The Prevalence and Risk Factors of Workplace Violence at a Psychiatric Hospital in The Gambia

Abstract

Purpose—This study aimed to provide a comprehensive report of workplace violence (WPV) at a psychiatric hospital in Gambia. Design/methodology/approach—A cross-sectional study involving self-administered questionnaires and an in-depth interview was conducted with 54 staff at the hospital and six senior managers of mental health treatment in Gambia. A descriptive statistical approach was applied to determine the prevalence, and a logistic regression approach was used to identify factors associated with violence at the hospital. The data from the in-depth interviews on WPV policies in Gambia were analysed thematically. Results—In the 12 months before the research, 55.6% of the respondents had been exposed to violence; of those, 46.3%, 27.8%, and 5.6% had experienced verbal abuse, physical assault, and sexual harassment, respectively. Inadequate staff, insufficient security measures, and insufficient medications were perceived by respondents as the causes of the violence. However, the level of professionalism, the kind of services provided by staff, and shift of work were strongly connected with violence. As a result of WPV, victims had injuries, posttraumatic stress disorder signs/symptoms, and work dissatisfaction. The interviewees also expressed concern about the lack of WPV polices and the necessity of creating such polices as soon as possible. Value—According to the research, there is an elevated risk of violence among the hospital staff. As a result, the hospital’s structure needs to change, staff members should receive training on how to address aggressive patients, and a constructive WPV policy should be created.

1. Introduction

Any act or threat of violence, including verbal or physical abuse of people who are working or performing their duties, is considered workplace violence (WPV). The effects of WPV might range from mental health problems to injury or even death. While WPV can occur for any kind of work, it is more likely to be fatal for workers in sales, transportation, and security services than those in the healthcare services [1]. At least one form of WPV affects more than one in five people (or 22.8% of the global population) in every country [2]. WPV is a major concern for businesses and employees everywhere, regardless of how it occurs [3]. According to the National Crime Victimization Survey in the USA, the likelihood that a healthcare worker may experience WPV is 20% greater than that of other workers. The Bureau of Labor Statistics (BLS) reported that injuries from WPV had a fourfold greater likelihood of necessitating medical professionals’ absence from their jobs than other types of injuries. Similarly, the World Health Organization (WHO) claimed that more than a quarter of WPVs occurred in healthcare institutions and that staff in the healthcare sector were 16 times more likely to be assaulted than those in other sectors of work [4]. Notably, compared to all other healthcare settings, psychiatry departments have a greater rate of WPV among nurses [5,6]. A study by Sisawo et al. (2017) [7] in Gambia showed that the prevalence of WPV among nurses was 62.1%. From the 62.1% of respondents who reported experiencing violence, 17.4% described it as physical, over 60.0% as verbal, and 10.0% as sexual harassment. The respondents in the research said that the main causes of WPV were the absence of a policy, poor management support, security issues, poor patient care, staffing issues, and nurses’ attitudes [7]. Along with the physical effects on the impacted health professionals, employers face significant difficulties due to psychological effects, including job dissatisfaction, work-related terror, and posttraumatic stress disorder [8]. WPV is consistently on the rise in the health profession as a result of growing workloads, demanding job pressures, excessive work stress, deteriorating interpersonal relationships, social instability, and financial restrictions [9]. Although some healthcare workers with physical abuse are attacked with a weapon, reports from studies suggest that it is not common. This is supported by a study in which, out of the twelve nurses who had experienced physical aggression, only two nurses had been attacked with a weapon in tertiary hospitals in Thailand [10]. Similarly, a study in Gambia reported that approximately 23.0% of individuals who reported physical violence were threatened with a weapon [7]. Studies have emphasized that a healthy workplace and the well-being of healthcare professionals are important elements of efficient healthcare systems. This study is crucial for staff in the psychiatric hospital since they can be subjected to verbal, physical, emotional, and psychological abuse, mostly from psychiatric patients with symptoms of paranoia, aggression, and restlessness [11]. In 2019, the ministry of health disclosed that a patient admitted at the hospital attacked and killed two other patients in the hospital. In addition to that, I witnessed an incident where a staff member was attacked by a patient with a stone at the hospital, thus an indication that the working environment at the hospital is hostile and staff are at a risk of being attacked by aggressive patients. The focus of this study was not only on nurses but also other staff who provide direct and indirect services to patients, such as managers, assistant occupational therapists, social workers, plumbers, electricians, drivers, security personnel, laundresses, cooks, and food servers, who were actively working at the hospital for at least 12 months prior to the study. This thesis has helped reveal the problem of WPV at the psychiatric hospital in Gambia, where there is limited discussion of this problem within the public health system. It has also broken the silence on WPV and has provided findings for policy makers to make informed decisions. Action at the policy level can focus on the prevalence of, risk factors for, and consequences of WPV at the hospital provided by this study. Furthermore, the insights from this study have highlighted current facilitating and hindering policy factors to prevent and reduce WPV at the hospital and suggested actions for policy makers and all other relevant stakeholders in the country.

