Workplace Violence Among Professional Nurses in a Private Healthcare Facility

Workplace violence among professional nurses in a private healthcare facility

Linda-Marie Schlebusch

Student number: 214253996

Submitted in fulfilment of the requirements for the degree of

MASTER OF NURSING (RESEARCH)

in the

SCHOOL OF CLINICAL CARE SCIENCES

in the

FACULTY OF HEALTH SCIENCES

at the

NELSON MANDELA METROPOLITAN UNIVERSITY

Supervisor: Dr S. M. du Rand

April 2016

DECLARATION

I, Linda-Marie Schlebusch, student number: 214253996, hereby declare that the dissertation for Master of Nursing (Research) is my own work and that it has not previously been submitted for assessment or completion of any postgraduate qualification to another University or for another qualification.

Linda-Marie Schlebusch

Official use: In accordance with Rule G5.6.3, 5.6.3 A treatise/dissertation/thesis must be accompanied by a written declaration on the part of the candidate to the effect that it is his/her own work and that it has not previously been submitted for assessment to another University or for another qualification. However, material from publications by the candidate may be embodied in a treatise/dissertation/thesis.

ACKNOWLEDGEMENTS

I would like to express my sincerest gratitude to the following people without whom this incredible journey would have been almost impossible:

 My Heavenly Father, who promised to never leave me, nor forsake me.  Dr S. du Rand, for your guidance and encouragement. Your understanding and support through good and bad times was much appreciated.  Professor N. Strumpher, who offered her assistance and ensured that high quality data were collected.  Dr D. Morton for advice and support throughout this year.  Dr M. Williams for suggestions regarding the themes.  The participants, for sharing their experience. Without you there would be no study.  My work colleagues, for support and encouragement.  My husband, Lourens, for being so patient while I was studying; Amanda my daughter, it was fun to study with you and Adriaan, my son, for all your love and support.  Karen, my sister, for all the flowers and your encouragement.

The journey of a thousand miles begins with one step.

Lao Tzu

LIST OF ABBREVIATIONS

ACAS Advisory, Conciliation and Arbitration Service

EEA Employment Equity Act

ICAS Independent Counselling and Advisory Service

ICU Intensive Care Unit

ISPN International Society of Psychiatric- Mental Health Nurse

HR Human Resources

NZ New Zealand

RNAO Registered Nurses’ Association of Ontario

SANC South African Nursing Council

USA United States of America

iii

ABSTRACT

Workplace violence is an international problem and has negative consequences for individuals, organizations and communities. For individuals, the effect includes symptoms of fear, stress, irritability, feelings of isolation, insecurity, and low self- esteem. Healthcare organizations incur increased cost due to litigation due to poor quality of care, high staff turnovers and absenteeism, and their brands are negatively affected. Community members, who are the recipients of care, are placed in danger and are indirectly the victims of such workplace violence, which in turn affects their trust in private healthcare organizations or professions to provide the quality health care that they expect and deserve. Workplace violence takes many forms such as incivility, horizontal violence and bullying to name but a few. The perpetrators of such violence are doctors, nurses, patients and relatives.

Workplace violence takes place in South Africa however, paucity in research was found by the researcher. The aim of the study was to explore and describe the experiences of professional nurses regarding workplace violence in a private healthcare facility in order to develop guidelines to address workplace violence in such a facility. A qualitative, explorative, contextual and descriptive study was conducted, using the Critical Social Theory as the paradigm. Data were gathered from professional nurses that have experienced workplace violence utilizing narratives. Fourteen narrative interviews were done until data was saturated. The data was transcribed verbatim and Tesch’s method of thematic synthesis was used to analyse the data. The three themes that emerged from the data were: Professional nurses acknowledge the existence of workplace violence where they work, Participants described the effect of workplace violence on themselves, others and the work environment, and Participants discussed their views regarding management of violence in the workplace. A thick description of the data with a literature control was provided. Thereafter inferences were made regarding the main themes of the guidelines and these focussed on: Preventing and addressing workplace violence by Nursing Service Managers; Preventing and addressing workplace violence by Nurse Unit Managers and Empowering professional nurses to address workplace violence.

To ensure rigour and trustworthiness of the study, the researcher used Lincoln and Guba’s criteria namely: credibility, dependability, conformability and transferability. To

iv protect the right and dignity of the participants and to safeguard the integrity of the study the researcher complied with the following ethical principles: beneficence, non- maleficence, autonomy, justice, veracity, privacy, and confidentiality.

The limitations of this study were that data was collected from only one category of nurses and only one private healthcare facility was used. Recommendations from this study include implementation of the guidelines to establish their effectiveness. The findings of this study can be used to empower professional nurses to deal with workplace violence and to prevent the short and long term effects of workplace violence on the individual, the organization and the community. Nursing education institutions can also incorporate workplace violence into their curriculum to increase the awareness of students regarding this phenomenon.

Keywords: Lateral violence, horizontal violence, bullying, abuse, nursing.

TABLE OF CONTENTS

DECLARATION ...... i

ACKNOWLEDGEMENTS ...... ii

LIST OF ABBREVIATIONS ...... iii

ABSTRACT ...... iv

ANNEXURES ...... xi

LIST OF TABLES ...... xii

CHAPTER ONE

BACKGROUND AND LITERATURE REVIEW

1.1 INTRODUCTION ...... 1

1.2 BACKGROUND AND RATIONALE FOR THE STUDY ...... 1

1.3 PROBLEM STATEMENT ...... 7

1.4 RESEARCH QUESTIONS ...... 9

1.5 AIM OF THE STUDY ...... 9

1.6 OBJECTIVES OF THE STUDY ...... 9

1.7 CONCEPT CLARIFICATION ...... 10

1.8 RESEARCH DESIGN AND METHODOLOGY ...... 12

1.9 GUIDELINE DEVELOPMENT ...... 12

1.10 TRUSTWORTHINESS OF THE STUDY ...... 13

1.11 ETHICAL CONSIDERATIONS ...... 13

1.12 CHAPTER DIVISION ...... 13

1.13 CONCLUSION ...... 13

CHAPTER TWO

RESEARCH DESIGN AND METHODOLOGY

2.1 INTRODUCTION ...... 14

2.2 THE RESEARCH DESIGN ...... 14

2.2.1 Qualitative Research ...... 14

2.2.2 Exploratory design ...... 15

2.2.3 Contextual design ...... 15

2.2.4 Descriptive design ...... 16

2.2.5 Narrative research ...... 16

2.2.6 Paradigmatic Perspective ...... 17

2.3 RESEARCH METHODS ...... 19

2.3.1 Research Population ...... 19

2.3.2 Sampling ...... 19

2.3.3 The data collection ...... 20

2.3.4 Field notes ...... 24

2.3.5 The data analysis ...... 24

2.3.6 The Literature Control ...... 26

2.4 PILOT STUDY ...... 26

2.5 DEVELOPING GUIDELINES ...... 27

2.6 RELIABILITY AND VALIDITY ...... 27

2.6.1 Credibility ...... 28

2.6.2 Dependability ...... 28

2.6.3 Confirmability ...... 29

2.6.4 Transferability ...... 29

2.7 ETHICAL CONSIDERATIONS ...... 30

2.7.1 Beneficence ...... 30

2.7.2 Non-maleficence...... 30

2.7.3 Autonomy ...... 31

2.7.4 Justice ...... 31

2.7.5 Veracity ...... 31

vii

2.8 PRIVACY AND CONFIDENTIALITY OR ANONYMITY ...... 31

2.9 DISSEMINATION OF THE RESULTS ...... 32

2.10 CONCLUSION ...... 33

CHAPTER THREE

DISCUSSION OF THE RESULTS AND THE LITERATURE CONTROL

3.1 INTRODUCTION ...... 34

3.2 CONTEXT OF THE STUDY ...... 34

3.3 CHARACTERISTICS OF THE SAMPLE ...... 36

3.4 DEMOGRAPHIC DATA OF THE SAMPLE ...... 37

3.5 DISCUSSION OF THE FINDINGS ...... 38

3.5.1 THEME 1: PROFESSIONAL NURSES ACKNOWLEDGE THE EXISTENCE OF WORKPLACE VIOLENCE WHERE THEY WORK. 39

3.5.1.1 Sub-theme 1.1. PARTICIPANTS EXPERIENCED EPISODES OF WORKPLACE VIOLENCE WITHIN THE HEALTHCARE TEAM AS FOLLOWS: DOCTORS TOWARDS NURSES .... 40

3.5.1.2 Sub-theme 1.2. PARTICIPANTS EXPERIENCED EPISODES OF WORKPLACE VIOLENCE WITHIN THE HEALTHCARE TEAM AS FOLLOWS: NURSES TOWARDS NURSES ...... 43

3.5.1.3 Sub-theme 1.3. PARTICIPANTS EXPERIENCED EPISODES OF WORKPLACE VIOLENCE WITHIN THE HEALTHCARE TEAM AS FOLLOWS: PATIENTS AND RELATIVES TOWARDS NURSES ...... 50

3.5.1.4 Sub-theme 1.4. PARTICIPANTS EXPERIENCED EPISODES OF WORKPLACE VIOLENCE WITHIN THE HEALTHCARE TEAM AS FOLLOWS: NURSES TOWARDS PATIENTS ..... 52

3.5.2 THEME 2: PARTICIPANTS DESCRIBED THE EFFECT OF WORKPLACE VIOLENCE ON THEMSELVES, OTHERS, AND THE WORK ENVIRONMENT ...... 53

viii

3.5.2.1 Sub-theme 2.1. PARTICIPANTS INDICATED THAT WORKPLACE VIOLENCE AFFECTED THEM AS INDIVIDUALS ...... 53

3.5.2.2 Sub-theme 2.2. PARTICIPANTS DESCRIBED THE IMPACT THAT WORKPLACE VIOLENCE HAD ON WORK PERFORMANCE, TEAM WORK AND PATIENT CARE ...... 64

3.5.3 THEME 3: PARTICIPANTS DISCUSSED THEIR VIEWS REGARDING THE MANAGEMENT OF VIOLENCE IN THE WORKPLACE ...... 69

3.5.3.1 Sub-theme 3.1. PARTICIPANTS STATED THAT WORKPLACE VIOLENCE WAS NOT ADEQUATELY MANAGED BY MANAGERS ...... 70

3.5.3.2 Sub-theme 3.2. PARTICIPANTS DISCUSSED PERSONAL STRATEGIES THEY USED TO MANAGE WORKPLACE VIOLENCE ...... 72

3.5.3.3 Sub-theme 3.3. PARTICIPANTS MADE GENERAL SUGGESTIONS TO IMPROVE THE MANAGEMENT OF WORKPLACE VIOLENCE ...... 75

3.6 CONCLUSION ...... 79

CHAPTER FOUR

THE CONCLUSIONS, RECOMMENDATIONS, GUIDELINES AND LIMITATIONS OF THIS STUDY

4.1 INTRODUCTION ...... 80

4.2 SUMMARY AND CONCLUSION OF THE STUDY ...... 80

4.3 DEVELOPING THE GUIDELINES ...... 83

4.3.1 Guideline 1: Preventing and addressing workplace violence by Nursing Service Managers ...... 84

4.3.1.1 Sub-guideline 1.1. Review existing organizational policies, processes and practices on workplace violence ...... 86

4.3.1.2 Sub-guideline 1.2. Promote effective management and preventive strategies to address workplace violence ...... 88

4.3.2 Guideline 2. Preventing and addressing workplace violence by Nurse Unit Managers ...... 92

4.3.2.1 Sub-guideline 2.1. Create a positive/conducive work environment to prevent workplace violence in the nursing unit ...... 92

4.3.2.2 Sub-guideline 2.2. Recognise and manage workplace violence in the operational setting...... 96

4.3.3 Guideline 3: Empower professional nurses to address workplace violence ...... 98

4.3.3.1 Sub-guideline 3.1. Display behaviour that prevents workplace violence and demonstrate behaviours to address it effectively, when it occurs ...... 99

4.3.3.2 Sub-guideline: 3.2. Apply the policies and procedures when workplace violence occurs ...... 103

4.4 LIMITATIONS OF THE STUDY ...... 106

4.5 RECOMMENDATIONS ...... 106

4.6 IMPLICATIONS FOR THE NURSING PROFESSION ...... 108

4.7 CONCLUSION OF THE STUDY ...... 108

REFERENCE LIST ...... 110

LIST OF ANNEXURES ...... 121

ANNEXURES

ANNEXURE A: CONSENT FORM ...... 122

ANNEXURE B: RECRUITMENT LETTER ...... 125

ANNEXURE C: INFORMATION LETTER FOR PARTICIPANT ...... 127

ANNEXURE D: REQUESTING PERMISSION TO CONDUCT RESEARCH FROM THE PRIVATE HEALTHCARE RESEARCH OPERATIONS COMMITTEE ...... 128

ANNEXURE E: RESEARCH OPERATIONS COMMITTEE APPROVAL .... 130

ANNEXURE F: REQUESTING PERMISSION TO CONDUCT RESEARCH FROM THE NURSING SERVICE MANAGER ...... 132

ANNEXURE G: APPROVAL FROM THE DEPARTMENT OF NURSING SCIENCE’S RESEARCH COMMITTEE ...... 134

ANNEXURE H: APPROVAL FROM THE FACULTY POSTGRADUATE STUDIES COMMITTEE ...... 135

ANNEXURE I: GUIDELINES FOR DATA ANALYSIS TO INDEPENDENT CODER ...... 136

ANNEXURE J: CONFIDENTIALITY AGREEMENT BY FIELDWORKER .. 137

ANNEXURE K: CONFIDENTIALITY AGREEMENT BY CODER ...... 138

ANNEXURE L: TRANSCRIPT OF AN INTERVIEW ...... 139

ANNEXURE M: DECLARATION LANGUAGE PRACTITIONER ...... 153

LIST OF TABLES

Table 3.1: The working experience of professional nurses ...... 37

Table 3.2: Nursing Units where participants worked ...... 37

Table 3.3: Workplace violence as experienced and reported by participants ...... 39

Table 4.1: Guidelines for Nursing Managers and professional nurses to prevent and address workplace violence in a private healthcare facility ...... 84

xii

CHAPTER ONE

BACKGROUND AND LITERATURE REVIEW

1.1 INTRODUCTION

Workplace violence is an international problem; and it has negative consequences for the individual, the team, the organization, patient care and patient outcomes. In private healthcare organizations, it contributes to a higher rate of staff turnover, low staff morale, loss of business and subsequent negative publicity. In this study, the researcher is attempting to explore and describe the phenomenon of workplace violence; as it is experienced by professional nurses in a private healthcare facility in the Nelson Mandela Bay.

The design chosen for this study is a qualitative study of an exploratory, contextual and descriptive nature – using the Critical Social Theory as the paradigm. The data were gathered from professional nurses that have experienced workplace violence through narratives. The data collection was continued until data saturation had been achieved. Analysis of the data took place using Tesch’s method of data analysis. The findings were reported and a literature control was done. Thereafter, the findings of the study were used to develop guidelines to address workplace violence among professional nurses in a private healthcare facility.

1.2 BACKGROUND AND RATIONALE FOR THE STUDY

Internationally, an increased focus has been placed on violence and bullying that occurs among health professions, and specifically the nursing profession. Lateral violence (Stanley, Martin, Michel, Welton & Nemeth, 2007:1247), horizontal violence (McKenna, Smith, Poole & Coverdale, 2003:90), bullying (Hutchinson, Vickers, Jackson & Wilkes, 2006:118 and Szutenbach, 2013:18), relational violence (Dellasega, 2009:52), workplace incivility (Hutton, 2008:2) and disruptive behaviour (Martin, 2008:21) are some of the various terms used to describe the physical, emotional or verbal abuse of employees (Centre for American Nurses, 2008:2).

No matter the term used to describe the phenomenon, it remains a serious matter in nursing (Bloom, 2014:3).

Workplace violence, according to the World Health Organization (2002), occurs where staff are abused, threatened or assaulted, in circumstances related to their work. Lateral violence, according to Hutton (2008:1), is often started by a minor incident, such as workplace incivility that spirals out of control. Workplace deviant behaviour is divided into workplace incivility, verbal abuse, and physical abuse. Hutton (2008:2) describes workplace incivility as an ambiguous intent to harm; and when the intent of the act is denied, it then becomes incivility.

However, as soon as there is a clear intent to harm, it becomes workplace violence. Lateral violence in the clinical setting involves nurses – either openly or secretly – directing their dissatisfaction at other nurses of equal (lateral) levels within an organization (Coursey, Rodriguez, Dieckmann & Austin, 2013:101; Hutchinson et al., 2006:118; Stanley et al., 2007:1248). Lateral violence includes many low-level types of hostile behaviour, including back-stabbing, failing to respect privacy, infighting, using innuendo, ostracism, sabotage, verbal affront, and withholding vital information (Coursey et al., 2013:101).

Lateral violence can extend beyond working hours; and it can occur in person, or by using technology per telephone or via cyberspace (Dellasega, 2009:53).

Bullying, according to the American Psychological Association (2014), is a form of aggressive behaviour, in which someone intentionally and repeatedly causes another person injury or discomfort (emotionally or otherwise). Bullying can take the form of physical contact, aggressive and harmful words, or actions – such as refusing to share, or withholding information from someone, who is perceived to have power over another (vertical aggression). McKenna et al. (2003:91) give examples of such verbal statements or actions: for instance, rude or abusive language, unjust criticism, or disapproval and humiliation, defamation, inappropriate chastisement, or insults.

Dellasega (2009:56) listed common nurse-to-nurse bullying behaviour, such as ostracism (“the silent treatment”), spreading rumours, humiliation and “put-downs” regarding a nurse’s skills and ability, failing to support a nurse, exclusion from social events, sharing information out of context – in order to reflect badly on the person, breaking confidence, making fun of another, setting the nurse up for failure, using negative body language (such as eye-rolling or head-tossing), manipulation or

2 intimidation, name-calling, teasing, and running a smear campaign.

The prevalence of such lateral violence is an international problem (Johnson, 2009:34), as evidenced by research done in Australia (Hutchinson et al., 2006:118), the United States of America (Stanley et al., 2007:1257), New Zealand (McKenna et al., 2003:90), South Africa (Kennedy & Julie, 2013:1), Brazil, Bulgaria, Lebanon, Portugal, Thailand and Australia (Di Martino, 2002). The findings from case studies done in Portugal and Australia, have revealed that more than half of the healthcare workers who participated in surveys associated with the studies had experienced at least one incident of physical or psychological violence during the twelve-month period prior to the survey (Di Martino, 2002:16).

Stanley et al. (2007:1247) examined the phenomenon of lateral violence among nursing staff, and found that 46% of the study participants reported that they had experienced lateral violence; while 65% reported having frequently observed lateral violent behaviour among co-workers. Furthermore, psychological violence, a major area of concern, is more prevalent; and it is associated with verbal abuse and bullying.

Nursing managers work very hard to retain staff, due to the cost and time it takes to train new staff, to bring staff to a fully functional level, and to replace staff. Stanley et al. (2007:1248) suggest that the phenomenon of lateral violence “undermines these efforts”. Nurses tend to leave workplaces that allow lateral violence to continue; and this ultimately impacts on the retention of newly qualified and skilled staff (Stanley et al., 2007:1254; Griffin, 2004:258).

Lateral violence is a threat to the physical, emotional and spiritual wellbeing of nurses, and therefore, indirectly also to the quality of patient care (ISPN, 2014:1). The Joint Commission on the Accreditation of Healthcare Organizations issued a Sentinel Alert (2008), stating that lateral violence undermines the culture of patient safety; and it contributes to poor patient satisfaction. It furthermore stated that preventable adverse outcomes and the cost of medical care increases because of lateral violence.

The effect of lateral violence on the nurse can manifest in physical and psychological symptoms (Bigony, Lipke, Lundberg, McGraw, Pagac & Rogers, 2009:689).

Physical symptoms include weight loss or gain, hypertension, cardiac palpitations, 3 gastrointestinal disorders, headache, insomnia, and chronic fatigue. Psychological symptoms include fear, anxiety, stress, depression, irritability, feelings of isolation, insecurity, and low levels of self-esteem; and in severe cases, post-traumatic stress disorder, including thinking patterns of suicide and homicide (Cunniff, 2011:1; Hurley, 2006:70; Johnson, 2009:36; Bigony et al., 2009:690).

The physical and psychological effects of bullying, according, to Cunniff (2011:1), manifest in absenteeism and the taking of excessive periods of sick leave.

Various theories and models have been used – in an attempt to explain the reasons why workplace violence occurs. According to The Oppressed Group Model (Stanley et al., 2007:1248; Griffin, 2004:257; Sheridan-Leos, 2008:399), individuals usually feel powerless in the face of their oppressors; and they turn their frustrations inwards and towards other group members, especially those whom they perceive to be less powerful (Szutenbach, 2013:19).

In an evaluation report on workplace violence, written by Wang, Hayes and O’Brien- Pallas (2008:5), minority nurses and nurses with lower job titles were found to be at a higher risk of being the victims of workplace violence. The nature of nursing with its hierarchal structure creates opportunities for workplace violence (Jacobs, 2013:97). Aggression is used as a tool to either punish people, or to make people do what you want them to do; and it is used to exert power over others (Jacobs, 2013:78).

Wang et al. (2008:5) have identified understaffing and excessive workload, as the main organizational stressors leading to workplace violence. The Time and Task theory describes the nurse’s overwhelmed reaction towards the number of tasks allocated to her (Sheridan-Leos, 2008:400). When it is perceived to be out of control, the nurse depersonalizes her care. Patients and colleagues are viewed as objects; and the nurse lashes out against her colleagues (Sheridan-Leos, 2008:400). Hutchinson et al. (2006:121) state that workplace violence is caused by organizational factors, such as the increased managerial focus to contain costs, initiatives to reduce the length of patient stay, because of medical aid constraints, and negotiated fee structures, utilizing acuity models to reduce financial expenses, and an increased focus on measuring patient outcomes.

Statistical and financial targets have to be met; and this pressurizes nursing staff to achieve these goals; and it therefore, changes the meaning of caring in the corporate context. There is thus conflict within the nurses regarding the value of caring and organizational expectations – leading to interpersonal conflict, frustration and aggression.

Lateral violence takes place in the South African context; however, a limited number of studies were found by the researcher. In a study done by Cunniff and Mostert (2012:3) to determine the prevalence of bullying in South Africa, 77.8% of the participants felt bullied in the workplace. Steinman (2003:3) stated that the term "workplace violence" is not commonly used in South Africa. Terms, like "harassment", "discrimination", "abuse", "bullying" and "intimidation" are widely used; but "violence", as such, is reserved almost exclusively to describe physical violence.

Section 6(3) of the Employment Equity Act 55 of 1998 (the EEA) recognises "harassment" as a form of unfair discrimination. Workplace harassment in the South African context is a violation of fundamental human rights that often leaves victims physically, psychologically, and professionally scarred (Viljoen, 2013). Psychological violence, especially verbal abuse, was singled out as the most common form of abuse by all focus groups, in the public, as well as the private healthcare sector in a South African study done by Steinman (2003:27).

Khalil (2009:207) investigated the levels of violence among nurses in Cape Town public hospitals. Khalil’s research findings (2009:210) concluded that, of 471 respondents, 54% indicated that violence did occur among nurses. The findings of a study done by Engelbrecht (2012:122) entitled: The magnitude of intra-professional violence that South African undergraduate nursing students are exposed to in the clinical environment, revealed that 70% of the participants “did nothing”; 59.3% “pretended not to see the behaviour”; while 30% “reported the behaviour to a superior”, when they experience professional violence.

Mvunelo (2013:111) conducted a study on workplace violence experienced by student nurses during clinical placement at psychiatric institutions in KwaZulu-Natal. She concluded that student nurses are victims of violence in the workplace; and that they commonly encounter non-physical violence. The common perpetrators of such

5 violence on student nurses are other nurses, particularly enrolled, assistant nurses and professional nurses (Mvunelo, 2013:91).

The author also suggested that workplace violence has a negative effect on the emotions of the student; and thus the standard of patient care is jeopardized (Mvunelo, 2013:112).

Steinman (2003:31) stated that the incidents of workplace violence in the private healthcare sector in South Africa were spread over a wide range of settings and facilities. Psychological workplace violence is recorded as the highest in areas, such as the specialised units, operating rooms and intensive care units (Steinman, 2003:31). The negative effect of psychological violence on the individual may continue for up to five years after the bullying has ceased (Steinman, 2003:6).

When the negative impact of workplace violence on employee’s performance, health, turnover and absenteeism is considered in terms of monetary value, the cost of workplace violence runs high. The cost of replacing a professional person lies in the region of R25 000 – R45 000 per individual (Steinman, 2003:41).

Khalil (2009:207) stated that the violence among nurses is unacceptable; and it negatively affects team work within nursing practice. Behaviours that impact on team work can be divided into six categories, namely: psychological, vertical, covert – such as gossip, horizontal, overt – such as shouting and physical violence (Khalil, 2009:208).

The study revealed three main factors that contribute to violence among nurses within the eight hospitals under study. The factors that were identified included: the lack of effective communication, the lack of respect among nurses, and inadequate anger management; since when nurses are frustrated, they tend to become violent towards each other (Khalil, 2009:215).

In a study done by Kennedy and Julie (2013:6) on the Nurses’ experiences and understanding of workplace violence in a Trauma and Emergency Department in South Africa at a large academic (public) hospital in the Western Cape, nurses reported that verbal abuse was such a common everyday occurrence that reporting this type of abuse was regarded as “senseless”. Verbal abuse was interpreted as swearing, 6 shouting, scolding and “hurling words at you” (Kennedy & Julie, 2013:4).

All the participants, except for one enrolled nurse, expected violence to happen in their workplace; however, it was ignored if it was linked to a patient’s diagnosis, or if it was linked to intoxication because the patients were perceived as “not being in a proper frame of mind” (Kennedy & Julie, 2013:5). The effect of workplace violence indicated a positive link to work-related aggressive incidents and negative emotions, job dissatisfaction, absenteeism, substance abuse, high staff turnover and possible intentions to leave the nursing profession (Bimenyimana, Poggenpoel, Myburgh & van Niekerk, 2009 in Kennedy & Julie, 2013:5).

The registered nurses in that study managed workplace violence effectively; however, the lower categories, such as the enrolled nurses, used a defensive mechanism, or equally abusive manners – in an attempt to stop the violence; while the enrolled nurse auxiliary group used avoidance; or they simply ignored the “everyday swearing”.

Under-reporting was confirmed; as the nurses in that study perceived non-physical violence as “minor” and as being the “norm” (Kennedy & Julie, 2013:7).

The findings of a study done by van Rooyen in public sector hospitals of the Eastern Cape reflected that registered nurses were overwhelmed; because of the abuse with which they were confronted in their work environment (2002:203). One of the limitations noted by van Rooyen (2002:205) was that the study was conducted in the public sector hospitals in the Nelson Mandela Metropole; and it did not include the private sector.

To date, the researcher has also found a paucity of research on this phenomenon in the private health sector in South Africa.

