Background: Globally, workplace violence is one of the negative workplace behaviors to which nurses are most vulnerable to. There is nevertheless a paucity of research on workplace violence and turnover intention among nurses in Nigeria. The aim of this study was to assess and determine the prevalence and perpetrators of workplace violence, level of turnover intention, influence of workplace violence and socio-demographic characteristics of nurses on turnover intention.
Methods: A cross sectional descriptive research design was adopted for the study. A non-probability convenience sampling method was used to distribute questionnaire to 381 nurses working in University College Hospital, Ibadan, Nigeria. Four items turnover intention scale and a modified workplace violence questionnaire were used to collect the data. Inferential and descriptive statistics were carried out using Statistical Packages for Social Sciences (SPSS).
Results: The prevalence of physical, verbal and sexual violence among the respondents was 53.3%, 85% and 25.2% respectively. Perpetrators of physical violence were patient families (49.5%) followed by the patients (30.8%). More than average nurses had turnover intention (mean) and physical violence (t = 0.293; P = 0.002); verbal violence (t = 2.58; P = 0.01) influenced turnover intention. Age (r = -0.302**; p = 0.000) of nurses and years of work experience (r = -0.248**; p = 0.000) negatively correlated with turnover intention. Level of education (t = 5.026, p = 0.007), Cadre (t = 9.201, p = 0.000) and Ward (t = 5.47, p = 0.000) influenced nurses turnover intention.
Conclusion: It was suggested that intervention to preventing workplace violence should be instituted.
Workplace violence, Turnover intention, Nurses, Prevalence, Perpetrators
Workplace violence is one of the negative workplace behavior to which nurses are most vulnerable to [1,2]. Nurses are at the highest risk of experiencing violence from patients and or their relatives because of long time contact with patients and interaction with their relatives . In addition, interaction with senior nurse colleagues can also be the source of the workplace violence .
Workplace violence is defined as an act or threat of physical or verbal aggression including incivility, bullying, lateral, vertical and horizontal violence [2,5-8] at the hospital environment. Physical workplace violence can result in sustained physical injury and may cause an individual's absence from duty while the nonphysical violence such as bullying affects the psychological health of the employee and are usually given less recognition and underreported .
Studies have shown that about half to three-quarter of nurses have experienced workplace violence [4,9,10]. Verbal violence has been discovered as the most common and sexual violence as the least [1,4,11]. However, most of them refused to report because the management will not act on it [10,12]. Cheung and Yip identified patients and their relatives, colleagues and supervisors as the most perpetrators of workplace violence respectively .
Laeeque and colleagues in Pakistan reveal that violence perpetrated by patient is related to the turnover intention among nurses and is made worse in the presence of occupational stress and increased the level of burnout . However, the findings of Chang and Cho among newly licensed nurses in South Korea showed that verbal violence was common but has no influence on the turnover intent .
Though there are records of nurses who have resigned from each of the tertiary hospitals in Nigeria and also of those who have migrated from the country, the information on those who are ready or have intention to quit and the reason for their intention is scanty . Turnover intention is a negative psychological response to specific challenges in the working environment resulting in withdrawal behaviors and moving to another ward within the same hospital or leaving the organization or profession [15,16].
Turnover intention can cause poor commitment to the organization and can result in proper turnover. Turnover phenomenon can lead to spending high costs on hiring and training new nurses, increased workload among the remaining nurses, reduced job satisfaction, stress, burnout, fatigue and eventually leading to turnover intention among other nurses [17-20]. A study suggested that increased workload, poor pay and harsh work environment are the main reasons for turnover intention among nurses in Nigeria ; however, the contribution of workplace violence to turnover intention is rarely explored. Therefore, this study assessed the prevalence, forms and perpetrators of workplace violence and how they might influence the turnover intention among nurses.
This study was conducted among nurses in University College Hospital, Ibadan, south western, Nigeria between June and September, 2020 using a cross sectional descriptive research design approach. Yamane formula: N/1 + N(e2) was used to calculate the sample size of three hundred and twenty-one from a total population of one thousand, four hundred nurses working in the institution. A non-probability convenient sampling technique was used to distribute the questionnaire to nurses in different wards because of the shifting nature of their work and the pandemic problem.
