Verbal abuse among newly hired registered Jordanian nurses and its correlate with self-esteem and job outcomes.

PURPOSES: 1) identify the verbal abuse prevalence among newly hired registered nurses in Jordan; 2) examine the mean score of self-esteem, intent to stay, and job commitment 3) examine the relationships between the exposure to and the effects of verbal abuse, self-esteem, job commitment, and intent to stay in newly hired Jordanian registered nurses.
BACKGROUND: Studies shows that verbal abuse in health care settings is a health-risk factor for both nurses and patients.
DESIGN: A cross-sectional descriptive correlational study was conducted jn 2019.
MATERIALS AND METHODS: A convenient sample of 200 registered nurses were recruited from two large cities in the North of Jordan. Self-reported questionnaires were used to collect data.
RESULTS: Verbal abuse is highly prevalent among newly hired registered nurses in Jordan 100%, the mean score of exposure to verbal abuse was M = 6.76, and the effect of verbal abuse scale was M = 28.35. The result of person r indicated that there is a significant negative correlation between verbal abuse affect/reactions and registered nurses' intention to stay p = ˂0.01, job commitment p = ˂0.01 and self-esteem p = ˂0.01. Also, the exposure to verbal abuse is negatively correlated with nurse's job commitment, (r = -.203, p = .004).
CONCLUSION: Verbal abuse is negatively correlated with nurses' self-esteem, intent to stay and job commitment. IMPLICATIONS: Administrators and nurse managers should establish educational training programs and workplace safety protocols to protect nurses and to create a safe positive work environment with no tolerance to verbal abuse.

Introduction

Verbal abuse against nurses is a growing problem that leads to negative consequences on personal health and work productivity among health care professionals. In this study, verbal abuse is defined as “language that is humiliating, degrading, or disrespectful; it may include the threat of ‘physical force, sexual or psychological harm, or other negative consequences” (Di Martino, 2002, p. 12). Although Jordanian labor law, social security law, public health assured employees’ occupational health and safety, verbal abuse against nurses is not properly addressed due to weak monitoring by the health agencies and lack of reporting.

Literature shows that verbal abuse in hospitals is a health-risk factor for both nurses and patients; and that it affects the health outcomes, services provided, and nurses’ attention during working hours; increases their errors; impaired communication, undermines ethics (Honarvar et al., 2019; Silwal and Joshi, 2019; Unsal et al., 2013). It also may cause emotional and social responses to abused nurses such as anger, frustration, sadness, isolation, fear, self-blame and job dissatisfaction; and could lead to quitting their jobs and health problems (Cengiz et al., 2018; Chang et al., 2019; Nantsupawat et al., 2017).

Verbal abuse prevalence among nurses is 69.4% in USA (Pompeii et al., 2015); 62% in Lebanon (Alameddine et al., 2015); 52.2% in Pakistan (Maaari et al., 2017); 74.1% in Saudi Arabia (Alyaemni and Alhudaithi, 2016). In Jordan, a recent study, conducted by Al-Omari et al. (2019), found that 71.9 % nurses reported that they had been victims of verbal abuse in the last 12 months. The actual number of verbal abuse incidents involving registered nurses is likely much higher because of under reporting.

Verbal abuse could come from various sources, such as patients, patients' families, nurses' coworkers, physicians, and managers. According to Albashtawy and Aljezawi (2016), the patients, patients’ families, physicians, and other health care personnel considered the most frequent source of verbal abuse against nurses. Another study conducted by Chang and Cho (2016) to examine the workplace violence and job outcomes of newly licensed nurses in Korea, found that 93 nurses out of 186 participants were exposed to verbal abuse by colleague nurses 50% and from the patients 47, 8%.

