Workplace violence among Registered Nurses in Saudi Arabia: A qualitative study

Abstract Aim The primary aim of this qualitative inquiry is to explore the experiences of Registered Nurses working in Saudi Arabia, which was a guide to answer the question, “what are the lived experiences of Registered Nurses working in a selected government hospital in Eastern Region of Saudi Arabia towards workplace violence?” Background Workplace violence is a social phenomenon that needs a widespread campaign to eradicate. Incidence from all over the world continues to grow in number, especially among Registered Nurses in Saudi Arabia. Methods Descriptive phenomenology. Purposive‐convenience sampling was used in selecting 21 Registered Nurses as participants for individual in‐depth interviews. Data were gathered over an 11 month's period from September 2017 to August 2018. We used Colaizzi's method for analysing the data. COREQ criteria were adapted in reporting the results of the study. Results Three themes had emerged from the experiences of the participants: “co‐workers become unjust and violent”; “socio‐cultural divergence towards healthcare workers”; and “violence from outside influences affecting the workplace.”

including Saudi Arabia (Basfr et al., 2019). This study aims to promote actions to discuss violence in the health sector workplaces particularly in the scope of the nursing profession and complement actions implemented by the different international agencies at different levels in decreasing the incidence of violence in the health sector all over the world.

| Background
Studies have shown that episodes of workplace violence had unfavourable effects on both the physiological and psychological aspects of nurses victimized by the perpetrators (Martinez, 2016). Numerous workplace violence incidences among healthcare professionals especially among nurses were not reported and studied (Alsaleem et al., 2018;Alshehry et al., 2019;Phillips, 2016). Nurses being the front liners play an essential role in the patient care delivery system, have always been considered as the most vulnerable subject for aggression, bullying and incivility in the healthcare setting in the past decades particularly in the emergency departments, inpatient psychiatric settings and nursing homes (Cheung & Yip, 2017). One evidence that workplace violence was rampant worldwide is the study conducted in Slovenia, out of 692 nurses recruited for a workplace violence survey, the small number of respondents had reported violence in writing form since they believed that in spite of knowing the figure of the victims, nothing will be changed. They would always fear losing their jobs if they tell the truth (Kvas & Seljak, 2014). Another proof that violence in the workplace does happen worldwide was the study conducted among 850 nurses in Hong Kong. A total of 44.6% of respondents revealed that they had experienced various kinds of workplace violence, such as verbal abuse (39.2%), physical assault (22.7%) and sexual harassment (1.1%; Najafi et al., 2018).
In the Middle East, for instance, a study conducted in Palestine revealed 80.4% of workplace violence, of which 20.8% were referred to physical and 59.6% were referred to non-physical workplace violence among physicians and nurses (Kitaneh & Hamdan, 2012).
Furthermore, substantial proportions of nurses have experienced workplace violence in Jordan and Lebanon, with a ratio of 75% and 64.8%, respectively (Alameddine et al., 2015;ALBashtawy & Aljezawi, 2016). These international studies concluded that workplace violence may lead a professional to render poor quality of patient care and this could make huge impacts on the nursing profession. Earlier systematic review study with a total of 3 million participants of the eligible studies found out that 61.9% of healthcare professionals were reported workplace violence (Liu et al., 2019).
Despite this fact, various works of literatures and studies were tackling this controversial issue; however, limited information about this phenomenon against healthcare professionals in the Gulf Cooperation Council (GCC) countries is available.
In Saudi Arabia, in line with Vision 2030 and the Ministry of Health's (MOH) endeavour to provide and raise the level of health services for all citizens, many achievements have been made, including an increase in healthcare facilities to provide comprehensive and accessible healthcare services (MOH, 2018a). Despite these efforts and achievements, programmes to mitigate workplace violence among healthcare professionals are needed. Nurses are most of the healthcare workforce in Saudi Arabia, with a total of 82,505 nurses in the public sector and 44,708 in the private sector (MOH, 2018b). Violence against nurses had been a major challenge for the hospital directors particularly with its aftermath negative impacts resulting in poor performances and low self-confidence and esteem (Alkorashy & Al Moalad, 2016). Based on the MOH annual report 1437-1438H (2016-2017G), expatriate nurses represent 40% (with a total of 32,832) of the nursing workforce in the public sector and 94.5% (with a total of 42,258) in private sector in Saudi Arabia (MOH, 2018b, pp. 76 & 376). Expatriate nurses refer to all non-Saudi nurses. A study reported by Alhusain et al. (2020) revealed that non-Arabic speaking healthcare workers are more likely to be exposed to violence than Arabic speakers. In a study conducted among 738 healthcare workers in 2 government health facility in Abha City, Saudi Arabia, 57.5% of the respondents were victims. Verbal assaults and slaps were the most common forms of violence (Al Anazi et al., 2020;Alsaleem et al., 2018). Another study conducted in a Saudi university hospital found out that almost half of the total sample quota of 360 nursing personnel had experienced violence during the 12-month period before the study was formally conducted using the Massachusetts Survey on Workplace Violence/ Abuse (Alkorashy & AL Moalad, 2016). Perpetrators were identified based on countless observations and research investigations.
Surprisingly, almost the same worldwide such as patients (36.6%), relatives (17.5%), co-workers (7.7%) and supervisors (6.3% ;Cheung & Yip, 2017;Najafi et al., 2018). Common reasons why perpetrators lead to violence were due to understaffing, misunderstandings, long cue of services, lack of staff training and absence of policies of workplace violence (Alkorashy & AL Moalad, 2016). As mentioned, only limited existing literatures tackle much of the experiences and feelings of workplace violence victims, which is why this study leads one step ahead from exploring ways and means to eradicate this controversial social phenomenon in the health sector.
The significance of workplace violence among nurses was more than the priority for policymakers, researchers and nurse managers locally and internationally. Most studies investigated workplace violence were conducted in Asia, Europe and North America.

