or devalued (see Figure 1). The purpose of this study was to determine perceptions of nurses involved in direct patient care of the characteristics, sources of, impact of, prevention of, and resolution of verbal abuse.
On January 1st, 2009, the Joint Commission began to require all accredited institutions and programs to institute a new “Leadership Standard” that addresses disruptive and inappropriate behaviors.12 Such behaviors were deemed a sentinel event to patient safety because they can cultivate medical errors, decrease patient satisfaction, increase the cost of care, and reduce the retention of qualified nurses.12
Nurses are subjected to physical, emotional, and verbal abuse in the workplace by patients, families, physicians, administrators, fellow nurses, and other healthcare workers. Rowe and Sherlock surveyed 213 nurses, using Cox’s Verbal Abuse survey,1 finding that 96.4% of the nurses had been verbally abused, and the most frequent source was other nurses (27%) of which 80% were fellow staff nurses and 20% were nurse managers.11Walrath, Dang, and Nyberg, through focus groups that included a total of 96 nurses, reported that the participants observed or experienced a total of 225 disruptive behaviors, and physicians were identified as instigators in 42% of these events.13
Verbal abuse toward nurses is an international concern. Oweis and Diabat surveyed 138 Jordanian nurses who had reported experiencing verbal abuse by physicians. Their results showed that judging and criticizing, accusing and blaming, and abusive anger were the most frequent and severe forms of verbal abuse reported.8 Maguire and Ryan surveyed 87 Irish mental health nurses of which 80% had experienced non-threatening verbal aggression, and 54% had experienced threatening verbal aggression at work in the last month.5 Roche, Diers, Duffield, and Catling-Paull surveyed 2,487 Australian nurses of which 65% reported experiencing emotional abuse in the last 5 shifts they had worked.10 The majority of the nurses reported experiencing emotional abuse (39.6%) from patients.10 Jonker, Goosens, Steenhuis surveyed 85 Netherland nurses and found that younger and less experienced nurses were more likely to be confronted with aggression.4 Oztunc surveyed 290 nurses employed at a large public hospital in Adana, Turkey, finding that 80.3% of the nurses had experienced verbal abuse in the previous year.9 He also found that those nurses working in the intensive care unit experienced the highest percentage (87.5%) of verbal abuse and that the majority (57.2%) of the nurses were abused by patients’ relatives.9
The impact of verbal abuse on nurses includes negative emotions, decreased productivity, increased potential for turnover, and a negative effect on nursing care. Rowe and Sherlock found that nurses who experienced verbal abuse also experienced stress as a consequence.11 Cox found that work productivity declined for 71.3% of nurses, and 87.1% of nurses asserted that medical errors were more likely to increase after a verbal abuse event.2 Oztunc discovered that 87.6% indicated that the verbal abuse negatively affected their morale, 91% experienced emotional exhaustion, 68.3% believed that it decreased their productivity, and 63.1% agreed that it negatively affected their nursing care.9 Roche et al. found a positive relationship between emotional abuse and loss of nurse productivity, such that tasks delayed per shift (r=.24, p<.05) and tasks not done per shift (r=.27, p<.05) increasing when emotional abuse increased.10 Walrath et al. reported that 48% of the nurses interviewed in focus groups knew of a nurse who had transferred to a different unit or department because of disruptive behavior, both verbal or physical acts that negatively affected patient care and one’s ability to work; and 34% stated that they knew nurses who had left the organization due to such behaviors.13
Design and Sample
A descriptive survey design was utilized. This study was conducted in five hospitals and approximately ten outpatient clinics in the southeast region of the United States. The research population included nurses involved in direct patient care. Packets included the survey and an educational sheet of current hospital policies and resources, were mailed to the homes of 3,121 nurses. The educational sheet included the researcher’s definition of verbal abuse (see Figure 1), an explanation of the “leadership standard” released in January 2009 by the Joint Commission,12 current hospital policies relating to workplace violence, and a list of local resources nurses could use as support and counseling. The survey revolved around potential sources, emotional reaction, and the perceived impact of abuse on nursing and patient care. The open ended question asked for nurse’s opinion on possible solutions. The number of completed and anonymously returned surveys was 517, for a response rate of 17%. Institutional Review Board (IRB) granted approval in January 2009 and data collection was completed in December 2009.
