Sisawo et al.

BMC Health Services Research (2017) 17:311

DOI 10.1186/s12913-017-2258-4

RESEARCH ARTICLE Open Access

Workplace violence against nurses in the

Gambia: mixed methods design
Ebrima J. Sisawo1,2, Saide Yacine Y. Arsène Ouédraogo2 and Song-Lih Huang3*

Abstract
Background: The aim of this study was to assess the prevalence, perpetrators and factors associated with workplace
violence against nurses in public secondary health care facilities from two health regions in the Gambia.
Methods: Data was collected from 219 nurses using self-administered questionnaire and 35 face-to-face interviews.
The data collection was conducted between July and September 2014 in 14 public secondary health care facilities.
Results: A sizable majority of respondents (62.1%) reported exposure to violence in the 12 months prior to the survey;
exposure to verbal abuse, physical violence, and sexual harassment was 59.8%, 17.2%, and 10% respectively.
The perpetrators were mostly patients’ escorts/relatives followed by patients themselves. Perceived reasons of
workplace violence were mainly attributed to nurse-client disagreement, understaffing, shortage of drugs and
supplies, security vacuum, and lack of management attention to workplace violence.
Conclusions: Nurses in the Gambia are at a relatively high risk of violent incidents at work. Policies and strategies that
are sensitive to local circumstances and needs should be developed for the prevention of workplace violence.
Keywords: Workplace violence, Secondary health care facilities, Nurses, Gambia

Background related-violence reported by nurses in Taiwan were

Workplace violence is defined as incidents where staff physical violence, verbal abuse, bullying/mobbing and
are abused, threatened or assaulted in circumstances re- sexual harassment [4]. Most studies on this subject
lated to their work, including commuting to and from highlighted patients’ relatives/escorts and patients them-
work, involving an explicit or implicit challenge to their selves as perpetrators of violence [4–7]. Increased num-
safety, well-being or health [1]. Studies have documented ber of evidence indicates that violence is now considered
workplace violence as one of the most complex and dan- to be a major occupational hazard for nurses worldwide
gerous occupational hazards facing nurses. The Inter- [8]. The problem of violence in health care is not new; it
national Labor Office (ILO)/International Council of has probably always been a part of nursing [9]. The joint
Nurses (ICN)/World Health Organization (WHO)/Pub- ILO/ICN/WHO/PSI research findings indicate that in
lic Services International (PSI) joint program on work- developing and transition countries, more than half of
place violence in the health sector in 2003 indicated that the health sector personnel experienced at least one inci-
nurses are 3 times more likely, on average, to experience dent of physical or psychological violence. The worry,
violence in the workplace than other occupational fear and anxiety of being exposed to verbal and physical
groups [1]. Nurses are subjected to verbal and physical violence are common among nurses [10].
abuse so frequently that these events are often accepted This study focuses on nurses working in public sec-
as “part of the job” [2]. ondary health care facilities in the Gambia. Gambian
An Egyptian study indicated that 69.5% and 9.3% of nurses fall under four main categories: State Registered
nurses faced verbal and physical violence, respectively Nurse (SRN), State Enrolled Nurse (SEN), Community
[3]. Pai and Lee revealed that the main forms of work- Health Nurse (CHN) and Community Nurse Attendant
(CNA) [11]. SRNs are the first level of general nurses
* Correspondence: slhuang@ym.edu.tw who performed general patient care. They also handle
3
Institute of Public Health, National Yang-Ming University, No.155, Sec.2,
Li-Nong Street, Taipei 112, Taiwan, Republic of China management and supervision roles in public secondary
Full list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Sisawo et al. BMC Health Services Research (2017) 17:311 Page 2 of 11

