A survey assessing the prevalence of in-hospital violence against veterinary nurses working in small animal hospitals

Background: In recent years, due to a strong concern about this issue, many studies have been conducted on in-hospital violence directed at medical personnel working in the field of human medicine. However, no such survey has been conducted in veterinary medicine to date. Veterinary nurses play an important role in small animal hospitals. This study aimed to investigate whether in-hospital violence occurred against veterinary nurses in small animal hospitals. Aim: We conducted a questionnaire survey among veterinary nurses working in small animal hospitals to assess their experience of being subjected to in-hospital violence (verbal and physical). Methods: The target period for this survey was 1 year before the completion of the questionnaire. A total of 134 nurses gave their consent to participate in this survey, and 126 survey responses were included in the final analysis (valid response rate: 94.0%). Incomplete responses were excluded from the analysis. Results: It was seen that 51 people (40.5%) reported having experienced incidents of verbal or physical violence or sexual harassment. Conclusion: Based on these results, we suggest measures that will help ensure that the staff can provide veterinary care without worrying about their safety and well-being.


Introduction
In recent years, due to a strong concern about this issue, many studies have been conducted on in-hospital violence directed at medical personnel working in the field of human medicine (Inoue et al., 2006;Fujita et al., 2012;Sato et al., 2013;Fujimoto et al., 2019). Previous studies have reported that 33-47% of the nurses they surveyed had experienced workplace violence during the previous 12 months (Fujita et al., 2012;Sato et al., 2013;Fujimoto et al., 2019). This survey and other similar focused studies sought to clarify the actual prevalence and severity of in-hospital violence. Medical treatments for small animals (dogs, cats, etc.) have advanced sharply in recent years, and owners' attachment to their pets has deepened. Therefore, owners expect high quality service and care from animal hospitals. Given such expectations, a similar potential exists for violence toward veterinary medical personnel. However, to date, no detailed study has assessed the prevalence and severity of violence in veterinary hospitals. The veterinary nurse, as a staff member assisting the veterinarian in small animal medical treatment, visits small animal medical facilities to consult veterinary medical care procedures (often, these visits involve interactions with pet owners). Veterinary nurses play an important role in modern veterinary medicine. In-hospital violence has become a major problem for nurses who provide medical care to humans and has led to the establishment of Guidelines for Countermeasures against Violence in Health and Welfare Facilities by the Japan Nursing Association. Recently, several occupational health surveys have been conducted in several veterinary hospitals; however, there are no detailed reports addressing inhospital verbal abuse, violence, and sexual harassment against veterinary nurses (van Soest and Fritschi, 2004;D'Souza et al., 2009;Sánchez et al., 2018). To meet this need, we conducted a questionnaire-based survey of veterinary nurses to determine the frequency and severity of in-hospital violence against personnel in small animal hospitals. This paper presents the questionnaire method, findings, and conclusion.

Materials and Methods
This is a preliminary study and, based on previous reports (D'Souza et al., 2009;Foster and Maples, 2014), we determined a sample size of approximately 110 was sufficient initial data. There has been no previous research on hospital violence in veterinary medicine; therefore, we created a new questionnaire. We defined "violence" in this study using the Framework Guidelines for Addressing Workplace Violence in the Health Sector  (ILO et al., 2002). We also prepared an investigative questionnaire that fully considered participants' privacy. After approval by the university's ethics committee, the questionnaire was distributed at various meetings and seminars for veterinary nurses. The completed forms were collected in sealed response envelopes. The survey covered 12 months immediately preceding the completion of the questionnaire. The study was conducted in the following periods: September to November 2014, February 2015, and July 2015. In total, 134 veterinary nurses agreed to participate in the survey. After excluding forms with incomplete answers, the final number of participants whose responses were analyzed was 126 (121 women and 5 men; valid response rate: 94.0%).

Ethical approval and consent to participate
This study was approved as a social science project by our university's ethics committee, and written informed consent was obtained from all participants.

