workplace violence research paper

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• Published: 30 May 2019

The impact of workplace violence on job satisfaction, job burnout, and turnover intention: the mediating role of social support

• Xiaojian Duan 1   na1 ,
• Xin Ni 2   na1 ,
• Lei Shi 1   na1 ,
• Leijing Zhang 3 ,
• Yuan Ye 1 ,
• Huitong Mu 4 ,
• Xin Liu 5 ,
• Lihua Fan   ORCID: orcid.org/0000-0002-3007-9341 1 &
• Yongchen Wang 6  

Health and Quality of Life Outcomes volume  17 , Article number:  93 ( 2019 ) Cite this article

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Workplace violence (WPV) is a global public health problem and has caused a serious threat to the physical and mental health of healthcare workers. Moreover, WPV also has an adverse effect on the workplace behavior of healthcare workers. This study has three purposes: (1) to identify the prevalence of workplace violence against physicians; (2) to examine the association between exposure to WPV, job satisfaction, job burnout and turnover intention of Chinese physicians and (3) to verify the mediating role of social support.

A cross-sectional study adopted a purposive sampling method to collect data from March 2017 through May 2017. A total of nine tertiary hospitals in four provinces, which provide healthcare from specialists in a large hospital after referral from primary and secondary care, were selected as research sites based on their geographical locations in the eastern, central and western regions of China. Descriptive analyses, a univariate analysis, a Pearson correlation, and a mediation regression analysis were used to estimate the prevalence of WPV and impact of WPV on job satisfaction, job burnout, and turnover intention.

WPV was positively correlated with turnover intention (r = 0.238, P  < 0.01) and job burnout (r = 0.150, P  < 0.01), and was negatively associated with job satisfaction (r = − 0.228, P  < 0.01) and social support (r = − 0.077, P  < 0.01). Social support was a partial mediator between WPV and job satisfaction, as well as burnout and turnover intention.

Conclusions

The results show a high prevalence of workplace violence in Chinese tertiary hospitals, which should not be ignored. The effects of social support on workplace behaviors suggest that it has practical implications for interventions to promote the stability of physicians’ teams.

Trial registration

(Project Identification Code: HMUIRB2014005), Registered March 1, 2014.

Workplace violence (WPV) is a serious global public health problem and has attracted public attention [ 1 , 2 ]. At the same time, WPV is inevitable in health service departments, and there is a universal belief that it is increasing [ 3 , 4 ]. Previous studies have shown that healthcare workers are more likely to become victims of violence or aggression than other workers [ 1 , 2 , 5 ]. The World Health Organization (WHO) divides WPV into two types of violent behaviors: (1) physical violence (e.g., beating, kicking, slapping, stabbing, shooting, pushing, biting, and pinching) and (2) psychological violence (including verbal abuse, threats, etc.) [ 6 ]. One survey showed that the prevalence of workplace violence for emergency physicians in Morocco was 70% [ 7 ]. The prevalence of WPV for medical staff ranges from 50 to 88% in different countries [ 8 , 9 , 10 ]. The prevalence of physical violence suffered by nurses ranged from 18.22% in Ethiopia to 56% in Jordan; verbal abuse ranged from 63.8% in Korea to 89.58% in Ethiopia; and sexual harassment ranged from 13.02% in Ethiopia to 19.7% in Korea [ 11 , 12 , 13 , 14 ]. In China, according to a report from the Chinese Hospital Association, the proportion of hospitals that experienced WPV increased from 90% in 2008 to 96% in 2012 [ 15 ]. One study stated clearly that many physicians have been attacked by patients or visitors, or have been seriously injured or even killed from 2003 to 2013 [ 16 ]. A big data study on Chinese workplace violence showed that 290 cases of violent injuries in hospitals were reported by the Chinese media from 2000 to 2015, and the incidents of violent injuries were on the rise, mostly concentrated in the area of high-quality medical resources [ 17 ]. Most studies have shown that the occupational safety of Chinese physicians has reached a very critical juncture [ 17 , 18 , 19 ].

Research showed that workplace violence has an impact on medical personnel, hospitals, and society [ 20 , 21 ]. Following instances in which doctors suffered workplace violence, this caused other issues such as reduced job performance [ 22 ], decreased job satisfaction [ 23 ], and negative effects in their own physical and mental health [ 24 ], which may increase turnover intention and influence their quality of life [ 19 ]. A study of emergency physicians in Turkey found a significant correlation between emotional exhaustion and total violence ( P  = 0.012) and verbal violence ( P  = 0.016); depersonalization and total violence ( P  = 0.021) and verbal violence ( P  = 0.012) also have a significant correlation [ 25 ]. Physical violence and bullying were related to turnover intentions and lower job satisfaction [ 23 ]. A study showed that WPV has a significant effect on burnout and turnover intention [ 26 ]. WPV has severely interfered with the normal medical order in hospitals, which has caused many negative effects for medical services [ 27 ].

Previous studies have found that social support can alleviate the impact of violence on health and work-related outcomes (such as high anxiety, work stress, and dissatisfaction) [ 28 , 29 ], thereby reducing the adverse consequences for medical staff who experience WPV. Although researchers have a variety of definitions for social support, the shared characteristic is the connection between the availability of external resources with social relationships. Social support can be divided into two categories. One type consists of objective, visible, or practical support, including direct material aid, social networks and the existence and participation of group relationships (such as family, spouses, friends and colleagues). The other type is subjective and experiential emotional support, which refers to the emotional experience and satisfaction of individuals who are respected, supported and understood in the society, and is closely related to the subjective feelings of the individual. Woodhead and other scholars have found that work resources (support from supervisors, friends, or family members, and the cultivation of opportunities) are associated with less emotional exhaustion and higher levels of personal achievement [ 30 ]. For employees with low levels of peer support, the negative relationship between unsafe working conditions and low work commitment was stronger [ 31 ]. Psychological violence at work was associated with low levels of workplace emotional commitment and high levels of turnover intention. Social support plays an intermediary role in the relationship between workplace violence and turnover intentions [ 32 ]. Social support plays a role in mitigating or mediating the impact of WPV on job burnout [ 33 ]. Brough’s findings indicated that managers’ support alleviated the psychological pressure of medical assistants who experienced verbal violence [ 34 ]. These previous empirical studies have demonstrated that social support plays a buffering or mediating role in the impact of WPV on work-related outcomes. Moreover, social support theory often focuses on vulnerable groups (such as battered women) [ 35 ]. Healthcare workers are considered vulnerable groups [ 36 ], therefore, we conducted research under the framework of social support. In summary, it is of great practical significance to study the roles of social support on the effects of WPV and workplace behaviors for the stability of hospital physicians. On the other hand, the development of this study is conducive to promoting the healthcare system in China to pay more attention to WPV and establish a unified WPV reporting system as soon as possible. The classical mediation test used the causal stepwise regression method [ 37 ], while the bootstrap test was used to re-examine the role of social support in workplace violence and workplace behavior [ 38 ]. Thus, to better understand the role of social support in workplace violence and physicians’ job satisfaction, job burnout, and turnover intention, we proposed the following hypotheses:

Hypothesis 1: WPV in hospitals is related to physicians’ job satisfaction, job burnout, and turnover intention; and.

Hypothesis 2: Social support plays a mediating role in WPV physicians’ job satisfaction, job burnout and turnover intention.

Study design and population

A cross-sectional survey was conducted based on the geographical location of the eastern (Beijing), middle (Heilongjiang, Anhui) and western (Shaanxi) regions in China. Nine tertiary public hospitals were selected as survey sites mainly with the assistance of China Hospital Association. The purposive sampling method was used to conduct a cross-sectional survey of physicians. These hospitals were similar in size, department setting and number of physicians. Therefore, the total number of physicians in nine hospitals is about 18,450; a total of 1486 samples were extracted, with these physicians accounting for 8.05% of the total. On average, 225 physicians from each hospital were extracted. All investigators conducted uniform training before starting investigations, and served in the role of investigator only after passing the assessment. Before the formal investigation, four hospitals in Harbin City were selected as our pre-surveyed sites, and 200 questionnaires were issued and collected. This part of the data was not included in the final analysis, because after processing the preliminary data, we further modified the questionnaire. Finally, we consulted health management experts, hospital administrators, clinicians, and other health experts (a total of six experts) on the questionnaire, and based on their feedback, we developed the final field survey questionnaire.

Data collection

The survey was conducted from March 2017 through May 2017. Before the investigation, we communicated and coordinated with each research hospital and started the field investigation after obtaining consent. Members of the research group distributed questionnaires at the scene, and the respondents completed the anonymous questionnaires on the same day and returned them to the designated box. The hospital manager did not supervise the whole process. A total of 1486 questionnaires were issued to physicians and 1257 valid questionnaires were recovered (the effective response rate was 84.59%). The following conditions were selected as the inclusion criteria for this study: 1) possessing a professional doctors’ certificate; 2) having at least one year of clinical experience; 3) being engaged in clinical work during the investigation; and 4) voluntary participation without prejudice to the participants’ work.

Final version of questionnaire

Demographic characteristics.

The demographic information of physicians was collected, including gender, age group, marital status, educational background, professional title, employment form, department, years of experience and daily working hours.

In this study, a new measurement tool developed by Chen was used to evaluate the prevalence of WPV in the past year [ 39 ]. The WPV was divided into three dimensions (verbal violence, physical violence and sexual harassment) and nine items (which can be seen in the Additional file  1 : Questionnaire). Verbal violence includes verbal attacks (insulting, degrading, or using other words that harm personal dignity, whether in face-to-face encounters or through phone calls, letters, networks, or leaflets, etc.), but no physical contact; threats (involving personal and property safety, as well as threatening complaints), but no physical contact. Physical violence includes physical contact or an attack with an object (including hitting, kicking, slapping, stabbing, pushing, biting, throwing objects, twisting arms, pulling hair, etc.), and sexual harassment/violence (sexual assault, rape or attempted rape). These behaviors were very common issues for Chinese physicians at work. Most importantly, these behaviors of mistreatment completely meet the standards for the definition and scope of WPV. The score for each item was four points, which reflected the frequency of respondents’ exposure to WPV (0 = zero times, 1 = 1 time, 2 = 2 or 3 times, and 3 = more than 3 times). The total possible score ranged from 0 to 27, and the higher the total score, the higher the frequency of violence exposure in the workplace. The scale had good reliability and validity, and has been widely used in China [ 2 , 19 , 40 ]. The Cronbach’s coefficient of this scale in this study was 0.871.

Social support rating scale

Social support was evaluated using the Chinese version of the Social Support Rating Scale (SSRS) [ 2 , 41 , 42 ], which is a brief measure of the respondents’ social support after experiencing WPV. This 10-item scale was divided into three dimensions: subjective support (three items), objective support (four items) and utilization of support (three items). Subjective support refers to an individual’s emotional experience of being respected, supported, and understood by their social group. Objective support refers to objective, visible, or actual support, including direct material support, support from social networks, and the existence and participation of group relationships, etc. The degree of utilization of social support refers to differences in the use of social support by individuals. The present study revealed that Cronbach’s α for SSRS was 0.875, and for the three subscales, it was 0.873 (subjective support), 0.886 (objective support) and 0.842 (utilization of support).

