Mosaic of Verbal Abuse Experienced by Nurses in Their Everyday Work

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Mosaic of verbal abuse experienced by nurses in their everyday work

Jackson, Debra; Hutchinson, Marie; Luck, Lauretta; et al. https://researchportal.scu.edu.au/discovery/delivery/61SCU_INST:ResearchRepository/1267308130002368?l#1367465310002368

Jackson, D., Hutchinson, M., Luck, L., & Wilkes, L. (2013). Mosaic of verbal abuse experienced by nurses in their everyday work. Journal of Advanced Nursing, 69(9), 2066–2075. https://doi.org/10.1111/jan.12074

Published Version: https://doi.org/10.1111/jan.12074

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Mosaic of verbal abuse experienced by nurses in their everyday work

Debra Jackson, Marie Hutchinson, Lauretta Luck & Lesley Wilkes

Correspondence to D. Jackson: JACKSON D . , HUTCHINSON M. , L UCK L . & WILKES L . (2013) Mosaic of e-mail: [email protected] verbal abuse experienced by nurses in their everyday work. Journal of Advanced Nursing 69(9), 2066–2075. doi: 10.1111/jan.12074 Debra Jackson PhD RN

Professor Faculty of Health, University of Abstract Technology, Sydney (UTS), New South Aims. To report observational data collected as part of a multi-phased study Wales, Australia examining violence in the health sector. The findings presented detail the nature of verbal abuse experienced by nurses during their everyday interactions with Marie Hutchinson PhD RN patient, their families, or companions. Senior Lecturer Background. Nurses have unacceptably high levels of exposure to violence, which School of Health and Human Science, commonly includes verbal abuse. However, relatively little is known about the Southern Cross University, Lismore, New nature of verbal abuse against nurses. South Wales, Australia Design. Observational design.

Lauretta Luck PhD RN Methods. During 2010, 1150 hours of observation resulted in data on 220 Senior Lecturer patients displaying cues for physical violence and 210 qualitative observational School of Nursing and Midwifery, notes. These observational notes constitute the data for this paper and reveal the University of Western Sydney, New South nature of verbal abuse experienced by nurses in their everyday work. Wales, Australia Results. A mosaic of abuse was revealed through three major categories: a discourse of gendered verbal abuse that was largely: sexual; insults, ridicule, and Lesley Wilkes PhD RN unreasonable demands; and hostility, threats, and menacing language. Professor School of Nursing and Midwifery, Conclusions. For the nurses observed in this study, everyday nursing practice University of Western Sydney, New South occurred in a backdrop of verbal abuse and hostility, which had a strong theme Wales, Australia of gendered and sexualized overtones. We recommend that interventions that target verbal abuse should address the gendered and sexualized nature of the abuse experienced by nurses.

Keywords: nurses, nurse–patient interactions, nursing, violence, workforce issues

ture is based on self-reports from both qualitative and sur- Introduction vey-based studies (Farrell et al. 2006, Chapman et al. It is well accepted in the literature that nursing is an 2009, Stone et al. 2011) and there are very few observa- occupation with an unacceptably high risk of exposure to tional studies (Luck et al. 2007). In many self-report stud- violence in its various forms (Gacki-Smith et al. 2009, ies, respondents are asked simply to indicate their Pich et al. 2010). However, relatively little is known about exposure to verbal abuse with a yes/no response, providing the nature of verbal abuse against nurses. Although a little elucidation of the nature of the abuse, the language plethora of evidence into the prevalence and nature of used, or the context. This paper reports findings of an workplace violence in nursing exists, much of this litera- observational study that sought to more fully describe the

