Public Reactions in Online Newspapers to Workplace Violence Against Nurses.

BACKGROUND: Nurses frequently suffer from workplace violence, but the public is often not fully aware of the situation because many events are not widely reported.
METHODS: This study is an attempt to describe public perceptions of and reactions to reports of incidents of violence against nurses in online newspapers. Articles about such violence in Vietnamese online newspapers published from January to December 2019 as well as readers' comments on those articles were collected for thematic analysis.
RESULTS: Nine assaults were reported in 152 articles, and 367 comments were left in the threads. The analysis found four themes: 1) proposing punishment, 2) showing sympathy, 3) being skeptical, and 4) taking gender into account. In particular, the audience called for stricter punishment of the assaulters and showed sympathy for the nurses. However, commenters' prior experiences with poor nursing services sometimes made them skeptical about the motivations of the attackers. Additionally, commenters saw the violence as a conflict between a man (assaulter) and a woman (assaultee) rather than between a client and a professional nurse.
CONCLUSIONS: In general, the public showed support to nurses. Nurses should take advantage of this support to advocate improved policies and measures to protect themselves from violence at work.

Workplace violence is described as any threat or physical assault that a worker experiences in association with a job (Schmidt et al., 2019). Among workers in healthcare sectors, nurses are at the highest risk of being victims of such violence (Liu et al., 2019; Phillips, 2016). Studies worldwide indicate that between 59.2% and 94.6% of interviewed nurses have suffered from certain forms of workplace violence. The forms of violence are varied, ranging from verbal aggression or physical assaults to sexual harassment. The most common perpetrators are patients and relatives (ALBashtawy & Aljezawi, 2016; Speroni et al., 2014; Yang et al., 2018; Zainal et al., 2018).

Workplace violence negatively impacts nurses. A systematic review reports that patient aggression has biological effects (fear, anxiety, and even posttraumatic stress disorder), cognitive effects (feeling disrespected, unappreciated, or threatened), emotional effects (anger, insecurity at work), and social effects (reduced willingness to engage with clients, increased skepticism about self-professional competency) on nurses (Needham et al., 2005; Speroni et al., 2014). Experience with workplace violence is also associated with reduced job motivation and satisfaction, increased burnout, lower patient safety, and more adverse incidents (Liu et al., 2019; Yang et al., 2018).

Sadly, nurses are not always willing to report violence (Martinez, 2016). A study by ALBashtawy and Aljezawi (2016) indicates that only 16.6% of victimized nurses actually reported the associated incidents. This points to the risk that the scale and impact of workplace violence might not be appropriately acknowledged by the public. Public awareness and support are important for preventing workplace violence against nurses (Ramacciati et al., 2018). First, the public can advocate for policy and other measures to prevent and manage such violence. In addition, understanding and empathy from the public can be a source of support for nurses to deal with negative experiences. More importantly, if violence against nurses and healthcare workers is seen as unacceptable, such social norms may, to some extent, shape proper behavior among people using healthcare services. Nevertheless, despite the importance of this topic, studies mapping the current views of society on workplace violence among nurses are still in their infancy (Hoyle et al., 2018; Teoh et al., 2019).

The current era is one of social media and online newspapers – channels that provide constant and endless streams of news and events. They also allow the audience to immediately share their reactions to the reported stories. Taking advantage of online media, this study attempts to describe the audience’s ideas on and reactions to news about workplace violence against nurses in online newspapers.

Methods

The objects of this qualitative study were readers’ comments on news articles about workplace violence against nurses in Vietnamese online newspapers. Currently, to enhance interaction, many online newspapers allow readers to leave their comments below the threads. All news articles about incidents of violence were retrieved, and audiences’ comments on the stories were then collected for thematic analysis.

Google was used as the search engine alongside Vietnamese dictionaries to find the terms that could be used interchangeably with violence (bạo hành) in Vietnamese. Two other words were identified, which were “đánh” and “tấn công”. Both mean “assault” or “attack”. To specify the subjects of the search, “nurse” (điều dưỡng) was used as an additional keyword. Hence, three sets of keywords were input separately into Google: (“bạo hành” AND “điều dưỡng”’), (“đánh” AND “điều dưỡng”), and (“tấn công” AND “điều dưỡng”).

The search covered articles published from January 1, 2019, to December 31, 2019; the two researchers then screened all the resulting news articles found by the search engine together. Any events that specified the victims as nurses but that were related to the nurses’ personal lives were excluded. All reader comments on the articles were retrieved for the analysis.

