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Violence in the Workplace

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• David Lester   ORCID: orcid.org/0000-0003-1357-8672 4  

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The types of violence that occur in the workplace are described, ranging from harassment to mobbing, murder, and murder-suicide. Examples of the individuals committing this violence are presented, along with suggestions for identifying potential perpetrators and prevention.

This is an updated and modified version of Lester ( 2011 ).

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Lester, D. (2024). Violence in the Workplace. In: Akande, A. (eds) Leadership and Politics. Springer Studies on Populism, Identity Politics and Social Justice. Springer, Cham. https://doi.org/10.1007/978-3-031-56415-4_16

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Introduction

Workplace violence refers to any form of disruption among employees that involves harassment, physical assault, and intimidation at the place of work. Violence at the work site significantly affects visitors, workers, clients, and other stakeholders. Since violent acts may result in injuries and impact the organization’s general performance, it has become one of the most significant issues of concern nationwide. Several actions have been enacted in my workstation at a health facility to protect workers against violence.

First, the institution has ensured increased employee awareness regarding workplace violence and the need for its avoidance. In addition, risk factors leading to violence have been identified alongside implementing the necessary precautions. Other ways to eradicate workplace violence include enacting preventive programs and ensuring proper working procedures (Salin et al., 2020). Moreover, ensuring proper documentation of workplace violence avoidance approaches is essential. Employees must also be fully aware of violence and the possible risk factors.

Several policies have been enacted to protect workers against workplace violence. In this case, proper reporting procedures and policies were put in place. The institution has ensured an appropriate system to keep track of the violent activities that are likely to occur and are reported. The collected information can be used to check whether anything has been done to nurses and determine the need to change existing trends in the organization to ensure the safety of employees.

Additionally, the institution has reduced the general normalization of workplace violence. Employees are trained to deal with violence with the full realization that it is not part of their job (Salin et al., 2020). I once witnessed workplace violence where nurses were involved in physical battles resulting from general workplace differences. In this incident, the management ensured the termination of the two for getting involved in violence. This acted as a warning to other workers leading to a reduction in workplace fierceness.

Salin, D., Cowan, R. L., Adewumi, O., Apospori, E., Bochantin, J., D’Cruz, P.,… & Zedlacher, E. (2020). Prevention of and interventions in workplace bullying: A global study of human resource professionals’ reflections on preferred action. The International Journal of Human Resource Management , 31 (20), 2622-2644.

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Workplace violence against nurses: a narrative review

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Workplace violence against nurses: a narrative review

Smita kafle.

1 Fayetteville State University School of Nursing, Fayetteville, NC, 28301, USA

Swosti Paudel

2 Kalgoorlie Health Campus, Kalgoorlie, WA, 6430, Australia

Anisha Thapaliya

3 Royal Perth Hospital, Perth WA 6000, Australia

Roshan Acharya

4 Carilion Roanoke Memorial Hospital, Roanoke, VA, 24014, USA

Background and Aim:

Any harmful act Physical, sexual, or psychological committed against the nurses in the workplace by a patient or visitor is called workplace violence (WPV) against nurses. WPV is directly related to decreasing job satisfaction, burnout, humiliation, guilt, emotional stress, intention to quit a job, and increased staff turnover. The purpose of this narrative review is to explore the concept of WPV, its prevalence, consequences, influence on nursing, and strategies developed to prevent such incidences. WPV is not acceptable and, regardless of the culprit’s physical or psychological status, should be held responsible for such a heinous crime. WPV can have a vastly negative impact on nurses. Unfortunately, violence in the workplace has become so common that it is now considered an unpleasant part of the job and ignored instead of being reported. Nurses should be educated appropriately on hospital policies against WPV and be encouraged to report any incidence.

Relevance for Patients:

WPV is detrimental to nurse and patient’s relationship which negatively affects patient care.

1. Background

Violence against nurses has been a pandemic. According to the World Health Organization (WHO), “between 8 and 38% of nurses suffer from health-care violence at some point of their career” [ 1 ]. Compared to other workplaces, health care workers have a higher risk of getting physically, sexually, or psychologically injured. Incidents where staff is abused, threatened, or assaulted in the circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being, or health are Workplace Violence (WPV) [ 2 ]. The WPV is divided into two main groups: Physical and psychological, including racial abuse, bullying, verbal abuse, and mobbing, which may overlap in both groups [ 3 ]. WPV can be directly related to increased job stress, decreased job satisfaction, absenteeism, burnout, sleep disorder, fatigue, post-traumatic stress disorder, fear, and suicide. Overall, WPV negatively affects a nurse’s working life, resulting in decreased productivity and quality of care. There is a paucity of information regarding WPV against nurses in the literature. A few publications available discuss WPV aggregately in the health-care profession [4–6]. A recent systematic literature review on WPV against nurses discussed the antecedent factors surrounding WPV [ 7 ]. However, articles written from the perspective of a nurse discussing exclusively WPV against nurses and the mental and professional implications of such WPV incidents are very rare to none. In this narrative review, we intend to exclusively discuss WPV against nurses and its implications.

The purpose of this paper is to explore the concept and prevalence of WPV, its trend, consequences, influence on nursing, and strategies developed to prevent such incidences.

3. Discussion

The prevalence of WPV is very high. Different research suggests variable prevalence but undoubtedly remains high. According to Cheung et al. , in 2017, among 25,630 incidences of WPV occurred in the United States, of which 74% occurred in healthcare settings. Similarly, the same study shows that medical occupation group represents 10.2% of all WPV [ 2 ]. Health-care professionals, and in particular, nurses, are most exposed to WPV [ 3 ]. Similarly, Liu et al . in their study reported that 62% of participants reported exposure to any form of WPV, 43% reported exposure to non-physical violence, and 24% reported experiencing physical violence in the past year [ 5 ]. Nurses are the frontline workers, and patients spend more time with nurses in care facilities than other health-care providers, automatically increasing the risk of violence. Other factors that increase the risk of violence in health-care settings include increased workplace stress, novice nurses, shift jobs, and understaffing. These situations can lead to delayed care for patients and they might take these situations as negligence of nurses causing the violence [ 3 ]. Similarly, other important components of violence are a patient’s viewpoint regarding the nurse and their role. They have a specific role for a nurse and violence occurs when those roles are not played out as the patient wishes. Similarly, WPV depends on the workplace environment because nurses are abused by patients and visitors and by coworkers, supervisors, or administrators.

Being a female dominant profession also puts nurses at risk of WPV. We live in a patriarchal society and nurses have been subject to violence since the beginning of time [ 3 ]. According to one study conducted in Iran, 90% of nurses who reported being victims of violence at the workplace were female [ 8 ]. Furthermore, according to Cheung et al. , engaging in direct patient care seems to correlate significantly with WPV. The incidence of WPV is very high in elderly units (63.8%), pediatrics (22.1%), maternity units (15.3%), psychiatric units (14.7%), and emergency rooms (<10%) [ 2 ]. The patients in these departments need high-level and direct care from nurses. Patients may feel powerless and lose control over their life and simultaneously may be in pain and under the influence of drugs or alcohol with no proper way to vent. The accumulation of anger, frustration, and powerlessness is often directed toward the nurses in verbal abuse or physical violence, which ultimately causes psychological problems. Ironically, the professional who helps the injured and abused toward better health is at the highest risk of getting abused and forgotten.

3.2. Current trends

WPV is increasing at an alarming rate. According to Arnetz et al . [ 9 ], hospital WPV-related injuries are four times greater than in other sectors. Similarly, according to the same study, one out of every five nurses had to experience WPV at some point in their career. Among the health care workers, nurses have been affected mainly by violence and nothing much has changed since the pioneering research of Marilyn Lanza in 1985 [ 3 ]. The rate of violence against nurses seems to be increasing rather than decreasing. In the health-care setting, nurses follow orders from doctors, which is perceived by many as a low hierarchy job, which is another reason for the incivility of the patient toward the nurses. Nurses are the backbone of the health-care system but often go unnoticed. Despite the disturbingly increasing rate of violence, very few things to none have been done to prevent it. Violence is taken as one of the ugly parts of the job and it is being ignored by the administrators and supervisors. Similarly, nothing much has been done by the federal or state governments to protect nurses. According to the American Nursing Association, only 36 states have established penalties for assault of nurses. Among those 36 states, seven states apply if the assaults have occurred in an emergency or mental institute only. In general, in a WPV case, the law only helps if severe bodily injuries are inflicted on nurses. There are no laws for emotional abuse or any other form of non-physical abuse [ 10 ].

3.3. Significance of issue

WPV creates constant fears in the mind of the nurses. WPV not only affects the health care worker like nurses and doctors but also the organization like hospitals or mental health institutions. Nurses and the health-care setting have an intimate and interdependent relationship; the deterioration of one leads to the ultimate deterioration of the other. More than 70% of nurses are constantly worried about being a victim of WPV. These stresses decrease job satisfaction and increase the constant psychological stress, which negatively affects nurses’ work and personal life. All forms of violence result in psychological distress. According to Li et al. , among all types of violence, nurses face verbal abuse and physical abuse the most [ 4 ]. In another study, verbal abuse (57.6%) was the most common form of non-physical violence reported, followed by threats (33.2%) and sexual harassment (12.4%) [ 5 ]. Physical abuse includes but is not limited to kicking, shooting, biting, beating, slapping, pinching, stabbing, and pushing. Constant physical and verbal abuse emotionally scares nurses.

WPV has a significant negative impact on nurses and has been categorized into four subgroups: Biophysiological, cognitive, emotional, and social [ 3 ]. Fear, anxiety, headache, and irritability fall under the biophysiological category, which physically interferes with the quality of care provided by a nurse. Similarly, disbelief, a threat to personal integrity, and transformed perception fall under the cognitive category, which causes decreased job satisfaction, increased staff turnover, burnout, and absenteeism. Anger, guilt, apathy, and helplessness fall under the emotional category, which causes sleeplessness. Likewise, insecurity and antisocial fall under the social category, which hampers coworkers’ relations and creates a toxic working environment [ 3 ]. All these humiliations and violence, in the long run, can cause severe emotional distress such as post-traumatic stress disorder, depression, and suicide [ 8 ]. Hence, it is vital to address these issues as fast as possible. WPV is constantly pushing the nursing profession backward.

3.4. Influence on nursing practice

WPV significantly hampers nursing professionals. Constant fear and anxiety dramatically decrease the quality of care provided by a nurse. WPV negatively affects the therapeutic relationship between nurse and patient. Violence results in humiliation and guilt, which negatively affects the psyche of a nurse. In the long run, this phenomenon causes burnout, decreased job satisfaction, and reduced attraction to the nursing profession. Living in constant fear of unavoidable violence causes physical exhaustion, increased stress, insomnia, and post-traumatic stress disorder. According to Escribano et al. , 1.4% of total homicide in the United States is related to WPV in the health-care system. It is a great irony that the group of people responsible for the well-being of others is being abused [ 3 ].

WPV creates a toxic working environment for nurses. Trust toward the administration, supervisor, and coworker diminishes, creating a hostile working environment. Furthermore, it creates significant consequences for victims, coworkers, and organizations.

3.5. Controversies

There are not sufficient pieces of consistent literature on WPV toward nurses. Inconsistent literature regarding the concepts of WPV makes these situations more complex. It could be true that some violent acts such as verbal abuse are simply considered an unpleasant part of the job. In a setting such as psychiatric, maternity, and pediatrics, this violence is regarded as an unavoidable or average risk of the job. Similarly, some psychiatric nurses can have a positive view of aggression [ 3 ]. However, this point of view does not protect nurses’ integrity and dignity. Despite the unit nurses are working, they will feel fear, humiliation, and stress in response to WPV.