D. Jackson et al. nature of verbal abuse that nurses are exposed to in the particularly among female nurses. Swearing associated work environment. with threats has been reported to cause less distress than swearing associated with personally demeaning comments (Stone et al. 2011). A mixed-method study on nurses Background exposure to swearing in Australia using a database analy- There remains a persistent discussion in the literature about sis of violent incidents and surveys and interviews with the definition of violence (Luck et al. 2007, Child & Mentes nurses suggests that nurses found ‘sexual/excretory words’ 2010). The World Health Organization promotes a broad (Stone et al. 2011) to be the most offensive and that definition of violence that encompasses threatened and actual abusive language from relatives was experienced as more use of power or physical force (Di Martino 2002). It is gener- distressing than that coming from patients. Use of ‘sexual/ ally agreed that violence encompasses behaviours that are excretory words’ fits in the construct of taboo language classified as verbal, physical, emotional, or sexual harm and (Jay 2009a, Stone et al. 2011). Jay (2009b, p. 153) defines abuse (Nachreiner et al. 2007, Hahn et al. 2010). Workplace taboo language as ‘offensive’ and ‘emotional’ and suggests violence and abuse are a common feature of working life for that it is used contextually for different personal, interper- many nurses (Lanza et al. 2006). Survey studies of violence sonal, cultural, societal and institutional reasons. Further- against nurses have shown that verbal abuse occurs more fre- more, there are many motivations to use taboo words quently and is often a precursor to the escalation of physical including the expression of frustration, anger, surprise, violence (Chapman et al. 2010). For this study, verbal abuse insult, to wish harm, and as part of a larger picture of is defined as language that is humiliating, degrading, or disre- violence and sexual harassment. The harm thesis on offen- spectful; it may include the threat of ‘physical force, sexual sive language argues that it is the context that is impor- or psychological harm, or other negative consequences’ (Di tant rather than the language itself (Jay 2009b, Stone Martino 2002, p. 12). et al. 2011) and it is recognized that taboo words can also There is compelling evidence that verbal abuse is the most be used with humour and may, on occasions, be person- common form of patient-to-nurse violence with threats, ally cathartic (McEnery & Xiao 2004). aggressive, and demeaning language being most common Despite these arguments about the contextual use of offen- (Stone et al. 2011) and is recognized to be widespread (Pich sive emotional language, verbal abuse targeting nurses et al. 2010). Verbal abuse is reported to be of concern inter- remains a concern. Literature suggests that nurses are more nationally. In Japan, 29% of nurses reported experiencing concerned about abuse when it involves attack on their per- verbal abuse in the previous year. The adjusted odds ratios sonhood (Luck et al. 2008). There are clear occupational of verbal abuse were significantly higher in psychiatric health and safety issues that surround verbal abuse towards wards, long-term care wards, outpatient departments, and nurses and to support nurses experiencing this type of abuse dialysis departments (Fujita et al. 2011). In a study of 210 in the best way, the nature, context and effects, both imme- Canadian hospitals, verbal sexual harassment was reported diate and cumulative, of such abuse need to be understood. by 7-6% of nurses and emotional abuse by 38% (Duncan et al. 2001). It cannot be assumed that verbal abuse in commonplace is The study devoid of any negative ramifications for those targeted. Gen- der role stereotyping, sexualized commentary, and demean- Aims ing sexist language are known to contribute to psychiatric This paper reports on one aspect of the second stage of a symptoms in targets (Berg 2006) as the personalized nature multi-phased study that sought to develop and test a predic- of these forms of attack can degrade self-worth and erode tive instrument for physical violence against healthcare staff. self-esteem. By reinforcing the personal power of the aggres- In the context of this larger study, the aim of this phase of the sor to control, humiliate, and degrade, demeaning sexualized study was to collect observational data on the nature of ver- language and swearing exploit individuals for the gratifica- bal abuse experienced by nurses during their everyday inter- tion of the aggressor (Rowe & Sherlock 2005). Among Turk- actions with patients and their families or companions. ish nurses, it has been reported that common reactions to verbal abuse include helplessness, humiliation, and depres- sion (Celik & Celik 2007). Design

Demeaning swearing has been identified by Australian Phase one of the study used a Delphi approach to refine sev- nurses as the most offensive form of verbal aggression, eral behavioural cues that could be used to predict physical