Minnesota job satisfaction short scale

The Minnesota Satisfaction Questionnaire Short Scale (MSQ-SS) was used to assess participants’ job satisfaction after experiencing WPV. [ 43 , 44 ]. It includes two subscales (intrinsic satisfaction and external satisfaction), with a total of 20 items. The intrinsic satisfaction scale contains 12 items and the extrinsic satisfaction scale includes eight items. The general satisfacttion scale was formed by all items. These 20 items measured the respondent’s satisfaction with their competency development, sense of accomplishment, activities, promotions, empowerment, company policies and practices, compensation, co-workers, creative freedom, social services, social status, management–employee relations, management’s skills, diversification in work, and working conditions. Each item was divided into five levels, (1 = strongly unsatisfied, 2 = unsatisfied, 3 = uncertain, 4 = satisfied, and 5 = strongly satisfied). The higher the self-evaluation of the participants, the higher their satisfaction with the work. This study showed that the Cronbach’s coefficient for the MSQ-SS is 0.894, and for the two subscales, it is 0.902 (internal satisfaction) and 0.876 (external satisfaction).

Maslach burnout inventory—general survey

In this study, burnout was measured using the Maslach Burnout Inventory—General Survey (MBI-GS), and there were a total of 15 items [ 45 , 46 ]. Each item of MBI-GS was rated based on the frequency of responder’s working experience, using 7 points of self-assessment, where 0 is never, and 6 is daily. MBI-GS is divided into three subscales to reflect job burnout, including emotional burnout, depersonalization, and reduced personal accomplishment. The first two subscales adopted the positive scoring, that is, the higher the score, the more serious the burnout. However, personal achievement was a reverse scoring system, that is, as the score becomes lower, the burnout is more serious. The scores of the three subscales are equal to the average of the sum of the items of each subscale. The total score was calculated from the scores of the three subscales, ranging from 0 to 18 points. The higher the score, the higher the burnout level. In this study, the Cronbach’s coefficient of MBI-GS was 0.872. The internal consistency coefficients were 0.834, 0.826, and 0.812, respectively, which were emotional exhaustion, depersonalization, and reduced personal accomplishment.

Turnover intention scale

This study used the turnover intention scale to measure nurse’ turnover intention after experiencing WPV. The scale was compiled by Michael and Spector [ 47 ] and revised by Lee G and Lee D [ 48 ], and included 6 items. The scale was divided into three dimensions: the possibility of employees resigning, the motivation of employees to find other jobs, and the possibility of employees obtaining external work. Each item reflected the number of times the participant had an intention to leave, and it was divided into four levels (1 = never, 2 = very few, 3 = occasionally, 4 = often). The total possible score was calculated by adding scores for all items, and it ranged from six to 24 points, with a higher score indicating a stronger intention to leave. A total average score ≤ 1 indicates that turnover intention is particularly low, low when it is from 1 to 2, higher when it is from 2 to 3, and exceptionally high when it is greater than 3. In this study, Cronbach’s α of turnover intention scale was 0.856.

Data analysis

IBM SPSS V.19.0 was used for the data analysis in this study. The demographic characteristics of respondents were collected to report sample information. We used independent sample t-tests or one-way analysis of variance to compare group differences on the measurements of the continuous variables. The Pearson correlation was assessed for WPV, job satisfaction, burnout, and turnover intention. The regressions including mediations were calculated with the SPSS PROCESS macro by Preacher and Hayes [ 38 ]. The mediation analyses were based on model number 4 and bootstrapping (1000 bootstrap samples) using 95% confidence intervals. Statistically significant variables in univariate analysis are included as covariates: WPV as an independent variable (X); social support as an M variable; and job satisfaction, job burnout and turnover intention as dependent variables (Y). The macro allows calculating and testing the direct effect, the total effect, and the indirect effect. The effect is significant when the 95% CI does not include 0. Based on the bootstrap mediation effect test, there are two steps. First, we test whether a*b is significant. If a*b is significant, we need to test the positive and negative of a*b*c′. If a*b*c′ is positive, it is a complementary mediation. All study variables were tested for multicollinearity. A P –value < 0.05 was considered statistically significant.

Demographics and characteristics of hospitals

Of the 1257 respondents who met our inclusion criteria, 53.6% were men, 56.6% received a postgraduate education, and 74.9% were married. The demographic characteristics of the participants are shown in Table  1 . The common feature of these nine tertiary hospitals is that the number of beds is more than 500. Moreover, these hospitals are medical prevention technology centers with comprehensive medical, teaching, and scientific research capabilities.

Prevalence of different styles of WPV against physicians

About 66.19% (832/1257) of participants reported having experienced WPV within the past 12 months. The 65.31% (821/1257) of physicians experienced verbal violence, which was the highest incident rate among all kinds of WPV in hospitals. During the previous 12 months, the prevalence of physical violence and sexual harassment toward physicians was 12.57% (158/1257) and 0.88% (11/1257), respectively. The respondents reported that the patients’ relatives were the main perpetrators (54.2%, 451/832), followed by the patients (26.4%, n  = 220/832).

Correlations between study variables

As shown in Table  2 , all variables were significantly correlated with each other. The average frequency of WPV was 2.31 times in the last year. The average scores of job satisfaction, job burnout and turnover intention were 3.47, 6.30, and 14.09 points, respectively. WPV was positively correlated with turnover intention (r = 0.238, P  < 0.01) and job burnout (r = 0.150, P  < 0.01). WPV was negatively associated with job satisfaction (r = − 0.228, P  < 0.01) and social support (r = − 0.077, P  < 0.01).

The difference between participants’ characteristics and scores of multiple variables

There was a significant difference in the scores on job satisfaction depending on the physicians’ demographics, including their age group, marital status, different professional titles, form of employment, department, years of experience, and daily working hours. The descriptive association between respondents’ characteristics and the burnout, workplace violence, social support, and turnover intention scores can be seen in Table  3 .

Mediation regression models of study variables

To give a brief overview, let us take Path 1 (seen in Table  4 ) as an example. The results of Table  4 and Fig.  1 can be summarized as follows: the direct effect of workplace violence on social support is − 0.2295, the direct effect of social support on job satisfaction is 0.4959, direct effect of WPV on job satisfaction is − 0.8478, and the total effect of WPV on job satisfaction is − 0.9616. Meanwhile, a*b*c′ is positive, showing the mediating role of social support in explaining the relation between the WPV and job satisfaction of physicians (Fig. 1 ). Similarly, Paths 2 and Path 3 indicate the mediating role of social support (Table 4 ).

The mediating role of SS in explaining the relation between the WPV and JS of physicians (path 1 in Table 4 ). N  = 1257; controlled for age, marital status, professional title, employment form, department, years of experience, and daily working hours; WPV, workplace violence; JS, job satisfaction; SS, social support; a = direct effect of WPV on mediator; b = direct effect of mediator on JS; c = total effect of WPV on JS; c′ = direct effect of WPV on JS

Prevalence of WPV against Chinese physicians

A cross-sectional study based on hospital physicians found that the prevalence of WPV experienced by physicians in the past year was 66.19%, which was lower than the result of a large sample of physicians experiencing WPV in China [ 19 ]. The prevalence of violence in hospitals in different countries varies [ 7 , 8 , 9 , 10 ]. This may be due to cultural differences in the perception of WPV in different countries and the diversity of assessment scales used in different studies. The prevalence of physicians exposed to verbal violence was 65.31%, which is the most frequent type of WPV experienced by Chinese physicians suffering from WPV. This result was similar to the previous study [ 2 , 17 , 19 ]. In addition, the prevalence of physical violence and sexual harassment/violence was 12.57 and 0.88%, respectively. These results indicated that the risk of Chinese physicians being exposed to WPV is high, which may be due to the tension between physicians and patients in China. In 2009, the Chinese government issued opinions on deepening the reform of the medical and health system; this round of health system reform was called the new medical reform [ 49 ]. It is worth noting that the new medical reform devotes more attention to the development of primary health care services, with the intention of maintaining the health of all citizens at the lowest possible cost [ 49 , 50 ]. Although the new medical reform has achieved significant success, there are still some problems, such as the unbalanced allocation of health resources [ 51 ]. In China, due to an imbalance in the distribution of medical resources, health professionals are concentrated in public tertiary hospitals [ 51 ]. In addition, residents have the right to choose their own hospital, and the majority of residents initially selected for a tertiary hospital, which may cause more patients to go to the tertiary hospitals, thus increasing the workload of doctors, increasing the demands on their time with the technical problems of medical services and prompting a situation in which the humanistic care entailed in the service process is not provided, which is also important [ 2 ]. For a long time, the continual accumulation of contradictions between physicians and patients may have increased distrust on both sides, thus aggravating the tension between physicians and patients [ 52 ]. Therefore, the occupation of medical physician has become one of the most dangerous professions in China. The study also found that the more frequently physicians experience different types of violence in hospital settings, the greater the damage they may suffer, which is consistent with the results of Sun et al. [ 19 ]. The results also showed that the main perpetrators were patients’ relatives, followed by patients, which was similar to previous studies [ 19 , 24 ].

The negative impact of WPV on doctors’ workplace behavior

Research showed that for physicians who have experienced WPV on a frequent basis, job satisfaction is lower, job burnout is higher, and some physicians even leave their job, which may cause a shortage in hospital physicians. These findings are consistent with previous research results [ 2 , 23 , 26 , 28 ]. WPV causes doctors to be in an unhealthy environment, which may lead to a marked decline in their enthusiasm. Moreover, they feel their own work does not receive respect and recognition from their patients and the patients’ families, and they begin to doubt their own value and professional status in the process of providing a medical service. Physicians with a higher frequency of violence may also have less empathy, which may lead to a lack of trust between physicians and patients. Eventually, it may cause them to avoid actively responding to and dealing with the conflicts they encounter, resulting in a lack of initiative in their work. Therefore, building a harmonious medical environment and reducing the prevalence of WPV is one effective measure for increasing physicians’ job satisfaction, reducing job burnout and turnover intention, and stabilizing the physicians’ team.

The mediating effect of social support on physicians’ job satisfaction, job burnout, and turnover intention

Our research also showed that social support plays a mediating role in the WPV impact on the physicians’ workplace behavior (job satisfaction, job burnout, turnover tendencies), which was consistent with the results of previous studies [ 32 , 33 ]. Moreover, the results showed that a* b * c′ was positive and can be considered as a supplementary mediation, indicating that part of the mediating role of social support was established. But the difference is that the direct and indirect effects of Paths 2 and 3 are opposite to those of Path 1. Obviously, these findings correspond to the results of correlation analysis. Physicians have a high level of work pressure, high risks, and heavy workloads, leading to long-term mental and physical fatigue. Once a doctor is attacked or experiences WPV, physicians’ negative emotions increase and job satisfaction declines, which may even cause indifference, apathy, helplessness, disappointment, lack of motivation, or resignation.

