Verbal abuse of nurses by physicians in a private sector setting

The aim of the study was to determine whether physicians in a private sector setting verbally abuse nurses, and to what extent. A review of the literature showed that verbal abuse by physicians accounts for the highest incidence of aggression towards nurses in health care, and that it is strongly related to turnover rates. It has also been reported in recent studies that within the context of verbally abusive episodes, patient care, work productivity, morale and job satisfaction have been negatively affected. Of the 120 questionnaires that were distributed among registered and enrolled nurses, 83 were returned in time to be used, which was a response rate of 69%. This response rate is consistent with previous studies and is exactly the same as for a study that was done in Turkey (Uzun, 2003:81). The questionnaire used was one that has been adapted from the Verbal Abuse Scale developed by Manderino and Berkey (1997:50) and the Revised Conflict Tactics Scale (CTS 2) as described by Little (1999:24), and was in the form of a 4-point Likert-scale with one open ended question. The results showed that 79% of the nurses admitted that verbal abuse was taking place. Forms of direct verbal abuse included 81% that felt they were criticised unjustly, 76% that were screamed at in front of others, and 81% that felt physicians vented their frustration on them. The results obtained in the study were consistent with previous studies done elsewhere and it indicated that nurses still experience high levels of verbal abuse in the workplace.


Introduction
Verbal abuse is an occupational hazard and the prevalence of it against nurses is o f g re a t c o n c e rn , e s p e c ia lly w hen c o m p a ris o n s are d raw n w ith o th e r professionals (International Council of N u rse s, 2 0 0 0 :5 ).A m o n g h e a lth personnel, the nursing staff are at the most risk of violence.Verbal abuse is ty p ic a lly fo u n d in re la tio n s h ip s o f u n eq u al p o w e r and is a fa c to r in maintaining the disproportional amount o f p o w e r o f o n e in d iv id u a l in the re la tio n sh ip (M a n d e rin o & B erkey, 1997:48).In the private health care sector, hospital management is obliged to favour ph ysician s, as a w ithdraw al o f their patients will lead to a decrease in the income of the hospital.This leaves the nurses highly vulnerable and creates relationships o f unequal power.

Background to the study
A c c o rd in g to D iaz and M c M illa n (1 991:98 ) the ro le -c o n flic t betw een p h y sician s and nurses arises from a difference in how they view the nursing role, either as a traditional repressive/ n u rtu rin g role resp o n siv e to o th e rs ' needs or, as the more recently defined in stru m e n ta l/a g e n tiv e role, th ro u g h which scientific knowledge is used to make rational decisions.The latter role has historically been delegated solely to physicians.
The differences in the interpretation of the role o f the nurse c o n trib u te s to m isunderstanding, and unfortunately, also to the verbal abuse of nurses.It can take on different form s ranging from accusing nurses of mistakes that they did not make, to venting their frustrations on them when something goes wrong, or to actually screaming at them and calling them names.and D isch (1997:35) violence in the workplace usually reflects the violence in the society.

Problem statement
V erbal abuse stro n g ly relates to the turnover rate of nurses (Cox, 1991 (b):66).It thus inevitably intensifies the stress placed on an often already short-staffed health care unit (International Council of Nurses, 2000:8) with detrimental effects on the quality o f care rendered to patients.
In the private health care secto r the hospital management try and negotiate with as many as possible physicians to make use of their facilities for the care of their patients.The physicians are thus in a favourable position as they determine the incom e o f the hospital.Hospital management at all times tries to meet all the needs of the physicians in order to ensure that they will continue to admit patients to the hospital.It is expected of the nurses as employees of the hospital management to support the management in meeting the needs o f physicians.This a ttitu d e le a v e s n u rse s p ro n e to unreasonable demands by physicians.

Aim of the research
The aim of the research was to determine w h eth er n urses w ere being verbally ab u se d by p h y sic ia n s in a se le c te d private sector setting, and to what extent.

Concept clarification
For the purpose o f this research, verbal abuse is defined as any communication a p e rso n p e rc e iv e s to be a h a rsh , condemnatory attack upon her or himself, p ro fe s s io n a lly o r p e rso n a lly (C o x , 1991(a):32), w hile the Intern atio n al Council o f Nurses (2002: 4) described abu se as b e h av io u rs that h u m iliate, degrade or otherwise indicate a lack of respect for the dignity and worth of an individual.