Self -esteem is defined as the degree to which individuals' value themselves (Reber and Reber, 2001). It is an outcome of mixed personal and professional values, a rational to maintain commitment to identity and professional standards, and act as a protective mechanism of moral distress when value conflict is occurred (Zamanzadeh et al., 2016). There are few studies examined the direct relationship between verbal abuse and nurse's self-esteem. However, studies showed that the consequences of verbal abuse against nurses may affect nurses' self-esteem. Evidence indicated that verbal and physical abuse against nurses threaten their identity which is considered a factor related to self-esteem. A study conducted with 441 nurses in turkey revealed that 60.8% of the nurses experienced verbal abuse were feeling anxious (65.0%); feelings of anger (47.0%), resentment (52.2%), fear (20.5%), disappointment (35.1%) and helpless (14.9), which leads them to consider quitting the profession (13.8%) because of feeling incompetent, insecure and affect their identity which all affecting nurse's self-esteem (Ünsal Atan et al., 2013). Based on this, administrators and managers should create a training program for the newly hired nurses, to be aware of the factors contributing to verbal abuse, how to handle the situations, and how to minimize the consequences at their personal and professional levels.

Intent to stay is considered one of the professional nursing aspects affected by verbal abuse (Al-Omari, 2015), it is defined as the likelihood of employees remaining in their jobs (Smith et al., 2007). A study targeted newly hired nurses showed that verbal abuse affected a nurse's intentions to stay in nursing because of negative work environment (Ahmed, 2012; Al-Hamdan et al., 2017). Administrators and managers should retain nursing workforce by monitoring sources of verbal abuse and communication system among nurses-patients ‘families, nurses-patients, and nurses-nurses to protect nurses from harm.

Job commitment is defined as “loyalty, the desire to be committed to a profession, and a sense of responsibility toward the profession's demands and challenges” (Jafaraghaee et al., 2017). Job commitment is also affected by verbal abuse, emotional and verbal abuse has negative impact on nurses’ work commitment due to higher psychological distress levels. According to Albashtawy and Aljezawi's (2016) study that examined the nurse's perception of workplace violence in 227 emergency department nurses, verbal abuse was reported by 63.9% pf participants, they found that experiencing verbal abuse decrease job performance and job satisfaction, and creating a hostile work climate in which nurses job commitment might decrease.

Nurses are the frontline health care workers with patients; therefore, any improvement in work environment will enhance better health outcomes for patients, increase work productivity, and reduce the cost of hiring and replacing nurses. Although nurses in Jordan are suffering from high prevalence of verbal abuse, there is a room for improvement and change. Investigating the consequences of verbal abuse on nurse's self-esteem, and their job commitment also their intent to stay in the organization will help to design programs to improve health outcomes and decrease retention.

Purpose

In Jordan, the number of studies that addressed verbal abuse is limited, most of the studies considered work place violence in general and conducted with experienced nurses. In addition, the consequences of verbal abuse were studied sufficiently on some variables such as job satisfaction, and lack on other variables such as self-esteem, and job commitment. Therefore, this study is designed to fill this gap in nursing knowledge. The objectives of this study are 1) identify the verbal abuse prevalence among newly hired registered nurses in Jordan; 2) examine the mean score of self-esteem, intent to stay, and job commitment among nurses; 3) examine the relationships between the exposure to verbal abuse and the effects of verbal abuse, self-esteem, job commitment, and intent to stay among newly hired Jordanian registered nurses. Newly hired registered nurses are defined as “nurses who have a bachelor's degree in nursing, received orientation to hospitals' standards and policies, and who have 0–3 years of experience”.

Theoretical framework

The Early Job Demand- Resources model (JD-R) established by Demerouti et al. (2001) was used to understand the relationship of study variables. The model suggesting that working condition could be categorized into two sections, job demands and job outcome. Job demands defined as “those physical, social, or organizational aspects of the job that require sustained physical or mental effort and are therefore associated with certain physiological and psychological costs”. Examples of job demands are work pressure, dealing with dependent patients, changing patient's positions, interpersonal problems, emotional demands and lack of job security, bullying, and abuse (Demerouti et al., 2001, p. 501). In addition, job resources were defined as “those physical, social, or organizational aspects of the job that may do any of the following (a) be functional in achieving work goals; (b) reduce job demands and the associated physiological and psychological costs; (c) stimulate personal growth and development” (Demerouti et al., 2001, p. 501). Examples of job resources are receiving support from head nurse, personal evaluation, incentives, and continuous education (Figure 1).

