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American Journal of Public Health Research
DOI: 10.12691/ajphr-1-1-3

The Implementation of a Tele-Homecare System with Service Oriented Architecture and HL7 Message Transmission Standard
Ching-Sung Wang

American Journal of Medical and Biological Research
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The Influence of Ethanol on Pyruvate Kinases Activity in Vivo, in Vitro, in Silico
Lelevich Sergey Vladimirovich, Khrustalev Vladislav Victorovich, Barkovsky Eugene Victorovich, Shedogubova Tatyana Aleksandrovna

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Clinical and Histological Features in Wegener Granulomatosis
Li Cavoli Gioacchino, Passantino Rita, Bono Luisa, Tortorici Calogera, Ferrantelli Angelo, Giammarresi Carlo, Rotolo Ugo

American Journal of Infectious Diseases and Microbiology
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The Curse of Lymphatic Filariasis: Would the Continual Use of Diethylcarbamazine Eliminate this Scourge in Papua New Guinea?
Anne Lanham, Lillian Mwanri

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Developing a Policy for Workplace Violence against Nurses and Health Care Professionals in Jordan: A Plan of Action

Ahmad Rayan*, Ali Qurneh, Rana Elayyan, Omar Baker

Zarqa University, Faculty of Nursing, Zarqa, Jordan

Abstract: Violence at workplace toward health care professionals including nurses is gaining a thoughtful concern worldwide. The prevalence of workplace violence in the Middle East including Jordan is considerably high although governmental policies and legislations exist. Tackling and preventing such issue of workplace violence necessitates reinforcing and reviving existing policies. The researchers in the current study adopted a plan of action using a systematic method to establish and implement specific strategies and policies to prevent workplace violence against health care professionals in Jordan. A detailed description for developing the policy was provided in this study based on the following steps: describing context of the problem, identifying policy goals and options, weighing policy alternatives, highlighting the recommended solutions, and providing a strategy for implementation and evaluation .

Keywords: policy, development, workplace violence, nurse, health care professionals, Jordan

Citation: Ahmad Rayan, Ali Qurneh, Rana Elayyan, Omar Baker, Developing a Policy for Workplace Violence against Nurses and Health Care Professionals in Jordan: A Plan of Action. American Journal of Public Health Research, 4 (2). 47-55. January 2016. doi:10.12691/ajphr-4-2-2

1. Introduction

An incremental approach was used in this paper to develop policy for workplace violence in Jordan. The new policy was developed by employing pre-established criteria to identify presenting problems in the current policy, and rational solutions for these problems were developed through utilizing a systematic method. The steps of describing nature of the problem, identifying policy goals and options, appraising policy alternatives, defining the recommended solutions, and furnishing a strategy for implementation and evaluation were adapted for developing the policy [28].

1.1. Policy Context

1.1.1. Problem Identification

Violence at workplace toward health care professionals is gaining a momentum on the global level [32]. The World Health Organization (WHO) defines workplace violence as “Incidents where staff are abused, threatened or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being or health” ([45], p. 1). This definition indicates that workplace violence can be physical, verbal, or psychological. Workplace includes all governmental and private health care settings such as hospitals, primary care services, community health provider settings, educational institutions, and clients’ homes.

The prevalence of workplace violence in healthcare settings remains unacceptably high. Workers in health care settings are at higher risk of verbal and physical abuse than any other occupational group [32]. Magnavita [27] examined the frequency of violent incidents against nurses and other health care workers in a residential rehabilitation unit between 1996 and 2009. The results indicated that majority of workers had been subjected to physical aggression over time. Furthermore, Magnavita [27] found that having a violence prevention program targeting organizational, educational, and medical measures had contributed to reducing violence in the workplace.

Workplace violence in the health care sector may lead to poor quality of care, turnover and absenteeism of healthcare professionals, reducing health services available to the general public, unhealthy work environment, improper societal behaviors, increasing health costs, and deterioration of staff health [13,31].

Health care professionals are usually exposed to violence from patients, family members, peers and employers [32]. Patients’ relatives were reported to be the greatest source of violence [5,14,15,40].

Blando, Ridenour, Hartley, and Casteel [11] reported seven major barriers to implementation of an effective workplace violence programs, these barriers are lack of accountability; profit-driven management models; a lack of action despite reporting; varying perceptions of violence; bullying; a focus on customer service; and weak social service and law enforcement approaches to patients.