2. Methods

This study used both cross-sectional and mixed types of data gathering and analytic techniques. Tanka Psychiatric Hospital (TTPH) is the only psychiatric hospital in Gambia, on land established by the former president of Gambia; it was constructed in 2009 by the Dutch nongovernmental organization (NGO) the Tanka Foundation [12]. The hospital is a subunit of the highest referral hospital, Edward Frances Small Teaching Hospital (EFSTH). According to the current hospital matron, as of December 2022, the hospital has 70 staff members, including 5 psychiatric nurses, 3 registered nurses (RNs), 4 enrolled nurses (ENs), 17 nurse attendants (NAs), 14 orderlies, 10 security personnel, 2 assistant occupational therapists (AOTs), 2 social workers, 3 laundresses, 3 cooks, 3 food servers, 2 store keepers, 2 drivers, an electrician, a plumber, and a baker. The nurses work on three different shifts in a day. The morning shift is from 8 a.m. to 2 p.m., the afternoon shift is from 2 p.m. to 8 p.m., and the night shift is from 8 p.m. to 8 a.m. The hospital has two main wards (the male and female wards), an occupational therapy room, an admission room, two consultation rooms, a record office, a kitchen, a laundry house, an administrative office, and a dining hall. Since the participants in this study were all the full-time staff who had worked in the hospital for at least 12 months prior to the study, no sampling method was required to identify the participants for quantitative data collection. For the qualitative data collection, a purposive sampling method was used to choose six senior managers that supervise and coordinate the daily activities of the hospital. Following the approval and clearance from the Thammasat University ethics committee, permission was obtained from the director of the health service in Gambia to conduct the study. The recruitment and data collection processes were performed from 15 April 2024 to 29 April 2024. The first week involved recruiting the participants, and the data collection was performed in the second week.

During this process, the researcher first sought permission from the management of the hospital to be able to talk to the participants. Then, he went to the hospital and met participants in their various working wards/units. He introduced himself and gave the participants information notes to read. After that, he asked the participants questions for any clarification before he gave them the self-administered questions to answer and conduct the interview.

3. Ethical Statement

In this research, consent notes were given to all participants before they were asked to answer the questions or they were taken through the interviews. Prior to the consent note, participants were given the information note, which included descriptions of the research proposal (e.g., title, objectives, scope of the study, inclusion criteria, purpose of the study, and research methodology).

In the consent note, participants’ involvement in the research is optional, and participants can withdraw at any time they wish to do so. It is also stated to them that their information will be kept strictly confidential and that their identities will be anonymous. At the end of the consent note, participants were given the option to sign that they agreed to participate in the research.

3.1. Research Instrument

The quantitative part of the study was collected using self-administered questionnaires adapted from the International Labor Organization (ILO), the World Health Organization (WHO), and the International Council of Nurses (ICN) and Public Services International (PSI) (2003) joint program on WPV in the health sector [13]. Despite the adaptation of the questionnaires from these institutions, the questions were modified to suit the Gambian context in terms of beliefs, norms, values, and cultural settings. The modification of the questions also factored the objectives of the study, which included the prevalence of WPV, the risk factors for violence, and the effects of violence at the hospital. However, there was no need to translate the questions to other languages because the only official language in Gambia is English, and the questions were written in the same language. Three experts on occupational and environmental health at Thammasat University checked the validity of the questions through a process of item-objective congruence (IOC). Questions with an IOC > 0.50 were adopted for this study. Since the adapted tool was previously used by many researchers and was able to provide the needed information on WPV, there was no need for a reliability test. The questionnaires comprised four sections from A to F. The sections covered personal and workplace data, physical violence, verbal abuse, sexual harassment, and employee opinions on violence at the institution. Psychological WPV was further divided into verbal abuse and sexual harassment. In this study, physical violence was defined as any act that results in physical harm through striking, pinching, pushing, kicking, or slapping; employing another sort of unlawful physical force; or using a weapon to inflict pain on staff at the hospital. Psychological violence was regarded as the use of words and body language to manipulate a staff member at the hospital with the goal of mentally or emotionally harming them. In addition, sexual harassment was assumed to be forcing or attempting to force another person to participate in a sexual act, sexual touching, or a nonphysical sexual encounter (such as sending sex messages). In addition to the self-administered questionnaires, the total number of inpatients and nurses during the week of data collection was taken from the matron’s office using a checklist for the morning shift, afternoon shift, and night shift. The reporting, remuneration, and efficacy of the hospital’s WPV policy were the subjects of an in-depth interview with six managers at the hospital.