3.6. Strategies

WPV has become so prevalent globally that the International Labor Office, International Council of Nurses, World Health Organization, and Public Services International in 2002 jointly issued guidelines to address WPV in the health-care sector. In 2003, the American Association of Occupational Health Nurses, Inc. signed an alliance with the Occupational Safety and Health Administration regarding WPV [ 11 ]. The health institutions have their specific strategies and workforce against WPV. Despite all the efforts, the WPV remains high, and the success data of such strategies remain elusive. Patients with dementia, schizophrenia, under the influence of alcohol or drugs, and anxiety are some of the major delinquents of WPV against the nurses [ 12 ]. However, the culprits of WPV are not limited to the above medical conditions but also patients in a lucid and normal state of consciousness. Hence, it is vital to perform a quick assessment of risk behavior. For example, according to D’Ettorre et al. , this assessment can be done by following the STAMPEDAR (staring, tone, and volume of voice, assertiveness, mumbling, pacing, emotions, disease process, anxiety, and resources) technique. However, this technique does not protect against the violence itself. This risk assessment helps predict whether the patient will be violent or not down the line and gives nurses some insight to prepare for what might come next [ 12 ].

In general, the common causes of WPV are understaffing, increased stress among nurses, the demanding nature of the job, and prolonged waiting period. These causes eventually end with dissatisfied patients and visitors, causing WPV [ 12 ]. In a study, 63% of emergency department violence was reported to have occurred in the waiting room, which can be attributed to the aforementioned causes [ 13 ]. To prevent WPV, the primary interventions should be carried out at the administrative level managing the high demanding job and improving the working environment. Frequent training should be conducted on improving patient-nurse relationships, stress management, communication skills, anger-control management, and de-escalation skills [ 12 ].

Health care workers, including nurses, should be appropriately educated on the hospital/organization’s policy on reporting violence. According to Escribano et al. , in a study conducted in Switzerland general hospital, only 7.6% of the participants knew about their hospital policy against WPV. Similarly, as per the same article, in a study conducted in Australia, among the 37.7% of official complaints against the WPV, only 1% got a response from the administration [ 3 ]. These two studies show that WPV is most likely not being reported due to a lack of knowledge on policies, and administration/supervisors utterly ignore those reported. Hence, it creates an untrusty working climate. WPV against nurses is getting worse day by day. Hence, it is imperative to have a zero-tolerance policy against WPV.

3.7. A nurse’s position

WPV is an occupational hazard that is getting uglier by the day. It is never acceptable, and no matter the culprit’s physical or psychological status, they should be held responsible for such a heinous crime. Among all health care workers, nurses, especially female nurses, are more at risk of being abused at the workplace. Despite being the most ethical and caring profession, the nursing profession is still a victim in today’s patriarchal society. It is disheartening to see that despite the increased violence against the nurses, nothing tangible has been done to protect them. The constant fear of being a victim of WPV makes nurses self-conscious around the patient, which hampers the nurse-patient relationship. This situation dramatically decreases the quality of care and willingness to care for a patient.

Nursing is not an easy profession. It is demanding and requires a lot of patience as the nurses work with people from different locations and cultural backgrounds. However, WPV is turning an already difficult job into an unbearable one. The nursing profession is already facing shortages due to increased life expectancy of patients and inequitable workforce distribution. Furthermore, if this WPV against nurses cannot be managed in time, we cannot say that the day will not come when we have a severe shortage of nurses which will eventually cause the collapse of the health-care services.

4. Conclusion

Any act that causes physical, psychological, or sexual harm to the nurses at the place of work is WPV against the nurses. Unfortunately, violence in the workplace has become so common that it is now considered an unpleasant part of the job and ignored instead of being reported. Nurses should be educated appropriately on hospital policies against WPV and be encouraged to report any incidence.

Acknowledgments

Conflicts of interest.

The authors have no conflicts of interest to declare.

• Research article
• Open access
• Published: 23 March 2021

Workplace gender-based violence and associated factors among university women in Enugu, South-East Nigeria: an institutional-based cross-sectional study

• Olaoluwa Samson Agbaje 1 ,
• Chinenye Kalu Arua 1 ,
• Joshua Emeka Umeifekwem 1 ,
• Prince Christian Iheanachor Umoke   ORCID: orcid.org/0000-0002-0802-9073 1 ,
• Chima Charles Igbokwe 1 ,
• Tochi Emmanuel Iwuagwu 1 ,
• Cylia Nkechi Iweama 1 ,
• Eyuche Lawretta Ozoemena 1 &
• Edith N. Obande-Ogbuinya 2  

BMC Women's Health volume  21 , Article number:  124 ( 2021 ) Cite this article

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Exposure to workplace gender-based violence (GBV) can affect women's mental and physical health and work productivity in higher educational settings. Therefore, this study aimed to examine the prevalence of GBV (workplace incivility, bullying, sexual harassment), and associated factors among Nigerian university women.

The study was an institutional-based cross-sectional survey. The multi-stage sampling technique was used to select 339 female staff from public and private universities in Enugu, south-east Nigeria. Data was collected using the Workplace Incivility Scale (WIS), Modified Workplace Incivility Scale (MWIS), Negative Acts Questionnaire-Revised (NAQ-R), and Sexual Experiences Questionnaire (SEQ). Descriptive statistics, independent samples t -test, Pearson’s Chi-square test, univariate ANOVA, bivariate, and multivariable logistic regression analyses were conducted at 0.05 level of significance.

The prevalence of workplace incivility, bullying, and sexual harassment (SH) was 63.8%, 53.5%, and 40.5%. The 12-month experience of the supervisor, coworker, and instigated incivilities was 67.4%, 58.8%, and 52.8%, respectively. Also, 47.5% of the participants initiated personal bullying, 62.5% experienced work-related bullying, and 42.2% experienced physical bullying. The 12-month experience of gender harassment, unwanted sexual attention, and sexual coercion were 36.5%, 25.6%, and 26.6%, respectively. Being aged 35–49 years (AOR 0.15; 95% CI (0.06, 0.40), and ≥ 50 years (AOR 0.04; 95% CI (0.01, 0.14) were associated with workplace incivility among female staff. Having a temporary appointment (AOR 7.79, 95% CI (2.26, 26.91) and casual/contract employment status (AOR 29.93, 95% CI (4.57, 192.2) were reported to be associated with workplace bullying. Having a doctoral degree (AOR 3.57, 95% CI (1.24, 10.34), temporary appointment (AOR 91.26, 95% CI (14.27, 583.4) and casual/contract employment status (AOR 73.81, 95% CI (7.26, 750.78) were associated with workplace SH.

Conclusions

The prevalence of GBV was high. There is an urgent need for workplace interventions to eliminate different forms of GBV and address associated factors to reduce the adverse mental, physical, and social health outcomes among university women.

Peer Review reports

Gender-based violence (GBV), or violence against women in the workplace is a major public health problem globally. The World Bank’s Inter-Agency Standing Committee defines GBV as "an umbrella term for any harmful act that is perpetrated against a person's will, and that is based on socially ascribed (gender) differences between males and females” [ 1 ]. Furthermore, GBV has been conceptualized as violence towards minority groups, individuals, and/or communities solely based on their gender, which can directly or indirectly result in psychological, physical, and sexual traumas or injury and deprivation of their right as a human being [ 2 ]. GBV primarily involves violence against a person based on gender (i.e., both men and women) [ 1 , 2 , 3 ]; however, women bear the brunt of violence due to the prevailing gender inequalities [ 4 ]. For instance, epidemiological studies [ 4 , 5 , 6 , 7 ] reported that GBV undermines the daily life activities of women.

In Nigeria, the prevalence of GBV is high. Previous studies reported that GBV is an important public health problem in Nigeria [ 4 , 8 , 9 , 10 ]. For instance, a study [ 8 ] reported that about 52.1% of the women indicated that domestic violence incidence is high, while 63.3% had experienced domestic violence at one time or the other. Sexual abuse was the most frequently reported form of abuse experienced [ 10 ]. The high prevalence of GBV in Nigeria has been attributed to a culture of silence, cultural values, and practices [ 4 , 8 ].

Also, research evidence suggests that GBV has deleterious effects on women’s health. Such adverse health outcomes include physical injuries, mental health problems, sexual and reproductive health problems, sexually transmitted infections (STIs), gynecological disorders, poor pregnancy outcomes, poor health outcomes in children of affected women [ 3 , 11 ].

Previous studies have indicated that GBV is a predominant phenomenon in higher educational institutions [ 9 , 12 ]. However, this problem is still under-studied in educational institutions in developing nations [ 13 ]. Thus, there may be a paucity of data available on the prevalence of GBV among university women in Nigeria. In the present study, we use the concept of GBV to encompass the most common and potential forms of workplace violence against women in higher education systems, such as the university environment. A previous study [ 14 ] adopted this approach. However, the present study focused on incivility, bullying, and sexual harassment among female university staff.

Workplace incivility refers to a subtle form of negative interpersonal behavior characterized by rudeness and disrespect [ 15 , 16 ]. Incivility also implies rude speech or behavior, impoliteness, bad manners, and inappropriateness [ 17 ]. From the victim's view, workplace incivility is caused by individuals such as coworkers/colleagues, clients or supervisors who exhibit rude behaviors towards him or her. Similarly, incivility exemplifies uncivil behavior that has low-intensity and that the intention to harm is not apparent [ 16 ]. Leiter [ 18 ] posited the uncivil workplace behaviors could be an integral part of an organization's climate or culture rather than as an individual phenomenon. Regardless of its subtleness, incivility has been considered as a risk factor for more severe aggressive behavior and adverse health outcomes [ 19 ]. In numerous work settings, women are more likely than men to experience uncivil behaviors such as rude and discourteous comments, and men are the primary perpetrators of workplace incivility [ 16 , 20 , 21 ]. Examples of uncivil behaviors in the workplace include receiving a commendation for others' endeavors, peddling unverified reports about coworkers, nonchalant attitude towards collective tasks, sending unwanted emails to colleagues [ 19 , 22 ].

Previous studies affirm that incivility can precipitate many adverse outcomes in the workplace, including university setting. Workplace incivility can result in academic stress, poor motivation, and low productivity, and absenteeism [ 23 ], mental health problems [ 16 , 19 ], low self-efficacy [ 24 ], poor self-control [ 25 ], diminished task performance [ 26 ], and burnout [ 27 ].

Moreover, incivility has been identified to be closely linked with other forms of workplace GBV such as bullying, abuse, harassment, antisocial behavior, and social undermining [ 27 , 28 ]. Workplace bullying (WPB) is a prevalent public health problem in many regions of the world [ 29 ]. Einarsen et al. [ 30 ] conceptualized workplace bullying as an act of harassing, offending, socially excluding someone, or negatively affecting someone's work tasks. Similarly, for an activity to be termed bullying, it has to be perpetrated repeatedly and regularly and over some time (e.g., about six months). Additionally, workplace bullying refers to repeated hurtful detrimental acts or acts (physical, verbal, or psychological intimidation) involving criticism and humiliation to cause fear, distress, or harm to the individual [ 31 ].

The two major linked forms of WPB identified in extant literature include work-related bullying (i.e., unfair deadlines, insurmountable workloads, excessive monitoring, and a feeling of denial of access to relevant information), and personal bullying. Personal bullying includes the persistent experience of gossip, discourteous/rude comments, unwarranted teasing, and persistent criticism [ 32 ]. Also, many factors besides individual factors (i.e., inadequate social competencies and psychosomatic symptoms) have been identified to promote and trigger WPB's perpetuation in diverse organizational and cultural climes. Such factors include power distance, uncertainty avoidance, fear of employee to express disagreement, patriarchalism, the overall decision-making process [ 33 ], organizational culture and climate [ 34 ], working conditions and job design [ 35 ], leadership [ 36 ], role conflict and role ambiguity [ 37 ]. Akella [ 31 ] further asserted that communities characterized by high power distance and low in uncertainty avoidance support the occurrence of workplace bullying.

A plethora of studies have identified the adverse outcomes of WPB [ 30 , 38 , 39 ]. For instance, WPB creates a toxic environment [ 40 ] with adverse outcomes such as diminished corporate/organizational productivity, decreased work motivation, a lack of concentration, errors, and absenteeism [ 41 , 42 ], sleep disorders, anxiety, chronic fatigue, anger, depression, and several somatic disorders and decreased performance [ 30 , 43 ]. Women in academia may be more prone to WPB than other work contexts due to high-stress levels [ 44 ]. Thus, identifying the prevalence of WPB among female university staff could offer profound insights that may further inform appropriate interventions.