Figure 1. Definition of Verbal Abuse provided to participants
Cox’s Verbal Abuse Survey1 was reduced from its original 100 to 21 questions that were most appropriate to the researcher’s study purpose. In addition, the survey was modified to capture the nurse’s “current job setting” along with the additional options of “same shift nurse” and “opposite shift nurse” as potential sources of verbal abuse. Permission was granted to modify and use the survey. A Cronbach’s alpha of 0.707 was obtained, demonstrating internal consistency reliability.
The survey included the following three sections:
All quantitative data were placed in PASW 17.0 for analysis of the demographic and survey questions, and thematic analysis was used for the open ended question pertaining to perceived solutions to verbal abuse. Chi-square analysis was used to determine relationships between current job setting and experiencing verbal abuse along with perceived physician power over the nurse’s current work environment and verbal abuse’s impact on morale. A p-value of .05 or less was used to define statistical significance.
Demographics of Participants [Nurses] and Work Environment
The majority of respondents were female (n=460, 90.4%, males: n=49, 9.6%). There was a distribution of age ranges with most between 41-50 years old (n=154, 30.4%) followed by; 31-40 years old (n=124, 24.5%), 51-60 years old (n=123, 23.8%), 21-30 years old (n=66, 13.0%), and 60 years and above (n=40, 7.7%). All work shifts were represented including 7am-7pm (n=238, 47.5%), 7pm-7am (n=157, 31.3%), 7am-3pm (n=81, 16.2%), 3pm-11pm (n=17, 3.4%), and other (n=8, 1.6%). Over 36% reported being a nurse for over 20 years, with nearly 24% having 5 or less years in nursing. Nearly 58% had been at their current job for 6 or more years. Work environments included Medical/Surgical Unit (n=181, 37.5%), Emergency Room (n=66, 13.6%), Intensive Care Unit (n=65, 13.4%), Operating Room (n=64, 13.2%), Mother/Baby Unit (n=56, 11.6%), Step Down Unit (n=26, 5.4%), Pediatrics (n=15, 3.1%), and other (n=11, 2.3%).
The majority of nurses (n=437, 84.5%) reported experiences of verbal abuse in their current job setting. Over 77% (n=339) reported that they experienced approximately 0-5 incidences of verbal abuse in one month’s time. The nurses with the highest percentage of verbal abuse experienced at their current job worked on a Medical/Surgical Unit (n=149, 36.3%), followed by Emergency Room (n=60, 14.6%), Operating Room (n=59, 14.2%), Intensive Care Unit (n=55, 13.4%), and Mother/Baby Unit (n=48, 11.7%). Pediatric nurses had the lowest percentage (n=8, 1.9%) of verbal abuse experienced at their current job. A statistically significant relationship was found between current job setting and experiencing verbal abuse (X2= 14.067, p=.05). The top four sources of verbal abuse reported by the nurses included physicians (n=328, 74.7%), followed by patients’ families (n=286, 65.1%), patients (n=280, 63.8%), and fellow patient care nurses (n=180, 41%). See Table 1.
Table 1. Sources of Verbal Abuse in Order of Frequency*
*Respondents gave multiple responses
Perceptions of Impact of Verbal Abuse on Nurses and Patient Care
Although 37.5% (n=161) of the nurses continued to think about an incident for a few hours, 26.1% (n=112) reported that it still bothers them. Nurses reported feeling a variety of emotions immediately proceeding a verbal abuse incidence with anger being the most common (n=202, 46.1%), followed by powerlessness (n=101, 23.1%), and embarrassment (n=95, 21.7%). Based on the nurses’ experiences with verbal abuse, 72.2% (n=325) believed that it negatively impacted their morale, 79.7% (n=357) believed it can lead to increased errors, 52% (n=233) believed that it decreased their level of productivity for a period of time, 79% (n=353) believed that it contributes to increased turnover in nursing staff, and 87.4% (n=390) believed that it contributes to an increased shortage of nurses. When asked about the level of power staff physicians have in their current work situation, 76.7% (n=396) of the nurses believed that it was higher than the nursing department’s power, while 19.1% (n=96) believed it was the same as the nursing department, and only 4.2% (n=21) believed it to be lower than the nursing department. The perception of staff physician power over the nurse’s current work environment showed a statistically significant relationship with impact on morale (X2=11.764, p=.003), such that 83% (n=269) believed that physicians have a higher level of power than nurses and that verbal abuse negatively impacts morale.