It is noteworthy that WPV is negatively correlated with social support. A previous study showed that the Deterioration Model of Social Support has been useful in discriminating the potential of stressors to reduce support [ 53 ]. This phenomenon may be due to a WPV -induced erosion of perceived social support for the increased danger of workplace behaviors among both primary and secondary victims; the loss of perceived social support also mediated workplace behaviors consequences. However, the Deterioration Deterrence Model of Social Support, which is similar to support mobilization models, has been used to explain how the perceived deterioration of social support can be counteracted by higher levels of received social support [ 54 , 55 ]. If post-WPV support mobilization is implemented, WPVshould be positively correlated with received support.

The social relationships established by physicians in their work are complicated, involving the physician–patient relationship, physician–nurse relationship, physician –physician relationship, and physician–leadership relationship. When physicians suffer violence in the workplace, the importance of their social network is highlighted, and colleagues and leaders take positive measures in a timely manner (such as giving a warning and preventing the perpetrators from continuing the attack) to reduce the harm damage to doctors caused by WPV. At the same time, physicians can also receive encouragement and support from their family members, friends, colleagues, and leaders, and they are able to experience significant emotional support. These effective social supports will help reduce the physicians’ sense of job burnout and work indifference, enhance their personal sense of accomplishment, increase job satisfaction, and reduce turnover intentions. Therefore, social support plays an important role in alleviating the physical and mental health of WPV and the impact of WPV on workplace behavior.

Hospitals can establish a “code green” response team to manage any potentially violent situation. Preventive measures for WPV among physicians include increasing the awareness of potentially violent patients; wearing suitable clothes; maintaining proper positioning when communicating with patients; keeping a safe distance; maintaining the correct posture; and listening actively. We further advise hospitals to strengthen the training and management of physicians to reduce the harm to them from WPV. Hospitals could provide post-WPV support, reducing the impact of physicians’ psychological and workplace behaviors. Therefore, it is necessary to establish a unified and appropriate reporting system and provide training programs for health professionals.

Limitations

Although there were some significant findings in the current study, several limitations still remain. First, purposive sampling results are greatly influenced by the preconceptions of the researchers. To the extent that subjective judgement may be biased, this can readily lead to sampling bias and cannot provide complete confidence in the results of the overall investigation. Second, we collected data about whether physicians had experienced WPV over the previous 12 months, so there may have been recall bias in the results. Third, the cross-sectional study reveals the status of the research object at a certain time, or the relationship between different variables at one point in time, and does not explain the causal relationship between the variables. However, this study has important significance for hospital managers as a reference, to maintain the stability of human resources.

The results of this study showed that there is a high prevalence of WPV against physicians in tertiary hospitals. It is becoming increasingly important to deal with WPV in tertiary hospitals. To prevent and manage WPV, it is necessary to establish a unified and appropriate reporting system and provide training programs for health professionals. The effects of social support on workplace behaviors suggest that it has practical implications for interventions to promote the stability of physicians’ team. Moreover, it provides a good reference for hospital management and policy-making.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Job burnout

• Job satisfaction

Maslach Burnout Inventory-General Survey

Minnesota Satisfaction Questionnaire Short Scale

• Social support

Social Support Rating Scale

• Turnover intention

World Health Organization

Workplace Violence

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Acknowledgements

The authors thank all the physicians, managers and the Chinese Hospital Association for their assistance and support for this project.

This study was funded by Social Science Foundation Research Projects of Beijing (16JDGLA028) to XN, the National Natural Science Foundation of China (71874043, 71473063) to LF and also was funded by the Innovative Research Projects of Graduate Students at Harbin Medical University (YJSCX2017-15HYD) to LS.

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Xiaojian Duan, Xin Ni and Lei Shi contributed equally to this work.

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Department of Health Management, School of Public Health, Harbin Medical University, Harbin, 150081, China

Xiaojian Duan, Lei Shi, Yuan Ye & Lihua Fan

Medical Dispute Office, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, Beijing, 100045, China

Xin Ni & Zhe Li

Department of Psychiatry, the Fourth Affiliated Hospital of Harbin Medical University, Harbin, 150001, China

Leijing Zhang

Department of Medical Records, Dalian Children’s Hospital, Dalian, 116012, China

Administrative Office, Harbin Children’s Hospital, Harbin, 150010, China

Department of General Practice, the Second Affiliated Hospital of Harbin Medical University, Harbin, 150001, China

Yongchen Wang

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XD, XN and LS conducted calculations, analyzed results, drafted the manuscript, and contributed equally to this work. XN, LF and YW were responsible for the overall design of the research, organized and conducted the survey, and designed the analyses framework. XD, XN and LS revised the paper. LZ, YY, ZL, HM and XL assisted with the literature review and data collection. All authors approval of the current version of this manuscript for publications.

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Correspondence to Lihua Fan or Yongchen Wang .

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The study was approved by the Institutional Review Board of Harbin Medical University. We obtained the consent of each hospital involved in the research process. All participants were guaranteed anonymity and the option not to participate and we provided informed consent to the medical staff before the survey (Project Identification Code: HMUIRB2014005).

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Duan, X., Ni, X., Shi, L. et al. The impact of workplace violence on job satisfaction, job burnout, and turnover intention: the mediating role of social support. Health Qual Life Outcomes 17 , 93 (2019). https://doi.org/10.1186/s12955-019-1164-3

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Contemporary evidence of workplace violence against the primary healthcare workforce worldwide: a systematic review

• Hanizah Mohd Yusoff 1 ,
• Hanis Ahmad   ORCID: orcid.org/0000-0001-6657-8698 1 ,
• Halim Ismail 1 ,
• Naiemy Reffin 1 ,
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• Faridah Kusnin 2 ,
• Nazaruddin Bahari 2 ,
• Hafiz Baharudin 1 ,
• Azila Aris 1 ,
• Huam Zhe Shen 1 &
• Maisarah Abdul Rahman 3  

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Violence against healthcare workers recently became a growing public health concern and has been intensively investigated, particularly in the tertiary setting. Nevertheless, little is known of workplace violence against healthcare workers in the primary setting. Given the nature of primary healthcare, which delivers essential healthcare services to the community, many primary healthcare workers are vulnerable to violent events. Since the Alma-Ata Declaration of 1978, the number of epidemiological studies on workplace violence against primary healthcare workers has increased globally. Nevertheless, a comprehensive review summarising the significant results from previous studies has not been published. Thus, this systematic review was conducted to collect and analyse recent evidence from previous workplace violence studies in primary healthcare settings. Eligible articles published in 2013–2023 were searched from the Web of Science, Scopus, and PubMed literature databases. Of 23 included studies, 16 were quantitative, four were qualitative, and three were mixed method. The extracted information was analysed and grouped into four main themes: prevalence and typology, predisposing factors, implications, and coping mechanisms or preventive measures. The prevalence of violence ranged from 45.6% to 90%. The most commonly reported form of violence was verbal abuse (46.9–90.3%), while the least commonly reported was sexual assault (2–17%). Most primary healthcare workers were at higher risk of patient- and family-perpetrated violence (Type II). Three sub-themes of predisposing factors were identified: individual factors (victims’ and perpetrators’ characteristics), community or geographical factors, and workplace factors. There were considerable negative consequences of violence on both the victims and organisations. Under-reporting remained the key issue, which was mainly due to the negative perception of the effectiveness of existing workplace policies for managing violence. Workplace violence is a complex issue that indicates a need for more serious consideration of a resolution on par with that in other healthcare settings. Several research gaps and limitations require additional rigorous analytical and interventional research. Information pertaining to violent events must be comprehensively collected to delineate the complete scope of the issue and formulate prevention strategies based on potentially modifiable risk factors to minimise the negative implications caused by workplace violence.

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Introduction

Events where healthcare workers (HCWs) are attacked, threatened, or abused during work-related situations and that present a direct or indirect threat to their security and well-being are referred to as workplace violence (WPV) [ 1 ]. Violence in the health sector has increased over the last decade and is a primary global concern [ 2 ]. Recent statistical data demonstrated that HCWs were five times more likely to experience violence than workers in other sectors and are involved in 73% of all nonfatal violent work incidents [ 3 ]. The experience of WPV is linked to reduced quality of life and negative psychological implications, such as low self-esteem, increased anxiety, and stress [ 4 , 5 , 6 ]. WPV is often linked to poor work performance caused by lower job satisfaction, higher absenteeism, and reduced worker retention [ 7 , 8 ], which may disrupt patient care quality and other healthcare service productivity [ 9 ]. Decision-makers and academics worldwide now recognise the seriousness of WPV in the health sector, which has been extensively examined in tertiary settings, particularly emergency and psychiatric departments. Nonetheless, understanding of WPV in primary healthcare (PHC) settings is minimal.

The modern health system has experienced a fundamental shift in delivery systems while moving towards universal health coverage and Sustainable Development Goals (SDGs) [ 7 ]. Despite the focus on tertiary-level individual disease management, the healthcare system recently moved towards empowering primary-level patient and community health needs [ 10 ]. Robust PHC system delivery provides deinstitutionalised patient care, which includes health promotion, acute disease management, rehabilitation, and palliative services, via primary health units in the community, which are referred to with different terms across countries, such as family health units, family medicine and community centres, and outpatient physician clinics [ 11 , 12 , 13 ]. In developing and developed countries, PHC services are associated with improved accessibility, improved health conditions, reduced hospitalisation rates, and fewer emergency department visits [ 14 ]. The backbone of this health system delivery is a PHC team of family physicians, physician assistants, nurses, laboratory technicians, pharmacists, social workers, administrative staff, auxiliaries, and community workers [ 15 ].

Nevertheless, the nature of PHC service, which delivers essential services to the community, requires direct interaction with patients and family members, thus increasing the likelihood of experiencing violent behaviour [ 10 ]. Understaffing occurs mainly due to the lack of comprehensive national data that could offer a complete view of the PHC workforce constitution and distribution, which results in increased responsibilities and compromised patient communication [ 15 ]. Considering the current worldwide employment patterns, a shortage of approximately 14.5 million health workers in 2030 is anticipated based on the threshold of human resource needs related to the SDG health targets [ 16 ]. Other challenges at the PHC level recently have also been addressed, including long waiting times, dissatisfaction with referral systems, high burnout rates, and limited accessibility in rural areas, which exacerbate existing WPV issues [ 14 ].

As PHC system quality relies entirely on its workers, the issue of WPV requires more attention. WPV issues must be examined separately between PHC and other clinical settings to support an effective violence prevention strategy for PHC, given that the violence characteristics and other relevant factors can vary by facility type. In addition, PHC workers also have distinct services, work tasks, and work environments [ 11 ]. Since the Alma-Ata Declaration of 1978, interest in conducting empirical studies investigating WPV in the PHC setting has increased worldwide [ 17 ]. Nevertheless, a comprehensive systematic review summarising the results from previous studies has never been published. Understanding this issue among workers who serve under a robust PHC system would be equally essential and requires attention to critical dimensions on par with WPV incidents in other clinical settings, especially hospitals. Therefore, this preliminary systematic review of WPV against the PHC workforce analysed and summarised the current information, including the WPV prevalence, predisposing factors, implications, and preventive measures in previous research.