1.3 PROBLEM STATEMENT

The phenomenon of workplace violence definitely occurs among nurses working in the private healthcare facility in Port Elizabeth, where the researcher was based. The nursing staff in the facility do not know the terms lateral or workplace violence; however, they talked about the aggressive behaviour or unprofessional behaviour, “skinder” (gossiping), back-stabbing and “agter-af” (two-faced) behaviour.

The researcher is a manager in a private healthcare facility; and she has been overseeing various nursing units, including the ICU and the theatre. She was exposed to bullying from doctors, has witnessed bulling by senior professional nurses towards junior professional nurses; and she has experienced nurse-on-nurse violence in the unit where she was working. The researcher has personally experienced behaviour of verbal abuse, insulting remarks, gossip, threats, swearing, non-compliance with requests and humiliation by colleagues (professional nurses and doctors).

In an attempt to address the negative behaviour, she has tried interventions, such as team meeting, personal growth and professional conduct sessions with persons demonstrating such behaviour; however, no significant change in behaviour was noted.

There was an increased focus by the private healthcare facility in which the researcher was employed to reduce healthcare costs and to increase effectiveness. Professional nurses that worked in the wards were verbalizing that they “cannot cope” with the limited number of staff per shift – due to the serious condition of the patients; and they were resigning as a result. Professional nurses had to answer for the increase in patient complaints, medication errors, stock losses, adverse events, and poor patient care. As a result, the pressure on the remaining staff was increased.

The doctors still expected everything to be done for the patient; so, they were impatient. The pressure from management and the senior staff was also increased – in an effort to improve the quality indicators. Unacceptable and negative behaviour of nursing staff (workplace violence) was therefore on the increase.

When the negative behaviour of professional nurses was addressed via the disciplinary route, the perpetrator, in many cases, laid a charge against those who attempted to report the negative behaviour. The outcomes of these grievance meetings were an apology to the perpetrator; and the negative behaviour or cause of the workplace violence was never even addressed. Thus, power was gained by the perpetrator; and the negative behaviour simply escalated.

The victims, therefore, experienced double injury: both as a recipient of workplace violence, and then having a grievance filed against their name.

In the event that the perpetrator had a union affiliation, the victimized nurse was reluctant to report negative behaviour, because they felt they would also be intimidated by the “union”.

The researcher observed that team cohesion and team work were deteriorating in the department where she was working; while absenteeism and interpersonal conflict were on the increase. Two professional nurses resigned because they “could no longer take” the negative workplace environment. Out of desperation, the researcher involved the human resource department when staff members requested yet another meeting to discuss the unacceptable, unprofessional behaviour of a particular nurse.

The formal disciplinary route was followed; and a final written warning was given to the perpetrator for her unprofessional conduct. It was only after the warning had been issued, that the researcher read the article in the Sentinel Event Alert (2008) on lateral violence. She then realised that she had indirectly promoted the violence in the workplace by being ‘tolerant’ of rude, uncivil and disrespectful behaviour. This prompted her to make the decision to undertake this research study.

1.4 RESEARCH QUESTIONS

The following research questions, therefore, had to be answered by the researcher:

 What are the experiences of professional nurses regarding workplace violence in a private healthcare facility?  What can be done to address workplace violence among professional nurses in a private healthcare facility?

1.5 AIM OF THE STUDY

The aim of the study was to explore and describe the experiences of professional nurses regarding workplace violence in a private healthcare facility, in order to develop guidelines to address this type of violence between and towards nurses.

1.6 OBJECTIVES OF THE STUDY

In research, objectives are used to detail the aim of the study (Parahoo, 2006:168).

The study was designed to:

 Explore and describe the experiences of professional nurses regarding workplace violence in a private healthcare facility.  Develop guidelines to address workplace violence between and towards nurses, in a private healthcare facility.

1.7 CONCEPT CLARIFICATION

Garbers (1996:290) states that the multiplicity of interpretations of concepts in the human sciences necessitates that the main concepts be clarified and operationalized in research.

Guidelines

Guidelines are defined by the Oxford Dictionary of English (2014) as a set of general rules, principles, or a piece of advice. They are principles put forward to set standards, or to determine a course of action (Collins English Dictionary, 2014). In this study, guidelines were developed, by using the findings, in order to empower professional nurses and nurse managers, and to provide a set of actions to follow when workplace violence occurs.

Workplace violence

The World Health Organization (2002) defined workplace violence as: “Incidents where staff are abused, threatened or assaulted in circumstances related to their work, involving an explicit or implicit challenge to their safety, wellbeing or health”. It includes physical and psychological violence, such as verbal abuse, harassment, bullying/mobbing and threat. (Di Martino, 2002:11). In this research workplace violence included incivility, verbal and emotional abuse, physical and psychological abuse, horizontal or lateral violence, for example rude or unsociable speech or behaviours between peers or colleagues; vertical violence, for example, is impolite or offensive behaviour in people on different levels within the organization.

This could include yelling, snide comments, withholding pertinent information, rude remarks, ignoring or humiliating behaviour (Cantey, 2013) or bullying, for example, a

10 person who uses power or influence to harm or intimidate someone, or force someone to do something, sexual harassment and behaviour demonstrated towards nurses, which they feel is unethical, unprofessional or inappropriate behaviour.

Address

Address means to think about and begin to deal with an issue or problem (Oxford Dictionary of English, 4th edition, 2005). It also means taking a stance and being prepared to do something about an issue (Oxford Dictionary of English, 4th edition, 2005). The researcher has developed guidelines to help nurses and nurse managers to deal with work place violence in a private healthcare facility.

Nurses

The Nursing Act (33 of 2005:6) defines a nurse as a person registered in a category under section 31(1) of the Act, in order to practise nursing or midwifery in South Africa. The Nursing Act (2005:25) states in section 31(1a) that:

“Subject to the provisions of section 37, no person may practise as a practitioner unless he or she is registered to practise in a certain category; for instance, as a professional nurse”.

Section 30(1) of the Nursing Act (2005:25) provides the following description for the category of a professional nurse:

 A professional nurse is a person who is qualified and competent to practise comprehensive nursing independently in the manner, and to the level prescribed, and who is capable of assuming responsibility and accountability for such practice.

Private Health Facilities

A private health establishment is a health establishment that is not owned or controlled by an organ of the State (National Health Act No. 61, 2003:14). In this study, a private healthcare facility would be a hospital owned by a private company that is listed on the Johannesburg Stock Exchange, and is a for-profit healthcare provider.

Nelson Mandela Bay Area

The Nelson Mandela Bay Municipality is known as the Nelson Mandela Bay (NMB). The NMB includes the city of Port Elizabeth, as well as the neighbouring towns of Uitenhage, Despatch and the surrounding urban dwellings, such as Colchester, Blue Horizon Bay, Ibhayi, Bethelsdorp, Kwanobuhle and others. It is situated in the Eastern Cape Province, and is considered to be the economic capital of the region (South African City Network: 2014).

The Metropole has a population of more than one million people. Consequently, both public and private hospitals play an integral part in offering healthcare services to the people. For the purpose of the study, the focus was on the private health facilities situated in Port Elizabeth only.

1.8 RESEARCH DESIGN AND METHODOLOGY

The design chosen for this study was a qualitative study of an exploratory, contextual and descriptive nature – using a narrative approach. The sampling was purposive; and the data were collected by giving the participants the opportunity to share their stories in personal interview sessions, so that the researcher could gain insight and an in- depth understanding of this phenomenon. The data were analysed using thematic synthesis; and the necessary measures were taken to ensure trustworthiness. All the ethical principles were strictly adhered to.

The research design and methodology will be discussed in depth in Chapter Two of this study.

1.9 GUIDELINE DEVELOPMENT

Guideline development constituted phase two of the study. Based on the research findings and the relevant literature, and discussions with experts in the field, guidelines were developed for nurse managers and professional nurses to address workplace violence in the private healthcare facility. Details of guideline development are presented in Chapter Two.

1.10 TRUSTWORTHINESS OF THE STUDY

Polit and Beck (2012:745) regard trustworthiness as the degree of confidence qualitative researchers have in the quality of gathered data and the research findings. In the current study, trustworthiness was assessed through using the following criteria - credibility, dependability, conformability and transferability.

1.11 ETHICAL CONSIDERATIONS

Social research deals with humans beings as study participants. Human beings have rights, which should not be violated by researchers in the name of their quest for new knowledge. In this study the ethical principles that were adhered to are beneficence, non-maleficence, autonomy, justice, veracity, privacy, and confidentiality. In addition to these principles, permission to conduct the study was obtained from the relevant authorities.

1.12 CHAPTER DIVISION

The research study is presented in four chapters as follows:

Chapter 1: Background and literature review

Chapter 2: Research design and Methodology

Chapter 3: Discussion of the results and the literature control

Chapter 4: The conclusions, recommendations, guidelines and limitations of this study

1.13 CONCLUSION

This chapter has provided a general overview of the research study; and it has included an introduction and background to the study. The aims and objective of the study were clarified; the terminology was described; and an overview of the research design and the methodology was given. Chapter Two will focus on a detailed description of the research design and methodology. The trustworthiness and the ethical considerations will also be discussed in the next chapter.

CHAPTER TWO

RESEARCH DESIGN AND METHODOLOGY

2.1 INTRODUCTION

The previous chapter gave an overview of the background and a rationale for the study, as well as the aim and objectives of this study. This chapter focuses on an in-depth description of the research design and methodology, the trustworthiness of the study and the ethical aspects of the study. In addition, the method used to formulate the guidelines, will be described.

2.2 THE RESEARCH DESIGN

The research design flows directly from the research question; and it forms the ‘blueprint’ for the study. This determines the methodology the researcher selects for the study (Brink, van der Walt & van Rensburg, 2012:96). Research design also enables the researcher to maximise control over any factors that could interfere with the validity of the research findings (Grove, Burns & Gray, 2013:195).

As mentioned in Chapter One, the design chosen for this study was a qualitative study of an exploratory, contextual and descriptive nature, using a narrative approach.

2.2.1 Qualitative Research

Qualitative research (Brink et al., 2012:120) is used when the nature, context and boundaries of a phenomenon are poorly understood. The design is ideal for researchers who desire to explore the meaning, or describe and provide an in-depth understanding of human experiences; and for those who find it difficult to quantify the data. The design is systematic and interactive (Grove et al., 2013:23). The researcher is committed to discovering and gaining an in-depth understanding of the phenomenon, and then through description giving a voice to the experiences of the participants (Streubert & Carpenter, 2001:21, 37).

The findings of a qualitative study lead to an understanding of a phenomenon in a particular situation; and they are, therefore, not generalized in the same way as can the findings of a quantitative study. However, these insights can be applied to guide

14 nursing practice, to change the perception of nurses and to change nursing practice (Burns & Grove, 2011:74). Scientific rigour is valued; because the findings of rigorous studies are deemed to be more credible and of greater worth; and they are, therefore, discussed in greater detail.

The qualitative researcher has to be aware of her own subjectivity, and is expected to provide sufficient information in the published report to allow a thorough critical appraisal (Burns & Grove, 2011:75). The qualitative researcher sets out to report on the different realities, which are expressed in different forms - by using the actual words of the different participants and presenting different perspectives provided by the different participants (Creswell, 2013:20).

When conducting a qualitative inquiry, the researcher gets as close as possible to the participants (where they are at) for as long as possible, in order to assemble objective and subjective evidence of people’s real experiences (Creswell, 2013:20).

In this study, the qualitative research design was chosen – due to the nature of the research problem. Paucity in research was found regarding workplace violence in private healthcare facilities, and more specifically in South Africa.

2.2.2 Exploratory design

The Collins English Dictionary (2014) defines explorative as exploratory action, which is undertaken to discover something, or to learn the truth about something. Wood and Ross-Kerr (2011:121) state that an exploratory design is a flexible research design that provides an opportunity to examine all the aspects of the problem. As the knowledge increases, the researcher may change the direction. An exploratory design was employed in this study; since paucity was found in research regarding workplace violence between professional nurses in the private healthcare sector.

The researcher aimed to gain a new insight and understanding of the phenomenon of workplace violence, including the current practices, the contexts of the occurrences, and the meaning each participant gave to the incidents of workplace violence.

2.2.3 Contextual design

All qualitative studies are contextual in nature; and therefore, the data gathered are 15 context-specific; and it is difficult to generalize these findings to the larger population. A thick description should, however, allow other researchers to replicate and transfer the selected findings to other contexts (Yon, 2015:21). The description should include the specific research setting in which the research took place, the participants, the phenomenon under study, and the researcher’s personal experiences (Botma, Greef, Mulaudzi & Wright, 2010:195).

The specific context of this study was a large private healthcare facility that provides mostly curative services in an urban environment; and the accounts of workplace violence that were reported, were related to professional nurses.

2.2.4 Descriptive design

Descriptive design relates to the researcher’s ability to provide a dense description of the findings of the phenomenon of interest, of how the data were collected, captured and analysed (Brink et al., 2012:122). The purpose of descriptive qualitative inquiry is to make an observation, to describe it, to document aspects of any event that naturally occurs and that serves as a starting point for the development of a theory (Polit & Beck, 2012:226). Furthermore, it offers the researcher a way to discover new meaning, to describe what exists, to determine the extent of something, and to categorize the information (Grove et al., 2013:26).

A descriptive design was applied in this study to answer the research question. The researcher studied and examined the participants’ unique stories of their experiences of workplace violence and the meaning they attached to it. The data that were collected enabled the researcher to give a rich and accurate description of the phenomenon. The findings of the study assisted her to draft guidelines for managers and professional nurses; and they could be used to assist in addressing workplace violence in the private healthcare facility.

2.2.5 Narrative research

In the human sciences, narratives and stories are used as a means of recreating experiences and events in people’s lives (Freshwater and Holloway in Gerrish and Lathlean, 2015:226). Freshwater and Rolfe (2004, in Gerrish and Lathlean 2015:226) emphasize the linkage between the plot, authority and reflexivity. The authors mention

16 the notion of power and freedom afforded through the narrative to expose the limitations and constraints of old meanings, and to refer to transformation (Gerrish and Lathlean, 2015:226).

Burns and Grove (2011:90) support this notion by stating that narrative research is a qualitative approach; and it uses individual participants’ stories of their experiences of past events as the data. This is a powerful means to gain insight into the phenomenon of interest. It comprises spontaneous and everyday conversation; and it is viewed as one of the natural cognitive and linguistic forms through which individuals attempt to organize and express meaning and knowledge in a naturalistic setting (Brinkman & Kvale, 2015:178; Polit &Beck, 2012:53).

Brinkman and Kvale, (2015:180) also state that the interviewer may introduce the interview with a specific question about the phenomena under study.

In this study, the participants were asked to tell their stories of their past experience of workplace violence. Through their stories, the researcher was able to enter the world of the participants, to get details about the incidents or events, to gain the meaning of workplace violence for the individual participants, and to make inferences on the experiences of the professional nurses in general. Refer to Chapter Three (Section 3.2) for the social context in which the workplace violence took place.

2.2.6 Paradigmatic Perspective

The Critical Social Theory will be used as the paradigm for this study. The Critical Social Theory was developed by Max Horkheimer; and it is oriented towards critiquing the existing conditions and changing society as a whole (Fui, Khin & Ying, 2011:129; Bloom 2014:26; Anderson, Curtis, & Wittig, 2014:14). Workplace violence is not unique to nursing; therefore, the phenomenon has to be discussed and understood in the broader social context.

Polit and Beck (2012:506) suggest that the aim of Critical Social Theory is to integrate theory and practice; such that people become aware of contradictions and disparity in their beliefs and social practices and become inspired to change them rather than to maintain the status quo (Polit & Beck, 2012:506). The goal of the theory is thus not to

17 just determine what is wrong, but to find ways to change society for the better (Finlayson, 2004 in Bloom, 2014:27).

In the late 1960s, Jurgen Habermas, a German philosopher and sociologist, revisited the Critical Social Theory. Habermas believed that society was not meeting the people’s needs and that institutions within society were manipulating individuals; however, he believed that people could be empowered to interact and respond to this manipulation (Finlayson, 2004 in Bloom, 2014:27).

The Critical Social Theory aims to explore various features of human life with the intention of providing a critique of their fairness or unfairness. It raises questions of whether situations are being distorted by power imbalances. Habermas also attempts to provide guidelines that would characterize ideal situations where these distortions could be avoided; and he describes mechanisms for change (Bloom, 2014:28).

The Critical Social Theory has as its main goal the improvement of the human condition; and there are four basic assumptions:

 The first assumption of the theory is that people can change their world. They can find alternatives to the existing social conditions; and they can also challenge taken-for-granted conditions.  The second assumption is that all social knowledge is value-laden, and that all scientific knowledge is a social construction.  The third assumption is that reason and critique are inseparable, and are reflexive.  The fourth premise of the Critical Social Theory is that theory and practice must be interconnected (Bloom, 2014:28).

The Critical Social Theory is action-oriented; and it involves a process of self- knowledge or self-reflection (Polit & Beck, 2012:506). Self-knowledge, in this paradigm, involves the discovery of problems in society; and it brings the problems to light; and it acts to change society for the better. Self-reflection involves learning – by reflecting on actions – in the hope of gaining insight from an experience to emancipate individuals to effect social change (Bloom, 2014:79; Polit & Beck, 2012:506).

In this study, the Critical Social Theory suggests that professional nurses should become aware of the problem of workplace violence, critically analyse people’s behaviour, and report on the elements in society that have a negative influence on them – and therefore the need to change. Furthermore, the Critical Social Theory also reviews relationships – for the purpose of enhancing individual responsibility and improving the culture within nursing. This fits well with the aim of this study (Polit & Beck, 2012:507).

2.3 RESEARCH METHODS

Research methodology, according to Burns and Grove (2011:58), refers to how the study is conducted; and it includes a description of the study population, the sample, the data-collection method and the method to be used to analyse the data. Phase one of the study consists of sampling, the recruitment of participants, the data collection and the analysis of the data.

2.3.1 Research Population

A population is the entire group of persons or objects that is of interest to the researcher, and who meet the criteria that the researcher has set (Brink et al., 2012:131). The research population for this study was professional nurses registered at the South African Nursing Council (SANC) under Section 30(1) of the Nursing Act (2005:25), and who were working in the particular private healthcare facility where the research was conducted.

2.3.2 Sampling

Sampling is the process of selecting respondents from the population, with the purpose of obtaining information on the phenomenon, in such a way that the respondents represent the population of interest (Brink et al., 2012:132; Hewett, 2010:35). Non- probability sampling implies that not all the elements in the research population have an equal likelihood of being chosen, and that the sample is selected from the population by non-random methods (Yon, 2015:23; Grove et al., 2013:362). Purposive or judgemental sampling allows the researcher to select participants who are typical or representative of the phenomenon under study.

The researcher is allowed to choose those elements who would provide the best explanation of the phenomenon under study (Botma et al., 2010:127).

The researcher, therefore, used a non-probability, purposive sampling method for this study; because she was investigating a particular phenomenon to which not all professional nurses had been subject.

A small sample was drawn from the population of professional nurses who met the inclusion criteria and were willing to participate in the narrative research study. Purposive sampling allowed the researcher a quick way to gather fourteen participants that she deemed to be representative of the professional nurses in the private healthcare facility (e.g. departments/units and disciplines), and who could provide rich data that were central to the study.

The inclusion criteria were as follows:

 Only professional nurses that had experienced workplace violence had the opportunity to participate and articulate their stories.  Only professional nurses that were permanently employed in the private healthcare facility, and had been employed longer than six months, were included in the study.

The researcher did not distinguish between genders or age groups; as workplace violence can affect all professionals. The researcher decided not to include the lower category of nurses as a convenience. The researcher believes that the professional nurses are the leaders of the clinical teams; and they are, therefore, subject to a lot of workplace violence; as was discussed in the problem statement in Chapter One.

2.3.3 The data collection

Data collection is the precise, systematic gathering of information relevant to the research purpose (Grove et al., 2013:45). Interviewing is a flexible technique that allows researchers to explore greater depth of the meaning of the phenomenon of interest (Grove et al., 2013:424). Mishler (1986, in Brinkman and Kvale, 2015:179) outlined how interviews understood as narratives emphasize the temporal (framing of time), the social, and the meaning structures of an interview. Some researchers focus

20 on the temporal ordering of a plot, while others focus on the themes (Phoenix in Andrew, Squire and Tamboukou, 2013:72).

The data were, therefore, collected by using individual in-depth face-to-face interviews, in which the participants were asked to narrate their stories about their past experiences of workplace violence. The data were collected during the month of June 2015.

Only after ethical approval was obtained from the research ethics committee of the university, the research operations committee of the organization, and the manager of the particular healthcare facility, could the researcher commence with the recruitment of possible participants.

The recruiting strategy involved identifying, accessing and communicating with potential participants, who would be representative of the target population (Grove et al., 2013:374). The potential participants were approached in writing and the recruitment process was implemented as follows:

 The recruitment letters were hand-delivered by the researcher to the various units in the healthcare facility. These letters were handed out to all the professional nurses by a dedicated person in the unit.  All the professional nurses, therefore, received a letter to inform them of the proposed study; and it requested their participation.  An envelope was attached to a recruitment letter (please see Annexure B), in which the professional nurses could insert a note with their names, telephone numbers, and their consent to participate in the study, or not.  They were asked to tick a box with the following question: Have you ever experienced workplace violence whilst being employed at this facility? Yes No

The potential participants were requested to put the sealed envelopes in the researcher’s pigeonhole at the back entrance of the hospital – to ensure that ethical principles would be adhered too. Thirty-six forms were returned; and twenty-one nurses indicated that they had experienced workplace violence and were willing to

21 participate in the study. The potential participants were phoned to arrange an interview at a time and a date that suited them.

The researcher is a manager in the institution; and she could have been perceived as a threat to the participants. The data collection was, therefore, done by a trained and experienced researcher (fieldworker). The fieldworker was not known to the staff members in the institution, and did not work in a private healthcare facility. There was only one fieldworker to ensure the reliability of the process. The fieldworker signed a confidentiality agreement and undertook not to give the information to anyone, except the researcher. (Please see Annexure J.)

The fieldworker was a seasoned researcher and data collector and was well-versed in using verbal and non-verbal communication to obtain information-rich data from the participants. Minimal training was, therefore, necessary.

The data collection took place in a private venue not used by the general staff members or generally known to the staff members. Directions were given to potential participants only, in order to protect their anonymity. Attention was given to the physical environment, for instance, by providing comfortable chairs, water and temperature control – in order to enhance the comfort of the participants.

After the fieldworker established rapport with the individual participants and set their minds at rest, the participants were asked if they were willing to participate in the study. The objectives were read out to the participants; and they were given an opportunity to ask questions; and information was provided to them freely. Once the participants had indicated that they were willing to proceed, they were asked to sign the consent form. (Please see Annexure A.) The participants were re-assured of the confidentiality of the information, and that their names would not be linked to any of the data they provided; and therefore, they would remain anonymous (Grove et al., 2013:172).

On the consent form, some demographic information was collected. (Please see Annexure A) The participants were asked if they would supply the fieldworker with their name and telephone number, in order for the researcher to clarify the findings, if necessary (member checking). The participants were told that only the fieldworker and

22 the researcher knew who they were; and that as soon as the data were transcribed, the transcription would receive a code that was only known to the researcher.

The participants were re-assured about their participation; and they were informed that they could say anything without fear of reprisal; and they could discontinue the process at any time – without fear of victimization or repercussions.

Once that was done, the participants were asked if they were willing to be recorded. The digital voice recorder was placed in plain view; and was used in a non-threatening manner.

The question that was put to the participants was:

 You indicated on your consent form that you had experienced workplace violence. Please tell me the story.

The role of the interviewer in narrative research is to be an active listener who allows the participant to speak freely in a non-threatening environment, in order to ensure that the information is forthcoming. The fieldworker gave the participants enough time to respond naturally, and abstained from any interruptions. She did, however, occasionally pose a question for clarification or understanding, to ask the participant to elaborate, to abstract meaning, or understanding and/or the reasons for the discussion.

The following probing questions were provided to the fieldworker to use when necessary:

 You said you were upset…… tell me more about your feelings….  What were the circumstances surrounding this incident?  The incident changed your relationships with your colleagues… how?  After the incident, did your behaviour change?... How?  Do/did you experience your work environment differently after the incident?... Please explain?

Once the interviews were completed, the participants were thanked for their participation; and it was confirmed that should the researcher need clarification, they

23 could be contacted again. A note was made of this on the consent form.

The data were collected until saturation had occurred; and when additional sampling yielded no new information, and redundancy was achieved (Burns & Grove, 2011:317).

2.3.4 Field notes

The fieldworker was asked to keep field notes of the interviews, which she made directly after the interviews with the participants. She noted her impressions, the non- verbal clues that were given by the participants, and the information that was not voiced during the recorded interviews. The researcher included this information with the data for analysis.

2.3.5 The data analysis

In qualitative research, data analysis occurs concurrently with the data collection. Therefore, the researcher simultaneously gathered, managed and interpreted the growing bulk of data. Volumes of data were gathered; and the researcher developed means of storing the data in an organized manner (Burns & Grove, 2011:93). In this study, electronic folders were created for the research literature, interviews, transcriptions and electronic communication. To ensure the safety of the data, a data- transfer stick (flash drive) was used as a back-up. Hardcopies of the recruitment documents, the completed consent forms, and the confidentiality agreements were all filed and kept in a safe, locked environment; and all the electronic data were stored in a password-protected folder on the researcher’s personal computer – to ensure that the ethical principles were adhered to.

As the interviews were completed, the researcher and an independent typist transcribed the interviews verbatim from the digital recordings. Transcriptions were labelled with codes that were only known to the researcher. The participants’ identity and contact details were kept in a separate file, in case the need to contact the participant arose. During the transcriptions, the researcher had the opportunity to listen and re-listen to the stories that were told by the participants and this facilitated the analysis process.

The researcher appointed an independent coder, who was experienced in data

24 analysis to ensure the trustworthiness of the study (Polit & Beck, 2012:584). The independent coder signed a confidentiality agreement before the transcripts were provided to her. (Please see Annexure K.) The transcripts that were given to the coder were anonymous; thus confidentiality was ensured. The coder was given a written copy of Tesch’s eight-step method of data analysis – to ensure that the coding of the researcher and the independent coder were the same.

The researcher attempted to code the data; while the experienced coder assisted in developing the themes and in finding the threads that flowed through all the stories. Qualitative researchers scrutinize their data carefully and deliberately, often reading the data over and over again, in search of meaning and understanding. Insight cannot emerge until the researchers become completely familiar with their data (Polit & Beck, 2012: 557).