Significance of the study
Nursing managers can be made aware of the incidence o f verbal abuse o f their staff through the findings of this research and encourage them not to m inim ize incidents o f verbal abuse and quietly accept them.By addressing the problem, the stress caused will be decreased with resulting jo b satisfaction and retention o f staff.

Research design and Methodology
A d escriptive co ntextual design was used.T he re se a rc h p o p u la tio n w as c o m p rise d o f all the re g iste re d and enrolled nurses working in the specific private sector hospital.All the nurses w ho w e re on d u ty on th e day o f distribution o f the questionnaires were invited to participate in the research.It included registered and enrolled nurses from all the wards, intensive care units and operating rooms.Ninety registered nurses and thirty enrolled nurses were on duty on that specific day.
A structured questionnaire, adapted from the Verbal Abuse Scale (VAS) developed by Manderino and Berkey (1997:50) and the Revised Conflict Tactics Scale (CTS2) as described by Little (1999:24), was used.The VAS is a 65 item self-report questionnaire which defines 11 different forms o f verbal abuse, while the CTS2 is a 15 item q u estio n n a ire , w hich was originally developed by Strauss, Hamby, Boney-McCoy and Sugarman( 1996).The VAS has an in tern al co n siste n c y o f Cronbach's alpha coefficient o f 0.67 to 0.95 (Cook et al. 2001:322).The CTS2 has been used in numerous community studies o f violence and was found to have excellent internal consistency and construct validity (Little 1994: 24).A 4p o in t L ik e rt-S c a le w as used in the questionnaire w ith only one question requesting a descriptive answer.
A meeting was arranged in each ward with the registered and enrolled nurses on the day o f the data collection in order to explain the research to them and to invite them to participate.Those who agreed an d in d ic a te d th a t th e y w a n te d to participate were given the questionnaire with a covering letter explaining that by completing the questionnaire informed c o n s e n t had b een o b ta in e d .
A ll respondents were also provided with an envelope labelled with the name o f the primary researcher.They were requested to com plete the q uestionnaire and to place it in a box provided in the office of the secretary o f the N ursing Service M anager and in the office o f the Nursing M anager of the operating room .From there, the questionnaires were collected on a specific date by the researcher.

Ethical considerations
Permission to carry out the study was obtained from the Ethical Com m ittee of the Faculty o f Health Sciences o f the U niversity o f P reto ria and from the re le v a n t a u th o ritie s o f th e p riv a te hospital.
As the covering letter handed to those w ho w ere w illing to p articip ate had e x p la in e d th a t c o m p le tio n o f the q u e stio n n a ire c o n s titu te d in fo rm e d consent, their anonymity was ensured.They were also asked not to write their names anywhere on the questionnaire, or provide any information that could lead to them being identified.The participants were also assured that their responses would be regarded as confidential.

Reliability and validity
As the instrument used was adapted from o th er instrum ents, a pilot study was earlier done, consisting o f 2 enrolled and 2 registered nurses.The results indicated that the questionnaire did not need any changes and was th erefore valid and reliable.The nurses were not further used in the main study.
A literature study about the topic had been done to ensure that an instrument is used that will ensure the validity of the findings.Instruments that were used by other researchers and have been proven to provide valid data were adapted for the unique circumstances and the context in which the research had been carried out.

Data analysis and findings
D escrip tiv e sta tistic s w ith reg ard to f re q u e n c ie s an d p e rc e n ta g e s w ere c a lc u la te d fo r all v a ria b le s on the structured questionnaire.Answers to the open question were analysed separately by the prim ary researcher.R ecurrent topics were identified and described.

