卫生保健系统中一直存在的暴力和虐待问题 | J Nurs Manag

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Violence and abuse in society is both a pervasive and pertinent issue for nurses, nurse managers and citizens alike. In recent times, the world has witnessed large-scale global events that have potentiated the conduct of violence and abuse at multiple yet interacting levels of society. The World Health Organization (WHO) defines violence as ‘The intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation’ (Krug et al., 2002, p. 6). While this definition is invaluable, I raise two relevant questions here. First, is it possible that an individual can be causing harm unintentionally by their practices and behaviours? And second, is it always possible to recognize violence and abuse? In my years of experience of life and researching this highly emotive topic, it is my contention that these two aspects, especially considering the historical and present-day challenges within our largely female workforce often go unchecked.

The presentation of people (experiencing the outcomes of violence and abuse) to health care services is perpetual, and as always, the nursing community and management remain steadfast at the forefront of responses. The call for papers to this special edition was intentionally broad and related to all types of violence and abuse (both terms are used here as they are often used interchangeably). We sought papers that reflected the multifaceted nature of violence and abuse to provide nurses and nurse managers alike with a strong evidence base from which to respond effectively. These papers do just this and usefully inform us about important aspects of this complex phenomenon. The breadth of international contributors (e.g., Korea, Australia, China, Slovenia, Saudi Arabia, Turkey, France, United Kingdom, Greece, Oman, Spain, Switzerland and Italy) highlights the clear international resonance of this problem. It contains studies of victimization, studies of nursing and midwifery responses and studies of perpetration. Some of the findings presented do not make for easy reading, but the purpose of research is to explore, describe, explain and predict, not to alter stark realities. Such as is the case in society, it seems that nurses, midwives and managers can be responders, recipients and perpetrators of violence and abuse. This unwelcome thought needs to be borne in mind when considering solutions to this complex problem.

I write this editorial with mixed emotions. On one hand, I am delighted to see the breadth of interesting and thought-provoking international research studies. On the other hand, I am deeply saddened at the sheer volume of papers pertaining to violence and abuse, in particular the large volume of papers highlighting how the nursing workforce is experiencing violence and abuse initiated by their (our?) colleagues. It made me wonder if aspects of the academic ‘killer elite’ toxicities described by Darbyshire and Thompson (2021) is present in all levels of care settings, not just academia. This would indeed resonate with the pervasiveness of violence and abuse throughout social contexts. Despite the inalienable right nurses (managers, students and academics) have to a healthy, violence-free environment (International Council of Nurses [ICN], 2017), the problem of violence and abuse in the workplace remains a pervasive and challenging problem.

While the WHO usefully highlights intentionality in the exercise of power to elicit harm (Krug et al., 2002) when defining violence, there are a multiplicity of ways in how that power is exercised and it is important that nurses and nurse managers remain mindful of the plethora of ways in which harm is exercised. A wide variety of violent acts are identified in the papers presented in this special edition (e.g., physical, physiological, sexual harassment, smear, mobbing, sex trafficking, sexual harassment, horizontal violence and workplace bullying), all of which illustrate the wide variation in the nature of violent and abusive acts. In this technological age, it is essential to always remain mindful of the scope of cyberbullying which augments and further deepens the effects of harmful behaviours well beyond face-to-face interactions. Although emerging from my research undertaken in relation to intimate partner violence against men, conceptualizing abuse in two waves (i.e. first wave abuse directly initiated by the abuser and second wave abuse being initiated by but not enacted by an abuser) (Corbally, 2011) provides a useful perspective to illustrate the potential for violence and abuse to be both directly and indirectly enacted. This resonates with aspects of direct and indirect abuse articulated in a study in this edition.