health care facilities. The SENs are the second level of facilities/secondary health care facilities (the focus of the
general nurses whose training is not as rigorous as that current study). The secondary level includes major and
of the SRNs. They assist the SRNs in carrying out basic minor health centers that provide preventive (including
nursing care procedures for patients. This allows the reproductive and child health services, curative and in-
SRNs to concentrate on more complex nursing care pro- patient services). Major health centers provide basic sur-
cedures. The CHNs live and work for the most part in gery if they have the staff to do so but minor health
primary health care villages, supervising the village facilities do not do surgery (except eye surgery, which is
health workers and traditional birth attendants. Some of handled by the National Eye Care Program trained staff ).
the CHNs are posted to the reproductive and child Nurses constitute the majority of staff composition in
health teams in public secondary health care facilities. public secondary health care facilities. There are posi-
The CNAs have basic nursing skills with no formal tions for pharmacy assistant, laboratory assistant, envir-
training in nursing decision-making. They receive on- onmental health officers and other support staff
the-job training to become nurse assistants. An 18 month including orderlies and ambulance drivers. The tertiary
advanced midwifery program is available to SRNs, SENs level comprise of hospitals which provide all services in-
and CHNs to become midwives. Human Resources for cluding specialist care and/or services. The hospitals
Health report in 2012 indicate a total of 1090 nurses provide care for patients whose conditions cannot be
working in the public health sector in the Gambia. Of handled at the basic/secondary health care facilities. The
these, 549 nurses were distributed in primary, secondary staffing profile of hospitals (tertiary level) consists of all
and tertiary levels of care in Western I and Western II categories of nurses, doctors (including specialists),
Health Regions [12]. The proportion of nurses in the X-ray, pharmacy, laboratory, medical record staff and
Gambia is 3.2/10,000 population [12] which is below the orderlies. A few dozen private health clinics and
WHO’s minimum threshold of 23 doctors, nurses and many pharmacies also diagnose and prescribe treat-
midwives per 10,000 population. There has been a high ment, particularly in the urban area. These are not
attrition within the health sector especially skilled staff integrated into the government system, and provide
such as nurses, doctors, public health officers and mid- services for fees paid by the patients.
wives both internally and externally and was estimated The current study focuses on nurses because they rep-
between 30% and 50% per two years [11]. A study con- resent approximately 75% of the total healthcare work-
ducted in 2002 linked attrition of nurses to poor remu- force in the Gambia [11]. They are the most available
neration and incentives, lack of housing facilities, poor personnel throughout health care settings in the country
working environment and conditions including equip- making them invaluable human resources for the health
ment, supplies and logistics, lack of/inability to develop care sector. They serve as front-line health care pro-
in one’s career and heavy workload with same remuner- viders which increases their contact with the public.
ation. Another study in 2016 reported 87% prevalence of Consequently, this increases their risk of exposure to
perceived effort-reward imbalance among health care violent behaviors from aggressive patients and the pub-
professionals in the Gambia including nurses [13]. This lic. Although nurses worldwide experienced violence in
study indicates that nurses reported higher perceived ef- their workplace, how nurses experience violence in the
forts, gain fewer rewards and express a higher degree of Gambia remains unclear. To the best of the authors’
over commitment at work than environmental health of- knowledge, there is no information on occupational vio-
ficers. Low job satisfaction and high attrition of nurses lence towards Gambian nurses in published literatures.
could exert work pressure on nurses due to low staffing- There is no incident reporting procedure or policy to
patient ratio consequently affecting their service monitor workplace violence in the Gambian nursing
behaviour. workforce. The absence of such policies renders it diffi-
Health services in the Gambia consists of three levels cult to document the extent of the problem.
[11]. The primary level is the first point of contact with Given that this research represents the first study to
the health system at community level. It provides mainly explore workplace violence against nurses in the
preventive care and treatment of minor ailments. The Gambia, the findings could serve as baseline information
primary level consists of health care villages that have for further large-scale studies to closely examine the
been selected from those with a population of 400 or oc- problem of violence in the Gambian nursing workforce.
casionally from ones located in relatively isolated areas The data generated could be valuable for health care
[11]. Health care delivery at primary level is provided by managers and policy makers in planning violence reduc-
Village Health Workers (VHWs) and Traditional Birth tion interventions. By extension, the findings could con-
Attendants who are both supervised by community tribute to existing literature in the developing world
health nurses (CHNs). Functioning in parallel with the where the subject is under researched. Given the afore-
primary health care villages are the basic health mentioned gaps and concerns, this study was conducted
Sisawo et al. BMC Health Services Research (2017) 17:311 Page 3 of 11

to address the following aims: First, to determine the Council of Nurses (ICN) and Public Services Inter-
prevalence and perpetrators of workplace violence national (PSI) joint program on workplace violence in
against nurses in the Gambia. Second, it attempts to the health sector [1]. The tool was modified to suit the
identify possible factors associated with workplace vio- study objectives and cultural context of the Gambia. The
lence against nurses in the Gambia. tool was maintained in its English version since Gam-
bian nurses are able to read and write in English. An ex-
Methods pert in Occupational Safety at the National Yang-Ming
Study design and selection of participants University in Taiwan and another at the University of
This study employed quantitative and qualitative designs the Gambia examined the content validity and reliability
to address the study aims. The study was conducted in of the tool. They were asked to assess the questionnaire
two (2) out of the seven (7) health administrative regions for its clarity, relevance, comprehensiveness, and sensi-
in the Gambia. The regions in question were Western I tivity to Gambian culture. Pretesting of the tool was con-
and Western II Health Regions. The two regions account ducted with 20 nurses who were subsequently excluded
for 52% (549 nurses) of the total nurse population work- from the study. Workplace violence was regarded when
ing in public health care facilities in the Gambia [12]. the study participants experienced at least one type of
Public health care facilities include hospitals (tertiary violence such as physical violence, verbal abuse, or sex-
level) major and minor health facilities (secondary level) ual harassment in circumstances related to their work
and primary health care villages (primary level). This twelve (12) months prior to the study. Physical abuse
study was focused on secondary health care facilities was defined as being hit, pushed, beaten, kicked, slapped,
(major and minor health facilities). These facilities pro- stabbed, shot, bitten and/or pinched in the workplace.
vide outpatient (including reproductive and child health Verbal abuse was regarded as being shouted at, insulted,
services) and inpatient services (but not specialist care). intimidated, embarrassed, blamed or verbally disre-
The study targeted all 298 nurses that were working in spected in the workplace. Sexual harassment was defined
the fourteen (14) public secondary health care facilities as being stared at, whistled at, embraced, kissed, touched
in Western I and Western II health regions. All nurses inappropriately, unwanted request for sexual favors/
with at least one (1) year of work experience and who dates, unwelcome verbal sex-based jokes/comments, in-
were present on the day of the survey were included, vited to date with promise of promotion/other privileges
while students and nurse trainees were excluded. Over- or sexually attacked. The questionnaire was used to ob-
all, 223 out of the 298 nurses met our inclusion criteria; tain the following information: personal and workplace
informed consent was obtained from 221 nurses and data of respondents, exposure to workplace violence,
there were 2 incomplete questionnaires. This report is perpetrator, location and time of violence. A face-to-face
based on data from the remaining 219 nurses corre- interview was conducted by the lead author with thirty-
sponding to a response rate of 98.2%. five (35) nurses to gather information on the circum-
For the interviews, purposive sampling was used to se- stances of the violence and perceived factors associated
lect respondents. In each health facility three (3) nurses with the occurrence of violence. The interviews were
were invited to participate in a face-to-face interview. guided by these grand tour questions: 1. Describe one
Participants were selected on the basis of either experi- incident of workplace violence you experienced within
encing or witnessing workplace violence 12 months the last 12 months 2. What do you think was the reason
prior to the study. Forty-two (42) nurses were why the incident happened? What do you think could be
approached but seven (7) declined participation on per- done to prevent such incidents from happening?
sonal grounds. Consequently, analysis in this study
was based on 35 nurses who consent participation. Statistical analysis
Permission to conduct this study was obtained from Data from the questionnaire was entered into Epi info
the Gambia Government/Medical Research Council and analysed with SPSS version 21. Descriptive statistics
Joint Ethics Committee and the Research and Publica- was used to analyse the socio-demographic and profes-
tion Committee of the University of the Gambia sional characteristics of the respondents, as well as the
(RePUBLIC). prevalence and perpetrators of workplace violence.
Crude odds ratios & 95% confidence intervals was used
Survey instrument to assess potential associations between exposure to
Data collection took place between July and September physical violence, verbal abuse and sexual harassment
2014. For the quantitative part, data was collected using and respondents’ characteristics including age, gender,
a pretested and self-administered questionnaire that was marital status, region, area (rural/urban) occupational/
adapted from the International Labor Office (ILO), nurse cadre, and number of co-workers. Adjustment was
World Health Organization (WHO), International made for the same pre-mentioned covariates using a
Sisawo et al. BMC Health Services Research (2017) 17:311 Page 4 of 11

