Impact of Workplace Violence on Sustainable Performance of Nurses with the Mediation of Social Well-being in the Pakistani Context

Sakina Bashir^1*, Shahaan Mehmood Cheema¹, Murtaza Ashiq²

¹Superior University, Lahore, Pakistan.

²University of the Punjab, Lahore, Pakistan

* Corresponding Author: [email protected]

Abstract

The current study investigated the impact of the predictors of workplace violence (harassment, physical violence, stalking, and ostracism) on sustainable work performance with mediating the role of social well-being of Pakistani nurses considering the ‘hierarchy of need theory. A survey method was used to conduct the current study. The data was collected from 400 respondents of four nursing teaching colleges, affiliated with hospitals of Lahore, Pakistan. The data was analyzed in Statistical Package for the Social Sciences (SPSS) and Smart Partial Least Square (PLS) software using structural equation modeling (PLS-SEM) technique. The results revealed a negative influence of workplace violence on the performance of nurses. Moreover, it tends to dissatisfy their safety and social needs, the most important human needs according to Maslows theory. Since Maslows time, researchers continued to explore how safety and social needs impact the well-being of nurses. Social well-being is related to better physical, mental, and social health and conversely, feeling isolated (unmet safety and social need) bears negative consequences for health and well-being. Eventually, it became the reason for low performance. The findings confirmed that workplace violence is the strong predictor of sustainable performance. Whereas, nurses social well-being mediates the relationship between the predictors (workplace violence) and the outcome variable (performance). Therefore, the study concluded that when safety and social needs are fulfilled, nurses perform their duties enthusiastically. This is the first endeavor to use the "hierarchy of need" theory in order to mediate the effect of violence, performance, and social well-being of nurses. Therefore, the current study served as a baseline for further research in this area. The findings helped the higher authorities and hospitals management to devise such policies which help nurses towards organizational growth and sustainable work environment.

Keywords: harassment, health care professionals, nurses, ostracism, PLS-SEM, social well-being, violence, work performance

Introduction

The core of nursing's ever-expanding mandate is to enhance the standard of care provided to patients on a daily basis. Nurses play a crucial role in hospitals, whether it is about providing support to doctors or taking care of their patients' health. It is crucial to recognize that the profession of nursing has grown. Moreover, nurses are now playing the role of health policy advocates, researchers, academicians, and educators. Additionally, nurses have progressed in their profession to decipher the position a great deal more than they had been able to do when their profession first started. Caring for the ill and the general public is simply one aspect of the job that nurses perform to continually influence nursing principles. They also play an important role in promoting patient wellness and influencing favorable treatment outcomes. However, with the growth of this profession, a number of issues have also emerged with the passage of time that nurses must learn to deal with.

Gellasch (2015) mentioned that levels of workplace violence in nursing persist exceptionally high. Similarly, the International Labor Organization (ILO) stated that violence and harassment are a major threat to the wellbeing and health of employees and it also causes civil rights violations that are incompatible with social well-being of the employees. When co-workers, patients, or visitors act violently, it creates an insecure environment and cause nurses to get hurt or feel traumatized or insecure. Patients and families who are under a lot of stress and do not know how to deal with it tend to pose a serious safety risk for nurses. According to Kim and Yang (2022) workplace violence in the profession of nursing threatens health, safety, morale, and job performance of nurses. Patient care and service quality also suffer. They identified that several nurse practitioners experienced workplace violence during their internships that ultimately affected their career intentions. According to Zhou et al. (2020) workplace violence increased among nurse practitioners across the world, especially during the COVID-19 pandemic. It augmented mistrust in health professionals. Physical violence among health workers was reported to be particularly 78% in the USA, 87% in Turkey, and 71% in China.

Workplace violence, sustainable performance, and social well-being are considered important elements at the workplace (Zhou et al., 2020). Workplace violence refers to an incident when employees are threatened, abused, or assaulted at their workplace (Saleem et al., 2021). Violence can be physical or non-physical. Non-physical violence includes verbal threats, stalking, ostracism, and sexual harassment. Whereas, physical violence includes shoving, kicking, slapping, grabbing, and other purposeful physical contacts (Zhou et al., 2020). Violence puts a professional's safety, pleasure, and health at risk, either directly or indirectly. Violence defined as "a range of unacceptable behaviors, in a single or repeated incident results in physical, psychological or economic disturbance (Beqiraj, 2019). An environment where employees are abused and threatened by one at the workplace is considered an unpleasant workplace environment. Workplace violence is a complex, risky, and widespread work-related problem (Schablon et al., 2012). Social well-being is defined as the ability to achieve a healthy work-life balance, manage work-related stress, and build interpersonal relationships with supervisors and associates (Bell et al., 2012). It includes both subjective and objective indicators of physical, mental, and social wellbeing in the workplace context. This definition explains positive i.e. good health and job contentment as well as negative health issues, anxiety and emotional enervation aspects.