| Research design
In this paper, descriptive phenomenology was chosen because the lived experience is understood from a lifeworld approach coming from the writing of Husserl as how individuals give meaning to experiences towards a certain phenomenon and its applicability in understanding the voices of the participants (Creswell, 2013;Dahlberg et al., 2008;Salvador, 2016a). Understanding lived experiences is based from the lifeworld, which forms the ontological and epistemological foundations of the study that is underpinned from the participant's awareness of the lifeworld, their bodily being in the world and how they interact with others (Sundler, Lindberg, Nilsson, & Palmer, 2019). Besides, the entire study was guided by the methodological principles of questioning pre-understanding, adopting a reflective attitude and emphasizing openness. In analysing the data, thematic analysis was used to come up with better understanding of patterns of meaning from the gathered descriptions of the experiences.

| Participants and sampling
Purposive-convenience sampling was used in selecting the 21 participants (11 males and 10 females). Purposive sampling (judgment) is the intended option of a participant due to the standards the participant have, which also involves identification and selection of a person or groups that are well-informed towards a phenomenon of interest (Creswell, 2013;Etikan et al., 2016), while convenience is a class of non-probability sampling that does not create statistical data, but aims to allow the phenomenon to occur. This was to find shared or mutual dimensions that cut through a varied sample while at the same time propose the prospect to detail unique or diverse variations (Bricki & Green, 2007;Patton, 2002). Participation in the study was purely voluntary and no conflict of interest between the researchers and the participants (Salvador and et al., (2020).
The demographic profiling of the enrolled participants can be seen in Table 1. The Registered Nurses were currently working in a government hospital in the Eastern Region of Saudi Arabia. Casual talks between the researchers and participants were done to establish rapport (Salvador, 2016b). The researchers explicated the purpose and flow of the interviews before signing the consent. The inclusion criteria included the following: (a) a Registered Nurse with a minimum of 2 years' experience as a Registered Nurse; (b) had an experience of violence in any form; (c) willingness to impart personal experiences; and (d) able to speak the English language. Each participant was expected to share personal experiences regarding the phenomenon under investigation that would provide new insights to the readers . Lastly, the researchers had chosen 2 years as work experience in the hospital because at this time, Registered Nurses had already adapted to the hospital environment and surpassed the probationary period of 6 months. This would enable them to see a comparison between the first year to the succeeding years as Registered Nurses towards workplace violence.