logistic regression model; the dependent variables being Table 1 Socio-demographic and professional characteristics of
exposure to physical violence, verbal abuse and sexual respondents (N = 219)
harassments. A p value <0.05 was considered statistically Characteristic N %
significant in the analysis. Region
The interviews were transcribed verbatim using Tran- Western I 149 68
scribe software. At first, the transcripts were coded by
Western II 70 32
highlighting significant statements. Through team dis-
Gender
cussions, codes with the same focus were combined into
themes. Subsequently 5 themes were developed, which Male 59 26.9
highlighted factors associated with workplace violence Female 160 73.1
against nurses. In this report, the participants’ names Age groups
and their health facilities are pseudonyms to preserve ≤ 30 years 78 35.6
anonymity.
31–40 years 84 38.4
≥ 41 years 54 24.7
Results
A total of 219 out of the 223 questionnaires sent were Missing 3 1.3
returned (response rate = 98.2%) from 29 State Regis- Marital status
tered Nurses, 52 State Enrolled Nurses, 64 Community Single 39 17.8
Health Nurses and 74 Community Nurse Attendants. Married 180 82.2
The profile of the nurses included in this study is pro-
Occupational cadre
vided in Table 1. A sizable majority (68%) of the respon- a
Midwives 72 32.9
dents came from Western I Health Region. Most of the
b
respondents were females (73.1%), older than 30 years General nurse 73 33.3
(63.1%) and married (82.2%). Nearly 66% of the partici- Nurse Attendant 74 33.8
pants are professional nurses (received certified training Length of service
in nursing [Midwives and General Nurses]), with the 1–5 years 66 30.1
experience of more than five years (69%) in nursing.
6–10 years 42 19.2
Besides, two-third (66.7%) of them indicated to have five
11–15 years 38 17.4
or less colleagues as regular co-workers in their units.
The prevalence of workplace violence is presented in Above 16 years 71 32.4
Table 2. Overall, 62.1% of the respondents reported ex- Missing 2 0.9
posure to workplace violence in the 12 months prior to Number of co-workers
the survey. Of them, 17.4% reported exposure to phys- ≤5 146 66.7
ical violence, nearly 60% reported verbal abuse while
6–10 44 20.1
10% reported to have been sexually harassed. Findings
≥ 11 29 13.2
further revealed that 22.5% of the victims of physical
a
SRNs, SENs and CHNs with Midwifery qualification
violence had encountered 2–4 episodes of physical b
SRNs, SENs and CHNs without Midwifery qualification
violence and almost 23% of them had been threatened
with a weapon. Moreover, 46% of the respondents
indicated having witnessed physical violence directed ward and 16% indicated the maternity ward. Similarly, the
towards peers. most frequent location for physical violence was the out-
Nurses who had experienced workplace violence were patient department followed by the admission ward and
asked to indicate the source of violence (Table 3). The the maternity ward. The majority of the incidents of sex-
respondents described perpetrators of verbal abuse as ual harassment also occurred in the outpatient depart-
mainly patients’ relatives/escorts followed by patients. ment with ‘on the way to work’ ranking second. Most
Similarly, the most frequent source of physical violence
was patients’ relatives/escorts and patients. Some nurses Table 2 Prevalence of violence reported by respondents in the
identified other staff members as perpetrators of verbal previous 12 months (N = 219)
abuse and physical violence. For sexual harassment, pa- Exposure to Physical Verbal Sexual Overall
tients’ relatives/escorts remained the primary aggressors, violence violence abuse harassment prevalence
followed by the general public and patients. N % n % n % n %
When asked about where the incident of verbal abuse Yes 38 17.4 131 59.8 22 10 136 62.1
took place, approximately 60% of victims indicated the
No 181 82.6 88 40.2 197 90 83 37.9
outpatient department, whereas 17.6% cited the admission
Sisawo et al. BMC Health Services Research (2017) 17:311 Page 5 of 11