A recent economic survey of Pakistan in 2022 identified that Pakistan has an estimated population of 224.78 million people which resulted in a total number of 121,245 registered nurses (Pakistan Economic Survey, 2021-2022). The current nurse-patient ratio in general wards of Pakistani hospitals is 1:40, however, the Pakistan Nursing Council (PNC) recommends a ratio of 3:10 between nurses and patients (Saleem et al., 2022). Some Pakistani studies revealed that in the country's largest hospitals, more than 70 percent of healthcare practitioners face various forms of violence. For instance, Mirza et al. (2012) that 12 percent physicians reported being victims of physical violence, while 65 percent reported being victims of verbal abuse.

Zafar et al. (2016) reported verbal abuse commonly and three out of five physicians experienced physical assault. Another study identified that bullying at workplace affects the mental health of doctors in Karachi (Khuwaja et al., 2004). It shows that violence is considered as a part of the job by the healthcare personnel and lack of violence preventive policies, unwillingness to report physical attack, and fear, are some of the major reasons for violence (Baydin & Erenler, 2014).

Most of the research on workplace violence, sustainable performance, and social well-being comes from the developed world. Workplace harassment is less discussed in developing countries (Österman & Boström, 2022; Lutgen-Sandvik et al., 2009; Ahmad et al., 2017). Saleem et al. (2021) stated that workplace violence, harassment, and performance are interrelated variables and mostly the victims do not prefer to talk about it due to certain organizational issues as well as the fear of defamation and losing their job. Hence, there is a need to investigate the impact of workplace violence on sustainable work performance by mediating the role of social well-being of nurses in Pakistan. The findings would significantly contribute to the existing knowledge by inquiring the mediating effect of social well-being on performance of the nurses. The findings would also help to add values in nursing practices which increase the quality of the patient care, nurses' social satisfaction, their retention in the nursing profession, and their commitment to their organization.

Literature Review

According to Maslow's "theory of hierarchy of needs", the safety needs are the second most essential aspect of human beings (Maslow, 1943). Workplace violence is a major component that erodes victims' sense of security. However, as a result of the agonizing nature of the violence, employees who experience workplace violence frequently lack happiness (Zhou et al., 2020). Employee social well-being refers to a series of content and ecstatic responses to the work environment based on the employee's own safety and contentment (Avey et al., 2010). In an organization, human resource is the most precious strength. Workforce is the same as an engine that provides sustainable work performance and service quality. In the health sector, doctors and nurse practitioners' security needs and satisfaction play a vibrant role in their performance as well as patients satisfaction and recovery. Their performance is affected by their absenteeism, turn over, and stress level. Previous studies support this argument that violence tends to moderate the performance of employees in the organization (Ferris et al., 2015; Rasool et al., 2020; Zhou et al., 2020).

Workplace violence is discussed less in the descent culture of developing countries (Ahmad et al., 2017). Maslow's theory of "hierarchy of needs" underpins the importance of employees' safety needs which affect their attitude and behavior, their performance as well as the workplace. The employees' needs and their impact on performance must be understood while applying the "hierarchy of needs '' theory at the workplace. Every employee needs to feel motivated and enriched which encourages motivation and satisfaction (Saleem et al., 2021). According to Maslows ‘hierarchy of needs theory, security is one of the basic needs of each individual (Maslow, 1958). Safety is an indispensable need that influences an employees overall satisfaction with the workplace. In the workplace, physical safety is the first priority.Ensuring a safe workplace comprises a safe and secure environment for colleagues as well as the clients/patients.Another aspect of security in the workplace involves feeling emotionally safe.According to Maslows theory, when human beings physiological needs are met or fulfilled, the next need is a safe and secure environment (Maslow, 1958). The employees' security needs urge them to protect the next esteem need which is the desire to feel good about them. According to Maslow, esteem needs to have two segments (Maslow, 1958). The first segment involves feeling confident and good about ones self. The other segment is feeling valued for their achievements and contributions. From this perspective, workplace violence does not satisfy employees' security needs, consequently affecting their performance. When their time and energy are spent on non-productive affairs, employees would inevitably face the dilemma of reducing production efficiency. This leads to a sense of insecurity among employees. Lastly, the ‘hierarchy of need theory is mostly used to explain why social well-being may be a link between violence and performance indicators.

