The findings of the present study show the high level of violence against nurses in Razi educational and medical centers in Rasht. Regarding physical violence, studies conducted in East Azerbaijan also showed a high level of violence (20) and Shoghi in his study on violence in nurses working in 20 hospitals in Tehran, showed that 19.1% of nurses have been subjected to physical violence at least once in the last six months (21) and this figure was 19.7% in the Argon study in Turkey(22). Shields et al, reported a 34% incidence of physical violence in their study in Canada(23). However, Nachreiner et al., In their study in the US state of Minnesota, estimated this rate at 13.2% per year and reported the level of physical violence in different countries during the year as follows: Thailand 10.5%, South Africa 9%, Bulgaria 7.5%, Brazil 6.4%, Lebanon 5.8% and Portugal 3%(24), all of which show high levels of physical violence among nurses in all parts of the world. Violence against nurses can occur for various reasons such as direct and more contact of nurses with patients and their companions, lack of facilities and hard work shifts. In many cases, due to the nurse being at the forefront of care, patients and the patient's families consider her as the main cause of possible deficiencies and resort to violence. Regarding the shift in which violence occurred, the present findings showed that the exposure to physical violence was higher in the night shift. In a study in Canada, Shields et al, reported that the most prevalent time for happening physical violence was in the evening shift (40.2%) followed by night shift (38.7%)(23). Behar-Estryn et al, also found a significant relationship between night shift and violence(25). The higher level of violence during night shifts can be due to lack of security forces or lack of manpower, including doctors and nurses, or even equipment. The perpetrator of physical violence in the present study was the patient in most cases and the gender of the perpetrator of physical violence was also male in most cases. In a study by Farrel et al, reported the highest level of physical violence by patients in Australia, too(26). In another study in the emergency department of a hospital in Tehran, Hassani states that in most cases, physical violence was reported by the patient and the patient’s family and the most common cause of violence were men(27). Many studies have shown that the expression of violence in men is higher than women, in addition to the high stress and anxiety that patients and their families experience at the time of hospitalization which can result in violence, some injuries such as head injuries, severe limb disease, glucose deficiency and incurable diseases can also act as a cause of violence(28).
Regarding verbal violence, the present study shows that the majority of the research participants have been subjected to verbal violence during their service. In his study in the emergency department of six hospitals in Ankara, Talas reported the occurrence of verbal violence in Turkish nurses in 79.6% of cases(29). However, the level of verbal violence in the study of Zamanzadeh, which was conducted in East Azerbaijan hospitals, was 72.1%(20). In the present study on shifts in which verbal violence occurred, the results showed that in most cases, exposure to verbal violence was reported in the evening shift. In Salimi's research, the occurrence of verbal violence has been mostly reported in evening and night shifts(30). In this study, the cause of verbal violence in most cases was the patient’s family and then the patient himself. In his study in Ankara, Talas reported the level of verbal violence by the patient's family are 98.8% and for patients are 64.2%(29). It seems that occurrence of violence in less crowded shifts such as evening and night shifts can be associated with the lack of nurses in the hospital. Regarding the frequency of reported and unreported cases of physical and verbal violence and its cause, the findings show that the majority of participants acknowledged that they reported high level of violence, while Shoghi in his study reported the rate of reporting violence only 35.9%(21). In another study, Ergun states that the rate of non-reporting violence is 62.9%(22). Kitaneh in his study in Palestine reported a rate of non-reporting violence 56.3%(31). The results of the present study show that most of the participants believed that reporting cases of violence is useless and some consider its occurrence to be unimportant. They do not consider it as part of their profession, which may be due to nurses' lack of familiarity with their individual, social and professional rights. They believe that violence by the patient and their families or colleagues is a part of their job, and that nurses' experience of inappropriate action by managers to whom violence has been reported or even their indifference causes the abused nurse to avoid reporting it. In this study, some participants were ashamed to report that these findings were similar to the results of the study of Ergun et al, In this regard, Kitaneh also states that nurses were ashamed of reporting violence and they are worried about their future careers and some of them did not consider the occurrence of violence as important and they do not report it(31). However, Zamanzadeh states in his study that non-reporting of violence and consequently lack of information in this field is one of the main problems in implementing programs to reduce cases of violence. Also, the lack of instructions for reporting cases of violence or the complexity and time consuming process of reporting can be another factor in the lack of reporting the violence. However, failure to report cases of violence prevents appropriate action to be taken against it(20). It seems that all these factors can be effective in not reporting the occurrence of violence, but it is possible that the lack of accuracy and proper follow-up of the authorities can play a significant role in this case. In examining the relationship between verbal and physical violence with individual and social variables, Chi-square test showed a significant relationship between nurse education level and verbal violence. In Mohamed's study, a significant relationship was observed between violence and education level, too(32). In another study, these two variables had a statistically significant relationship(33). Perhaps raising the level of education by increasing public awareness and culture has been able to affect the incidence of violence.
In the present study, sampling was performed only from one central hospital for COVID-19 in Guilan province and it may not be possible to generalize to all nurses in Guilan province or Iran. Therefore, further research in this field is recommended.