The challenges inherent in the measurement of this complex phenomenon are well known especially due to varying definitions. This special edition is particularly encouraging due to the methodological breadth evident in the papers submitted. Techniques such as structural equation modelling, social network analysis, surveys, dialectical phenomenology, systematic review, scoping review, focus groups, interviews and diary logging are some examples of diverse methodological approaches, data collection and evidence synthesis techniques presented here, all of which creatively contribute to the creation of what terms a ‘scientific mosaic’ (Becker, 2009) of understanding. Each of the studies here as well as additional literature reviews and discussion papers constitute a piece in this larger mosaic which is particularly helpful in building a larger picture of understanding and more importantly prompt appropriate responses. The national studies presented here represent great strides in establishing prevalence. Utilization of a unified international definition of violence and abuse in future research would prove useful in enabling cross comparison of future studies of prevalence rates internationally. Methodologically, violent ‘acts’ are often (wrongly) equated with ‘harm experienced’ and it is encouraging to see studies which acknowledged this important consideration. Capturing the frequency of abuse experiences is an important (and often overlooked) factor which has the potential to make findings even more stark as everyday (often invisible) incivility and day-to-day toxicity has potential to cause significant distress.

The importance of viewing violence and abuse through an ecological framework (i.e., recognizing the interrelatedness of individual, relationship, community and societal levels) is essential in understanding the full breadth and depth of this multifaceted problem as well as being foundational to its solution (Heise, 1998; Krug et al., 2002). Key individual factors relating to violence and abuse identified in studies submitted relate to gender, age, vulnerability, clinical experience, religiosity, marital status and having children. For nurse victims, being female and young unsurprisingly proved to be key factors for increased victimization. Cultural factors, clinical experience and being married were also interesting findings. For men, fear of not being believed remains a continual challenge inhibiting this cohort from recognizing abuse and seeking help. Evidence of all classifications of abuse (physical, psychological, sexual and controlling behaviours) are evidenced. This is mirrored by an unfortunate myriad of human outcomes (e.g., physical injuries, physical symptoms, decreased resilience, psychological and psychosocial distress not to mention deterioration in quality of life).

It is well known that under reporting of violence and abuse experiences occur for many reasons and the actual ‘dark figures’, that is, what goes unnoticed or unreported are often much more extensive. This perpetual problem and reasons for under reporting are equally multifaceted and are discussed within the papers presented here. Accepting violence as inevitable, self blame, guilt, fear of abusers, fear of lack of action and possible retaliation are some reasons individuals choose not to report. Such reasons highlight current problems with facilitation of disclosure whilst also reinforcing the ongoing need for open, trusting and respectful environments both within and outside the workplace. The concept of individual resilience as a coping mechanism strongly features in several papers as does a call for promotion of this attribute by nursing managers. Individuals also used other forms of what I term ‘understandable resistance’, ‘survival strategies’ or coping which extreme situations (e.g., absenteeism, increased turnover and sick leave, being silent, reduced productivity, leaving early, decreased job and life satisfaction) especially considering the multi-layered discrediting contexts they experience.

Where violence is concerned, sometimes priority is given to what is more ‘visible’ or ‘dramatic’ than what is not. The ‘everydayness’ of violence being overlooked in favour of more dramatic events is an interesting phenomenon discussed in two papers in this special edition. Quite often, lifetime prevalence statistics and dramatically violent incidents get more attention subsequently, overlooking the frequent day-to day violence where abuse and incivility are endured often daily. Sadly and more seriously, many (victims and perpetrators) do not recognize violence and abuse (intentional use of power) as harmful. This is particularly problematic within the nursing and midwifery culture (Darbyshire & Thompson 2021).

The presence of violence and abuse amongst the nursing community (and indeed any community) represents an erosion or denial of a human right to just and favourable conditions of work (Article 23) as well as security of person (Article 3) (United Nations, 1948). It is sad that almost 74 years after this declaration, workplace bullying is sadly alive and well and evidenced in the multiple international studies presented in this edition. Nurses (and their managers) work in risky spaces and practice heroically in the most challenging of environments. The ability for nurses to care even through the most difficult of circumstances is a source of international pride of this wonderful profession. However, the unfortunate phenomenon of workplace bullying makes such challenges even more difficult. It could be argued that if workplace violence and abuse was a ‘disease’ it is easily at pandemic levels with harm being inflicted and experienced on our profession by our profession. The reasons behind such high rates of workplace bullying amongst those charged with caring is discussed extensive organizational inertia resulting from not taking the allegations seriously perpetuates a community where victimization is wrongly experienced as an occupational hazard rather than an unacceptable practice.