If any violent act occurs at a workplace, it gives employees an inferior feeling, lack of confidence, and less productivity (Gelfand et al., 2015). Resultantly, nowadays organizations are facing employee turnover, less commitment, and low performance (Hershcovis, 2011). The negative emotions of employees hamper sustainable organization performance (Chernyak-Hai & Tziner, 2014). Basically, the concept of sustainability refers to an organization that primarily focuses on the current employees needs (Zink et al., 2008). Contrasting between customary management exclusively focuses on the economic performance of an organization, sustainability emphasizes on caring for the environment which enhances the well-being of society in the long run (Rupp et al., 2013). At its core, the term "employee well-being" refers to an employee's positive emotional state which is formed by the employee's assessment of their work or their work experience (Rasool et al., 2020).

Zhou et al. (2020) investigated the correlation between violence, stress, and viable work related performance. Notably, some recent studies investigated the impact of COVID-19 on nursing. For instance, Weiner-Lastinger et al. (2022) highlighted the difficulties faced by nurses during COVID-19 pandemic and indicated the difficult situation in the Swedish health care profession. Similarly, Kim and Yang (2022) investigated the nursing experiences in Korea and identified critical components of professional practices to serve the patients in a better way. It shows that COVID-19 had a significant impact on the wellness and performance of the nurses.

Past studies used "Conservation of Resources" (COR) theories to examine the impact of violence on certain factors in the developed world (Anjum et al., 2018; Zhou et al., 2020). No examination could be found measuring the impact of violence of the reformulated Maslow's "hierarchy of need theory with the additional construct of social well-being of employees. In Pakistan, a considerable descriptive research-based literature on workplace violence is available (Iqbal & Fatima, 2021; Saleem et al., 2021), while limited work is available on workplace violence factors affecting the sustainable performance. Although, in the Pakistani context, workplace violence related to employee engagement and organization culture has been studied (Saleem et al., 2021). However, no study has been conducted so far to investigate the workplace violence of nurses' performance predictors from a theoretical lens of the Maslows hierarchy of need theory. It highlights the importance to use this theoretical lens in different countries and context. Adding a construct to the Maslows hierarchy of need theory may assist in discovering workplace violence issues and their impact in the context of Pakistan. In this study, workplace violence is a dependent variable and social well-being is a mediator. The current investigation aimed to determine workplace violences influence on the performance of nurses in Pakistan.

Workplace Violence and Performance of Nurses

Nowadays, the workplace environment has become a global concern with a diverse workforce and managerial values. The workplace environment is becoming more dynamic and complicated. Conversely, violence at workplace is a much pervasive problem, especially in the nursing profession. Workplace violence is subdivided into harassment, physical violence, ostracism, and stalking (Saleem et al., 2020). Workplace violence or harassment are the terms that are synonymously used in literature along with other variables, such as bullying, (shaking fists and pitching objects) vocal or written threats, oral exploitation(swearing), and physical attacks, such as pushing, kicking, and hitting. (Hartin et al., 2020). Although, harassment is an individual activity, if an organization lacks a mechanism to restrict it, victims often view it as acquiescence. If the organization cannot prevent workplace harassment, affected employees may reduce performance of the employees.

H1a: Physical violence inversely affects nurses' sustainable performance.

Unexpected or annoying behavior at workplace causes an individuals self-esteem to suffer which makes him/her a victim of harassment. Workplace harassment occurs when an individual is disgraced by others at the workplace. It lets the workers self-esteem down which affects his performance, ultimately causing organizational low output. In Asian countries, limited research is available on the issue since people consider it a domestic matter and they are not willing to discuss and consider it a disgrace for the victims as well (Maran & Varetto, 2018; Nikolić & Visnjić, 2020). Various studies indicated that there is a significant negative impact among various professions in the service sector. On the grounds of mentioned literature, the following hypothesis can be drawn.