Approval to collect the data was obtained from the ethical committee of the University Teaching Hospital. Consent was obtained from the participants and the details of the study were explained to the participants before the questionnaire was distributed to them. The participants were encouraged to fill the questionnaire immediately and same received after completion while others who did not have time were given to fill at their leisure hour and the collection of the questionnaires was done the following day.
The instrument used to collect the data was questionnaire and it was divided into three parts. The first part was the sociodemographic characteristics of the nurse which consists of the ward, gender, years of experience etc. The second part was on the workplace violence: A modified workplace violence questionnaire was used and it comprises of physical violence (seven items), Verbal violence (six items) and sexual violence (seven items). It also comprises of the perpetrators of each of the violence. The instrument was first used by Kim  and further modified by Cho and Lee. The overall reliability of the tool according to was Cronbach's alpha = 0.94 .
Four items turnover intention scale (TIS) was used to measure the turnover intention. The instrument was developed by Lawler  and modified by Park . The four items are scored on 5-point likert scale and range from strongly agree to strongly disagree. The Cronbach alpha according to Park's in his study is 0.84 and a study on Effect of Nurses' Organizational Culture, Workplace Bullying and Work Burnout on Turnover Intention is 0.85 .
Data was analyzed using statistical packages for the Social Sciences (SPSS version 21). Simple frequency and percentages were used to determine the prevalence, while mean and standard deviation were used to know the level of turnover intention; t-test/ANOVA measured the relationship between turnover intention and workplace violence; t-test and Pearson correlation measured the relationship between turnover intention and sociodemographic characteristics of the nurses while t-test measured the relationship between workplace violence and turnover intention.
Majority of the respondents were females (96.3%) and only few (3.7%) were males. Their mean age was 37.9 and the range of their age was 35. The larger proportions of the nurses were Christians (88.8%) and the highest respondents were of Yoruba ethnicity (79.4%). Most of them have gotten their first degrees (60.7%) and only thirty of them have master's degree. The highest years of work experience of the respondents was 30 years while the least was one. Few (1.95%) of the respondents were at the position of Assistant Chief Nursing Officer while majority of them were Nursing officer One (30.8%). Larger proportion of the respondents (26.2%) worked at medical ward and 17.8% worked at surgical unit (Table 1).
Table 1: Socio demographic characteristics of the respondents (n = 321). View Table 1
The prevalence of physical, verbal and sexual violence among the respondents was 53.3%, 85% and 25.2% respectively. More than average (52.6%) of the respondents had experienced kicking or hitting while 26.3% had been pushed. The highest forms of verbal violence experienced by the responders were yelling/shouting (38.9%) and impolite speech (39.6%).Making sexual comments about physical appearance (54.5%) was the most common sexual violence experienced by the nurses followed by making sexual jokes and remarks (30.3%). (Table 2).
Table 2: Prevalence and forms of workplace violence. View Table 2
Table 3 reveals the perpetrators of workplace violence. The most perpetrators of physical violence against nurses were patients' families (49.5%) followed by the patients (30.8%).The least perpetrator of physical violence were support staff (1.9%) and colleagues (3.7%). On verbal violence, large proportions of the violence were perpetrated by the patients' relatives (42.25) followed by the patients (27.9%) while the least were support staff (3.9%) and colleagues (7.1%). Patients' relatives (34.7%) and patients (26.5%) were the most perpetrators of sexual violence followed by the physicians (14.3%).
Table 3: Perpetrators of workplace violence. View Table 3
Table 4 reveals the level of turnover intention. The result shows that the respondents had turnover intention (mean = 3.30). The large proportions of nurses agreed that they did not plan to be at the organizations for much longer (mean = 3.60) and they intend to ask people about new job opportunities (mean = 3.29) while others are planning to look for a new job (mean = 3.17). The least of the statements responded to by the respondents is applying for another job already (mean = 2.1). This implies that less than half of the respondents have applied for another job.
Table 4: Level of turnover intention. View Table 4
Table 5 shows the influence of physical, verbal and sexual violence on turnover intention. The findings show that physical violence (t = 0.293; P = 0.002) and verbal violence (t = 2.58; P = 0.01) influence turnover intention. Sexual violence did not influence turnover intention. Those who are victims of physical violence (M = 19.51; SD = 6.35) have higher rate of turnover intention than those who are not (M = 17.42; SD = 5.71). Also, nurses who are verbally abused in past 12 months (M = 18.90; SD = 6.20) have higher rate of turn over intention than those who are not (M = 16.44; SD = 5.40).