The data for this study were synthesized into themes of commonalities, by using Tesch’s eight-step method of data analysis. Tesch’s data analysis and coding process involve the following eight steps:

 All the interview transcripts were read and reread, in order to get a general sense of the content of the transcriptions. Some ideas were written down, as they came to mind, as possible themes. Field notes were included as data.  One interview transcription from all the transcriptions was selected; and the researcher read the document critically to deduce any deeper meaning of the content of the transcription. Once again, ideas and thoughts were written down, in the margin on the interview transcript.  Once that was done for several interview transcripts, the emerging themes and ideas were clustered together, with similar topics in one group. Thereafter, the researcher abbreviated the themes or topics into codes; and she put the code at the specific segment of the interview data, and also the emergence of any new themes or codes. The researcher continuously observed the organization of the data, in order to check whether any new categories or codes emerged  The researcher worded the topics in the most descriptive way possible, and then converted them to categories. The list of categories was reduced by clustering

related topics together. Lines were drawn between categories that indicated the inter-relationship of the categories.  The researcher made a final decision on the abbreviation for each category.  The data material belonging to each category was put together in one place; and a preliminary analysis was conducted (Creswell, 2014:198).

Once the researcher and the independent coder had completed the coding, a meeting was held; and a consensus document was drawn up and submitted to the supervisor.

2.3.6 The Literature Control

The researcher will conduct a literature control of the findings, which form part of Chapter Three. A literature control locates a researcher’s findings within the existing literature, and demonstrates how the findings contribute, develop further, or challenge what is already known about the topic (Braun & Clarke, 2013:257). Mouton (2001:6) adds that a literature control aids in understanding how other researchers have theorised and conceptualised the research issues.

2.4 PILOT STUDY

In order to test the practical aspects of a research study, the researcher can conduct a pilot study (Brink et al., 2012:174). A pilot interview was conducted as a small-scale version or trial run designed to ensure that the meaning and in-depth understanding of the phenomenon was obtained (Polit & Beck, 2012:195).

The pilot interview was done exactly like the real study was going to be done; and it consisted of two professional nurses from the same healthcare facility in which the research was done. The fieldworker was an experienced researcher; and she was comfortable with the processes, and had the skill to obtain high-quality data during the interviews. The interviews were digitally recorded; and the data were transcribed. The data were then analysed, according to Tesch’s method of analysis to see whether any themes could be identified. Themes were identified; and no adjustments were needed to the research question; therefore the data were included in the study.

2.5 DEVELOPING GUIDELINES

Phase two of the study entailed the development of guidelines for nurse managers and professional nurses to address workplace violence in a private healthcare facility. Polit and Beck (2012:31) state that guidelines define a minimum set of services and actions appropriate for certain clinical conditions. Du Rand and van Rooyen (2015:1) and Nyangeni (2015:27) suggest the following processes for the development of guidelines:

 Make inferences from the data about the overarching topics that are needed to address the task at hand.  State the principle and sub-guidelines required to create a framework for the actions that need to be taken, in order to achieve the goal/purpose of the guideline.  State the main purpose and rationale of each guideline and for the sub- guidelines – if necessary.  Identify the actions (behaviours) that are needed or necessary to operationalize and achieve the guideline and its sub-guidelines; and order these actions in a logical and sequential order taking operational implications, such as resources and possible operational consequences of the actions into account.

From the themes identified out of the data collection of the study, the researcher developed guidelines for nurse managers and professional nurses to address workplace violence in a private healthcare facility, using the above method. (Please see Chapter Four for the details.)

2.6 RELIABILITY AND VALIDITY

In Qualitative research, reliability and validity are ensured by means of establishing trustworthiness (Sliep, Poggenpoel & Gmeiner, 2001:69; Klopper, 2008:69). A study is trustworthy if and only if the reader of the research report, judges it to be so (Rolfe, 2006:305). Lincoln and Guba (1985, in Polit and Beck, 2012:584) suggested four criteria for assessing the trustworthiness of a qualitative inquiry, namely: credibility, dependability, conformability and transferability.

2.6.1 Credibility

Credibility, according to Polit and Beck (2012:585) refers to confidence in the truth of the data and the interpretations thereof. The following were used to ensure credibility:

 The researcher ensured that she would bracket any preconceived beliefs and opinions about workplace violence, and would remain unbiased.  Triangulation is used to ensure the credibility and the accurate representation of the reality of the phenomenon (Brink et al., 2012:99). In this study, several participants, as well as some from different nursing units in the healthcare facility, were selected, in order to ensure the trustworthiness of the information.  Member-checking took the findings back to the participants for confirmation of their interpretation, or to clarify any uncertainties.  Quotes from the participant’s stories were used to capture the core ideas of the phenomenon from each person’s dialogue in the report of the findings (Polit & Beck, 2012:497).  Thick and rich descriptions of the participants’ stories of workplace violence are presented in Chapter Three.  An independent coder was used to identify and verify the themes and the subthemes from the transcripts. The researcher attended a workshop in research methodology and received guidance from her academic supervisor throughout the research process.

2.6.2 Dependability

Dependability or consistency refers to the stability (reliability) of the data over time and in other conditions. The dependability question is: Would the findings of an inquiry be repeated if it were replicated with the same participants in the same context (Polit & Beck, 2012:585). The context was described in which the research took place (Chapter Three, section 3.2.), to enable another researcher to make an informed choice about the circumstances in which this study took place, and to enable decisions to be made about repeating such a study. In this study, the researcher paid particular attention to dependability; and therefore, used an experienced fieldworker to do the interviews. Only one fieldworker was used for all the interviews. The content of the field notes was included in the data analysis. Interviews continued until saturation was reached.

The researcher applied triangulation by collecting the data from multiple participants; and they worked in different units to ensure a cross-section of the findings.

Analysis of the collected data was done by the researcher, the coder and overseen by the academic supervisor, in order to ensure dependability.

2.6.3 Confirmability

Confirmability, according to Polit and Beck (2012:585), refers to objectivity, which for the purpose of this study would mean that congruency between two or more independent people on the accuracy of the data, as well as the relevance, or meaning thereof. Klopper (2008:70) state that neutrality entails freedom from bias in the research procedures and results; and it refers to the degree to which the findings are a function solely of the informants and conditions of the research, and not of any biases, motivations and/or perspectives.

In this study, the researcher utilized one fieldworker to collect the data, and an independent typist to transcribe the voice recordings. She also utilized an independent coder. She bracketed her own opinion and beliefs, by being reflexive at all times, and questioning her own position (objectivity) during the analyses of the data; as she had been exposed to workplace violence herself. The researcher remained aware of her own unique background, set of values and experiences that could affect this study.

To maintain reflexive and limit her subjectivity, she kept a file with notes about the research events. Member checking ensured that the interpretation of the data obtained from the participants was a good representation of the participant’s reality.

2.6.4 Transferability

Transferability or applicability refers to the degree to which the findings of this inquiry can apply to different contexts and settings, or with other groups (Polit & Beck, 2012: 585). For the purpose of this study, the researcher ensured adequate and thick descriptions of the context, research method and findings; so that the conclusions drawn from the data and guidelines could be transferred to other groups and other contexts – for example other private healthcare organizations by other researchers, if or when applicable.

2.7 ETHICAL CONSIDERATIONS

The researcher has the responsibility to search for the truth in the most rigorous way, but never at the expense of the rights of the individual, communities or with malicious intent (Babbie & Mouton, 2001 in Brink et al., 2012:32). The researcher adhered to all the ethical principles at each stage of the research process, and protected the research participants.

2.7.1 Beneficence

Beneficence imposes a duty on the researcher to maximize benefit (Polit & Beck, 2012:152). This principle is intended to produce benefit for the participant and others. For the purpose of this study, the fieldworker explained to the participants that the benefits of sharing their experience might not benefit them directly; but that they would afford the institution and the company at large the opportunity to design guidelines to address workplace violence and bring an organizational-culture change about.

The interviews might, however, have been of benefit to the participants; as they gave them an opportunity to speak about the incident for the first time, and consequently alleviated the stress associated with the incident.

2.7.2 Non-maleficence

Non-maleficence requires that the researcher avoid actually causing harm to the participants (Burkhardt & Nathaniel, 2014:71). Due to the nature of the study, emotional discomfort or distress of the participant was possible; as in some cases, workplace violence can be a traumatic experience. The participants were forewarned that the study was about workplace violence; and they were given an opportunity to refuse participation.

The fieldworker, also an experienced psychiatric nurse, was asked to discontinue any interview if the participants become unduly distressed, or wanted to discontinue the interview. A therapist was on standby to assist in such cases. The participants could also have been referred to the employee-support services of the healthcare facility if necessary, which is available 24 hours a day, free of charge to the employees.

2.7.3 Autonomy

Autonomy means self-governing; therefore, the individual has the freedom to make their own informed choices about issues that affect his/her life (Burkhardt & Nathaniel, 2014:59-60). The researcher and/or fieldworker treated the prospective participant as autonomous agents, by supplying full and honest information to them about the proposed study. Any questions posed were answered truthfully and comprehensively by the researcher and/or the fieldworker. The professional nurses’ decision to participate or not was respected and the right to withdraw (at any time of the study) without any victimization or different treatment imposed on them, was upheld.

2.7.4 Justice

Justice is an ethical principle that relates to fair, equitable and appropriate treatment in the light of what is due or owed to a person (Burkhardt & Nathaniel, 2014:81). Brink et al. (2012:36) state that it refers to the participant’s right to fair selection and treatment. Selection of the participants was directly related to the research problem, as discussed above. All qualifying participants had an equal chance of being included in the study. The right to fair treatment further meant that the researcher treated all the participants who withdraw from the study, after the initial agreement, in a non-judgmental manner; she and honoured all the agreements made with the participants.

2.7.5 Veracity

Veracity relates to the practice of telling the truth (Burkhardt & Nathaniel, 2014:73). Truth-telling engenders respect, open communication, trust and shared responsibility. The research must demonstrate respect towards the scientific community by protecting the integrity of scientific knowledge (Brink et al., 2012:43). The researcher and fieldworker gave all the participants truthful and comprehensive information about the study; as this was needed or requested. The researcher also gave an unbiased, honest reflection of the phenomenon that was studied. The researcher did not fabricate any data, and reported the stories truthfully and comprehensively.

2.8 PRIVACY AND CONFIDENTIALITY OR ANONYMITY

According to Burkhardt and Nathaniel (2014:76), the terms confidentiality and privacy are inter-related. Privacy refers to the right of an individual to control personal

31 information or secrets that are disclosed to others. Confidentiality demands the non- disclosure of private or secret information about another person, with which one is entrusted. Furthermore, the ability to maintain privacy in one’s life is an expression of autonomy (Burkhardt & Nathaniel, 2014:77).

For a researcher, to maintain confidentiality is an expression of respect for a person. Confidentiality is also a pledge that any information provided by the participant will not be publicly reported in a manner that identifies the participants, the perpetrators of the workplace violence, or the institution; and it would not be accessible to others (Polit & Beck, 2012:162). The process of anonymity, therefore, refers to the researcher keeping the participants identity a secret with regard to their participation in the research study. Anonymity (Polit & Beck, 2012:162) occurs when the researcher does not link the participants to their data, personal information or the name of the healthcare facility.

The researcher took all the necessary and possible steps to ensure that no breach of confidentiality and anonymity occurred. The interviews were done in a private setting; so the interviewees could not be identified by other staff members, or the link between them and their participation in the research could not be made. As indicated above, the fieldworker, the transcriber and the independent coder signed a confidentiality agreement. Codes were assigned to each participant’s interview; and only the researcher knew the code and could attach it to the actual data.

These codes were used in the transcriptions and the research report. The original data will remain in a locked cupboard in the researcher’s home, and will be destroyed after 5 years. The electronic data on the researcher’s computer will be removed as soon as the reports are completed. The data will be placed on CDs, and also be kept under lock and key for 5 years. In the meantime, the password protection of the data on the computer will be kept secret.

2.9 DISSEMINATION OF THE RESULTS

The researcher intends to make the findings of this study public by publishing an article in an accredited peer-reviewed journal. The researcher will do a podium presentation at a national conference to create awareness of the problem and provide possible

32 solutions to address the phenomenon at hand. The researcher will also provide in- service training in the private healthcare facility for professional nurses and managers, in order to ensure that workplace violence is addressed in the organization.

2.10 CONCLUSION

This chapter has focused on and provided an in-depth description of the research design and methodology that was utilised in this study. Chapter Three will describe the findings of the study. The researcher will discuss the themes and subthemes that emerged from the data analysis and any comparisons to the relevant literature will be followed up.

CHAPTER THREE

DISCUSSION OF THE RESULTS AND THE LITERATURE CONTROL

3.1 INTRODUCTION

In the previous chapters, the research design and methodology that was used were discussed in detail. In this chapter, the findings will be reported and discussed; and the evidence of a literature control will be presented.

The reader is reminded that the concept clarification in Chapter One classified workplace violence as incivility, verbal and emotional abuse, physical and psychological abuse, horizontal or lateral violence, such as, for example, rude or unsociable speech or behaviours between peers or colleagues; vertical violence, for example, is impolite or offensive behaviour in people on different levels within the organization. This could include yelling, snide comments, withholding pertinent information, rude remarks, ignoring or humiliating behaviour (Cantey, 2013) or bullying. For example, a person who uses power or influence to harm or intimidate someone or force someone to do something, sexual harassment and those behaviours demonstrated towards nurses, which they feel are unethical, unprofessional or types of inappropriate behaviour.

The researcher will henceforth use the term workplace violence to describe any of these actions or behaviours, as they are mentioned.

In this study, it was found that workplace violence does exist within the private healthcare facility; and that it comes from different sources. The participants also indicated that the workplace violence had an emotional and physical effect on them and others, as well as on the work environment. They made suggestions regarding the need for change and how it could be accomplished.

3.2 CONTEXT OF THE STUDY

The healthcare facility where the research took place is a 340-bed, acute-care facility offering 24-hour emergency care. The following disciplines are offered: Bariatric Surgery, Cardiology (including paediatric cardiology), Cardio-thoracic surgery, Gastro- enterology, General surgery, Gynaecology, Neurology and Neurosurgery, Orthopaedic

34 surgery, Plastic and Reconstructive Surgery, Rheumatology, Urology and Vascular surgery. To support the above disciplines, specialised facilities are available, such as Intensive-care units (General, Cardiothoracic, Cardiac Care and Neonatal), High-care units (Adult and Paediatric), Operating theatres and Cardiac-Catheterisation Laboratories.

The hospital manager (non-medical person) is responsible for ensuring that the healthcare facility is correctly managed – by using sound financial principles. One of the manager’s primary functions is to ensure that the high achieving private medical practitioners (specialists and general practitioners) remain committed to and working in the private healthcare facility, as their practices generate income and create an influx of patients to the facility. Doctors, in the private healthcare facility, are viewed as leaders of the healthcare teams and important customers of the business. Doctors are not employed by the private healthcare institution; but they have practising privileges to work at the healthcare facility.

A total of 721 staff members (nursing and non-nursing) are employed at the healthcare facility. Nurses comprise 321 of the total number of staff members.

Nursing has a formal hierarchical structure led by the Nursing Service Manager. Strategic planning and policy formulation occur on this level in the healthcare facility. The Nursing Service Manager liaises with head office, and is responsible to implement/operationalize strategic decisions, including introducing and creating a certain corporate culture, which is based on the mission and vision of the organization, and to create a feedback loop back to head office.

The Nursing Service Manager is supported by deputy-nursing managers; and their responsibility is to ensure quality patient care/service delivery in the most cost-effective manner. Their task is to ensure the implementation of continuous improvement programmes and effective interventions, in order to improve patient outcomes and quality indicators, such as the reduction in patient falls.The deputy nurse managers also ensure that policies are implemented and due processes are followed, such as resolving grievances between nurses and initiating or chairing disciplinary proceedings because of the unacceptable behaviour of staff members.

The Nursing units in the private healthcare facility vary in size from 8 to 47 beds. Each Nursing Unit has a Nurse Unit Manager, who is in charge of the unit. The Nurse Unit Manager’s primary task is the general management of the nursing unit to ensure good quality nursing care, cost-effective patient outcomes, and to manage human and other resources in the unit. The Nurse Unit Manager is responsible for creating a conducive working environment, where two-way communication flows easily between all the stakeholders, the promotion and maintenance of a positive corporate culture, where induction, orientation and training programmes are well established, nurses are appreciated and developed, unacceptable behaviour is addressed, conflict is managed and discipline applied – when needed.

There are normally three levels of nurses working in a Nursing Unit, namely: professional nurses, enrolled nurses and the enrolled-nurse auxiliaries. Their primary function is the 24-hour nursing care of the patients. They ensure that doctors’ prescriptions are implemented to facilitate positive patient outcomes. In some of the nursing units, support staff (care workers) are employed to assist the nurses with basic patient care, such as the bathing or feeding of the patients.

Team leaders, who are always professional nurses, are allocated per shift to ensure that high standards of nursing care are maintained at all times. The team leader is accountable and responsible for patient and task allocation, the delegation of duties and the control thereof. This may be a staff member, who is the most experienced in a specific discipline, and would be responsible for critical decisions regarding patient care. In this study, the participants refer to the team leader as the shift leader.

3.3 CHARACTERISTICS OF THE SAMPLE

The sample of this study were all professional nurses, who had been permanently employed at the private healthcare facility for a period greater than six months prior to the study. All genders and age groups were included in the study. A purposive sample was drawn from the population, as discussed in Chapter Two. The sample consisted of fourteen professional nurses who were selected after the completed recruitment forms were returned, and who met the inclusion criteria and consented to participate.

3.4 DEMOGRAPHIC DATA OF THE SAMPLE

Demographic data were obtained from the professional nurses that were willing to participate. Both genders were represented: 13 females and 1 male. The working experience of the participants varied from 2 to 20 years, or more. Table 3.1 indicates the particulars. The sample consisted of nurses who had worked in many different units.

Table 3.1: The working experience of professional nurses

Number of years of nursing Number of participants experience

2-5 years 1

5-10 years 5

10-20 years 3

>20 years 5

Nursing Units where participants worked

Participants worked in a variety of units in the healthcare facility. Most of the participants were from specialized units, even though all the nurses, from all the units in the hospital were asked to participate in the study. A summary is provided in the table below.

Table 3.2: Nursing Units where participants worked

Nursing Unit Number of participants

Theatre (including recovery room and minor theatre) 4

High care 3

Intensive-Care Unit 2

Cardiac-Care Unit 2

Surgical unit (ward) 1

Accident and Emergency department 1

Urological unit (ward) 1

3.5 DISCUSSION OF THE FINDINGS

The participants acknowledged that violence occurred in their workplace and reported that they had never experienced such unprofessional behaviour in their entire nursing career. They reported that they had experienced episodes of violence form various source within the healthcare team. The sources were reported as being: doctors, nurses, patients and relatives. The fieldworker noted that the participants from the wards had experienced fewer episodes of workplace violence to report. However, the participants from the specialised units had information-rich data to share on their experiences of workplace violence. She further noted that it appeared that the softer and gentle person experienced the most violence and abuse.

The professional nurses indicated that the impact of the workplace violence affected them as individuals, as a team, and ultimately influenced patient care. The impact of workplace violence was also felt on an organizational level with increased absenteeism, loss of productivity, higher staff turnover and reputational damage – due to poor patient care.

The participants described their experiences as “traumatic”; and, at times, they cried all the way home because of an incident that had happened at the workplace. The symptoms that professional nurses experienced after enduring workplace violence were both physical and psychological in nature. Team dynamics were affected negatively – leading to a reduction in team work, poor work standards and increased unsafe and unacceptable patient-care practices.

The participants reported that workplace violence was not adequately managed by managers - in spite of the fact that it was reported on more than one occasion by various people. Professional nurses, therefore, made use of personal strategies to deal with workplace violence; and they made suggestions to the fieldworker/researcher to improve the management of workplace violence. Table 3.3. below provides a summary of the themes identified from the data.

Table 3.3: Workplace violence as experienced and reported by participants

Themes Sub-themes

Theme 1: Participants experienced episodes of workplace Professional nurses violence within the healthcare team as follows: acknowledge the existence of 1.1. Doctors towards nurses. workplace violence where 1.2. Nurses towards nurses. they work. 1.3. Patients and relatives towards nurses. 1.4. Nurses towards patients.

Theme 2: 2.1. Participants indicated that workplace violence Participants described the affected them as individuals. effect of workplace violence 2.2. Participants described the impact that on themselves, others, and workplace violence had on work performance, the work environment. team work and patient care.

Theme 3: 3.1. Participants stated that workplace violence Participants discussed their was not adequately managed by managers. views regarding the 3.2. Participants discussed personal strategies management of violence in they used to manage workplace violence. the workplace. 3.3. Participants made general suggestions to improve the management of workplace violence.

The themes will now be discussed individually and in detail.

3.5.1 THEME 1: PROFESSIONAL NURSES ACKNOWLEDGE THE EXISTENCE OF WORKPLACE VIOLENCE WHERE THEY WORK.

Professional nurses mentioned that they had experienced and witnessed workplace violence from a variety of sources, such as doctors, nurses, patients and patient relatives. Bloom (2014:2) confirmed that hostile interaction directed at nurses came from a variety of sources, which included patients, family, physicians, other hospital staff and nursing colleagues. In this study, the professional nurses that were interviewed reported that doctors and nurses frequently displayed unacceptable behaviour towards the nurses.

Nurse-on-nurse workplace violence was reported to be on lateral and vertical levels. Some of the participants experienced that their colleagues in the nursing units were the perpetrators of the violence: for instance, the shift leaders; while others reported

39 the disruptive and verbally abusive behaviour of nurse managers towards junior nursing staff. One participant reported that in spite of her efforts to “please” the perpetrator (the shift leader), the violence had continued.

A number of professional nurses also maintained that patients and relatives were aggressive and abusive towards them. The participants did, however, express their understanding of violent behaviour (physical and verbal violence) experienced by them from the confused patients. The participants acknowledged that patients and relatives were stressed on admission to the private healthcare facility; and therefore, they mostly accepted the rude and disruptive behaviour as part of their normal everyday working environment. Nurses were also the perpetrators of abusive behaviour towards the patients – especially when they were short-staffed. Patient care was delivered in a rough and unacceptable manner.

The findings are congruent with the Critical Social Theory. (Please see the paradigmatic perspective in Chapter Two, section 2.2.6.) Professional nurses in this study have become aware of the unacceptable behaviour and reported on workplace violence and the negative effect on them as individuals and on their teams; and they have, therefore, expressed the need for change.

3.5.1.1 Sub-theme 1.1. PARTICIPANTS EXPERIENCED EPISODES OF WORKPLACE VIOLENCE WITHIN THE HEALTHCARE TEAM AS FOLLOWS: DOCTORS TOWARDS NURSES

Private medical practitioners visit the healthcare units once or twice a day, depending on the diagnosis and the treatment plan for the individual patient. In a private healthcare facility, medical practitioners are often regarded as the most important healthcare team members by managers, due to the financial contribution they make to the organization. Many nurses also regard them as the leaders of the healthcare team – due to the overemphasis of the dependent functions of the nurse, especially in a private healthcare facility, where litigation is to be prevented at all costs.

This has served to create power imbalances within the healthcare teams.

Professional nurses are members of the multi-disciplinary teams; however, in this study, some of the participants reported that nurses were not always respected as

40 equal professional team members, or as a person. Verbal abuse, according to Kennedy and Julie (2013:2), is defined as the intentional use of language that humiliates, degrades or indicates lack of respect for the dignity and worth of the individual. Participants reported that abusive language was used by doctors towards nursing staff, when doctors were phoned regarding their patients. Participants reported that the phone was put down in their ears – even before the reason for phoning had been addressed.

It was also voiced that staff members were afraid to phone some doctors and/ or only phoned the doctor as a last resort.

“…The language some of the doctors is using is inappropriate; so like verbally I was abused by doctors…You are just afraid to call some of the doctors you ...make how many plans and phoning him will be the last option…The language they are using its the style why the F do you phone me this time? I mean it’s his patient…” (WV3:1-2).

The findings of this study can be confirmed by Johnson (2009:6); where the results of an electronic survey, done by the American College of Physician Executives on doctor- nurse behaviour, were examined; and 98% of the participants reported behavioural problems between the doctors and the nurses.

Bullying, according to Smith (2011:4) is behaviour categorized as a threat to the nurse’s professional status and belittling deeds; and it includes insults or name-calling. In the present study, some of the professional nurses reported that doctors belittled them in front of the patients – and not even in a private area. After the professional nurse was reprimanded by the doctor, he walked away and left the nurse to continue taking care of the patient. It was reported that quite often the nurses on duty were not responsible for what was done incorrectly.

The participants reported that this type of behaviour from the doctors undermined the nurse-patient relationship; since the patients then question the nurse’s competency and skill.

“…There are some doctors in this hospital and also more who like verbal abusive, I suppose um, if they belittle sisters [professional nurses] in front of the

patients, sometimes if something is not done, rather than taking the sister away from the patient into a separate room…they reprimand you in front of the patient and at the end of the day the doctor just walks off, you sit there having to nurse the patient; and it just shows the patient that you are incompetent actually, when half the time it wasn’t even you that did the wrong, doing it was someone else …” (WV5:1).

Joubert, du Rand and van Wyk (2005:39) did a South African study in a private healthcare setting and found that 79% of the respondents indicated that nurses were verbally abused by the physicians. Furthermore, the highest percentage of abuse was as follows: being criticised even when they had not done anything wrong (81%), and made to feel responsible for the mistakes of others (76%). The findings of the study are thus confirmed.

In a study by Sheridan-Leos (2008:401), it was found that continued exposure to violence drained the nurses of their enthusiasm for the nursing profession and caused low morale. Those findings are supported by Szutenbach (2013:19), where participants in their study identified feelings of being undervalued and unsupported.

In the present study, a number of participants stated that doctors behaved in a physically violent manner – in that items were thrown around – and items were thrown at nurses. The participants reported that they were not used to this type of behaviour at home; however, they perceived that it was expected of them to permit this type of behaviour in the workplace. Another participant reported that during a life-saving procedure, such as an intubation of a critically ill patient, the doctor’s violent behaviour of throwing pillows at nurses drove the supporting nursing team away.

“…hy was met almal aggresief en nie net met my nie…goed rondgeruk…rond gegooi hier rondom my want dan kan ek nie funksioneer nie want mens laat dit nie eers jou huis by jou man toe nie maar mens moet dit toelaat by die werk wat nie reg is nie…dit het vir my gevoel ek het beheer oor die situasie verloor…” (WV11:1-2).

[Translation: He was aggressive towards everyone, not just me…jerked things around …threw things around me, so that I could not function, because you

don’t allow it at home, with your husband; but at work you have to allow it; and it is not right…I felt like I had lost control of the situation.]

“…ons was besig om die pasient te intubeer en wat hy toe nou gooi die een suster met die kussing toe ons nou weer kyk toe is dit net ek en hy om die bed want toe is almal nou al weg…” (WV15:2).

[Translation: We were busy intubating the patient, and he threw a pillow at one sister; and when we looked again, it was only him and me around the bed; because everyone else had left.]

Doctors throwing charts at nurses is a “common practice”, according to Martin (2008:21). In a survey conducted by the American College of Physician Executives, the participants reported that objects were thrown to express frustration; and it was a common occurrence (Johnson, 2009:6). More than 2100 physicians and nurses participated in that study. The findings of Johnson (2009) revealed that nurses had ducked to avoid scalpels, power tools, telephones, surgical instruments, clipboards and floor mats. In this study, the author found that nurses had any objects that were at hand thrown at them.