3.2. Statistical Analysis

The quantitative data were first entered into the Epi data application and later entered into the SPSS application. A descriptive statistical analysis was used for the quantitative analysis in the form of percentages, means, medians, modes, frequencies, and standard deviations with SPSS version 23 (Licence number; 6e3ec130e5b907411a4e). Logistic regression was used to determine the relationships between risk factors and WPV. The diagnostic criteria for PTSD from the DSM-5 were used to analyse PTSD resulting from violence among the respondents. The crude odds ratio and a confidence interval of 95% were used to assess the relationship between violence and respondent characteristics, such as sex, age, educational level, professional level, type of work, shift of work, and marital status. The above mentioned co-variables were adjusted using a logistic regression model. The dependent variables were physical violence and verbal abuse, and a p value < 0.05 indicated statistical significance. The interviews were transcribed directly from the recorded interviews and analysed thematically. Codes and themes were developed from the answers given by the interviewees. The themes were further defined and discussed in detail.

4. Results

Of the 63 staff members eligible to participate in this research, 54 answered and returned their questionnaires. Thus, the response rate of the research was 85.7%. Three staff members left the hospital shortly before the commencement of data collection, and the rest who did not participate in the research were either on leave or ineligible to participate.

The majority of the respondents were middle-aged people (36–45, 44.4%), followed by young adults 25–35 years (40.7%). The remaining respondents in the age groups of 46–55 (9.3%), 56–65 (3.7%), and 18–25 (1.9%) formed minority age groups in this research. The average age of the respondents was 37.5 years. Most of the respondents were men (53.7%) and married (55.6%). A total of 27.8% of the respondents were single, and of the remaining, 11.1% were divorced and 5.6% were widowed (

Table 1. Demographic characteristics of the respondents at the TTPH (n = 54).

Demographic Characteristics		Number	Percent
Age groups
	18–25 years	1	1.9
	26–35 years	22	40.7
	36–45 years	24	44.4
	46–55 years	5	9.3
	56–65 years	2	3.7
Min–Max 24–56 yrs.   Mean ± SD 37.5 ± 7.66 yrs.
Gender
	Female	25	46.3
	Male	29	53.7
Marital status
	Single	15	27.8
	Married	30	55.6
	Divorced	6	11.1
	Widowed	3	5.6
Highest educational attainment
	Secondary level	41	75.9
	Tertiary level	13	24.1
Professional group (High vs. Low level)
	High Level
	Psychiatric Nurse	3	5.6
	Registered Nurse	3	5.6
	Enroll Nurse	4	7.4
	Social Worker	3	5.6
	Auxiliary Nurse	14	25.9
	Medically Related Profession	3	5.6
	Low level
	Support Staff	5	9.3
	Security	3	5.6
	Orderly	8	14.8
	Driver	1	1.9
	Plumber	1	1.9
	Electrician	1	1.9
	Others	5	9.3
	Bakery	1	1.9
	Laundry	2	3.7
	Store Keeper	1	1.9
	Volunteer	1	1.9

).

Only thirteen respondents had a tertiary level of education (24.1%), three of whom had a degree in psychiatric nursing and one who was a registered nurse. The rest of the respondents with a tertiary level of education had diplomatic certificates from various tertiary-level institutions. The majority of the respondents’ education stopped at the secondary level (75.9%). Among them, 25.9% were auxiliary nurses (nurses without formal training), 9.3% support staff, and 5.6% worked in medical-related occupations such as therapists and security guards. The rest of the professions comprised only one or two people, as shown in Table 1.

Overall, 55.6% of the respondents reported at least one form of violence within 12 months prior to hospital data collection. Among them, 27.8% reported physical violence, 46.3% reported verbal abuse, and 5.6% were victims of sexual harassment. The average number of attacks was reported to be once a week for physical violence, 2.3 times per week for verbal abuse, and daily for sexual harassment (

Table 2. Prevalence of violence at the TTPH (n = 54).

Violence Characteristics	Physical Violence n (%)	Verbal Abuse n (%)	Sexual Harassment n (%)
Exposure to violence	15 (27.8%)	25 (46.3)	3 (5.6)
Average number of attacks
Day	0 (0)	3.7 (14.8)	1(33.3)
Week	1 (6.7)	2.3 (9.2)	0 (0)
Month	5 (33.3)	5 (20.0)	1 (33.3)
Year	1.3 (8.7)	0 (0)	1 (33.3)
Perpetrator (multiple responses)
Patient/Client	13 (86.7)	24 (96.0)	3 (100)
Patients relatives	2 (13.3)	1 (4.0)	0 (0)
Colleague at work	2 (13.3)	0 (0)	0 (0)
External colleague	1 (6.7)	0 (0)	0 (0)

).

The main perpetrators of this violence were patients. Patients committed 86.7% of the physical violence, 90.6% of the verbal abuse, and all the sexual harassment. The rest of the violence was either committed by patients’ relatives or other staff at the hospital.