Mosaic of verbal abuse violence and has been reported elsewhere (Wilkes et al. as early in the data collection process, it was found that 2010). To address the lack of observational data on violence this is where most physical violence and verbal abuse experienced by nurses, the second phase of the study further occurred. The observations were conducted in 2010 over all validated the behavioural cues for violence by collecting shifts, for 4 months in the later part of the year. Each epi- detailed observational records on violence occurrences. The sode of observations was 4–8 hours in length. All observers second phase of the study was conducted at inpatient and (n = 9) were experienced nurses and participated in training emergency departments in a large acute metropolitan teach- workshops prior to entering the field to ensure their famil- ing hospital on the outskirts of a major Australian city. To iarity and confidence in the use of the observation tool. ensure privacy of patients and staff, observations were only The workshops provided opportunities to test their accu- undertaken in thoroughfares and waiting areas of the hospi- racy and consistency in using the tool and recording obser- tal. Records of observations were made in the settings being vations. Observers were provided ongoing support and observed at the time of carrying out the observation. The pri- access to counselling services at all times during the data mary aim of the observation was to record the detail of collection period. behaviours that fell in the definition of violence and there Given the nature of the observations, it was also not pos- was no attempt to record explanatory details. sible to observe the total occurrences of violence or draw The instrument used to collect the observational data conclusions about the proportion of incidents observed as included a check list of 17 behavioural cues for physical observers may have missed some violence and abuse and violence drawn from the first phase of the study (Luck et al. some non-violent/abusive patient/nurse encounters. During 2007, Wilkes et al. 2010), this checklist included space for the period of observation, a total of 1501 cues for potential recording additional qualitative information, including out- physical violence were observed from 220 patients. Addi- comes in relation to the observations. The narrative text tional notes were recorded by the nine observers on 210 collected during these observations constitutes the data for occasions providing a total of 1150 hours of observation, this paper. Observational records included the date, exact which detailed the nature of violence occurrences; time the observation commenced and ceased, location/set- 918 hours of these observations were conducted in the ting or situational context, actors in the setting, actions and emergency department. reactions of actors such as behavioural acts and characteristics of the behaviour, observed dynamics or interactive pat- Ethical considerations terns, gestures and non-verbal behaviour, language – tone and content and details on space and objects in the setting This research was approved by university and hospital where relevant. human ethics committees. Due to the sensitive nature of undertaking observations in a hospital setting, precautions to protect the privacy of patients and staff were put in Data collection place. Observers were placed in thoroughfares and wait- The advantage of non-participant unstructured observation ing areas of the hospital, rather than more private treat- is that it enables researchers to gather data about usual and ment spaces, such as individual cubicles. In this way, unusual events in the world (Gray 2009) and has value in observers did not intrude on the therapeutic encounter capturing social action and interaction (Caldwell & Atwal between patients and health professionals. Because of this 2005). The observer is detached from the events being and the undertaking that we would collect no identifying observed, but is able to see actions and behaviours first- data on patients or staff themselves, the institutional eth- hand (Bucknell 2000, Polit & Beck 2012). The use of non- ics committee deemed that individual consent was not participant unstructured observation has the potential to necessary (National Health & Medical Research Council record taken-for-granted or everyday occurrences, to reveal 2007). previously unknown characteristics of violence towards Respect for the personal privacy of health professional nurses by capturing events and interactions in the hospital staff and patients remained a priority throughout the pro- setting. ject. Notices were displayed in the departments where the The observations were overt and conducted in thorough- observers were located, detailing their role and the nature fares and waiting areas in several departments in the hospi- of data collected. Additional verbal information was pro- tal including delivery unit, acute general wards, geriatric vided to anyone who inquired. As there was an opportunity assessment ward, and the emergency department. Most of vicarious trauma (Kadambi & Ennis 2004) on the observations were conducted in the emergency department; observers, special attention was made to provide telephone