3.5.1.2 Sub-theme 1.2. PARTICIPANTS EXPERIENCED EPISODES OF WORKPLACE VIOLENCE WITHIN THE HEALTHCARE TEAM AS FOLLOWS: NURSES TOWARDS NURSES

Many nurses have chosen nursing as a career because of the desire to care for others. The private healthcare organizational values of care, dignity, truth, passion and participation resonate well within professional nurses; because for most, it is a personal value as well. When working for this organization, it is expected of all the employees to act in a certain way to enhance the branding and professional image of the healthcare business. Senior staff and managers are carefully selected and appointed to lead by example. However, abnormal, disruptive and abusive behaviour from senior nurses and managers has been reported by the participants.

The participants verbalized that nurse-on-nurse violence took place from a senior to a junior level, and among the same level or category of nurses.

Senior nurses towards junior nurses

The interviewees articulated that workplace violence was displayed by nurse managers and senior nurses towards their subordinates in various ways. Professional nurses indicated that senior nurses – for instance, the Nurse Unit Managers, displayed threatening and physically violent behaviour towards their juniors. The participants felt that they did not have the opportunity to report such behaviour; because in spite of reporting negative incidents, the violence escalated; and the situation became worse. One of the participants was threatened with disciplinary action after having reported a negative incident that involved a senior staff member towards the Nurse Unit Manager.

“…ek sê abuse in die hospitaal is meesal van aard dat jy voel jy word gedreig in ‘n posisie waar jy voel jy het nie ‘n mondstuk om te kan praat…” (WV12:1).

[Translation: I think abuse in the hospital is mostly by means of a threat to your position; and you do not have a voice to report it.]

“…I thought she [the nurse unit manager] was going to punch me; and it actually ended up in tears…there were a couple of third-year students working; and they were literally physically pushed out of the way. Get out my Way; Get out of my way! The [students] were physically pushed; and I don’t know you don’t treat people like that um in a strange sort of way the abuse that the staff suffered made the team closer and we became quite a strong team. Um, at one stage we reported her [the nurse unit manager] to management…” (WV10:2).

Johnston, Phanhtharath and Jackson (2010:36) confirm the present study. In their study, they suggested that the nurse manager who demonstrated bullying behaviour towards the subordinates lack personal power; and then they misused their rightful power by becoming abusive.

Jooste and Yako (in Jooste, 2010:143) confirm that teams with a sense of solidarity stick together. In this study, the team members had all experienced workplace violence; and therefore, their group cohesiveness became stronger. The participants reported that the team became so strong that they reported the Nurse Unit Manager to the senior-management team of the healthcare facility.

Some of the participants reported that the Nurse Unit Managers displayed verbally abusive behaviour towards their subordinates in front of others. Some of the participants tried to ignore it; while others tried to confront the Nurse Unit Manager; however, the violence did not stop.

“…a lot of verbal abuse mainly from the unit manager; um initially, we just ignored it things like…shouting out at staff in front of everybody…doctors, visitors, patients and whoever just happened to be there at the time…” (WV10:1).

“…sy [the nurse unit manager] het so op my geskreeu sy het my geshout en aan gegaan ek sê sister as jy nie met my op ‘n ordentlike manier kan praat nie dan praat jy nie met my at all nie…UH, dit was SHUT UP! You can go others listen to me [the nurse unit manager]…” (WV 13:4).

[Translation: She screamed at me; she shouted at me, and carried on. I said sister if you cannot talk to me in a civilised manner then do not talk to me at all… she said, SHUT UP! You can go, others listen to me.]

Johnson (2009:37) did a study on the International perspective on workplace bullying among nurses, and found that managers can be the direct cause of bullying. The findings of Cunniff and Mostert (2012:10) support these data with research done on the prevalence of workplace bullying of South African employees. Those authors found that workplace bullying was a “common” problem and that direct workplace bullying and bullying by supervisors was more prevalent than indirect bullying and bullying by colleagues. However, Sauer (2013:101) reported the contrary, stating that co-workers were the main perpetrators of workplace bullying. The findings of this study have demonstrated that nurse managers can also be a direct cause of workplace violence.

One participant stated that she was the shift leader; and she had the responsibility of ensuring adequate staffing for the next day; but the Nurse Unit Manager ignored her suggestions; and the agency staff were not phoned. This happened numerous times – resulting in the next night or day shift being extremely short-staffed. The participant further indicated that competent agency staff were available; but because the Nurse Unit Manager did not like the individual nurse, she did not approve or arrange additional

45 staff.

“…I personally…experienced numerous incidents; where I was a shift leader, so clearly I had to arrange for staff…I would make suggestions like xyz; and I would just be ignored and xyz person wasn’t on the list of people that she [the unit manager] liked and it would end up…where I would be the night staff or the next day shift staff would be extremely short because person xyz was not phoned because she [the unit manager] didn’t like that person, not because they were not a good worker because she [the unit manager] didn’t like that person…” (WV10:1).

Simons and Mawn (2010:307) did a study on bullying in the workplace; and one of the themes in their findings was about structural bullying. Structural bullying is a term that was developed by researchers to represent perceived unfair treatment or actions by the supervisor; and it includes unfair off-duty scheduling, removal of administrative support, work organised to isolate an employee, denial of tea and lunch breaks, sabotaging or hampering work, and excessive scrutiny of the work of an employee (Simons and Mawn, 2010:307).

The researcher of this study, therefore, deduces that the participants experienced structural bullying when the Nurse Unit Manager allowed inadequate staffing levels to occur – even when agency staff were available; and she, therefore, created an unmanageable workload and an unsafe environment for the patients.

Workplace violence between nurses

Professional nurses in this study stated that their nurse colleagues, that worked with them in the same nursing unit and had the same qualifications as they had were the perpetrators of workplace violence. Workplace violence, according to Walrafen, Brewer and Mulvenon (2012:9) was the result of a culture within the unit; and the nurses were “caught up in a drama”. The participants in the Walrafen et al., (2012:9) study responded that sometimes nurses were both the perpetrator and the victim of workplace violence. At times, the nurses excused their personal action and reframed the circumstances that caused them to act in a negative way (Walrafen, 2012:9). In the current study, one participant voiced the opinion that working in her nursing unit was

46 like a drama from morning to night.

“…we are about eight, seven to eight people working in the recovery room and you know it’s like a constant…it’s like drama from the morning at seven till seven at night…there’s swearing and loud talking going on…” (WV8:2).

All the participants working in one particular unit of the private healthcare facility where this study was done, reported that nurse-on-nurse workplace violence was part of the culture in that nursing unit. One of the interviewees indicated that the nurses working in that unit were a unique group of people; and although outsiders viewed them as aggressive, excuses were made for their actions. She reframed the situation by saying:

“We are a unique group of people; and everyone has a different personality and to most people that’s coming from outside and they view us then they will see that we are a bit aggressive with each other; but it’s a play, play aggression if maybe you bump me; but you don’t say sorry; you walk on, then I know okay she is having a bad morning…” (WV8:8).

The findings of the current study support the findings of the study of Walrafen et al., (2012:9), in which they found that a culture of nurse-on-nurse violence has been established in some of the units within the healthcare facility.

Participants in the present study also expressed the view that the following abusive behaviours from their colleagues occurred: name-calling, making racial and personal remarks, shouting, swearing, disrespectful behaviour, belittling, gossiping, in-fighting, argumentation, loud and raised voices during communication, innuendos, insulting remarks being made, outbursts of anger, targeting of individuals, bickering, trouble- making, making fun of others, and not keeping information confidential.

One participant gave an account of her experience where she became the target and was insulted because of the colour of her skin, her age and her religion. When she asked the perpetrator to stop, the violent behaviour (verbal abuse and physical threats) escalated.

“…being called names, people making racial remarks toward other colleagues, being shouted at, being sworn at, treating you like you’re from the streets...like

common people, which don’t deserve those treatment, belittling of people, gossiping about people and it’s just in one vicinity…everyone is attacking the others…aggressive…it like loud shouting, its swearing, its arguing…” (WV8:1, 8:2 & 8:7).

“…hulle het geen respek vir hulle werk vir hulle kollegas…die geskreeuery teenoor mekaar…” (VW1:2).

[Translation: They have no respect for their colleagues or for their work...they shout at one another.]

“…dit word geskimp aanhou dit word in die lug gepraat…” (WV1:5).

[Translation: They make innuendos; or they make covert reference about something.]

“…almal beledig…in hulle kele af te spring oor enigiets… toe bevlieg sy…vir my en ek is toe die target gewees…Bickering of altyd dwarstrek…Kwaadstokers…” (WV2:1, 2:3 & 2:4).

[Translation: Everybody insults…jumps down their throats for anything…then she confronted me and I became the target…Bickering or always being obstructive…Troublemakers.]

The findings of the current study are supported by the studies done by McKenna et al. (2003:91) and Hewett (2010:21). They found in their studies that violence among nurses included verbal manifestations, such as rude or demeaning comments, or actions – such as not being available to help with difficult care-related issues. Purpora and Blegen (2012:1) described horizontal violence as behaviour directed by one peer towards another that harms, disrespects and devalues the worth of the individual, while denying them their human rights. The findings of this study are supported by their work, in that nurses voiced that they were devalued and disrespected by their own colleagues.

One participant reported that she was sexually harassed by her male colleague; but she did not report his behaviour; because he was well liked and his behaviour was accepted by the group as the norm. Furthermore, she feared being made fun of or

48 being accused of being old-fashioned. She did not report the matter, as the lack of confidentiality when such incidents were reported, was well known to her.

“…een van die male staff nurse…sexually inappropriate gedrag teenoor my getoon het wat ek nog nooit van tevore rerig ondervind het nie en dis by tye baie unwanted physical contact soos byvoorbeeld hy gaan jou hare streel gaan jou arm streel gaan partykeer vir jou ‘n klap op jou boud gee… hy het verbally…horrible kommentaar gelewer…” and “…aanvaarbaar vir die res maar dit is nie vir my aanvaarbaar…omdat jy weet almal hou van hom wil ek nie met die eenheids bestuurder of die skofleier praat nie want almal gaan kom sê dit is omdat jy so preuts is…ek voel nie gemaklik om met iemand daaroor te praat nie want jy voel…almal met jou spot want ongelukkig dinge is nie altyd konfidensieel tussen jou en jou seniors nie, I mean, die mense praat …” (WV9:3-4).

[Translations: One of the male staff nurses…displayed sexually inappropriate behaviour toward me, which I have never previously experienced; and this is at times very unwanted physical contact; for example, he would stroke your hair, would stroke your arm; sometimes he would give you a pat on the butt … he has verbally…given horrible comments…and…it is acceptable for the others; but not for me…because I know that everybody likes him, I do not want to talk to the unit manager or the shift leader; because they are going to say it is because I am old-fashioned…I do not feel comfortable to talk to anybody; because I feel…everybody is going to make fun of me; because unfortunately thing are not always confidential between you and your seniors I mean, the people talk.

Ferns (2006:43) stated that workplace violence is severely under-reported. The results of a study done by Magnavita and Heponiemi (2011:206) indicated that nurses do report episodes of sexual harassment; however, the current study reflected that sexual harassment was not always reported.

3.5.1.3 Sub-theme 1.3. PARTICIPANTS EXPERIENCED EPISODES OF WORKPLACE VIOLENCE WITHIN THE HEALTHCARE TEAM AS FOLLOWS: PATIENTS AND RELATIVES TOWARDS NURSES

Kamchuchat, Chongsuvivatwong, Oncheunjit, Yip & Sangthong (2008:203) reported that patients and relatives were the main perpetrators of verbal and physical abuse directed at nurses. In this study, it was found that there were certain times when nurses were more exposed to abuse, such as during the patient’s journey, such as on admission to the healthcare facility, during visiting hours; and when a crisis arose.

The following utterance by one participant was heard:

“…the conflict is always with the visiting time and the number of patients…” (WV14:4).

In the present study, the participants differentiated between and reacted differently to certain types of violence from the patient and their relatives. The participants expressed their understanding of the confused patient; and exceptions were made for the violent behaviour of relatives when a critically ill patient was admitted to the Intensive-Care Unit. The participants expressed the following:

“...patient abuse yes okay I’m not even going to speak about the confused patients because…I understand that they are not in the right frame of mind…” (WV6:4).

“…ek het al gehad hulle [family] sal jou uit die pad stamp…jy sal maar staan en dink: Ag weet jy wat, jy kan nou maar verstaan…die pasiente is siek hulle het nie altyd ‘n manier om te cope met hoe hulle voel nie…” (VW15:1).

[Translation: I have already had that they will push you out of the way…you will pause and think: Ag you know what, you can understand...the patients are sick and they do not always have a way to cope with how they feel.]

These findings confirm the results of the research done by Steinman (2003:5) that healthcare workers can distinguish and react differently to violence from patients under different circumstance. In their study, they found that the patient post anaesthesia, Alzheimer’s, or psychiatric patients may be confused and become violent. Kennedy

50 and Julie (2013:5) also found that nurses working in the Trauma and Emergency department condoned workplace violence, if it was linked to intoxication; since the patients did “not always know” what they were doing.

The interviewees indicated that they did not accept perceived deliberate disrespectful and abusive behaviour from a patient or the relatives. The following utterances were heard from the participants:

“…ek het al gehad dat hulle [die pasiente] in jou gesig spoeg…as hulle kwaad raak of wat ook al en dis nie altyd te sê dit is as gevolg van medikasie dat hulle deurmekaar is nie; ek dink soms is daar bietjie van disrespek…” (WV15:1).

[Translation: I have already had it that they spit in your face…if they become annoyed or whatever, it is not always to say that it is due to the medication that they are confused, I think sometimes it is due to disrespect.]

“…familie lid raak aggressief langs die bed byvoorbeeld hulle [familie] sal skreeu as jy byvoorbeeld vir hulle nie na besoektyd toelaat nie dan, jy weet hulle ruk aan die deure in jou, baie, jy weet in jou persoonlike spasie, in jou gesig, ek het al gehad dat hulle van die een kant van die eenheid af aan agter my aan geloop het en op my geskreeu het…wat ons al gedoen het is om sekuriteit te vra om die persoon te verwyder…of om die familie betrokke te kry …[om] hom weg [te hou] of werk met hom buite [die eenheid]…” (WV15:1 & 15:3).

[Translation: Family members become aggressive next to the bed; for example, they will scream/shout if you do not allow them in after visiting time; then they jerk the doors…, in your personal space, in your face, I have had [experienced] that they walked behind me and screamed at me from one side of the unit to the other…what we did was to ask security to remove the person…or to involve the family to keep the individual away or work with him outside the unit.]

Johnston, Phanhtharath and Jackson (2010:41) did a study and found that the nurse can stop the cycle of violence by refusing to accept such behaviour. Nurses work in an environment of caring; and their work often requires of them to “manage situations where extreme emotions govern behaviour”. As seen in this study, nurses do have compassion; but, when necessary, they can also refuse to accept violent behaviour in

51 the workplace.

3.5.1.4 Sub-theme 1.4. PARTICIPANTS EXPERIENCED EPISODES OF WORKPLACE VIOLENCE WITHIN THE HEALTHCARE TEAM AS FOLLOWS: NURSES TOWARDS PATIENTS

Private healthcare facilities are in the business of healthcare service delivery; and therefore, they are profit-oriented. Staffing ratios are closely monitored to ensure cost efficiency; and because salaries are the largest expense of healthcare organizations. In the Eastern Cape, there is a limited number of agency nursing staff to draw from; and it is therefore, difficult to get additional staff when needed. In this study, a few participants acknowledged that when they were short-staffed for extended periods of time, they did not have the resilience to render the care that was needed; and they became perpetrators of violence in that they deliver rough and unacceptable levels of care to the patients. They said:

“…I have seen incidents, where patients are handled roughly um in turning and…when we are busy when we are short-staffed; and I think we are probably all guilty of that…” (WV10:7).

A few participants reported that in a unit where violence was out of control, the patients were suffering as a result thereof. Procedures were no longer done, according to the set standards; and nurses were aggressive when direct patient care was delivered. In the recovery room, the patients were no longer awakened with a gentle tap after anaesthesia; and the patient was “suffering through the recovery process” (VW8:6).

“…we stimulate the patients to wake; up but then it’s like an aggressive stimulation…now the patient has to just suffer…” (VW8:6).

Nurses, according to Jacobs (2013:7) and Stanley et al. (2007:1256) can, instead of caring, become the perpetrators of violence. This study confirms their findings. Furthermore, it confirms the findings of a study done by Sheridan-Leos (2008:400), in which it was found that if nurses are overwhelmed by tasks (workload), they depersonalise care and treat the patients like objects. These findings can be confirmed by a Sentinel Event Alert (2010:1), where administrators were alerted that healthcare workers have the potential to become perpetrators of violence towards the patients.

3.5.2 THEME 2: PARTICIPANTS DESCRIBED THE EFFECT OF WORKPLACE VIOLENCE ON THEMSELVES, OTHERS, AND THE WORK ENVIRONMENT

Hutchinson, Vickers, Wilkes and Jackson (2010:2319) stated that for many nurses, their workplace is a hostile and harmful environment. In the present study, the participants expressed the negative effect that workplace violence has either on them – as an individual, and on the team. The participants reported physical symptoms; and others reported that they were aware and concerned about their colleagues. Most of the participants reported psychological symptoms related to the workplace violence: for instance, high levels of stress and disharmony with colleagues. Some of the participants reported that they were actively looking for another job, which provides evidence that change has become necessary, as was discussed in the Critical Social Theory.

3.5.2.1 Sub-theme 2.1. PARTICIPANTS INDICATED THAT WORKPLACE VIOLENCE AFFECTED THEM AS INDIVIDUALS

Disharmony in a Nursing Unit is stressful for all the individuals working in that unit. Some individuals react quickly, and talk about their experiences; while others take time – before they voice an opinion, or do anything about it. Some of the participants in this study reflected on negative incidents for 3-4 days before they discussed these with a loved one. The effect of the workplace violence was perceived by participants to be so bad that their colleagues and they themselves sometimes suffered from physical symptoms.

One of the participants reported she usually suffered physical symptoms after episodes of workplace violence when the atmosphere remained tense, unhappy and uncomfortable for an extended period of one to two weeks.

Physical symptoms

One of the participants blamed the healthcare organization for allowing professional nurses to work in such an unhealthy environment. The participants were suffering physical symptoms as a result of the direct and indirect workplace violence. The physical symptoms that professional nurses experienced due to workplace violence were reported as the following: cardiac palpitations, exhaustion/fatigue and

53 headaches.

“…jy palpitasie kry ek praat van myself, wat my pols ‘n bietjie opgaan…I see you people I hear you people ek sien julle actions en dit affek my…ek is totally pap na dit…ek is moeg asseblief kry end…maar dit gaan net aan…” (WV1:6 &1:8).

[Translation: You get palpitations. I am talking about myself; my pulse goes up …I see the people, I hear them, I see their actions and it affects me…I am totally exhausted after that…I am [emotionally] tired…please stop…but it just carries on.]

“…I have one colleague…her pulse goes up to about one hundred and fifty…she mightn’t be the one on the receiving end; but then she has like palpitations and anxiety…” (WV8:2).

“…helse kopseer gehad…” (WV13:8).

[Translation: Had a severe headache.]

In this study, only a few of the participants experienced some physical symptoms. These findings are confirmed by studies done by Vessy, DeMarco and DiFazio (2011:144), McKenna et al. (2003:95) and Engelbrecht (2012:50). Namie (2003:3) found that physical symptoms are the result of prolonged exposure to workplace bulling. However, Johnson (2009:36) also found in their research that prolonged bullying was associated with a new onset of cardiac disease; but Sauer (2013:108) found no relationship between workplace violence and decreased physical health.

Psychological symptoms

Magnavita and Heponiemi (2011:208) found in their study that non-physical violence, such as verbal abuse produced more severe psychological effects than physical abuse; and they indicated that the effect could last for months after the incident had occurred. Psychological symptoms that have been reported across research studies include anxiety, irritability, frustration, panic attacks, tearfulness, sadness, depression, mistrust, loss of confidence and self-esteem, and post-traumatic stress (Vessy, DeMarco & DiFazio, 2011:144; McKenna et al., 2003:95; Hutchinson et al., 2006:119).

In this study, the interviewees gave an account of the psychological symptoms that had they experienced, as a result of workplace violence, which included feelings of being despondent, irritation, frustration, fear, stress, loss of self-esteem, isolation and sadness, absenteeism and questioning their own ability and nursing as a career choice.

 Feelings of being despondent

The professional nurses reported that they felt that they could no longer continue to work in an environment where workplace violence takes place. The participants stated that their manager did not listen and did not address the workplace violence, in spite of reporting the verbally abusive behaviour numerous times; and therefore, they felt despondent. The participants also indicated that they had witnessed, or were forced by their Nurse Unit Managers to participate in unfair treatment towards physicians.

In one specialised unit, beds were reserved in favour of the one doctor that displayed disruptive and abusive behaviour (physically and psychologically) towards nurses. This particular doctor was the only one doing specialised procedures, new to the Eastern Cape; and therefore, his behaviour was accepted by the Nurse Unit Manager. The participants found this practice of unfairness towards the other “respectable” physicians unacceptable, unprofessional and demoralising.

Furthermore, the workplace was described as a battlefield, where continuous fighting took place.

“…It makes me feel despondent; it makes me feel I don’t want to be here anymore…and its very negative…you can’t be fighting every single battle every single day…” (WV8:3 & 8:9).

“...almal is bang...party mense wil nie meer na sy pasiente kyk nie…dit is onse um…dan gaan sy aan…you must give the bed to (naam)…ek was skaam toe ek hoor eendag toe een van ons dokters sê los maar die bed; ek sal die pasient by ‘n (ander) hospitaal toelaat…dokters wat ons [nurses] so getreat het; en dit is vir my absolutely demoralising, jy voel net jy weet jy kan nie so werk…” (WV13:8).

[Translation: Everybody is scared…some people do not want to look after his patients…it is our um [unit manager]…then she carries on…you must give the bed to (name)...I was embarrassed when I heard one of our doctors say leave the bed, I will admit the patient to another hospital…doctors that are treated like that by us …this is absolutely demoralising for me, you feel, you just know that you cannot work like this.]

Bimenyimana, Poggenpoel, Myburgh and van Niekerk (2009:9) confirmed the above findings. The participants’ in their study experienced emotions of fear, despair, hopelessness and apathy. The findings of this study are supported by the research mentioned above.

 Irritability

The participants expressed their irritation with some colleagues, who always had the last say; or who just had too much to say; for example, continuous remarks about time that was spent with a patient or counting the number of patients that were nursed. One participant verbalised that it was irritating to work with someone who made continuous remarks about everything that was done.

“…jy raak geirriteerd met dit; en dit irriteer die span want daar is altyd een [nurse] wat die meeste [te] sê het; en die laaste sê het en die grootste mond het en…ons is eintlik dankbaar vir die dae wat sy af is…” and “…sy sal nou sê...steek jy lyf weg vandag en as jy nou opstaan om jou pasient te gaan sien onthou ek tel hoeveel jy doen of...jy moet nie so lank met die pasient staan nie want as jy lank met ‘n pasient staan doen jy minder werk…krap waar dit nie jeuk nie; dit is verskriklik irriteerend…” (WV2:3 & 2:5).

[Translation: You get irritated with it; and it irritates the team; because there is always one that has a lot to say, and has the last word, and has the biggest/loudest mouth and…we are grateful for the days that she is off…and…she will say…you are not pulling your weight today; and when you get up to see the patient, you are reminded that she is counting how much you do...she says...you should not take so long with the patient; because if you do take your time, you do less work…scratching where it is not itching; it is terribly irritating.] 56

The findings of this study are confirmed by Engelbrecht (2012:50) and Vessy, DeMarco and DiFazio (2011:144), where irritability has been identified as one of the physiological symptoms of workplace violence. Momberg (2011:98) did a study on the prevalence and consequences of workplace bullying in South Africa and found that irritability and tearfulness were classified as symptoms of stress.

 Frustration

Nurses are most vulnerable and apt to engage in negative behaviour, when they are short-staffed or have a heavy workload (Walrafen et al., 2012:11). The participants acknowledged their frustration towards their colleagues when the nursing units were too busy; because they felt that they could not cope. One of the participants reported that there were too few nurses to do the work; and therefore, they became frustrated and lashed out at one another.

“…sometime maybe with words…especially if it is busy, and they [the nurses] are frustrated and they will…can’t you see I am busy…when the stress gets there you get a little chirpier…” (WV4:4).

“…ons is always short-staffed maar jy wil nie daar werk nie want jy sien nie kans vir wat gaan gebeur daar nie…” (WV13:8).

[Translation: We are always short-staffed; but you do not want to work there; because you just do not see your way open to stay; if you know what is going to happen there.]

“…as dit besiger raak of hoe meer onder druk mense raak, hoe meer lash [hulle] out…” (WV9:11).

[Translation: The busier it is, or when the pressure increases, then people lash out.]

The findings of this study are supported by a study done by Hastie (2007:26); where the participants found workplace violence was reinforced when staff became frustrated with their peers. The participants in their study described it as “they build up their frustrations and then release them as anger on their fellow workmates” (Hastie, 2007:26).

 Fear

After an episode of nurse-on-nurse violence in the private healthcare facility under study, a grievance was lodged against a perpetrator. Although the grievance was resolved, the nurses remained scared of becoming the next target of workplace violence. The participants reported that they had remained cautious; and they rather kept quiet; because even small things were blown out of proportion. One participant indicated that she said that she missed a particular staff member; however her words were twisted; and the situation got out of hand.

“…daar is definitief friction as hulle [perpetrators] hier is, jy is te bang om iets te sê; dan bly jy eerder stil want dit gaan heeltemal uit konteks uit opgeblaas word…jy moet twee keer dink voor jy iets sê en die manier wat jy dit sê… ” (WV2:3-4).

[Translation: There is definitely friction. if they are here, you are too scared to say anything; you would rather keep quiet; because it is going to be blown out of proportion…you have to think twice before you say anything and how you say it.]

“…you feel frustrated, you feel your hands are tied; because you’re unable to do anything; you can’t even say anything; because then you’re in the line of fire…if you give attention, then it gets worse; or if you try to protect the person that’s in the line of fire, you get abused verbally, psychologically and emotionally…” (WV8:9).

“…partykeer wil jy iets sê om te sê hou op dit is nie reg nie hoekom waarom maar jy is so bang om in te tree…nie jou problem nie, nie jou besigheid nie en dan raak die probleem net groter…” (WV1:12).

[Translation: Sometimes you want to say stop it; it is not right; why or what happened; but you are too scared to intervene…it is not your problem, or your business; and then the problem just escalates.]

Bimenyimana, Poggenpoel, Myburgh and van Niekerk (2009:8) found in their study that fear dictated the participant’s reaction; and every time they went to work, they

58 sensed that it was going to be another day of being traumatised. The findings of this study are thus supported.