Different studies focused on workplace violence against health care workers worldwide [9,18,19,42,43]. In 2007, the World Health Assembly approved a global 10 year plan of action on health workers from 2008 – 2017 and recommended Ministries of Health to develop national programs that include the prevention and control of workplace violence (WHO, 2007).

Recently, workplace violence in healthcare settings in the Middle East has been extensively studied. Literature review provided findings on workplace violence in Jordan [2,5], Iraq [3], Kuwait [7], Morocco [10], Egypt [40], and other countries. These studies reported a high prevalence of workplace violence.

Some of these studies highlighted different causes of workplace violence including lack of specific policies on workplace violence [2,3], poor communication with patients, family members, and close friends [7], high levels of anxiety for both health care professionals and service users [10], and carelessness and malpractice of nurses [40]. Additional causes reported by other researchers include substance abuse, access to firearms, poor security system, and poor regulatory system related to movement of people in health sectors [42]. Additionally, younger, less experienced nurses and those in emergency and intensive care departments usually experience high levels of violence [5,37].

AbuAlRub et al. [3] conducted a study in Iraq and found that forty-nine of 116 health care professionals have been physically attacked at work. Adib et al. [7] reported that verbal violence during 6 months period was experienced by 48% of participating health care professionals in a Kuwaiti study. Belayachi et al. [10] investigated workplace violence in Morocco and found that 70% of violence in emergency departments was directed toward doctors. In addition, Oztunc [34] examined incidents of verbal abuse against nurses in Turkey and found that 80.3 % of 290 participating hospital nurses faced verbal abuse in their workplace in the last year. Additionally, Samir et al. [40] studied workplace violence against obstetrics and 416 gynaecology nurses in 8 hospitals in Cairo, Egypt, and found the majority of nurses (86.1%) had been exposed to workplace violence. Abualrub and Al-Asmar [2] investigated physical workplace violence among 420 Jordanian nurses and found that 22.5% of the participants were exposed to physical workplace violence and they were very dissatisfied with the manner in which the incidents were handled. Ahmed [5] studied verbal and physical workplace abuse in 447 nurses working in various departments in 3 hospitals in Amman, Jordan, and found that the prevalence of verbal and physical abuse was 37.1% and 18.3% respectively. In the same study, Ahmed [5] reported that most of the abused nurses did not report it because they thought that it was useless to do so. All of these studies recommended adopting policies for protection of health care professionals either by hospital policies or judicial punishment to minimize workplace violence.

In spite of the presence of governmental policies and legislations concerning workplace violence against health care professional, but the zero level of workplace violence in Middle East countries including Jordan was not achieved. In Kuwaiti law, for example, anyone attacks a medical staff in a governmental hospital or a public servant in any ministry will be punishment of imprisonment and a fine right of assault [8]. In Qatar, for example, Article 167 of the Penal Code states that any one attacks a public officer, or in charge of a public service, or resisted him or her by force or violence, during or because of the performance of his or her job, or his service, shall be punished by imprisonment for a time not exceeding three years, and a fine not exceeding ten thousand Riyals [22]. In Jordan, the penal code based on Jordanian law number (187) for the year 1960 of the act 16, the panel code number 2 work intensity, paragraph 1 indicates that "Striking employee or assaulting him or her by another influential or using weapons to threaten him or her during doing of his or her job or for what conducted by virtue of the job, shall be punished by imprisonment for a term not less than six months. According to the law amendment, the penal code number 49 for the year 2007 replaced the (six months) with (from one to two years). In 2011, another modification to the amended article 33 for the year 2011 number 8 paragraph 2 indicated that "any one hit the employee or assaulted him or her by another influential or violence during doing of his or her job or conducted by virtue of job, shall be punished by imprisonment of not less than six months" paragraph (1b) added " for purposes of this paragraph, the word (the employee) includes a faculty member at a private university or teacher at a college or private school or a doctor or nurse in a private hospital."