Profile of the respondents
O f the 90 re g iste re d n u rses and 30 enrolled nurses who were on duty on that day, 14 (47%) enrolled nurses and 69 (7 7 % ) re g is te re d n u rse s re tu rn e d com pleted question-naires.A response rate o f 69% has thus been achieved, exactly the same as in a study on the perceptions and experiences o f nurses in clinical settings that had been done in T u rk e y (U zun, 20 0 3 :8 1 ).P erso n s younger than 40 years of age represented 61 % o f the respondents.With the largest group being between 30 and 39 years old, they co n stituted 37% o f the sam ple.Only 15% o f the respondents were 50 y e a rs and o ld er.T he m a jo rity o f respondents, namely 50 persons (61%), were married.The majority of the respondents (56%) were in the specific posts for less than 10 years at the time of the research.Only 21 persons (26% ) were em ployed for 15 years and longer.
The complete sample of 69 registered nurses held qualifications, registered w ith the SA N ursing C o u n cil, in G eneral N ursing Science, while 53 (7 7 % ) a lso had q u a lific a tio n s in M idw ifery, 14 (20% ) in O perating Room Nursing Science, 38 (55%) in P sy c h ia tric N u rsin g S cie n ce and Community Nursing Science, 19 (28%) in Intensive Care Nursing Science and 2 (3%) in Trauma Nursing.The 14 enrolled nurses had qualifications in fundamental and general nursing.
Nursing is viewed as a female profession in the South African context.It is also re fle c te d in the co m p o sitio n o f the respondents of this study as only 3 male nurses w ere involved.As nursing is viewed as a female dominated profession in South Africa, and physicians are still m ostly m ale, this could influence the interpersonal relationships.

Nurses as victims of verbal abuse
O f the 82 respondents who answered this question, 49 (60%) reported that verbal abuse o f nurses by p h y sicians takes place sometimes, while 15(18% ) were of the opinion that it happens often (refer to: Table 1).Seventeen respondents (21 %) were not aware of such incidents.By far the majority of the respondents agreed that verbal abuse o f nurses by physicians does take place.In the study that had been done in Turkey by Uzun (2003:81) 87% of the respondents in d icated that they had e x p erien ced verb al abu se in the 12 m onths that p re c e d e d the study.A lth o u g h the incidence in the South African study is much lower, the mere fact that it takes place is u n acceptable.Verbal abuse in flu en ces the relatio n sh ip betw een physicians and nurses negatively (Geyer & Zondagh: 2003:32).This may explain why nurses in a study done by Begany (1995:32) reported that nurses felt that physicians did not respect them.
As indicated earlier, verbal abuse has been defined as any com m unication perceived as a harsh, condem natory attack.One can therefore divide it into two groups, namely direct verbal abuse, and indirect verbal abuse.Last named implying that non-verbal communication (body-language or behaving as if the nurse does not exist) would also be a form o f verbal abuse.

Direct verbal abuse
The occurrence of 3 types of direct verbal abuse were determined in this research, nam ely: being criticise d w ith o u t a reason; being sworn at or insulted; and screamed or shouted at in front o f other people.Not all the respondents answered this question (refer to: Figure 1).O f the 81 respondents who answered the question on being criticised unjustly, 59% indicated that it happens som etim es, while 21 % indicated that it often happens.It seems as if nurses are less frequently insulted, as 50% of the 76 respondents who answered this question reported that it does not take place at all, while 38% reported that it happens sometimes and 11 % that it often happens.

Forms of spitefulness experienced by the respondents
The majority o f the respondents (67%) w ho answ ered the q u estio n felt that according to their experience, physicians never said bad things to the nurses just to spite them (refer to: Figure 3).It seems as if it is not com m on p ractice that physicians verbally abuse nurses ju st for the sake of abusing them.

Forms of meanness experienced by the respondents:
Two aspects, namely suggestive jokes, and th a t o f p h y s ic ia n s d e lib e ra te ly misunderstanding nurses when they take part in discussions, were investigated.O f the 76 respondents who answered this q u estio n , 37% had b een v ic tim s o f suggestive jo k es made by physicians.This is considered to be a less aggressive form of verbal abuse and nurses working In this study 44% of the 77 respondents who responded indicated that they have experienced the latter (refer to: Figure 4).The relatively small percentage in this instance compared to the percentages of re sp o n d e n ts w ho ex p e rie n c ed o th e r types o f verbal abuse, can possibly be attributed to the fact that this type of ab u se is m ore often ex p e rie n c ed in operating theatre rooms whereas all the nurses who were on duty in all units of the hospital were invited to take part in the research.

Forms of indirect verbal abuse
This form o f verbal abuse relates more to a non-verbal form of abuse, as it is not so much what is being said than the bodylanguage or behaviour.It is as if the nurse does not matter and does not exist, that em barrasses the nurses.