Furthermore, exposure to workplace incivility and bullying could also lead to workplace sexual harassment (WSH). Workplace SH has been identified as a severe public health problem in extant literature. Sexual harassment is any form of unwanted verbal, non-verbal or physical conduct of a sexual nature that occurs with the purpose or effect of violating a person's dignity, particularly when creating an intimidating, hostile, degrading, humiliating or offensive environment [ 45 ]. Also, WSH is a form of workplace harassment typically characterized by gender or sex lines [ 46 ]. Besides, the literature suggests that women are more likely than men to experience sexual harassment in a lifetime [ 47 , 48 , 49 ]. Fitzgerald identified three dimensions of SH. These include gender harassment (GH), unwanted sexual attention (UwSA), and sexual attention (SA). Gender harassment entails verbal and nonverbal behaviors that portray abusive, unfriendly, or undignified attitudes towards women. GH's primary purpose is not sexual intercourse; however, it accentuates the dispersion of attitudes that foster hatred of women.

In contrast, UwSA encompasses forms of sexual advances perceived by the victim as offensive, unwanted, and unrequited. Such can include requests for dates, letters, phone calls, touching, grabbing, and other sexual assaults forms. Sexual coercion highlights the request for sexual favors as compensation for job rewards or prospects.

Previous studies [ 9 , 50 , 51 , 52 ] have reported a high prevalence of SH in higher educational settings. Also, prior studies [ 50 , 52 ] had reported that women in most cases are the victims of SH in higher educational settings. Women exposed to SH in the workplace experience adverse health outcomes such as decreased job satisfaction, long-term sickness absence, depression, and anxiety [ 53 , 54 , 55 , 56 ]. The literature further shows that SH negatively impacts the victims' mental health [ 53 , 56 ]. Since SH is a preventable occupational health problem, concerted efforts are needed to identify its magnitude and predictors in the Nigerian university context. Thus, the present study is birthed as part of the efforts to ascertain the prevalence of SH and associated factors among university women in south-east Nigeria.

Research evidence has shown that an interplay of different factors influences GBV perpetration and victimization. For instance, past studies [ 57 , 58 , 59 ] identified age, rural residence, parity, childhood exposure or experience of violence, educational status, marital conflict, partner, and personal substance use as the predictors of GBV. GBV, as a complex and multidimensional concept, is influenced by an interplay of several factors, such as personal, situational, and sociocultural factors [ 60 ]. This understanding supports the underlying assumptions of the social ecological model (SEM). Therefore, we employed the socio-ecological model to investigate associated factors of GBV among university women, such as individual and institutional. The SEM posits that multiple factors interact to influence health behaviors and efforts designed to motivate an individual to change their behavior should embrace all the factors or web of influence that support such behaviors to be effective. The SEM identifies the individual as the core of an ecosystem and offers a valuable and integrative framework to enhance an in-depth understanding of the numerous factors that sustain systemic perpetuation of GBV in higher education systems and those that hinder its eradication [ 61 , 62 ]. The socio-ecological models [ 61 , 62 ] provide a wide-ranging framework of systems and interactive levels such as intrapersonal, interpersonal, institutional, community, and policy that helped explain the associated factors of GBV perpetration, victimization and further informs interventions that can be implemented at each level to address GBV.

This study aimed to determine whether the prevalence of incivility, bullying and sexual harassment (i.e., forms of GBV) is high among university women and examines if women's GBV experiences are associated with their personal factors and contextual variables (staff category, employment status). Next, we hypothesized that there are interrelationships among the outcomes-workplace bullying, incivility, and sexual harassment. Hopefully, the findings may substantiate and add to the existing data on the prevalence of GBV and associated factors among university women. This study may further increase an understanding of factors that influence GBV perpetration and contribute to prevention programs. The findings can also help identify evidence-based prevention interventions and those for mitigating the effects of GBV exposure among university women.

Study design and setting

This study was an institutional-based cross-sectional design. It was conducted in Enugu, south-east Nigeria. The study period covered five months from May 25 to October 30, 2019. The Igbo communities mainly inhabit Enugu state. People from other tribes also reside in the states. Examples of such tribes include Yoruba, Hausas/Fulani, Itsekiri people, Ibibio and Efik people, Idoma people, Igala people, etc. Enugu state has a population of 3,267,837 people, according to the 2006 population census [ 63 ]. The University of Nigeria Enugu Campus (UNEC) is a federal tertiary institution in Enugu city. Also, the Enugu State University of Science and Technology (ESUT) is a state university located in Enugu and Agbani, respectively. Private/mission universities such as Renaissance University with its main campus in Ugbawka, Enugu; Godfrey Okoye University, Enugu; Caritas University, Amorji-Nike, Enugu. The universities serve as academic hubs for the south-east, south-south, south-west, and the northern states. The population for the study comprises 4995 female staff in the sampled universities during the 2018/2019 academic session. Female employees constitute the bulk of manpower in these universities.

Sample size determination and procedure

We used the Leslie Kish single population proportion formula to calculate the study sample size. We assumed the prevalence of workplace incivility, bullying, and sexual harassment to be 30% among female university staff with a 95% confidence level and 5% margin of error. Also, a 5% non-response rate was added to the initial sample size. Thus, 339 women constituted the study sample size.

The calculated sample size for the study was 323. Afterwards, the sample size was multiplied by 5% non-response rate (323 * 0.05 = 16) and was added to 323 (i.e., 323 + 16). Finally, the study sample was determined to be 339. The sample size is an approximation. Thus, three hundred and thirty-nine female staff were recruited from the universities in Enugu, Enugu State. Multi-stage random sampling was used to select participants for the study. At the first stage, we stratified the universities to private and public institutions, and subsequently, we randomly selected four out of six universities in Enugu City. Two public and two private universities were selected. In the second stage, a systematic sampling technique was employed to select the faculties using the list of faculties in the respective universities as a sampling frame. The principal investigators and well-trained research assistants approached the eligible participants individually, invited them to participate, and the study’s aims were explained to them. The participants were informed that participation is voluntary and that they can withdraw from participation at any time they deem fit without any reason. When necessary, we provided clarification, and participants were assured that their responses would be treated confidentially and without identity disclosure. We obtained informed verbal consent from the participants. The approval of the University of Nigeria's institutional review board (IRB), Nsukka, was obtained (Reference number: NHREC/05/01/2008B-FWA00002458-IRB00002323). The inclusion criteria include working for at least 12 months as university staff, absence of ill health, and issuance of voluntary informed consent. Exclusion criteria include a work experience of fewer than 12 months, and refusal to participate in the study, and ill-health. Interviews were conducted face-to-face, and each interview lasted, on average, 30–45 min.

After obtaining informed verbal consent from the participants, the investigators and trained data collectors administered the demographic information sheet, 7-item workplace incivility Scale (WIS), the 7-item modified workplace incivility Scale (MWIS) by Blau and Andersson, the Negative Acts Questionnaire-Revised (NAQ-R), and the Sexual Experiences Questionnaire (SEQ). The WIS, MWIS, NAQ-R and SEQ are not under license. They are available in the public domain. Thus, licenses were required for their use.

Sociodemographic characteristics

Information on demographic characteristics of the participants was collected using an information sheet developed by the researchers. The information sheet collected data on the participant’s age, academic qualification, marital status (having a partner or spouse, divorced, single, widowed), employment status, work experience (i.e., years of experience working as an academic or non-academic staff) salary grade, and staff category/position. Moreover, we coded the participants' age in years, both as a continuous and discrete variable. Participants’ age was categorized as follows: 18–34 years coded as 1; 35–49 years coded as 2; and ≥ 50 years coded as 3 (older female staff). Academic qualification was categorized into five groups such as Senior Secondary School Certificate of Examination-SSCE (coded as 1), Ordinary National Diploma/National Certificate of Examination-OND/NCE (coded as 2), first degree-B.Sc., B.Ed., B.A, etc. (coded as 3), having master’s degree-M.Sc., M.A., M.Ed. (coded as 4). Furthermore, possession of a doctoral degree/Ph.D. (coded as 5). Marital status was coded 1 for single, 2 for married, 3 for divorced/separated, and 4 for widowed. We created three categories for employment status, which include permanent appointment (coded as 1), temporary appointment (coded as 2), and casual/contract (coded as 3). Work experience (i.e., length of years of teaching/working as a staff in the university) was categorized into < 5 years (coded as 1), 5–9 years (coded as 2), and ≥ 10 years (coded as 3). Other variables were categorized as follows: salary grade (CONTISS II grade 01–05, CONTISS II grade 06–10, CONTISS II grade 11–15, CONAUSS II Grade 01–04, and CONAUSS II Grade 05–07) [ 64 , 65 ]; staff category/position was grouped into academic staff, and non-academic/clerical staff (coded as 1 and 2, respectively), and the institutional type was categorized into private university (coded as 1) and public university (coded as 2).

Workplace incivility

We used the 7-item Workplace Incivility Scale (WIS) developed by Cortina et al. [ 15 ] to measure experienced incivility from the supervisors and co-workers. The scale assesses the frequency of perceived incivility in the past five years. However, to minimize recall bias or ambiguity, the study participants were asked to describe their workplace incivility experience in the last 12 months or academic session . This is a shorter period than the five-year period recommended by Cortina et al. [ 15 ]. The scale comprised items that measure both direct and indirect forms of workplace aggression. Examples of items in the 7-item WIS include 'My co-workers address me in unprofessional terms, either publicly or privately,' 'My co-workers put me down or are condescending to me,' and 'My co-workers make demeaning or derogatory remarks about me.' The response format ranges from 0 (never) to 5 (daily). Next, we calculated the total WIS score for all the participants. The WIS score ranges from 0 to 35. Higher scores indicate a high level of workplace incivility experience. To assess women's supervisor and co-worker incivility experience, we dichotomized the response option into "Yes" or "No." Women answered "Yes," when their responses showed rarely to daily to at least one item on the WIS in the past 12 months while a never response was regarded "No." The WIS has been used in a previous study [ 66 ]. The WIS has good internal consistency reliability that ranged from 0.85 to 0.89 [ 67 , 68 , 69 ]. The Cronbach’s alpha reliability for the entire 7-item WIS was 0.65. The alpha coefficients for the supervisor incivility and co-worker incivility subscales were 0.50 and 0.73, respectively.

Additionally, we used the seven-item modified Workplace Incivility Scale (MWIS) developed by Blau and Andersson [ 70 ] to measure person-initiated or instigated incivility. sample questions from the MWIS include “How often have you exhibited the following behaviors in the past year to someone at work (e.g., co-worker, other employees, supervisor)? “During the past year, while employed in the current organization, have often have you made demeaning or derogatory remarks about others?” The MWIS used a 4-point Likert response format 1 = hardly ever (once every few months or less, 2 = rarely (about once a month), 3 = sometimes (at least once a week), and 4 = frequently (at least once a day). The scores range from 1 to 28, with higher scores implies much involvement in person-initiated incivility in the workplace. However, to assess women’s perpetration/involvement in instigated incivility, responses that indicated rarely (about once a month) to frequently (at least once a day) to at least one item on the MWIS were categorized as “Yes” while responses that indicated hardly ever to all the items on the MWIS were considered “No”. Thus, we dichotomized participants’ instigated incivility into Yes (coded as 1) and No (coded as 0). The internal consistency reliability coefficient via Cronbach’s alpha for Blau and Andersson MWIS scale was 0.81 (Additional File 1 ). The alpha coefficient for the combined 7-item Cortina et al. WIS and Blau and Andersson MWIS scale was 0.84 (Additional File 2 ).