Literature sources

This systematic review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 review protocol [ 18 ]. A comprehensive database search of the Web of Science, Scopus, and PubMed databases was conducted in February 2023 using key terms related to WPV (“violence”, “harassment”, “abuse”, “conflict”, “confrontation”, and “assault”), workplace setting (“primary healthcare”, “primary care”, “community unit”, “family care”, “general practice”), and victims (“healthcare personnel”, “healthcare provider”, “medical staff”, “healthcare worker”). The keywords were combined using advanced field code searching (TITLE–ABS–KEY), phrase searching, truncation, and the Boolean operators “OR” and “AND”.

Eligibility criteria

All selected studies were original articles written in English and published within the last 10 years (2013–2023) on optimal sources or current literature. The articles were selected based on the following criteria:

Inclusion criteria

Described all violence typology (Types I–IV) and its form (verbal abuse, physical assault, physical threat, racism, bullying, or sexual assault);

The topic of interest concerned every category of PHC personnel (family doctor, general practitioner, nurse, pharmacist, administrative staff).

Exclusion criteria

The violence occurred in a tertiary or secondary setting (during training/industrial attachment at a hospital);

Case reports or series, and technical notes.

Study selection and data extraction

All research team members were involved in screening the titles and abstracts of all articles according to the inclusion and exclusion criteria. All potentially eligible articles were retained to evaluate the full text, which was conducted interchangeably by two teams of four members. Differences in opinion were resolved with the research team leader’s input. Before the data extraction and analysis, the methodological quality of the finalised article was assessed using the Mixed-Methods Appraisal Tool (MMAT). Based on the outcomes of interest, the information obtained from the included articles was compiled in Excel and grouped into the following categories: (i) prevalence, typology, and form of violence, (ii) predisposing factors, (iii) implications, and (iv) preventive measures. Figure  1 depicts the article selection process flow.

PRISMA flow diagram

General characteristics of the studies

Forty-three articles were potentially eligible for further consideration, but only 23 articles provided information that answered the research questions (Table 1 ) [ 13 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 ]. The studies mainly covered 16 countries across Asia, Europe, and North and South America, thus providing good ethnic or cultural background diversity. All included articles were observational studies. Sixteen studies were quantitative descriptive studies conducted through self-administered surveys using different validated local versions of WPV study tools (response rate: 59–94.47%). Four qualitative studies collected data through in-depth interviews and focus group discussions. The remaining studies were mixed-method studies that combined quantitative and qualitative research elements. Of the 23 studies, 15 involved various categories of healthcare personnel, seven involved primary clinicians, and one involved pharmacist.

Prevalence, typology, and form of violence

14 studies focused on the prevalence of patient- or family-perpetrated violence (Type II), three studies focused on co-worker-perpetrated violence (Type III), while six studies reported on both type II and III violence (Table 2 ). Evidence of domestic- and crime-type violence (Types I and IV) was not found in the literature. In most studies, the primary outcome was determined based on recall incidents over the previous 12 months. The reported prevalence of violence against was 45.6–90%. The incidence rate of verbal abuse was 46.9–90.3%, which rendered it the most commonly identified form of violence, followed by threats or assault (13–44%), bullying (19–27%), physical assault (15.9–20.6%), and sexual harassment (2–17%). The reported prevalence of violence against doctors was 14.0–73.0%, followed by that against nurses (6.0–48.5%), pharmacists (61.8%), and others (from 40% to < 5%). Patients and their families were the main perpetrators of violence, followed by co-workers or supervisors (Table 2 ).

Predisposing factors of WPV

Victims’ personal characteristics

Several socio-demographic factors were identified as predictors of WPV. Male gender and female gender were associated with risk of physical violence [ 21 , 22 , 23 ] and non-physical violence [ 12 , 19 , 24 , 32 , 35 , 39 ], respectively. Nevertheless, a specific form of non-physical violence, such as coercion, was also reported less frequently among women [ 34 ]. A minority group of HCWs with individual sexual identities perceived a severe form of intra-profession violence, such as threats to their licenses [ 24 ]. Being young presented a higher risk for violence, especially sexual harassment, and was frequently complicated by physical injury [ 23 , 27 , 34 ]. A personality trait study demonstrated a significant association between aggression incidents with “reserved” and “careless” personality types [ 20 ]. Regarding professional background, medical workers were more vulnerable to physical violence compared to non-medical workers [ 12 , 22 , 34 ]. Nurses faced a higher risk of WPV than others [ 19 , 23 , 27 , 37 ]. Nevertheless, non-medical staff were also vulnerable to physical violence [ 35 ]. Due to less work experience, certain HCWs were identified as vulnerable to violence [ 22 , 26 , 35 ]. Furthermore, violent clinic incidents could occur due to poor professional–client relationships triggered by workers’ attitudes, such as a lack of communication and problem-solving skills [ 25 , 26 ] (Table 3 ).

Perpetrators’ personal characteristics

Patients and their family members mainly triggered WPV, and some exhibited aggressive behaviours, such as psychiatric disorders or drug influence [ 20 , 23 , 28 ]. Female patients in a particular age group were noted as being at risk of causing both physical and non-physical violence [ 34 ]. WPV was also prevalent in clinics, which was attributable to poor patient–professional relationships triggered by the perpetrator’s inappropriate attitude, such as being excessively demanding, or when clients did not fully understand the role of HCWs or used PHC services for malingering [ 25 , 26 , 31 ] (Table 3 ).

Community/Geographical factors

We identified the role of the local community, where WPV was prevalent among HCWs who served at PHC facilities in drug trafficking areas [ 27 ] and that were surrounded by a population of lower socio-economic status [ 28 ]. Furthermore, WPV was increased in clinics in urban and larger districts, which have a lower HCW density per a given population compared to the national threshold of human resource requirement [ 29 , 32 , 39 ], whereas WPV reduced in rural areas, where medical service was perceived more accessible due to lower population density [ 39 ] (Table 3 ). 

Workplace factors

The operational service, healthcare system delivery, and organisational factors were identified as the three major sub-themes of work-related predictors of WPV. Specific operational services increased the likelihood of WPV, for example, during home visit activities, handling preschool students, dealing with clients at the counter, and triaging emergency cases [ 27 , 36 , 37 , 38 , 39 ]. WPV was more prevalent if the service was delivered by HCWs who worked extra hours with multiple shifts, particularly during the evening and night shifts [ 30 , 36 , 37 , 39 ]. HCWs who worked in clinics with poor healthcare delivery systems due to ineffective appointment systems, uncertainty of service or waiting times, and inadequate staffing [ 25 , 26 , 27 , 31 , 33 , 36 , 37 ] faced higher potential exposure to aggressive events compared to those working in clinics with better systems. WPV was also linked to a lack of organisational support, mainly in fulfilling workers’ needs, such as providing sufficient human resources, capital, and on-job training, or equal pay schedule and job task distribution, or ensuring a safety climate and clear policy for WPV management [ 22 , 26 , 27 , 29 , 30 , 33 , 35 , 36 , 37 ]. We also determined that the lack of a multidisciplinary work team and devalued family medicine speciality by other specialists caused many HCWs to remain in poor intra- or inter-profession relationships and be vulnerable to co-worker-perpetrated incidents in PHC settings [ 24 , 26 , 33 , 39 ] (Table 3 ).

Effects of WPV

The most frequently reported implications by the victims of WPV involved their professional life, where most studies mentioned reduced performance, absenteeism, the decision to change practice, and feeling dissatisfied or overlooked in their roles. This was followed by poor psychological well-being (anxiety, stress, or burnout), and emotional effects (feeling guilty, ashamed, and punished) [ 13 , 21 , 24 , 30 , 31 , 34 , 35 , 38 ]. Three studies reported on physical injuries [ 13 , 21 , 34 ], while only one study reported a deficit in victims’ cognitive function, which might lead to near-miss events involving patients’ safety elements, and social function defects, where some victims refused to deal with patients in the future [ 31 ]. Only one study reported the WPV implication of being environmentally damaged [ 34 ] (Table 3 ).

Victims’ coping mechanisms and organisational interventions

The coping strategies adopted by HCWs varied depending on the timing of the violent events. Safety approaches such as carrying a personal alarm, bearing a chevron, and other similar steps were used, especially by female HCWs, as a proactive coping measure against potentially hazardous incidents [ 21 ]. “During an aggressive situation triggered by patients, certain workers used non-technical skills, which included leadership, task management, situational awareness, and decision-making [ 31 ]. During inter-professional conflict (physician–nurse conflict), the most predominant conflict resolution styles were compromise and avoiding, followed by accommodating, collaborating, and competing [ 40 ]. Avoiding conflict resolution was most common among nurses, whereas compromise was most common among doctors [ 40 ]. Post-violent event, most HCWs chose to take no action, while some utilised a formal reporting channel either via their supervisors, higher managers, police officers, or legal prosecution. Some HCWs also utilised informal channels by sharing problems with their social network members, such as colleagues, friends, or family members [ 13 , 30 , 36 , 39 ]. Only one article mentioned health managers’ organisational preventive interventions, which included internal workplace rotation, staff replacement, and writing formal explanation letters [ 34 ] (Table 3 ).

We analysed the global prevalence and other vital information on WPV against HCWs who serve in the PHC setting. We identified noteworthy findings not reported in earlier systematic reviews and meta-analyses, where the healthcare setting type was not taken into primary consideration [ 2 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 ].

Determining a definite judgement on WPV incidence against PHC workers worldwide is challenging, given that several of the studies selected for analysis were conducted using convenience sampling with low response rates. Nevertheless, notable results were obtained. WPV prevalence varied significantly, where the highest prevalence was reported in Germany (91%) and the lowest was reported in China (14%). Based on the average 1-year prevalence rate of WPV, we determined that the European and American regions had a greater WPV prevalence than others, which was consistent with a recent meta-analysis [ 50 ]. One reason might be the more effective reporting system in these regions, which facilitate more reports through a formal channel, as mentioned previously [ 51 ]. Contrastingly, opposite circumstances might cause WPV events to go unreported in other parts of the world. We also revealed a need for more evidence on WPV in the PHC context in Southeast–East Asia and African regions. The number of peer-reviewed articles from these regions could have been much higher, which inferred that the issue in these continents still requires resolution.

Various incidents of violence, including those of a criminal or domestic nature, commonly occur in the tertiary setting. The Healthcare Crime Survey by the International Association for Healthcare Security and Safety (IAHSS) reported that within a 10-year period (2010–2022), the number of hospital workers who experienced ten types of crime-related events in the workplace, such as murder, rape, robbery, burglary, theft (Type I), increased by the year [ 52 ]. In contrast, most studies conducted in PHC settings focused on providing more evidence of Type II violence, whereby other types (I and IV) were rarely detected. The scarcity of evidence does not necessarily indicate that PHC workers are not vulnerable to criminal or domestic violence. Rather, it implies that WPV is still not entirely explored in the PHC setting, which undermines the establishment of a comprehensive violence prevention strategy that encompasses all types of violence [ 53 ].