Figure 1

The job demands-resources (JD-R) model.

The JD-R model explains that when job demands are high, more effort will be required from the employee to prevent any decrease in job performance, which eventually increases the employee fatigue stress and effort, and increases the employee physical and mental exhaustion. Also, the lack of resources hinder job demands from being met and that work goals are reached, which leads to avoidance and withdrawal attitudes.

In the past years, this model has been extensively used across many disciplines, including nursing and psychology. Nurses who are experiencing verbal abuse often share experiences of chronic stress/strain associated with verbal abuse and suffer from its negative work-related effects. Although nurses may have various stressors and resources, the focus in the current study is on verbal abuse and self-esteem because these variables are well documented as having impacts on job related outcomes such as job commitment and intent to stay. Research to date suggested that individuals with high self-esteem had less verbal abuse effects as self-esteem encourage nurses and motivate them to move forward, overcome stressors, and stay active and professional (Hassankhani et al., 2018; Keller et al., 2018). Finally, a strength of this model is that it makes a clear connection and relationship between work demand (safe work environment free from verbal abuse), strain, personal resources, and job outcomes (job commitment and intent to stay) which is the primary purpose of this study.

Materials and methods

Cross sectional correlational design was utilized to meet the research purpose. Data was collected conveniently from 200 newly hired registered nurses (zero to 3 years of experience) in two governmental hospitals and two private hospitals in North of Jordan. Newly hired nurses were selected to participate in this study because they have serious challenges related to lack of experience, adapting to work environment and demands, workload, and adherence to stress. Nurses were recruited from different units (medical/surgical ward, operation room, clinics). The sample size measured by using G∗power software (Faul et al., 2009). By using Pearson correlation and entering the following data: a power of 0.8, alpha of 0.05, and medium effect size (0.3). Calculated sample size was 111, and the actual sample size was increased to 200 nurses in order to cover the attrition rate.

Instruments

The first part of the questionnaire was self-developed questions about the demographic characteristic of the sample. The information included: (age, gender, social status, work setting, shifts (yes or no), shifts hours (12 h , a, b, c) job status (full, part time), time since hired, income, organization size, organization type).

Verbal abuse scale (VAS) developed by Manderino and Banton (1994) was used in this study. The scale includes 41 items in four subscales (Type 9Q, Sources 4Q, Reporting 9Q, and effect/reaction 19Q) (Manderino and Berkey, 1997). Examples of the questions included in types subscale are: Anyone swears, or directs obscene comments at you, any one ignores you, controls the conversation, or refuses to comment. The Content validity of Manderino and Berkey's (1997) tool was tested by a group of experts knowledgeable in Lazarus' theory of stress-coping as well as verbal abuse concepts. During development of the scale, the author examined the instrument by a committee of staff nurses for clarity and completeness. Twenty-one staff nurses engaged in a test-re-test examination of the tool. The reliability of each subscale in our study was ranged from .501 to 0.924 which is considered acceptable.

Self-esteem was measured by using Rosenberg self-esteem scale (Rosenberg, 1965). The scale consists of 10 items rated as (0 = strongly disagree, 3 = strongly agree). Items number 3, 5, 8,9,10 were reversely coded as instructed by the original author. The score is ranges from zero to 30. Scores between 15 and 25 are considered within normal range; low self-esteem is suggested with scores below 15 (Rosenberg, 1965). The original scale Cronbach's alpha is .70. The Arabic version showed internal consistency of 0.71 (Kazarian, 2009) and in our study the Cronbach's alpha was 0.759 which is considered high.