 Taking stress home

The participants in this study reported that they were taking the stress home; because of the severity of the workplace violence. In the past, they were reluctant to share work issues at home; but the situation had become so severe that even their relatives noticed that something was wrong. Some of the professional nurses reported that they were seeking advice from loved ones at home; because they did not know how to deal with the situation at work. Some of the participants reported that they became “quiet” in the workplace; and only talked when it is necessary – in an effort to avoid a potential situation that could lead to workplace violence.

One of the participants stated that her colleagues were stressed; and that she was upset and hurting because she had witnessed the ongoing nurse-on-nurse violence.

“…ek kan nie glo dat mense so van mekaar praat nie…mens vat dit huis toe, jy wil nie jou familie inlig nie; maar dit maak jou seer en jou familie let op jy is nie jouself by die huis nie…en later…[is] dit nie meer ‘n werk situasie nie, maar ‘n housing situation ook…haai is verbal abuse…” (WV1:11-12).

[Translation: I cannot believe that people talk about another person like that…a person takes it home, you do not want to inform your family; but it hurts and your family observes that you are not yourself at home…and later…it is no longer a work issued; but it involves your home as well…then you realise that this is verbal abuse.]

“…dit was seker so 3-4 dae het dit met my man bespreek by die huis en so toe sê hy vir my ek kan dit nie so los nie ek moet iets daaromtrent doen… ek kan dit nie hanteer nie…dit het my regtig gehinder; en ek gaan nie gewoonlik huis toe en praat met my man oor werksgoed nie; maar ek het nie gevoel ek kan dit nie los…” (WV2:1 & 2:3).

[Translation: it was plus minus 3 – 4 days when I discussed it with my husband at home; and he told me that I cannot just leave it; I have to do something about

it…I could not handle it …it really disturbed me; and I do not usually go home and talk to my husband about work-related issues; but I felt I could not leave this.]

Kennedy and Julie (2013:5) found that the negative effect of workplace violence is taken home by employees; and it was described by a participant in their study as “I think all nurses are stressed out” and “they take all that home”. In contrast to the findings of the current study; where the participants reported that they did not want to discuss the work-related issues at home. Kennedy and Julie (2013:7) found that family and friends are an external support system; they provided the necessary encouragement to deal with the problem of workplace violence.

 Loss of self-esteem, sadness and isolation

The professional nurses expressed a loss of self-esteem, sadness and isolation after a major incident at the workplace. One participant was appointed in a senior position, and requested help and support from the management from the beginning. At some point, the team, in that nursing unit, turned against her. They threatened to take the matter to a higher authority if the situation was not addressed. Eventually, she was demoted. In retrospect, this participant acknowledged that she had made many mistakes, such as shouting back at the staff, when they expressed verbally abuse behaviour. She has accepted that it all happened for a reason and a purpose; but she admitted that she had to dig very deep into her emotions to tell the story of what happened to her some years ago. This incident happened 6 years ago; however, the participant could recall the extreme negative emotions clearly. No notes or observations were recorded by the fieldworker; however, additional time was allocated for the interview.

“…ek is aangestel in ‘n pos…is meer in the HR kantoor as wat ek hier is…ek is die hele tyd in die moeilikheid…en so kyk sy my so en ignoreer my heeltemal toe weet ek daar is groot fout…as ek terugdink aan daai tyd was ek ‘n absoluut ‘n totale mislukking…ek het baie foute gemaak; die grootste was om die pos te aanvaar…as ek terug dink voel ek steeds ‘n mislukking…bitter slegte tyd in my lewe…hulle wou eintlik gehad het ek moet bedank….want ek was so bitterlik…baie hartseer elke keer wou ek net huil as iemand met my praat…die

skaamte, die vernedering…ek het geen ondersteuning gehad nie; ek was bitter alleen…hulle het nie eintlike tyd vir my gehad nie…wat my professionele lewe aan betref was dit die slegste tyd in my lewe…dit het gevoel...hulle wou net van my ontslae raak…ek het gestep down maar so na ‘n maand of wat het [ek] gesê…ek is gefire…” (WV7:2-5, 7:8, 7:10 & 7:15-17).

[Translation: I was appointed in a position…I was in the HR office more often than here…I was in trouble all the time…and so she looked at me and totally ignored me, then I knew there was big trouble…when I think back at that time, I was an absolute total failure…I made many mistakes; but the biggest one was to accept that position…when I think back, I still feel like a failure…it was an incredibly bad time in my life…they actually wanted me to resign…because I was so bitterly…heartbroken and wanted to cry every time when someone talked to me…the shame and humiliation…I had no support, I was isolated…they did not have time for me…in my professional career this was the worst time of my life…it felt as if they wanted to get rid of me…I stepped down; but one month later I said…I was fired.]

The findings of this study are supported by the studies of Hewett (2010:27) and Kisa (2008:204), who found that emotional response to abuse was found to be anger, sadness or hurt, shock and surprise, powerlessness, fear and shame.

Johnston, Phanhtharath and Jackson (2010:38) confirm that the victims of bullying who suffer from post-traumatic stress disorder can take 4–5 years to recover, and that some never do.

 Absenteeism

The professional nurses verbalized that they could no longer work in a “hostile”, “unhealthy” and bitter environment, where workplace violence takes place; and they resorted to absenteeism – either in a physical or a psychological way. Some participants reported that they disengaged emotionally; while others reported that it was too painful to interact with the perpetrator of workplace violence; therefore, they took sick leave (stayed at home) – even when they were not physical ill.

“… I just switch off because if you can’t approach people professionally then you leave… ” (WV8:9).

“…daar is van ons wat partykeer wat vir dae af siek is nie omdat ons siek is nie…emotionally wil.jy nie…die persoon sien vir paar dae nie of interact of werk met daai persoon en dan is daar mense wat by die huis bly omdat hulle nie hier wil wees nie…” (WV1:7).

[Translation: There are some of us that are off for days…not because we are sick…emotionally; but you do not want to see the person or interact or work with that person for a few days; and then there are those that stay at home; because they do not want to be here anymore.]

Simons and Mawn (2010:306) support the findings of this study in that workplace bullying was associated with a significant increase in absenteeism. In their qualitative study, they examined the stories of bullying among nurses, based on actual or witnessed experiences.

 Questioning one’s own ability and career choice

The professional nurses stated that they were reporting to someone (higher level) that they do not “gel” with; and their perception was that they were micro-managed. They said that at times it felt as if their ability to make decisions was undermined; because the nurse manager would question the junior nurses when they were not on duty (checking up on their decisions). The juniors, in return, would inform the professional nurses about these discussions; and the questions that were raised; and they reported the information they had received. The professional nurses verbalised that they were available for open discussions; and they would have preferred to provide the answers to the unit managers themselves. The situation has been ongoing on for the past year; and it left them questioning their career choice, and their own ability to do the job. The professional nurses reported that they could not pin-point the behaviour; and they felt it was under cover; whereas aggressive behaviour is easily observed and the problem is identified.

They further stated that they were not sure if it is aggressive or a bullying type of behaviour; but they perceived it as such.

“…op so ‘n punt dat ek al gedink het weet jy wat is dit regtig die moeite werd om nog hierdie tipe werk te doen…dit voel vir my so of dit agteraf half gedoen work nie…jy kan dit nie rerig pin point…dan begin jy aan jouself twyfel en dis…” (WV15:4).

[Translation: I am at a stage that I have been asking myself if it really is worth the effort to do this type of work…it feels as if it [bullying] is done behind your back/ underhand…you cannot really pin point it…and then you start doubting yourself.]

Overt and covert are two levels of workplace violence described by Khalil (2009:208). Covert behaviour includes back-stabbing and negative criticism of a person’s performance; whereas overt behaviour includes public humiliation. Becher and Visovsky (2012:210) describe covert violence as being hard to discern, or discover; and thus it is difficult for the victim to seek assistance within the work environment. Vessy, DeMarco and DiFazio (2011:136) found that workplace violence (bullying, harassment and horizontal violence) leaves the individual with feelings of humiliation; and it undermines their self-confidence. The findings of this study are, therefore, confirmed by the above-mentioned studies.

Another participant voiced that she endured the workplace violence for 4 years; however, her fear of the shift leader has still not subsided; and she has considered giving up. She questioned her job fit, nursing as a career; and she stated that she was not sure that she wanted to be a nurse any longer.

“…I am still here after 4 years, ek het nogal gedink met die klomp [span] dit is maar moeilik…ek het ‘n absolute vrees vir die skofleier se skof, want as sy eers op jou draai is dit ‘n nagmerrie…ek het begin voel…dalk is dit net tyd vir jou om tou op te gooi…dalk is dit ‘n boodskap vir jou dat jy nie hier hoort nie…ek dink vir my die laagste punt toe ek actually my…professie gequery het ek vir myself gedink ek weet nie of ek meer in nursing wil wees…” (WV9:5).

[Translation: I am still here after 4 years; and I thought that with the team, it is difficult…I have an absolute fear to be on the shift of that particular shift leader; because when she turns on you it is a nightmare…I started to feel…maybe it is time to give up…maybe it is a message that I do not belong here…I thought 63

rock bottom for me was when I actually…queried my profession. I thought I am not sure that I want to be in nursing any longer.]

Nurses exposed to workplace violence intended to leave their current job, or are considering leaving nursing altogether (Vessy, DeMarco & DiFazio, 2011:136; Purpora & Blegen, 2012:1 & Hurley, 2006:70). In the study done by McKenna et al., (2003:95) one out of three respondents indicated that they had considered leaving nursing as a consequence of the horizontal violence. This study is thus supported by the above research findings.

3.5.2.2 Sub-theme 2.2. PARTICIPANTS DESCRIBED THE IMPACT THAT WORKPLACE VIOLENCE HAD ON WORK PERFORMANCE, TEAM WORK AND PATIENT CARE

The mission of the private healthcare facility is to offer a high standard quality and cost- efficient services to the healthcare users. All individuals and teams have to work together towards the goal; and to ensure that standards are achieved and maintained. Vessy, DeMarco and DiFazio (2011:145) indicated that in an event where teams become dysfunctional due to workplace violence, critical components, such as team work, communication, the exchange of health information and collaborative decision- making are compromised.

The authors of that research stated that all of the above are associated with medical errors and poorer patient outcomes. Quality care and work standards are thus lowered; productivity is reduced; cost increases are incurred, due to absenteeism and staff- turnover increases.

In this research, the participants reported the following, as a result of workplace violence: reduced work standards, reduced productivity and job satisfaction, reduced team work, reduced communication, and the loss of patient information, and increased staff turnover. The Critical Social Theory is supported; in that the participants reflected on the negative effects of workplace violence; and therefore, they recognised the need for change.

Reduced work standards

In a unit where nurse-on-nurse violence was reported to be “constant”, the participants expressed their frustration; because set standards were not implemented or maintained. Nurses verbalised that the patient could have been their relatives; and they only want the best care for them, their families and their patients. Some of the nurses feared the doctor, due to previous encounters of workplace violence; and therefore, they did not get clarity on the instructions that were not understood; so ultimately, the patient did not get the prescribed care and treatment that they deserved.

“…when people [nurses] do things that’s not according to the standards of [company name]…I want the best care for myself and my family so I try to give the best care to my patient…you try and give your best; but then it frustrates me because you see that a specific patient is not getting the best; and you feel to yourself you know that’s not how it’s done …” (WV8:3-4).

“…hy [dokter] gee bevele dat partykeer verstaan jy nie die bevele nie nou vra jy of bel jy hom dan is dit ‘n probleem…almal wil goeie behandeling vir die pasiente hê maar tog as staff nie verstaan nie dan verduidelik jy...maar almal vrees om te vra…” (WV13:6 & 13:9).

[Translation: He [the doctor] gives instructions; and sometimes you do not understand the instructions; and you ask or you phone him, and then it is problematic…everybody wants good treatment for the patient; but if the staff do not understand, you have to explain…but everybody is too scared to ask.]

Purpora and Blegen (2012:4) confirmed that there is a direct link between the increased workplace violence and a decrease in the quality and safety of patient care. In a study done by Johnson (2009:37) on the international perspective on bullying, it was found that new nurses in the USA reported being afraid to ask questions of other healthcare professionals (nurses); because of a general climate of workplace bullying, leading to mistakes and unsafe patient care practices. Furthermore, according to Johnson (2009:37), patient care is compromised, when bullying takes place; because the victim of bullying experiences less job satisfaction, becomes more easily upset, and does not have the energy to do the job properly.

The findings of the current study are thus confirmed; since in an environment of workplace violence, work standards are reduced.

Reduced productivity and job satisfaction

Some of the interviewees in this study gave an account of the trauma they had experienced, due to threatening, abusive and physical violence in the workplace. The participants stated that the occurrence of workplace violence was stressful; and as a result, they were less productive and had experienced less job satisfaction. Some of the participants reported that they were anxious, and were just not getting their job done properly. Other participants reported that as a result of covert violence, they were not functioning at the level where they should be. One participant verbalised that she found it difficult to be productive; while she was aware of things going on behind her back.

“…dit veroorsaak stres en dit veroorsaak minder werksbevrediging en minder produktiwiteit, want as iemand wat aggresief is om jou op jou senuwees kry, en jy kry jy minder gedoen…ons is nie gewoond aan aggressie in die eenheid nie” (WV11:3).

[Translation: It causes stress; and this causes reduced job satisfaction and reduced productivity; because if someone is aggressive, you become nervous/ anxious and you get less done…we are not used to aggression in this unit.]

“…dit word agteraf...gedoen…so half om ‘n draai en…dan funksioneer jy nie waar jy moet funksioneer nie…” (WV15:4).

[Translation: It is done behind your back/covertly…not directly…then you do not function as you should function.]

The findings of the study were confirmed by Johnson’s (2009:36) findings that the impact on organizations where bullying occur results in decreased job satisfaction and poorer performance. In their study, it was found that the entire workforce was impacted by workplace bullying; and employees that witnessed bullying reported higher stress levels and lower job satisfaction. Momberg (2011:93) did a study on organizational conflict, as both hierarchical (vertical) and horizontal abuse and found that conflict

(workplace bullying) had “destructive consequences”; and it had a definite impact on the productivity of an organization. Workplace violence was regarded as an occupational hazard; and it has growing costs associated with decreased productivity, reduced job satisfaction and an increased intent to leave the nursing profession (Wang, Hayes & O’Brien-Pallas, 2008:5).

Reduced team work, poor communication and loss of healthcare information

The participants maintained that in the unhealthy environment of the private healthcare facility, there was constant workplace violence, unacceptable behaviour and poor standards of patient care; but that nothing was done about it. The participants reported that they were “upset”, and felt “like you don’t want to talk anymore” (WV8:4). Even if their colleagues were participating in incorrect practices, it was no longer their concern. They stated that team work was severely compromised; and in the face of a crisis situation (where a child for instance had desaturated to 23%), the colleagues just watched and did not offer any assistance.

One of the participants verbalized the importance of good team work; however, in their unit, they experienced poor team work, a breakdown in communication, resulting in incorrect or a loss of information on patient care, or treatment to the next colleague taking over the care of the patient, meaning there was a breakdown in the continuity of care.

“…if someone does something wrong, whatever it doesn’t have anything to do with me; as long as I know what I’m doing; and that’s not the idea of nursing, nursing is a team work effort, but we are not a team…” and

“…I was struggling and another nurse was also struggling with a patient; while our colleague watched us. My patient’s sats [saturation] was twenty-three. Ninety-five is normal; but she just sat there and she watched; she didn’t come and help me…” (WV8:4 & 8:11).

“…As jy ‘n goeie span het wat besef dat hier is spanwerk van alle belang maar as jy nie spanwerk het, nie kommunikasie gaan daarmee heen; en as kommunikasie heengaan, gaan jy nie die regte boodskap oordra vir jou

volgende kollega, of die een wat volgende vir jou pasient iets moet doen nie…” (WV13:7).

[Translation: If you have a good team, they realise that team work is of the utmost importance; but if you do not have team work, then communication is lost and when communication is lost, you do not transfer the correct message to the next colleague, or to the one that is going to do something for the patient.]

Becher and Visovsky (2012:210) stated that quality patient care can only be offered if team work is present. The authors stressed that horizontal violence created a negative environment that impaired team work and compromised the safety of the patient. Becher and Visovsky (2012:211) found that when essential information related to patient care was omitted, as an act of horizontal violence, the nurse who was victimised could not render the care, which the patient required; and therefore, the safety of the patient was compromised.

When a nurse perceived the environment as being unsafe and suffered psychological trauma, as a result of workplace violence, she would then be reluctant to interact with others. This was perceived as a threat that might cause further harm (Purpora & Blegen, 2012:3). Purpora and Blegen (2012:3) demonstrated a link between horizontal violence and peer communication, and they stated that as horizontal violence increases, so does communication decrease. Therefore, the literature is consistent with the findings of the current study.

Increased staff turnover

Internationally, there is a shortage of nurses; therefore, no organization can afford to lose skilled and trained staff. The participants expressed their concerned about losing good and hardworking nurses. Some of their colleagues had already resigned; while another was asking for a transfer out of the unit where the violence had taken place.

“…two people have already resigned from all the drama that’s going on in the recovery room; and I mean they are losing good people, hardworking people…” (WV8:6).

“…Ek gaan nou klaarmaak daar binne, ek het ‘n transfer gevra…ek het gesê as dit die toestand van sake is in die eenheid dan wil ek nie meer daar werk nie…” (WV13:6 &13:7).

[Translation: I am done in there; I have requested a transfer…I have said if this is how it works in the unit, then I believe I cannot work there any longer.]

Sanner-Stiehr and Ward-Smith (2013:86) are supported by the findings of this research study. In their research, it was found that staff turnover and leaving the nursing profession was linked to lateral violence.

The participants also voiced that some of their team members were going for interviews, due to the unfavourable work environment.

“…there are people going for interviews like its no-one’s business, they don’t want to work here anymore; because it’s an unhealthy environment…” (WV8:6).

“…dit het weer gegal vandag…” (WV1:16).

[Translation: Today, it was bitter again.]

“…I will never work in the [unit] again…the unit was like hell…” (WV10:2).

Ritter (2011:31) confirms the danger of an unhealthy work environment; where poor communication, abusive behaviour and disrespect are displayed. In that study, evidence was demonstrated between a healthy work environment and the retention of nurses. Our current study is thus confirmed; since nurses do leave an unhealthy work environment.

3.5.3 THEME 3: PARTICIPANTS DISCUSSED THEIR VIEWS REGARDING THE MANAGEMENT OF VIOLENCE IN THE WORKPLACE

Some of the participants reported that they perceived that nothing was done by management, in spite of the fact that the workplace violence was reported. One participant narrated how she and her team had been abused (nurse-on-nurse violence), and found it unacceptable that in spite of reporting it to management, the workplace violence was not addressed, or dealt with. This participant felt the company did not care for staff members, and did not protect them from perpetrators of violence 69

(WV8:2).

The participants reported the way they dealt with workplace violence; some used effective strategies; and others did not. One participant reported that she accepted conflict as part of workplace relations; and when it occurred, it had to be resolved before the end of the shift. Other participants reported that they either ignored or avoided the perpetrator of the violence. One participant said that after an episode where the doctor was verbally abusive towards her, that she she “did not greet” him; and that she “just avoided him and walked past” him (WV6:3).

Some of the participants made suggestions about how workplace violence could be addressed in the work environment. One participant reported that organizational structures (for instance, a Whistle-Blowing processes) in the private healthcare facility was not used by nurses, due to lack of knowledge, not being user-friendly, and fear of breaches of confidentiality relating to sensitive issues.

3.5.3.1 Sub-theme 3.1. PARTICIPANTS STATED THAT WORKPLACE VIOLENCE WAS NOT ADEQUATELY MANAGED BY MANAGERS

Any staff member may phone the SHOUT line to report untoward behaviour, fraud, corruption or workplace violence in this private healthcare facility. The shout line was specifically introduced for this purpose. This phone call is made anonymously and posters with the telephone number are displayed throughout the healthcare facility. An Independent Counselling and Advisory Service (ICAS), the employee-assistance program, is also available free of charge for 24 hours per day per phone, to all staff members working at the healthcare facility.

ICAS was introduced to support staff that needed debriefing, social or psychological support – due to some or other traumatic experience. The staff member must initiate contact; and often the Nurse Unit Managers would allow nurses to make the first contact session on duty in a secure and private office. ICAS will either counsel staff members per phone, or face-to-face contact sessions could be held, depending on the needs of the individual.

At the private healthcare facility, in which the study took place, the following is available to address workplace violence:

 Report the incident of workplace violence to the Nurse Unit Manager; and if nothing is done, it should be escalated to the next level, or to the HR department.  A written code of conduct with guidelines on unacceptable behaviour, and what procedure should be followed after an incident of workplace violence is available. Written HR policies and procedures include how to activate the grievance procedure, how to investigate misconduct, and how to take progressive disciplinary action should workplace violence not improve.

The participants verbalised that workplace violence is a managerial (Nurse Unit Manager, Nursing Service Manager and HR manager) function. They indicated that a lot of incidents were reported; but these were not dealt with by the managers. The professional nurse, therefore, felt that they did not have any support. One participant blamed the Nurse Unit Manager for not taking action when swearing and loud talking occurred; because “the door is always open” and the unit manager “doesn’t listen” (WV8:2). Meetings have also been reported as a waste of time; because no interventions were undertaken; and therefore, no change has taken place in the behaviour of the perpetrators of the workplace violence.

“…many people have actually addressed the situation; and there is a lot of incident reports that have been written – not only from the recovery room, but from people outside…but unfortunately nothing is being done about it; and personally I feel you know that the company is not protecting us…we don’t have support from the top level…There is no change; I don’t want to go to a meeting in this place anymore; because I feel that it’s a waste of my time…” (WV8:2, 8:6 & 8:8).

“…the doctors don’t have a way to speak to the staff; we do report, but the matter doesn’t get addressed, because clearly their attitude just doesn’t change …” (WV3:1).

In the study of Simons and Mawn (2010:308), a participant wrote that she recently left another unit because of the gossip and bullying that took place. She further stated that the nurse manager was fully aware of the actions; but she “chose not to do anything about it”.

Sanner-Stiehr and Ward-Smith (2013:88) found that if workplace violence is not addressed effectively, it only perpetuates the problem. Johnson (2009:38) stated that nurse leaders should become aware of the potential of workplace violence in the form of bullying; and they should make a concerted effort to eliminate it. Authentic leaders, according to Lachman (2014:58), would not tolerate workplace violence. She further stated that administrators need to enforce the zero-tolerance policies and take action when abuse takes place; however, Namie (2003:5) suggested that zero-tolerance does not work, and suggested that progressive disciplinary action should be undertaken to allow for change in the unacceptable behaviour.

The findings of this study are that managers did not take action when workplace violence was reported; and therefore, the Sanner-Stiehr and Ward-Smith (2013) study is supported.

3.5.3.2 Sub-theme 3.2. PARTICIPANTS DISCUSSED PERSONAL STRATEGIES THEY USED TO MANAGE WORKPLACE VIOLENCE

The professional nurses in the current study discussed what they did, as individuals, to deal with workplace violence. This supports the paradigm used in this study; as it explains the reflection of the individual – looking at their strengths and weaknesses, and critically analysing the circumstances and context within which the phenomenon takes place, to understand and explain it, to reduce the entrapment in systems of domination and dependence, and to improve the autonomy of the individual. Strategies are then developed to actualise the necessary change (Anderson, Curtis & Wittig, 2014:14; Wilson-Thomas, 1995, in Bloom, 2014:79).

Some of the participants felt that it was normal to have differences in the workplace; but others described techniques that they used to deal with the phenomenon, such as avoidance; while other participants applied assertiveness and life skills to deal with workplace violence. The stated strategies that were used to deal with the workplace violence were as follows: putting it behind them, seeing it as normal (acceptance), avoidance, laughing about it, keeping quiet, ignoring the individual, assertiveness, and undertaking positive self-talk.

Some of the participants were quite resilient, and stated that once the matter had been resolved, it was soon forgotten.

Acceptance of conflict

The participants reported that once the matter had been resolved, it was forgotten; but other participants were of the opinion that it is normal to have differences or conflict in the workplace, as long as it is resolved by the end of the day. One participant said that the doctors do explode; however, once it is done it was over. She also stated that nurses could address the situation, if they were not comfortable with the way the doctor handled the situation.

“…they [doctors] will say something now; and its done and forgotten; and they don’t harp on a thing over and over again…” (WV5:6).

“…I think that it’s natural clashing in the workplace…” (WV3:5).

The Best Practice Guidelines on Managing and Mitigating Conflict state that conflict in the workplace setting is inevitable due to different goals, responsibilities and perceptions (The Registered Nurses’ Association of Ontario (RNAO), 2012:6). Conflict has a meaning; and if it is understood and managed, it can result in positive outcomes (RNAO, 2012:6). The findings of this study are confirmed that a difference of opinion or conflict in the workplace is inevitable.

Avoidance

Avoidance is a strategy that was reported by a few of the participants. Sometimes, nurses would keep quiet, ignore or avoid the violent person. Other participants minimized the impact – by reducing it to a laughing matter, as an alternative to avoidance.

“…die meerderheid bly maar stil en sê maar niks…ek vermy haar…hulle [kollegas] probeer haar sover soos moontlik ook maar vermy of lag dit maar af…” (WV2:5, 2:6 & 2:7).

[Translation: The majority keep quiet and do not say anything…I avoid her… they try to avoid her, as much as possible or [we] laugh about it.]

“…next day obviously, I didn’t greet him. I just avoided him [the doctor] and walked past…” (WV6:3).

“…everyone just keeps quiet and ignores because…” (WV8:9).

Muller (2009:186) described the different styles of handling conflict, of which some are effective, and others are not. These styles vary between avoidance, attack, compromise, consolation or confrontation. The turtle style would avoid the conflict, and pretend that it does not exist; while the nurse would withdraw. Personal goals are not important to the turtle; and no effort would be made to address the problem or conflict situation. The teddy bear implies a consoling approach to reduce the impact, and prefers to restore the relationship without necessarily addressing the matter (Muller, 2009:187).

The findings of this study are confirmed in the avoidance and consolation was used as an ineffective strategy to handle workplace violence.

Assertiveness

Some of the interviewees explained that in spite of the fact that they were busy and the team members were shouting at one another, they stood firm and did not allow patient-care to be compromised. They indicated that they were assertive and gave their opinion, regardless, and informed the team of what they thought was right; and thus made it happen.

“…I’m a very assertive person; so um if it comes to the wellbeing of my patients, I’m going to say what I want to say, irrespective…I am going to let people know that’s what I think is right; and I am going to let it happen…” (WV3:6).

Kagan and Evan (1995, in Greef, 2013:139) described assertiveness as non- aggressive, non-defensive and non-manipulative communication and behaviour, which does not interfere with other people’s freedom to take an assertive stance or make decisions. To be assertive is not always getting your own way; therefore, assertiveness is “saying your say”; but not being rude, aggressive, manipulative, disrespectful or putting yourself first.

This study has found that professional nurses tend to behave in an assertive manner.

Resilience

Professional nurses reported that after the ongoing episodes of workplace violence over a prolonged period, they used their own resilience [inner strength/ toughness and ability to bounce back] and positive self-talk to motivate and regain their energy and strength.