H1b: Harassment inversely affects nurses' sustainable performance.

H1c: Ostracisms inversely affect nurses' sustainable performance.

H1d: Stalking inversely affects nurses' sustainable performance.

Ostracism is defined as isolation in the working environment for the employee by his colleagues (De Clercq et al., 2019). Stalking is a pattern of unwanted behavior directed towards a specific person that makes him feel afraid, nervous, or in danger. Repeated and unwanted phone calls, texts, and messages may or may not be threatening (Maran & Varetto, 2018). It gathers a different response from every victim based on their emotional strength. Isolation faced by individuals at the workplace affects their performance in a way of turnover, less work engagement, and dissatisfaction (Coetzee & van Dyk, 2018). Similarly, Saleem et al. (2021) revealed that workplace harassment including ostracism and stalking negatively affects the performance of the employees. The current research explored that this phenomena entrenched the mental and physical condition of employees that cause stress and less output (Miller, 2015). Consequently, this attitude affects work efficiency, adverse attitude, and miserable mental tiredness. In an organization, employees stop working and regress to suffer isolation, diminishing their motivation and as a result, the work performance and efficiency is at stake (Ajala, 2012; Maran & Veretto, 2018).

Mediating Effect of Social Well-being on Sustainable Work Performance

Well-being is a subjective term as it labels people's contentment, satisfaction of their needs, pleasure, capacities, and job accomplishments (Weziak-Bialowolska, 2020). Employee well-being directly affects organizational success and performance (Ogbonnaya & Messersmith, 2019). Studies acknowledged that employee well-being is the pre-requisite of many organizational outcomes, such as improved productivity or vice versa (Hewett et al., 2018). Social well-being refers to the ability of human beings in order to maintain a positive relationship with other people, such as family, friends, and co-workers. Good social well-being covers not only to have relationships, however, also appropriate behavior in order to maintain those relationships and social standards. Social well-being is built through interaction with people in different roles. These interactions involve using good communication skills, creating and maintaining meaningful relationships, respecting ourselves and others along with creating support systems. It is associated with a sense of belongingness (Mansveld, 2017).

In our society, hopelessness, anxiety, and depression are negative psychological states of employees which can be the outcomes of harmful work settings experienced by employees (Thoits, 2010). Previous studies explored that violence in the working environment creates inverse results on employee well-being. Employees who face violence also suffer downheartedness, tension and nervousness and suffer depression, tension, trauma, low morale, dissatisfaction, and emotional instability. Therefore, violence adversely affects work engagement of employees in an organization (Pai et al., 2015). This phenomenon carries adverse effects on the mental and physical health of employees.

Sustainability is a key concern in the Human Resource Management (HRM). Organizations focus on sustainability, leading towards long term prosperity (Glover et al., 2014). It is considered as an important feature in organizations for building a healthier, involved, and sustainable set of employees. The sustainability at workplace and societal level of work is great, specifically with reference to diverse workforce. This concern is considered as sustainable work performance. This performance is sustained through good health of the worker as well as his well-being. In administrations, the crucial intention is to ensure a staff of vibrant workers—employees who are happy, vigorous, eager, zealous, and involved. These vibrant workers are innovative to be extremely valuable workers as well.

Sustainable employees in an organization are assets who perform their roles using their mental and emotional skills. Salahuddin et al. (2020) stated that Malaysian teachers have been repetitively the sufferers of stress which affect their outcome. A study indicated that working Information Technology (IT) professionals in public hospitals in the USA face graft-related anxiety (Anthony‐McMann et al., 2017). As far as knowledge gaps are concerned, prospective contributing factors of social well-being of employees in their working environment include diverse professional groups, such as senior citizens, minorities, physically retorted and health care professionals, involving spirit to sustainable work performance. It is hypothesized that it creates a negative relationship between productivity and violence (Nikolić & Visnjić, 2020). Trepanier et al. (2013) made a model in which violence in the workplace was linked to poor mental health and employee well-being because basic psychological needs were not met (autonomy, ability, and interpersonal relationships). The results showed that workplace violence affects employees' performance, autonomy, abilities, and relationships with others. However, burnout and lack of autonomy are good indicators of workplace violence. Therefore, workplace violence causes employees to feel anxious, sad, tired, angry, and other feelings that are not good for their health, ultimately affecting their health ((Bechtoldt et al., 2010).