The current policy regarding workplace violence in Jordan had major problems; the first problem is that the last updated modification of the law decreased the minimum duration of imprisonment for persons assaulting health care professionals from one year to six months. In addition, addressing nurses and doctors in the private work settings while ignoring governmental doctors and nurses signify a bias in the law. Moreover, there is a problem related to the policy application, most cases of workplace violence against heath care professionals in Jordan were considered fight or dispute rather than attacks [21]. In 2010, the Minister of Health discussed this topic with the Director of Public Security then who ordered the regional leaders and police to consider assault cases on health staff during official working as an attack on public employee according to Article 187 of the Penal Code rather than just a dispute or fight between the citizens [35]. However, many attacks on health care professionals still poorly handled and the problem of workplace violence still evident. Recently, on 15 Mach 2013, doctor and nurse working in the health center in Albaj area in the Northern Badia of the Mafraq Governorate were assaulted by one of the reviewers. The doctor and nurse were injured and taken to Al Mafraq Hospital for treatment, the nurse condition was critical after being stabbed with a sharp object [38]. In addition, on Thursday, 4 April 2013 a doctor working at Princess Basma Hospital in Irbid in northern Jordan was beaten with hands which led to loss of consciousness [24]. Many other workplace violence accidents were recently reported indicating and necessitating a need for implementing effective solutions to decrease workplace violence in Jordan.

All health care workers are at risk for violence, it is the role of Ministry of health (MOH), Jordan Nurses and Midwives Council (JNMC), and Jordan Nursing Council (JNC) and health care workers to raise the issue to modify the current law and its application to ensure protecting all health care professionals from workplace violence.

Adopting effective workplace violence policy will positively affect outcomes for clients, health care professionals, and healthcare systems. When work place violence is controlled, there will be better delivery of effective client care, improvement of patient safety and positive patients' outcomes [23]. Nurses and health care professionals will benefit from such policy because violence can result in physical injury, psychological disturbances, and absenteeism from work [29]. Moreover, the health care system in general can benefit from implementing such policy. Application of this policy will decrease rate of absenteeism, improve employee morale, increase productivity, decrease staff turnover and sick leave, reduce additional recruitment costs, payouts and legal fees [26].

1.2. Background

1.2.1. Sociocultural Context

Cultural factors can indirectly legitimize violence toward nurses. For example, some cultures view women less valuable than men, so striking them or paying them less than their male counterparts is somehow acceptable [16]. In addition, some nurses in Jordan come from poor countries such as Philippines. Such foreign nurses are sometimes radicalized and experience some kind of discrimination from patients and their relatives.

According to Ahmed [5], there is a negative societal image of nurses in Jordan; this resulted in blaming nurses and attacking them. In addition, there is a low public image of nursing and gender issues knowing that most of nurses are females [41]. Although the social view of nursing has improved and many men are admitted to university-based nursing programs in Jordan, nursing is still viewed as women’s work and often involves unclean tasks [30]. This will support the negative societal image of nurses and increase the risk of violence toward them. Therefore, media can play a pivotal role in rectifying and improving nurses’ image to the public.

1.2.2. Economical Context

Violence at workplace in health care setting imposes severe economic burden on countries. Even though there is no specific estimate of cost for the workplace violence in Jordan, there are international reports about its detrimental effects on economy. In Australia, for example, it is estimated that the cost of violence at workplace is about $ 5582 per victim and $ 837 million annually which negatively affect the economy. In addition, 600 non-fatal workplace violence acts in United States of America cost $ 3694 compensation for each of them. The reports of the International Labor Organization (ILO) estimated cost of violence as ranging from $ 4.9 billion to $43.4 billion in USA only [31]. These reports indicate the high cost of workplace violence. This will be detrimental for poor countries as Jordan.

1.2.3. Moral and Ethical Context

Workplace violence can cause physical and psychological or emotional harm for the employees which in return will have a negative impact on work related outcomes, resulting in poor work attitudes, decreased affective commitment, increased turnover intentions and job neglect and decreased job performance and productivity [25,32]. Many researchers reported that workplace violence impact nurses’ job satisfaction, commitment to the organization, and decisions to quit the job [39].

Violence against health care professionals can compromise health care provided for the patients. It can undermine the nurse-patient relationship by causing behavioral responses such as a decreased willingness to spend time with patients and answer their calls, avoidance of patients, and adopting a passive role in treatment, or even causing harm towards patients [20,44]. This was supported by a study conducted in Jordan that found violence against nurses affect their quality of work and make them leave the profession [5].