5. Risk Factors

Almost all of the respondents in this research highlighted three main factors that increase the risk of violence at the hospital. The factors they mentioned were as follows:

(1)

Inadequate security measures;

(2)

Inadequate staff;

(3)

Inadequate medicines.

This was re-echoed when respondents were asked to rate the usefulness in reducing violence at the hospital through the measures in

Table 3. Respondents’ ratings of the usefulness of factors that can reduce workplace violence (n = 54).

Factors That Can Reduce Violence at TTPH	Level of Usefulness
	Very n (%)	Moderate n (%)	Little n (%)	Not at All n (%)
Security measures	45 (83.3)	7 (13.0)	1 (1.9)	1 (1.9)
Improve environment	43 (79.6)	10 (18.5)	0 (0)	1 (1.9)
Restrict public access	14 (25.9)	14 (25.9)	22 (40.7)	4 (7.4)
Patient screening	22 (40.7)	24 (44.4)	5 (9.3)	3 (5.6)
Patient protocol	22 (40.7)	25 (46.3)	5 (9.3)	2 (3.7)
Restrict exchange of money	15 (27.8)	12 (22.21)	22 (40.7)	5 (9.3)
Increase staff number	34 (63.0)	16 (29.6)	2 (3.7)	2 (3.7)
Human resource development	43 (79.6)	9 (16.7)	1 (1.9)	1 (1.9)
Reduced period of working alone	37 (68.5)	13 (24.1)	1 (1.9)	3 (5.6)
Change shift or rotates	27 (50.0)	23 (42.6)	2 (3.7)	2 (3.7)
Training of staff	44 (81.5)	9 (16.7)	1 (1.9)	0 (0)
Special equipment/clothing	25 (46.3)	25 (46.3)	1 (1.9)	3 (5.6)

. High on the rating is security measures, 83.3%, as a very useful measure to reduce violence at the hospital. While 76.6% of respondents gave a very useful rating to improvement of the working environment, the same rating was given by 63.0% of respondents for the usefulness of increasing staff numbers. Other factors that were given a very useful rating were reducing staff working alone by 68.5%, staff training by 81.5%, and human resource development by 79.6% of respondents.

The results of the crude analysis of the risk for physical violence are shown below (

Table 4. Factors related to physical violence and verbal abuse in the last 12 months at TTPH (n = 54).

				Physical Violence in the Last 12 Months						Verbal Abuse in the Last 12 Months
Risk Factors			Total Responses			p Value	Crude Odds Ratio (COR)	95% CI for COR				p Value	Crude Odds Ratio (COR)	95% CI for COR
				Number	Percent			LL	UL	Number	Percent			LL	UL
Individual Risk factors
	Age in years					0.708						0.721
		18–35	23	7	30.4		1.26	0.38	4.17	13	56.5		0.82	0.28	2.43
		36–65	31	8	25.8		Ref			16	51.6		Ref
	Gender					0.241						0.436
		Female	25	5	20		Ref			13	52		Ref
		Male	29	10	34.5		2.11	0.61	7.3	12	41.4		0.65	0.22	1.91
	Marital status					0.91						0.973
		Single	15	4	26.7		Ref			7	46.7		Ref
		Married	39	11	28.2		1.08	0.28	4.13	18	46.2		0.98	0.3	3.23
	Educational group					0.328						0.532
		Secondary	41	10	24.4		0.52	0.14	1.94	18	43.9		0.67	0.19	2.35
		Tertiary	13	5	38.5		ref			7	53.8		Ref
	Professional group					0.11						0.001
		High-level professionals	30	11	36.7		2.89	0.78	10.68	24	80		7.6	2.19	26.36
		Low-level professionals	24	4	16.7		ref			1	4.2		Ref
	Duration of work at TTPH					0.811						0.456
		1–3 years	31	9	29		1.16	0.35	3.89	13	41.9		0.66	0.22	1.96
		4–22 years	23	6	26.1		ref			12	52.2		Ref
Work environment
	Shift work					0.54						0.009
		Day shift	40	12	30		1.57	0.37	6.66	14	35		0.15	0.04	0.62
		Night shift	14	3	21.4		ref			11	78.6		Ref
	Direct contact with patients					0.087						0
		Yes	33	12	36.4		3.43	0.83	14.09	24	72.7		53.33	6.22	457.64
		No	21	3	14.3		ref			1	4.8		Ref
	Encouragement of violence reporting					0.748						0.504
		No	6	2	33.3		ref			2	33.3		Ref
		Yes	48	13	27.1		0.74	0.12	4.55	23	47.9		1.84	0.31	11.01

). Among all the factors included in this research, the only factor that had a possible risk of association with this type of violence was the type of care that respondents provided at the hospital. Although not significant, respondents who provided direct care to patients were 3.43 times more likely to be victims of physical violence than were those who did not provide direct care to patients (OR = 3.43, 95% CI = 0.83–14.09).