Table 3 Perpetrator, location and time of the most recent incidents experienced by nurses (N = 219)
Verbal abuse Physical violence Sexual harassment
n (%) n (%) n (%)
Exposure to violence (Yes) 131(59.8) 38 (17.4) 22 (10)
Perpetrator
Patient 44 (33.6) 15 (39.5) 4 (18.2)
Patients’ relative/escort 71 (54.2) 18 (47.4) 9 (40.9)
Staff member 7 (5.34) 3 (7.9) 2 (9.1)
Management/supervisor 4 (3.05) 1 (2.6) 1 (4.5)
Colleague from other health facility 1 (0.76) 1 (2.6) 0 (0.0)
General public 4 (3.05) 0 (0.0) 6 (27.3)
Location of incident
Outpatient department 78 (59.5) 18 (47.4) 11 (50.0)
Admission ward 23 (17.6) 11 (28.9) 4 (18.2)
Maternity ward 21 (16.0) 8 (21.1) 1 (4.5)
Elsewhere 9 (6.9) 1 (2.6) 6 (27.3)
Time of incident
Morning shift (8 am–2 pm) 81 (61.8) 26 (68.4) 8 (36.4)
Afternoon shift (2 pm–8 pm) 25 (19.1) 6 (15.8) 7 (31.8)
Night shift (8 pm–8 am) 23 (17.6) 5 (13.2) 7 (31.8)
Missing 2 (1.5) 1 (2.6) 0 (0.0)

violence incidents took place in the morning shift, or witnessed. From their descriptions, five common
followed by the afternoon shift. themes were identified which pointed out factors associ-
Table 4 shows the results of the unadjusted and ated with workplace violence. In presenting the results,
multivariate-adjusted risk estimates for exposure to physical quotes were used to reflect participants’ voices.
violence, verbal abuse and sexual harassment. Unadjusted
analysis indicates that exposure to physical violence was Nurse-client disagreement
significantly associated with respondents who were nurse Responses from participants indicate lack of cooperation
attendants (OR = 2.6; 95% CI = 1.04-6.37) and those work- from patients and their escorts as a precursor to violent
ing in Western I Health Region (OR = 2.9; 95% CI = 1.16– incidents. In some instances, patients or their escorts re-
7.35). On verbal abuse, nurses who were single had 60% less fused nurses’ instructions culminating in abuses directed
odds of reporting incidents as compared to married nurses towards nurses. This was reflected in Foday’s response
(OR = 0.4; 95% CI = 0.22-0.90). Also, General nurses had as to how he received abusive utterances from a patient
higher odds of reporting sexual harassment than midwives escort. “We were conducting ward round and there were
(OR = 4.1; 95% CI = 1.09–15.30). In multivariate analysis, many escorts in the labor ward at the time. We asked
only three characteristics remained significantly associated them to go out and there was this lady [a patient escort]
with exposure to workplace violence. In particular, respon- who refused to comply. She was furious with our directive
dents who were working in Western I Region were almost and started telling me you don’t know yourself; you
3 times more likely to report physical violence than those are stupid”. (Foday/male Registered Nurse Midwife,
in Western II Region (OR =2.8; 95% CI = 1.09–7.20). Re- Facility WII-1).
spondents who were single were less likely to report verbal Divergence in nurses’ and escorts’ interpretation of an
abuse than married nurses (OR = 0.3; 95% CI = 0.12–0.62). emergency case provoke both verbal and attempted-
Nurses with five or less co-workers had significantly higher physical abuse towards participants. There were in-
odds of reporting verbal abuse than those with 11 co- stances when escorts demanded their patients to be
workers and more (OR = 3.0; 95% CI = 1.22–7.38). accorded emergency care and had such requests turned
down by nurses. Nurses’ reports indicate that some es-
Factors associated with workplace violence corts would present their patients as emergency cases
Interviews were conducted with 35 nurses regarding the on the pretext of bypassing long queues and waiting
circumstances of the violence incidents they experienced time for care. Fanta, a female Officer-in-Charge from
Sisawo et al. BMC Health Services Research (2017) 17:311 Page 6 of 11