• Workplace bullying

The Negative Acts Questionnaire-Revised (NAQ-R) is the most used scale to evaluate workplace bullying [ 71 , 72 , 73 , 74 ]. The NAQ-R is a 22-item questionnaire designed to measure workplace bullying in diverse workplace settings [ 75 , 76 ]. The 22 items in the NAQ-R are structured to measure bullying behaviors. The NAQ-R is a free 22-item questionnaire for use in non-commercial research projects. The NAQ-R is available in the public domain for surveys. The NAQ-R involves three different categories of negative behaviors, such as person-oriented bullying, workplace-related bullying, and physically intimidating bullying. Additionally, 12 items measure person-oriented bullying; 7 items measure work-related bullying, and 3 items measure physically intimidating bullying [ 75 , 76 ]. Examples of such items include “been excluded from the social fellowship” and “exposed to exaggerated teasing and joking.” The NAQ-R has a five-point Likert scale response format to evaluate workplace bullying exposure in the past 6 months (i.e., 1 = never, 2 = occasionally, 3 = monthly, 4 = weekly, 5 = daily). We used a cut-off point of 33 on the NAQ-R to categorize the participants into two exclusive groups of bullied vs. not bullied, based on their workplace bullying exposure. Thus, participants with a score lower than 33 (< 33) are not bullied, while participants with a score greater than 33 (≥ 33) are bullied. The cut-off point has been used in a previous study [ 77 ]. The NAQ-R has good psychometric properties. [ 71 , 72 , 73 , 74 , 75 ]. The Cronbach’s alpha of 0.91 was obtained for the NAQ-R in this study (Additional File 3 ).

Sexual harassment (SH)

The 20-item version of the Sexual Experiences Questionnaire (SEQ) [ 78 ] was used to measure SH experiences. The SEQ is a non-proprietary instrument that is available for non-commercial research purpose. The SEQ measures three dimensions of SH, such as gender harassment, unwanted sexual attention, and sexual coercion. Participants were asked to rate the frequency of each experience on a 5-point scale that ranged from 0 (never) through 4 (many times); SEQ total scores indicate the frequency with which the participants reported experiencing SH in the university environment in the past 12 months [ 78 , 79 ]. However, we dichotomized the SH experience of the participants for the prevalence analyses. We coded one or more experiences of SH as 1 (Yes) , while no experience/never experienced SH was coded as 0 (No). Otherwise, we used the composite score. This procedure was used by Rospenda et al. [ 80 ]. Fitzgerald et al. reported that the internal consistency coefficient for the SEQ ranged between 0.86 and 0.92, and a test–retest coefficient of 0.86 for 1 week [ 80 ]. The Cronbach's alpha coefficient for the SEQ was 0.73. The subscales' alpha coefficients were as follows: 0.77 for gender harassment; 0.72 for unwanted sexual attention; and 0.93 for sexual coercion (Additional File 4 ).

Data processing and analyses

We conducted data entry, data cleaning, and coding using SPSS version 25 software (IBM Corp., Armonk, NY, USA) and analyzed with the same software. First, we conducted test of normality on the data to inform the selection of statistics used for data analyses. The normality of the continuous data was examined using the Kolmogorov–Smirnov test, and data distribution fulfilled the criteria for normality. The skewness and kurtosis were also performed. We also conducted descriptive statistics such as frequencies, means, and standard deviations (SD), and bivariate correlation analysis using Pearson’s r to present the information. The skewness and kurtosis values were considered appropriate for any item values if they fall within the range of + 2 or − 2 [ 81 ]. We used the Chi-squared test to examine the association between the groups (experienced/yes vs. never experienced/no) and the categorical variables. In contrast, independent samples t -test and one-way analysis of variance (ANOVA) were used to test mean differences in the WIS, NAQ-R, and SEQ index scores using the participants' sociodemographic variables.

Furthermore, each independent variable was fitted separately into the bivariate logistic analysis to evaluate for the degree of association with the forms of workplace GBV (incivility, bullying, and sexual harassment). We conducted bivariate logistic regression to check the crude association between the outcome variables and predictors using the forced entry method. Before the use of bivariate logistic regression, we examined multi-collinearity for all the models through the variance inflation factor (VIF) [ 82 ], and none was detected (VIF values < 5). We selected the variables with P  < 0.05 for further exploration in the multivariable logistic regression analysis (MLR). We used the MLR analysis to identify the independently associated predictors of GBV. The staggered entry method was used for the MLR by entering first the demographic variables (age, academic qualification, and marital status), second, the work-related variables (employment status and work experience) and third, staff category was entered. We checked the goodness of fit of the final model using Hosmer and Lemeshow [ 83 ] and was found fit. The results were summarized using crude odds ratio (COR), adjusted odds ratio (AOR), and 95% confidence interval (CI). A P -value of 0.05 was considered as the threshold for statistical significance. Also, the study adhered to the STROBE guideline (Additional File 5 ).

Descriptive statistics

A total of 301 out of 339 participants completed the survey with full information, representing an 88.8% response rate. Among the 301 that completed the questionnaires, 113 (37.5%) were academic staff, and 188 (62.5%) were non-academic staff (administrative/clerical staff). One hundred and sixty-two (53.8%) were from public universities, and 139 participants (46.2%) were from private universities. Also, 89.4% had permanent job status, 6.6% had a temporary appointment/employment status, and 4.0% had casual or contract employment status. Furthermore, 16.3% of the participants had a doctorate, 22.6% had a master's degree or its equivalent, 29.6% had a first degree, 16.6% possessed OND/NCE certificate, and 15.0% had SSCE. The mean age for participants was 40.1 years (SD = 12.9), ranging from 22 to 66 years (Table 1 ). Table 2 shows the means, standard deviations, and intercorrelations for all the study variables. The mean WIS score was 24.7 (SD = 7.39), and the mean NAQ-R score was 36.1 (SD = 12.9). Besides, the mean score for the SEQ was 8.30 (SD = 11.0). There was a positive moderate relationship between workplace incivility and sexual harassment ( r  = 0.36, p  < 0.000) and workplace bullying ( r  = 0.43, p  < 0.000). Moreover, there was a strong relationship between workplace bullying and sexual harassment ( r  = 0.76, p  < 0.000) (Table 2 ).

Prevalence of workplace incivility, bullying, and sexual harassment

A total of 63.8% of respondents had experienced at least one form of workplace incivility during the previous session (i.e., past 12 months). In detail, 67.4% experienced supervisor incivility, 58.8% experienced coworker incivility and 52.8% experienced instigated incivility. Also, a total of 53.5% of participants had experienced at least one form of WPB. Concerning types of WPB, 47.5% of the participants initiated personal bullying, 62.5% experienced work-related bullying and 42.2% experienced physical bullying. Also, 40.5% of the women experienced sexual harassment (SH). Regarding other of forms of SH, 36.5% experienced gender harassment, 25.6% experienced unwanted sexual attention and 26.6% experienced sexual coercion (Table 3 ). There was a significant difference in the NAQ-R scores [ F (2, 298)  = 7.663, η 2  = 0.05, p  = 0.001] among the participants of different age groups. Besides, there was a significant difference in the bullying status-bullied vs. not bullied, [χ 2 (2) = 11.362, p  = 0.003] among participants of different age groups. In addition, participants of diverse age groups differed significantly in their SH experience-harassed vs. never harassed [χ 2 (2) = 7.118, p  = 0.028]. There were significant differences in the WIS scores [ F (4, 296)  = 7.593, η 2  = 0.10, p  < 0.0001], NAQ-R scores [ F (4, 296)  = 3.160, η 2  = 0.04, p  = 0.014], and SEQ scores [ F (4, 296)  = 3.781, η 2  = 0.05, p  = 0.005] among the participants in terms of academic qualification groups. Also, there were significant differences in the WIS scores [ F (2, 298)  = 4.880, η 2  = 0.03, p  = 0.008] among women in terms of employment status. Furthermore, there were significant differences in the WIS scores [ F (2, 298)  = 30.835, η 2  = 0.17, p  < 0.0001], NAQ-R scores [ F (2, 298)  = 21.971, η 2  = 0.13, p  < 0.0001], and SEQ scores [ F (2, 298)  = 11.423, η 2  = 0.07, p  < 0.0001] among the participants in terms of work experience. Women differed significantly in their WIS scores [ F (4, 296)  = 5.560, η 2  = 0.07, p  < 0.0001], NAQ-R scores [ F (4, 296)  = 3.214, η 2  = 0.04, p  = 0.013], and SEQ scores [ F (4, 296)  = 3.214, η 2  = 0.04, p  = 0.031]. Moreover, there was a significant difference in WIS scores of female academic and non-academic staff [ t (299) = -2.874, η 2  = 0.03, p  = 0.004]. In addition, female academic and non-academic staff differed significantly in their workplace incivility experience-yes vs. no [χ 2 (1) = 6.036, p  = 0.014], and SH experience-harassed vs. never harassed [χ 2 (1) = 6.115, p  = 0.013] (Tables 4 , 5 ).

Workplace incivility, bullying, sexual harassment, and associated factors

Table 6 presents the results of the analyses to examine workplace incivility, bullying, sexual harassment among female university staff, and associated factors. In both the bivariate and multivariable logistic regressions, we entered workplace incivility, bullying, and sexual harassment into the models as dependent variables, being aged ≥ 50 years, having a doctoral degree (Ph.D.), having temporal and contract appointments, having a work experience of ≥ 10 years, being on CONUASSII Grade 01–04, and being an academic staff were associated with workplace incivility experience among female staff. Furthermore, being aged 35–49 years and ≥ 50 years, having OND/NCE and first degree, being separated/divorced, having temporal and contract appointments, having work experience of 5–9 years, and ≥ 10 years were associated with workplace bullying among female staff. Also, having a doctoral degree (Ph.D.), having temporal and contract appointments, having a work experience of ≥ 10 years, and being an academic staff were associated with sexual harassment of female university staff.

In the multivariable logistic regression model, being aged 35–49 years (AOR 0.15; 95% CI (0.06, 0.40) and ≥ 50 years (AOR 0.04; 95% CI (0.01, 0.14) were associated with workplace incivility among female staff. Female staff with doctoral degree had higher odds to experience workplace incivility compared to female staff with SSCE (AOR 8.32, 95% CI (2.01, 34.38). Women on temporal and casual/contract appointments were 7 times (AOR 6.99, 95% CI (1.48, 32.94) and 20 times (AOR 19.9, 95% CI (3.10, 128.4), respectively more likely than women with a permanent appointment to experience uncivil behaviors. Also, women with a work experience of ≥ 10 years had higher odds to experience incivility from supervisors, and co-workers compared to women with less than 5 years’ experience (AOR 23.36, 95% CI (8.19, 66.7) (Table 7 ). Next, women having a CONTISS II Grade 06–10 (AOR 2.73, 95% CI (1.03, 7.22) and CONUASS II Grade 01–04 (AOR 9.14, 95% CI (3.08, 27.08) had higher odds to experience workplace incivility compared to women on CONTISS II Grade 01–05.

Additionally, women aged 35–49 years had higher odds to be bullied compared to those aged 18–34 years (AOR 2.50, 95% (1.16, 5.40). However, being ≥ 50 years (AOR 0.39, 95% (0.16, 0.94) reduced the odds of being bullied in the workplace compared to being aged 18–34 years.

Having OND/NCE (AOR 0.32, 95% CI (0.12, 0.89) and a first degree (AOR 0.32 95% CI (0.13, 0.80) reduced the odds of workplace bullying compared to female staff with SSCE. Similarly, being single (AOR 0.36, 95% CI (0.14, 0.88) and separated/divorced (AOR 0.27 95% CI (0.08, 0.88) reduced the odds of workplace bullying compared to the married female staff.

Women with temporary appointment (AOR 7.79, 95% CI (2.26, 26.91) and casual/contract appointment (AOR 29.93, 95% CI (4.57, 196.2) had higher odds to report workplace bullying compared to women with a permanent appointment/employment status. Women with 5–9 years’ work experience had lesser odds to experience workplace bullying compared to women with < 5 years’ work experience in the university (AOR 0.33; 95% CI (0.12, 0.89). Also, women with ≥ 10 years had higher odds to be bullied in the university compared to women with 5 years’ work experience (AOR 3.71; 95% CI (1.75, 7.86) (Table 7 ).