| Interviews
Data were gathered over 11 months from September 2017 to August 2018 through individual interviews. Individual in-depth phenomenological interview was used to probe the participant's attitude, beliefs, desires and experiences to provide better comprehension of the phenomenon. Initially, the research team piloted a "subject-object interview" to 3 Registered Nurses in the selected government university hospital who met the inclusion criteria and used as a basis in creating an interview protocol that includes questions and probes to use for followup seen in Table 2 (Bryman, 2012;Dikko, 2016). The Registered Nurses enrolled in the pilot interviews were excluded from the actual study.
Before conducting individual interviews, all researchers underwent workshops about proper approach and techniques in conducting the interview sessions, which includes peer debriefing, transferability, triangulation of data and various techniques in handling data and analysis. After 2 months, the researchers revisited and directed individual interviews (Bauger & Bongaardt, 2016). The schedule of interview depends on the availability and most suitable time of the participants, usually during off-duty hours and/or before and after scheduled shifts.

| Data analysis
The data saturation process was patterned according to Colaizzi's seven steps in analysing qualitative data. Initially, the researchers started analysing by reading and re-reading individually the transcript to draw the general sense of the conversation. The significant statements identified in relation to the phenomenon were extricated, which was followed by a series of discussions of the meanings formed from the statements. To eliminate possible biases, each researcher's pre-conceived ideas were placed in brackets, to prevent a theoretical-deductive approach and focus on an inductive process . The word files and excel spreadsheets containing the researchers were shared and arrived in the final synthesis; thus, themes generated were identified based solely on the data analysis. The formulated meanings were clustered until such time it cannot anymore be categorized.
The final deliberation of the results came up with 3 major themes.
In cases of disagreement, the researchers go back and discuss the data analysis and final results will be based on the consensus of the research team usually done by casting votes. The final outcomes were immersed into an "exhaustive description" to fully uncover the fundamental structure of the phenomenon. Lastly, results were discussed among the participants for member checking (Colaizzi, 1978).

| Rigour
To guarantee the rigourously scientific nature of this qualitative investigation, 4 concepts were thoroughly considered: credibility, confirmability, dependability and transferability . To ensure credibility, researchers transcribed the interviews on the same day to prohibit any form of vagueness and ambiguity, all results were validated from the transcript files, field notes and audio-recorded individual interviews. Reflective journals were used to recognize any personal biases. Moreover, the researchers also sought three hospital staff nurses who were not enrolled in the study to validate the emerging essence of the phenomenon compared with their own experiences through a referral system from nursing colleagues from different countries. The following are the criteria of selection: (a) a Registered Nurse who experienced workplace violence first-hand; (b) willingness to share insights about the results of the study to personal experience; and (c) can speak the English language. These Registered Nurses were from the Philippines, the USA and Saudi Arabia. This process enabled the researchers to confirm that findings can happen not only in one place, which would attest to the study's transferability. For dependability, the researchers ensured that all processes throughout the study were recorded for consistency and reliability, so whenever an individual checks it, similar results will be generated (Polit & Beck, 2012). Three independent peer reviewers were invited to double checked the relevancy, accuracy and meaning of the data for conformability. Peer reviewers have expansive experiences in nursing education, practice, administration and research.
Specific criteria were as follows: (a) 10 years in the nursing profession; and (b) with expertise on qualitative research with multiple number of publications. All reviewers have similar perspectives towards the objectivity of the study. More so, participants were also given the chance to check on the theme clusters and major themes (fittingness) by using direct quotations to embody how the phenomenon was perceived (Lincoln & Guba, 1985;Polit & Beck, 2012).
Finally, in reporting the results, Consolidated Criteria for Reporting Qualitative Research (COREQ) criteria (Tong et al., 2007) was adapted. All interviews were audiotaped, transcribed into verbatim on the same day and kept in a case for proper safekeeping and future reference. Participants were well-informed of the confidentiality and data will be destroyed and disposed securely once it is no longer needed, after agreed periods of retention have expired per the University's Information Handling Policy.