D. Jackson et al. contact with the team and debriefing or counselling was major categories. These were as follows: discourse of made available. There were two occasions early in the data gendered verbal abuse that is largely sexual; ridicule and collection where debriefing was necessary, but no observer unreasonable demands; and hostility, threats, and menacing required further counselling. language. These categories formed the basis for the in-depth interpretation and description of the nature of nurses’ experiences of verbal violence and abuse in their everyday work- Data analysis ing lives. Each of these categories of abuse is explored in Qualitative content analysis is widely used in exploratory more detail in the following section. and descriptive studies. It is a method of analysing written, verbal, or visual data to condense a description of the phe- Discourse of gendered verbal abuse that is largely sexual nomenon under study by deriving concepts or categories Central to the mosaic of abuse experienced by nurses in (Elo & Kyng€as 2008). In this study, content analysis was their routine work interactions was heavily gendered verbal used inductively to develop a condensed description of vio- insult and threat of harm. This form of verbal abuse was lence observations (Graneheim & Lundman 2004, Elo & not simply a raised voice or terse words. Instead, language Kyng€as 2008). The unit of analysis for content analysis can was used in a way, which conveyed a discourse that was be words, sentences, or paragraphs that are related to each imbued with gendered insults and demeaning statements other because of their content or context. Data are coded about nurses and their character as women. At this point, it and categorized (Graneheim & Lundman 2004, Elo & Kyn- should be noted that many of the threats observed to be g€as 2008) and a conceptual system or a model developed. made against nurses contained a gendered overtone – most In this study, text from the observational tool was tran- commonly directs at nurses as women. scribed and initially analysed for words and phrases denot- Patients and less commonly their family and friends were ing verbal violence and abuse such as threats, raised voice, observed to make sexualized insults, judgements, threats, or swearing, and humiliating or degrading language. suggestions that targeted nurses through sexualized demeaning language. The sexualized taunts and insults conveyed stereotypical gendered assumptions about nursing and Rigour nurses. The sexualized and strongly pejorative language An audit trail was established from the conception of the included descriptions of nurses as ‘c*nts’, ‘-’, ‘bitches’, project (Borbasi et al.2008). Data analysis was initially ‘whores’, and ‘sluts’. The insults were made in public spaces undertaken by two members of the research team. in front of others. By labelling their femininity as deviant, Following this initial analysis, emergent categories were these insults explicitly debased the character of a particular cross-checked by other team members for rigour including nurse by drawing attention to their supposed sexual worth. audibility and confirmability (Graneheim & Lundman The following interaction was observed to occur in a busy 2004). waiting room; the outburst was triggered when a nurse did not bring ice quickly enough when requested. Patients Friend (said about the nurses): ‘All these f*cking Results lazy c*nts, we pay taxes for this! She’s a f*cking whore’ Analysis of data revealed a variety of forms of abuse occur- (directed at the individual nurse). ring in the everyday interactions among nurses, patients The gendered verbal attacks not only implied that nurses and persons accompanying patients. Sustained in the back- were debased or deviant by way of their sexuality, they also drop of care delivery were indirect and non-verbal threaten- focused on denigrating their intelligence. Much of the gen- ing behaviours and verbal insults, attacks on competence, dered verbal violence contained language that was coloured threats, and physical assault. This created, on occasions, a by notions of gendered stupidity, which was used to malign milieu of hostility where nurse–patient interactions were the intelligence or capability of individuals. This type of insult enacted. We have conceptualized this as a mosaic of verbal included taunts such as ‘that’s the bitch one’ (one patient to abuse. another), ‘this nurse doesn’t know anything – silly cow’ (patient to nurse) and ‘this place is full of uneducated f*cking sluts. They should be ashamed’ (patient to nurse). These types A mosaic of verbal abuse of verbal attacks bracketed nurses under the stereotypes of The montage of interconnecting acts of verbal abuse formed battleaxe, uncaring, stupid, and shameful. Through these an interconnected mosaic of abuse described through three verbal gendered insults, nurses were simultaneously

