Workplace violence against healthcare workers has increased worldwide (Bernardes et al, 2021). As there is a high risk of being a victim, it has become a leading concern for all healthcare workers, including doctors, nurses, and other paramedical staff who are discharging their duties selflessly even amidst a health crisis such as the COVID pandemic. Workplace violence has a significant negative impact on the health of the staff and the delivery of health care services. It also decreases job satisfaction among nurses who decide to resign or take early discharge from service, which can further burden the health system, worsening the acute nursing shortage globally.

The primary reason nursing staff succumbs to workplace violence is that they spend long hours in patient care-related activities in the hospital. They are the ones who spend maximum time in contact with the patient, relatives, coworkers, and other hospital staff (WorkSafeBC, 2020). In India, the typical case of workplace violence involves a nurse Aruna Shanbaug who died in May 2015 after being in a vegetative state for more than four decades following her brutal rape in 1973 by a ward boy at the same hospital in which she was employed. It shows nurses vulnerability to their safety (BBC News, 2015). In another incident (reported by The Telegraph Online) in November 2018, two nursing staff were physically assaulted by the patient attendants on night duty at the Patna Medical College and Hospital, leaving them with significant injuries and prolonged hospitalisation. The incident created fear among other nurses to such an extent that they all sought police security at the workplace. These cases are just the tip of the iceberg that got highlighted, but many more remain under or not reported.

Studies on workplace violence have been done globally showing enough evidence to suggest increasing workplace violence although legal procedures and laws related to workplace violence are well-established in developed countries. The literature on this issue is scarce. Few studies have been carried out in developing countries such as India, where the laws related to workplace violence are still in infancy. Some aspects are covered in the Sexual Harassment of Women at Workplace (Prevention, Prohibition and Redressal) Act, 2013. It defined sexual harassment, laid down the procedures for a complaint and inquiry, and the needed action. In April 2020, the government of India introduced the Epidemic Diseases (Amendment) Ordinance 2020 (which became an Act in September 2020), making offences against healthcare personnel cognisable and nonbailable. However, it is yet to be made effective. Further, it is not even uniformly implemented in all states of India. Thus, no clear legislature has comprehensively protected healthcare workers against workplace violence. The studies done in India have methodological limitations, and none of the studies has discussed this issue legislative aspect (The Gazette of India, 2020).

Literature Review
Sinha (2018) found that the common factors noted to be contributing to violence against the nurses are: Individual characteristics, Environment Characteristics, Relational Characteristics - poor rapport, short temper, low frustration tolerance and societal causes - ignorance, acceptance of violence, insufficient backing, and hostility. Ruchi Garg et al (2019) reported that of 394 respondents, 136 (34.5%) workers had experienced workplace violence in the last 12 months. A total of 32 incidents of workplace violence were reported to the concerned authority. The reporting rate of violence is significantly low (23.5%) as against a high prevalence (34.5%). The level of awareness regarding the reporting mechanism and regulations for safeguarding healthcare workers against workplace violence was also found to be 24.6 percent. The present study aims to assess the prevalence, types, circumstances, associated factors, and incident reporting about workplace violence faced by Indian nurses and to explore the in-depth experiences of the victim nurses to explore and understand the extent of physical and mental damage caused and use the research findings as a base to suggest remedial measures and prevention strategies to bring out a policy document for workplace violence prevention for nurses.

Need for the study: There are many studies on workplace violence in the developed world; very few studies have been carried out in developing countries like India. Considering the scale of violence against nurses, there is a need to have a policy document for workplace violence prevention for nurses that can act as a framework for the regulatory bodies and national nursing organisations to advocate for nurses.

Methodology
Research approach: A mixed methodological approach was used in the study as the data was collected in both quantitative and qualitative forms. It included questionnaires and interview schedules. In addition, in-depth interview method was employed for collecting data related to workplace violence in the form of the experiences of nurses who had witnessed or experienced any violence at the workplace.

Research setting:
The research setting comprised of nurses employed at selected hospitals in and around Haryana. The hospitals were selected using purposive sampling. The researcher approached all the government and private hospitals with more than 300 beds in and around Haryana physically for the permission. Considering the sensitive nature of the research area only three private hospitals granted permission. However, the researcher shared the google link to the nurses via other modes also as WhatsApp groups to have wider representation from the government hospitals. To target a larger sample size a google survey form and inperson data collection through self-administered questionnaire was used.

Sampling technique:
The purposive sampling technique was used. A total of 511 nurses participated in the study from which 56 Nurses were working in government hospitals and 425 in the private hospitals. From these a total of 29 nurses agreed for face to face in depth qualitative interviews for the exploration of their WPV experience.