Table 2. Content Analysis of Perceived Solutions to Verbal Abuse
Content Analysis of Perceived Solutions to Verbal Abuse
Nurses were asked to provide in detail what they believed might be possible solution(s) to verbal abuse experienced by nurses. A total of 339 responses were coded and thematically grouped into the following six main categories: accountability, communication, education, respect, support, and value. Within each main category, sub-themes were identified to represent specific solutions perceived by the patient care nurses. These categories with corresponding sub-themes are provided in Table 2.
The five sub-themes that comprised the category of accountability included: apologize, consequences, physician accountability, reporting, and zero tolerance. Many nurses voiced the need for abusers to apologize to their victims, such as, “I believe the individuals causing the abuse should be made to apologize and recognize their wrong doing.” Numerous nurses requested that appropriate consequences be established. One nurse wrote, “Don’t gently smack a hand and turn the other way.” There was an overwhelming sense from the nurses that physicians are not held to the same standards of behavior as other members of the hospital. Comments included, “Physicians should be held more accountable,” and “Physicians in my case are the abusers; they need to be held accountable for their actions.” Nurses also made suggestions to have a reporting system in place and training on how to properly document incidents. Although hospital policies define a zero tolerance policy in regards to harassment including verbal abuse, 23 nurses referred to developing and/or implementing such a policy. One nurse wrote, “A no tolerance policy and a place to call when it is experienced by nurses where nurses do not feel that they will bear any repercussions for reporting.” Several nurses suggested expansion of such a policy to include members of the community: “Inform staff, patients, and relatives that this hospital has a zero tolerance for abuse of any kind.”
The three sub-themes represented by the category of communication were: etiquette, relationship dynamics, and resolution. Many of the nurses suggested that the communication among nurses and physicians, patients, and management be “open” and more respectful to the opinions and needs of the nurse. One nurse wrote, “Maybe better communication between physicians and nurses or nurses and patients. Doctors to be more open to listen and appreciate nurses.” Nurses wanted communication to be an avenue for resolution where verbal abuse incidences are addressed immediately and resolved through open communication and professionalism. Two nurses wrote, “Act professionally at all times. Resolve issue right away,” and “Open communication. Good problem solving. Address issue immediately.” Nurses repeatedly reported that key players in facilitating both communication and resolution were members of nursing leadership such as mangers, supervisors, and administration.
The six sub-themes within the category of education were: anger management, education on hospital policy, management education, responding to verbal abuse, reporting process, and verbal abuse awareness. Many responses suggested that abusers undergo anger management classes and staff members be provided education on hospital policies and the reporting process. One nurse wrote, “Do an in-service or skills lab [on] how to handle verbal abuse done by staff, physicians, and patients in order to stop that person and prevent any further damage to your self esteem,” and another nurse suggested, “Classes for all staff on how to deal with verbal abuse.” Nurses stated that management also needed specific education on how to treat employees with respect and supporting a nurse while providing resolution to the incidence. Several nurses suggested posting messages on the unit discouraging verbal abuse such as, “Posting disclaimer statements or actual hospital policy in plain view that states that ‘this is a non-hostile harassment free environment’.” Another nurse suggested, “Make nurses aware that they can be protected against verbal abuse. Most of us would treat verbal abuse as part o the ‘norm’ in MD-RN relationship(s). In the same way how hand washing materials are posted, literature on verbal abuse should be out in the open: How to deal with, who to turn to.”
The four sub-themes in the category of respect were: across professions (families), imbalance of power, physician-to-nurse and nurse-to-nurse. There was an overwhelming belief by the responding nurses that verbal abuse is directly connected to a lack of respect for nurses as educated professionals. One nurse voiced these concerns, “When nursing is considered a profession, not merely a vocation; when RN’s have recognized status and power; when there is recognition of the subtle bullying of nurses by nurses; perhaps it will improve.” One nurse proposed, “One solution is to educate people to respect nurses. I think there is a great lack of respect for nurses and people don’t realize how hard they work.” Another nurse wrote, “Increased respect from administration and recognition of nurses as professionals.”
The seven sub-themes represented by the category of support are: co-worker/colleagues, leadership intervention, leadership support, nurse/patient balance, policy and procedures, resources, and safety. Many nurses reported that the support they can provide each other is essential. A nurse responded, “Nurses need to present a unified front.” Over 30 nurses voiced the need for leadership to play an active role in changing the culture of verbal abuse. One nurse wrote, “More support from supervisors and immediate action from him/her to correct the situation.” Many wrote simply, “More support,” “Support from leadership staff,” “Support from upper management,” and “Management support is crucial.” Others thought of pragmatic solutions such as, “More frequent rounding on patients by mangers to solve problems patients may be having.” Nurses also suggested various resources that could be offered to those experiencing verbal abuse such as a hotline dedicated for reporting and providing support and solutions, the formulation of a committee of individuals who can review incidences and provide resolution. There were numerous nurses who wrote the need for more security in “high volume areas” such as the emergency room, intensive care unit, and obstetrics.