Mosaic of verbal abuse demeaned by having their sexuality sullied and their intelli- was often said loudly or in front of others to draw negative gence questioned. The following verbal abuse contained gen- attention to those targeted. By publicly questioning skills dered denigration of a nurse’s intelligence and was directed at and capabilities, this behaviour denigrated professional the nurse while she prepared treatment for the patient. Dur- identity and competence. Ridicule through loud comments ing the interaction, three police and a security guard were that called into question the competence of nurses and the also in attendance: care they provided were observed to be enacted through the comments ‘f*cking hopeless’ and ‘f*cking idiot’. Patient (said to nurse): ‘You’re f*cking useless’… You’re a f*cking Demeaning insults included openly questioning whether nurse, how can you agree to take my liberty away. For f*cks sake. ‘they (nurses) know how to do their jobs’ and debasing the You bitch. Are you sure you know what you’re doing?… You character and competence of nurses was observed to occur f*cking stupid twat.’ through such accusations as: ‘You’re lying, you’re falsify- By grounding the abuse on gender, attention was drawn ing’, and ‘You are animals’, ‘You bastards… this is a joke’. to essential supposed female stupidity, ignoring the individ- Associated with these insults were attacks on services pro- ual’s personal qualities or capabilities, they were cast as les- vided with remarks that they were ‘disgraceful’ and swear- ser, soiled, or stupid by way of their female gender. Framed ing and cursing that was directed at the actions of nurses in this way, nurses were depicted as warranting or encour- through comments such as ‘bullshit’ and ‘for God’s sake get aging of sexual advances and were open to sexualized it right’. Patients and their visitors demanded nurses act commentary that publicly positioned them as deserving or more quickly, fetch the doctor ‘I need the bloody doctor’, inviting of sexual advances. This was reflected in the taunt or bring food when demanded ‘NOW’. Demands that from one patient: ‘Come up here baby, come up here’ and followed gendered and sexualized attacks had an implied the comments made by a patient’s companion (in a group overtone of slovenliness: ‘Hurry up, there’s people waiting of three) who called out loudly about one nurse: ‘She’s here, not only me, everybody else. F*cking hurry up’. hot… Sexy bitch, come home with me’. It was evident that nurses were regularly subjected to Gendered verbal abuse was also employed by patients as swearing, which can be considered to be part of the terri- a means to gain dominance or control over a situation. The tory of many forms of nursing work (Luck et al. 2008). types of verbal threat noted ranged from an incident where, The perception or likelihood of harm may be influenced by frustrated about having to wait, a patient’s companion said the combination or frequency of demeaning insults, swear- to the patient ‘Go sort those bitches out!’ through to more ing, ridicule and unreasonable demands. Demands may take menacing implied threats made directly to nurses by on a more menacing overtone when delivered in combina- patients such as: ‘I will get you, you f*cking c*nt sluts’ and tion with insults and threats and repeated over time. another ‘I hope you’re scared bitch. I hope your quivering in your little nurse sneakers’. Hostility, threats, and menacing language This theme draws attention to the place of gendered and Forms of non-verbal hostility and verbal threat featured sexualized abuse directed at nurses from patients and their throughout the observed interactions. Non-verbal hostility companions and the construction of gender in everyday and included damaging property such as the patient in a waiting routine nurse–patient interactions. It is known that lan- area who picked up a magazine and tore it up before guage can be used to inflict harm by attacking or question- returning it, with another observed to state ‘I’ll knock that ing character, dignity, or integrity (Gabriel 1998). Among wheelchair off’. Other forms of non-verbal hostility nurses, guilt and shame have been reported as one of the expressed by patients and their companions included behav- most common responses to patient aggression (Needham iours such as ‘crossing their arms’, ‘glaring’ at staff’, et al. 2005, Felblinger 2008). This category highlights the ‘throwing their arms up in the air’, ‘pacing’ and ‘rolling way gendered and sexualized verbal abuse can be directed and shaking their head around’ while talking to staff. towards nurses to erode their self-image and self-worth and In one instance in a waiting room, it was observed that a threaten their personal safety. patient and their companion ‘moved to sit directly in front of the nurses’ station – both sitting forward and staring Insults, ridicule, and unreasonable demands intensely at the nursing staff’. Episodes of verbal abuse that did not include a gendered By sustaining the hostile dynamic, these behaviours served overtone were also observed to be day-to-day experiences to provide further opportunities for an escalation or continu- for the nurses we observed. This form of abuse involved ation of the violence. Threats of complaint or legal action fol- demeaning insults or comments, ridicule and sarcasm, and lowed several incidents of verbal abuse and demand. In one