1.2.4. Health Context

Workplace stress and abuse have serious consequences on physical, mental, and social health [18]. Sustained exposure to abusive behaviors has serious physical and psychological consequences (MacIntosh, 2005). Most nurses reported that workplace violence has a negative effect of on them [40]. While physical injury is one potential result of violence, the psychological impact of violence on health can be more harmful [18]. Though the psychological impact of violence may be less obvious, some recent reports found that consequences of this violence include: anger, post traumatic stress disorder, fear, guilt, shame and self-blame [18].

1.2.5. Legal and Political Context

The source of policy can be legislative, administrative, and constitutional. Health care professionals need to understand these sources to create a safe workplace that corresponds with their situation. Violence at workplace should be controlled by the criminal law [18]. Lack of effective governmental legislative policies will increase workplace violence. In addition, poor policies developed by hospital administrators can contribute to increase the incidents of workplace violence. Moreover, some administrators can put their employees at risk as a result of inadequate staffing and poor work environment [2,5].

1.3. Issue Statement

All health care professionals in Jordan have the right to practice in a safe environment where there is a zero tolerance policy for workplace violence.

2. Policy Goals and Objectives

1. Establish and implement specific strategies and policies to prevent workplace violence against health care professionals in all areas of practice in Jordan.

2. Improve the social view of nursing and provide mechanism to disseminate "Zero Tolerance to Violence" policy to the public utilizing the media.

3. Provide financial support to all health-care sectors to ensure making safe working environments and high quality client care.

4. Construct a mechanism to report all incidents of violence to the legal authorities.

5. Develop education and training programs for all staff regarding violence prevention and management.

6. Provide immediate responses for actual or potential violence incidents.

3. Policy Options and Alternatives

To identify our alternatives, brainstorming and obtaining solutions by interviewing experts, researchers, policy makers from the Jordan parliament, and key persons from nursing organizations were executed. However, considering the status quo or no-action alternative was also taken into consideration.

3.1. Analysis of Stakeholders’ Viewpoints

Workplace violence policy can affect different stakeholders, some stakeholders are more affected by the policy than others, especially, those who are working within the health care system, those stakeholders are called the primary stakeholders, and other stakeholders are called secondary stakeholders (Rabinowitz, 2006).

3.1.1. Primary Stakeholders

Primary stakeholders are MOH, JNC, JNMC, representatives from the Jordan parliament, health care workers including nurses and physicians, and other employees in the health-care setting, clients, nursing professionals, regulatory and labor organizations, nurse educators and researchers, health service delivery and accreditation organizations, and funders. Also, hospital managers in different levels such as the chief executives, all managers who are working in hospitals and health care settings, in addition to all employees in the hospital, who are responsible for adhering to workplace violence policy are considered primary stakeholders.

3.1.2. Secondary Stakeholders

Other persons who can be affected by this policy are families of employees, clients, visitors, the public, police and security persons. Finally, the government and citizens living in community will benefit from having and reinforcing this policy by increasing productivity of the work in health care settings, and decreasing the cost resulted from workplace violence.

These stakeholders are expected to be affected by the policy in different ways. Each of the stakeholders has several important roles in promoting and maintaining violence-free workplaces, MOH and JNMC should raise the issue to the general community and adopt policies regarding workplace violence. The representatives from the Jordan parliament will ensure moving the issue to the policy agenda by the parliament. Employers in all health care settings should adhere to and apply all legal and legislative requirements to apply the policy and enforce strategies for policy application. This will require providing mandatory education and training programs to implement the policy. Nurses and other employees in the health-care settings should participate in policy implementation and report violence incidents. In addition, they should respect the patients and their families to decrease these incidents.

The policy will directly affect patients and their relatives; they will respect health care providers to protect themselves, their patients, and health care professionals. Regulatory and labor organizations need to support zero tolerance for violence in the workplace by promoting involvement of health and safety committees to observe policy application. Nurse educators and researchers should educate students about the policy and conduct researches to identify causes of the problem and suggest appropriate solutions [4,6]. Health accreditation organizations have major roles in evaluating policy implementation in all health care settings. Finally, funders should support organizations that have strategies to control violence at workplace.

Opponents may be those who have negative image toward health care professionals, especially nurses, or those who committed violence toward health care professionals, in addition to some political persons who may resist the current policy modification.