Table 5: Influence of physical, verbal and sexual violence on turnover intention. View Table 5
There is a negative correlation between turnover intention and the age (r = -0.302**; p = 0.000) of nurses and years of work experience (r = -0.248**; p = 0.000) of nurses (Table 6a).
Table 6a: Influence of sociodemographic variables on turnover intention. View Table 6a
Table 6b: Influence of sociodemographic variables on turnover intention. View Table 6b
Religion (t = -5.077; p = 0.000), educational level (influence the turnover intention (t = -5.077; p = 0.000), educational level (t = 5.026, p = 0.007), Cadre (t = 9.201, p = 0.000), Ward (t = 5.47, p = 0.000). The result further shows that Muslim (M/SD = 23.05/4.94), Nurses without degree education (M/SD = 19.00/5.8), lowest cadre of nursing officer (M/SD = 21.00/5.45), Nurses working in Neurological ward (M/SD = 22.83/4.94) had higher level of turnover intention (Table 6a and Table 6b).
We examined the prevalence, forms, and perpetrators of workplace place violence and how they influenced the intention of nurses in quitting their present place of work among nurses in a Nigerian teaching hospital. The findings show that nurses experienced high prevalence of verbal violence followed by physical violence and sexual violence was the least. Impolite speech and shouting or yelling were discovered to be the commonest forms of the verbal violence experienced by them. Previous studies on the prevalence of workplace violence among nurses have also reported that verbal violence against nurses are common and they rarely experience sexual violence at their workplace [3,4,9]. Physical, verbal and sexual workplace violence against nurses was mostly perpetrated by patients and their relatives. Larger proportions of physicians were also culprits of physical and sexual workplace violence while a substantial number of senior nurses perpetrated verbal violence. Similar to our results on the perpetrators of workplace violence against nurses, Cheung and Yip stated that patients and their relatives, colleagues and supervisors are the most perpetrators of workplace violence respectively .
Our findings on the level of turnover intention among the respondents indicated that higher number of nurses have the intention to quit their present place of work with most of them showing the optimism that they are not planning to stay in the hospital for much longer. Studies in that claim indicated that nurses' voluntary turnover is a global problem and is one of the reasons for nurses' shortage and this is making the hospital administrators spend a huge sum of money on hiring and training new nurses which often lead to organization loss and inability to maintain quality staff .
Nurses who were physical and verbal workplace violence victims in this study had higher turnover intention than those who were not. However, increase in age and years of experience reduced the desire to quit the hospital. This might be because of the years spent in service which has caused them to develop hardness and subsequently regard the violence as part of their work. In Nigeria, the prospects of nurses to secure new jobs decrease with age and years of experience because of unapproved formal scheme of service that makes nurses in Nigeria irrespective of their cadre to perform related roles; hence, a slogan "a nurse is a nurse". The newly employed nurses, according to our findings also had high turnover intention compared with others. There are opportunities for young nurses to explore, especially in Europeans countries, where they can be respected and earn good pay. This is contrary to the findings of among newly licensed nurses in South Korea which revealed that verbal violence was common but has no influence on the turnover intent . Nurses working in neurological ward had higher turnover intention than those in other wards or units. The nature of patients admitted to neurological ward including unconscious, spinal cord injury and other chronic neurological problems necessitating patients' confinement to bed require more care from nurses. The stress experienced in this unit might influence the higher turnover intent among nurses reported in this finding.
Nurses experienced high prevalence of verbal and physical workplace violence and about one fourth of them had been a victim of sexual violence. The major perpetrators of the workplace violence were patients and their relatives while colleagues and physicians also perpetrated verbal and sexual workplace violence respectively. Both physical and verbal violence influenced turnover intention among nurses. There were also negative correlations between workplace violence, years of work experience and age; educational levels of nurses, their wards of work and their cadres of nurses influenced the turnover intention among nurses.
It is therefore suggested that intervention to preventing workplace violence should be instituted and appropriate punishment should be meted out to the perpetrators of workplace violence against nurses. Special consideration should be given to nurses working in neurological ward and to young nurses on how to retain them in the organization.
The authors declare that there is no conflict of interests regarding the publication of this manuscript.
Conceptualization: OIA. Investigation & making scale: OIA, AO, AF, ARA. Methodology: OIA, AO TO. Writing - original draft: OIA, TO, AF. Writing-review & editing: OIA, AO, AF, ARA.