Many researches imply that employee wellness affects job performance and organizational citizenship (Bryson et al., 2017; Daniels, 2000). Well-being affects resource perception. When people don't feel happy in their jobs, they limit their input and interest in job-related activities which harms their job performance (De Clercq, 2019). Therefore, it is stated on the basis of above discussion that social well-being mediates between workplace harassment and sustainable work performance. Shahzad and Malik (2014) reported that nurses are victims of workplace violence by patients and they experience stress, low job satisfaction, high absenteeism, and high turnover intentions.

H2a. Social wellbeing mediates the relationship between physical violence and sustainable performance.

H2b. Social wellbeing mediates the relationship between harassment and sustainable performance.

H2c. Social wellbeing mediates the relationship between ostracism and sustainable performance.

H2d. Social wellbeing mediates the relationship between stalking and sustainable performance.

Figure 1

Hypothetical Model of Study

Note. Arrows show the inverse relationship, dashed arrows show indirect relation, and solid arrows show direct relationship

As identified, there is a gap in the literature with reference to the relationship amongst workplace violence and nurse practitioners sustainable performance at work. In order to further explore the impact of social well-being on the basis of these research gaps, the researchers proposed a hypothetical model (Figure 1). This model investigated the impact of the predictors of workplace violence (harassment, physical violence, stalking, and ostracism) on sustainable work performance with mediating role of social well-being of nurses in Pakistan considering hierarchy of need theory.

Materials and Method

A quantitative descriptive approach was used to conduct the current study and the data was collected through a survey method.It was a cross sectional study and the data was collected from female nurses studying in nurses teaching colleges as well as practicing in affiliated hospitals of Lahore, Pakistan. The city of Lahore was selected since most of the top ranked nursing hospitals with the highest merit and enrollment are situated in it. According to the Department of Specialized Healthcare and Medical Education (2018), there are 10 public nurses teaching colleges in Lahore. Five colleges were selected where BSN (Bachelor of Science in Nursing) and BSM (Bachelor of Science in medicine) studies of Midwifery are taught. Quota sampling method was used and 80 responses from each hospital (out of five hospitals) were collected. The total sample size was 400, whereas the total usable responses were 310 (as some incomplete responses were excluded) with a response rate of 77.5%.

A questionnaire was adapted from the previous studies. Workplace violence along with sub variables of (physical violence, harassment, stalking ostracism, and physical violence) was measured by twenty items. Violence sub variable "harassment" contains eight items which were adapted from Rasool et al. (2019) and Zhou et al. (2020), stalking was measured using six items and was adapted from Duan et al. (2019), ostracism used six items, and physical violence was measured through three items which were adapted from Gilman et al. (2013). Sustainable performance was measured through work safety performance and environment perspective through eight items adapted from Rasool et al. (2019). The mediating effect of social well-being was measured with twenty items (Fisher, 2014)

Data Analysis

The current study used Statistical Package for the Social Sciences (SPSS) to examine the demographic and social characteristics of nurses. Afterwards, the data was saved in CSV file and Smart Partial Least Square 3.0 (PLS) software was used to validate the hypothetical relationship of variables proposed in the model (Figure 1). PLS-SEM technique was used for hypothesis testing which is considered to be the latest assessment technique in the business sector (Ali et al., 2018). This pragmatic study intended to anticipate the underlying variables dealing with Maslow"s hierarchy of need theory. The second important reason for using PLS-SEM was reduced requirements of sample size than other data normality tests, PLS algorithm and bootstrapping technique were employed for factor loadings (Hussain, 2016). Measurement model assessment was designed and then structural model assessment was performed.

Results

Table 1 shows that in terms of age, most nurses were up to 25 (56.8%) and 134 were 26-35 (43.2%). In terms of education, most 201 (64.8 %) were BSM followed by 109 (35.3%) were BSN (Bachelor in Nursing). For the ward of hospitals where they were working, 43 (13.9%) were from emergency, 69 (22.3%) from outdoor, 62 (20%) from Medicine, 38 (12.3%) from Surgical, and 98 (31.6%) from other departments that were not mentioned in the questionnaire."