The three sub-themes included in the category of value were: employee satisfaction, inequality, and professional worth. Several of the nurses voiced the need for their institutions to value employee satisfaction equally with satisfaction of the patient. One nurse wrote, “Nursing has become more about customer service and less about science and caring. A lot of times the patient is wrong and out of line but management still supports the patient and family and makes the nurse look incompetent.” There was frequent reference to the inequality between physicians and nurses and nurses are viewed as less valuable to healthcare in the eyes of patients and physicians. One example was, “Physicians must view nurses as equals in the delivery of healthcare. Professional respect must be a necessary component in the resolution of this problem.” Another nurse wrote, “Reminding MDs that they are part of a team. RNs are patient advocates. Reminding patient and their families we are professionals not servants.”
The purpose of this study was to determine nurses' perceptions of the characteristics, sources of, impact of, prevention of and resolution of verbal abuse. Results indicate that verbal abuse does occur within the nursing community and impacts both the nurse and her perceptions of the quality of patient care provided. The proportion of nurses who experience verbal abuse in their current work environments in this study is consistent with other studies.2,4,5,9-11 Rowe and Sherlock, who also used a modified version of Cox’s Verbal Abuse Survey,1 reported that 96.4% of the nurses surveyed had been verbally abused.11 Oztunc who studied Turkish nurses found that 80.3% of those surveyed reported being verbally abused.9 Table 3 illustrates nearly 20 years of nursing struggling with verbal abuse at the workplace using Cox’s Abuse Survey.1
Table 3. Twenty Years of Documented Unchanged Culture of Verbal Abuse, Using Cox’s Verbal Abuse Survey
The majority of the nurses reported from none to five incidences of verbal abuse in a month, with Medical/Surgical nurses reporting the highest percentage of incidences. Roche et al.’s focus on medical/ surgical nurses also reports a rise in verbal aggression suggesting that vulnerability to such disruptive behaviors is spreading throughout nursing,10 as other studies that have found emergency rooms, intensive care units, and mental health facilities having the highest prevalence.4,5,9,10
In this study, physicians were recognized as the predominant source of verbal abuse toward the nurses, with patients’ families and patients following. Examples of potential solutions provided by the nurses in this study indicate that this may connected to nurses’ perceptions that doctors view nurses as a less valuable member of the healthcare team. Nurses also reported that they felt they were sometimes perceived by patients’ families and patients much as servants and hotel staff versus healthcare professions.
A common connection among the themes that emerged from the suggestions for solutions of verbal abuse of the nurses in this study was the role of nursing leadership. Previous research evaluating solutions include teaching new nurses cognitive rehearsal3 and strategies nurses can employ to protect themselves and their co-workers.7 However, it is paramount, as shown in this study, that nurses need the support and intervention of their nurse leaders.
Limitations of this study include the convenience sample of nurses with a relatively the low response rate. Though the sample size was large, there may be a question of generalizability. The results are based on nurses in the southeast area rather than a national level, suggesting that they may not be generalized to other parts of the country. Nevertheless, this study confirms the idea of 20 years of unchanged culture of verbal abuse experienced by nurses and begins to launch next steps of research toward finding solutions to this epic problem through the collection of suggestions provided by the nurses studied.
Recommendations for Future Studies
There are numerous terms and corresponding definitions of violence experienced by nurses. Concepts need to be defined by the actual nurses in practice. Further, there is little research on effective education and prevention of such disruptive behaviors. It is not only important to evaluate the problem in a clinical setting but utilize that knowledge to assist in developing effective education and interventions that equip nurses and nursing leadership. There is a need to re-define verbal abuse through the experiences and perceptions of patient care nurses, which could then be included in the development of educational and intervention programs for nursing, physicians, and health care leaders to change the culture of verbal abuse. An important component of such change is to incorporate the needs and suggestions voiced directly by nurses. This could potentially be achieved through the collection and implementation of nurse driven solutions to verbal abuse on a hospital unit level. These solutions could then be evaluated to determine their success in changing the culture of verbal abuse.