D. Jackson et al. incident, a family member complained: ‘Your hospital is Few studies of violence in the nursing context explicate going to be all over the media’ while she filmed staff on her the gendered nature of aggressive language or threat perpe- camera phone. Threats of harm were observed to be directed trated. Although the place of gender in shaping organiza- occasionally at other treating staff (ambulance officer and tional relationships, power dynamics and oppressive doctor), but were most commonly aimed at nurses, either as behaviours that enable ‘insider’ perpetrated violence has a group or individually. The threats included several different been explored (Roberts 2000, Speedy 2004, Strauss 2008), types of violence: killing, shooting, blowing up, punching, the gendered and sexualized nature of physical, emotional, and stabbing with a needle. In some instances, threats came and verbal violence and abuse directed towards nurses by from patients’ companions, who were individuals, families or those not employed in the organization has been largely larger groups. In one recorded incident, a group of ten hostile overlooked (Lawoko et al. 2004, Rowe & Sherlock 2005, visitors were observed to be swearing and making loud Roche 2010). In the nursing context, sexual harassment has threatening statements. Direct threats and physical violence been largely considered a separate issue to violence and were most often directed at nursing staff and were observed aggression and studies of sexual harassment do not always to occur almost entirely during the delivery of care interven- include an examination of patients as perpetrators (Finnis tions. Threats ranged from generalized statements such as: et al. 1993, Leiter et al. 2001, Valent & Bullough 2004, ‘Don’t touch me. I’ll get you’ ‘I’ll punch you’ and ‘I’ll do my Celik et al. 2007). Furthermore, narrow definitions of sex- block here in a minute’ to more specific threats to individuals: ual violence have been adopted, with only physical acts Patient to nurse: ‘When I get out of here I’m going to come included in the category of sexual violence in some studies back and kill you all, or if I see you in the street…’ And (Oliveira & Flava 2008). Investigations that have examined another, Patient to nurse: ‘I hate you all… I’ll kill you, I’ll sexual harassment towards nurses have repeatedly identified shoot you all… I ‘ll get you’. patients as the most common source of this form of violence, with more than 50% of nurses sampled reporting sexual harassment from patients (Hibino et al. 2006, 2009, Discussion Cogin & Fish 2009). The broad categories identified in this study resonate with Examining the effect of workplace discrimination on jus- previous research on aggression and violence in the nursing tice perceptions, well-being, and job satisfaction for mental context (Chappell & Di Martino 2000, Ferns & Meerabeau health workers (Wood et al. 2012) reported that discrimi- 2007). What is original in our study is the insight provided nation from patients had negative effects on anxiety and into the potential magnitude, density, scope, and complex- job satisfaction and eroded enthusiasm and engagement. ity of the mosaic of verbal abuse evidenced in nurse–patient Little research has specifically examined how gendered and interactions. The observational data provides insight into sexualized verbal abuse has an impact on the well-being of the gendered and sexualized nature of verbal aggression nurses and no studies have examined the interaction and threat of harm experienced by nurses; the cumulative between gender and this type of abuse in terms of nature of the violence experienced; and the potential for outcomes, particularly when it is accompanied by physical individual acts to be magnified by their co-occurrence with violence or threat of violence. other acts over time. The findings suggest that narrow inter- In this study, the pattern of gendered sexualized demean- pretations of violence are inadequate to understand the ing insults and verbal threats that preceded or surrounded complex nature of abuse directed towards nurses and the other verbal or physical forms of violence provides further context where it occurs. insight into the under-reporting of nurse violence. It is In many contexts, nursing is still considered as woman’s known that sexual harassment and unwanted sexual atten- work (Bilgin & Buzlu 2006). Founded on notions of female tion is still accepted by many women as a fact of life. subservience, the masculinized discourse of gendered Among nurses, the tendency to under-acknowledge sexual violence enacted by patients, their families, and companions harassment has been reported (Madison & Minichiello observed in this study reflect a power dynamic that served 2000, Hibino et al. 2006). It has been assumed that under- to disempower nurses through sexualized connotations that reporting of violence among nurses stems from assumptions legitimate violence. It is now more than a decade since that violence is simply part of the job, taken for granted studies confirmed that women in several occupations are and accepted (Jackson et al. 2002) or reflective of a fear of more at risk of violence than their male counterparts and reporting (Hegney et al. 2003). Under-reporting may also women are more at risk of sexual violence in the workplace be related to the emotional distress associated with vio- (Fisher & Gunnison 2001, Leiter et al. 2001). lence, or reflective of cumulative patterns of exposure that