| Ethical considerations
This study was approved by the Institutional Review Board of Imam Abdulrahman Bin Faisal University (IAU 2017-134). The researchers also sought permission to conduct a study in the selected government university hospital. All requirements were submitted (IRB certification, a brief summary of the study, informed consent and interview questions). After several weeks, approval to conduct the study was given to the research team. A memorandum was given to the nursing service office to circulate in all nursing departments that interviews will be conducted. Prior to data gathering, participants signed informed consent that included permission to publish quotes. Participants were given the autonomy to express and verbalize their lived experiences as well as other concerns (e.g. emotional, moral, etc.). Individuals who were a priori vulnerable were not interviewed (e.g. mental and psychological problems). Participants who were unintentionally become a posteriori vulnerable were given counselling from the hospital's counselling department during or after the duration of the interviews (Larsen et al. (2008).

| RE SULTS
After extensive meetings and deliberations with the selected panel of reviewers, the researchers came up with 3 themes and 9 theme clusters that reflected the workplace violence experiences of the participants given in Table 3.

Theme cluster Themes
Assaulting junior staff nurses by senior staff nurses

| Co-workers become unjust and violent
This major theme depicts the workplace violence experiences of the participants with their co-workers. In their accounts, the perpetrators do not only pertain to the co-nurses, but also from various healthcare professionals and departments. Three theme clusters emerged: (1) "assaulting junior staff nurses by senior staff nurses" refers to verbally assaulting junior nurses typically in their probationary periods usually 6 months on their poor performances, lack of initiative, incompetence, bad attitude and insubordination: Most of them think that we are just nurses. We feel that we should be respected as we respect them.
Honestly, it is not only the doctors, other departments have their own share of not so good experience. I just hope, we will be able to mend these differences….

| Socio-cultural divergence towards healthcare workers
This major theme illustrates the workplace violence experiences with their respective patients, client's family members and visitors.
Three theme clusters were generated: (1) "public humiliation due to miscommunication" refers to language barriers, body languages and cultural gestures causes some people to misunderstood what nurses want to say resulting in verbal clashes, commotions and worst physical attacking:

During my first 3 years in the hospital, it was really hard
for me to adapt the situation because I cannot speak and understand the Arabic language. There was an instance that my patient got upset because he cannot understand me and told me 'mafi muk' (Arabic). I asked my co-worker about the meaning of that phrase, to my dismay I found out that the meaning of it was 'no brain'. (2) "typecasting nurses due to religious disparity" embraces religious practices and customs that serve as guiding principles for people, which affected on their interaction with nurses with dissimilar religion: It is known for a fact that Saudi Arabia is known to have rich culture and traditions. However, in the healthcare delivery system, somehow, people should be accepting.
There are some instances that because of no familiarization with their cultural, social and religious practices, they will be telling you 'not so good things'. Whenever they utter things like that, I feel ashamed of myself….

(P2)
and (3) "wrong impression of men in nursing" pertains to the socio-cultural ideology that the nursing profession is only for females: There was a time I am in-charged of a local patient.
The patient was not cooperative because I am literally an expat. His family was not happy too, they raised their voices and tell me that they wanted a female nurse or someone who could understand them unlike me who has different backgrounds…. (P8)

| Violence from outside influences affecting the workplace
This major theme portrays the workplace violence experiences that involve some personal and professional involvements with loved ones, family members, friends and acquaintances whom the participants had various close encounters happening inside and outside the hospital premises. Three theme clusters emerged from this theme: (1) "threatening co-workers by a loved one" refers to personal issues from family and friends, which resulted in harassment, mocking, abuse and/or any kind of violence happening in the workplace causing someone to feel uncomfortable and uneasy: My husband got angry because of rumors and gossips bout my involvement with one male staff nurse who happens to be her ex-boyfriend. In fact, he was just a friend. They started spreading bad news about me and single me out during duty. And someone informed my husband. My husband confronted the involved person and almost had a fight….