Hospital-based studies reported diverse forms of violence, where both physical and verbal violence were dominant [ 47 , 54 , 55 , 56 ]. Violence as a whole and physical violence in particular tend to occur in nursing homes and certain hospital departments, such as the psychiatric department, emergency rooms, and geriatric nursing units [ 47 , 55 , 56 ]. Volatile individuals with serious medical conditions or psychiatric issues or who are under the influence of drugs or alcohol were mainly responsible for this severe physical aggression [ 53 ]. Similar to previous hospital-based studies, diverse forms of violence (verbal abuse, physical attacks, bullying, sexual-based violence, psychological abuse) were recorded in PHC settings. Despite this, most of the studies determined that the perpetrators’ disparate characteristics resulted in more frequent documentation of verbal violence than physical violence. Dissatisfied patients or family members were more likely to perpetrate greater incidents of verbal abuse [ 25 , 26 , 31 ], either due to their medical conditions or dissatisfaction with the services provided [ 30 ]. This noteworthy discovery prompted new ideas, indicating that variance in the form of violence might also be determined by the healthcare setting role [ 57 ].

Our findings demonstrated that sexual-based violence was the least frequently documented form of violence, with a regional differences pattern indicating relatively lower sexual-based violence reporting in the Middle Eastern region [ 13 , 30 ]. This result contrasted with a previous systematic review of African countries that reported that sexual-based violence was one of the dominant forms of WPV. This lower incidence was possibly due to under-reporting by female employees who were reluctant to report sexual harassment aggravated by cultural sensitivities regarding sexual assault exposure [ 58 ]. Such culturally driven decision-making practices are worrying, as they could lead to underestimation of the true extent of the issues and cause more humiliating incidents and the lack of a proper response.

We identified considerable numbers of significant predisposing factors, which were determined via advanced multivariate modelling. Most factors were comparable with that in previous WPV research, especially those related to the victims’ individual socio-demographic and professional backgrounds [ 2 , 41 , 42 ]. Several studies consistently reported that nurses were vulnerable to WPV compared to physicians and others, which was supported by numerous prior systematic studies [ 19 , 23 , 27 , 37 ]. This could be explained by the accessible nature of nurses as healthcare professionals to patients and families [ 50 ]. Furthermore, nurses interact first-hand with clients during treatment, rendering them more likely to become the initial victims of WPV before others. Nevertheless, this result should not necessarily suggest that other professions are not at risk for violence. Due to the shortage of evidence regarding the remaining category of PHC workers, it is impossible to provide a more conclusive and realistic assessment of the above.

The results demonstrated that many PHC clinics were built in community areas with a variety of settings, such as high-density commercial developments in urban or rural areas, resource-limited locations, or areas with a high crime concentration [ 27 , 28 , 29 , 32 , 39 ]. Therefore, an additional new sub-theme under predisposing factors, namely, “community and geographical factors”, was created to include all evidence on the relationship between WPV vulnerability and community social character and geo-spatial factors. Although several hospital-based studies deemed this topic less significant, several studies in the present review that examined the relationship between geographic information and the surrounding population characteristics with WPV reported valuable and constructive information for PHC prevention framework efforts.

In general, we identified a similar correlation between work-related factors and WPV as in hospital-based studies, particularly on healthcare system delivery and organisational support elements [ 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 ]. Nonetheless, the evidence on operational service was vastly distinct. As several PHC services are expanded outside facilities, there is increased potential for violence against HCWs when they provide out of clinic services, for example, during home visits and school health services [ 21 , 37 , 39 ]. Such situations might require more comprehensive prevention measures compared to violent events that occur within health facilities. Unfortunately, the available literature that describes and assesses the safety elements of HCWs in PHC settings mainly focused on services inside the health facilities, indicating that WPV prevention and management should be expanded to outdoor services [ 21 ].

The studies included in this review comprehensively described the observed implications on WPV victims in PHC settings. Nonetheless, additional vital information on the adverse effects on organisational elements remains lacking, especially regarding the quality of patient care involving potential near-miss events, negligence, and reduced safety elements [ 31 ]. The economic effect is another important aspect that requires further consideration. Recent financial expense data were only available from hospital-based research. A systematic review revealed that WPV events resulting in 3757 days of absence at one hospital over 1–3 years involved a cost exceeding USD 1.3 billion that was mainly due to reduced productivity [ 43 ].

The magnitude of under-reporting among HCWs was concerning, as most respondents admitted that they declined to report WPV cases through formal reporting channels, such as via electronic notification systems, supervisors, or police officers [ 13 , 30 , 36 , 39 ]. Although the included articles mentioned several impediments to reporting, such as fear of retaliation, fear of missing one’s job, and feelings of regret and humiliation, [ 13 , 30 , 36 ], the main reason for under-reporting was a lack of trust in existing WPV preventive institutional policies. Most respondents perceived that reporting the case would not lead to positive changes and were dissatisfied with how the policy was administered [ 13 , 30 ]. Despite much evidence on proactive coping mechanisms utilised by the HCWs, which were either behaviour change technique or conflict resolution style, we did not obtain additional crucial information on existing regional WPV policies or specific intervention frameworks at institutional level [ 31 , 40 ]. Furthermore, reports of the mediating functions of federal- or state-level central funding and legal acts or regulatory support in establishing effective regional violence policies were also absent in primary settings. Further discussion in this area is crucial as significant federal or state government support would improve HCWs’ perceptions of regional prevention program and would potentially reduce the rate of violence against HCWs.

Opportunities for future research

Only a few studies discussing WPV in the PHC setting have been published over the 10 years covered in this review. Local researchers and stakeholders should define and prioritise important areas of study. Given the heterogeneity of the forms of violence, it might be advantageous to conduct additional observational research in the future to describe the situation and investigate the associations between the rate of violence and its multiple predictors using Poisson regression analysis [ 59 ]. At the present stage, quasi-experimental evidence is ambitious. Therefore, more longitudinal studies are required to evaluate the efficacy of any newly introduced violence prevention and management measures designed in primary healthcare settings [ 60 ].

A comprehensive investigation of WPV occurrences beyond Type II violence is required to accurately reflect the breadth of the issue and focus on prevention efforts. In the present study, the association pattern between the consequences of WPV for specific perpetrators was not investigated as in prior research due to the scarcity of evidence on Type I, III, and IV violence. For example, Nowrouzi-Kia et al. revealed that the victims of inter-professional perpetuation (Type III) experienced more severe consequences involving their professional life (low job satisfaction, increased intention to quit) than those who experienced patient or family-perpetrated violence (Type II), which involved psychological and emotional changes [ 61 , 62 ]. In addition, the study scope must also be expanded to include assaults against both healthcare personnel and patients in primary settings. A hospital-based investigation by Staggs 2015 revealed a significant association between the number of staff at psychiatric patient units and the frequency of violent incidents. Surprisingly, this rigorous investigation determined that higher levels of hospital staffing of registered nurses were associated with a higher assault rate against hospital staff and a lower assault rate against patients [ 63 ].

Despite universal exposure to WPV, the incidence rates and types of violence vary between regions. Thus, the primary investigation focus should be tailored to specific violence issues in a particular setting. Our results highlighted the need for further research into strengthening WPV policy, particularly concerning the reporting systems in regions outside European and American countries. Compared to other regions, local academicians in Southeast Asia and Africa are encouraged to increase their efforts to perform more epidemiological WPV studies in the future to better understand the WPV issue. It is crucial to identify the underlying causes of low prevalence of sexual harassment, particularly in the Middle East, which might be caused by under-reporting influenced by culture or gender bias. Although it is asserted that sexual-based violence is likely to occur commonly in cultures that foster beliefs of perceived male superiority and female social and cultural inferiority, the reported prevalence rate of such violence in certain regions [ 64 ], particularly in the Middle East, was low, possibly due to under-reporting. Thus, to address this persistent problem, the existing reporting mechanisms must be improved and sexual-based violence should be distinguished from other forms of violence to encourage more case reporting. Simultaneously, sexual-based violence should also be defined differently across countries and various social and cultural contexts to reduce impediments to reporting [ 64 ].

In existing studies, the main focus of work-related predisposing factors is based on superficial situational analysis, which is identified using the local version of the standard WPV instrument tool via a quantitative approach. Nevertheless, this weak evidence would not support a more effective preventive WPV framework. This issue should be addressed in more depth and involve psychosocial workplace elements that cover interpersonal interactions at work and individual work and its effects on employees, organisational conditions, and culture. Qualitative investigations that complement and contextualise quantitative findings is one means of obtaining a greater understanding and more viewpoints.

Implications of WPV policies

The results had major effects on WPV prevention and intervention policies in the PHC setting. The results highlighted the importance of enacting supportive organisational conditions, such as providing adequate staffing, adjusting working hours to acceptable shifts, or developing education and training programmes. As part of a holistic solution to violence, training programmes should focus on recognising early indicators of possible violence, assertiveness approaches, redirection strategies, and patient management protocols to mitigate negative effects on physical, psychological, and professional well-being. While previous WPV studies focused more on physical violence and inspired intervention efforts in many organisational settings, our results necessitate attention on non-physical forms of violence, which include verbal harassment, sexual misconduct, and intimidation. The increased potential of domestic- and crime-type violence in PHC settings necessitates expanded prevention programmes that address patients, visitors, healthcare providers, the surrounding community, and the general population.

Our results demonstrated that under-reporting of violent events remains a key issue, which is attributable to a lack of standardised WPV policies in many PHC settings. The initial action that should be implemented in accordance with human resource policy is to establish a system that renders it mandatory for victims, witnesses, and supervisors to report known instances of violence to HCWs. Unnecessary and redundant reporting processes can be reduced by an advanced system for rapidly recording WPV incidents, such as in hospital settings, where WPV is reported via a centralised electronic system. However, healthcare professional and organisational advocacy remains necessary. These parties must promote the value of routine procedures to ask employees about their encounters with patient violence and to foster an environment, where the organisation encourages reporting of violent incidents.

In addition to insufficient reporting, it is crucial to draw attention to the manner in which violent incident investigations are currently conducted in most workplaces. In reality, the incident reporting focuses on the violence itself and its superficial or circumstantial analysis, as opposed to an in-depth examination of the causes of violence, which are due to workplace psychosocial hazards, poor clinic environment, or poor customer service. For example, if any patient-inflicted violence occurred as a result of unsatisfactory conditions caused by poor clinic service, such as unnecessary delay, the tendency is to report on the perpetrator’s behaviour or on the violence itself rather than the unmet health service provision issue. In the long-term, however, the findings of such an investigation would not support the development of a violence prevention and management guideline, as it focuses on addressing aggressive patients rather than enhancing clinic service quality. Therefore, the relevant authorities should formulate a proper plan to improve the existing reporting and investigations mechanism to ensure that it is more comprehensive, structured, and detailed, either by providing proper training for the investigators or conducting institutional-level routine root cause analysis discussions, so that the violence hazard risk assessment can be framed effectively to resolve the antecedent factors in the future.

Nonetheless, there remains much room for primary-level improvement in WPV awareness and abilities. Reports on the mediating roles of federal- and state-level central funding and regulatory support for efficient local WPV policies at primary level have not been found. Therefore, more studies will be necessary to fill these gaps and concentrate on examining the relationship between regional WPV policies and national support. Possibly, more central funding and state regulation following new positive results can be made available to aid local preventive programs. A strong central financial support is essential to support regional preventive programmes, such as employing security guards, enhancing the physical security of health facilities buildings, and research grants. Awadalla and Roughton strongly suggested that adequate national-level financial support is one of the essential components of successful regional policies that would alter HCW perceptions [ 65 ]. In terms of law and regulation, for example, Ferris and Murphy firmly supported the role of the Occupational Safety and Health Act (OSHA) via the issuance of the “Enforcement Procedures for Investigating or Inspecting Workplace Violence” instructions to institutional-level officers as one of the essential components of local WPV prevention strategies [ 66 ].