However, when verbal abuse was used as a unit of analysis for the risk factors associated with WPV, the factors significantly associated with verbal abuse in this research were the respondents’ level of professionalism, shift of work, and type of care provided to patients (p values < 0.05) (Table 4). The risk of verbal abuse was 7.6 times greater for respondents with a high level of professionalism than for those with a lower level of professionalism (OR = 7.60, 95% CI: 2.19–26.36). Respondents who worked in daytime shifts were 85.0% less likely to be victims of verbal abuse (OR = 0.15, 95% CI: 0.04–0.06), and respondents who had direct contact with patients were 53.3 times more likely to be victims of verbal abuse compared to the opposite group of respondents (OR = 53.33, 95% CI: 6.22–457.64).

By controlling for all other variables in this research, it was found that high-level professionals are 18.1 times more likely to experience verbal abuse than their counterparts are (adjusted odds ratio (AOR) = 18.09, 95% CI: 2.46–132.73). None of the other variables in this research showed any significant risk or association with violence at the hospital according to the multiple regressions, as their p values were >0.05 (

Table 5. Multiple logistic regressions for factors related to both physical and verbal abuse in the last 12 months at the TTPH (n = 54).

Variable Name and Ref	Physical Violence						Verbal Abuse
	B	SE(b)	p Value	Adjusted Odds Ratio (AOR)	95% C.I. for AOR		b	SE(b)	p Value	Adjusted Odds Ratio (AOR)	95% C.I. for AOR
					LL	UL					LL	UL
Age 18–35 years (36–65 years = ref)	0.05	0.87	0.953	1.05	0.19	5.77	−0.66	0.92	0.472	0.52	0.08	3.14
Male (Female = ref)	1.08	0.79	0.174	2.93	0.62	13.83	−0.60	0.79	0.448	0.55	0.12	2.59
Married (Single = ref)	−0.80	0.94	0.395	0.45	0.07	2.85	−0.038	0.92	0.683	0.69	0.11	4.17
Secondary level of Educational (Tertiary = ref)	0.04	0.93	0.965	1.04	0.17	6.45	1.67	1.07	0.118	5.30	0.66	42.80
High-level professionals (Low-level professionals = ref)	0.93	1.02	0.366	2.53	0.34	18.84	2.90	1.02	0.004	18.09	2.46	132.73
1–3 years of experience (4–5 years = ref)	0.51	0.81	0.526	1.67	0.34	8.20	0.27	0.82	0.745	1.31	0.26	6.58
Day shift (Night shift = ref)	1.51	0.89	0.092	4.51	0.78	25.98	−1.66	0.86	0.052	0.19	0.04	1.02
Direct contact with patients (No = ref)	1.61	1.06	0.129	4.99	0.63	39.62
Encouraged to report violence (No = ref)	−0.89	1.15	0.438	0.41	0.04	3.91	1.97	1.30	0.128	7.20	0.57	91.61

).

6. Effects of Violence

A small number (11.1%) of the victims of physical violence were injured, and only 5.6% of them received professional treatment. Moreover, only 7.4% were absent from work due to injuries resulting from physical violence. One respondent was absent for 2–3 days, two were absent for 1 week, and the rest of the victims were absent for 2–3 weeks (

Table 6. Effects of violence on staff at TTPH (n = 54).

Effects Characteristics	Number	Percent
Sustained injury	6	11.1
Received professional treatment	3	5.6
Absent from work	4	7.4
Signs of PTSD	30	55.6
Dissatisfied with job	30	55.6

).

All respondents who were victims of WPV at the hospital reported having at least one sign of posttraumatic stress disorder. Although more than half of the respondents (55.6%) reported not being satisfied with their job at the hospital due to violence, however, only one planned to quit the job. Many indicated that they neither planned to quit the job nor take leave without salary nor request study leave without salary. Furthermore, a small percentage of the respondents (13.0%) reported that they did not have a choice but to continue their work at the hospital even though the violence at the hospital made them not satisfied with their jobs.

6.1. Gaps in Existing Workplace Violence Polices and Reporting Systems

The interviews were conducted with six managers at the hospital in the areas of WPV policies, WPV reporting systems, and compensation for victims of violence at the institution. Three themes were generated from the participants’ responses. The themes are discussed with some of the quotations from the participants’ responses.