Furthermore, having a doctoral degree, (AOR 3.57, 95% CI (1.24, 10.34), and being single (AOR 0.19, 95% CI (0.06, 0.58) were significantly associated with sexual harassment of female staff. Women with temporary appointment (AOR 91.26, 95% CI (14.27, 583.4) and casual/contract appointment (AOR 73.81, 95% CI (7.26, 750.78), respectively had higher odds to experience sexual harassment from a supervisor, head of the department/unit, senior colleagues, or other colleagues in the workplace compared to women with SSCE. The odds of being sexually harassed were higher among female staff with ≥ 10 years’ work experience (AOR 3.94, 95% CI (1.85, 8.42) compared to those with less than 5 years' work experience. Female staff on CONUASS II Grade 01–04 had higher odds to experience sexual harassment from a supervisor, head of department/unit, senior male colleagues, or other male colleagues compared to female on CONTISS II Grade 01–05 (AOR 2.92, 95% CI (1.25, 6.84).

Main findings

The study aimed to examine the prevalence of workplace GBV and associated factors among female university staff. Workplace GBV is a prevalent problem in higher educational institutions and manifested as workplace incivility, bullying, and sexual harassment. In this study, the prevalence of workplace incivility, bullying, and sexual harassment was 63.8%, 53.5%, and 40.5%, respectively. The prevalence of workplace incivility, bullying, and sexual harassment in our study is higher than the reported prevalence in a Nigerian study [ 9 ]. The high prevalence of GBV in our study could be due to many factors, including women’s reluctance to report incidents of GBV, fear of social stigma, fear of consequence such as job loss, and retribution [ 49 , 84 ]. This finding is consistent with the reported prevalence of GBV in previous studies [ 9 , 14 , 15 , 44 , 47 , 85 ].

Also, there was a high prevalence of sub-types of workplace incivility-supervisor, coworker, and instigated incivility in our sample. A plausible explanation for our finding could be that the university women experience persistent uncivil or discourteous behaviors while performing their duties due to high job strain and demands that characterize the university environments. Also, a poor working environment characterized by lower support from co-workers, lower levels of job insecurity, reduced job satisfaction, aggression, and low incentives for workers has been linked to a higher level of incivility from coworkers [ 84 , 86 , 87 , 88 ]. Such workplace settings foster organizational pressures that support uncivil behaviors from supervisors, colleagues, and subordinates. The findings are consistent with prior studies [ 15 , 19 , 22 , 23 , 24 , 27 , 28 ] which reported that coworkers perpetrate diverse forms of incivility as a retributory or retaliatory response to recent exposure to perceived or actual uncivil or rude behaviors such as low social support from supervisors and co-workers and high job demands. Future research should focus on evidence-based preventive interventions that consider the organizational aspects implicated in the persistent occurrence of workplace incivility in Nigerian university contexts. Such intervention could reduce workplace incivility in educational environments.

This study reported a high prevalence of personal, work-related, and physical bullying among our sample. The finding could suggest a persistent and prolonged problem and dysfunctional system suggestive of an organizational culture that tolerates harmful behaviors or negative acts. Consistent with the view of Cortina et al. [ 15 ], bullying variants could be attributed to the spiraling effects of negative acts in the working environment. Our findings are consistent with previous studies [ 15 , 16 , 44 , 52 , 88 ]. The findings also imply that university management needs to create a workplace climate that mitigates the negative acts since WPB is associated with poor health outcomes [ 39 ]. Interventions that identify bullying subcultures and incorporate preventive and mitigating measures, are vital for promoting health among university employees, especially women [ 88 ].

The high prevalence of SH observed in our study could be due to a poor working environment or organizational climate that permits SH's forms by supervisors, colleagues, or subordinates. For instance, studies have suggested power imbalance (i.e., power imbalance predisposes female staff to sexual coercion) in the workplace context, the offer of bonuses and promotion in return for sexual attention are prevalent in many workplaces including the academia [ 47 ]. Our findings corroborate prior research showing that sexual harassment of women is prevalent in diverse workplaces, including academia [ 48 , 49 , 52 , 79 , 84 ]. The finding is an urgent call for well-functioning support structures for SH's victims, and active organizational structures are also essential for preventing SH in higher education. Also, creating an inclusive, structurally egalitarian workplaces that ensure power balance and equality between women and men prevents sexual harassment since women in male-dominated workplaces are at higher risk of sexual harassment [ 84 , 86 , 87 ]. Furthermore, from a theoretical point of view, the socioecological model offers a theoretical understanding of the diversity of SH's risk factors in higher education. Thus, future intervention studies should leverage the SEM to design appropriate interventions to address the risk factors at the individual and organizational levels.

. Our results further showed that being aged 35–49 years and ≥ 50 years and having a doctoral degree were associated with workplace incivility. The finding that having a doctoral degree is associated with workplace incivility contradicts available evidence. that shows that education serves as a buffer against rude or uncivil behaviors among women in the workplace, including academia [ 86 , 89 , 90 ]. The finding could suggest that possession of a higher degree does not protect women from workplace uncivil behaviours. The finding is inconsistent with previous studies [ 9 , 86 , 90 ].

In our study, having temporary and casual/contract employment status, and work experience of ≥ 10 years increased the odds of workplace incivility among women. Additionally, the finding could suggest that marital status does not protect against exposure to rude and discourteous acts in the workplace. This finding is inconsistent with a previous study [ 9 ] that reported being married as a protective factor against GBV. Similarly, women with temporary and casual/contract employment status may be insensitive to covert or overt uncivil behaviors towards them because of their status. In many circumstances in Nigerian workplace environments, the status and privileges that come with permanent or full-time appointments are not usually accorded temporal and casual workers. To prevent job loss, women with temporal and casual/contract appointments "endure" these behaviors possibly to secure a permanent appointment or at least secure a decent means of livelihood. The limited research on the association between GBV and employment status among women in Nigeria's tertiary education community hinders finding comparison. Nevertheless, higher education institutions can provide viable mechanisms for women regardless of their educational qualification, employment status, and work experience to identify, report, and avoid rude behaviors. Similarly, incivility victims should be provided with emotional or psychological support structures that can help them build resilience against rude behaviors [ 91 ].

Furthermore, our findings showed that older age reduced the odds of bullying among university women. A reasonable explanation for the finding may be that people’s respect for old age in many Nigerian cultures inhibits the display of aggression towards older women. Future research may further explore the protective or mediating role of advanced or older age in women’s experience of GBV in higher educational environments.

Concerning the association between having a temporary and casual/contract employment (TCCE) status and WPB, female staff with TCCE status experience WPB due to non-existence or ineffective mechanisms to deal with WPB and fear of retribution. Many victims of WPB may not have sought help because they perceive the university-oriented policy and support structures as dysfunctional. Thus, higher education institutions should provide emotional or psychological support structures that can help them build resilience against rude behaviors [ 91 ]. In general, university administrations should explore measures that support gender-related expectations about how people should be treated, which permeate countries, industries, professions, and work domains [ 89 ].

Furthermore, our findings showed that having a doctoral degree, being single and having a TCCE status, work experience of ≥ 10 years, and having a low income (CONUASS II Grade 01–04, i.e., #1, 478,046-#3,125, 980) [ 64 , 65 ] were significantly associated with sexual harassment among university women. A plausible explanation for the findings could be unsafe working conditions, inactive or passive leadership, inequalities between men and women in terms of accessibility to research funding, a societal normalization of GBV, toxic academic masculine cultures, and poor economic condition [ 86 , 92 ]. The findings agree with previous studies [ 2 , 9 , 13 , 14 , 80 , 92 ]. Further, university administrators could adopt standard guidelines and policies that provide employees with criteria for acceptable and non-acceptable behavior regarding sexual harassment in the workplace [ 47 ]. Social support from colleagues and supervisors for a victim could help in ameliorating adverse health outcomes following SH [ 79 ]. Also, there is a need for restructuring working conditions in higher education, especially for women, challenging toxic academic masculine cultures, and implementing viable measures to eradicate men's violence against women [ 86 ]. Although women’s financial or economic condition improves overtime as they advance through the ranks in academia, women who currently earn an annual income between #1, 478,046 (i.e., equivalent of USD 3,213 at the current exchange rate of #460 per 1 USD) and #3,125, 980 (USD 6795.60) could be exposed to SH due persistent economic problems. however, research evidence on the association between women’s income and SH is mixed. Studies suggested that higher income is a protective factor and low income is a risk factor [ 92 , 93 ]. Another study reported that higher income does not immune women from sexual assault or harassment [ 94 ,  95 ]. Nevertheless, interventions to increase university women’s access to economic opportunities such as research grants, scholarships and other financial incentives may help mitigate the incidence of SH.

Study strengths and weaknesses

The present study offers new insights and valuable evidence on the prevalence of GBV forms and associated factors among university women, an under-studied group in health surveys in Nigerian academia. The cross-sectional nature of the present study limits the ability to draw any conclusions concerning the associated factors of GBV, and thus, causality cannot be established. Future studies that employ more robust designs such as experimental or longitudinal research methodologies may help establish causality. Another limitation of this study is the small sample size. Future research would benefit from a larger sample size. The use cut-off points on the NAQ-R for dichotomization of university women’s GBV experience may lead to overestimation or underestimation of WPB prevalence in our study. However, since the tool's psychometric properties have been established in many populations or subgroups, our findings are comparable with previous studies. This situation could potentially be addressed in future studies by adopting objective measures of WPB so that findings do not only reflect the individual’s subjective responses. The study data were also collected subjectively and retrospectively, although this method is more convenient and beneficial for surveys. However, there is the possibility of recall bias and response biases since research evidence suggests that women tend not to report SH experience for fear of stigma or retribution. Nevertheless, we used standardized anonymous scales which have potential to significantly reduce response bias due to social desirability and sensitive items. Besides, the study participants were drawn from the high educational setting (university environments). Thus, the generalizability of findings to other higher education settings such as colleges of education, monotechnics, polytechnics, and sectors may be limited. Despite these limitations, the survey reflects the current situation of GBV in many Nigerian university environments.

There was a high prevalence of GBV (incivility, bullying, and sexual harassment) among university women. Interrelationship was found between women’s experience of incivility, bullying, and sexual harassment in the university environment. Women's experience of forms of GBV in the workplace was significantly associated with their age, higher academic qualification, marital status, having temporal and contract/casual appointment, and work experience of ≥ 10 years. This study's findings could inform the development of evidence-based interventions in university environments to prevent workplace GBV and its detrimental effects on women’s health. Also, such interventions should be aimed at eliminating different forms of GBV and addressing associated factors to reduce the adverse mental, physical, and social health outcomes among women. In addition, human resource policies that focus on addressing GBV in academia are imperative.

Availability of data and materials

All data generated or analysed during this study are included in this published article [and its supplementary information files].

Abbreviations

• Gender-based violence

Bachelor of Science

Bachelor of Education

Bachelor of Arts

National Certificate of Examination

National Population Commission

Master of Science

Master of Education

Master of Arts

Multivariable logistic regression

Ordinary National Diploma

Socio-ecological model

Sexual Experiences Questionnaire

Negative Acts Questionnaire-Revised

• Sexual harassment

Workplace incivility scale

Workplace sexual harassment

Temporal and casual/contract employment status

Local Government Area

Unwanted sexual attention

Adjusted odds ratio

Crude odds ratio

Confidence interval

Institutional Review Board

Variance inflation factor

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Acknowledgements

We would like to acknowledge the technical support provided by the staff of personnel departments and human resource units of the selected universities that assisted in providing data on the female staff population. We sincerely appreciate the university women who participated in this study.