Mosaic of verbal abuse

are important, particularly in light of the finding that these What is already known about this topic behaviours can be employed coercively by patients to gain advantage. Human resource managers and nurse managers ● Survey studies of violence against nurses have shown that verbal abuse occurs most frequently and is often a should review the utility of zero tolerance approaches to precursor to the escalation of violence. managing violence and abuse and establish whether these types of policies fail to provide adequate protection, as they ● Existing evidence on the prevalence and nature of workplace abuse towards nurses is most often based commonly rely on reports of abuse, which may be less on self-reports; there are very limited observational likely to occur in the context of humiliating sexualized or studies. gendered abuse. The clear articulation of standards and the development What this paper adds of training in bystander intervention strategies may be of particular importance in addressing inaction that arises ● The paper highlights the place of verbal abuse in the through taboo or tolerance reactions in the face of offensive construction of gender in nurse–patient interactions. gendered and sexualized verbal abuse. Given the previously ● Attention is drawn to the complex nature of verbal reported levels of under-reporting of verbal abuse by nurses abuse experienced by nurses in their routine work. (Jackson et al. 2002), bystander intervention programmes ● The paper illustrates how verbal abuse, particularly are one strategy to reduce the tolerance of gendered abuse sexualized offensive abuse, can be used as a coercive through openly addressing workgroup norms that tacitly device to pressure nurses. condone such abuse. Furthermore, the effects of such abuse of non-abusive patients and their family members’ require Implications for practice and policy exploration. In this study, observations were undertaken in ● Current prohibitive and zero tolerance approaches public areas of the health facility and so other patients may be insufficient to address gendered and sexualized awaiting attention were witness to the abuse. Questions verbal abuse. about how witnessing such abuse affects the view of others ● Human resource managers and nurse managers should of hospitals as sanctuaries of health care and healing are ensure intervention strategies aimed at health person- raised. nel, consumers, and the wider community to specifically address sexualized and gendered verbal abuse are Limitations designed. The major strength of this study was that it used observa- ● Future longitudinal research could usefully explore how gendered and sexualized abuse interacts with gen- tional data. Most studies contributing to the literature of der in terms of outcomes for nurses and non-abusive workplace violence in the health environment are based on patients. self-report only and often restricted to a yes/no response meaning that the nature of the workplace abuse is not fully

elucidated. Furthermore, our choice of method meant that make it difficult to discern discrete acts. Given the preva- we were able to capture the abuse encountered by nurses in lence of intimate partner violence reported among nurses their everyday working lives. Nevertheless, there are several (Oliveira & Flava 2008) and the shame and fear associated limitations to this study. One is associated with observation with sexualized violence when it occurs in the workplace, as method. Due to the observational nature of the data, it victims may remain silent as the violence is integrally asso- was not possible to record all incidents occurring during ciated with the forms of violence they have experienced in the observation period in their full detail and some events their private lives. may have been missed. Furthermore, observation is a Findings of this study highlight the need to develop inno- human activity and so the subjective nature of the data vative ways of dealing with verbal abuse directed at health- must be acknowledged. In addition and for ethical reasons, care personnel. Strategies should be multi-layered and no patient data could be collected and information associ- target both the need to reduce levels of verbal abuse and ated with their reasons for being in hospital, which may also reduce the risk of trauma or distress to personnel aris- have been contributing factors for their violence, is not ing from exposure to verbal abuse. The nature of the abuse recorded. Similarly, data were not collected in private reported suggests that strategies to address bystander non- spaces and it is not possible to identify whether the violence intervention or tolerance of gendered and sexualized abuse continued in this context.

