Objective This study aims to explore (1) nurses’ reported incidence of swearing in Chinese healthcare settings; (2) the impact of swearing on nurses; (3) nurses’ perceptions about swearing; (4) the impact of swearing on the therapeutic relationship.
Methods This study is a cross-sectional mixed methods study. A total of 538 nurses who have at least six months’ clinical experience in their current units were recruited through convenience sampling from registered nurses working in four hospitals in Wuhan City. One self-report questionnaire, the Nursing Swearing Impact Questionnaire (CHINA) was utilized.
Results Of the total 538 participants, 489 respondents returned valid data about incidence; 320 (65.4%) reported they had not experienced swearing by patient/carer in the last week. Respondents who reported they had experienced swearing 1-5 times a week by patient/carer was 143 (29.2%). Male nurses reported the frequency of “more than once” in the last week more than females and the difference was significant (X2 =8.07, p=.005).
The majority of nurses considered swearing associated with each work situation highly distressing (M=3.40，SD= 0.66). Across the six different work situations, “being sworn at repeatedly” (M=3.49, SD=0.72), “swearing associated with personal comment” (M=3.47, SD=0.70), “being sworn at by a patient’s relatives or carer” (M=3.41, SD=0.75) had the highest scores. Those who were in positions of nurse-in charge or higher (M=3.52, SD=0.57) reported significantly higher scores than those who were nurses (M=3.32, SD=0.68). Nurses work on a pediatric outpatient/emergent unit had significantly higher distressing scores (M=3.68, SD=0.52). Mental health nurses had significantly lower scores (M=3.24, SD=0.69) compared to the other five groups.
The emotional impact on nurses was evident from the affective responses of nurses in the categories of the most distressing swearing episodes: being annoyed/angry, wronged/sad, hurt, suffer in silence, depressed, frustrated, uncomfortable, embarrassed, helpless, indifference/numb, job burnout/intention to quit, moral judgment and reflection on practice. The majority of the nurses (403, 80.90%) had personal rules about swearing and 284 (56.7%) nurses reported that professional carers and educators should not use swearwords. Context, age and relationship, control and word-specific were the cited factors which influencing personal rules. The majority of nurses agreed on negative descriptions which included “people who swear sound uneducated” (357, 69.9%), “do not approve of swearing” (424, 83.1%) and “swearing at nurses should not be tolerated” (469, 91.6%). However, some nurses also agreed on positive descriptions: “swearing is an important feature of their speaking style” (57, 11.2%), “I accept my use of swearwords” (113, 22.3%), “swearing can make communication more effective (61, 12.0%), “swearing can establish and maintain effective communication with certain patients” (78, 15.3%), and “swearing can allow you to safely let off steam” (160, 31.3%).
The most distressing incidents of swearing were briefly outlined by nurses: 137 (54.8%) of swearers were patients and 86 (34.4%) were carers; 106 (52.5%) were female; 146 (74.1%) of swearers ranged from 20 to 40 years of age. The majority of incidents occurred on the day shift (170, 68.0%) and on the ward (143, 57.7%). Psychosis, no understandable provocation and being asked to do something were the three major perceived reasons for swearing. Nurses reported that the most common tone of swearing incidents was that of anger (71, 14.3%), sarcasm (61, 12.2%) and a threat (47, 9.4%). Nurses reported that they respond to swearing most frequently by withdrawal (187, 37.4%), ignoring it (138, 27.6%), or placating the swearer (112, 22.4%).
Conclusions Though the incidence of swearing is not as high as it was assumed to be, and it was similar to the related studies in western countries, most of the participant nurses considered swearing associated with each work situation to be highly distressing. Swearing from patients/carers caused a series of emotional response in nurses, which resulted in job burnout and turnover intention. Swearing from carers rather than patients was more readily evoked anger and other negative feelings. Obscenities and swearing about nurses’ family members may induce defensive affective responses more easily. Nurses who were sworn at for no specific reason, were demeaned the value of nursing work, or were questioned about professional ethics may provoke negative emotional responses too. Nurses reported feeling hurt, wronged and sad by a perceived lack of appreciation by the patient/carer after having invested themselves in caring for the patient. Some studies indicated if a nurse had the experience being attacked by a patient or carer, her/his attitude toward patients would be affected. It implies that nurses may decrease their involvements into nursing practice to avoid attack, which might finally affect the quality of nursing care. In addition, was sworn at by a patient or carer repeatedly would produce indifference and numb feelings and make nurses being less empathy.
In this study, factors caused swearing included: the psychosis symptoms, anxiety or pain of patients; environmental and administrative factors, such as crowded unit, understaffing, too many non-professional tasks which may distract energy and attention from nurses, such as asking patient or carer to pay medical bills; societal factors, such as media bias report about WPV; nurses need to improve communication and de-escalation skills of conflicts. Under a complex context which influenced by these factors, the environment is unsupportive and vulnerable. When there are some triggers appear, both patient and nurse easily to do wrong attribution and situation is easily to be escalated. Mental health nurses reported higher incidence of swearing from patients/carers but most of them usually attributed their swearing to the psychosis symptoms of the patient. These mental health nurses reported lower distressing scores and higher scores on quality of life. However, nurses work on a pediatric emergency or outpatient unit reported higher distressing scores and lower SF-36 scores more often. Nurses work on pediatric units experienced swearing mostly by carers and had strong affective responses. Pediatric nurses usually attribute swearing to the disrespect and demean of nursing practice from carers.
The majority of nurses have negative feelings about swearing and dislike hearing swearing in any situation. Nurses seldom use swearwords in work situations although they may swear at home or in social contexts. These swearwords used by nurses are the least offensive words and usually perceived as habitually used words. Nurses reported the most highly offensive swearwords were sexual in nature. It is noteworthy that some nurses agreed that swearing had some positive aspects which can make communication being more effective and develop or maintain a positive nurse-patient relationship. In some studies, swearing was perceived as one effective way to encourage patients to express their feelings, and swearing can increase patients’ tolerance to pain. Though swearing in healthcare settings affect the physical and mental health of nurses, it also had some positive aspects to improve relationship. It should be emphasized that swearing and workplace violence should be differentiated, nurses’ attitude is essential to prevent swearing or verbal aggression escalate to physical violence. If nurses could realize that at most of time swearing is a way for patients/carers to express their feelings and to relieve pain, negative emotion of anxiety, anger or fear, and uncertainty of symptoms and treatment, they could use more effective communication skills to deal with situations and decrease impact on their physical and mental health. So, it is essential to integrate communication and de-escalating skills into internship stage, pre-work standard training stage, or continuing education programs. Interactive strategies, such as real scenarios role play/simulation, or computerized virtual simulation could be provided more chances to nursing students or nurses to experience and deal with conflicts.
When swearing happened, some nurses would placate patients/carers or seek help from colleagues or leaders. Most of them withdrew from or ignored swearing, and some others choose to keep silence or tolerate these situations. The way of avoiding or tolerating is not a good way to deal with swearing or workplace violence. A supportive environment should be provided to nurses to encourage them to explore reasons of swearing from patients/ carers and practice more therapeutic communication skills. From policy and administrative aspects, hospital, zero-tolerance policy toward workplace violence was suggested by some studies to protect clinicians. Protocols should be made to instruct clinicians to cope with swearing or verbal aggression issues. It is necessary for hospital and government to decrease the risk factors from environmental and administrative aspects to provide a more supportive environment. In a safer and less stress environment, a more positive nurse-patient relationship could be established.