“…dan moet jy maar êrens bietjie resilience uittrek en sê: weet jy wat, ek weet wie ek is, ek weet watse standaarde ek het, ek weet watse ondervinding ek het, en ek glo in my besluite…” (WV15:4-5).

[Translation: Then you have to find some resilience and say: you know what; I know who I am, what standards I have, I know what experience I have, I believe in my own decisions.]

Jackson (2007 in Hutchinson and Hurley, 2013:555) found that the emotional resilience and optimism has been identified as personal characteristics that buffer the impact of work, job demands and emotional exhaustion. In their research, links were drawn from workplace violence and bullying to the importance of emotional awareness and resilience to help individuals cope with workplace adversities. In the current research findings, some of the participants applied an effective strategy when dealing with workplace violence.

3.5.3.3 Sub-theme 3.3. PARTICIPANTS MADE GENERAL SUGGESTIONS TO IMPROVE THE MANAGEMENT OF WORKPLACE VIOLENCE

Some professional nurses in the current study articulated strategies that have already been employed to improve workplace violence in the private healthcare facility, in which the study was done, such as debriefing, positive leadership roles, conflict management, creating awareness and creating awareness of organizational systems that were available to the nurses.

The Critical Social Theory is supported; since the nurses recognised the need to change, and have already employed (action) strategies towards improving the workplace environment.

Debriefing sessions

The professional nurse articulated that debriefing sessions were held among nurses after crisis situations in the specialised units. These had great value for the team members, and allowed individuals to voice their concern in an environment in which differences and negative behaviours could be discussed in a non-threatening way. During this process, they gained self-knowledge and knowledge about others in the team.

“…there is quite a problem, when we are busy – like people shouting…but after all our crises, we have a debriefing session; and I can say that this is actually working; because then we say: I didn’t like the way you said this; and that is my way of expressing the importance of what is happening…” (WV3:5).

Debriefing allows the individual to reflect on what has happened, their own performance and feedback from others, and that of the team leader (Savoldelli, Naik, Park, Joo, Chow & Hamstra, 2006: 279). The findings of their study reflected that participants’ performances did not improve in the absence of debriefing; whereas the provision of constructive feedback on the initial performance by instructors resulted in a significant improvement (Savoldelli et al., 2006:283). The findings of the study are confirmed, that when debriefing is done, team performance has usually improved.

Leadership

The participants reported that their Nurse Unit Manager had a positive input towards the team dynamics; and she acknowledged the input of each individual of the team. The team worked and prayed together; and if any of the team members or their family were ill, they could expect a phone call. The participants reported that their unit was like “home”.

“…ja, I think we are a great group the ones that are working there now; and it probably comes from the unit manager…she likes to say that the only reason why everybody says she is good, is because of the staff she has got; but I think it comes from the leader as well; but ja we work together; we pray…if anybody is sick you know we will phone and ask how you are. Are they in hospital, or their family; I think that is how it should be; I mean we are here most of the time

I want to say it is our second home; but it is our first home because we (laughing) are here most of the time…” (WV4:7).

Managers who integrate the resonant leadership skills of empathy, relating, listening, and responding to concerns in their everyday interactions with nurses create empowering respectful and civil climates that lead to quality relationships among leaders and staff (Laschinger, Wong, Cummings, & Grau, 2014:13). Resonant leadership is based on emotional intelligence and leaders that are in tune with their surroundings, with the thoughts and emotions of the staff working with them. Not only can they control their own emotions; but also, the emotions of those they lead, while concurrently building strong trusting relationships (Boyatzis & McKee, 2005 in Laschinger et al., 2014:7).

The importance of resonant leadership is thus supported in the current study.

Conflict management

In the same unit in an atmosphere where team members were valued and empowered, the participants gave an account of how they deal with conflict situations. One participant gave an account of how she dealt with conflict situations; and that she reminded herself to remain focused to resolve the issue at hand.

“…I try and speak to them; I’ll call them aside, I have learnt now; but when I started, I probably made a lot of mistakes, offended people…but now I…listen to your and…I tell myself don’t you now also raise your voice; because I mean two people shouting are not going to hear each other; so I try to speak; I try to find out what the problem is, to see if I can help you…most of the time, this works…” (WV4:8).

Conflict can be constructive or destructive. Constructive conflict is the result of the clarification of important problems and issues; and it results in the solution of problems.

Destructive conflict is the consequence of conflict that is poorly managed. It creates distrust among health professionals in an organization; it lowers their self-concept; it depresses staff morale; it reduces co-operation; it increases differences; and it leads to irresponsible behaviour, such as name-calling and lowered productivity (Jooste,

2010:216).

In this study, only one nurse reportedly dealt with conflict in a constructive manner; however, the findings reflected that the majority of the participants did not confront conflict.

Creating awareness

The professional nurses reported that shift leaders were made aware of the way they addressed junior staff. Shift leaders were not aware of how they were perceived; and how their behaviour impacted on the junior staff. One of the participants told the story of the shift leaders who used phrases, such as: “don’t be stupid” towards junior nurses; and she took it upon herself to inform junior nurses not to take it personally (WV10:6).

“…shift leaders…very strong personalities; they are the sort of people who will speak what they think…they come across very abruptly, very degrading…and the young girls can’t handle it…we’ve addressed it; and I think the seniors are becoming more aware of how they are speaking to people…” (WV10:6).

Griffin (2004:262) found in her study that raising the consciousness about lateral violence had a positive outcome. Knowledge of lateral violence and behavioural actions to stop it, empowered the newly registered nurses to confront the perpetrator; and to thus reduce the violent behaviour (Bloom, 2014:85). The findings of that study revealed that the respondents recognised aggressive behaviour in their co-workers; but not in themselves. Nurses were surprised that they were maltreating their colleagues (Walrafen et al., 2012:12).

The findings of this study are confirmed; since nurses are sometimes not aware of the role they play in workplace violence.

Availability of organizational systems

The participants reported that there were formal systems available; however, they questioned the awareness, user-friendliness, and the confidentiality that goes with reporting of these incidents or events.

“…daar is…SHOUT line…hoeveel van hulle weet rerig van dit ons het die sisteem wat jy sê ICAS maar dit is ook nie ‘n baie vriendelike gebruiker sisteem nie dit vat jou ‘n week dan kan jy miskien ‘n afspraak by iemand kry …die ander ding waaroor die ouens altyd bekommerd is, is konfidensialiteit jy weet hulle wil ook nie altyd…na die HR toe gaan nie…” (WV15:7).

[Translation: There is a SHOUT line...how many know the system called ICAS, but it is not very user-friendly; it can take a week for you to get an appointment with someone…something else that is worrying, is confidentiality you know… they do not always …want to go to HR.]

Bimenyimana et al. (2009:12) found in their study that ICAS was reported to be a “faceless” organization; because the initial contact is done per telephone and in conversation with someone that the participant does not know. In the study by Bimenyimana et al. (2009:12), the institution did not have a program to deal with stress- related problems and it relied on ICAS only. The RNAO (2009:49) suggest that nurses who were victims of workplace violence should be referred for debriefing and counselling to prevent the effects of post-traumatic stress disorder. In this study, ICAS is the formalised employee-assistant program available to assist the victims of workplace violence; however, the participants stated that it was not user-friendly.

3.6 CONCLUSION

In this chapter, the researcher has explored the experiences of workplace violence among professional nurses in a private healthcare facility. She analysed the data and described them by using themes synthesized from the data. The findings were placed within the present literature by means of a literature control.

The professional nurses acknowledged the existence of workplace violence where they work; and they deliberated on their experiences in the healthcare team. They described the effect of workplace violence on themselves, others and the work environment; and they discussed their views on the management of violence in the workplace.

In the next chapter, the conclusions, recommendations, guidelines, and limitations of the study, will be discussed.

CHAPTER FOUR

THE CONCLUSIONS, RECOMMENDATIONS, GUIDELINES AND LIMITATIONS OF THIS STUDY

4.1 INTRODUCTION

In Chapter One, an overview was given of the research process; while Chapter Two presented the research design and method. In the previous chapter, the findings related to workplace violence, as experienced by professional nurses in a private healthcare facility, were discussed. The findings were compared with the relevant literature; and any similarities or differences were discussed. This last chapter will focus on the conclusion and limitations of the study. The researcher will make some recommendations for nursing practice, research, and education; and thereafter, guidelines will be offered to assist managers and nurses to address workplace violence.

4.2 SUMMARY AND CONCLUSION OF THE STUDY

The researcher has been a manager at a private healthcare facility for a number of years; and she has been exposed to workplace violence from doctors, nurses, patients and visitors. She was unaware that the unprofessional and negative behaviour was in fact workplace violence; and she therefore, dealt with it in an incorrect manner. She observed how the unprofessional behaviour among nurses escalated, team work deteriorated, and absenteeism increased. Out of desperation, she involved the Human Resource Department; and it was only after the disciplinary process was followed with one of the nurses that the researcher read an article on lateral violence.

She then realised that she was indirectly promoting violence in the workplace. This prompted her to make the decision to do this research.

The aim of this study was to explore and describe the experiences of professional nurses regarding workplace violence in a private healthcare facility, in order to develop guidelines to address this type of violence between and towards nurses.

The researcher wanted to gain an in-depth understanding of professional nurses’ experiences; and she therefore, decided on a qualitative, exploratory, contextual and

80 descriptive study. In phase one of the study, the data were gathered through narratives from fourteen purposively selected participants (professional nurses) who had experienced workplace violence first-hand during in-depth personal interviews. The interviews were transcribed verbatim; and the analysis of the data was done using Tesch’s method of thematic synthesis.

The analysis of the data was based on the experiences of the participants, as discussed in Chapter Three. Three themes emerged from the data; and a thick description of the data with a literature control was provided.

Theme 1: Professional nurses acknowledge the existence of workplace violence where they work

Professional nurses reported that a lack of respect between doctors and nurses was displayed by the use of abusive language, belittling and humiliating behaviour, and even instances of physical violence towards nurses. Patient care was compromised – due to the fact that the participants were too scared to phone the doctor regarding treatment or any care issues.

The professional nurses indicated that nurses abused their own. Nurse Unit Managers applied structural bullying and were reported for verbal abuse, threatening behaviour, and physical violence towards students. Nurses reported that nurse-on-nurse violence in one unit was like a drama; and the workplace was a battlefield. Their behaviour towards their colleagues was disrespectful, verbally abusive (swearing, shouting), aggressive, covert (gossiping), overt (belittling in front of others) and bullying (targeting an individual with perceived less power).

Sexual harassment was not reported; because the male colleague was liked by the group; and the nurse’s fear of being made fun off, name-calling and a lack of confidentiality when such incidents were reported.

Abusive behaviour from patients and visitors was reported; however, the nurses expressed their empathy towards the confused patient and the visitors of the critically ill patient in the intensive-care unit. The participants indicated that they did not accept perceived deliberate disrespectful or abusive behaviour from a patient or their relatives. The participants reported substandard patient care, as a result of the psychological 81 effects workplace violence had on them and the nursing team.

It was, however, mentioned that staff shortages and excessive workloads exacerbated the problem.

Theme 2: Participants described the effect of workplace violence on themselves, others, and the work environment

The impact of workplace violence on the individuals, the healthcare team and patient safety, was described. Only a few physical symptoms were reported; however, the psychological effect of violence had the greatest impact; and individuals felt despondent, frustrated, irritated, fearful, and sad. Some of the participants ultimately removed themselves (physically and psychologically) from the environment where such violence took place. As a result, team work was compromised, work standards dropped; job satisfaction and productivity decreased, and poor communication took place.

An increase in absenteeism, resignations and staff turnover was, therefore, reported.

Theme 3: Participants discussed their views regarding the management of violence in the workplace

When workplace violence was reported to the Nurse Unit Manager, meetings were held; but the violent behaviour did not change. This could mean that either the perpetrator (doctor or nurse) was not disciplined, or ineffective strategies were used to deal with the person that demonstrated/committed the violent behaviour/action.

The participants managed workplace violence by a variety of personal strategies, such as the acceptance of conflict, avoidance and assertiveness. The majority of the participants applied non-assertive or ineffective strategies when dealing with workplace violence.

In this study, the Critical Social Theory was used to analyse the self-knowledge of the effect of workplace violence on participants, ensuring autonomy in decision-making, and taking responsibility to change their behaviour and that of society (Polit & Beck, 2012: 506; Bloom, 2014:79). The researcher, therefore, developed guidelines to

82 facilitate such changes.

4.3 DEVELOPING THE GUIDELINES

As seen in the paradigm and the findings, there is a need to change behaviour in a society, when the behaviour is deemed unacceptable, and does not serve the society anymore. In this case, the society is the private healthcare organization/facility. Guidelines (please see the concept clarification in Chapter One) are used in healthcare facilities to guide behaviour. These guidelines seek to set a standard for acceptable behaviour in the workplace. It was, therefore, decided to develop guidelines to address the workplace violence in the private healthcare facility. Developing guidelines is phase two of the study. (Please see the detailed description of the method used to develop the guidelines as discussed in Chapter Two.)

From the themes identified in Chapter Three, the researcher made inferences about the overarching topics of the guidelines that would best serve the organization. Although professional nurses and Nurse Managers (Nurse Unit Managers and Nursing Service Managers) all address workplace violence; it is done on different levels; and therefore, individual guidelines were developed for these three groups.

The topics that were identified for the principal guidelines were therefore:

 Preventing and addressing workplace violence by Nursing Service Managers  Preventing and addressing workplace violence by Nurse Unit Managers  Empowering professional nurses to address workplace violence

The overarching goal of these guidelines is, therefore, to provide a guide for Nursing Service Managers, Nurse Unit Managers and professional nurses to facilitate change in their own behaviour and guide the behaviour of others, in order to prevent and address workplace violence in the private healthcare facility. Each guideline has sub- guidelines to order, structure and facilitate the activities that are put forward, when the implementation of these guidelines take place.

The following table will provide a summary of the guidelines and sub-guidelines.

Table 4.1: Guidelines for Nursing Managers and professional nurses to prevent and address workplace violence in a private healthcare facility

Principal guideline Sub-guidelines

Guideline1: 1.1. Review existing organizational policies, Preventing and addressing processes and practises on workplace workplace violence by violence. Nursing Service Managers. 1.2. Promote effective management and preventive strategies to address workplace violence.

Guideline 2: 2.1. Create a positive/conducive work environment Preventing and addressing to prevent workplace violence in the nursing workplace violence by Nurse unit. Unit Managers. 2.2. Recognise and manage workplace violence in the operational setting.

Guideline 3: 3.1. Display behaviour that prevents workplace Empower professional nurses violence and demonstrates behaviours to address it effectively, when it occurs. to address workplace violence. 3.2. Apply policies and procedures when workplace violence occurs.

4.3.1 Guideline 1: Preventing and addressing workplace violence by Nursing Service Managers

From the findings, the professional nurses reported that “nothing was done” by management regarding workplace violence. The Nursing Service Manager and the deputies are in a position to effect change within the healthcare facility. They need to revise all practices and policies that condone workplace violence. Policies are generated from top-management when there are insufficient or no guidelines regarding a particular matter, such as workplace violence (Marriner-Tomey (2000) in Jooste, 2010:94).

When organizational policies and practices do exist or are insufficient, they have to be revised to reflect an organizational culture that prevents and addresses workplace violence at all levels of the organization (RNAO, 2009:8). This implies that strategies are needed to facilitate the systems and processes within the organization to combat and manage vertical and horizontal workplace violence. These strategies should be

84 part of the strategic planning process and should include such things as: budgeting for training sessions of Nurse Unit Managers and professional nurses, such as making pamphlets available about the prevention of violence, and dealing with workplace violence, training on the systems in place and the process to deal with workplace violence, whistle-blowing, emotional-intelligence training, resilience and assertiveness training.

Information sessions on workplace violence can, however, be included in the existing induction programs, in-service training and workshops, in order to limit the cost.

According to Max Horkheimer (Horkheimer & Adorno, 1969 in Anderson, Curtis & Wittig, 2014:14), the Critical Social Theory is adequate – but only if it meets three criteria: it must be explanatory, practical, and normative, all at the same time. That is, it must explain what is wrong with current social reality, identify the actors to change it (change agents), and provide both clear norms for criticism and achievable practical goals for social transformation. Furthermore, the Critical Social Theory attempts to interpret the world (why things are the way they are) for a purpose. That purpose is emancipatory.

The professional nurses in this study were enlightened; and therefore, they recognised the need to change from dependence to autonomy for instance – from being at the receiving end of workplace violence to being able to address the perpetrators of such violence. The Critical Social Theory is value-laden – it seeks to transform society on the principals of justice, fairness, the righting of wrongs and the meeting of needs – rather than simply understanding society as an end in itself (Anderson, Curtis, & Wittig, 2014:15).

During the transformation process (change process), the existing values, norms and behaviour that contributed/caused workplace violence have to change and new values, norms and behaviour are introduced, which are conducive to an environment where violence is prevented. Therefore, a re-education of norms has to take place (Kelly, 2008:279). The most successful plan for change is one in which the affected people are involved, satisfied and committed (Kelly, 2008:279).

The Nursing Service Manager, as leader of her team, should encourage professional

85 nurses to participate in the planning phase of the change-management process. The plans should include activities, such as awareness campaigns, information and training sessions, and the reviewing of policies, procedures and practices.

4.3.1.1 Sub-guideline 1.1. Review existing organizational policies, processes and practices on workplace violence

From the utterances of the professional nurses, it was clear that the current policies, processes and practices within the healthcare facility were not effective; or, they were not being implemented appropriately when dealing with workplace violence.

Policy development begins with constructing statements and instructions that define the actions taken and decisions made in the workplace (Yon, 2015:89). These statements derive from the healthcare organization’s philosophy and goals and give direction to the achievement of the objectives of the organization. The healthcare facility uses procedures to realise the successful implementation of policies. Policies outline the steps the healthcare facility needs to take to direct action and decision- making at the unit level (Jooste, 2010:79).

Once policies have been written, they should be made available to all units and staff in the organization (Booyens, 2008:44).

The purpose of the sub-guidelines

The purpose of the sub-guidelines is to make Nursing Service Managers aware of the actions that need to be taken to investigate and review the policies, processes and practices (which include the data) pertaining to workplace violence in the healthcare organization.

Rationale

All health organizations have to adhere to the legislative framework of the country, under the auspices of the Constitution. Chapter Two of the Constitution stipulates the bill of rights of all citizens. These rights are contained within the South African Patients’ Right Charter. The healthcare user has the right to a healthy and safe environment, as well as protection from all forms of danger. Patients also have the right to access and enjoy quality healthcare (Muller, 2009:15). Professional nurses work in a legislative 86 framework, to ensure that all people are treated fairly and equally, and according to their basic rights.

Healthcare organizations formulate their own policies; but these must be in line with national legislation and provincial ordinances. Such policies involve professional- ethical or legal implications; and they should be reviewed at least annually – in order to prevent possible litigation (Muller, 2009:144). Best-practice guidelines have been written based on the evidence, literature and practical insight to address the unwanted behaviour in the workplace (Evesson, Oxenbridge & Taylor, 2015:9).

Contracts, policies, procedures and guidelines make up the control mechanism in healthcare organizations.

The rationale for the sub-guidelines is, therefore, to ensure that the system is in place and operational, in order to prevent and manage workplace violence legitimately and effectively.

Action steps

 Talk with senior organizational managers with regard to the philosophy of the organization and policies on workplace violence  Review the legislative framework guiding all healthcare professionals  Review existing policies, procedures and practices and establish any lacuna with regard to workplace violence  Do a data analysis and situational analysis to establish what the present situation is in the organization  Communicate with HR regarding the legal and accepted practices on workplace violence  Benchmark and compare the policies of the organization with national and international guidelines  Develop new policies that prevent workplace violence and indicate what the consequences are if the staff do not adhere to these policies and processes  Create a culture of civility and co-operation within the organization  Verbalise the expectations of acceptable behaviour to all the staff on as many platforms as possible

 Introduce normative assessment into staff assessment practices  Ensure that disciplinary and grievance processes and procedures are functional and effective  Work with the hospital manager to develop guidelines for external stakeholders utilizing the facility, for example, good manners and etiquette when visiting or working in the different units to ensure that role expectations are adhered to  Budget for educational programmes to inform, prevent and train staff to address workplace violence  Make sure that there are policies on racial discrimination, horizontal and vertical workplace violence (or develop them)  Introduce a quick and anonymous help line for staff to consult, if they are victims of workplace violence or sexual harassment  Ensure that there is a process on the re-deployment of staff – when they request transfer to other units – due to workplace violence in certain units  Provide feedback to head office on workplace violence taking place in your healthcare facility  Liaise with the ethical team of the organization with regard to the expectation and management of staff and doctors when workplace violence takes place  Review organizational workloads and staff-ratio policy and engage with senior management at head office on the findings of studies and international trends  Involve the nursing team to assist with the policy implementation and with planning the change from the existing norm, where workplace violence exists to an environment where violence is prevented  Assess the implementation of the Health and Safety Act no 85 of 1993 with regard to workplace violence in the healthcare facility  Assess the measures in place to combat the effect of workplace violence on the individual and the organization

4.3.1.2 Sub-guideline 1.2. Promote effective management and preventive strategies to address workplace violence

From the study, the doctors, the Nurse Unit Manager and the professional nurses were identified as perpetrators of workplace violence. Nurses reported that the workplace violence was not managed; and consequently, it was established as a culture in some of the nursing units. 88

Horizontal violence is found in work environments where the management is viewed as ineffective and non-supportive. The workplace culture is a precipitating factor for workplace violence. Healthcare organization need to place a value on the way the employees treat one another, and ensure that support is offered, in order to prevent the psychological sequels of horizontal violence (RNAO, 2009:47).

The Nursing Service Manager is the leader of the nursing team; and she has to apply the transformational leadership that will bring a significant change in both the followers and the organization. Marriner-Tomey (1993 in Jooste, 2009:85) postulates that transformational leadership is the key to future of nursing and multi-disciplinary development, which promotes the entrepreneurial spirit and facilitates innovation. This is an empowering leadership style; and it is characterised as being caring and highly ethical in people’s conduct (Sofarelli & Brown, 1998 in Jooste, 2009:85).

The Nursing Service Manager’s role in conflict should be role-modelling of conflict management, and to create an environment conducive to prevent, manage and mitigate conflict. The Nursing Service Manager should facilitate conflict resolution in a formal manner. She has the power and authority to address unacceptable standards or behaviour in the healthcare facility (Kelly, 2008:290).

The purpose of the sub-guidelines

The purpose of the sub-guidelines is to guide the Nursing Service Manager on the steps that have to be taken to bring about change, so that nurses would act in an ethical and professional manner towards colleagues and healthcare team members in the organization/healthcare facility.

Rationale

The Nurses’ Pledge provides the ethical foundation of the nursing profession in South Africa. The Pledge is derived from the Nightingale Pledge; and it has been in use since the institution of nurse training in South Africa. The South African Nurses’ Pledge is as follows:

Nurses' Pledge of Service

I solemnly pledge myself to the service of humanity, and will endeavour to practise my profession with conscience and with dignity.

I will maintain, by all the means in my power, the honour and noble tradition of my profession.

The total health of my patients will be my first consideration.

I will hold in confidence all personal matters coming to my knowledge.

I will not permit considerations of religion, nationality, race or social standing to intervene between my duty and my patient.

I will maintain the utmost respect for human life.

I make these promises solemnly, freely and upon my honour (SANC, 2015).

This Code of Ethics for Nursing in South Africa is clear about the Nursing Professional’s responsibilities towards individuals, families, groups and communities, namely to protect, promote and restore health, to prevent illness, preserve life and alleviate suffering (SANC, 2013).

The rationale of the sub-guideline is to ensure that workplace violence is prevented, managed, and that the effects of workplace violence are limited or mitigated effectively. The sub-guideline should also ensure that the ethical standards of the nursing profession and the organization are upheld in the process.

Action steps

 Put workplace violence on the data-analysis sheet  Role-model the appropriate behaviour  Ensure that everyone knows the process and that workplace violence is reported without victimisation; because they are aware of the consequences of such actions

 Provide printed materials to all staff regarding workplace violence and the process to follow  Ensure that each Unit Nurse Manager understand his/her role and job description, and role-model the expected organizational behaviour  Ensure compulsory training of Nurse Unit Manager on how to prevent and deal with workplace violence  Assess Nurse Unit Manager competences by using a simulated assessment method – for example, role-modelling once a year  Ensure that the staff are empowered to deal with workplace violence, for instance provide workshops for staff members on assertive behaviour and how to deal with aggressive doctors, staff and patients  Provide training of senior management team on complex situations, such as internal and external customers with unrealistic expectations, resulting in workplace violence  Implement training, workshops and awareness campaigns on workplace violence  Put measures in place to ensure adequate staffing in the nursing units and investigate all reported incidents of staff shortages  Address negative behaviour in private and not in front of colleagues  Discuss ethical dilemmas at monthly Clinical Governance committee meetings; and refer any unresolved issues to the Organizational Ethical department for guidance  Promote a workplace fee of violence by investigating all reported incidents; and implement progressive disciplinary action, when workplace violence occurs  Support the victims of workplace violence  Implement mentorship for staff who find it difficult to respond and address the perpetrator of workplace violence in spite of training sessions  Promote professionalism by ensuring that workplace violence does not influence the care of the patient  Make the staff to know that they should not accept bullying behaviour from patients or relatives, and that the management team will support them if they are themselves behaving in a professional manner

 Manage conflict quickly, fairly and effectively – to ensure that it does not escalate into workplace violence

4.3.2 Guideline 2. Preventing and addressing workplace violence by Nurse Unit Managers

The Nurse Unit Manager is accountable for quality nursing care in her unit, as well as cost efficiency, cost effectiveness and personnel management (Muller, 2009:173). This study has found that standards of care dropped, absenteeism increased, and nurses suffered (physically and psychologically) from the consequences of workplace violence. Furthermore, productivity was reduced and important healthcare information was lost. Nurses reported that they questioned their decision of nursing as a career; and they either requested transfers to other units, or resigned, because of workplace violence.

The Nursing Unit Manager has the power and authority to address unacceptable behaviour within her unit. However, addressing the unacceptable behaviour is no longer sufficient, as shown in the current study. An environment has to be created where patient safety is valued, nurses are respected, and practices that permit workplace violence are stopped. The Nurse Unit Manager, as the leader of her team, has to empower and inspire her staff to implement such a change (Jooste, 2009:26).

The Critical Social Theory states that transformation should take place, and that transformational leaders demonstrate a strong commitment to their profession, are trusted and respected by their followers, have the ability to inspire and stimulate their followers intellectually by challenging the status quo, initiate change to improve organizational and individual growth, create a friendly environment with new ideas, and encourage creative-participative problem-solving strategies, recognise the contribution of the team members, and celebrate any successes (Jooste, 2009:86-87).

4.3.2.1 Sub-guideline 2.1. Create a positive/conducive work environment to prevent workplace violence in the nursing unit

The Nurse Unit Manager is a fundamental link in the retention of nurses (Ritter, 2011:30). The Nurse Unit Manager has to set the direction, so that her team can be inspired to follow the new direction. That direction would include plans to create an

92 environment where the leader (Nurse Unit Manager) allows professional nurses to participate in decision-making and problem-solving (workplace violence), where individual and team success are celebrated, and giving credit when it is due (Jooste, 2009:26-27).