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Department of Human Kinetics and Health Education, Faculty of Education, University of Nigeria, Nsukka, Nigeria

Olaoluwa Samson Agbaje, Chinenye Kalu Arua, Joshua Emeka Umeifekwem, Prince Christian Iheanachor Umoke, Chima Charles Igbokwe, Tochi Emmanuel Iwuagwu, Cylia Nkechi Iweama & Eyuche Lawretta Ozoemena

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OSA, CKA, PCIU, CCI, ELO and EOO conceptualized and designed the study. OSA and CKA, TEI performed the statistical analyses. OSA, CKA, JEU, ENI, and CNO drafted the manuscript, and all authors were involved in the interpretation of data, critically revising the manuscript, and approving the final version. All authors read and approved the final manuscript.

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Additional file 1:.

Reliability test results for MWIS.

Additional file 2:

Reliability test results for WIS.

Additional file 3:

Reliability test results for NAQ-R.

Additional file 4:

Reliability test results for SEQ.

Additional file 5: 

STROBE Checklist.

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Agbaje, O.S., Arua, C.K., Umeifekwem, J.E. et al. Workplace gender-based violence and associated factors among university women in Enugu, South-East Nigeria: an institutional-based cross-sectional study. BMC Women's Health 21 , 124 (2021). https://doi.org/10.1186/s12905-021-01273-w

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Workplace violence and turnover intention among Chinese nurses: the mediating role of compassion fatigue and the moderating role of psychological resilience

• Miao Chen 1 ,
• Hao Xie 2 ,
• Xiaoli Liao 3 &
• Juan Ni 4  

BMC Public Health volume  24 , Article number:  2437 ( 2024 ) Cite this article

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Workplace violence is a global public health issue and a major occupational hazard cross borders and environments. Nurses are the primary victims of workplace violence due to their frontline roles and continuous interactions.

The present study aimed to investigate the status of workplace violence, turnover intention, compassion fatigue, and psychological resilience among Chinese nurses, and explore the mediating role of compassion fatigue and the moderating role of psychological resilience on relationship between workplace violence and turnover intention among Chinese nurses.

A cross-sectional study was conducted among a convenience sample of clinical registered nurses from public hospitals in Changsha, Hunan, China. Data was collected through an online questionnaire, which included a demographic information form, the Workplace Violence Scale (WVS), the Turnover Intention Questionnaire (TIQ), the Compassion Fatigue Scale (CF-CN), and the Connor-Davidson Resilience Scale (CD-RISC). Descriptive statistics and correlation analysis were employed to examine the relationships among the main variables. A moderated mediation analysis was further conducted using the PROCESS macro for SPSS (Model 4 and Model 8) to examine the mediating role of compassion fatigue and the moderating role of psychological resilience.

The present survey recruited a convenience sample of 1,141 clinical registered nurses, who reported experiencing multiple types of workplace violence during the past year. Correlation analysis revealed significant positive correlations between workplace violence and turnover intention ( r  = 0.466, P  < 0.01) as well as compassion fatigue ( r  = 0.452, P  < 0.01), while negative correlation between workplace violence and psychological resilience ( r =-0.414, P  < 0.01). Moderated mediation analysis revealed that compassion fatigue mediated, while psychological resilience moderated, the positive relationship between workplace violence and turnover intention (all P  < 0.05).

This study underscores the mediating effect of compassion fatigue and the moderating role of psychological resilience in the relationship between workplace violence and turnover intention among Chinese nurses. Future efforts should be undertaken to develop effective preventive measures and intervention strategies at individual, organizational, and national levels to mitigate workplace violence and foster supportive work environment.

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Not applicable.

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Introduction

Workplace violence refers to any type of acts, incidents, or behaviors where staffs are attacked, threatened, or humiliated in professional circumstances [ 1 , 2 ], which takes in forms of physical violence and psychological violence. World Health Organization (WHO) has identified workplace violence towards healthcare workers as a significant concern within the healthcare systems [ 3 ]. Workplace violence is one of the most complex occupational hazards in healthcare environment around the world. An umbrella review of meta-analysis examined the prevalence of workplace violence against healthcare workers, which reported a prevalence of 58.7% for overall workplace violence, a prevalence of 20.8% for physical violence, a prevalence of 66.8% for verbal violence, and a prevalence of 10.5% for sexual harassment against healthcare workers [ 4 ]. Nurses is one of the professional groups most exposed to workplace violence due to the nature of their professions and the characteristics of their work environments [ 5 , 6 , 7 ]. The prevalence of workplace violence against nurses remains high around the world, and the estimate was 43% in United States (US) [ 8 ], 44% in Japan [ 9 ], and 67% in Italy [ 10 ]. In addition, a meta-analysis of cross-sectional studies examined the prevalence of workplace violence against Chinese nurses, which reported an incidence of 71% for overall workplace violence, an incidence of 63% for verbal violence, an incidence of 14% for physical violence, and an incidence of 6% for sexual harassment among these Chinese nurses during the last year [ 11 ]. International Council of Nurses (ICN) has issued a position statement to condemn all forms of workplace violence against nurses [ 12 ]. Nurses witnessing or experiencing workplace violence can threaten their health and safety as well as impair their work performance and professional attitudes [ 13 , 14 ]. ICN has stated that workplace violence in the healthcare sectors can impair the delivery of patient services and the assurance of patient safety [ 15 ]. Specifically, a cross-sectional study indicated workplace violence as a major occupational hazard, since the experience of such violence impaired the health status and career satisfaction of victims [ 16 ]. Additionally, other study implicated workplace violence as the main cause of occupational stress, as the experience of such violence increased psychological stress and damaged health status of nurses [ 17 ].

Turnover intention refers to an employee’s tendency to leave the current profession and seek an alternative occupation within a certain timeframe [ 18 ]. Turnover intention represents the final stage of turnover perception, and can serve as an excellent indicator for actual turnover [ 18 ]. The turnover rates among nurses remain high around the word, reaching 18.7% in the US [ 19 ] and 12.3% in the United Kingdom (UK) [ 20 ]. The shortage of nurses is a prevalent challenge encountered by healthcare systems worldwide, with the WHO estimating a deficit of over 9 million nurses by 2030 [ 21 ]. China also faces high turnover rates among nurses, a cross-sectional survey of 12,291 nurses across 23 hospitals found that 9.82% of Chinese nurses exhibited strong turnover intention [ 22 ]. Studies have converged to examine the antecedents of turnover intention among nurses, with workplace violence emerging as a strong predictor of turnover intention [ 23 ]. For example, a longitudinal survey with data gathered from 2006 to 2010 examined the relationship between turnover intention and workplace violence among 1,515 Finnish physicians, revealed that workplace violence was positively associated with turnover intention [ 24 ]. In addition, a cross-sectional study investigated the relationship between turnover intention and workplace violence among Chinese nurses, which involved 1,761 nurses among 9 public tertiary hospitals across 4 provinces, indicated that workplace violence was positively associated with turnover intention [ 25 ]. Exposure to workplace violence can make nurses to doubt their own occupational value and professional status, which further causes nurses dissatisfaction with job and intention to leave job [ 26 , 27 ]. While previous studies have primarily examined the occurrence rate and risk assessment of workplace violence, few studies have investigated the consequences and mechanisms of workplace violence on work outcomes [ 28 ]. Therefore, the present study aims to further explore the impacts of workplace violence on turnover intention, and uncover the mechanism behind this correlation among Chinese nurses.

Compassion fatigue refers to a state of physiological dysfunction and emotional exhaustion, which can induce emotional stress and psychological distress in affected individuals [ 29 , 30 ]. Compassion fatigue is a synonymous term for various occupational stresses, encompassing dimensions of both occupational burnout and secondary traumatic stress. Occupational burnout is defined as a sense of exhaustion, frustration, and fatigue resulting from work pressure, while secondary traumatic stress is defined as a syndrome of intrusion, avoidance, and arousal stemming from indirect exposure to traumatic events. Nurses are recognized as the healthcare professionals who struggle the most with compassion fatigue, with reported prevalence ranging from 7.3 to 44.8% among this population [ 31 ]. Compassion fatigue is considered an occupational hazard within healthcare sectors, posing serious consequences for nurses, patients, and organizations alike. Studies have indicated that exposure to workplace violence can decrease compassion satisfaction and evoke compassion fatigue among victimized nurses [ 32 ]. Evidence has also implicated that the presence of compassion fatigue decreased the quality of occupational life and increased the risk of turnover intention among nurses [ 33 ]. Given the relationship between workplace violence and compassion fatigue as well as the association between compassion fatigue and turnover intention, compassion fatigue may act as a critical mediator through which workplace violence impacts turnover intention.

Psychological resilience represents a personality attribute which enables individuals to cope successfully with and recover quickly from adverse circumstances [ 34 ]. Psychological resilience constitutes a protective factor that helps nurses transform adverse events into positive experiences, thus enhancing retention intentions of nurses and stabilizing human resources of healthcare organizations. Previous studies have identified psychological resilience as a protective factor that can alleviate the adverse impacts of workplace violence on affected nurses [ 32 ]. Meanwhile, current evidence also demonstrated that psychological resilience constituted a personal resource to maintain positive professional attitudes and reduce turnover intentions among nurses [ 35 ]. In addition, previous studies have linked both compassion fatigue and psychological resilience to turnover intention, where higher level of compassion fatigue and lower level of psychological resilience predicted stronger turnover intention among nurses [ 36 ]. As psychological resilience can mitigate the negative impact of adverse events and foster professional growth after negative experiences, psychological resilience may act as a protective factor to moderate the impact of workplace violence on turnover intention.

Despite the recognized correlations among these variables, the underlying mechanisms driving these correlations merits further elucidations. Therefore, this study was performed to verify the correlations between these variables and to explore the mechanisms behind these correlations. The stressor-strain-outcome (SSO) model delineates a process between the stressors and the outcomes under the mediating role of strain, where stressors are environmental stimulus, strains are personal emotions, and outcomes are behavioral responses [ 37 , 38 ]. The present study adopts the SSO model as the theoretical framework, where the stressor is workplace violence, the strains are compassion fatigue and psychological resilience, and the outcome is turnover intention. Thus, this study aims to examine the relationship between workplace violence and turnover intention, and to explore the mediating role of compassion fatigue and the moderating effect of psychological resilience in this relationship.

The present study was reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist for cross-sectional studies.

A cross-sectional study was undertaken among a convenience sample of clinical registered nurses from public hospitals in Changsha, Hunan, China.

Participants

A convenience sampling method was adopted to recruit clinical registered nurses as study participants.

Inclusion criteria were set as: nurses who work in local public hospitals, obtained a Chinese registered nurse license, engaged in clinical patient care at least one year, and provided informed consent to participate.

Exclusion criteria were set as: nurse not employed by hospitals, such as training nurses and nursing interns.

Sample size

The equation n = Z 2 α/2 P(1-P)/δ 2 was used to calculate the sample size. The type I error α was set as 0.05, the Z α/2 was set as 1.96, and the absolute error δ was set as 0.03. With a reference prevalence of workplace violence set at 65.8% [ 39 ], the initial sample size was calculated to be 961. To account for a 10% allowance for invalid responses, the minimum required sample size was determined to be 1,058.

Recruitment

Wenjuanxing, the most popular online survey platform in China, was utilized to create the anonymous online questionnaires. WeChat, the largest social communication platform in China, was used to distribute the online questionnaire. The online questionnaire comprised four parts, the first part was an information sheet and the informed consent form, the second part was the inclusion and exclusion criteria, the third part was an instruction about questionnaire contents and response requirements, and the fourth part was the specific questionnaire items. The web link and a quick response (QR) code for accessing the online questionnaire were then distributed to nurses through WeChat. Head nurses on each unit were asked to share the access information with the nurses on their respective units, allowing participating nurses to conveniently complete the survey using their mobile phones or computers. A rule was set as one internet protocol address could only submit the questionnaire once to avoid duplicate submissions.