3.1.3. Interviews with Stakeholders

Interviews with representatives from MOH, JMNC, Jordan parliament, senior management, heads of departments such as the medical, pediatric, surgical, and head of quality departments and staff members from different governmental and private hospitals were carried out as planned. In addition, a number of external stakeholders were interviewed, such as, nurse educators, researchers, and hospital managers in different levels. These interviews aimed at obtaining data regarding their perception toward workplace violence in the health sector, finding out the potential causes of the problem in Jordan, describing the organizational consequences of workplace violence in the health sector, discussing the effectiveness of the current policy regarding workplace violence, and identifying the obstacles for implementing and adopting of workplace violence policy, and finally, providing suggestions to modify the current workplace violence policy to achieve its intended goals.

Analysis of stakeholders’ viewpoints and perceptions revealed that the current governmental policy about workplace violence is not implemented in Jordan. In addition, many hospitals do not have their own workplace violence policy. Therefore, the enforcement of existing policies -not resort to tribal customs- would stop violence in the workplace, “If the government does not put any effort into it, it won’t work,” some participants said. However, the participants stressed the fact that only some hospitals of the private health sector have implemented adequate policies in response to violence at workplace.

Lack of policies and assertive legislations on workplace violence has placed health care providers at frequent risk of workplace violence. Moreover, they determined the negative impacts of workplace violence on nurses and health care system such as absenteeism, turnover, medical costs, and reduced productivity that contribute to adding costs and thus decrease profits. Head of quality department in one hospital stated that intimidation and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction, increase the cost of care, and cause qualified clinicians, administrators, and managers to seek new positions in more safe environments. He reported that safety and quality of patient care is dependent on safe environments. He suggested strengthening the current systems to detect unprofessional behaviors including violence, responses to patient's and family's needs, and provide training for employees to deal with violence acts. In addition, he recommended establishing a standard, assertive communication styles, conflict resolution, and maintaining a system of accountability to prevent work-related violence.

Many stakeholders emphasized the importance of raising awareness towards workplace violence by the media, training health care professionals, and implementing effective policies to create safe work environments. Without the provision of support, education, and training programs that address prevention and intervention techniques, policies alone cannot effectively reduce the incidence of workplace violence. Clearly, there is an increased professional and organizational attention on workplace violence.

Meeting with Captain Nurses revealed that the employers must protect employees from being hurt or threatened at workplace, and to develop policies to protect workers from violence that may occur to them.

Through the interview with a parliamentarian, we discussed the issue with him. He encouraged us to go through the formal decision making process followed at the parliament. He adopted the issue and mentioned that he can get signatures of at least ten parliamentarians to meet the criterion of the parliament law “Suggesting law or modifying law according to interest under the condition to be signed by at least ten parliamentarians” to introduce the issue through the legislative process in several stages, starting to attach the bill, and its reasons from the Prime Minister to the President of the House of Representatives offered by the Council. Then, the proposal will be referred to the competent committee to be studied. After that, the printed committee's report is sent with the provisions of the bill, its amendments, and the reasons. The following steps include discussion of the articles and amendments. After the completion of the discussion, opinion of the council on the entire project will be taken, and if approved, it will be sent to the Senate to complete its constitutional procedures. After it returns from the Senate and approved, it will be submitted to his Majesty the King for ratification and approval, and then, it will be published in the Official newspaper. The law becomes valid after thirty days of its publication in the official newspaper.

3.2. Suggested Policy Options and Alternatives

The first suggested option is do nothing or staying on the status quo option, this option will not make any modification on the current policy. This means that health care professionals will stay at very high risk for violence. The second option is doing an incremental change on the current policy to make it more effective in controlling violence at workplace. The third option is making a major change, or changing the policy from its roots. This includes ignoring the current policy and developing a new one that protects health care professionals from workplace violence.

3.3. Evaluation of Policy Options and Alternatives

3.3.1. Establishing Evaluation Criteria

Comparison of policy alternatives will be based on five criteria including effectiveness, political feasibility, fairness, cost, and social acceptability. The selection of criteria was based on their relevance to workplace violence policy. The most important criterion is the effectiveness of policy by achieving the desired goals, especially, protecting health care professionals from workplace violence. Other important criteria include political feasibility, and cost of implementing solutions. In addition, fairness in distribution of benefits is also important. Finally, social acceptability refers to the fact that the proposed solution becomes popular and acceptable among general citizens.