Table 4 Un-adjusted and multivariate adjusted odds ratios for exposure to violence among respondents in the past 12 months
Variable Physical violence Verbal abuse Sexual harassment
Unadjusted OR Adjusted OR Unadjusted Adjusted Unadjusted Adjusted
(95% CI) (95 CI)
OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)
Area
Urban 3.3 (0.43, 26.11) 4.3 (0.52, 34.72) 1.5 (0.56, 4.26) 1.9 (0.66, 5.47) 1.7 (0.22, 13.77) 1.7 (0.21, 13.92)
Rural 1 1 1 1 1 1
Gender
Male 1.5 (0.72–3.23) 1.5 (0.68–3.32) 1.6 (0.85–2.99) 1.9 (0.95–3.64) 1.3 (0.50–3.37) 1.2 (0.43–3.30)
Female 1 1 1 1 1
Age group
≤ 30 years 1.4 (0.59–3.76) 1.3 (0.47–3.64) 1.5 (0.74–2.99) 2.0 (0.89–4.65) 2.9 (0.61–14.58) 2.6 (0.49–13.92)
31–40 years 0.9 (0.36–2.52) 1.2 (0.45–3.40) 1.5 (0.76–3.01) 1.7 (0.78–3.52) 3.5 (0.74–16.70) 3.6 (0.73–17.56)
≥ 41 years 1 1 1 1 1 1
Marital status
Single 1.3 (0.54–3.08) 0.9 (0.37–2.49) 0.4 (0.22–0.90)* 0.3 (0.12–0.62)* 1.0 (0.33–3.23) 0.9 (0.26–3.18)
Married 1 1 1 1 1 1
Occupational Cadre
Nurse attendant 2.6 (1.04–6.37)* 1.9 (0.71–5.07) 0.8 (0.41–1.53) 0.6 (0.30–1.31) 2.8 (0.71–10.96) 2.1 (0.48–9.21)
General nurse 1.6 (0.60–4.11) 1.2 (0.42–3.67) 1.6 (0.79–3.07) 1.2 (0.53–2.56) 4.1 (1.09–15.30)* 4.1 (0.98–17.38)
Midwives 1 1 1 1 1
Region
Western I 2.9 (1.16–7.35)* 2.8 (1.09–7.20)* 1.3 (0.72–2.28) 1.6 (0.89–3.06) 1.0 (0.39–2.59) 0.9 (0.32–2.32)
Western II 1 1 1 1 1 1
Number of co-workers
≤5 1.1 (0.40–3.25) 1.5 (0.46–4.89) 2.1 (0.95–4.75) 3.0 (1.22–7.38)* 0.9 (0.23–3.18) 0.9 (0.19–4.95)
6–10 0.6 (0.16–2.35) 1.1 (0.25–4.95) 0.9 (0.35–2.29) 1.2 (0.42–3.36) 1.4 (0.31–5.97) 2.1 (0.35–12.56)
≥ 11 1 1 1 1 1
*Statistically significant (p value <0.05)

facility WI-8, frustratingly recounted how she got facility WI-7 indicated that sometimes, nurses give pa-
insulted by a patient company. She reflected an encoun- tients the cause to abuse them. He cited an encounter of
ter in which she was on duty alone and attending to a a peer nurse who was slapped by a lactating mother for
baby with severe birth asphyxia. While resuscitating the uttering obscene language to her. In describing the inci-
baby, a man accompanying an injured patient arrived dent, he said: “This woman was in labor. While scream-
and demanded immediate attention for his patient. Fan- ing and yelling for help, the attending nurse was telling
ta’s attempt to make the man understand that his injured her ‘I was not there when you had this nice time [conju-
patient was not an emergency case irritated the escort. gal happiness] with your husband’. One week later, when
“His patient sustained laceration which was not deep the mother returns to the clinic for her child’s first
and not bleeding either. So I asked the escort to allow me immunization, she went into the labor ward to look for
some time to revive the baby but this does not go down the nurse and gave her a very hot slap in retaliation”.
well with him. He insisted I should turn my attention to Another eyewitness account was given by Ndey, a Reg-
his patient. When I did not, he started telling me all sorts istered Nurse Midwife from facility WI-2. She narrated
of nonsense, all sorts of bad words you could imagine”. the experience of a colleague: “One of my colleagues who
is a CHN General was attending to infants at the infant
Nurses’ workplace manners welfare clinic where infants are screened and treated for
In some cases, participants labelled nurses as the initia- minor ailments. While attending to a patient, a waiting
tors of workplace violence. One of the commonly cited mother was asking the nurse several questions but got ig-
reasons for this was nurses uttering indecent languages nored by the nurse. This makes the mother so furious
towards clients. Musa, a Community Health Nurse from that she could not suppress her emotions and ended up
Sisawo et al. BMC Health Services Research (2017) 17:311 Page 7 of 11