Table 1

Demographics (N=310)

Common Method Bias (CMB)

It is more likely that Common Method Bias (CMB) can complement the data if it has been taken by a single source, such as only from nurses working in hospitals. The estimated scores of VIF decide that cut-off significance was greater than 3.3 which determine that model may have a CMB issue. Preliminary tests involved data screening, missing value analysis, detection of outliers, and fundamental statistical assumptions were performed on the data in SPSS software.

Reflective Measurement Model Assessment

The reliability of reflective constructs was measured through convergent and discriminant validity."

Convergent Validity

In measurement model evaluation, convergent validity was measured by using loadings, Cronbach Alpha (CA), composite reliability (CR), and average variance extract (AVE)." Referring to the Table 2 results on composite reliability, all variables are proved to have high level of internal consistency as compared to the threshold, that is, 0.70 ( Items were deleted by factor loading (<0.50).

Table 2

Convergent Validity

Note. Average variance extract (AVE), Composite Reliability (CR), Cronbach Alpha (CA), (SH2, SH5, SH6, SH7, O2, O3, O4, O5, S4, S5, SP2, SP4, SP5, SWB4,SWB8,SWB10,SWB12,SWB15,SW B16,SWB18,SWB 20) 4 items of Harassment, 4 items of Ostracism, 3 items of Stalking deleted from workplace violence. 3 items of sustainable performance and 8 items of social Well Being were deleted from social Well Being.

Discriminant Validity

In the analysis, two measures were used to assess the discriminant validity, that is, Fornell-Larcker criterion (Table 3) and Heterotrait-Monotrait Ratio (Table 4). The cross-loadings of constructs have values that are less than the threshold of 0.90. Thus, the findings confirmed that each construct was empirically different from the other constructs.

Table 3

Fornell-Larcker Criterion  

Heterotrait-Monotrait Ratio

Discriminant validity is compromised when the HTMT ratio exceeds the aforementioned thresholds. The HTMT ratio should be lower than 0.85 (Watson et al., 1995) or it should be lower than 0.90.

Table 4

Heterotrait-Monotrait Ratio (HTMT)

Structural Model Assessment (SEM)

Table 5 shows that f2 of Harassment, Sustainable Work Performance, Physical violence, ostracism, and stalking represented comparatively modest to tiny impact size (Cohen, 2013). Given that there are numerous factors that affect nurses performance, this range of effect sizes was a reasonable one (Luk et al., 2008).

Direct Relationship-Path Analysis (Bootstrapping)

In order to test hypotheses in the context of a hypothetical model and standard deviation, T-square was calculated to conclude the model and relationships. Path coefficient values in Table 6 show whether hypotheses were supported or rejected. These were supported on the basis of critical ratio (t >1.645; p <0.05).

Figure 2

Measurement Model Assessment

Table 5

Effect Size

Note. f2 ≥ 0.02 (small), f2 ≥ 0.15 (medium), and f2 ≥ 0.35 (Large). (Cohen, 2013)

Table 6

Results of Direct Relationship

Note. Original Sample (O), Sample Mean (M), Standard Deviation (STDEV), T Statistics (|O/STDEV|), P Values

Indirect Relationship

A researcher must first fit an SEM model in order to estimate the relationship between the mediator and predictor variables. Bootstrapping was used to achieve this. According to Table 7, all indirect effects were found to be significant at the 0.05 level. Summary statistics of indirect path coefficients is given in Table 8.

Description of Model Fit

The value of SRMR should be less than 0.08 for the fitness of the estimated model (Ali & Qazi, 2018). In the estimated model, the value of SRMR is 0.070 which confirms the fitness of this model. Summary statistics of indirect path coefficients is given in Table 8. All indirect path coefficients are significant (P Value <0.05) except the mediating role of social well-being in the relationship between physical violence and sustainable performance.

Table 8

Results of Indirect Relationship

Note. Original Sample (O), Sample Mean (M), Standard Deviation (STDEV), T Statistics (|O/STDEV|), P Values

Figure 3

Structural Model Assessment

Discussion

The findings showed that physical violence has a negative impact on sustainable work performance (tested by direct path coefficient; H1a, H1b, H1d hypotheses were supported and results were in agreement with the existing literature. Overall, the findings indicated that health care professionals in Pakistan are facing violence that affects their performance. Iqbal and Fatima (2021) mentioned that violent behaviors not only cause physical harm, however, they also cause verbal abuse, threats, and bullying. In addition to direct impact, social well-being significantly mediates the relationship between workplace violence and sustainable performance of nurses through an indirect path presented in Table 8. Thus, H2b, H2c, and H2d were supported. Similarly, social well-being insignificantly mediates the relationship of physical violence and performance and H2a was rejected.