Sampling technique and sample size estimation:
Purposive sampling technique; the sample size was determined by the desired level of precision and the variability of the population. The sample size formula used for calculating the sample size is given as:

n = (Z^2 * P * (1-P)) / E^2, Where:
n is the sample size
Z is the Z-score corresponding to the desired confidence level (e.g. Z=1.96 for 95% confidence)
P is the estimated proportion of the population with the characteristic of interest (if unknown, it can be assumed to be 0.5)

E is the margin of error, the maximum difference between the sample estimate and the true population value. Thus, for 95% confidence level, Z = 1.96, p = 0.5, and a margin of error of 5%, E = 0.05, then substituting all these values in the formula : n = (1.96^2 * 0.5 * (1-0.5)) / 0.05^2 = 384.16. Rounding up to the nearest whole number, the sample size required would be 385. Considering the non-response rate of the respondents to be 10 percent, the sample size was determined as 422. Thus, the sample size required is rounded off to 420. From these nurses, those who have experienced incidents of workplace violence, indepth interviews were taken after taking their written, informed consent. The verbatim was analysed using NVIVO version 14.

Inclusion criteria: The government/private/ autonomous hospitals with bed strength of 200 and above were included; Nurses willing to participate and provide an unbiased response according to the Questionnaire developed for data collection, and those with at least six months of working experience in the hospital or healthcare centre. Duration of the study: One year, data collection took place from June 2023 to November 2023; data compilation and analysis was carried out by March 2024.

Tools for Data Collection

1. Standard tool developed by a team of AIIMS, New Delhi doctors ± Questionnaire for workplace violence in health care settings (Kumari et al, 2021) was used for collecting the data. Demographic details were modified. This tool has 37 items, comprising five sections: forms of violence (2 questions), the impact of violent episodes (5 questions), reporting of incidence (7 questions), mitigation strategies (11 questions), and risk factors related to the health care workers (12 questions). The tool is available in the public domain, free to use.
   
2. An in-depth interview was carried out for the 29 nurses who had experienced WPV and were willing to share and audio record their experience. Data was collected until saturation. A semi structured interview guide was used to collect data.

Descriptive and inferential statistics using SPSS version 23.0. Descriptive data analysis was determined to assess the prevalence of workplace violence (physical, verbal, psychological, sexual) and sociodemographic data of the nurses. Chi-square test was applied to assess the association between workplace violence and related demographic factors. Logistic regression analysis was done to determine the predictors of workplace violence.

Results
Table 1 and Fig 1 depict demographic characteristics of the nursing personnel. Majority of them were; aged less than 25 years (54.5%), female (72.6%), married (52.3%), working in private hospital (83.2%); having temporary status (56.6%), on rotational nature of duty (75.3%). Highest percentage of them were in general ward (46%); majority of the hospitals had security cameras (81.8%); majority of the hospitals had security person (85.1%), majority of security persons were prepared to handle workplace violence at the hospital (66.3%).

Table 1: Demographic profile (n=511)
Fig 1: Distribution of nursing personnel based on demographic characteristics.

Table 2 depicts that, among 511 nursing personnel, 169 (33.1%) have reported that they experienced work place violence and 342 (66.9 %) have reported not faced any workplace violence.

Figure 2: Percentage wise distribution of hospital having security cameras installed.

Table 2: Prevalence of work place violence among nursing personnel (n=511)

Fig 2-4 depict percent distribution of hospitals having security camera, availability of security as per nures's strength and preparation to handle work place violence.

Fig 5 shows the reasons for not experiencing WPV. For most (26%) good hospital policies, adequate information to all nursing staff (16.7%), training and debriefing sessions (15.8%), proactive and sensitive management (15.5%), (14.9%) expressed tight security system and (11.1%) had others as the reason.

Figure 3: Percentage wise distribution of nursing personnel according to availability of security person.

Figure 4: Percentage wise distribution of security persons preparation to handle WPV

Figure 5: Frequency and percentage of reasons for not having workplace violence among nursing personnel.

Table 3: Type of workplace violence among nursing personnel (n=169)

The data presented in Table 3 depicts type of workplace violence. Out of 169 who experienced WPV, almost all 97.5 percent had experienced verbal violence, 44.4 percent had experienced physical violence, 22.3 percent had experienced sexual violence. Table 4 shows forms of verbal, physical, sexual violence among nursing personnel out of 169. Almost all, 156 (97.5 %) had experienced any one of the verbal violence such as threats (10.9%), abuse (30.1), exaggerated argument (39.1), offensive comments (9.6), any other (10.3%). Similarly, 75 (44.4%) had experienced any one of the physical violence such as slapping (25.3%), beating (18.7%), thrashing (30.7%), vandalising (21.3%), attack with weapon (4%). Further, 55 (22.3%) had experienced any one of the sexual violence such as verbal offensive remarks (50.9%), physical inappropriate behaviour (18.2%), use of professional authority (5.5%), stalking (12.7%), spreading rumours about private life (12.7%).