The New Zealand Government’s Best-practice guideline (2014) states that creating an environment that builds good relationships should prevent bullying. This environment should value diversity and the strengths that each individual adds. An effective Nurse Unit manager can reduce absenteeism through increasing job satisfaction and positive interpersonal relationships among the staff (WorkSafe, New Zealand (NZ), 2014:28- 29).

The purpose of the sub-guideline

The purpose of this sub-guideline is to inform the Nurse Unit Manager of the steps she can implement to create a healthy work environment, in which the nurses are respected, and where they choose to stay and work.

Rationale

Nurses leave unhealthy work environments; however, a positive work environment enhances retention (Ritter, 2011:30). Healthy work environments yield financial benefits to the organization in terms of reduction in absenteeism, higher productivity, lower healthcare costs and a reduction in costs arising from adverse events (RNAO, 2009:23).

Nursing staff have the right to a workplace where harmony and co-operation exist. In a healthy work environment, the staff have a positive culture of caring for colleagues and others. Such an environment is open to change, it can manage conflict in a mature manner, it can think innovatively to solve problems, and it communicates in a clear and respectful way, and it values diversity.

The rationale of the sub-guideline is to ensure that workplace violence is prevented, and that positive work relationships are promoted.

Action steps

 Draft a set of non-negotiable rules for the nursing unit with the team, to ensure respectful communication and behaviour at all times towards healthcare professionals and patients  Orientate new staff regarding expected organizational behaviour and non- negotiable rules of the nursing unit  Ensure that everybody knows the rules, including the doctors, nursing staff, the patients and their families  Make sure everyone knows what happens if they don’t adhere to the rules and what the procedures are if they don’t, for example, implement a progressive disciplinary action when staff are involved  Ensure that all the staff know the organizational code of conduct, grievance procedure and the whistle-blowing process  Allocate appropriate authority and resources to shift leaders to arrange adequate staff for the next shift  Promote professional relationships towards nurses, colleagues and members of the healthcare teams through: o Role delineation to ensure that the nursing categories work within their scope of practice o Use professional etiquette and good manners towards nurses and address frustrations in private o Keep nurses responsible and accountable to act, according to the expected organizational standard introduced during induction (macro-orientation) to the healthcare facility o Model respectful behaviour, for instance, greeting and asking permission to interrupt o Address professionals by using their title, in order to eliminate familiarity o Prevent actions that might lead to aggression or workplace violence, for example, phone the doctor to clarify therapy and do not wait until the next ward round  Keep a record of all incidents of workplace violence, who was involved, and what actions were taken

 Liaise with Nursing Service Manager regarding incidents involving external stakeholders and doctors  Encourage staff to report any incidents of workplace violence  Protect staff from workplace violence, for example, address doctors who behave in an unacceptable manner towards nursing staff, and escalate it to the next organizational structure on behalf of the staff if the behaviour does not improve  Support nurses during the process of change to an environment that is free from workplace violence  Ensure that all categories of nurses are permitted to attend workshops and training sessions on workplace violence  Manage conflict as a matter of priority, and see that nurses are trained on the various strategies on conflict resolution, such as avoidance, withdrawal, accommodation, compromising and confronting.  Encourage nurses to handle less complex situations, and to be available to support and to allow nurses the opportunity for growth  Offer support (physical or emotional) to staff when needed, and refer to the employee assistance program (ICAS) via either the formal or voluntary route  Arrange for debriefing sessions after an extremely busy day or emergency situations – so that the staff can de-stress  Develop a culture where each individual in the team feels valued and respected through an understanding that their contribution counts towards the team’s success o Caring is delivered in a professional manner and is modelled by the Nurse Unit Manager in dealing with staff, patients and relatives o Maintain confidentiality of any sensitive information o Address absenteeism out of concern for the individual o Participation is voluntary, because the Nurse Unit Manager and the colleagues recognise the contribution of each member o Acknowledge the value of punctuality and time management to meet deadlines and to enhance service delivery, resulting in more satisfied customers and less complaints o Celebrate individual and team success as encouragement and to achieve set individual/ unit goals

o Encourage participative decision-making to obtain buy-in and commitment of nursing staff to the prevention of workplace violence o Encourage staff to care for the team members who have experienced workplace violence o Teach the staff to reflect on what could have been done differently in the heat of the moment

4.3.2.2 Sub-guideline 2.2. Recognise and manage workplace violence in the operational setting

The findings from the study reflected the negative consequences of workplace violence on the individual (physical and psychological), the patient (lowered standards of care) and the organization (absenteeism, loss of nurses and nursing experience due to resignations). The Nurse Unit Manager is responsible to ensure that nurses are made aware, know the policies and procedures and the most suitable action when workplace violence occurs. The most appropriate time to address workplace violence is during or immediately after the incident has taken place (Becher & Visovsky, 2012:212).

The ACAS guide (2014) for manager and employers stipulates that behaviour, which is considered bullying by one person may be considered firm management by another. Most people will agree on extreme cases of bullying and harassment; but it is sometimes the ‘grey’ areas that cause the most problems. It is good practice for employers to give examples of what is unacceptable behaviour in their organization (ACAS, 2014:3). (Please see the findings of this study in Chapter Three, section 3.5.1.)

The purpose of the sub-guideline

The purpose of the sub-guideline is to ensure that Nurse Unit Managers recognise and manage workplace violence in the nursing units effectively.

Rationale

The ACAS guide (2014:3) for managers and employers states that bullying and harassment are unacceptable on moral grounds, but if left unchecked, or not managed properly, this creates serious problems for the organization, namely: poor morale and poor employee relations, no respect for supervisors and managers, loss of productivity

96 and the consequences discussed in this study. (Please see Chapter Three, section 3.5.2).

To function effectively as part of a team, nurses must establish positive working relationships. These would result in good communication, mutual respect and understanding. To manage conflict is an integral part of building positive relationships. Colleagues who work together to manage conflict effectively would foster an environment that produces positive outcomes for both the healthcare user and the nurse (College of Nurses of Ontario, 2009:6).

The rationale of the sub-guideline is to limit and mitigate the negative effects of workplace violence as quickly, and as effectively, as possible, to ensure and maintain good working relationships and a good morale for the staff.

Actions

The following actions pertain to workplace violence, even though they are generically stated. The Nurse Unit Manager must:

 Implement the rules, as drafted by the team, and take action when the rules are contravened  Ensure that all nurses attend the training and would be able to recognise workplace violence, and are clear about the consequences, should this type of behaviour be displayed  Encourage nurses to communicate effectively to ensure that patients receive their prescribed therapy, and thus maintain a healthy work relationship with the doctor  Empower nurses by interactive conflict-management training programs, so that nurses can practise the skill, in order to be equipped when conflict occurs during the everyday working interaction  Aim towards resolving the problem; so that the working relationship is restored, once the conflict has been dealt with  Encourage nurses to be assertive and address workplace violence from whichever source

 Encourage nurses to report all instances of workplace violence to the Nurse Unit Manager, so that she can support staff members and intervene if necessary  Discuss workplace violence in team meetings, so that nurses learn how to deal with workplace violence and coping strategies from each other  Present a report about workplace violence at staff meetings, as part of the incident reports given to the staff; so that they can become aware of the incidents and can work towards a common goal (which is stated in the strategic plan of the hospital)  Resolve written grievances between staff members related to workplace violence  Co-ordinate union representation on the staff member request to resolve the grievance  Mediate/arbitrate when workplace violence takes place between doctors and the nursing staff  Remove the perpetrator of workplace violence that is screaming and shouting from the workplace to the Nursing Unit Manager’s office to minimize the negative effects  Ensure that communication is clear and specific to the situation that caused the workplace violence and kept in the “here and now” o Focus on the negative behaviour that is seen as workplace violence – and not on the person o Use silence to allow the individual to express his/her negative feelings, and the reason why they reacted in this unacceptable manner o Remain objective, and do not allow other issues or incidents to be discussed during this meeting o Explain to the perpetrator that workplace violence is unacceptable and will not be tolerated in a firm; but do this in a non-threatening way  Look for ways to help the individual to return to the workplace with dignity

4.3.3 Guideline 3: Empower professional nurses to address workplace violence

The professional nurses in the study acknowledged the existence of workplace violence where they work. They gave narratives of their first-hand experiences and

98 how this had affected them. The Best-practice guidelines on Preventing and Managing Violence in the Workplace (RNAO, 2009) state that violence is a learned behaviour perpetrated by persons who are often insecure, fearful, or jealous, and who use violence as a means of protecting themselves. It is allowed to continue, when the antagonist is unaware of the impact their behaviour has on others, and when violent events go unreported (RNAO, 2009:53).

Nurses are responsible for conducting themselves in a professional manner when nursing care is delivered to the patient. Accountability implies taking responsibility for one’s conduct, or being answerable for one’s actions. When a professional nurse is accountable to the Nursing Service Manager, they are obliged to inform the Nursing Service Manager of past and future actions and decisions to justify them, or to be disciplined in the case of severe misconduct. This implies that the nurse would accept the consequences of their behaviour (Jooste, 2010:57).

Nurses should be empowered to recognise the type of workplace violence that they experience, in order to address it. The best-practice guideline on Preventing and Responding to Workplace Bulling advises employees to address bullying behaviour – otherwise, it just gets worse (WorkSafe NZ, 2014:18). Bullying from managers is frequently deliberate and repeated. In extreme cases, it may progress to employees feeling isolated, powerless and worthless. When the employee resigns, the manager will find the next employee to target. This is often the most visible and well-defined type of bullying (Worksafe NZ, 2014:9). Employees have a right not to be harassed by their manager or by any other healthcare professional.

4.3.3.1 Sub-guideline 3.1. Display behaviour that prevents workplace violence and demonstrate behaviours to address it effectively, when it occurs

Nurses as individuals have an impact on their workplace. This can be positive or negative (as seen in this study). Nurses need to become self-aware of their own actions and the impact of their behaviour on others, and manage their own and other people’s behaviour, in order to transform their thinking and the workplace culture to a workplace that is free of violence (RNOA, 2009:54).

The purpose of the sub-guideline

The sub-guideline should empower professional nurses to develop strategies to prevent workplace violence and to address the workplace violence when it occurs.

Rationale

Conflict is inevitable in the workplace – due to the inherent differences in goals, needs, desires, responsibility, perceptions and ideas. In nursing, the quality of the relationship between colleagues, patients and relatives and other members of the healthcare teams is vital to the everyday interaction, co-operation – and to achieve good health outcomes (RNAO, 2012:26).

The rationale for the sub-guideline is to empower professional nurses, in order for them to take preventive action and address workplace violence in an appropriate way, and in so doing, to limit the negative personal and professional effects that workplace violence would have on them and on their fellow nurses.

Action steps

 Know your rights as a professional nurse: to be treated with dignity and respect by all healthcare professionals  Make a conscious decision NOT BE A PERPETRATOR OF WORKPLACE VIOLENCE YOURSELF – MANAGE YOUR EMOTIONS AND YOUR OWN BEHAVIOUR  Maintain respectful attitudes and behave professionally towards colleagues, and other healthcare workers, in order to enhance good working relationships o Be friendly and courteous at all times and behave in a professional manner that enhances relationships o Address the healthcare professionals by their titles, and not first name – as a sign of respect o Demonstrate a positive co-operative attitude towards your work, and show that you are willing to accept additional tasks aimed at improving the outcome of the patients’ care o Refrain from making negative comments about your colleagues, and

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endeavour to maintain a good team spirit, in order to avoid any escalation of conflict into workplace violence o Keep information confidential, to ensure that the trust relationship is maintained o Support your colleagues when they are going through a difficult time, or are being exposed to workplace violence, in order to display the importance of care o Communicate with the perpetrator of the workplace violence and make them aware of their negative behaviour, and demonstrate acceptable behaviour, when you make it known to them that their behaviour is unacceptable  Establish your own boundaries, and let others know where they are and what you will allow or will not permit  Learn to deal with difficult situations and people, by attending workshops on bullying, vertical and horizontal violence and conflict management  Make sure that your conduct is exemplary, so that you do not elicit workplace violence. For example, demonstrate competence in your work, comply with the standards of care, and ensure that your people-skills are good  Know your role within the nursing unit; as this would support you when you have to take a firm stand, for example, when the shift leader is addressing workplace violence, or delegating additional duties  Ensure effective communication using verbal, non-verbal and written forms, and clarify if the instruction is unclear, to ensure that no healthcare information is lost  Be self-aware and reflect on your own feelings and behaviour, and clarify any misinterpretations that can take place, and correct your actions  Practise cognitive rehearsal (Griffin 2004:259) o Hold the information received (abusive language) in your mind o Actively and consciously, do not respond or react o Process the information, based on what has been taught about workplace violence o Act when you have worked through the information (settled down) and decided on a plan of action  Practise assertiveness (Greef, 2013:139)

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o Be true to yourself; however, know your rights and the rights of others o Verbalise you needs and opinions, be positive and negative in honest, clear, open and direct communication o Think and speak positively about yourself, others and life o Be comfortable with selective self-exposure o Give and receive constructive criticism o Learn to say no, and to persevere o Give compliments, and initiate conversation o Be able to make and refuse requests o Learn non-verbal skills to enhance your assertiveness, such as controlling you anger, learn to relax, listen attentively, make eye-contact; and use a firm, relaxed and well-modulated voice  Manage your stress, and be aware of your own and other people’s as the triggers to possible violent behaviour (Greef, 2013:79) o Identify what causes stress in your work life and at home o Identify triggers of workplace violence in your workplace and negotiate around them, in order to prevent violence o Determine what you want to do about it o Develop effective coping skills: for example, go for training on emotional intelligence, resilience, and dealing with difficult people o Talk to people (someone you trust) when you feel that people are bullying you, or when you are exposed to workplace violence – get it off your chest, so that you do not experience physical symptoms o Try to prevent going over and over and over the incident in your head, because this could escalate the problem or negatively influence your coping strategies o Try to focus on the positive aspects of your work, instead of the workplace violence or negative effects that you experience after such an episode o Seek help when you feel it is necessary e.g. after exposure to workplace violence o Enjoy a balanced life  Be involved with the planning towards a healthy work environment and volunteer for additional duties, such as being the Health and Safety employee representative, or an advocate against workplace violence 102

 Practise and demonstrate appropriate behaviour, when people are offensive  Blow the whistle and encourage other nurses to also do so  Report workplace violence if and when it happens – no matter who the perpetrator is – do not be afraid – stand for what you believe in and demonstrate courage

4.3.3.2 Sub-guideline: 3.2. Apply the policies and procedures when workplace violence occurs

The policies and procedure manual provides a basis for orientation and staff development; and it is a ready reference for nurses. The policies and procedure manual is an instrument for orientating new staff; and a reference document, when an unexpected problem arises; it is also a foundation on which to develop administrative procedures; and it provides a firm basis for discussion. These manuals establish boundaries within which the institution should operate and convey its beliefs; and without these manuals, management lacks direction, and is vulnerable to inconsistent decisions (Jooste, 2010:95).

The international guideline on the Prevention of Workplace Violence has been written to provide the best available evidence to support the creation of a healthy work environment. These guidelines, when applied, will serve to support nurses in their day- to-day practice (RNAO, 2009:1).

Policies and procedures on workplace violence are included in the Health and Safety standards. Reporting processes should be easy to access; and all staff should know about it (Worksafe NZ, 2014:3). It is suggested that a dedicated person, other than the manager of the nursing unit, is trained and receives any complaints about bullying behaviour – especially because even the manager might sometimes display bullying behaviour.

The purpose of the sub-guideline

This sub-guideline is developed to ensure that nurses are aware of the policies and procedures related to workplace violence, and can utilize them to address workplace violence effectively when it occurs.

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Rationale

The rationale of the sub-guideline is to ensure that professional nurses know the procedures to follow when workplace violence occurs, in order to ensure that all incidents are reported in an appropriate and efficient way, and can be dealt with in the minimum amount of time, causing as little distress as possible for the victims and the perpetrators.

Action steps

 Actively participate when policies and procedures are developed and discussed at macro-orientation level, by asking questions and comparing policies with the existing practices on workplace violence  Be cognisant of the policies and procedures, and the steps to follow when workplace violence takes place – for example by reporting such behaviour  Be aware of the resources available within the healthcare facility, such as the support line and the whistle-blowing process, so that you can deal effectively with or address the workplace violence when it occurs  Identify the unacceptable/inappropriate behaviour and try low-key interventions, such as talking to the person first  Report any form of workplace violence to the Nurse Unit Manager and hold her accountable to address the issue  Keep any documentation of the incident, to ensure accurate and factual information  Escalate the matter to the next level, such as the Nursing Service Manager or the HR department, if the unacceptable behaviour from the perpetrator of the workplace violence is not addressed after a reasonable amount of time  Resolve grievance procedures at the lowest level possible; however, if the outcomes are unsatisfactory, the reporting person may take the grievance to the next level, such as the HR department  Accept the perception that workplace violence, such as bullying, may need to be negotiated between the parties by using formal structures, and take the necessary action, or stand your ground

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 Challenge the existing policies, procedures and practices that are not conducive to a health environment, such as staff shortages; and do something about them, e.g. report, complain, write a letter etc.  During the conflict situation, remain calm; do not blame or argue with the perpetrator of the workplace violence o If it is physical violence, remove yourself from the situation and stay safe o If it is verbal abuse or bullying: . Allow the other person to express his/her concern . Listen for any hidden meaning that is not verbalised (if there is one) . Acknowledge if you are at fault and apologise . Clarify issues to ensure your understanding . Re-phrase to allow the individual to confirm your understanding . Aim to resolve the conflict as soon as possible . Call for help if the situation is escalating, or getting out of hand . Make the perpetrator aware of your displeasure of the situation (but do not let them use the negative energy to your disadvantage). Indicate to them, that you will speak to them at a later stage . Speak to the person when they have calmed down (and you have too) and resolve the issue at hand; but make the person aware of the expected professional behaviour . Behave appropriately when people make mistakes – do not be aggressive, take a breath, accept that it might be an honest mistake, and behave professionally  Train or mentor other nurses, especially student nurses, on what to do to prevent workplace violence, and what to do when workplace violence occurs  Be a role-model for other nurses on professional behaviour, and especially when dealing with workplace violence e.g. being assertive when the perpetrator tries to bully you, or is abusive  Be consistent in your behaviour, so that people know where they stand with you. Do not accept the violence one day, and then the next day you do not accept it – because people get confused by your inconsistent behaviour  Initiate employee assistance (ICAS) if the effects of workplace violence linger for longer than a few days

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 Request team debriefing sessions after the nursing of patients in the healthcare facility, due to physical violence in the community, or the death of children; as this affects all staff members and impacts the entire team  Discuss workplace violence and the effect thereof at formal employee forums – aiming at improving the working conditions for employees  When all else fails…ask for another shift, or ask to be moved out of a unit, but that should be done only as a last resort

4.4 LIMITATIONS OF THE STUDY

The richness of the data in the study provided an in-depth understanding of the experiences of the professional nurses with workplace violence; and this has enabled the researcher to achieve the goals for this research project; but the researcher is obligated to identify any possible limitations of the study; as all studies have their limitations.

Narrative research allows for collection of data from varying media, such as diaries, photo albums, drawings and writing. In this study the data collection were limited to storytelling. The use of additional media might have increased the number and richness of the stories.

The data were collected from only one category of nurses; and only one private healthcare facility. A study where all the categories of nursing staff, or even medical practitioners are included across more healthcare facilities, might have brought other information to light. However, this creates an opportunity for further study.

4.5 RECOMMENDATIONS

In this study, the experiences of professional nurses were explored and described. Based on the findings of the study, the researcher makes the following recommendations:

Recommendations for Nursing practice:

It is recommended that the guidelines be implemented and tested within the private healthcare facility.

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The findings of the study should also be disseminated to all the staff in the healthcare facility, in order to improve their awareness of the phenomenon. Furthermore, much has to be done to empower professional nurse to deal with workplace violence, in order to prevent the short- and long-term effects of workplace violence on individuals, and on the organization and the community.

Recommendations for Nursing Education:

It is recommended that Nursing education institutions incorporate workplace violence into their curricula, in order to increase the awareness of students of the phenomenon. These institutions need to train their students specifically on how to prevent workplace violence, how to cope with workplace violence, how to handle it when it happens, and what they need to do, when and if it happens e.g. whistle-blowing or the reporting of bullying or lateral violence.

Disseminate the findings to the Nursing Education Institutions, so that the guidelines can be incorporated into the curriculum of nurse managers, to facilitate the effective management of the phenomenon by future managers.

Clinical nurse educators in the private healthcare facility should also receive special training to support and guide student nurses in clinical practice where workplace violence takes place.

The training of Nursing Service Managers and Nurse Unit Managers should be facilitated, so that they can implement preventive strategies, and guide and support professional nurse in the operational setting, where workplace violence takes place.

Recommendations for Nursing Research:

The following recommendations are proposed for nursing research:

 It might be very useful to assess the specific organization again, once the guidelines have been introduced and implemented, in order to assess whether the guidelines were effective and have made a change in the organization.  A study could be conducted to assess the incidence of workplace violence at other healthcare facilities within the Eastern Cape.

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 A subsequent study could focus on all the categories of nursing staff (or even medical practitioners) who are employed at private healthcare facilities in the Eastern Cape.  The study can be repeated in, or extended to, other private healthcare facilities within the private healthcare organization.  It might also be useful to do a study in a private healthcare facility to assess the incidence of a certain type of workplace violence, which could improve the management of workplace violence in the facility.

4.6 IMPLICATIONS FOR THE NURSING PROFESSION

The Critical Social Theory (Polit & Beck, 2012: 506) was used as the paradigm for this study. The Critical Social Theory is action-oriented. The aim was to integrate the theory and knowledge that have been obtained during the study into the private healthcare workplace environment, so that nurses become aware of the contradictions and practices, and become inspired to change them. The researcher is aware that the process of enlightenment and change will take time; however, a critical researcher is oriented towards a transformation process, according to Polit & Beck (2012:506).

The participants in the study did not realise that by adopting the negative behaviour and attitudes of the perpetrators, they have allowed for a new culture to develop.

The findings have made it necessary to reinforce the ethical conduct of nurses and the need to reinforce the values that underpin nursing, such as civility, respect, co- operation, participation, care and dignity. In this study, guidelines have been developed to empower nurses, so that they can become inspired to stop the cycle of workplace violence. Every nurse has the right to say NO to workplace violence.

4.7 CONCLUSION OF THE STUDY

The research study has provided an in-depth understanding of workplace violence, as professional nurses have experienced it in a private healthcare facility. Evidence of lack of knowledge about the phenomenon and how to address it was found. Guidelines have been put forward to assist nurse managers and professional nurses to introduce and implement strategies, in order to address workplace violence effectively.

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POST SCRIPT

After my journey, through this study, I have realised that I applied ineffective strategies to address the workplace violence, such as allowing people to be rude or abusive and not addressing it – for whatever reason. With my new knowledge, I will address the unacceptable behaviour immediately, whoever it is, and be assertive and consequent. I will make my feelings known to the person, and speak to them, as one professional to another, to show my disapproval of their behaviour, whatever the reason may be. I will also report the incidents and make a point to care for and support my colleagues, and to protect them against this sort of behaviour, as far as possible.

As a manager, I have also learnt that my staff expect me to be a change agent and to deal with perpetrators; and for that reason, I will introduce progressive action, even if it is uncomfortable and it leads to disciplinary action. I will also ensure that all managers understand the need for these guidelines, and try to convince them to incorporate them into their everyday practices in the private healthcare facility. I will also drive the training programmes to enlighten and empower my colleagues and my staff.

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Vessey, J.A., DeMarco, R. & DiFazio, R. 2011. Bullying, Harassment, and Horizontal Violence in the Nursing Workforce in the workplace. Annual Review of Nursing Research. Springer Publishing Company. [pp. 133-157].

Viljoen, D. 2013. South Africa: Do you have a bully in the workplace? [Online] Available at: http://www.ensafrica.com/news/Do-you-have-a-bully-in-the workplace?Id=1053&STitle=forensics+ENSight. Accessed September 2014.

Walrafen, N., Brewer, M.K. & Mulvenon, C. 2012. Sadly caught up in the moment: An exploration of horizontal violence. Nursing Economics, 30(1), 6-13.

Wang, S., Hayes. L. & O’Brien-Pallas, L. 2008. A Review and Evaluation of Workplace Violence Prevention Programs in the Health Sector. Nursing Health Services Research Unit: University of Toronto, Toronto, Ontario.

Watson, R. McKenna, H., Cowman, S. & Keady, J. 2008. Nursing Research. Designs and Methods. London: Elsevier Churchhill Livingstone.

World Health Organization (WHO). 2002. WHO: World report on violence and health: Summary. [Online]. Available at: http://www.who.int/violence_injury_ prevention/violence/world_report/en/summaryen. Accessed November 2014.

Wood, M.J. & Ross-Kerr, J.C. 2011. Basic Steps in Planning Nursing Research. From Question to Proposal. 7th Edition. Sudbury: Jones & Bartlett Publishers.

Yon, G. 2015. Community Service Professional nurses’ experiences of bullying in State hospitals. Unpublished Master’s dissertation. Nelson Mandela Metropolitan University, Port Elizabeth, Eastern Cape, South Africa.

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LIST OF ANNEXURES

ANNEXURE A: CONSENT FORM

ANNEXURE B: RECRUITMENT LETTER

ANNEXURE C: INFORMATION LETTER FOR PARTICIPANTS

ANNEXURE D: REQUESTING PERMISSION TO CONDUCT RESEARCH FROM THE PRIVATE HEALTHCARE RESEARCH OPERATIONS COMMITTEE ANNEXURE E: RESEARCH OPERATIONS COMMITTEE APPROVAL

ANNEXURE F: REQUESTING PERMISSION TO CONDUCT RESEARCH FROM THE NURSING SERVICE MANAGER

ANNEXURE G: APPROVAL FROM THE DEPARTMENT OF NURSING SCIENCE’S RESEARCH COMMITTEE

ANNEXURE H: APPROVAL FROM THE FACULTY POSTGRADUATE STUDIES COMMITTEE

ANNEXURE I: GUIDELINES FOR DATA ANALYSIS TO INDEPENDENT CODER

ANNEXURE J: CONFIDENTIALITY AGREEMENT BY FIELDWORKER

ANNEXURE K: CONFIDENTIALITY AGREEMENT BY CODER

ANNEXURE L: TRANSCRIPT OF AN INTERVIEW

ANNEXURE M: DECLARATION LANGUAGE PRACTITIONER

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ANNEXURE A: CONSENT FORM

NELSON MANDELA UNIVERSITY

RESEARCHER’S DETAILS

Title of research project Workplace violence amongst professional nurses in a private healthcare facility in the Nelson Mandela Bay.