Study strength and limitations

The present study is a preliminary systematic review that explored evidence of WPV against all PHC workers in empirical studies worldwide. The breadth of the review was achieved by incorporating numerous peer-reviewed high-quality published studies, which enabled us to derive a solid conclusion. The approach relied on the authors’ prior knowledge of the study topic, the standard review technique, and specialised keywords.

It is also important to emphasise several potential limitations. First, recall bias was introduced in most studies as the authors used self-reporting to recall previous incidents either up to 12 months prior or after a lifetime. As most of the included studies involved small sample sizes, a few studies with low response rates restricted the generalisability of the findings. Several studies were descriptive and were cross-sectional; consequently, extra caution should be applied when making inferences pertaining to the risk factor interactions with violence. Variability in the instrument used, data collection and analysis methods, the notion of violence, and the general study objective might account for the heterogeneity across studies, which limited comparisons across studies. As PHC health system delivery between countries is described by different terms or names or might be identified by names besides those used in the present study, studies that use such terms might have been overlooked during the database search.

WPV in the PHC setting is a common and growing issue worldwide. Many PHC workers reported experiencing violence in recent years, strongly suggesting that violence is a well-recognised psychosocial hazard in PHC comparable to hospital settings. HCWs are highly susceptible to violence perpetrated by patients or their families, which results in considerable negative consequences. With various predisposing factors, this complex issue indicates a need for more serious consideration of a resolution on par with that in the tertiary setting. Several research gaps and limitations necessitate additional rigorous analytical and interventional research in the future. Information on violent events must be comprehensively collected to delineate the complete scope of the issue and formulate prevention strategies based on potentially modifiable risk factors. Thus, a new interventions framework to mitigate violent events and control their negative implications can be established. The results presented here were derived from literature on diverse cultures worldwide, and, therefore, can be used as a data reference for policymakers and academicians for future opportunities in the healthcare system field.

Availability of data and materials

All data generated or analysed during this study are included in this published article.

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We are grateful to the Dean of the Universiti Kebangsaan Malaysia (UKM) School of Medicine for granting permission to publish this work. We also thank the head of the UKM Community Health Department and its staff for their excellent cooperation during this study.

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Yusoff, H.M., Ahmad, H., Ismail, H. et al. Contemporary evidence of workplace violence against the primary healthcare workforce worldwide: a systematic review. Hum Resour Health 21 , 82 (2023). https://doi.org/10.1186/s12960-023-00868-8

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Original research article, workplace violence and its associated factors among nurses working in university teaching hospitals in southern ethiopia: a mixed approach.

• 1 Department of Nursing, Hawassa College of Health Sciences, Hawassa, Ethiopia
• 2 Department of Nursing, School of Health Sciences, Goba Referral Hospital, Madda Walabu University, Bale Goba, Ethiopia
• 3 Department of Nursing, Wachemo University, Hossana, Ethiopia
• 4 Department of Public Health, Hawassa College of Health Sciences, Hawassa, Ethiopia

Background: Workplace violence among nurses has increased dramatically in the last decade. Still, mitigation techniques have not been well explored; many studies used a quantitative research approach, and there is a knowledge gap on the current status of workplace violence. The aim of this study was to assess the prevalence of workplace violence and associated factors among nurses working at university teaching hospitals in the South Region of Ethiopia.

Methods: An institution-based cross-sectional study was conducted using a mixed approach. A random sample of 400 nurses was interviewed for the quantitative analysis, and nine key informants were interviewed for the qualitative analysis. Descriptive statistics were used to summarize the data. A logistic regression model was used to analyze the data. An adjusted odds ratio with a 95% confidence interval and a corresponding p -value < 0.05 was used to determine the association between variables. The qualitative data were transcribed and translated, then themes were created, followed by thematic analysis using Open Code version 4.02.

Results: The prevalence of workplace violence was 61.3% within the last 12 months. Nurses working in emergency departments [AOR = 4.27, 95% CI: 2.21, 8.24], nurses working in inpatient departments [AOR = 2.58, 95% CI: 1.40, 4.72], the number of nurses in the same working unit from one to five [AOR = 2.36, 95% CI: 1.21, 4.63], and six to ten staff nurses [AOR = 2.12, 95% CI: 1.17, 3.85], nurses routinely making direct physical contact [AOR = 2.77, 95% CI: 1.55, 4.95], and nurses' work time between 6 pm and 7 am [AOR = 1.68, 95% CI: 1.00, 2.82] were factors significantly associated with workplace violence.

Conclusion: In this study, the prevalence of workplace violence against nurses was high. We identified factors significantly associated with workplace violence among nurses. Interventions should focus on early risk identification, the management of violent incidents, and the establishment of violence protection strategies that consider contextual factors to reduce workplace violence.

Introduction

Workplace violence (WPV) is defined as incidents where staff is abused, threatened, or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit threat to their health, safety, or well-being ( 1 ). According to the National Institute for Occupational Safety and Health, workplace injuries are classified as Type I: the perpetrator is acting criminally and has no ties to the company or its workers, Type II: When a customer, client, or patient receives care or services, they get violent. Type III: employee-to-employee violence, and Type IV: personal relationship violence ( 2 ). Workplace violence against nurses has increased dramatically in the last decade. According to some research, there has been a 110 percent increase in the rate of violent injuries against health care employees in the last decade in the United States of America (USA) from 2005 to 2014 ( 3 ).

Workplace violence toward health service professionals is recognized as a global public health issue ( 4 ). Violence against nurses is a major challenge for healthcare administrators. So workplace violence is considered an endemic problem in the health care system ( 5 ), and nurses are at a higher risk of abuse compared to other healthcare providers ( 3 ). Nearly 1/4th of the world`s workplace violence occurs in that sector ( 6 ). Workplace violence in the health sector found that nurses were three times more likely than other occupational groups to experience workplace violence ( 7 ).

Violence against nurses at the workplace is increasing at an alarming rate in both developed and developing countries, affecting the quality of their work ( 3 ). Nurses frequently experience violence, which causes feelings of job insecurity and physical and psychological injury ( 8 ). Also, workplace violence decreases interest in the job, causes burnout, turnover, and feelings of inadequate support, reduces the organization's power, and ultimately reduces the performance and reputation of the organization ( 8 ). Many studies were done using a quantitative approach, which provided less detail on perception, motivation, and belief among nurses. To the knowledge of the investigators, much is not known about the prevalence and factors associated with workplace violence among nurses. The aim of this study was to assess the prevalence and associated factors of workplace violence among nurses working at university teaching hospitals in the South Region of Ethiopia, using a mixed approach.

Materials and methods

Study setting and period.

The study was conducted at the university teaching hospitals found in SNNPR, South Ethiopia. SNNPR is the third-largest administrative region in the country and the most diverse region in terms of language, culture, and ethnic background. Administratively, the region is divided into 15 zones and 7 special districts. According to the 2021 Regional Health Bureau Report, there is one specialized hospital, four university teaching hospitals, nine general hospitals, 59 primary hospitals, 594 health centers, and 3,422 health posts found in the region. Wolkite, Wachemo, and Wolaita Sodo University Teaching Hospitals were included in the study. According to the human resource management report, there were 950 nurses in total (156 at Wolkite University Teaching Hospital, 342 at Wachemo University Teaching Hospital, and 452 at Wolaita Sodo University Teaching Hospital). The study was conducted to assess workplace violence among nurses within the past 12 months, from April 6 to May 6, 2022.

Study design

Institution-based cross-sectional study that includes both quantitative and qualitative methods was conducted.

Study population and sample size

Nurses working at the teaching hospitals in the South Region of Ethiopia were included in the study. Academic staff nurses were not included in the study. The sample size was calculated using a single population proportion formula, considering the 43.1% prevalence of WPV in public health facilities in Gamo Gofa, Ethiopia ( 9 ). Assuming the margin of error is 0.05, and the confidence level of 0.05 at a 95% confidence interval ( 9 ). It was calculated as n = (Z1-α/2) 2 p (1-p)/ d 2  = (1.96)2*0.431*0.569/0.05) 2  = 377. The calculated sample size was 377. Adding the 10% non-response rate, a total of 415 randomly selected nurses were included in the study by proportional allocation. For the qualitative part, nine purposefully selected staff nurses, unit leader nurses, and matrons of the University Teaching Hospitals, SNNPR, South Ethiopia, were involved in the study.

Main study outcome variable

The main outcome variable in this study was workplace violence among nurses within the last 12 months, which included abuse, threat, or assault related to their work, including commuting to and from work, involving an explicit or implicit threat to their health, safety, or well-being. The outcome variable was obtained using the question, “In the last 12 months, have you been attacked in your workplace?” It was explained as a categorical variable with two possible values: the presence (“yes”) or absence (“no”) of workplace violence.

Data collection tools and procedure

The questionnaire adapted from “WPV in the Healthcare Sector” developed by the “Joint Programme on WPV in the Health Sector by ILO/ICN/WHO/PSI” and an instrument developed by the American Emergency Nurses Association were used in this study ( 7 ). The questionnaire was prepared first in English, translated into Amharic, and then back to English to maintain its consistency. A pretest was done on five percent of the total sample size at Hawassa University Teaching Hospital to evaluate the validity of the instruments. The data were collected on socio-demographic and workplace characteristics, physical violence, verbal abuse, and sexual harassment by nurses in their workplaces. Two BSc. nurses were used as data collection facilitators, with one supervisor per hospital. Both the facilitators and supervisors were given a one-day training to explain the aim and content of the instrument and ensure the quality of the data. The collected data were checked for completeness and consistency on the spot during the data collection period.

Concerning qualitative data, the principal investigator and one supervisor conducted the interview, which was guided by an unstructured questionnaire. Each individual contributor was interviewed separately in a private room, at a different time, outside of working hours, for 20–30 min. The interview was tape-recorded, and the principal investigator took notes to capture the conversation points. To ensure the credibility of the qualitative data, we used members' checks by sending the findings back to key informants for confirmation and validation of their opinion and perception, and the consistency of the findings with the raw data was checked.

Data analysis

The data were checked for completeness, coded, and entered into Epi Data version 3.1. Then the data were exported and analyzed using Statistical Package for Social Science (SPSS) version 26. Frequency with a percentage was used to report categorical variables, while mean with a standard deviation was used to report continuous variables. Binary logistic regression was conducted to identify candidate variables for the adjusted model, with a p -value of ≤0.25. The variables considered include: sex of respondents, level of education, work experience, work unit, number of staff in the same working unit, routine direct physical contact with the client, worry about violence in the workplace, and work time between 6 p.m. and 7 a.m. The model's fitness was evaluated using the Hosmer-Lemeshow fitness of good test, which yielded a non-significant value ( p  = 0.604), indicating that the data fit reasonably well. The variance inflation factor was used to determine multicollinearity (VIF = 1.02), showing the absence of extreme multicollinearity among explanatory variables. An adjusted odds ratio (AOR) with a 95% confidence interval was used to identify factors significantly associated with the outcome variable.