3.3.2. Analysis and Comparison of Policy Alternatives

Option 1. The first option is staying on the status quo or no-action alternative. This option includes leaving the current policy free from any modifications. This will threaten the life of health care professionals. In addition, this will not achieve goals of the policy. This policy is politically feasible and applicable, with the same cost as arranged. However, it is not fair because it put the life of health care professionals at risk. In addition, it is not socially acceptable because it makes harm to health care professionals, patients, and general citizens. Therefore, it may need to be rejected and discarded, but we need it as a baseline to be compared with the other options.

Option 2. The second option is doing an incremental change on the current policy to make it more effective in controlling violence at workplace. This aims at making more measures to protect health care professionals from workplace violence. This will achieve the policy goals. This option can be politically feasible but it is more difficult to achieve than the first one. It is applicable because it will include minor changes in the current policy. Application of this policy will indirectly decrease the cost of compensation for people affected by workplace violence and decrease the cost of absenteeism which outweighs the cost of policy application. In addition, this option is fair because it punishes persons who commit aggression toward health care professionals. Moreover, this option is socially acceptable because it protect health care professionals who provide care for the general citizens.

Option 3. The third option is making a major change, or changing the policy from its root. This includes ignoring the current policy and developing a new one. This option can achieve policy goals and is socially acceptable. Application of this policy will indirectly decrease the cost of compensation for health care professionals affected by workplace violence and decrease the cost of absenteeism which outweighs the cost of policy application. However it is difficult to be achieved because it includes major changes, this will make it politically infeasible.

After generating three policies, it is necessary to narrow the options to choose the policy that is most consistent with the evaluation criteria. Table 1 describes and compares the policies using scorecard based on strengths and weaknesses of each alternative according to the evaluation criteria. Option three is fair, effective, not costly, but it could be less feasible and socially acceptable than option two. This gives option two higher total score than option three. In addition, option two is more effective, fair, and socially acceptable than option one. Therefore, option two has the highest score on the scorecard.

Table 1. Policy Analysis Scorecard

4. Recommended Solution

Option two is considered the recommended solution for the problem identified in the policy. The current policy needs to be modified based on incremental approach. As we mentioned earlier, the current policy regarding workplace violence in Jordan had major problems, the first problem is that the last updated modification of the law decreased the minimum duration of imprisonment for persons attacking health care professionals from one year to six months. The second problem is including private nurses and doctors and ignoring governmental doctors and nurses which represent a bias in the law. The third problem is related to policy application, most cases of workplace violence against heath care professionals in Jordan were considered fight or dispute rather than attacks. The modified policy should increase the minimum duration of imprisonment for persons who attack health care professionals from six months to one year, include both private and governmental nurses under the penal code based on Jordanian law number (187), and consider any type of abuse against nurses whether physical, verbal, or psychological, as a crime rather than dispute. In addition, conducting violence toward health care professionals by any person should be is considered as an abuse directed toward the entire organization in which health care professional is working. Finally, it is critical to state that "All health care professionals in Jordan have the right to practice in an environment where workplace violence is not tolerated". To modify the current policy, it is important to make a clear strategy for policy modification, as described in the following section.

5. Implementation

5.1. Introduction about Policy Advocacy Strategy

Health care professionals should be involved in changing the current health care system [37]. The experience and knowledge of health care professionals make them more able to change the policies that govern the health care system. While advocating the policy, we should be aware that there are some obstacles related to the existing legislation or society disagreement. Therefore, it is important to understand these obstacles and factors influencing decision-makers and use them positively to achieve our goals [46]. Workplace violence policy is very complex and requires health care professionals to have knowledge and make efforts to form organized groups with the help of health care professional organizations, and make long term efforts to achieve the intended goals. Health care professionals should be supportive for each other, vote in elections, and join official organizations to have a source of power to change the existing policies in beneficial ways for health care professionals [1].

Involvement of all health care professionals together could become a very strong power of change. Moreover, linking with people who have legitimate power is a very important way to change the current policy. The media also can be utilized to support health care professionals’ view point. As voters, nurses and health care professionals can reward their own elected officials by voting them back into office and working for their reelection [1]. This can be an important source of coercion power via a representative in the government. Understanding and using the various sources of power available to health care professionals is critical to ultimate success in the legislative arena. Health care professionals also can get use from accreditation programs of healthcare organizations [1].