grabbing the nurse’s neck. It was a real fight. We had to In expressing how staff shortage makes nurses victims
intervene to calm the situation”. of abuse, a female CHN said: “I was on night duty run-
In some instances, the attitude of nurses towards work ning both the labor ward and the outpatient department.
provoked reactions from other staff members. The nar- This patient arrived and I was alone at the time. So the
ration of Binta, a female Community Nurse Attendant at patient was furious for not attending to him immediately
WII-5 describes how she was humiliated by her Officer- because at the time of his arrival, I had a labor case and
in-Charge (OIC) for reporting late to work. In her words I cannot leave that case because two lives were in-
“There was a day I reported to work late. On arrival, be- volved— the lady and her child. And this patient walked
fore saying good morning, my Officer-In-Charge started by himself to the health center and it was only headache
to humiliate me. On that day I felt sad. I couldn't do and fever he had. So I explained my engagement to him
anything. I couldn't talk to anyone because I felt so sad but he couldn’t understand and started shouting, insult-
on that day. It affected my work on that day. I was not ing but I ignored him and conducted my delivery and
comfortable and felt disturbed on that day”. then attended to him afterwards. That's a common
thing we often experience here. Even yesterday there
Shortage of drugs and staff was another one. For that one the patient decided to
Participants bemoaned drug shortage as a fundamental leave unattended”. (Maimuna, female CHN General,
factor triggering aggressive reactions from clients. A facility WI-3).
significant fraction of prescribers in public secondary
health care facilities in the Gambia are nurses. Accord- Lack of Security
ing to participants’ accounts, nurses often carry the Security gap was a commonly cited issue making health
blame when prescribed drugs are in short. Patients’ reac- care facilities violent-prone. Most participants expressed
tions to drug shortage took the form of abusive utter- inadequate or complete absence of security guards in
ances and request to have their consultation fee their health centers. Those appointed to take charge of
returned. Sulayman, a male OIC at Facility WI-3 health center security were mostly the elderly with no
described a bitter confrontation his nurses had with a professional training in security service. Lisa, a female
patient escort due to a prescribed drug that was not Registered Nurse from facility WI-8 indicated that
available. An OIC at facility WI-2 similarly stressed drug nurses in her health facility will feel safer if there are
shortage as an important factor precipitating violent in- security guards. In her words: “I think here we don't have
cidents towards nurses in his health center. He said: security. I think if we have security and in case of any
“Well, there are so many violent acts in our work setting. attempt to abuse a staff, we can call the security to inter-
But just to single out one very important factor. Some- vene”. Respondents’ feedbacks further indicated that the
times, I do run the outpatient department. Sometimes security vacuum creates a challenge in restricting patient
you can prescribe a drug that is not available in the visitors entering admission wards during restricted
health center. As a result, they (patients) will insult you. hours. When nurses attempt to prevent entry of patient
They will say very nasty words. And it is not our duty to visitors in the admission wards outside official visiting
provide drugs but what can you do? Nothing. You just have hours, they consequently received abusive utterances.
to take it in good faith”. (Biran, male OIC, facility WI-2). One of the participants, who was working in a private
Staff shortage stands out as a cardinal factor for long clinic (Family Planning Clinic) and then switched to the
waiting time rendering clients in becoming bored and public sector, gave a comparison between the security
impatient. Such frustrations engender remarks from pa- situation at the private and public health facilities. She
tients like “nurses are inefficient and incompetent” and said “Working in the private and the public sector are
in certain instances physical confrontation. In describing different. In the private sector, we are secured but for the
how a colleague was harassed by a patient, Lalia, a fe- public sector, nurses are not secured at all. When I came
male Enrolled Midwife at facility WI-5 said: “The patient here [her new workplace], I have been hearing nurses
visited the outpatient department and found the nurse complaining about people coming here, insulting them,
busy—attending to someone who was unconscious. And and I witnessed one myself at Facility WII-1. People
that person wanted the nurse to leave the unconscious come, they fight them (nurses), they beat them, they in-
patient and attend to him. It was in the afternoon and sult them and after all nothing comes out of it. This
the nurse was alone at the outpatient department. So doesn't happen in private health facilities”. (Ndey, SEN
when the nurse asked him to wait to finish attending to Midwife WII-2).
the unconscious patient since his condition was not an
emergency, the boy [patient] started insulting the nurse. Policy vacuum and inadequate management support
If there were enough nurses in that facility, that incident The absence of a workplace violence policy both at the
wouldn't have occurred”, Lalia concluded. national and health facility levels affects nurses’ ability to
Sisawo et al. BMC Health Services Research (2017) 17:311 Page 8 of 11

prevent and respond appropriately to incidents of work- to patients’ needs; a situation that often triggers aggres-
place aggressions. Feedbacks from participants suggest sive reactions from patients and their escorts. The
that some of their peers’ inability to communicate, plausible explanation for such poor service behaviors
understand and respond appropriately to clients’ needs could be lack of training as nearly 88% of participants
often triggers aggressions from care seekers. And this indicated not receiving any form of training on violence
was partly attributed to the lack of a well-defined policy recognition, prevention and management. As highlighted
guiding nurses on communication skills, service psych- by Kamchuchat et al. 2008, training is an essential elem-
ology and behavior. Participants frustratingly expressed ent of an effective violence prevention program. Their
limited attention from authorities in addressing work- findings showed that training could reduce the risk of
place violence. Some cited the failure of concerned verbal abuse by 40% [6]. Similarly, a study on workplace
health authorities in recognizing workplace violence as a violence against nurses in Texas in the USA revealed
pressing issue. Others disappointedly stated authorities staff training/education/awareness as one of the most
going to media outlets to castigate nurses which provoke successful strategies for preventing workplace violence
public mistrust and hatred for nurses. “Our bosses are directed towards nurses [16]. Our study further revealed
not supportive; they did not regard violence as an im- that nurses at times give clients the cause to abuse them
portant problem. They did not regard security as a prob- by making offensive utterances to patients. Patients and
lem” said Jainaba, a female Registered Nurse Midwife escorts often come to health care facilities in stressful
from facility WII-1. Musa, a male Community Health states; if nurses are not prepared to accommodate such
Nurse at facility WI-7 said: “I have seen instances where emotions with restraint, it often results in aggressive
people go to the media, telling the population that nurses confrontations between them and care seekers.
are bad, nurses are this, nurses are that, with all that Similar to many of the previous studies, patients’ rela-
stuff. And this helps to create enmity between the popula- tives/escorts and patients were reported as the main
tion and nurses”. sources of violence. These results were comparable to
previous researches in Ghana [17], Egypt [18], Palestine
Discussion [5], Turkey [19], Taiwan [4], Thailand [6], Iran [7], India
This study represents the first to document the preva- [20] and Iraq [21]. A study on workplace violence to-
lence of workplace violence against nurses in the ward emergency department staff in Jordanian hospitals
Gambia. Findings in 219 nurses indicate a rather high similarly reported patients and their relatives as the main
(62.1%) prevalence of exposure to workplace violence source of violence [22]. Our study participants cited
12 months prior to the study. The most common form communication gap between clients and nurses, delay in
was verbal abuse. The primary perpetrators of reported services due to understaffing, shortage of drugs and
incidents were patients’ escorts/relatives and patients supplies as the key reasons provoking aggressions from
themselves. The outpatient department was reported as patients and their escorts/relatives. Some public pre-
the site where most violent incidents occurred. Qualita- conceptions put Gambian nurses in an unfavorable
tive feedbacks from participants attributed the perceived situation. For instance, patients or their escorts construe
reasons of workplace violence mainly to attitude prob- nurses as ‘inefficient’ even if this is as a result of under-
lems on the part of nurses and patients, understaffing staffing. Such preconception could unduly influence the
and shortage of drugs, security vacuum and lack of man- behavior of patients and their escorts/relatives in nega-
agement attention to workplace violence. tive ways toward nursing staff.
Regarding the prevalence of workplace violence, des- The reflection of participants suggests that nurses’
pite some variations in the definition of violence, tar- approach towards clients and work sometimes makes
geted health professionals, sample size and methods them victims of abuse. Such misconducts were reported
used, the prevalence in this study (62.1%) is comparable to, to take the form of nurses uttering indecent languages
but higher than several international studies [3, 4, 6, 14]. In towards patients, snubbing patient companies and
general, nurses in the Gambia have higher rate of exposure reporting to work late. These behaviors among other
(62.1%) to both verbal (59.8%), physical (17.4%) and sexual possible reasons may have been affected by gaps in staff
harassment (10%) than many country studies [15]. The motivation. There was a joint national survey conducted
higher prevalence of violence in our study could be ex- in 2010 by the Ministry of Health & Social Welfare of
plained by personal, societal and institutional factors. the Gambia, Center for Innovation Against Malaria
Findings from interviews with participants indicate (CIAM) and West Africa Health Organization (WAHO)
that miscommunication between providers (nurses) and on the effects of incentives on health service providers’
care seekers (patients and their escorts) often culminate performance in the Gambian public sector [23]. In this
into wrangling. This has been attributed to the inability survey, nurses represent 88.3% of the participants. Sixty-
of some nurses to understand and respond appropriately five (65%) of respondents in this study expressed
Sisawo et al. BMC Health Services Research (2017) 17:311 Page 9 of 11