6.2. No Specific Workplace Violence Policy for the Institution

It was unanimously reported that either the institution does not have a policy on WPV or they are not aware of any. The managers of the institution expressed the lack of a policy as a matter of concern that is affecting situations of WPV at the hospital. Staff were expected to support and protect themselves from WPV through the management protocols taught in their nursing schools. However, the mental health program officer stressed that these management protocols are not well understood by the hospital staff. The only document to rely on is the National Labor Act, which is not helpful in addressing the challenges of WPV at the hospital according to the chief matron of the main hospital, who has served the hospital for thirty-four years. This is supported by her response “for me, I feel the hospital should have its own policy. It would have been better because it will easily address issues quickly than going through those long procedures and processes. Therefore, I would recommend that the hospital have its own policy regarding violence against staff, not only for your area of study in the psychiatric unit but also for me and other staff at the general hospital who encounter violence from normal patients and escorts”. Another person who has served as a mental health program office for eighteen years said, “No, there is no policy. It is only a management protocol for how to control violence, and most of the time, staff are not oriented to them, and it is used in training schools. Within the national health or mental health policy, the violence on staff is not captured”.

6.3. Only Physical Violence Has a Reporting System

The interviews revealed that the hospital had a reporting system only for victims of physical violence. The respondents who had knowledge of the established reporting system all said that only physical violence was reported in the incident reporting book. According to the participants, verbal abuse and sexual harassment were managed within the hospital by the matron or the most senior person present at the moment that the violence was committed. This was reflected in the response given by the chief matron “Yea normally some of those types of violence happen but normally what they report is the physical violence, even if they have verbal violence they address it at the hospital level, most of them when they encounter physical violence that is the time their report is sent to the chief matron office, and if there is any injury we will ask the staff to write to the human resource department for compensation”.

The matron of the psychiatric hospital also provided a similar explanation, but he went further to mention that the compensation was based on the severity of the physical injury and was provided by the hospital board. “Well, we have an incident reporting book; if any staff member feels he/she is physically abused, then you can report to anyone in charge, and a statement will be made in the incident book. Based on their severity, the hospital board will act on it, and if possible, compensation will be considered for the staff”.

6.4. Ineffective Compensation for Victims

The managers interviewed in this study described the compensation of staff who were victims of physical violence as ineffective. They described the process to follow as rigorous and long for the victims of the violence. The matron of the hospital said it was quite frustrating for the victims before they could receive compensation from the institution. He was able to provide an example of the most recent case at the time of data collection: “Last year, a staff member was slap from behind by a patient on the face, and her face was injured. It took that staff some time to recover; she was referred to be checked by the ear nose and throat (ENT) doctor, but for three months, she still told me she did not hear from the board for her compensation”. Despite the ineffectiveness of the compensation plan, it appears that not all the staff of the hospital knows that there is compensation for staff who are victims of physical violence. This was observed from the psychiatric nurses interviewed in this study who had worked at the hospital for two years: “Am not aware of any compensation unless the sick leave was given”.

7. Discussion

This is the first study on the prevalence of WPV at the hospital and the second of its kind among healthcare workers in Gambia. Findings from 54 respondents in this research showed a 55.6% prevalence of violence at the hospital 12 months prior to the data collection. A similar prevalence of 62.1% was reported by Sisawo et al. (2017) for violence against nurses in The Gambia [7]. Comparing this study to the previous study in Gambia, the findings contradict the claim that violence is greater in psychiatric institutions than in other healthcare units [5,6]. Like many other previous studies on violence in healthcare settings [7,14,15], the most common form of violence was verbal abuse. This study revealed that the most common forms of WPV at the hospital were verbal abuse (46.3%), physical violence (27.8%), and sexual harassment (5.6%).

The main perpetrators of this type of violence were patients (86.7% for physical violence, 96.0% for verbal abuse, and all three cases of sexual harassment). This is in line with a study in Saudi Arabia in which 81.3% of the violence was committed by patients in three psychiatric hospitals [14]. Thus, the findings support the claims of NIOSH that most WPV (85.5%) is type II (client-on-worker violence) [16]. Furthermore, most of the physical violence was committed without a weapon, which is in conformity with a study in Thailand that revealed that only 2 out of the 12 nurses were physically attacked with a weapon [10].

Insufficient staff, insufficient security measures, and insufficient medication were the three primary factors that respondents identified as increasing their likelihood of experiencing violence at the hospital. The same factors were identified in the first study on violence in healthcare settings in Gambia [7]. A total of 83.3% of the respondents described improving security measures as a very useful step towards reducing violence on staff at the hospital. Many (63.0%) also believed that by employing more staff, the risk of violence would decrease. These findings were also confirmed by another study [17].

Although institutional settings vary, the maximum number of patients whom a psychiatric nurse should be caring for at one time is six patients, according to California state law. The hospital’s three psychiatric nurses, who were present during the data collection period, were insufficient to care for 60 psychiatric patients. Using the California state law criteria of six psychiatric patients for one psychiatric nurse, the hospital must have at least 10 psychiatric nurses in each working shift to be sufficient to provide effective care to the patients. It is clear from the results of the various research methods utilized in this study that the hospital lacks the staff necessary to adequately care for its patients. A lack of staff can result in working alone and prolonged patient wait times, both of which increase the risk of staff assault [1].