Interpersonal relationships are intrinsic to our humanity and our practice. Those who recognize and bear witness to violence and abuse of others also experience vicarious harm as illustrated in several studies. Proof of the direct relationship between supportive management and increased employee satisfaction is evident and reinforces the crucial role managers play in the promotion and maintenance of healthy workplaces. Supportive relationships (i.e., collegial support and supportive management) mitigate the effects of violent experiences and highlight that the role of nurse managers in recognizing and responding and acting accordingly is more crucial than ever.

Whilst violence and abuse can be experienced by individuals of any gender, the significant prevalence and effects of violence and abuse against women and girls and its significant violation of women's rights worldwide (WHO, 2021) cannot be ignored. Gender is inextricably linked with violence and abuse, and aspects relating to ones gender are used as a means by which to exercise power. In several studies presented here, worldwide prevalence and resonance of violence against women is evident in the studies presented and rates are equally stark. For example, being a female is a strong risk factor for violence and abuse in many studies here, being young and female even stronger. Given that the nursing workforce is predominantly female and our graduates are young, this should be a cause for alarm. Women's hesitancy in reporting in the studies presented here highlights an urgent need for nurse managers to foster environments which support staff and encourage disclosure.

The ecological nature of abuse warrants education and awareness raising programmes which are sensitive to its multifaceted, ever evolving and complex nature. Creative suggestions for content and implementation of necessary and meaningful educational programmes are made by authors in this issue, all providing encouraging material from which to assist our workforce to be more cognisant and prepared. The need for multidisciplinary involvement is also acknowledged and welcomed.

To conclude, this special edition commands us to take seriously the pervasive problem of violence and abuse at personal, professional, community, organizational and societal levels. If there ever was a case for the need for good managers, this special edition and the research presented within it reinforces the crucial role they perform. The late Archbishop Tutu's sentiment ‘if you are neutral in situations of injustice—you have chosen the side of the oppressor’ (Yongue, 2009) is a signal to us all to develop a critical consciousness of the consequences of our actions and inactions as we practice and respond within eternally challenging contexts.

全文翻译（仅供参考）

社会中的暴力和虐待对护士、护士管理人员和公民来说都是一个普遍而相关的问题。近年来，世界目睹了大规模的全球事件，这些事件加剧了社会多个但相互影响的层面上的暴力和虐待行为。世界卫生组织（WHO）将暴力定义为“对自己、他人或群体或社区故意使用威胁或实际的武力或权力，导致或极有可能导致伤害、死亡、心理伤害、发育不良或剥夺”（Krug等人，2002年，第6页）。虽然这个定义是无价的，但我在这里提出了两个相关的问题。第一，个人的行为和行为是否可能无意中造成伤害？第二，总是有可能认识到暴力和虐待吗？在我多年的生活经验和对这个高度激动人心的话题的研究中，我认为这两个方面，尤其是考虑到我们主要是女性劳动力的历史和当今挑战，往往会被忽视。

人们（经历暴力和虐待的后果）获得医疗服务的机会是永恒的，护理社区和管理层一如既往地坚定不移地站在应对措施的前列。本特别版对论文的呼吁是有意的，涉及所有类型的暴力和虐待（这两个术语在这里使用，因为它们经常互换使用）。我们寻求能够反映暴力和虐待的多方面性质的文件，以便为护士和护士管理人员提供有力的证据基础，以便有效应对。这些论文正是这样做的，并为我们提供了关于这一复杂现象的重要方面的有用信息。国际捐助国（例如，韩国、澳大利亚、中国、斯洛文尼亚、沙特阿拉伯、土耳其、法国、联合王国、希腊、阿曼、西班牙、瑞士和意大利）的广泛性突出表明了这一问题的明显国际共鸣。它包括受害研究、护理和助产反应研究以及犯罪研究。一些研究结果并不容易阅读，但研究的目的是探索、描述、解释和预测，而不是改变严峻的现实。就像社会上的情况一样，护士、助产士和管理人员似乎可以成为暴力和虐待的应对者、接受者和肇事者。在考虑这个复杂问题的解决方案时，需要记住这种不受欢迎的想法。