dissatisfaction with their living and working conditions This result could be explained due to high number of
including lack of access to equipment, drugs, utilities, patient visits in the morning shift as compared to other
sanitary facilities, mobility and opportunities for career shifts. This finding is congruent with Shogi’s et al. (2008)
advancement. The study indicates that these factors had results in Iran reflecting the crowdedness of hospitals in
negative effects on the motivation and performance of different times of the day. In the present study, married
health care providers and were thus considered disincen- nurses were more likely to report verbal abuse than
tives. It is possible that such disincentives were affecting respondents who were single. In the Gambia, married
the service behaviors of nurses towards clients and work women are expected to take care of the domestic front
as reported in our study. in addition to their job demands, which may account for
The interview data suggest that inadequate drugs and this difference. High domestic burden could result in
supplies, long waiting time/delay in services often caused nurses reporting to work late. As the qualitative results
by understaffing were additional triggering factors of indicate, this might suggest the reason rendering late
workplace violence. This finding is in accordance with reporting to work by some nurses which often precipi-
the results of Kamchuchat and colleagues in Southern tates angry reaction from waiting patients. A qualitative
Thailand [6]. Reports from the interview in our study study in Papua New Guinea indicates juggling family
highlighted aggressive behaviors towards nurses from and work life as barriers to commit fully to patient needs
patients in instances of drug shortage. Similarly, staff and delays in coming to work [24]. Additional reason
shortage was described as an important triggering factor accounting for this difference could be that married
for reported incidents. Patients tend to express dissatis- nurses are generally more assertive. In contrast, a study
faction in aggressive manners towards nursing staff in Lebanon reported that single nurses were more likely
when services get delayed due to long waiting times; a to have been exposed to verbal abuse as compared to
situation that often occurs where there is low staffing- married nurses [25].
patient ratio. These findings are in conformity with a The logistic regression analysis indicates that re-
2016 study in Ghana that reported inadequate staff and spondents with five (5) or less co-workers have higher
infrastructure which lead to long waiting times [17]. odds of reporting verbal abuse than those with 11 or
Similar to our findings, this study indicates that the frus- more co-workers. This could suggest that perpetrators
tration that patients and their relatives may have to go were less inclined to direct verbal aggressions towards
through before they are attended to (due to long waiting nurses where there are sheer number of staffs
times) and dissatisfaction with service could make them present. This is in agreement with a study in North-
more inclined to abuse nurses verbally. A Jordanian west Ethiopia which indicates that the odds of work-
study [22] similarly cited lack of resources, staff shortage place violence among nurses with 1–5 number of
and overcrowding as contributing factors to workplace staff during the same working shift were 2 times
violence in Jordanian hospitals. A study conducted higher as compared to those nurses who had more
in Egypt revealed comparable findings. This study than 11 number of staff during the same working
cited increased workload and shortage of nursing shift [26]. The plausible explanation for this is that
staff as the main causes of violence perprated against when the number of nurses is low in a given shift,
nursing staff [18]. patient care could be delayed resulting in irritation
In the current study, majority of the events (59.5% of from patients or their accompanying persons. Our re-
verbal abuse, 47.4% physical violence and 50% of sexual sults and the Ethiopian findings however, contradict
harassment incidents) occurred at the outpatient depart- an Egyptian study which indicates that about one
ments (OPD). This could be due to the sheer number of third of nurses reported exposure to violence even in
care seekers seen in the OPDs as compared to other the presence of more than 10 other colleagues [3].
units that exist in public secondary health care facilities Our results indicate that nurses in Western I Health
in the Gambia. Besides, in the Gambia, the outpatient Region were more likely to report physical violence than
departments in public secondary health care facilities at- their counterparts in Western II. Possible explanations
tend to accident and emergency victims in addition to accounting for this variation could be due to differences
regular outpatient care/services. Many studies recog- in location in terms of urban and rural setting for the
nized outpatient and emergency departments as particu- health facilities in the two regions. All the public sec-
larly violent environments. These departments are ondary health care facilities in Western I are situated in
usually attended by aggressive and stressed patients who urban areas which are relatively more volatile than those
are more likely to commit violence against health in Western II where almost all the public secondary
workers [5, 6]. Our results further indicate that a sizable health care facilities are located in rural settings.
majority of incidents (61.8% of verbal abuse and 68.4% Furthermore, there is higher patient burden in health
of physical violence) occurred during the morning shift. facilities situtated in Western I.
Sisawo et al. BMC Health Services Research (2017) 17:311 Page 10 of 11