The intent to stay was measured using the Arabic version of the McCain intent to stay scale (McCloskey and McCain 1987). This scale is five items scale rated on a five-point Likert scale (1 = strongly disagree, 5 = strongly agree). The Cronbach's alpha coefficient of the scale was 0.86 (McCloskey and McCain 1987). and in our study was .868 which considered high. AbuAlRub used an Arabic version of the instrument in her study and also tested and modified the scale according to the Jordanian culture, the results revealed acceptable reliability (AbuAlRub et al., 2012).

The Career Commitment Questionnaire (Blau, 1985) included eight items, was used to measure career commitment. For each question, the respondents answered on a five-point Likert scale ranging from 1 ′strongly disagree' to 5 ′strongly agree’. Examples of the items include; 'If I could get another job different from being a nurse but paying the same amount, 1 would probably take it'; I am disappointed that I ever entered the nursing profession'; and 'I spend a significant amount of personal time reading nursing related journals or books'. Item scores were summed for a total score. After reverse coding of some items, scores could range from 8 to 40; higher level of career commitment is indicated with higher scores. Reliability and validity have been reported in various studies using both nursing and other professional groups. Cronbach's alpha reliability coefficients for internal consistency values range from .66 (Arnold, 1990) to .87 (Blau, 1985). The Cronbach's alpha coefficient of the scale was .886 which is considered high.

Data collection and statistical analysis

The participants learnt about the study from the researcher and from heads of departments. The data was collected from the newly hired registered nurses in their departments after taking the permission from the hospitals administration, a total number of 200 questionnaires were filled with response rate of 100%. The reasercher personally approached the nurses, filled the questionnaire with them and provided explanation about the study which enhanced the response rate. Approval obtained from institutional review board (IRB) from Jordan University of Science and Technology, Irbid, Jordan (Ethical approval number 22/125/2019) and also from Ministry of Health and private hospitals (Ibn-Alhaytham hospital and the Arab Medical Center) in Jordan. The study registration number is (20190409). The participation in the study was voluntary, nurses signed a written consent attached with questionnaires before filling the data, nurses were provided with explanation about the nature and the objectives of the study. The researcher directly handed surveys to subjects and answered their questions. In addition, the anonymity and confidentiality were maintained. The statistical package of social sciences (SPSS) version 25 was used for data analysis. Descriptive statistics (frequencies, mean and percentages) were used to describe the participant's demographical characteristics as well as the verbal abuse exposure, effect, sources, and reporting. Pearson's correlation (r) was used to test the correlations between exposure to verbal abuse subscale, effect of verbal abuse subscale, self-esteem scale, intent to stay scale and job commitment scale. A pilot study was conducted using a sample of 10 participants who were not included in the main study. Cronbach's alpha ranged from .501 to 0.92 which is acceptable. The items for both questionnaires were clear, and understandable by pilot study participants. No changes were made due to the pilot study.

Descriptive statistics were computed in order to inspect the distribution for each variable. According to the data skewness, all of the scales total score was within accepted limit, also the kurtosis values were ranged +1 to-1 which considered very good for most psychometric uses, so the data was normally distributed. In addition, histogram showed normal distribution results for all study variables.

Results

Almost half of the participants were aged between 21-25 years 92 (46%, SD = 3.991, M = 27.17), over half of the participants had 2–3 years of experience 69.5%, and only 26 participants 13% had 0–1 year of experience and 17.5% were between 1-2 years of experience, and the majority of the registered nurses were females 126 (63%), males 74 (37%), and about 54.5 % of the participants were married (Table 1).

Table 1

Demographics of study participants (N = 200).