Factors found to be significantly associated with WPV at the hospital are the individual level of professionalism, staff working shifts, and the type of service that they provide to patients. Staff with a high level of professionalism are at least seven-fold more likely to be victims of violence than those with a lower level of professionalism. Although many studies revealed the opposite, the results of the present study were attributed to the fact that staff with a high level of professionalism interact directly with patients, who are the main perpetrators of the violence. This was supported by a study on factors affecting psychiatric patients’ treatment in Gambia, in which all respondents from the hospital were very concerned about dealing with patient anger on a daily basis [18]. A study in Jordan by AL-Sagarat et al. (2018) and Di Martino, V. (2003) contradicted the findings by indicating that a high level of professionalism is negatively related to WPV [13,19]. They outlined the characteristics of high-level professional staff as being more competent, more capable of critical thinking, and more capable of performing specific professional care activities in an ethical and secure manner.

Since staff working the day shift were less likely to experience violence than their counterparts working other shifts were, it was discovered that working the night shift was positively correlated with WPV. This finding is supported by a study in Ghana in which it was found that working at night increases the risk of encountering WPV [20].

Six of the victims of physical violence sustained injuries, but only three of them received professional treatment. More than half of them were absent from work for at least 2 days. The prevalence of absenteeism was higher than that reported in a study in the USA, where only 9.4% of the victims skipped work [21]. All the victims of violence in this research had at least one sign/symptom of PTSD. The reason could be linked to the response given by the mental health program manager that the violence management protocols are not usually well understood by staff at the hospital. Hence, previous studies have reported fewer victims with PTSD signs/symptoms in the USA, Saudi Arabia, Pakistan, and China [14,21,22,23], respectively. Due to the irritability and behaviors that a person with PTSD signs/symptoms displays, they could easily be irritated and angry. With the irritation, difficulties concentrating, anxiety, and depression associated with PTSD signs/symptoms, it might be challenging to perform their job as expected. According to the aforementioned justification, staff members who exhibit PTSD symptoms will not be able to provide patient care properly, which inevitably will put more pressure on other employees and cause a delay in patient care. Patients may become aggressive in response to the service delay. In this research, all of the victims of WPV stated that they were dissatisfied with their jobs at the hospital. However, only two of them had plans to quit their job due to the violence they encountered at the hospital. Preceding studies in Africa (Ghana and Botswana) supported the report that some of the victims of violence are dissatisfied with their jobs and have plans to quit. The percentage of those who wanted to quit their job due to violence in China was 69.7% [15]. The main reason for this difference could be job opportunity disparities and poverty levels. Hence, 13.0% of those who were dissatisfied indicated that they did not have another option but to maintain their only source of income.

It was unanimously reported by interviewees that there is no policy on violence for the hospital. The only document to rely on is the Gambia labor act, which was described by the chief matron of the hospital as ineffective in addressing the challenges of violence and compensation for victims of violence at the hospital.

The mental health program manager at the Gambia Ministry of Health went further to add that the management protocol used to train staff at the tertiary institution is not enough for preparing staff to face a violent patient. This is supported by the responses given in the study of [18], where participants (nurses) in Gambia said they needed more training in the areas of counselling, psychotherapy, and medication for the treatment of patients with mental disability. A lack of staff training and a lack of protocols for dealing with crises involving potentially volatile patients are a few of the issues that can arise, particularly during mealtimes and visiting hours, according to the National Institution for Occupational Safety and Health [1]. Furthermore, according to AL-Sagarat et al. (2018), one of the variables contributing significantly to the high prevalence of WPV in the Jordanian healthcare system was the absence of WPV management regulations [19]. The absence of WPV regulations for the hospital, as reported by its senior managers, can thus be argued to be a factor in the hospital’s high rate of violence.

Furthermore, only physical violence is reported in the incident reporting book at the hospital, through which victims can claim compensation. However, compensation is not effective or satisfactory, as explained by the chief matron at the hospital. She lamented that victims must follow a long process and wait for a long time before any possible compensation.

8. Conclusions

In conclusion, the prevalence of 55.6% is close to the prevalence of 62.1% reported in the first study on WPV in healthcare settings in Gambia. As reported by many previous studies on WPV, the most common form of violence was verbal abuse, followed by physical violence, and the least common form was sexual harassment.

The risk factors for violence identified by the respondents were inadequate staff, inadequate security measures, and insufficient medication. However, logistic regression revealed that the factors significantly associated with WPV at the hospital were professional level, type of care provided to patients, and shift of work.

The effects of the violence have left victims with injuries, signs/symptoms of posttraumatic stress disorder, and job dissatisfaction. However, most of them do not have plans to quit due to the fear of being jobless.

All senior managers in Gambia’s mental health treatment have highlighted the lack of policy on violence as a matter of concern and the need to draft a WPV policy for the hospital as soon as possible.