The qualitative data were transcribed word for word into the local language and then translated into English after the in-depth interview. Then, based on the study's subject topic or key variables, similar replies were aggregated and summarized. By importing the data in plain text into Open Code version 4.02, codes were created, followed by categories and themes. The themes were defined and interpreted, followed by a narration of the pertinent findings. Finally, the qualitative findings were presented in a narrative format.

Quantitative analysis

In this study, we included a sample of 415 randomly selected nurses from the hospitals, with a response rate of 96.38%. Nearly half (50.3%) of the participants were male, and 36.5% of them were in the age category of 20–24 years. One-third (66%) of the participants were married. Concerning their academic status, more than three-fourths (76%) of the respondents had bachelor's degrees, and 40.5% of the respondents were working in the inpatient ward at the time of the study ( Table 1 ).

Table 1 . The socio-demographic characteristics of nurses who were working at University Teaching Hospitals in the South Region, Ethiopia, 2022, ( n  = 400).

The magnitude of workplace violence and forms of violence

Among the 400 nurses enrolled in this study, 245 (61.3%) had experienced workplace violence during the previous 12 months. The majority of the respondents, 165 (67.07%), reported that they had experienced verbal abuse as a form of workplace violence, while 11 (4.47%) experienced sexual harassment ( Figure 1 ).

Figure 1 . Magnitude of the different forms of workplace violence among nurses in University Teaching Hospitals in South Nation, Nationalities, and People Region South Ethiopia, April, 2022 ( n  = 400).

Organizational characteristics of the study participants

More than half (56.4%) of the nurses were working in shifts. About 51% of the participants` work time was between 6 PM and 7 AM, and 44% of them contained 6–10 nurses in the same working unit. Nearly three-fourths (73.2%) of them had routine direct physical contact with their client. About 37.3% and 25.3% of the participants were worried and very worried about workplace violence, respectively. About 46.7% of the participants were dissatisfied, and 78% of them were very dissatisfied with the way the institutions handled violent incidents ( Table 2 ).

Table 2 . Organizational characteristics of nurses who worked at University Teaching Hospitals in South Region, Ethiopia, 2022, ( n  = 400).

Perpetrator factors

Among the respondents, about 297 (74.4%) of the respondents described perpetrators of workplace violence as mainly patients' relatives, while 18 (4.5%) described them as management or supervisors ( Figure 2 ).

Figure 2 . Perpetrators for workplace violence among nurses working in University Teaching Hospitals in South Nation, Nationalities and People Region South Ethiopia, April 2022, ( n  = 400).

Bivariate and multivariable analysis of factors associated with workplace violence

In the bi-variable logistic regression analysis, the sex of respondents, level of education, work experience, work unit, number of staff in the same working unit, routine direct physical contact with the client, worry about violence in the workplace, and work time between 6 p.m. and 7 a.m. were considered candidate variables for multivariable analysis at a p -value ≤ 0.25. Among the eight variables that were identified in the bi-variable logistic regression analysis, only four variables remained to have a statistically significant association with workplace violence at a 95% CI and a significance level of p  ≤ 0.05 in the multivariable logistic regression analysis ( Table 3 ).

Table 3 . Multivariable logistic regression analysis of factors associated with workplace violence among nurse in University Teaching Hospitals in South Ethiopia, 2022, ( n  = 400).

Qualitative analysis

Themes, sub -themes and codes from in-depth interview.

After conducting a key informant (KI) interview, the audio recorded data were translated from Amharic to English and transcribed into a text transcript, followed by importing into Open Code version 4.02. Thematic analysis was done using open source code version 4.02. Two themes, eight sub-themes and thirteen codes were created from thematic analysis ( Table 4 ).

Table 4 . Themes, sub -themes codes from thematic analysis of in-depth interview key informants in the University Teaching Hospitals in the South Region, Ethiopia, 2022.

Explored qualitative findings of mitigation approaches to workplace

Runners and guardians should be hired sufficiently in health facilities, nurses' job descriptions should be put clearly and the independents' roles of nurses should be well addressed.

A key informant (KI) said, “Runners and guardians should be hired sufficiently in health facilities. Nurses should not do the runner's work. When nurses are at school, they are well educated, both theoretically and practically. But in the work area, there is no well-identified job description and no established system to diagnose, treat, etc. them. So nurses’ job descriptions should be clearly stated, and the independents roles of nurses should be well addressed (we can clerk, take histories, diagnose, and treat). The ENA should give attention to this issue.” All staff should be punctual; card room workers should keep patient cards in a good manner.

KI said, “Every staff member should work through team spirit. As well, the hierarchy should be kept. Every staff member should know their responsibility and perform it accordingly. All staff should be punctual. They should always be available at their workplace during working and duty hours. Card room workers should keep patient cards in a good manner. Also, it is better if card work is computerized. ENA should be strengthened and organized to minimize such violence.” Admin and runners should welcome customers and raise awareness of their rights and duties to patients and their attendants.

KI said, “Admin and runners should welcome customers and give awareness of their rights and duties to patients and their attendants. Physicians should be available on time. They should not be negligent. Every employee should play his or her role.” Nurses should use words that patients understand easily. KI said, “Nurses and physicians should be punctual. Nurses should use words that patients understand easily and never use jargon words.” The nurse should be sufficiently hired, a lab machine should be available in the facility, and porters should collect lab findings without delay and on time.

KI said, “Human resources should be increased in the card room. And nurses should be hired. A lab machine should be available in the facility to reduce referrals for lab investigations. Also, porters should collect lab findings without delay and timely important measures that would reduce violence.” Nurses should have good knowledge and skill. When perform different procedures, privacy should be kept, and it is better if the guardians are nearby nurses. Nurses should be recognized for their good performance. KI said, “Nurses should have good knowledge and skills that challenge others who undermine them. Those measures might reduce violence. When nurses perform different procedures, privacy should be kept, and it is better if the guardians are nearby nurses. Duty rooms for male and female nurses should be separated. Nurses should be recognized for their good performance.” The guardians (security measures) and restricted public access were important to reduce workplace violence.

KI said, “When nurses perform different procedures, privacy should be kept, and it is better if the guardians are nearby nurses.”

Another KI said, “The health facility's security should be strengthened.”

In this study, we determined the prevalence and associated factors of workplace violence among nurses in southern Ethiopia. As a result, we found that the prevalence was high and that there were factors significantly associated with workplace violence against nurses. Working in emergency departments, working in inpatient departments, work shifts, the number of nurses in a working unit, and the presence of regular direct physical contact with clients were identified as risk factors of workplace violence in our study.

In the current study, the majority (61.3%) of the respondents had a history of workplace violence within the past 12 months. Nearly similar findings were reported from the studies conducted in the Amhara region, Ethiopia (58.2%) ( 10 ), North east Ethiopia (56%) ( 9 ), and Eastern Ethiopia (64%) ( 11 ), Tunisia (56.3%) ( 12 ), Rwanda (58.5%) ( 13 ), Gambia (62.1%) ( 14 ), Bangladesh (64.2%) ( 15 ), Nepal (64.5%) ( 16 ), and Istanbul, Turkey (64.1%) ( 17 ). However, it was lower than a certain study finding conducted in the Oromia region, Ethiopia, reported at 82.2% ( 18 ), in Egypt (80.4%) ( 19 ), elsewhere in Iran (82.6%) ( 20 ), and China (79.39%) ( 21 ). On the other hand, our finding was higher compared to the research results conducted in Hawassa, Ethiopia (29.9%), Gamo Gofa, Ethiopia (43.1%) ( 22 , 23 ), northwest Ethiopia (26.7%) ( 8 , 24 ), and elsewhere in China (34%) ( 25 ), respectively. The discrepancies may be due to the differences in sample size, socioeconomic characteristics, study designs, and the duration of the studies.

The majority of nurses were worried about workplace violence and dissatisfied with the way the situation was handled in this study. Similar results were reported from the studies conducted in Ethiopia ( 22 , 26 ). The possible justification could be due to the shortage of guardians (security measures) and a lack of training on effective workplace violence prevention measures. The major perpetrators of workplace violence were patients' relatives and patients, which was similar to the study reports done in the Oromia region, Ethiopia ( 27 ), Gamo Gofa zone, Ethiopia ( 9 ), and Saudi University Hospitals ( 4 ). This similarity could be because nurses interact with patients and their relatives in high-stress circumstances; nurses also have a closer and longer relationship with patients; poor communication between nurses and clients; understaffing; shortage of drugs and supplies; staying a long hour to get a card and when the card is missed; and a shortage of security. In the Ethiopian healthcare system, appointment cards are very important for service provisions. At the first visit, after registration, clients are given appointment cards, and they are expected to bring the cards every time they come for medical services. If they lose it, they are expected to get new card with additional charges, or the person in charge is expected to search their registry manually since they lost the card number, which takes time. This is the point where conflicts arise between clients and healthcare professionals due to delay or charges to get new appointment card. Card rooms require proper organization, adequate staffing, and sufficient space. Furthermore, all patient information must be recorded in the electronic medical catalog system, avoiding any duplication. The card room, when managed properly, facilitates health service delivery by keeping patient information safe and accessible.

In this study, we found that nurses working in emergency departments had 4 times higher odds of experiencing workplace violence compared to those in outpatient departments. This finding is similar to that of a study conducted in Hawassa, Ethiopia ( 22 ), Eastern Ethiopia ( 11 ), Northwest Ethiopia ( 24 ), Rwanda ( 13 ), elsewhere in Iran ( 28 ), and in Kathmandu, Nepal ( 29 ). The possible reasons for the similarity could be due to the fact that emergency rooms are the more stressful and anxious areas for a client, the attendants, and the nurses, where unexpected events like deaths occurred and there was an absence of security. Furthermore, high patient flow, the seriousness of the patient's condition, a high workload, and longer hours of contact with the patient and their relatives might be possible reasons. This study revealed that the odds of workplace violence were 3 times higher among nurses working in inpatient departments compared to those who work in outpatient departments. This finding is supported by the results of studies conducted in Ethiopia ( 8 , 11 , 22 , 24 , 27 ) and a study done in Kathmandu, Nepal ( 29 ). This could be because of client pathologic conditions and waiting for a long time to get the service, which causes them to become irritated and dissatisfied and results in violence against nurses in the workplace.

In the current study, work shift was statistically significantly associated with work place violence against nurses. The odds of workplace violence were 2 times higher among nurses who work night shifts compared to those who work day shifts. This finding is in line with the results of certain studies conducted in Gondar, Ethiopia ( 10 ), elsewhere in Egypt ( 2 ), KwaZulu-Natal Province, South Africa ( 30 ), and Macau, China ( 31 ). This could be due to the fact that the hospital administration's reduced presence and the shortage of staff during the evening and night shifts, which would require individuals to work alone. Overloaded work creates workplace stress, which would increase conflict with patients and visitors.

This study revealed that work units with 1–5 staff nurses were 2.4 times at higher odds of experiencing workplace violence compared to those with 11 or more. Similarly, those who had 6–10 staff nurses were 2.1 times more likely to experience workplace violence compared to those who had 11 or more. This finding is aligned with the results of a study conducted in Amhara, Ethiopia ( 32 ). This might be due to dissatisfaction with client care and treatment due to an overloading patient-to-nurse imbalance. Furthermore, the lower number of nurses resulted in a patient care delay, causing patients to get irritated.