Demographic characteristics	NO.	Percentage%
Age (years):
21–25	92	46.0
26–30	76	38.0
31–35	21	10.5
36–39	11	5.5
Gender
Male	74	37.0
Female	126	63.0
Social status
Married	109	54.5
Single	89	44.5
Divorced	2	1.0
Widow	-	-
Job status
Full time	192	96.0
Part time	8	4.0
Years of experience
0–1	26	13.0
1–2	35	17.5
2–3	139	69.5
Working department
ICU/CCU	54	27.0
Emergency	44	22.0
Medical and surgical floors	49	24.5
Maternity unit	16	8.0
Dialysis	13	6.5
Other departments	24	12.0
Educational level
Baccalaureate degree	182	91.0
Master degree	17	8.5
Doctoral degree	1	.5
Hospital type
Private	100	50.0
Public	100	50.0
Working shifts
Yes	196	98.0
No	4	2.0
Working system
Day/night (12 Hrs.)	99	49.5
A, B and C shift (8 Hrs.)	24	12.0
A + (BC) shifts	77	38.5
Income average in (JD)
280–380	50	25.0
387–445	52	26.0
450–555	46	23.0
600–850	52	26.0
Organizational size
Large institution (capacity> =1000 bed)	164	82
Small institution (capacity<500 bed)	36	18.0

Descriptive statistic for each scale including exposure and the effects of verbal abuse scale, self-esteem scale, commitment, and intent to stay scales were computed, The mean score of the verbal abuse exposure was 6.76 and for the effect of verbal abuse was 28.355, the mean score for the self-esteem scale was 22.6 which is considered within normal range, the intent to stay mean was 14.86 which considered moderately low and job commitment mean was 22.93 which considered remarkably low.

Verbal abuse

The results showed that all the 200 participants experienced at least to one type of verbal abuse, which makes the verbal abuse prevalence 100% among the newly hired registered Jordanian nurses regardless of type. The most common type of verbal abuse experienced by the newly hired registered nurses in the last 6 months was yelling and others raises their voices on angry fashion, the percentage was 91 % which consist of 182 nurses, the higher frequency was from 1 to 5 times (n = 127, 63.5%), the second most frequent verbal abuse type was speaking to nurses in a condescending fashion (n = 158, 79%), and its frequency was also from 1 to 5 times at the last 6 months.(n = 99. 49.5%), and the third type was making a humiliating or abusive comment disguised as a joke of the nurses (n = 121, 60.5%), and its frequency was from 1 to 5 times at the last 6 months (n = 67, 33.5%).

The next most frequent type was” Any one makes an indirect threat towards you (implies you will be reported etc.) “(n = 94, 47%), and the highest frequency was from 1 to 5 during the last 6 months (n = 64, 32%). The second and the third type of verbal abuse (Any one swears, or directs obscene comments at you; Any one makes insulting comments about you) were almost similar due to their consistency (n = 79, 85, percentage 39.5%, 42.5% respectively).

The most common source was the patient's family and visitors (n = 147, 74%), the second common source was the other staff nurses (n = 97, 48.5 %), the third source was the patients (n = 92, 46%), then the head nurse (n = 45, 22.5%). Furthermore, the nurses asked to choose one of the most frequent sources of verbal abuse, and the patient's family and visitors was the highest n = 90, 45%.

As for reporting, 142 nurses decided not to report the episode. Our results revealed that more than two thirds nurses (n = 167, 83.5%) reported that there is “nothing will be done or changed “, and 143 nurses reported that they showed “Concern for a valuable patient” and 138 nurses said that the “Situation handled/resolved” and 124 nurses understood the patient situation.

The most frequent effect/response to verbal abuse experience reported by nurses were, “felt angry” (n = 180, 90%), have “negative feeling about their environment” (n = 175, 87.5%), which also “decreased their sense of relaxation and wellbeing in their job setting” (n = 171, 85.5%), and finally “felt unsupported” (n = 169, 84.5%).

Self-esteem scale

The scores of nurses self-esteem was 22.625 for the total sample, and according Rosenberg original scale, the mean indicates acceptable self-esteem level, the standard deviation was 4.377, the minimum score was 9 and the highest score was 30.