Reference number H15-HEA-NUR-001

Principal investigator L Schlebusch

Address 11 Yale Road, Bluewater Bay

Postal Code 6212

Contact telephone number 041 390 7179

I give my consent that a fieldworker interviews me and I am willing to participate in the above-mentioned project. I have read the accompanying letter explaining the purpose of the research project and understand that:

I have read the accompanying letter explaining the Initial purpose of the research project and understand that:  My participation is voluntary

 I may decide to withdraw at any time without penalty

 All information obtained will be treated in the strictest confidence

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 My name will not be identifiable and used in any written reports

 A report of the findings will be made available to me via my institution  I may seek further information on the project from L. Schlebusch

I hereby voluntarily consent to participate in the above-mentioned project

Signed at: …………………………on…………………………………………2015 place date

Signature of participant: Signature of fieldworker:

Mark the appropriate block with an X

Indicate the number of years that you have been nursing?

< 1 year 1-2 years 2-5 years 5-10 years 10- 20 >20 years years

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Indicate the unit where you are currently working?

Medical Surgical High care CCU ICU

Orthopaedic Theatre Minor theatre Urology Accident & Emergency

Statement by fieldworker on behalf of the researcher

I declare that I ………………….. have explained the information of this document to: (Name of participant)

He/she was encouraged and given ample time to ask questions before the interview commenced

The conversation was conducted in:

(language)

Signed:

(signature of interviewer)

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ANNEXURE B: RECRUITMENT LETTER

• PO Box 77000 • Nelson Mandela Metropolitan University • Port Elizabeth • 6031 • South Africa • www.nmmu.ac.za

14 April 2015

Dear Professional Nurse

Recruitment for research study

A research study is being conducted at the Nelson Mandela Metropolitan University (NMMU) in Port Elizabeth with regard to workplace violence.

The World Health Organization (2002) defined workplace violence as: “Incidents where staff are abused, threatened or assaulted in circumstances related to their work, involving an explicit or implicit challenge to their safety, well-being or health”. It includes physical and psychological violence, such as verbal abuse, harassment, bullying/mobbing and threat. (Di Martino, 2002:11). In this research workplace violence will include verbal abuse, psychological abuse, lateral violence, horizontal violence and bullying.

Please answer the following question and tick the appropriate block.

 Have you ever experienced workplace violence whilst being employed at this facility?  Yes No

If you agree to participate, a field worker will contact you and to set up a date for an interview and a fieldworker will do the interview. The interview will take approximately 45 minutes. It will be held in a private and secure location, and all information revealed will be strictly confidential.

I, …………………………………...... , agree to participate in above study.

NAME

My contact number: ……………………………………

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Please put this document in the attached envelope provided and drop it in my pigeon hole at the back of the healthcare facility.

If you require any further information, please do not hesitate to contact

Dr S du Rand at: Tel: +27 (0)41 5042615 Fax: +27 (0)41 5042616 Email: [email protected]

Thank you for your time and consideration in this matter.

Yours sincerely,

L. Schlebusch

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ANNEXURE C: INFORMATION LETTER FOR PARTICIPANT

• PO Box 77000 • Nelson Mandela Metropolitan University • Port Elizabeth • 6031 • South Africa • www.nmmu.ac.za

Dear Participant

INFORMATION LETTER FOR PARTICIPANT

My name is Linda-Marie Schlebusch, and I am a Master’s student at the Nelson Mandela Metropolitan University (NMMU) in Port Elizabeth. The research I wish to conduct for my Master’s dissertation is entitled: Workplace violence amongst professional nurses in a private healthcare facility in Nelson Mandela Bay. The project is being conducted under the supervision of Dr S du Rand at the Department of Nursing Science at the NMMU.

The goal of the study is to explore and describe the experiences of professional nurses regarding workplace violence in the private health sector. This information gathered will be used to develop guidelines to address workplace violence within the private sector.

I am hereby seeking your consent for an interview with you for the purposes of this study. A fieldworker will be interviewing nurses at your institution. Each interview will last approximately 45-60 minutes.

Participation is voluntarily and you may withdraw at any time. Information will be managed confidentially. Quotes from the interviews may be used in the research report or in an academic article. However, the actual names of the participants will be replaced with pseudonyms. There are no direct benefits for you, but the guidelines developed from the study will be of benefit to all the nurses working at your facility.

Upon completion of the study, I undertake to provide your healthcare facility with a bound copy of the full research report. If you require any further information, please do not hesitate to contact me:

 Cell: 0728121523  Tel.: 041 390 7179 or  Email: [email protected]

Thank you for your time and consideration in this matter.

Yours sincerely,

L. Schlebusch

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ANNEXURE D: REQUESTING PERMISSION TO CONDUCT RESEARCH FROM THE PRIVATE HEALTHCARE RESEARCH OPERATIONS COMMITTEE

• PO Box 77000 • Nelson Mandela Metropolitan University • Port Elizabeth • 6031 • South Africa • www.nmmu.ac.za

Ms ……………………..

Research and Ethic Committee

Sandton

Dear Ms …………,

RE: REQUEST FOR PERMISSION TO CONDUCT RESEARCH

My name is Linda-Marie Schlebusch, and I am a Master’s student at the Nelson Mandela Metropolitan University (NMMU) in Port Elizabeth. The research I wish to conduct for my Master’s dissertation is entitled: Guidelines to address workplace violence amongst professional nurses in a private healthcare facility in the Nelson Mandela Metropole. The project is being conducted under the supervision of Dr S du Rand at the Department of Nursing Science at the NMMU.

I wish to interview nursing staff at your private healthcare facility in Port Elizabeth. The data will be collected by a fieldworker during a narrative interview with each participant. Each interview will last approximately 45-60 minutes. The question that they will be asked are:

 You indicated on your consent form that you have experienced workplace violence. Please tell me the story.

Participants will not be coerced and they may withdraw from participating in the study at any time. The information gathered will be managed confidentially. Quotes from interviews may be used in the research report or in an academic article. However, the actual names of the participants will be replaced with pseudonyms. There are no direct benefits for the participants, but the guidelines developed from the study will be of benefit to all nurses in the future.

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I am hereby seeking your consent to conduct research at your healthcare facility. I have attached a copy of my proposal which includes copies of the consent forms to be used in the research process, as well as copies of the approval letters which I received from the NMMU Faculty Postgraduate Studies Committee (FPGSC) and the NMMU’s Research Ethics Committee (Human).

Upon completion of the study, I undertake to provide your facility with a copy of the summary report. If you require any further information, please do not hesitate to contact my supervisor, Dr S du Rand, at: Tel: +27 (0)41 5042615; fax: +27 (0)41 504 2616 or email: [email protected].

Thank you for your time and consideration in this matter.

Yours sincerely,

L. Schlebusch

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ANNEXURE E: RESEARCH OPERATIONS COMMITTEE APPROVAL

130

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ANNEXURE F: REQUESTING PERMISSION TO CONDUCT RESEARCH FROM THE NURSING SERVICE MANAGER

• PO Box 77000 • Nelson Mandela Metropolitan University • Port Elizabeth • 6031 • South Africa • www.nmmu.ac.za

26 January 2015

Mrs ………

…….Hospital

Port Elizabeth

6000

Dear Mrs ………..,

RE: REQUEST FOR PERMISSION TO CONDUCT RESEARCH IN ……………HOSPITAL

My name is Linda-Marie Schlebusch, and I am a Master’s student at the Nelson Mandela Metropolitan University (NMMU) in Port Elizabeth. The research I wish to conduct for my Master’s dissertation is entitled: Guidelines to address workplace violence amongst professional nurses in a private healthcare facility in the Nelson Mandela Metropole. The project is being conducted under the supervision of Dr S du Rand at the Department of Nursing Science at the NMMU.

 You indicated on your consent form that you have experienced workplace violence. Please tell me the story.

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Upon completion of the study, I undertake to provide your healthcare facility with a copy of the summary report. If you require any further information, please do not hesitate to contact me:

Cell: 0728121523 Tel.: 041 390 7179 Email: [email protected]

Thank you for your time and consideration in this matter.

Yours sincerely,

L. Schlebusch

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ANNEXURE G: APPROVAL FROM THE DEPARTMENT OF NURSING SCIENCE’S RESEARCH COMMITTEE

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ANNEXURE H: APPROVAL FROM THE FACULTY POSTGRADUATE STUDIES COMMITTEE

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ANNEXURE I: GUIDELINES FOR DATA ANALYSIS TO INDEPENDENT CODER

Please use Tesch’s data analysis process which involves the following eight steps (Creswell, 2014: 198):

 Step One: Read and reread through all the transcriptions to get a general idea of the content of the transcriptions. Some ideas are to be written down as they come to mind, as possible themes.  Step Two: Select one transcript and read the document critically. The researcher will look for the underlying deeper meaning of the content of the transcript. Once again, ideas and thoughts are to be written down, in the margin on the interview transcript.  Step Three: Read through all the transcripts, repeating what was done in Step Two. Cluster emerging themes and ideas, with similar topics together in one group.  Step Four: Take the list of topics and return to the data. The topics should be abbreviated in codes and put the code at the specific segment of the interviewed data, and next, see the emergence of new themes or codes.  Step Five: Word the topics in the most descriptive way possible and then convert them to categories. The list of categories should be reduced by clustering related topics together. Draw lines between categories that indicate inter- relationship of categories.  Step Six: Each category should be abbreviated.  Step Seven: Data material belonging to each category should be put together in one place; and a preliminary analysis will be conducted.  Step Eight: If it is required, the existing data should be recorded.

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ANNEXURE J: CONFIDENTIALITY AGREEMENT BY FIELDWORKER

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ANNEXURE K: CONFIDENTIALITY AGREEMENT BY CODER

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ANNEXURE L: TRANSCRIPT OF AN INTERVIEW

WV 8 – 5 June 2015

I Interviewer

P Participant

(Sound of recorder being tested and Interviewer enquires in Afrikaans if the Participant has read the question about workplace violence)

I Are you English? You can speak English or Afrikaans – it doesn’t matter

P I’m much more fluent in English because I really

I Then you speak English um what I wanted to say um that the whole question is about what were your experiences with violence in the workplace? So what is your story, what can you tell me…?

P Well, at the moment I’m working in the (unit) and it’s quite a hostile environment (giggles).

I In what sense?

P Um we have a lot of victimisation that’s going on in the (unit) a lot of unfair treatment and basically we have a racial issue there as well and um ja I think it’s about that but I think the victimisation is the worst peoples been called

I So tell me what has been happening? Incidents and so on?

P Okay people being called names, peoples been making racial remarks towards other colleagues um peoples being shouted at, being sworn at, you know, being treated like you’re from the streets you know common people which doesn’t deserve those treatments um belittling of people gossiping about people and it’s just in this one vicinity specifically that I feel that you know it’s kind of a dangerous environment. I have one colleague she actually came to see you yesterday her pulse goes up to about one hundred and fifty.

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I When she is at work

P When she, when there is an incident regarding the violence the victimisation

I She might be anxious

P Ja she mightn’t be the one on the receiving end but then she has like palpitations and anxiety her pulse hits about one fifty, which is very unhealthy and it’s a concern because nothing is being done about the situation although many people have actually addressed the situation and there is a lot of incident reports that have been written not only from the (unit) but from people outside the (unit) that’s just viewing and listening what is happening; but unfortunately nothing is being done about it and personally I feel you know that the company is not protecting us against specific individuals

I Okay, so you’ve mentioned the things that… is happening there it all sounds like verbal

P Ja verbal and emotional abuse

I And emotional abuse

P Psychological abuse as well you know we are about talking under correction now but we are about eight, seven to eight people working in the (unit) and you know it’s like a constant you get to work and it’s like drama from the morning seven till seven at night; and it’s like you can’t live with the negativity its always negative there is no positive in fact and where I’m sitting now our door is just across, over here and there’s swearing and loud talking going on but our unit manager doesn’t listen I mean she can possibly hear it from there because the door is always open but nothing is being done about it

I So how does that make you feel

P It makes me feel despondent it makes me feel I don’t want to be here anymore, it makes me feel that you know we are people in a profession and I would like to be associated and addressed professionally but due to certain colleagues you know not being as professional all the time, I mean 140

we all have our faults, we’re not perfect but we try to ad… what is the word I’m looking for

I Adapt

P Adapt and behave in a professional manner; so for me it’s like very despondent and its very negative because it’s not a reflection on the person that’s doing it but it’s a reflection on the (unit) sisters so doctors don’t go to the hospital and say (name) is da a dah they say the (unit) sisters at (hospital name) are blah, blah so you get combed under the same comb and I just feel it’s unfair because I have pride in my job, i have pride in how I um hold myself up you know and now my profession is being smeared through the mud because someone doesn’t have the same belief standards, moral values as I have; and we are all different people; but when it comes to our job we need to have the same ideas

I Mmm you said you’re despondent but I also from what you are saying, I pick up you’re frustrated

P Very, very frustrated

I Tell me a little about that …

P When people do things that’s not according to the standards of (name of company) or standards according to you because I feel that in nursing the patient that is lying there could have been my mother; she could have been my sister; he could of been my uncle, my child, my husband; so I want the best care for myself and my family; so I try to give the best care to my patient obviously you have your off day; but you try and give your best; but then it frustrates me because you see that a specific patient is not getting the best; and you feel to yourself you know that’s not how it’s done; but it doesn’t help you complaining about it because nothing is being done about it; so I think mostly that is the reason why I am frustrated and anxious at the same time and I’m upset and sad that it’s come to a certain level where you feel like you don’t want to talk anymore

I You don’t want to be here anymore

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P Ja, you don’t want to be here anymore if someone does something wrong, whatever it doesn’t have anything to do with me as long as I know what I’m doing and that’s not the idea of nursing, nursing is a team work; but we are not a team; we are not a team

I Ja okay if I could just go back to a few of the things you’ve said um the violence is it only directed between professional people so one nurse against another or to other professions, patients or anything like that?

P Ja it goes into each area there are no limitations I actually thought that there was limitations to only specific the professional people but it seems like its seeping out into other areas as well where people from outside are attacking us now because of your behaviour now they have the perception that all of us behave the same way and you know I feel I worked here for four years then I went away for a year then I came back and I feel I studied here so I feel I’ve built up a great relationship with most of the people in the hospital I mean I came back from my previous work and the pharmacy lady was like hi, (name of participant) how are you I was like she remembers my name and I don’t know what her name is and I just found that you built the relationships up and people remember you by the way that you treat them and act and react

I It affects their conducts towards you

P And now everyone is grumpy everyone is attacking the other and it’s like why are you being so aggressive I just asked you to lower this or bring this or whatever, I didn’t ask for the attitude I’m getting now but one attitude influences another one and influences another one and then you just have a lot of angry people verbally abusing each other so ja it’s come down to that

I Okay so what you’re saying also what I’m hearing it’s not just a question of just one person being abusive to everybody but the people now are fighting with each other

P Ja

I So that also makes it more unpleasant

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P Ja because now you are aggressive as well because you feel like why are you attacking me I haven’t even done anything wrong I haven’t even been aggressive with you but all of a sudden your aggressive with me and I find there are nurses that came for operations, they actually requested to be (procedure to be done) by only certain nurses and not being (procedure to be done) by specific other nurses I mean that says a lot in itself

I Ja so they identify certain people that has problems

P Ja umm like the other morning I came because I come to work earlier than the rest of my colleagues and I saw that this one colleague was lying in front and like always we go say hello and we are excited what are you coming for blah blah blah and she is like please (do procedure) me don’t let anyone else (procedure) me or let (name) (procedure) me or something but don’t let a specific person touch me

I And then your embarrassed

P And this is only of what they see how you are like presenting yourself to others not even being attacked or anything just by seeing how this person works what this persons personality is like how they address their patients and things and you as a patient you obviously want the best so you’re not prepared to take your

I Because you’re in any case scared

P Your scared freaked out of your mind and worried this person might kill me (giggles)

I Or even just be nasty towards me

P Or not careful enough

I Okay so what you are talking about is nurse on nurse violence

P Ja

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I But then you also say because this is now talking about nurse on patient um shouting of what

P Its shouting sometimes its like you know we stimulate the patients to wake up but then its like an aggressive stimulation

I Not just little pats

P and I’m saying how is it that my unit manager is unable to hear but it doesn’t help that we complain about it because nothing is being done about it now the patient has to just suffer through the recovery process but that’s just the way it is there is nothing we can do about it I say we can change if we have support system that supports us in our actions but if we don’t have support from the top level then we are useless here at the bottom and you don’t want to be responsible for people losing their jobs and things but something has to be done there needs to be a change it can’t go on like this I’m telling you now there are people going for interviews like it’s no one’s business, they don’t want to work here anymore because it’s an unhealthy environment people take their stress home two people have already resigned from all the drama that’s going on in the recovery room and I mean they are losing good people hard working people the doctors just have so much respect for most of the people in there but now you can see in the doctors attitudes as well when they leave a patient with you they are not really comfortable leaving you with a patient whereas they trusted you completely before so that is also influencing our relationships with our doctors and I just feel you know that I have worked hard to get to where I am and earn the respect that I have because it’s difficult for the doctors to get used to a new person in the (unit) they’ll shove you one side and say I don’t know you but for them to actually trust you is a big thing for me and now everyone is suddenly like you can see the doctors not really comfortable any more

I Ja they don’t trust anybody

P Ja and it’s just because of certain peoples actions I mean the doctors are in there and it’s like loud shouting, it’s swearing, it’s arguing and it gives this bad impression that all of us are like that and I feel like yet again nothing is being

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done about it because I feel that I am the nurse he is the doctor I see him in a professional manner I want him to see me in the same way.

I So are you saying that sometimes now it’s the doctors who are doing the shouting and the

P There has been conflict between

I Incidents

P Between specific people in the (unit) that’s also involved in the other incidents that’s attacking the doctors as well but yet again I don’t know if they’re not complaining or if they are okay with it, or if there is something being done, if there is a record being kept about the incidents that specific people are involved with but I don’t know, we come here and we don’t get feed back

I Ja ja

P No one comes back and says look we’ve informed blah blah and they are coming down to have a meeting with you or whatever we had a huge meeting were everything seemed okay, everyone said their dues, they were completely honest but then it wasn’t five to ten minutes and we were back to square one and it was like you know what screw these meetings, screw these meetings it’s a waste of time, nothing is being done there is no change I don’t want to go to a meeting in this place anymore because I feel it’s a waste of my time I hear the same thing we are not talking about the problems we are not addressing them we are not trying to find solutions we are just talking and talking and talking but nothing is being done

I Okay, to get away from the things that you’ve said now because I think actually you have said quite a lot um do you sometimes get violence in other areas…parts of the (unit)?

P We are a unique group of people and everyone has a different personality and to most people that’s coming from outside and they view us then they will see that are a bit aggressive with each other but its a play, play aggression. If maybe

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you bump me but you don’t say sorry, you walk on then I know okay she is having a bad morning, keep going and then later on you’ll greet me and talk to me you won’t even apologies for bumping me but I know you are having a busy morning or you might not have gotten up well this morning or your having drama or whatever I know that you are eventually going to talk to me again but I know that I don’t take it in a negative way

I A personal way

P Ja but to someone that’s looking out inside they will think that these people are so aggressive they are so rude but we all understand each other I mean there are people who walk around and moan and complain all day you used to that, that’s just the way (name) is leave her then there is me I am only like this after ten so everyone knows leave (name) alone until its ten because you’re going to get uurgh so you know everyone has their moods but there are specific people that are specifically that want to fight every battle every day aggressively and it’s like you know sometimes you need to let something just slide you are wasting your time and your energy focusing on all these little things while you could have made a change in a bigger way with something more positive, in a positive mind

I Fight the large battles not the small ones

P Ja I mean you can’t be fighting every single battle, every single day because it makes the people around you tired it makes them despondent, it makes them negative

I Yes and I think this is what you say in the (unit) at the moment the whole atmosphere is negative

P Its negative, unhealthy

I Angry

P Anger you feel frustrated you feel like your hands are tied because your unable to do anything you can’t even say anything because then you’re in the line of

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fire we’ve come to the point where everyone just keeps quiet and ignore because if you give attention then it just gets worse or if you try to protect the person that’s in the line of fire then you get abused verbally and psychologically and emotionally and then it steps into your personal life and people are starting to they don’t keep it professional they go below the belt and to me I just switch off because if you can’t approach people professionally then you leave don’t come and talk about my husband or my kids or my house or my car or whatever it is that I have I have nothing to do with you I work for it we, you don’t pay my bond this is my work place I’m just here to do my job I’m not your friend I condone you because no one is doing anything about you but if I had my way I would get rid of you

I Ja because you are causing problems for everybody

P For everyone and I mean this people take their problems home with them then their husbands get pissed off at home because why are you allowing this why is nothing being done about the situation why are you even listening to the people you know it’s like do you realise that we have four walls without a window we are trapped for twelve hours with those negative influences

I And you are with each other all the time

P All the time so if we are angry with each other now we have to look at each other all the time which is fine because I had an issue when I became a shift leader a while back and I was chosen as a shift leader someone else didn’t get the position that’s been there longer that’s older than me that has more experience and she was quite angry at me but you know what I thought to myself we still have to work together because this is a patient it’s their lives it could of been your mother, could of been your father, so I’m going to help you as far as I can as far as that we don’t need to talk as long as we can keep it professional that’s I need and that’s not being done at the moment no one is being professional everyone is being petty and childish and I’m going to get you back that type of attitude and it’s like or the doctors smiling too much with you oh you can take your patients the whole day, what the heck. I mean stop being childish stop

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being petty it’s a work place it’s not a school we are not kids anymore act your age or buy a life (giggle)

I (chuckles) I can hear you, you’re very frustrated

P Ja hey

I I’m hearing this person shouting outside so it reminds me again do you sometimes get patients that are violent towards the nurses

P Yes here we do especially in the (unit) we do have patients that are sometimes violent but then its from the anaesthetic or sometimes they just have aggression when they wake up but I must say or anaesthetists are very good especially Dr (name) he will not allow our patient even under anaesthetic to hit the nurse although I’ve almost been hit in my face once I think I was grabbed at he was “You don’t grab my nurses” so at least we know your anaesthetists care

I And they protect you

P Ja and we have the Menere; so we always like Menere and they rush in and help and say hold him down and you get something so you do get those moments but I must say that we are very well supported by our male doctors and by the Menere and we, everything said, most of the (unit) nurses they are good team workers if I have a problem everyone is going to come help me

I Your colleagues are coming to help

P Ja but the day we had two kids that came in and we are all scared of kids because they can’t you I can’t breathe or I can’t this or I can’t that

I Yes of course I didn’t realise that

P So there are two nurses per patient for children because they [desaturate] relatively quickly like within seconds so I was struggling and another nurse was also struggling with a patient while our colleague watched us my patients stats was twenty three, ninety five is normal she just sat there and she watched she didn’t come help me I had to call the nurse that was helping the other nurse

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with her emergency child to come and help me as well because she was at the emergency trolley and I didn’t want to let the doctor down with a child so I just thought to myself you know what this is what we are stuck with the situation isn’t going away nothing is being done about it so we will just have to accept it if this child dies well she didn’t come help me I need help I can’t do it on my own with an adult it’s much easier

I Ja its easier to…

P Ja it starts getting frustrating when you feel that people’s lives are at stake like someone could of helped me someone could of responded earlier or quicker but then they sit and watch you while you thinking you deserve it or something because in the (unit) if you even here the stats is going low or (name) looks a bit panicky or (name) just called (another staff member) “Kom kyk hier” you know certain people will react where as others sit there and they are not concerned about your crisis

I So what you are saying is that this whole atmosphere is also influencing the work

P Definitely

I The work that you are doing

P Definitely

I Endangering the patient

P Its scary at this point that you feel that you can’t trust your colleague and we are supposed to be a team we are part of a bigger team but we are supposed to me a team I am supposed to know that if I am alone with you I can rely on you one hundred percent but now I feel that I can’t even call you because you don’t even respond to the normal things so ja

I It makes life difficult

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P It does, it does but we just come to work we do our work until we go home dissatisfied because the day was crappy and then when people don’t come to work we are short of staff but we have the most fun we actually laugh, we talk everyone is relaxed no one has an issue and the work still goes on

I So it sounds to me as if its certain people who, that are aggressive towards the other one

P Very, very

I Other incidents of aggression that you have had, perhaps before you came to work in the (unit)

P No not really now it’s just that otherwise I haven’t come across any

I You get along with your colleagues quite fine

P Ja I’ve never had the need to be aggressive with the situation of me being chosen as the (unit) nurse there was also victimisation going on and things but you know what I came here alone I applied alone so I really don’t care what people have to say about me as long as the doctors are satisfied my patients are breathing and alive and satisfied and happy I don’t really care about anyone else

I Anything else that you want to talk about

P No not really I think I have said quite enough (laughs) I think I’ve said too much

I No I wouldn’t say you said too much but

P I said a mouthful

I I think you’ve got your message across that the situation is frustrating at the moment

P Ja very and I’m just waiting for the new hospital to open for me to go as well

I Where is that one in Lorraine

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P Ja I’m just waiting for that I think everyone is just waiting for an opportunity to leave

I You don’t want to leave the organization but just here

P And the organization isn’t so great as well so I would prefer not being at (company name) I mean they don’t really care about their staff, ten people resign and they don’t get anyone to come and work so the people that’s left they get abused cos know they still have to smile through everything and they have pain they can’t stay out of work because there is a shortage of staff and I just feel it’s unfair to the people who stay behind but no one is applying to this place because this place doesn’t have a good reputation with regard to their employees they are great with their patients but they treat the employees like slaves

I Ja

P There is no sense of appreciation one year for nurses they gave us what they called a first aid kind of bag thing for nurses day, there was a pencil in there, there was an elastic band in there and there was a rubber in there a chappie bubble gum we are not children we are adults what am I going to do with the elastic band I’ve never even used it in the (unit) I’m just saying you know there is no sense of appreciation from the company’s side but everyone is doing their utmost and their best till there are complaints coming through which is obvious because we are short of staff and that’s also one of the reasons why everyone is becoming aggressive and attacking each other because you keep phoning me to bring the patient but do you realise I have five admissions and I’m the only nurse on my side so now it’s like I didn’t know I’m sorry I do apologise for today I’ll phone earlier so that you can be prepared earlier you know it’s like so everyone is frustrated everyone is attacking everyone, everyone is aggressive everyone is despondent everyone is like have you heard of anything yet and everyone is going for interviews left right and centre and the company is not realising that everyone is leaving the ship

I And the ones that stay behind they suffer

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P Ja they suffer and they are the loyal one they have been working here for twenty seven years and they get three thousand rand for their twenty five years of service I mean that is not even a patch on the twenty five years that I have devoted my life to you that my children didn’t have a mother at home and they say we should be grateful that we have a job but they should be grateful that someone is even prepared to work here at this point because it is an unhealthy environment now they employ all these mentally ill sick people who come a terrorise everyone else and it’s like a lose-lose situation and then we would rather work without this person

I Or go and work somewhere else

P Ja any other questions

I No I don’t have any questions for you anymore, thank you very much

P No problem enjoy the rest of your day

I You too.

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ANNEXURE M: DECLARATION LANGUAGE PRACTITIONER

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