D. Jackson et al.

Bilgin H. & Buzlu S. (2006) A study of psychiatric nurses’ beliefs Conclusion and attitudes about work safety and assaults in Turkey. Issues in Mental Health Nursing 27, 75–90. The findings of this study have implications for the develop- Borbasi S., Jackson D. & Langford R.W. (2008) Chapter 6: ment of intervention programmes and policy frameworks Qualitative research: the whole picture. In Navigating the Maze that address violence in the health sector. In particular, we of Nursing Research: An Interactive Learning Adventure (2nd recommend that nurse managers ensure that the nature and edn) Borbasi S., Jackson D. & Langford R.W., eds), Mosby/ implications of sexual harassment and gendered abuse from Elsevier, Marrickville, NSW, pp. 92–103. care recipients, their family and companions, are addressed Bucknell T.K. (2000) Critical care nurses’ decision-making activities in the natural clinical setting. Journal of Clinical Nursing 9, 25–36. in intervention programmes. The findings of this study also Caldwell K. & Atwal A. (2005) Non-participant observation: using confirm the utility of observational methods for understand- video tapes to collect data in nursing research. Nurse Researcher ing the nature of the nursing work environment. Further 13, 42–54. detailed studies using a similar approach are suggested for Celik Y. & Celik S. (2007) Sexual harassment against nurses in the systematic examination of the escalation dynamic in ver- Turkey. Journal of Nursing Scholarship 39, 200–206. Celik S., Celik Y., Avgirba_s I. & Uvgurluovglu O. (2007) Verbal and physical bal abuse and the place of gendered and sexualized abuse in abuse against nurses in Turkey. International Nursing Review 54, 359–366. this dynamic. Further research might also usefully explore Chapman R., Perry L., Styles L. & Combs S. (2009) Consequences whether gendered and sexualized abuse directed towards of workplace violence directed at nurses. British Journal of nurses is employed as a form of provocation or to escalate Nursing 18, 1256–1261. pressure or coercion on nurses. Clearly, there is a need to rec- Chapman R., Styles I., Perry L. & Combs S. (2010) Examining the characteristics of workplace violence in one non-tertiary hospital. ognize the effects, both initial and cumulative of verbal abuse Journal of Clinical Nursing 19, 479–488. in the health sector and to provide adequate infrastructure Chappell D. & Di Martino V. (2000) Violence at Work, 2nd edn. and support for those experiencing and witnessing such International Labour Organization, Geneva. abuse. This study reports data from a snap shot in time and Child R.J. & Mentes J.C. (2010) Violence against women: the longitudinal studies that looked at the prevalence and effects phenomenon of workplace violence against nurses. Issues in of such abuse over time would be particularly helpful. Mental Health Nursing 31, 89–95. Cogin J. & Fish A. (2009) Sexual harassment – a touchy subject for nurses. Journal of Health Organisation Management 23, 442–462. Funding Di Martino V. (2002) Workplace Violence in the Health Sector, Country Case Studies Brazil,Bulgaria, Lebanon, Portugal, South This research was supported under Australian Research Africa, Thailand and an Additional Australian study. Synthesis Council’s Linkage Projects funding scheme (Project number Report. ILO/ICN/WHO/PSI Joint Programme on Workplace Violence LPO989290). in the Health Sector, Geneva. Retrieved from http:// www.icn.ch/SynthesisReportWorkplaceViolenceHealthSector.pdf on 29 December 2012. Conflict of interest Duncan S.M., Hyndman K., Estabrooks C.A., Humphrey C.K., Wong J.S., Acorn S., Elo S. & Kyngas H. (2001) Nurses’ experience of No conflict of interest has been declared by the authors. violence in Alberta and British Columbia hospitals. CJNR: Canadian Journal of Nursing Research 32, 57–78. Elo S. & Kyng€as H. (2008) The qualitative content analysis Author contributions process. Journal of Advanced Nursing 62, 107–115. Farrell G.A., Bobrowski C. & Bobrowski P. (2006) Scoping All authors meet at least one of the following criteria workplace aggression in nursing: findings from an Australian (recommended by the ICMJE: http://www.icmje.org/ study. Journal of Advanced Nursing 55, 778–787. ethical_1author.html) and have agreed on the final version: Felblinger D.M. (2008) Incivility and bullying in the workplace and nurses’ shame responses. Journal of Obstetric, Gynecologic, & ● substantial contributions to conception and design, acqui- Neonatal Nursing 37, 234–242. sition of data, or analysis and interpretation of data; Ferns T. & Meerabeau L. (2007) Verbal abuse experienced by ● drafting the article or revising it critically for important nursing students. Journal of Advanced Nursing 61, 436–444. intellectual content. Finnis S.J., Robbins I. & Bender M.P. (1993) A pilot study of the prevalence and psychological sequelae of sexual harassment of

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