Intent to stay scale

The mean score of the total sample score was 14.8650, which considered remarkably low, the minimum score was 5 and maximum score was 25, the standard deviation was 4.93.

Career commitment scale

The mean score of the total sample score was 22.9350 which considered moderately low, the minimum score was 8 and maximum score was 40, the standard deviation was 7.2611.

The correlation between main study variables

The results of the Pearson correlation indicated that there was a significant negative correlation between exposure to verbal abuse and job commitment, (r = -.203, p = .004), which means that highly exposure to verbal abuse decrease the nurse's job commitment, also the result showed that exposure of verbal abuse and self-esteem were found to be negatively correlated as (r = -.140, p = .048.), which means that the increased exposure to verbal abuse decrease the nurse's self-esteem. However, this correlation is considered weak. In addition, the results of the Pearson correlation indicated that there was a significant negative correlation between verbal abuse effect on nurses, intent to stay, job commitment, and self-esteem (r = -.253, p = 0.00; r = -.306, p = p = 0.00; r = -.231, p = 0.001 respectively), Thus, the increased effect of verbal abuse on the newly hired nurses encourage nurses to quit, decrease their self-esteem and their job commitment which is supported by the Early Job Demand- Resources model (JD-R) (Demerouti et al., 2001).

Statistical correlation was computed between variables using Pearson r, showed that there is a positive correlation between the nurses' self-esteem and their career commitment r = .277, p = 0.00), which means that increasing the nurses’ self-esteem increases their job commitment, also increasing their job commitment, increase their intention to stay, r = .529, p = 0.00), and no relationship between self-esteem and intent to stay was found, Table 2.

Table 2

Pearson r Correlations among Measured Variables.

		Intent to stay scale	Career commitment scale	Self-esteem scale	Exposure to verbal abuse	Effect of verbal abuse
Intent to stay scale	Pearson Correlation	1
	Sig. (2-tailed)
Career commitment scale	Pearson Correlation	0.529∗∗	1
	Sig. (2-tailed)	0.000
Self- esteem scale	Pearson Correlation	0.107	0.277∗∗	1
	Sig. (2-tailed)	0.133	0.000
Exposure to verbal abuse	Pearson Correlation	-0.112	-0.203∗∗	-0.140∗	1
	Sig. (2-tailed)	0.114	0.004	0.048
Effect of verbal abuse	Pearson Correlation	-0.253∗∗	-0.306∗∗	-0.231∗∗	0.448∗∗	1
	Sig. (2-tailed)	0.000	0.000	0.001	0.000

∗Correlation is significant at the 0.05 level (2-tailed).

∗∗Correlation is significant at the 0.01 level (2-tailed).

Discussion

The total number of participants was 200 newly hired registered nurses, the majority of the participants were females (n = 126, 63%). Females' representation in the Jordanian nursing workforce is higher than males (Jordanian Nursing Council, 2014). More than half of our sample were married nurses (54.5%) which is justified as Jordanian women's marriage age is around the age of 24, and men is around the age of 29 (Higher Population Council, 2017).

According to the results, the newly hired nurses are highly exposed to verbal abuse. Newly hired nurses in our study are lack of awareness and skills to respond to abusers, often already double burdened due to being identified into new work conditions, dealing with difficult patients and workload, and poor experience in carrying out the serious responsibilities of their work. In South Korea, a study found that the percentage of verbal abuse was 59.5% (Chang & Cho, 2016). In Jordan, a study found that 71.9 % nurses revealed that they had been verbally abused in the last 12 months (Al-Omari et al., 2019).