It is important to understand the scope of the problem and its dimensions, and the phase in which we are working. For example, are we in the formulation phase, the implementation phase, or the evaluation phase? [1]. Health care professionals should know their roles during each of these phases and involve in policy making.

5.2. Legislative Strategy

We designed a comprehensive strategy in which we will mobilize all of the available resources with the help of the major policy players and stakeholders, our framework for policy implementation utilized a legislative strategy. Table 2 summarize this framework and describe our resources including the major stakeholders and their characteristics and capabilities that make policy implementation feasible. For each resource, a strategy of action including the major applied activities to design our work in plausible way is documented with a major goal related to adopting a workplace violence policy.

There are many factors that need to be considered during our implementation of the legislative strategy to adopt workplace violence:

5.2.1. Politics

By politics, we will influence decision makers to achieve what we want. We need to attract the audience and get them engaged to adopt workplace violence policy issue. Audience consists of two groups: government policy makers and the community [46]. Once the audience is siding with us, the political process will be supported. We can use some brochures and work with media to gain the public support for our issue.

5.2.2. Areas of Advocacy

We need to be aware of the areas of advocacy which include workplace, government, professional organizations, and community. Our role in this stage is to influence all of these areas to be engaged and advocate for our issue.

Table 2. Policy Implementation to Reduce Workplace Violence

5.2.3. Analysis of Political System

Political system should be analyzed; we need to understand where, who and how to lobby to achieve objectives in policy development. Political system include five major elements that characterize Jordan including consensus and agreement regarding the policy content and application, the legal structures for public and private activities and interactions and basic human rights, competition through elections, in the media, and in the market place of ideas, inclusion of people who differ in their religion, ethnicity, gender, geography, or income status, and adequate governance [46].

5.2.4. The Political Arena

Analysis of the political arena focuses on its structure and presence of subgroups or committees who communicate formally and report to the parliament [46].

5.2.5. Rule Makers and Timeframe

We need to identify the key players in the political process and their positions toward the issue to utilize the capabilities of supporters. In addition, it is useful to create a timetable of the planned events [46]. We will pass our issue through a parliament member and discuss our large number of nurses who always participate in election and if we get his support we will vote to him in the next parliament elections.

5.2.6. Decision Making Process

Understanding the decision-making processes assist to access them in an effective and efficient way. We need to take in considerations many economic, political, social and environmental factors that have impact on decision-making process. We are in a position to decide how and where to influence policy through the policy making process [46]. As described in the interviews with stake holders, we contacted a parliament member and were assured that the issue will be adopted by utilizing the formal decision making steps in Jordan.

5.2.7. The Role of Media

Media has an essential role to achieve our goal to raise the issue and get support from many parties, including the community, and stakeholders. The role of media includes making a public media campaign to increase community awareness about the workplace violence against health care providers, through using the social media such as Facebook, twitter, and other sources to increase the awareness about the issue within the community and particularly, health care providers. We also need to participate in local conferences and introduce the issue through scientific papers. In addition, we can work with the professional associations and make interviews with them in the local media to discuss the issue. Moreover, we can make interviews with real cases of workplace violence against health care providers. Finally, the parliament member who supports our proposed policy might raise the issue during his meetings in the parliament, and during his formal and informal meeting with lobbying stakeholders.

5.2.8. Other Recommendations

Prevention is more important than interventions, as we identified the causes of the problem; we need to suggest appropriate solutions for them. Health care professionals should respect their patients and satisfy their healthcare needs using the available resources, it is the responsibility of managers to provide adequate staffing, safety team and security personnel should be available in critical areas such as emergency departments. Each hospital should have a specific policy regarding workplace violence. Violence assessment and early interventions should be conducted. Health care professionals should be trained to deal with violent behaviors [33]. Annual reviews should be conducted to determine the positive and negative aspects of the current policy.

6. Evaluation

Policy evaluation is mainly focused on achievement of policy goals, incidents of violence should be reported to evaluate the difference between these incidents before and after policy development and application. In addition, the policy may need additional modifications based on the ongoing policy evaluation. The evaluation process will stop when achieving all of policy goals.

Acknowledgment

This research is funded by the Deanship of Research in Zarqa University /Jordan.

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