(P13)
(2) "cyberbullying" pertains to an intentional social media attacking that may lead to character assassination and public scandal: Some of the staff nurses expressed their rants and emotions thru social media especially in Facebook. Although most of the time, no names were mentioned but people from the hospital or unit would easily notice who the person is referring to. Gossips and hearsays are usual occurrence after posting in the social media. I was victimized twice, at first I ignored it but the last one, I confronted the person but that person kept denying it…. There were group of teenagers who mobbed me when I am about to go to my flat. I was really scared and tried my best to run but they were throwing stones that caused me some bruises.
(P14) Workplace violence between co-workers is a worldwide phenomenon and common in every healthcare facility. This could be in various forms of aggression and bullying that often manifests as verbal abuse and emotional torture, which is cruel, rude, vindictive, humiliating and/or offensive (NIOSH, 2016). Nurses tend to be violent for innumerable unexplainable reasons. This is mostly coming from fellow staff nurses rather than from their immediate supervisors (Granstra, 2015). This kind of workplace violence in the nursing profession is called "horizontal bullying or lateral violence" and currently investigated as one of the most alarming issues in the healthcare profession today. This type of violence is viewed as being "the lower on the food chain" such as in a manager to staff or physician to staff nurse though the incidence of peer-to-peer violence is also common as shared by the participants (NIOSH, 2016). It is not only in the hospital that this phenomenon can be experienced, but it can also happen in any professional setting like academic institutions, primary health clinics, private institutions. Unfortunately, not all hospital personnel recognize it especially in special areas like the operating rooms and emergency departments (Chipps et al., 2013).

| D ISCUSS I ON
Since the operating room environment is competitive and "toxic," healthcare workers viewed misbehaviour and incongruous attitude from workers as normal. One participant emphasized that awareness among healthcare professionals should be imposed to let them know the nature of this phenomenon to prevent it from occurring.
Another common lived experience of violence shared by the participants and considered as the most common in a healthcare setting is the "socio-cultural divergence towards healthcare workers" especially in Saudi Arabia where most of the workforce in the hospitals are expatriates. Comparable to the participants' experiences, a study conducted in India mentioned that the client and their family members become aggressive and violent to nurses and junior residents who have less clinical experiences, comparatively less age group and male gender, which resulted in physiological and psychological damages on the healthcare provider (Sachdeva et al., 2019). Similarly, 70.6% and 43.1% of workplace violence incidents in a public hospital in Iran were from patients and companions respectively. Unrealistic expectations were the most common attributing factors leading to verbal abuse, threats, physical abuse, sexual abuse and ethical discriminations (Honarva et al., 2019).
The study concluded detrimental effects not only for healthcare providers but as well as university lecturers causing them to lose their self-confidence, composure and competency bringing serious repercussions in their work areas (Gupta et al., 2017). Thus, this shows a worldwide phenomenon that usually happens in any hospital department commonly in psychiatric and emergency care facilities, hold backrooms and geriatric facilities; however, it is not limited to these areas.
"Violence from outside influence affecting workplace" was identified as the last kind of lived experience identified by the participants. The perpetrator of violence can also come from people within the nurse's circle of friends, relatives, acquaintances and/or anyone not related to the victim. This type of violence can be a source of physical and psychological violence at work coming from family problems, relationship with other people, unsettled transaction and businesses; thus, its major effects may lead to deprived physical and physiological health, amplified psychological stress and decreased employment fulfilment (Brewer & Whiteside, 2012). Moreover, the perpetrator may also have no legal connection to any of the workplace employees and is intently attributed to crimes such as kidnapping, robbery, trespassing and even mobbing resulting in physical violence. Campo and Klijn (2018) mentioned that there was a low percentage of reported violence since healthcare professionals believed that this would be useless, insignificant and will not be given appropriate action by the administrators.
CDC has enumerated common causes of workplace violence with the following reasons, which were consequently evident in the Despite numerous awareness campaigns to successfully eliminate it, more and more cases were being reported either direct (verbal and physical) or indirect (relational and psychological) ways due to unsustainable implementations (Karatuna, 2015). Anti-workplace violence programmes were reported to decrease the incidence among nurses in the hospital at one period, however, 6 months after the implementation, it started to increase once again due to lack of leadership and management and proper way of handling cases of violence still needs to be improved (NIOSH, 2016;Stagg et al., 2013).