Nurses in our study were highly subjected to yelling. Prolong treatment, and nursing shortage may provoke the family members to express verbal abuse by yelling. In addition, yelling could be a way to seek attention of the nurses and get the health care in a faster way. Similar result found in other Jordanian studies, Ahmed (2012) found that shouting and swearing from the patients ‘relatives and patients was (75.3% and 44.5% respectively) followed by sworn at (44.5%, 23.5%, respectively) and humiliation (30.7%,19.9%, respectively) were common types of verbal abuse due to highly family member stress because of the patient's condition.

In this study, the number of nurses that decided not to report the incident of verbal abuse was higher than nurses who decided to report the incident. Reasons could be lack of trust to find a proper solution, patients are excused because they are patients, the situation handled. AbuAlRub and Al-Asmar (2013) found same reasons in their study. Based on this, hospital administration should encourage reporting, enforce regulations, and create positive working environment.

Verbal abuse at hospitals lower the emotional and psychological well-being of the employed nurses. A previous study reported that employees who experienced verbal abuse reported emotions such as anxiety, anger-hostility, disappointment, fear of assertiveness, helplessness, and difficulty in remembering appointments following incidents (Yun et al., 2019). Our study results also indicated that verbal abuse affect nurse’ mental and physical health, made nurses feel angry, tearful, decrease their self-esteem, and feeling unsupported which eventually made them hate their jobs.

The mean score of nurse's self-esteem in this study was 22.6, which considered moderate, which indicate that the newly hired nurses have moderate self-confidence, which can affect their social performance and they may struggle in the work setting, Maniou et al. (2018) found that the majority of nurses had a moderate self-esteem 51.6%. An explanation could be that newly hired nurses are challenged to adapt to new work setting's, policies, and regulations and work environment, demonstrate some nursing procedures for the first time, being responsible for a number of patients with different needs, so it is possible to feel dis-comfortable, incompetent, insecure and this may affect nurse's identity which all considered the component of self-esteem. On the other hand, JD-R model explained that when nurses are exposed to humiliation, stress, and emotional distress caused by verbal abuse, this is negatively affected personal appreciation and self-confidence which is consistent with our study findings.

In the current study, the intent to stay mean score was 14.86 which is considered moderately low, several studies indicated that exposure to verbal abuse may decrease nurses’ intention to stay in the profession and increase their intention to leave (Ahmed, 2012; Al-Omari, 2015). Nurses deserve to work in a comfortable respectful environment that foster professional development and wellbeing.

The nurses job commitment mean score was 22.93 which is considered remarkably low, and indicates that the nurses have weak bond and attachment with their organization. Chang and Cho (2016) supported this idea. Low salaries and high living expenses in Jordan could justify nurse's intentions to leave their jobs to earn more money to provide for their families (Al-Motlaq et al., 2017). Average Monthly Salary for registered nurses at the Ministry Of Health in Jordan is 666 JOD equals 939.36 USD (National Human Resources for Health Observatory Annual Report (2017).

According to JD-R model, increasing the job demands increases the job strain which increases the negative job outcomes at both personal (health problems) and job level (performance), Our study indicated that verbal abuse strained nurses and affected negatively the job outcomes evidenced by decreasing their job commitment and increased their intents to quit their jobs. The model successfully helped us to explain the connection and relationship between work demand (safe work environment free of verbal abuse), strain (verbal abuse), personal resources, and job outcomes (job commitment and intent to stay) which is the primary assumption of this study.

The correlation between verbal abuse and other variables

In our study, exposure to verbal abuse found to be moderately negatively correlated with nurses' self-esteem (r = .140, p = .048), which mean that higher frequency of experiencing verbal abuse decrease nurses' self-esteem. In addition, the effect of verbal abuse found to be strongly negatively correlated with nurses’ self-esteem (r = .231, p = ˂0.01), this finding is consistent with another study conducted by Cengiz et al. (2018) that showed that psychological violence such as humiliation towards nurses lead to a decrease in their self-esteem. (r = -.191 < 0.05). Since that self-esteem involves a variety of beliefs about individuals, such as the appraisal of appearance, beliefs, emotions, and behaviors, exposure to verbal abuse leave individuals feeling defeated or depressed, therefore, decrease valuing selves, and capabilities of success.