Limitations & strengths Additionally, the qualitative feedbacks from respondents

This study has some limitations. One major limitation allowed us to gain detailed and cross-verifying the study
was the self-report design. This method depends on the results (triangulation).
ability of the participants to recall events in the last
12 months prior to the study, which is subject to recall Conclusions
bias. Moreover, due to the sensitive nature of the subject This study revealed an overall prevalence of 62.1% to
(sexual harassment in particular), the study results may workplace violence suggesting that nurses in the Gambia
have suffered reporting bias resulting to an underestima- are at high risk of workplace violence particularly verbal
tion of nurses’ exposure to workplace violence. This may abuse. A great caution is thus needed because verbal
have resulted to only 17.4% of physical violence and 10% abuse could cause serious psychological harm [28]. It
sexual harassment reported in our study. Although the could affect a nurse’s motivation and ability to offer
study was open to all categories of nurses, time and re- effective care [29]. Most importantly, the persistent oc-
source restrictions limited participation to only public currence of verbal abuse could affect the attraction and
secondary health care facilities in Western I and West- retention of nurses within the health care system [30].
ern II Health Regions in the Gambia. Therefore, these The most common perpetrators of violence were pa-
results may not be generalized to the private and other tients’ relatives/escorts and patients themselves. Qualita-
categories of public health care facilities in the country. tive feedbacks conclude understaffing, shortage of drugs
Due to time restriction for the data collection exercise, & supplies, security vacuum and lack of management
health care managers were not approached for inter- attention to workplace violence as the fundamental
views. This may have restricted information regarding factors provoking violent incidents at work.
management’s response to reported events and the rea- Given the said concerns, this study recommends that
sons for their lack of actions as asserted by nurses. To future interventions should be responsive to the need of
this end, future research should take into account the the nursing staff for effective prevention of workplace
concerns and limitations reported in this study. We violence. Thus, the Ministry of Health & Social Welfare
would also recommend future studies to assess the of the Gambia should institute programs that will guide
outcomes/consequences of exposure to violence in nurses to recognize, prevent and deal with workplace
order to attract urgent policy interventions to this violence. A compulsory in-service education on work-
occupational hazard. place violence should be introduced for all nurses. The
Nonetheless, this study provides a preliminary inves- content of such programs should include communica-
tigation of the violence episodes against nurses in the tion skills, service psychology (understanding clients’
Gambian context and may pave the way for further needs), service behaviour (how to respond appropriately
research. The data generated could also trigger policy to clients’ needs and personality improvement) and
response for the formulation of workplace violence pre- safety training (handling aggression and defusing hostile
vention policy for Gambian nurses. Besides, limiting situations). It may also be necessary for nurse training
recall to the previous 12 months has been used success- institutions to include strategies to deal with assaults at
fully in other studies of violence at workplace [5, 27]. workplace in their curricula, as incoming nurses may be
Efforts were made to maximise response rate through exposed to this behavior.
active follow-ups with participants. These efforts yielded There should be a public-based violence prevention
an overall response rate of 98.25%. Therefore, the results education programs to heighten awareness on workplace
could provide useful insight into the problem of work- violence. Mass education programs directed to improv-
place violence against nurses in the Gambia. Reporting ing the public image of nurses should be promulgated
bias as highlighted in other studies may also have been by the Health Promotion & Education Directorate of the
minimised. Emphasis on the benefits of the study find- Ministry of Health & Social Welfare of the Gambia.
ings in terms of heightening awareness and implement- Such programs could give an accurate impression of
ing effective policies on workplace violence were nurses to the public. It could inform the public about
underscored to participants throughout. Besides, report- the true value of nursing and how dispelling nursing
ing bias that is due to involving head nurses in distri- stereotype could improve nurse-client relationship. In
buting and collecting completed questionnaires as done order to meet clients’ expectations, the government
in some previous studies may have been minimized. The should ensure availability of adequate staff, drugs and
lead author personally distributed and collected all supplies at all times. Staff protection by beefing up se-
completed questionnaires from participants. The respon- curity at health facilities is fundamental. This should in-
dents were given assurance about confidentiality of their clude assigning trained security guards, installing
responses. This may have yielded objective reporting by security cameras/video monitoring systems and check-in
participants about their workplace violence experiences. procedures for patient visitors.
Sisawo et al. BMC Health Services Research (2017) 17:311 Page 11 of 11

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Author details
1 Occupational Violence in Lebanon: Prevalence, Consequences and
The University of the Gambia, Brikama, The Gambia. 2International Health
Associated Factors. PLoS One. 2015;10:e0137105.
Program, National Yang-Ming University, Taipei, Taiwan. 3Institute of Public
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Health, National Yang-Ming University, No.155, Sec.2, Li-Nong Street, Taipei
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112, Taiwan, Republic of China.
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