The first part of the online questionnaire presented an information sheet and the informed consent form. Nurses were required to carefully review the relevant content and then click either “Yes” or “No” to indicate whether they fully understood the research details and were willing to provide their consent to participate. Only nurses who clicked “Yes” to signify their informed consent were then able to proceed to the next part of the survey. The second part of the online questionnaire presented the inclusion and exclusion criteria. Nurses were required to carefully review the relevant content and then click either “Yes” or “No” to confirm that they fully understood the participation requirements and met the eligibility criteria. Only nurses who clicked “Yes” to affirm their eligibility were then able to advance to the next part of the survey. The third part of the online questionnaire provided an instruction about questionnaire contents and response requirements. Nurses were required to carefully review this relevant information and then click either “Yes” or “No” to indicate their readiness to begin completing the questionnaire. Only nurses who clicked “Yes” to confirm their understanding and willingness to proceed were then able to advance to the next part of the survey. Nurses were then guided to the part of specific questionnaire items where they could complete the survey at their own pace. The confidentiality of questionnaire data was strictly maintained to guarantee the anonymity of participation.

Variables and measurements

Data was collected through an online questionnaire, comprising demographic information form, Workplace Violence Scale (WVS), Turnover Intention Questionnaire (TIQ), Compassion Fatigue Scale (CF-CN), and Connor-Davidsion Resilience Scale (CD-RISC).

Demographic information form

A demographic information form was constructed to collect general information, including gender, age, ethnicity, occupational department, and professional title. Gender was categorized as “Male” and “Female”. Ethnicity was categorized as “Han nationality” and “Other nationality”. Occupational department was classified into “Internal medicine department”, “Surgery department”, “Emergency medicine department”, and “Intensive care unit department”. Professional title was divided into “Primary title”, “Intermediate title”, and “Senior title”.

Workplace Violence Scale

The Chinese version of Workplace Violence Scale (WVS) was used to measure nurses’ experiences of workplace violence over the past year [ 40 , 41 ]. The WVS has been widely utilized to assess workplace violence against healthcare workers in China, demonstrating favorable validity and reliability across diverse samples [ 42 ]. This scale consisted of 5 dimensions measuring physical assault (PA), emotional abuse (EA), threats (T), verbal sexual harassment (VSH), and sexual abuse (SA). Each item was rated on a 4-point scale ranging from “0 = none” to “3 = more than 3 times”. The total score of the scale was the sum of the responses of each item, with higher scores indicating higher frequencies of workplace violences. A total score of 0 indicated that the nurse did not experience workplace violence, and a total score of 1–15 indicated that the nurse experienced some level of workplace violence. The Cronbach’s α coefficient for the scale was 0.62, indicating acceptable internal consistency of this scale.

Turnover Intention Questionnaire

The Chinese version of Turnover Intention Questionnaire (TIQ) was used to measure nurses’ turnover intention [ 43 , 44 ]. The TIQ has been widely applied to assess turnover intention among nurses, exhibiting high reliability and validity across different samples [ 45 ]. This scale consisted of 6 items across 3 dimensions, including the likelihood of quitting the current job (item 1 and 6), the motivation of finding another job (item 2 and 3), and the possibility of getting another job (item 4 and 5). Each item was rated on a 4-point scale ranging from “1 = never” to “4 = always”. The total score of the scale was the sum of the responses of each item (6–24), with higher scores indicating greater turnover intention. The Cronbach’s α coefficient for the scale was 0.71, indicating favorable internal consistency of this scale.

Compassion fatigue scale

The Chinese version of the Compassion Fatigue Scale (CF-CN) was adopted to measure nurses’ compassion fatigue [ 46 ]. The CF-CN has been widely used and validated among healthcare professionals in China, supporting the reliability and validity of this scale in the current study context [ 47 , 48 ]. This scale comprised 30 items across 3 dimensions, including compassion satisfaction (10 items), occupational burnout (10 items), and secondary traumatic stress (10 items). Each item was scored on a 5-point scale ranging from “1 = never” to “5 = always”, with items 1, 4, 15, 17, and 29 designated as reverse scoring questions. The present study used two subscales, occupational burnout and secondary traumatic stress, to measure compassion fatigue among nurses [ 47 ]. The test-retest reliability coefficients for each dimension ranged from 0.76 to 0.86, and the Cronbach’s α coefficients of each subscale ranged from 0.75 to 0.82, indicating acceptable reliability and internal consistency of the instrument.

Connor-davidsion resilience scale

The Chinese version of Connor-Davidson Resilience Scale (CD-RISC) was used to measure nurses’ psychological resilience [ 49 ]. The CD-RISC has been widely used and validated among healthcare professionals in China, supporting the reliability and validity of this scale in the current study context [ 50 , 51 ]. This scale comprised 25 self-rated items across 3 dimensions, including optimism (4 items), strength (8 items), and tenacity (13 items). Each item was scored on a 5-point scale ranging from “0 = not true at all” to “4 = true nearly all the time”. The total score of the scale was the sum of the responses of each item, with higher scores indicating better resilience capacity. The Cronbach’s α coefficients of optimism subscale, strength subscale, and tenacity subscale was 0.60, 0.78, and 0.82, respectively. The CD-RISC exhibited high internal consistency, with a Cronbach’s α coefficient of 0.90 for the total scale in this study.

Data analysis

Data analyses were conducted using SPSS V.25.0 for Windows. The threshold for statistical significance was set at P  < 0.05 for all analyses. Descriptive analysis was performed to calculate means and standard deviations for quantitative variables as well as frequencies and percentages for categorical variables. The normality of the quantitative data distribution was assessed using the Shapiro-Wilk test or the Kolmogorov-Smirnov test. For quantitative data that followed a normal distribution, independent samples t-tests and one-way Analysis of Variance (ANOVA) were performed to determine differences in workplace violence and turnover intention across demographic characteristics. For quantitative data that did not follow a normal distribution, Wilcoxon Mann-Whitney (U-test) and Kruskal-Wallis H-tests were performed to determine differences in workplace violence and turnover intention across demographic characteristics. For quantitative data that followed a normal distribution, Pearson’s correlation coefficient was conducted to examine the relationships between the main variables. For quantitative data that did not follow a normal distribution, Spearman’s rank correlation coefficient was conducted to examine the relationships between the main variables.

A moderated mediation analysis was conducted using the PROCESS macro for SPSS (Model 4 and Model 8) to examine the mediating role of compassion fatigue and the moderating role of psychological resilience. Mediation analysis was performed using Model 4 in the PROCESS macro to examine whether compassion fatigue (mediator) mediated the relationship between workplace violence (independent variable) and turnover intention (dependent variable). Bias-corrected bootstrap confidence intervals (95%) were used to assess the statistical significance of the indirect effect. If the 95% CI did not contain 0, it indicated a significant mediating effect of compassion fatigue. Moderated mediation analysis was conducted using Model 8 in the PROCESS macro to investigate whether the mediating effect of compassion fatigue (mediator) varied depending on the level of psychological resilience (moderator). Bias-corrected bootstrap confidence intervals (95%) were used to assess the statistical significance of the conditional indirect effects at different levels of psychological resilience (-1 SD, mean, + 1 SD). If the 95% CI did not contain 0, it indicated a significant moderated mediation effect, suggesting that the mediating effect of compassion fatigue was influenced by the level of psychological resilience.

Ethical considerations

This study obtained ethic approval from the institutional review board of the Third Xiangya Hospital, Central South University (Reference number: kuai 23773). All procedures were conducted in accordance with the provisions of the Declaration of Helsinki. The informed consent was obtained from all participants before they completed the questionnaire. As the questionnaire was distributed and collected anonymously online, this study did not collect handwritten informed consent forms from the participants. The submission of the completed questionnaire was considered as evidence of the participants’ informed consent and voluntary agreement to take part in the study.

A total of 1,324 questionnaires were received, yielding 1,141 valid responses and achieving an effective response rate of 86.17%.

Demographic characteristics

Table  1 presents the demographic characteristics of the study participants. The sample was predominantly female, with 95.18% women and 4.82% men. The age of participants ranged from 21 to 54 years, with a mean age of 32.45 ± 6.80 years. With regard to ethnicity, the majority of participants (99.21%) identified as Han Chinese, while 0.79% belonged to other ethnic groups. In relation to occupational department, 53.46% of the participants were affiliated with the internal medicine department, 38.74% with the surgery department, 4.21% with the emergency medicine department, and 3.59% with the intensive care unit department. With respect to professional titles, 38.47% of the participants held a primary title, 36.54% held an intermediate title, and 24.99% held a senior title.

Descriptive statistics

Table  2 presents the scores of the different variables measured for these nurses. The mean total score of the WVS was 1.43 ± 1.72, the mean total score of the TIQ scale was 10.65 ± 2.39, the mean score of the CF-CN was 41.69 ± 4.01, and the mean score of the CD-RISC was 64.01 ± 11.99.

Table  3 present the mean total score of the WVS and the TIQ across demographic characteristics. Given the non-normal distribution of the data, the Mann-Whitney test was used to compare two groups while the Kruskal-Wallis test was employed to compare multiple groups. The results indicated that there were no significant differences in the mean total scores of the WVS and the TIQ across gender, age, ethnicity, occupational department, and professional title (all P  > 0.05).

Correlation analysis

Table 4 presents the results of correlation analysis between different variables measured for these nurses. Spearman’s correlation analysis revealed significant positive correlations between workplace violence and turnover intention ( r  = 0.466, P  < 0.01), as well as compassion fatigue ( r  = 0.452, P  < 0.01), while negative correlations between workplace violence and psychological resilience ( r =-0.414, P  < 0.01)

Moderated mediation analysis

The PROCESS macro for SPSS was used to perform a moderated mediation analysis, Model 4 was used to examine the mediating role of compassion fatigue, and Model 8 was used to explore the moderating role of psychological resilience. The mediation analysis using Model 4 of the PROCESS macro examined the mediating role of compassion fatigue in the relationship between workplace violence (independent variable) and turnover intention (dependent variable). The direct effect of workplace violence on compassion fatigue was significant (β = 0.923, t = 14.432), indicating that workplace violence significantly influenced the mediation variable compassion fatigue. The direct effect of workplace violence on turnover intention was also significant (β = 0.567, t = 15.090), showing that workplace violence significantly influenced the dependent variable turnover intention. When the effects of both workplace violence and compassion fatigue were examined on turnover intention, the results showed that workplace violence (β = 0.165, t = 6.015) and compassion fatigue (β = 0.436, t = 37.238) both significantly influenced turnover intention. This suggested that compassion fatigue played a partial mediating role in the relationship between workplace violence and turnover intention. The bootstrap 95% confidence interval for the indirect effect of workplace violence on turnover intention through compassion fatigue did not include 0, further confirming the existence of this mediation effect (as shown in Tables  5 and 6 ).

The moderated mediation analysis using Model 8 of the PROCESS macro examined the moderating role of psychological resilience on the mediating effect of compassion fatigue. At the low level of psychological resilience (-SD), the bootstrap 95% confidence interval did not include 0, indicating that compassion fatigue had a significant mediating effect with an effect size of 0.097. At the average level of psychological resilience (mean), the bootstrap 95% confidence interval did not include 0, indicating that compassion fatigue also had a significant mediating effect with an effect size of 0.071. At the high level of psychological resilience (+ SD), the bootstrap 95% confidence interval included 0, indicating that compassion fatigue did not have a significant mediating effect. These results suggested that the mediating effect of compassion fatigue was contingent on the level of psychological resilience, with the mediating effect being stronger at lower levels of psychological resilience and being weaker at higher levels of psychological resilience. This finding demonstrated the moderating role of psychological resilience in the mediation process (as shown in Tables  7 and 8 ).

Workplace violence represents an occupational hazard cross borders, occupations, and cultures, drawing attention from organizations, researchers, and media [ 52 ]. Nurses, who constitute a majority of healthcare personnel, are recognized as the group most susceptible to workplace violence in healthcare circumstances [ 53 ]. The prevalence and seriousness of workplace violence against nurses highlight the characterization of consequences and mechanisms. Despite the established correlation between workplace violence and nurse outcome, the relationship and mechanism between workplace violence and turnover intention warrant further elaboration. Therefore, the present cross-sectional survey recruited a convenience sample of 1,141 nurses to examine the relationship between workplace violence and turnover intention, and to clarify the mediating role of compassion fatigue and the moderating effect of psychological resilience within this link.