Four presentations of indirect verbal abuse have been studied
Speaking to the nurse via other people; addressing the nurses only when it is absolutely necessary; making nurses feel bad; and making nurses feel responsible for other people's mistakes.It happened to nearly half of the respondents (46%) w ho responded to this question that physicians have, in the past spoken to th em via o th e r p eo p le , w h ich they experienced as extremely degrading.
By far the majority of the respondents, namely 83%, indicated that a physician made them feel bad, while 82% felt that th ey w ere o n ly sp o k en to w hen necessary, and 76% felt that they were m ade to fe el re sp o n sib le fo r o th e r people's mistakes (refer to: Figure 5).

Being overlooked by the physicians
The majority of the respondents (74%) felt that, in the past, physicians ignored them as if they did not exist or were not worthy o f being noticed.This usually h a p p en e d a fte r d isa g re e m e n ts.

Other forms of verbal abuse
In the o p e n -e n d e d q u e s tio n , the respondents were given the opportunity to describe any other type o f verbal abuse that took place that had not been covered by th e s tru c tu re d q u e s tio n s .T he comments did not reveal anything that had not b een in c lu d e d in th e questionnaire.However, it is clear that the n u rs e s feel u p se t a b o u t the belittlement that they experience.One of them passed the com m ent that " ...th e physician tries to m ake you resignmake life difficult for you".

Summary of findings
The majority o f the respondents (7 9 % ) experienced verbal abuse.Although all forms of verbal abuse were reported as h a v in g b een e x p e rie n c e d by th e respondents, the highest p ercentages were allocated to: • Being criticised even when they had not done anything wrong (81% ).
• Having been the victim for physicians to vent their frustration on them (81%).
• Having been screamed and shouted at in front of other people (76% ).

Limitations of the research
This descriptive study of perceptions and experiences of nurses of verbal abuse had been done in one private hospital only.
T h e fin d in g s can th e re fo re not be g e n e ra liz e d and a p p lie d to o th e r h o s p ita ls .T he re se a rc h e r th e re fo re recom m end that similar studies be done in other hospitals in both private and public sectors.

Recommendations
Based on the findings, it is recommended that: • Protocols have to be developed for the prevention, reporting and dealing with verbal abuse.
• Nurses should be encouraged not to minimize incidents of verbal abuse and quietly accept them.
• Nurses should be taught how to deal with verbal abuse and should be encouraged to report threats or incidents of abuse to the hospital management.
• Colleagues and nursing managers should be encouraged to support nurses who report incidents.

List of sources
The verbal abuse o f nurses in South A fric a is a se rio u s pro b lem th a t is increasing.In 2002 Geyer and Zondagh (2 0 0 2 :3 2 ) s ta te d th a t: " D E N O S A (D em o cratic N urses O rganization of South Africa) received several complaints a b o u t m e d ic a l p r a c titio n e r s ' unacceptable conduct tow ards nurses over the past few months.Nurses are v e rb a lly a b u se d , b e little d and the practitioners imply that nurses are stupid and incom petent in front of the patients, visitors and other staff."A lthough verbal abuse o f nurses by p h y s ic ia n s is a w o rld w id e tre n d (International Council of Nurses, 2000:5), the occurrence of verbal abuse in South Africa can be attributed to the occurrence of violence in the society.According to Kreitzer, Wright, Hamlin, Towey, Marko in operating theatres are often exposed to it.Operating theatre nurses have to e n d u re w h at W atson (2 0 0 2 :2 2 8 ) describes as lewd jokes and comments about co-w orkers' anatomies.It is also in th is a tm o sp h e re th a t p h y sic ia n s som etim es deliberately m isunderstand n u rs e s w h en th ey say so m e th in g in n o c e n tly .It is d o n e in o rd e r to c o n trib u te to the jo k e s th a t are exchanged.
o rd in g to the a n sw e rs o f the re s p o n d e n ts , 4 4 (6 2 % ) o f the 71 re s p o n d e n ts w ho re sp o n d e d to the question indicated that, at the time of the investigation, more than one physician w ere involved in practices that they considered to be verbal abuse.Twelve o f the respondents, out o f the whole

Figure 6 :
Figure 6 : Forms of being overlooked experienced by participants

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