9. Recommendations

9.1. Establishment of a Zero-Tolerance Workplace Violence Policy

First, a policy that aims at preventing violence from occurring at all should be formed by the relevant authorities and stakeholders in Gambia’s healthcare system. Establishing a zero-tolerance policy for WPV is one of the strongest safeguards organizations can use for their employees. This policy should cover all employees, patients, clients, visitors, contractors, and anyone else who may interact with company staff. The Occupational Safety and Health Administration (OSHA) indicated that a well-crafted and effectively implemented program for preventing WPV, including administrative controls, engineering controls, and training, can lower the incidence of WPV in both the private sector and federal workplaces [24].

9.2. Establishment of a Safety Committee Team

It is essential to create a safety committee team for the healthcare system in Gambia in addition to establishing a zero-tolerance workplace violence policy for workplace.

9.3. More Training on the Available Violence Management Protocols

The violence management protocols mentioned by mental health program managers should be revisited and ratified as necessary. In addition, lecturers in healthcare training institutions should be reoriented to those3 protocols. Through those protocols, special training should be conducted for all healthcare workers and students in healthcare training institutions in Gambia. Furthermore, there should be special orientation and training for any staff posted at the hospital on how to identify early warning signs of aggression from a patient and how to react to those signs to prevent aggression from the patient.

9.4. Structural Adjustment at the Hospital

Since working at night was positively associated with violence, there is a need to adjust the structures at the hospital by providing more bulbs to make the environment very visible and clear to work in at night. An alarm and an emergency response system that staff can use if they are at imminent risk of violence should be installed. A special ward for acutely psychotic patients and aggressive and restless patients should be created for close monitoring and prevention of violence.

9.5. Employment of More Staff at the Hospital

The different methods utilized in this study to evaluate the staffing level at the hospital have demonstrated beyond reasonable doubts that the hospital requires more staff, particularly nurses and security personnel, for optimal service delivery. A significant factor in stress at work is workload understaffing. Staff may not feel in control of their rapidly increasing workload in an understaffed hospital, which will make it difficult for them to provide timely patient care that is in high demand. Patients may react violently if they feel ignored, or their conditions may worsen as a result of the inadequate attention they receive from limited staff.

9.6. Provision of Professional Care for All Victims of WPV at the Hospital

The recipients of medical care should not be limited to those who suffer injuries physically. Any WPV victim should be assessed, and if necessary, professional treatment should be provided, especially for victims who have PTSD symptoms or signs. In fact, those who have PTSD symptoms may require more time to heal than those who have only suffered physical injuries. Professional counselling therapy, such as narrative exposure therapy (NEP), should be the primary treatment for this group of victims. An on-site staff clinic at the hospital should be established to provide holistic medical attention for victims of violence.

9.7. Improving the Violence Reporting System

The hospital’s violent incident reporting system, which the interviewees reported, should include both verbal abuse and sexual harassment in addition to physical violence. The records can be utilized by further researchers, and they will assist the hospital in creating effective WPV policies and taking WPV-related action.

9.8. Effective Compensation for Victims of Violence

The compensation procedure should be restructured to make it more successful. According to the hospital managers interviewed in this research, physical abuse compensation for victims is ineffective because it is a rigorous and long process to follow. It should be reorganized to speed up compensation and to make it more inclusive to cover all forms of violence that hospital workers may experience. The length of the compensation period should be limited in time, and managers should be responsible for ensuring that victims receive their compensation as soon as possible.

9.9. More Medication for the Hospital

Given that the hospital is the only psychiatric hospital in Gambia, the government and the ministry of health in particular should take special care and establish a reliable and efficient medication supply for it. This can be accomplished by setting up a specific budget for the hospital and inviting donors to donate medicine on a regular basis.

9.10. Suggestions for Further Studies

Although respondents were asked to identify the effects of the violence, it is not possible to conclude that there is a strong relation between the violence and the effects identified by respondents, as the study was cross-sectional. This type of study cannot establish the causes and effects of factors, and a longitudinal study should be conducted in the future to assess the effects of violence on victims at hospitals, particularly PTSD victims.

9.11. Limitations of the Study

This study’s primary weakness is the participants’ inability to accurately recollect all violent incidents that occurred. Despite the study’s restrictions on participants reporting only violence they experienced or witnessed in the previous year, there is still a tendency for participants to forget some of the violent incidents they witnessed or experienced while working in the hospital. Recall bias can therefore be present in this study. In addition to remembering bias, some participants may have refrained from talking about or reporting sensitive incidents such as sexual harassment. Discussions of those events might make them feel slightly uncomfortable psychologically.

Despite the fact that the study provided information on the effects of WPV on hospital staff, it is not possible to conclude that there is a cause-and-effect relationship because the research was cross-sectional and could not prove causation. Additionally, information was only gathered for one week.