Results and Discussion
In response to the question, "Have you experienced any incidents of physical or verbal violence, or sexual harassment?" 51 (40.5%) responded "yes." Among these types of violence, "verbal violence" was the most common, as it was experienced by 39.7% of the respondents. In response to the question, "What kind of violence have you experienced?" 31 respondents indicated that they were "screamed at," 27 respondents were "insulted," and 21 were verbally abused in normal speaking tones. Among the respondents who had experienced verbal violence, 17 were abused by male clients, 12 by female clients, 28 by hospital directors, and 22 by staff. Respondents' reported coping methods included consultations with the hospital director, colleagues/seniors, friends, and family. Eleven participants reported doing nothing and 4 of these 11 worried that complaining could have adverse effects on their employment. Just over 7% (7.14%) of the participants answered "yes" to the question "Have you ever experienced physical violence?" Incidents of physical violence included being pressed, having their arm or hand grabbed, being knocked out or "knocked," and having objects thrown at them. "Staff" was the most frequent answer to the question "Who inflicted the physical violence?" The stated reasons for physical violence included "character of staff," "insufficient communication," and "I'm bad" in order of prevalence. Three respondents answered the question "How did you deal with physical violence" with "I spoke to the director." Two replied, "I spoke to a colleague/senior," and three replied, "I spoke to friends and family." Three said, "I asked the other party to stop the violence." Three responded, "I did nothing." Nearly 10% (9.52%) answered "yes" to the question "Have you ever been sexually harassed?" Comments about the respondent's face or body were the most common type of sexual harassment. Five of these incidents involved a male client, director, or staff member. In addition, 31% of the respondents answered, "I did not experience violence, but did experience a dangerous situation that could have become violent." In response to the question, "Do you have a manual for organizational efforts?" 93.7% answered "no." In response to the question, "Are employees required to report violence?" 92.1% answered "not required." "Do you want to strengthen the management system?" 60.3% answered "yes." This survey revealed the frequency and severity of physical and verbal violence and sexual harassment among veterinary nurses. In the free description section, some respondents stated that "(violence in words) has become a daily routine." Others describe situations in which they have been "ambushed" and "subjected to physical violence during an examination." We assume that these situations are severe. In previous surveys of nonveterinary hospital nurses, 33%-47% of the respondents had experienced workplace violence during the previous 12 months (Fujita et al., 2012;Sato et al., 2013;Fujimoto et al., 2019;Kobayashi et al., 2020). However, further research is needed to establish whether the in-hospital violence experienced by veterinary nurses is of the same magnitude as that experienced by nurses in human medicine. The Journal of Occupational Health has reported a new concept for analyzing workplace violence against nurses (Al-Qadi, 2021) that outlines necessary factors' study designers must consider when conducting further analyses in the future. A previous study demonstrated that mental healthcare nurses in Japan who experienced workplace violence themselves had poorer mental health and experienced more burnout (Kobayashi et al., 2020). Similarly, burnout among veterinary nurses has also received attention (Thompson-Hughes, 2019), suggesting that a reduction in workplace violence against veterinary nurses may reduce the number who experience burnout. Regarding the question of who inflicts abuse, we received a wide range of responses from directors, staff members, and clients. The design of this survey, did not allow us to rule out respondents referring to their director as "staff." Therefore, it was not possible to distinguish whether references to colleagues or senior staff members were referred to veterinarians or veterinary nurses. Liu et al. (2018) reported that perceived organizational support served as a mediator between workplace violence, job satisfaction, burnout, and turnover intention, and significantly reduced the latter (Liu et al., 2018). Therefore, the directors of small animal hospitals should understand the importance of visibly providing organizational support to nurses experiencing workplace violence. A study conducted by the Japanese Nursing Association in the fiscal year 2003 found that the factors underlying violence suffered by staff included a lack of communication among staff members, response to patients, and educational S. Yukawa and M.Yukawa. Open Veterinary Journal, (2022) There are some limitations to be considered in this study: firstly, there are approximately 28,500 veterinary nurses in Japan, of which this study surveyed only 134 (approximately 0.5%). Further studies will need significantly larger sample sizes in order to better describe national trends. Secondly, the surveys conducted in this study occurred between 2014 and 2015, making the study results somewhat outdated. Current analytical methods and changing social trends may produce different results if the study were to be conducted today. However, to the best of our knowledge, this is the first study of its type reporting on in-hospital violence against veterinary nurses. The limitations of the study data merely highlight the crucial need for further investigation of veterinary hospital workplace violence in Japan with larger sample sizes and more up-to-date data. Based on the results of this survey, we would next like to investigate the status of the current management systems of small animal hospitals in terms of their role in the prevalence and prevention of workplace violence, and recommend measures to help create environments in which staff can feel safer and more comfortable while providing veterinary care. In addition, we would like to continue accumulating survey responses to clarify the current situation further.

Conflict of interest
The authors declare that they have no competing interests.

Authors' contributions
SY conceived and designed the experiments. SY performed data collection. SY and MY analyzed the data and wrote the manuscript. SY approved data analysis. All the authors contributed equally to this work and approved the final manuscript.