The search engine found ten discrete incidents of violence against nurses, but one event was excluded because it was a personal conflict, not an incident of workplace violence. In total, there were 122 articles about the nine events and 26 other articles that were discussions about workplace violence against nurses in general (Table 1). Among these articles, 31 had comments from readers. In total, 367 comments were retrieved. The description of each violent incident was developed by two researchers (NHL, LTT) and cross-checked by two others (NTMC, TTA).

Table 1.

Incidents of Workplace Violence Reported in Online Newspapers (From January to December 2020).

Event	Descriptions of the incident	Number of articles	Number of comments
No. 1	Location: A provincial hospitalOn July 20, an older man was admitted to the medical ward. A nurse noticed that his oxygenation tube was misplaced and approached the patient to correct it. The patient’s son thought that the nurse was removing his father oxygenation tube and attacked her. Witnesses reported that the assaulter’s breath had a strong smell of alcohol.	2	26
Nos. 2 and 3	Location: A regional hospitalOn July 28, a young woman was brought to the emergency department because of chemical poisoning. A nurse was taking the patient's vital signs and completing other documents. The patient's husband (for an unreported reason) became upset with the nurse and slapped her. The second event happened in the same department, two days later. In July 30, a man was brought to the hospital for the treatment of a wound to his left shoulder. The patient appeared to be drunk upon admission. Three hours after his admission, the patient became agitated and tried to remove his IV line. He almost attacked a male nurse, but the hospital security personnel stopped him.	1	15
No. 4	Location: A provincial pediatrics hospitalOn November 18, a 9-year-old boy was hospitalized because of an asthma attack. While waiting for nebulization, he got into an empty bed in the ward. According to the policy of the hospital, a patient who is waiting for nebulization is not considered a severe case, and hence, the boy should have sat in a chair to save the bed for severe patients. Since there were few patients, the nurse allowed the boy to stay in the bed. However, when a new patient was admitted to the ward, the nurse asked the boy to move to a chair. The patient’s mother did not agree, even though the nurse tried to explain. The father suddenly approached the nurse and slapped her while the mother continued to shout. The couple agreed to leave the room only when the police arrived.	74	93
No. 5	Location: A district general hospitalOn June 21, a group of young people brought a patient with a hand injury to the hospital at night. They went directly to the surgical ward and began shouting when they observed that the ward’s door was closed. The medical team went out and took the patient to the observation room. In the room, one man and his wife attacked a nurse because they thought the medical team was not actively caring for the patient. The man who attacked the nurse then admitted to the police that he had been drinking, which was why he could not control his behavior. The man was sentenced to 6 months in prison.	16	52
No. 6	Location: A district general hospitalOn May 29, two young men took their brother to the hospital after he was involved in a traffic accident. At the emergency department, a nurse completed the admission procedures and used a wheelchair to transfer the patient to the surgical ward. While the nurse was doing her work, one of the two men grew upset with and attacked her. The patient was transferred to the medical ward. In the surgical ward, the man attacked another nurse while she was trying to clean the patient’s wound. At the police station, the man confessed that he was drunk and that he was worried about his brother’s health. The police then detected that the assaulter had also used drugs.	4	32
No. 7	Location: A regional leprosy and dermatology hospitalAt 3:00 am on December 26, one patient was hospitalized because of a wounded leg. At approximately 4:00 am, he lit a fire in the restroom and then started burning blankets and a mattress in the patients' room. One nurse tried to stop the patient but she was assaulted by him. Notably, the nurse was pregnant (3 months), and she fainted because of the man’s assault.	9	31
No. 8	Location: A regional general hospitalOn August 25, a man was admitted to the emergency department due to a traffic accident. He was drunk and did not want to cooperate with the nurses. One nurse tried to contact his wife by phone to explain the situation, hoping his wife could convince the patient to cooperate. The patient kept shouting and harassing the healthcare providers for no reason and then suddenly slapped the nurse. She fell to the floor. The man then destroyed some medical equipment and assaulted another nurse in the room.	8	44
No. 9	Location: National surgery hospitalA man was admitted to the hospital on October 27 with chest, head, and facial injuries. He had a history of drug use and became irritated many times during his hospitalization. The incident occurred on December 4, eight days after his admission. The patient became irritated, and the nurse and his relatives tried to keep him in bed. When the nurse tried to leave, the patient attacked her. The nurse was pregnant, so as a reflex, she lowered her body and crossed her arms over her stomach, so fortunately the patient only hit her forehead. The patient underwent an operation two days after the event and was closely monitored during his hospitalization.	8	59
General discussions	These articles summarize incidents of workplace violence related to nurses to discuss/raise concerns over the protection of nurses and healthcare workers at work.	26	15
	Total	148	367