The current study extended interesting results of the predictors of workplace violence (harassment, physical violence, stalking, and ostracism) on sustainable performance with the mediating role of the social well-being of nurses, as six out of eight hypotheses were validated (as given in Table 6, Table 8).

In this study a proposed theoretical model hypothesizing the implications of violence at the workplace in relation to sustainable performance underpinnings of Maslow's "hierarchy of need" theory. Based on Maslow's theory, the researchers extended the scholarly effort of Zhou et al. (2020) by probing workplace violence with the mediating role of social well-being and investigated the impact of violence on sustainability of nurses' performance at workplace. The findings showed that violence at workplace has a significant negative relationship with sustainability of performance. Moreover, the findings also advocated that victims of violence contribute negatively to the organization. The current study indicated that social well-being mediates the relationship between performance and violence (Hartin et al., 2020; Zhou et al., 2020). The violence has a negative impact on the performance.

The current study upgraded the information on nurses' performance as well as the intervening role of their social well-being. Moreover, it has also become a notable area in the research

Besides, it is essential for nurses to have access to ongoing training and educational opportunities in order to effectively address and minimize the harmful consequences of harassment issues. In their article, Saleem et al. (2021) stated that professional values are the criteria for behaviors that are acknowledged by professional organizations and individuals and that these standards are utilized to judge the credibility of the individual or organization.

Conclusion

Violence, which was traditionally assumed to affect the quality and sustainability of performance, has proved to affect the security needs of the employees as well. The current study analyzed the workplace violence, social well-being, and sustainable performance of nurses in Pakistan with a theoretical lens of Maslow's "hierarchy of need theory". Likewise, the results showed that isolation of employees in the working environment reduces the efficiency of employees. Therefore, violence increases the level of stress in employees that affect the organization culture overall, decrease its productivity, and loses its impression in the eyes of the public as well. Thus, mediation analysis of social well-being was employed to test the measurement and structural relationship. The data was collected from 310 nurses of Lahore using quota sampling technique.

The results confirmed the significant relations among violence, social well-being, and performance of nurses.  Violence and performance have a direct relationship. On the basis of results, it can be claimed that the "hierarchy of need theory" serves as a theoretical basis to understand the factors that dissatisfied nurses' security needs causing low performance. The social well-being of human beings intervenes their physical health also. Employees with effective social relationships and social circles are happier and satisfied as mentioned in Maslow"s safety and social needs. It further leads employees towards "esteem needs".

To sum up the discussion, social well-being mediates the relationship between workplace violence (physical violence, harassment, ostracism and stalking) and performance. Nurses' social well-being helps them for their sustainable performance. Thus, as security needs are satisfied and feeling emotionally and physically secure they will perform better.

Implications

According to the findings, hospital administrators must pay attention and take immediate and long-term measures to minimize workplace violence along with developing a culture where employees should feel satisfied. The study provided valued implications to reduce workplace violence and improve well-being and sustainable performance of the nurses in hospitals. The government, hospital administration, and head nurses altogether must play their role to promote a better workplace environment. The top management and head nurses should arrange healthy events for employees to maintain a positive, flexible, and good working environment, especially in communication skills, such as how to communicate with other professionals, hospital staff, and patients. The employees who violate the rules must be identified and treated strictly or softly according to their attitude and provide training on better relationship management along with work-life balance strategies. The executive management ought to boost an affirmative workplace environment and relationship management culture among the employees. These steps would bring sustainability in the performance of employees and output of the organization. Moreover, these steps would reduce negative reflection of violence among employees.

Limitations and Future Direction

Although, the results are significant with certain limitations, the study was conducted in a single developing country and one city, that is, Lahore. It is a city where the nursing is expanding and progressing. The nurses are seemingly under impact by their culture, therefore the findings from other cities and countries may present different results.

The data was collected from the nurses that may cause common method bias; further research in different geographical areas of Pakistan and different sectors like business, health and academia can be done. For future research, it would be fascinating to investigate the relationship between violence at work using the organizational burnout as mediator. A qualitative study investigating the reasons behind workplace violence, work-pressure, and their impact of performance and well-being would be productive and fruitful for the healthcare profession.

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