Fig 6 depicts frequency and percentage distribution of perpetrators of WPV among nursing personnel. For most (26.0%) patient relatives, for 17.8 percent senior nurse or supervisor, for 17.2 percent co-workers, 11.2 percent patient, 7.7 percent client and any other hospital staff and 7 percent general public (7%) were expressed as the perpetrators of WPV. Out of 169, highest percentage (31.4%) of nurses in mental psychological wellbeing were in -moderately affected followed by -mildly affected (30.8%) personal wellbeing and self-care activities, and in family life was (29%) (Table 5).

The data presented in Table 6 depicts Reporting of workplace violence and mitigation strategies among nursing personnel among 169 nursing personnel are shown in Tables 6 and 7.

Figure 5: Frequency and percentage of perpetrators of workplace violence among nursing personnel.

Table 4: Forms of verbal, physical, sexual violence among nursing personnel (n=169)

Table 5: Impact of workplace violence among nursing personnel (n=169)

Table 8 depicts risk factors related to workplace violence. The association between verbal workplace violence and selected demographic variables is presented in Table 9.

Table 10 portrays that the association between physical workplace violence and selected demographic variables. Pearson Chi-square test was used to calculate the association. There was significant association between physical workplace violence and demographic variables such as age (β2=15.805, p=0.001), type of hospital as government, private and autonomous (β2 =8.130, p=0.004), job status (β2 =7.007, p=0.008), working area (β2 =10.839, p=0.004). Association between sexual workplace violence and selected demographic variables, predictors of workplace violence among nursing personnel (n=511) are presented in Tables 11-13. Table 13 shows the data extract process (N=29).

Data analysis: Original transcripts for a study involving purposive sample of 29 staff nurses working in the various medical and surgical wards, who had experienced work place violence provided the source of data. Data was collected from July 23 to Dec 23. For data analysis hybrid thematic analysis approach was carried out with NVIVO qualitative research software.

Results
A total of 29 nursing staff participated in the study. Five themes emerged from the narratives of the study participants: verbal aggression, safety concerns, harassment experiences, training needs, conflict resolution and advocacy. According to the interviews conducted, all the staff members, whether they had experienced or witnessed violent behaviour, reported that such incidents occurred frequently, ranging from verbal abuse to physical assault majorly from the patient care givers or family members and in few cases from the patients.

Table 6: Reporting of workplace violence among nursing personnel (n=169)

Table 7: Mitigation strategies of workplace violence among nursing personnel (n=169)

Table 8: Risk factor related to workplace violence among nursing personnel (n=169)

Table 9: Association between verbal workplace violence and selected demographic variables (n=169)
*Significant at 0.05 level (p 0.05)

Table 10: Association between physical workplace violence and selected demographic Variables (n=169)
* Significant at 0.001 level (p 0.01)

Table 11: Association between sexual workplace violence and selected demographic variables (n=169)
* Significant at 0.05 level (p 0.05)

Draft of the Workplace Violence Prevention Policy
Based on the findings of the research project and the critical analysis of the existing policies and procedures for WPV prevention for nurses in India the following policy draft has been proposed.

The proposed National Policy against Workplace Violence Targeting Nursing Personnel in India (NPAWVTNPI) covers preventive measures to mitigate risks and promote awareness and education campaigns.

Conclusion
The implementation of this national policy against workplace violence targeting nursing personnel in India signifies a pivotal milestone in our collective efforts to create safer and more supportive work environments for healthcare workers nationwide. By adopting a comprehensive approach to addressing workplace violence, we aim to tackle the root causes of this pervasive issue and safeguard the safety, dignity, and well-being of nursing personnel across the country.

Table 12: Predictors of workplace violence among nursing personnel (n=511)
β2 (5) = 29.53, 0.001

Table 13: Data extract process (N=29)

Through collaborative efforts and sustained commitment from stakeholders at all levels, including healthcare institutions, government agencies, law enforcement, nursing associations, and civil society organisations, we can achieve meaningful progress in preventing workplace violence and promoting a culture of respect, professionalism, and zero tolerance for violence in healthcare settings. This national policy underscores our unwavering commitment to prioritising the safety and well-being of nursing personnel, who play a crucial role in delivering quality patient care and upholding the integrity of the healthcare system. Under this policy, healthcare institutions shall be responsible for enforcing this policy within their respective organisations.