Thematic analysis was used to identify the patterns of meaning in the data. The analysis was performed in six steps as proposed by Braun and Clarke (2006; Nowell et al., 2017). Each individual researcher first read all the descriptions of the violent incidents along with the relevant comments and then examined all comments as a whole to become familiar with the data. Comments from all individual events were then aggregated for the researchers to develop their own codes from the data, using inductive approach. All the researchers then worked in groups to collate all the initial codes, based on which they identified, reviewed, and defined themes and prepared the report.

Results

Three hundred sixty-seven comments are found. Commonly, comments are short, with two to five sentences. The comments usually aim to narrate readers’ feelings and thoughts about the news they have read. Very few comments are in form of interactive conversations between readers. The analysis finds four themes: 1) proposing punishment, 2) showing sympathy, 3) being skeptical, and 4) taking gender into account.

Proposing Punishment

Commenters advocate for punishment of those who assault nurses. They proposed different forms of punishments. One of the most common ideas is to imprison the attackers.Interestingly, prohibiting attackers from using medical services in the future is also mentioned as a form of punishment and means of preventing future incidents.Other commenters mention more vaguely that the assaulters should in general be punished (more) severely.

“I request that the government officers bring him (the assaulter) to court…because he destroyed public property, created chaos in public, and harmed others’ health…. He should also pay money to compensate for what he has done.”

“The assaulter should be put in prison plus given a monetary fine. His portrait, name, and address should also be exposed to everyone to create public pressure on such bad behavior.”

“If any patient attacks healthcare providers, either verbally or physically, the Ministry of Health should prohibit them from using medical services for a year.”

“If someone behaves like that on an airplane, the aviation authority has the right to refuse him in the future. Why can’t they (assaulters) be banned from using medical services when something similar happens in healthcare? It is unfair.”

“If these persons are not disciplined properly, one day, doctors and nurses will not dare to work in hospitals.”

“If the authorities give a light punishment to people who assault healthcare staff, the problem will not end. Indeed, it will get worse. I recommend that the government properly discipline this criminal so that healthcare providers feel safe at work.”

“The healthcare profession should be treated as a special job…. People are using alcohol as an excuse to attack those who are saving others’ lives. The law should be revised to prevent this kind of crime.”

Showing Sympathy

Commenters also express sympathy, appreciation and encouragement toward nurses and healthcare workers. They understand the workload and pressures that nurses have to handle in their daily work. Interestingly, they feel sorry for nurses, who earn a low income but have to face danger.

“The emergency department is the place to save severely ill patients’ lives…. Any violence should be strictly punished. People should know that the salaries of nurses are very low. Poor them for being assaulted.”

“Hospital [name not disclosed here; the location of one violent incident] is extremely overloaded because patients from surrounding areas also come there. I took my kids to the outpatient department several times and saw that the nurses and doctors were gracious. In the hospital, children are crying out loud, and there is lots of pressure. I myself got a headache, but they have to work there every day.”

“I hope all nurses are loved and try their best to complete their missions. There is always hope somewhere. Keep thinking that way to motivates yourselves.”

Being Skeptical

Some commenters are skeptical about the causes of violence. They assume that there must be provocations for the violent behavior. Many of them use their previous experiences in hospitals as a basis for their interpretation. Notably, such experiences lead to negative viewpoints about healthcare providers' attitudes and communication. Some refer explicitly to nurses, some mention doctors, and some mention both nurses and doctors.

“I believe that there must be a reason. Everyone who goes to hospitals has witnessed the attitudes of nurses and doctors. Not all of them are enthusiastic and kind. Previously, my daughter had a fever of 42 degrees Celsius. She screamed, and I took her to the emergency department. The doctor told me to take her to the pediatric ward, but the pediatric ward asked me to take her back to the emergency department. I went back there, and the doctor told me, ‘Can’t you see another patient just had an accident? Put her here. Don’t worry, she will not die’”.

“Attacking others is wrong, but everything has a reason. No one gets mad voluntarily. Let’s wait for the results of the police investigation”.