我写这篇社论时情绪复杂。一方面，我很高兴看到各种有趣和发人深省的国际研究。另一方面，我对大量有关暴力和虐待的论文深感痛心，尤其是大量强调护理人员如何经历他们（我们的）同事发起的暴力和虐待行为的论文。这让我想知道Darbyshire和Thompson（2021）描述的学术“杀手精英”毒性是否存在于各级护理环境中，而不仅仅是学术界。这确实会与暴力和虐待在整个社会环境中的普遍性产生共鸣。尽管护士（管理者、学生和学者）拥有健康、无暴力环境的不可剥夺的权利（国际护士理事会[ICN]，2017年），但工作场所的暴力和虐待问题仍然是一个普遍存在且具有挑战性的问题。

虽然世界卫生组织在定义暴力时强调了行使权力以引起伤害的意向性（Krug等人，2002），但行使这一权力的方式多种多样，护士和护士管理人员必须注意行使伤害的方式过多。本特别版的论文中列举了各种各样的暴力行为（例如，身体、生理、性骚扰、诽谤、聚众、性贩卖、性骚扰，横向暴力和工作场所欺凌），所有这些都说明了暴力和虐待行为的性质有很大的差异。在这个技术时代，必须时刻注意网络欺凌的范围，这大大超出了面对面交流的范围，扩大并进一步加深了有害行为的影响。虽然我的研究是关于亲密伴侣对男性的暴力行为，将虐待分为两波（即第一波由施虐者直接发起的虐待和第二波由施虐者发起但未实施的虐待）（Corbally，2011）提供了一个有用的视角来说明暴力和虐待可能直接和间接实施。这与本版一项研究中阐述的直接和间接虐待的方面产生了共鸣。

测量这一复杂现象所固有的挑战是众所周知的，特别是由于定义不同。这一特别版特别令人鼓舞，因为在提交的论文中，方法的广度是显而易见的。诸如结构方程建模、社会网络分析、调查、辩证现象学、系统回顾、范围回顾、焦点小组、访谈和日志记录等技术是本文所述各种方法方法、数据收集和证据合成技术的一些例子，所有这些都创造性地促进了理解的“科学马赛克”（Becker，2009）的创造。这里的每一项研究以及额外的文献综述和讨论论文都构成了这幅更大的拼图中的一部分，这对构建更大的理解图景特别有帮助，更重要的是，它能促使人们做出适当的反应。这里介绍的国家研究表明，在确定流行率方面取得了巨大进展。在今后的研究中使用统一的暴力和虐待的国际定义将证明有助于对今后的国际流行率研究进行交叉比较。从方法上讲，暴力“行为”常常（错误地）等同于“经历的伤害”，令人鼓舞的是，有研究承认了这一重要考虑。捕捉虐待经历的频率是一个重要的（经常被忽视的）因素，它有可能使调查结果更加明显，因为日常（往往看不见）的不文明行为和日常毒性有可能造成严重的痛苦。

通过生态框架看待暴力和虐待的重要性（即承认个人、关系、社区和社会层面的相互关联性）对于理解这一多层面问题的全面广度和深度以及解决这一问题的基础至关重要（Heise，1998；Krug等人，2002）。提交的研究中确定的与暴力和虐待有关的关键个人因素与性别、年龄、脆弱性、临床经验、宗教信仰、婚姻状况和生育有关。对于护士受害者来说，女性和年轻人无疑是增加受害的关键因素。文化因素、临床经验和结婚也是有趣的发现。对于男性来说，害怕不被相信仍然是一个持续的挑战，阻碍了这一群体认识到虐待和寻求帮助。所有虐待分类（身体、心理、性和控制行为）的证据都有证据。这反映在无数不幸的人类后果（例如，身体伤害、身体症状、适应力下降、心理和社会心理痛苦，更不用说生活质量下降）。

众所周知，对暴力和虐待经历的报道不足有很多原因，而实际的“黑暗数字”，即未被注意或未被报道的情况往往更为广泛。这一长期存在的问题和报告不足的原因同样是多方面的，本文将对此进行讨论。接受暴力是不可避免的，自责、内疚、对施虐者的恐惧、对缺乏行动的恐惧和可能的报复是个人选择不报告的一些原因。这些原因突出了目前在促进披露方面存在的问题，同时也加强了工作场所内外对开放、信任和尊重环境的持续需求。作为一种应对机制的个体韧性的概念在几篇论文中有很强的特点，护理管理者也呼吁提升这一属性。个人还使用了其他形式的我所称的“可理解的抵抗”、“生存策略”或应对极端情况（例如，缺勤、更替和病假增加、沉默、生产力下降、早退、工作和生活满意度下降），尤其是考虑到他们所经历的多层次的不信任环境。