In the current study, there was a significant negative correlation between verbal abuse effect on nurses and intent to stay (r = .253, p = ˂0.01), Similar results were found by Sofield and Salmond (2003), the study indicated a significant relationship between the effect of verbal abuse and intent to leave. JD-R model justified this result that when nurses are exposed to unsafe work environment and different sources of verbal abuse, they will leave the profession looking for more comfortable and respectful positions in different institution or even in different fields. Nurses spend long working hours dealing with different demands of patient's needs, need to make urgent decisions in short time to save patients' lives, and they are the advocates for patients' rights, therefore, it's considered very tiring and disappointing for not only getting the respect they deserve, but also being exposed to verbal abuse, therefore, it is reasonable to leave the profession if this problem is not appropriately solved.

In our study, job commitment found to be strongly negatively correlated with exposure and effect of verbal abuse (r = .203, p = .004); (r = .306, p = ˂0.01) respectively, Similar result found in a study that showed that the verbal abuse had the highest prevalence (59.6%), and was strongly negatively correlated with nurses job commitment (p < 0.1). Job commitment involve nurse's feelings to be bounded or obligated to patients and health organization, in cases of exposure to verbal abuse, nurses lose their trust in their organizations that failed to protect them, and consequently become disloyal to their organizations and more likely to leave.

Recommendations for nursing practice, policy, and future research

The verbal abuse is highly frequent among the newly hired registered nurses. Nurses in clinical practice need to communicate effectively in situations that are considered at high risk for verbal abuse. Nurses should calm down and use silence, attentive listening, and reflections to deal with angry patients and family members. Hotlines for reporting abuse should be available to nurses. Nursing is a challenging profession, therefore, administrators and nurse managers required to develop new policies and regulations that create a safe positive work environment with low level of stressors and free from verbal abuse. Nurse managers also should encourage open communication with nurses in order to effectively examine the incidents and reporting system and to create awareness about the importance of reporting verbal abuse in order to find appropriate solutions. Also, mangers need to investigate the contributing factors in order to minimize the frequency of the incident. Entertaining programs and comfort measures should be established to minimize the stress level among nurses. Managers should encourage nurses and support them psychologically and socially. More correlational studies using randomized samples are needed, more studies are needed to fully understand the contributing factors to verbal abuse.

Limitations

This study used convenient sampling, which makes it difficult to generalize the data to other nurses in other Jordanian health care settings. Small sample size also affect the generalizability of the study, although confidentiality was guaranteed, nurses participated in this study may had concerns of disclosing verbal abuse that may affect their job and reputation. Socially acceptable answers may lead to biased responses and misinterpretation of questionnaire items.

Conclusion

This study highlighted the impact of verbal abuse on newly hired nurses and their job outcomes. Verbal abuse is highly prevalent among nurses, the most common source was the patient's family and visitors. As verbal abuse is negatively correlated with nurses' self-esteem, intent to stay and job commitment, health care organizations and nurse managers should establish educational training programs and workplace safety protocols to protect nurses. Nurses are the frontline health care workers with patients; therefore, any improvement in work environment will enhance better health outcomes for patients, increase work productivity, and reduce the cost of hiring and replacing nurses.

Declarations

Author contribution statement

Fatmeh Alzoubi, Diana Jaradat: Conceived and designed the experiments; Performed the experiments; Analyzed and interpreted the data; Contributed reagents, materials, analysis tools or data; Wrote the paper.

Aziza Abu Juda: Performed the experiments; Analyzed and interpreted the data; Contributed reagents, materials, analysis tools or data; Wrote the paper.

Funding statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability statement

Data will be made available on request.

Declaration of interests statement

The authors declare no conflict of interest.

Additional information

No additional information is available for this paper.