| Limitations
The study solely investigated the experiences of nurses and does not involve any of the perspectives of the nursing administrators or the behaviour of the perpetrators.

| CON CLUS IONS
Workplace violence is a global phenomenon that leaves detrimental and unfavourable effects to both private and public healthcare professionals, particularly among Registered Nurses who are considered as the front liners in any healthcare setting. Saudi Arabia has the same issues just like any other country facing this kind of social problem, which nursing managers and advocates need to act on for eradication or if not at least a continuous decrease in number each year. Three themes had emerged from the experiences of the participants: "co-workers become unjust and violent; sociocultural divergence towards healthcare workers; and violence from outside influences affecting workplace." Knowing the narratives of Registered Nurses who first-hand experience workplace violence would give awareness to nurse managers to come up with specific, measurable and realistic interventions to eradicate this growing social phenomenon especially in health care. Therefore, the study would like to conclude that the lived workplace violence experiences of Registered Nurses working in Saudi Arabia increases an individual's understanding of the subject, which may contribute to finding collective resolutions to eliminate this social phenomenon. Nurses, as well as other healthcare providers, must need to feel safe in the workplace to fully function as a healthcare provider and to deliver the best quality service for the clients (Bent, 2016).

| Recommendations
Establishing a robust and systematic multi-streaming initiative should be implemented to safeguard the nurses from any possibility of harm in the clinical settings that include setting up a powerful violence prevention and training programme for which employees are welloriented such as establishing policies for its occurrence and near misses reporting, recording and screening that may encourage an atmosphere of confidence and respect between staff and management.
Creating a comprehensive physical and psychological counselling and debriefing plan for employees who encountered any form of abuse or aggression-related issues and the provision of trauma-informed treatment. For nurse managers, creating workplace surveys may help recognize various types of issues encountered by employees in their daily jobs. It would also be helpful to design an assessment tool for employment hazard analysis that focuses on job tasks to spot hazards associated with workplace aggression, incivility and violence and/ or maybe modified to cut back the likelihood of violence occurring.
Patients can also engage in the detection of reasons for violence, day-to-day events contributing to violence and successful response. Remodeling of workplace environment, such as re-arranging the work areas and stations that would eliminate hazards at work or build barriers between the worker and the hazards as well; door locks are used to minimize risk exposure for employees; better or more lighting and more open exits. Finally, developing training programmes for new nurses before assigning jobs.
All nurses should also be trained regularly to improve their health awareness and safety and prepare them on how to respond to the warning signs of workplace violence. draft of the article was reviewed and approved by all authors in a roundtable discussion. Ithenticate was utilized in checking the similarity index.

E TH I C A L A PPROVA L
This study was approved by the Institutional Review Board of Imam Abdulrahman Bin Faisal University (IRB approval number: IAU 2017-134). Prior to data gathering procedures, informed consents were collected and signed by the participants. The informed consent included permission to publish quotes. Moreover, autonomy was highly-observed throughout the process as well as participants' confidentiality. The researchers made sure that participants has the freedom to withdraw whenever they feel uncomfortable and unsafe. Participation was purely voluntary and no conflict of interest between the researchers and the participants.

DATA AVA I L A B I L I T Y S TAT E M E N T
The date sets used for the current study are available from the corresponding author on reasonable request.