就暴力而言，有时优先考虑的是什么比什么更“明显”或“戏剧性”。暴力的“日常性”被忽视，而偏爱更戏剧性的事件，这是一个有趣的现象，在本特刊的两篇文章中进行了讨论。很多时候，终生流行率统计数据和戏剧性的暴力事件随后得到了更多的关注，而忽视了每天经常发生的虐待和不文明行为。可悲和更严重的是，许多人（受害者和犯罪者）不承认暴力和虐待（故意使用权力）是有害的。这在护理和助产文化中尤其成问题（Darbyshire&Thompson，2021）。

护理社区（甚至任何社区）中存在的暴力和虐待行为，代表着对享有公正和有利工作条件（第23条）以及人身安全（第3条）的人权的侵蚀或剥夺（联合国，1948年）。令人遗憾的是，几乎74 在这一声明发表多年后，职场欺凌现象令人遗憾地依然存在，并在本版的多项国际研究中得到了证明。护士（和他们的经理）在危险的环境中工作，在最具挑战性的环境中英勇地练习。护士即使在最困难的情况下也能照看病人，这是这个美妙职业的国际自豪感的来源。然而，令人遗憾的职场欺凌现象使这种挑战更加困难。可以说，如果工作场所的暴力和虐待是一种“疾病”，那么它很容易达到流行病水平，我们的职业会对我们的职业造成伤害。负责照料的人中职场欺凌率如此之高的背后原因是广泛的组织惰性，这是由于没有认真对待这些指控而导致的，在这种情况下，受害被错误地认为是职业危害，而不是不可接受的做法。

人际关系是我们人性和实践的内在属性。一些研究表明，那些承认并目睹暴力和虐待他人行为的人也会受到间接伤害。支持性管理与提高员工满意度之间的直接关系得到了明显的证明，并加强了管理者在促进和维护健康工作场所方面所起的关键作用。支持性关系（即同事支持和支持性管理）减轻了暴力经历的影响，并强调护士管理者在识别、应对和采取相应行动方面的作用比以往任何时候都更加重要。

尽管任何性别的个人都可能遭受暴力和虐待，但对妇女和女孩的暴力和虐待的严重流行和影响及其对全世界妇女权利的严重侵犯（世界卫生组织，2021）不容忽视。性别与暴力和虐待有着密不可分的联系，与性别有关的方面被用作行使权力的手段。在这里介绍的几项研究中，暴力侵害妇女行为在世界范围内的普遍性和共鸣在所介绍的研究中是明显的，而且比率也同样明显。例如，在这里的许多研究中，女性是暴力和虐待的一个很强的风险因素，年轻和女性更是如此。鉴于护理工作人员主要是女性，而我们的毕业生都很年轻，这应该引起警惕。在这里介绍的研究中，妇女在报告方面的犹豫不决突出表明，护士管理人员迫切需要营造支持工作人员和鼓励披露信息的环境。

虐待行为的生态性质要求教育和提高认识方案对其多方面、不断演变和复杂的性质敏感。本期的作者对必要和有意义的教育计划的内容和实施提出了创造性的建议，所有这些都提供了令人鼓舞的材料，帮助我们的工作人员提高认识和准备。多学科参与的必要性也得到承认和欢迎。

最后，本特别版要求我们认真对待个人、专业、社区、组织和社会层面普遍存在的暴力和虐待问题。如果真的有理由需要优秀的管理者，那么这个特别版和其中的研究将加强他们所扮演的关键角色。已故的图图大主教的观点“如果你在不公正的情况下保持中立，你就选择了压迫者的一边”（Yongue，2009年）是一个信号，告诉我们所有人，当我们在不断挑战的环境中练习和应对时，要对自己的行为和不作为的后果形成一种批判意识。

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