“All hospital staff should learn communication skills to behave appropriately with patients’ emotions. I see many cold-hearted and bossy mannerisms among such staff when patients are upset.”

“Honestly, many hospital staff, especially nurses, communicate with patients and their families very impolitely. Of course, I do not support the father [who slapped the nurse], but I have a feeling [that his behavior might have been motivated by such impoliteness].”

Taking Gender Into Account

Many commenters not only judge violence through the lens of the professional relationship between healthcare providers and patients. They also think of such violence as inappropriate behavior of males toward females for the simple reason that a man should not attack a woman. Notably, this kind of comment is not specific to any individual incident. It is quite common across all events.

“He is only good at bullying a woman who is saving his friend’s life. So raffish. He is an embarrassment of a man.”

“What a bad guy. He had to be hospitalized because he fought with others and then he attacks the FEMALE nurse” [capitals in original].

“He looks like a tiger, but he assaults a weak woman.”

“It is unacceptable that a big, tall guy assaulted a woman. She is just a weak woman. I feel so angry seeing the video. He should be punished.”

Discussion

Nurses suffer from severe violence at work, and it has been reported that staff nurses in emergency departments and in mental health institutions are at higher risk (Phillips, 2016). The present study also found that the majority of the incidents occurred in such settings (Table 1). All the reported incidents were physical attacks, so it is evident that there is an urgent need to protect nurses in their workplaces.

Sadly, most of the victims were attacked because the perpetrators were drunk and were not able to control their behavior, which seems to be a convenient excuse for the assaulters (Ramacciati et al., 2017). It should also be noted that currently in Vietnam, if an attack does not cause severe injury to the victim or lead to damage to hospital property, the perpetrators are simply fined a small amount of money. However, this study finds that the public often demands stricter punishments. Even though some of the proposed punishments, such as prohibiting assaulters from using healthcare services in the future, would not be applicable, it is encouraging that the public sees a need for better measures to prevent violence in healthcare environments. This sentiment could offer strong support for any future policies.

It should be noted that commenters expressed their sympathy toward the nurses but at the same time were curious about why the assaulters were provoked. There is a saying in Vietnamese, “No fire, no smoke”, which implies that nothing happens without a cause. The perpetrators often expressed their experiences with poor nursing and healthcare services as a catalyst for their violent behavior; however, such arguments are dangerous because they can lead to a perception that the victims deserved to be attacked, which normalizes the view that nurses can be assaulted if they underperform. Nurses, for their part, are accustomed to workplace violence and consider it part of their job (ALBashtawy & Aljezawi, 2016; Schmidt et al., 2019). The implications of these two perceptions undermine efforts to protect nurses from violence at work. Hence, improving nursing services, enhancing understanding of the nursing profession among patients, and encouraging nurses to stand up for their own safety seem to be equally important approaches to protecting nurses (Ramacciati et al., 2018).

It was found that commenters considered attacking nurses, as professional healthcare workers, unacceptable. However, they also believed that assaulting nurses cannot be tolerated because nurses are women. In other words, commenters not only saw a patient attacking a nurse but also perceived a man hurting a woman. This is to an extent understandable because nursing has traditionally been considered a feminine occupation (Hoeve et al., 2014). However, if commenters have this perception, they are considering violence in terms of a personal rather than professional relationship between patient and nurse, which might not be the appropriate perception. Any violence at work should be seen as a professional, not personal, issue. Nevertheless, additional studies are needed to further explore this viewpoint of the public.

Conclusion

In conclusion, this study reveals that the public expressed great sympathy toward the nurses who had been assaulted and believed that more aggressive penalties should be imposed on perpetrators. Additionally, experiences with poor nursing services made some commenters express skepticism about what may have provoked the behavior of the perpetrators. The violence was also viewed as a conflict between a man (assaulter) and a woman (assaultee) rather than between a client and a nurse. In general, commenters showed support for nurses. Nurses should take advantage of this support to advocate improved policies and measures to protect themselves from violence at work.

Study Limitations

The findings of this study relied on violent incidents that were exclusively reported in Vietnamese online newspapers. Despite the differing forms of violence that occurred in the incidents, all the news items retrieved in this study were about physical attacks. Therefore, the findings may better reflect public reactions to assaults rather than workplace violence in general. In addition, it appears that not all readers left comments on what they read, so a range of different ideas and voices have not been heard and integrated into the findings. More importantly, the nature of this study does not allow direct verification of the findings or control of the sample selection. These issues may lead to limited confirmability of the findings.