Nurses face a high risk of workplace violence due to the nature of their occupation and the characteristics of their work environment. This study found that nurses experienced various forms of workplace violence in the past year, with emotional abuse and physical assault being the two most common types. The high prevalence of workplace violence observed in this study was similar to findings from previous studies conducted in China and other countries. For instance, a cross-sectional study involving 266 nurses from 165 hospitals in China observed that 64.7% of nurses experienced at least one type of workplace violence in the previous year, with verbal abuse being the most frequent form [ 54 ]. Furthermore, a cross-sectional study involving 599 mental healthcare nurses in Japan revealed that over 40% of nurses experienced workplace violence in the past year [ 9 ]. In addition, a cross-sectional study examining the prevalence of workplace violence among nurses in five European countries found that 54% experienced non-physical violence, 20% experienced physical violence, and 15% experienced both forms [ 55 ]. The types and incidences of workplace violence against nurses vary across geographic locations and hospital environments [ 56 ]; however, studies around the world converge to support a high prevalence of workplace violence against nurses. Notably, the rates of workplace violence against nurses remain underreported, as nurses often rationalize violent incidents as a regrettable part of their professions and accept violent events as an inevitable hazard of their occupations [ 57 ]. For example, a cross-sectional survey of 692 nurses in Slovenia concluded that only a portion of nurses reported violent incidents in formal written form, with the reporting rate being 6.5% for psychological violence and 10.9% for physical violence [ 58 ]. Furthermore, a whole-population survey of 411 nurses in the UK indicated that while 74.7% of nurses experienced workplace violence, only 18.2% of nurses reported all violent incidents [ 59 ]. Workplace violence is a professional hazard of nurses, inflicting not only physical injuries but also psychological harms on victimized nurses. The prevalence and seriousness of workplace violence against nurses underscore the urgency for healthcare institutions and systems to implement legislative measures and procedural frameworks preventing such occurrences and ensuring workplace safety. This study supports the prevalence of workplace violence against nurses and emphasize the characterization of consequence and mechanism of workplace violence among nurses.

Turnover intention refers to a behavioral tendency wherein staffs intend to leave their current professions. Turnover intention is a strong predictor of actual turnover, acting as both a proxy for and a predictor of actual turnover. This study was consistent with the results of previous studies, indicating the presence of turnover intention among significant proportion of nurses. For instance, a meta-analysis examining the prevalence of turnover intention among 37,672 primary health workers in China found that 30.4% of these primary health workers exhibited turnover intention to their current jobs [ 60 ]. Furthermore, a nationwide study of 11,942 nurses from 87 hospitals in China found that 22.93% of nurses exhibited strong turnover intention to their current positions [ 61 ]. Meanwhile, a cross-sectional study of 506 novice nurses from 5 hospitals in China reported an even higher prevalence of 51.9% for turnover intention among this population [ 62 ]. In addition, Dall’Ora et al. (2015) investigated the prevalence of turnover intention among a sample of 31,627 registered nurses in 488 hospitals across 12 European countries, found that 33% of nurses demonstrated turnover intention to their current jobs [ 63 ]. Nurses, as the largest sector of healthcare workers, are the foundation and guarantee for the development and sustainability of hospitals. The presence of high turnover intention among nurses not only impairs the professional identity and growth of nurses but also affects the workforce and development of hospitals. The global shortage of nurses combined with the high rates of turnover intention emphasizes the imperative for healthcare institutions and systems to take implement prevention measures and intervention strategies bolstering organizational commitment and promoting occupational retention among nurses. This study indicates the presence of high turnover intention among nurses, which highlight the identification of antecedents of turnover intention among nurses.

This study identified a positive correlation between workplace violence and turnover intention among these nurses, implying that exposure to workplace violence increased turnover intention within this population. This finding was in line with previous studies, which observed that the experience of workplace violence decreased the quality of occupational life and induced the emergence of turnover intention among nurses [ 64 ]. Specifically, a cross-sectional survey of 1,024 nurses from 26 cities in China found that workplace violence was positively related to turnover intention among this sample [ 65 ]. Additionally, a cross-sectional study of 415 emergency nurses in China reported a positive association between workplace violence and turnover intention among this group [ 66 ]. This study aligned with previous studies support the adverse impact of workplace violence on turnover intention, underscoring the exploration of mechanisms behind this correlation. Evidence indicated that exposure to workplace violence provoked negative professional attitudes and decreased job satisfaction, thus impaired occupational commitment and elicited turnover intention among nurses [ 67 ].

This study revealed that compassion fatigue mediated the positive correlation between workplace violence and turnover intention among nurses. Nurses, who work on the frontlines of healthcare, face both physical challenges and emotional pressures in their daily duties. Compassion fatigue refers to a state of holistic exhaustion and deprivation, manifesting as physical decline in energetic endurance, emotional decline in empathetic ability, and spiritual decline in recovery capability [ 68 , 69 ]. Compassion fatigue arisen from chronic exposure to patient distress, work pressure, occupational devotion, lack of personal-professional boundaries, and absence of self-care measures [ 68 , 69 ]. The findings of this study suggested that the experience of workplace violence caused the presence of compassion fatigue, which further induced the emergence turnover intention among nurses. Exposure to workplace violence originates compassion discomfort, progresses to compassion stress, and culminates in compassion fatigue, ultimately eliciting job dissatisfaction, occupational burnout, and turnover intention among nurses. Numerous studies have demonstrated the detrimental consequences of compassion fatigue on nurse outcomes and the deleterious influences of workplace violence on compassion fatigue. This study was consistent with previous studies to confirm the mediating role of compassion fatigue in the link between workplace violence and turnover intention. Specifically, Chen et al. (2022) performed a cross-sectional survey of 4,520 psychiatrists among 41 tertiary psychiatric hospitals in China, found a positive relationship between workplace violence and turnover intention under the mediation effect of job burnout and occupational stress [ 70 ]. Additionally, Choi and Lee (2017) conducted a cross-sectional study among 358 nurses in Korea, found that workplace violence increased compassion fatigue, which in turn fueled turnover intention [ 64 ]. Evidence indicated that exposure to workplace violence caused compassion fatigue, which elicited job dissatisfaction, decreased organizational loyalty, and stimulated turnover intention among nurses [ 71 ]. Since mediating role of compassion fatigue proposed in this study, preventive measures and intervention strategies should aim to alleviate compassion fatigue and promote compassion satisfaction among nurses, mitigating the detrimental effects of workplace violence and preventing the emergence of turnover intention. Hospital administrators and nurse managers should formulate policies and provide opportunities for nurses to participate in group psychological debriefing or individual psychological counseling, thereby alleviating occupational burnout and traumatic stress.

This study identified that psychological resilience moderated the positive correlation between workplace violence and turnover intention among nurses. Resilience represents a personality attribute which enables nurses to cope with challenges, adaptation to adversity, and recover from setbacks [ 72 , 73 ]. Resilience allows nurses to copy with pressure events and adapt to stressful environments, further enhance supportive systems and personal abilities [ 72 , 73 ]. Resilience helps nurses to build professional relationships, enhance emotional insights, and achieve life spirituality, which enables nurses to buffer, mitigate, and resist the detrimental effects of workplace violence. Studies supported the protective effects of psychological resilience on nurse outcomes and the buffer roles of psychological resilience on workplace violence. While previous studies did not directly illustrate the moderating role of psychological resilience in the link between workplace violence and turnover intention, they have jointly indicated the negative impact of workplace violence on turnover intention and the protective effect of psychological resilience on turnover intention [ 74 ]. Other positive psychological indicators, similar to psychological resilience, have also been shown to play a moderating role in the relationship between workplace violence and turnover intention. For instance, a cross-sectional survey of 1,063 Chinese healthcare workers found that workplace violence was positively associated with turnover intention, and perceived social support and mental health mediated the relationship between workplace violence and turnover intention [ 75 ]. In addition, a longitudinal survey of 1,515 Finnish physicians found that workplace violence was positively associated with turnover intention, and job control moderated the relationship between workplace violence and turnover intention [ 26 ]. Evidence implicated psychological resilience as a psychological resources and personal attributes which enabled nurses to perceive workplace violence as a solvable problem and stimulate an adaptation process to workplace violence, thus buffered the fluctuation of job satisfaction and inhibited the emergence of turnover intention among nurses [ 76 ]. Given the moderating role of psychological resilience confirmed in this study, preventive measures and intervention strategies should aim to foster psychological resilience among nurses, alleviating the adverse effects of workplace violence and preventing the emergence of turnover intention. Preventive measures and intervention strategies should, therefore, focus on fostering psychological resilience among nurses to alleviate the adverse effects of workplace violence and mitigate the emergence of turnover intentions. Institutions or hospitals can implement positive psychology workshops and professional development programs to equip nurses with emotion regulation strategies and stress management techniques, thereby overcoming workplace violence and fostering occupational commitment.

The present study has several limitations that should be acknowledged. First, the cross-sectional design of this study precluded any causal inferences about the relationships between the study variables. Future research should employ longitudinal designs to clarify temporal precedence necessary to infer causality. Second, the self-reported nature of this study introduced the potential for common method bias to inflate the observed relationships. Future research should incorporate objective measures, such as incident reports or observational data, to corroborate the findings. Third, the sample was drawn from public hospitals in a specific geographic region, which may limit the generalizability of the findings. Future research should replicate this study in more diverse samples to strengthen the external validity of the results.

Despite the promotion of “zero tolerance” policies, the incidence of workplace violence against healthcare workers, particularly nurses, remains a persistent issue [ 77 ]. The prevalence and seriousness of workplace violence against nurses underscore the characterization of consequence and mechanism behind this phenomenon. Therefore, this cross-sectional survey recruited a convenience sample of 1,141 nurses to examine the relationship between workplace violence and turnover intention, and further explore the mediating role of compassion fatigue and the moderating role of psychological resilience on this link among Chinese nurses. The findings of this study supported the mediating role of compassion fatigue and the moderating role of psychological resilience on relationship between workplace violence and turnover intention among Chinese nurses. Nurses represent the primary victims of workplace violence in healthcare sectors, facing a higher risk of such incidents than other types of healthcare staffs. Nurses witnessing and experiencing workplace violence not only impacts their health and safety but also impairs their work performance and job productivity [ 78 , 79 ]. Various countries around the world have initiated coordinated strategies such as “zero tolerance zone” to prevent workplace violence in health sectors. National Health Commission of China established the “safe hospital” policy to build safe work environments and maintain medical orders in health institutions. Future research and practical efforts should be directed toward developing effective preventive measures and intervention strategies at the individual, organizational, and national levels to mitigate workplace violence and cultivate harmonious work atmosphere for nurses and other healthcare professionals. These efforts could mitigate the adverse effects of workplace violence and prevent the emergence of turnover intention by addressing compassion fatigue and fostering psychological resilience.

Data availability

Data that support the findings of this study are available from the corresponding author Xiaoli Liao upon reasonable request.

Abbreviations

World Health Organization

International Council of Nurses

Compassion Fatigue Scale

Connor-Davidson Resilience Scale

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The authors would like to express their gratitude to all the participants and researchers involved in this study.

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All authors have reviewed and approved the final manuscript. Miao Chen: Designed questionnaire, collected data, performed data reanalysis, revised the manuscript. Hao Xie: Collected data, and reviewed the manuscript.Xiaoli Liao: Conceptualized proposal, designed questionnaire, performed initial data analyses, and wrote the original manuscript draft.Juan Ni: Collected data, and reviewed the manuscript.All authors reviewed the manuscript.

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Chen, M., Xie, H., Liao, X. et al. Workplace violence and turnover intention among Chinese nurses: the mediating role of compassion fatigue and the moderating role of psychological resilience. BMC Public Health 24 , 2437 (2024). https://doi.org/10.1186/s12889-024-19964-y

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