Finally, nurses who had regular direct physical contact with the client had a three-fold higher chance of experiencing workplace violence compared to those who did not have direct physical contact. This finding is supported by the results of studies conducted in Thailand ( 33 ), and China ( 34 ). This could be because the nurses have frequent direct contact with the client, but nurses have a limited independent role in the university teaching hospital system. When nurses instruct patients to wait for physicians, they may encounter aggressive patients, relatives, and attendants in the service area.

Based on our qualitative findings, by increasing the number of nurses in the working unit, this could reduce the shortening of staff during the evening and night shifts, which would reduce individuals working alone. Overloaded work demands place stress on human resources, which would also decrease conflict with patients and visitors. This might also increase satisfaction with client care and treatment due to the patient-to-nurse balance. When the number of nurses on duty is high during a shift, patient care may be fast, causing patients to feel satisfied. Privacy during the procedure, guardians nearby to nurse, possible justification for the guardians (security measures), and the presence of training on effective workplace violence encourage prevention measures, which would reduce workplace violence. Nurses should use easy words to communicate; porters should collect lab findings without delay and timely; provide training in reducing strategies; and update knowledge and skills for important actions that would reduce violence. Possible justification: this may increase interest in the job and feelings of adequate support, ultimately increasing the quality of nursing care.

Limitations of the study

This study is dependent on the nurses’ capability to recall events in the last 12 months before the study, which is subject to recall bias. Because of the sensitive nature of the subjects (sexual harassment in particular), the study results may have suffered from reporting bias, resulting in an underestimation of nurses' exposure to workplace violence. Cultural norms might also cause recall bias since nurses might not disclose violence in order to keep customs that are accepted by the community. Furthermore, we could not establish the cause-and-effect relationship given that it was a cross-sectional study.

This study revealed that the overall prevalence of workplace violence was high in the study area. We have identified factors significantly affecting workplace violence against nurses. Nurses working in emergency departments, nurses working in inpatient departments, the number of nurses in the same working unit (1–5) and (6–10), nurses direct physical contact, and nurses work time between 6 p.m. and 7 a.m. were significantly associated with workplace violence among nurses. Interventions should focus on increasing the number of nurses, establishing private rooms for procedures, providing training on reduction strategies, and updating nurses' knowledge and skills that would help reduce violence.

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics statement

The studies involving humans were approved by Research Ethics Committee of Madda Walabu University, Goba Referral Hospital. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

Author contributions

BA: Conceptualization, Data curation, Formal Analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. AR: Conceptualization, Data curation, Investigation, Methodology, Software, Supervision, Validation, Visualization, Writing – review & editing. ZG: Conceptualization, Data curation, Investigation, Methodology, Software, Supervision, Validation, Visualization, Writing – review & editing. AH: Conceptualization, Data curation, Investigation, Methodology, Resources, Software, Validation, Writing – review & editing. SN: Conceptualization, Data curation, Investigation, Methodology, Software, Validation, Visualization, Writing – review & editing. TA: Conceptualization, Data curation, Investigation, Methodology, Software, Validation, Visualization, Writing – review & editing.

The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.

Acknowledgments

We would like to thank the data collectors and supervisor for their coordinated work during data collection. Our heartfelt gratitude also goes to the study participants for giving valuable information to make our study fruitful.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Abbreviations

AOR, adjusted odds ratio; BSc, Bachelor of Science; WPV, workplace violence; SNNPR, southern nations, nationalities and peoples region; ILO, International Labor Organization; WHO, World Health Organization; VIF, variance inflation factor; SPSS, statistical software packages for social sciences.

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Keywords: nurses, workplace, violence, South Ethiopia, associated factors

Citation: Anose BH, Roba AE, Gemechu ZR, Heliso AZ, Negassa SB and Ashamo TB (2024) Workplace violence and its associated factors among nurses working in university teaching hospitals in Southern Ethiopia: a mixed approach. Front. Environ. Health 3:1385411. doi: 10.3389/fenvh.2024.1385411

Received: 12 February 2024; Accepted: 17 April 2024; Published: 9 May 2024.

Reviewed by:

© 2024 Anose, Roba, Gemechu, Heliso, Negassa, and Ashamo. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Teshale Belayneh Ashamo [email protected]

This article is part of the Research Topic

Global environmental injustice: the workplace and beyond

Workplace Violence Research

In the 1980’s a series of shootings at post offices drew public attention towards the issue of workplace violence. While mass shootings receive a lot of media attention, they actually account for a small number of workplace violence events . NIOSH has been studying workplace violence since the 1980s. In 1993, NIOSH released the document Preventing Homicide in the Workplace . This was the first NIOSH publication to identify high-risk occupations and workplaces. The research revealed that taxicab establishments had the highest rate of workplace homicide–nearly 40 times the national average and more than three times the rate of liquor stores which had the next highest rate. NIOSH worked to further inform workers and employers about the risk and encourage steps to prevent homicide in the workplace in the 1996 document Violence in the Workplace which reviewed what was known about fatal and nonfatal workplace violence to focus needed research and prevention strategies. The document addressed workplace violence in various settings such as offices, factories, warehouses, hospitals, convenience stores, and taxicabs, and identified risk factors and prevention strategies.

Workplace violence is the act or threat of violence, ranging from verbal abuse to physical assaults directed toward persons at work or on duty. The impact of workplace violence can range from psychological issues to physical injury, or even death. Violence can occur in any workplace and among any type of worker, but the risk for fatal violence is greater for workers in sales, protective services, and transportation, while the risk for nonfatal violence resulting in days away from work is greatest for healthcare and social assistance workers.

There continues to be groups of workers who are disproportionately affected by workplace violence. In 2013, NIOSH researchers contributed to a publication focused on health disparities and inequalities. [i] Number and rates of homicide deaths over a 5-year span for industry and occupation groups were presented by race/ethnicity and nativity. Further analyses published in 2014 in the American Journal of Industrial Medicine controlling for other factors reported elevated homicide rate ratios for workers who are Black, American Indian, Alaska Natives, Asian, or Pacific Islanders, and those who were born outside of the United States.[ii] NIOSH researchers continue to work towards identifying disparities where they exist so we can better focus our research and translation efforts to the workforces and communities of workers that need them. See below for examples of research conducted by NIOSH on identifying disparities in specific workforces.

Health Care

In the late 1990s and early 2000s, U.S. healthcare workers accounted for two-thirds of the nonfatal workplace violence injuries in all industries involving days away from work.[iii] To address the issue of violence in healthcare, in 2002, NIOSH published Violence: Occupational Hazards in Hospitals which discussed prevention strategies in terms of environmental (installing security devices), administrative (staffing patterns), and behavioral (training).

NIOSH and its partners recognized the lack of workplace violence prevention training available to nurses and other healthcare workers. To address this need, in 2013, NIOSH and healthcare partners developed a free on-line course aimed at training nurses in recognizing and preventing workplace violence. This award-winning course, Workplace Violence Prevention for Nurses , has been completed by more than 65,000 healthcare workers. Violence remains an issue for healthcare workers. Home healthcare workers are also at risk for violence as they work closely with patients and often are in close contact with the public while they provide healthcare services to patient. The issue of violence in home healthcare will likely increase as the industry is projected to grow dramatically in the coming years.

Convenience Stores

Robbery-related homicides and assaults are the leading cause of death in retail businesses. In 2019, workers in convenience stores had a 14 times higher rate of deaths due to work-related violence than in private industry overall (6.8 homicides per 100,000 workers vs. 0.48 per 100,000 workers). With these deaths are disparities among the homicide victims. Specifically, Black, Asian, and Hispanic men have disproportionately higher homicide rates than white men. Additionally, foreign-born men have disproportionately higher homicide rates than U.S.-born men, and men 65 and older have disproportionately higher homicide rates than any other age group.[iv]

NIOSH research demonstrated that retail establishments using Crime Prevention Through Environmental Design (CPTED) programs, which suggest that environments can be modified to reduce robberies, experienced 30%–84% decreases in robberies and a 61% decrease in non-fatal injuries. A recent analysis of crime reports spanning 10 years found robbery rates decreased significantly in convenience stores and small retail establishments after a Houston ordinance based on CPTED countermeasures became effective.[v]

 Taxicab Drivers

Driving a taxi remains a dangerous job. The most serious workplace violence issues facing taxi drivers are homicide and physical assaults which are often related to a robbery. Deaths due to workplace violence among taxi drivers occur disproportionately among drivers who are men (6 times higher than women), drivers who are Black or Hispanic (double that of drivers who are Non-Hispanic and White), and drivers in the South United States (almost triple that of drivers in Northeast).[vi] NIOSH research evaluated the effect of cameras installed citywide on taxi driver homicide rates in 26 U.S. cities spanning 15 years and found those cities with camera-equipped taxis experienced a 3-fold reduction in driver homicides compared with control cities. [vii] NIOSH and the Occupational Safety and Health Administration together identified prevention measures to reduce the risk of violence including increasing visibility into the taxi, minimizing cash transactions, and security measures such as security cameras, silent alarms, and bullet-resistant barriers. [viii]

Teachers and School Staff

In 2008, NIOSH undertook a large state-wide study to measure physical and non-physical violence directed at teachers and school staff in Pennsylvania. Working with national, state, and local education unions, the study described and quantified physical workplace violence against teachers and school staff and measured the impact of violence on job satisfaction and the mental health of teachers and staff. Some of the most significant findings from that study include:

• Special education teachers were at the highest risk of all teachers and school staff for both physical and nonphysical workplace violence.
• While physical assaults were rare, non-physical violence was not. Over 34% of teachers and school staff had experienced either bullying, threats, verbal abuse, or sexual harassment. Coworkers were the most common source of the violence.
• Both physical and non-physical violence significantly impacted teachers and school workers’ job satisfaction, stress, and quality of life. Those who experienced physical violence were over 2 times more likely to report work as stressful, 2.4 times more likely to report dissatisfaction with their jobs, 11 times more likely to consider leaving the education field and had a higher mean number of poor physical health and mental health days.
• This study highlighted the need for specific prevention efforts and post-event responses that address the risk factors for violence, especially among special education workers. [ix] [x]

Workplace Violence During the COVID-19 Pandemic

Over the last 50 years, NIOSH has seen changes in the risk of workplace violence. The COVID-19 pandemic has presented unique instances of workplace violence. Since the pandemic began in early 2020, U.S. media have reported on retail workers and workers in other industries being verbally assaulted, spit on, and physically attacked while enforcing COVID-19 mitigation practices such as mask wearing or physical distancing. Several international studies have examined violence toward healthcare personnel during the pandemic. Unfortunately, the significant time-lag from the occurrence of these events to data delivery using traditional occupational safety and health surveillance sources means that COVID-19-related workplace violence data will not be available for some time. To address this lag, NIOSH has undertaken multiple studies that used media reports to provide more timely information on the number and characteristics of workplace violence events (WVEs) occurring in U.S. workplaces in the early phases of the COVID-19 pandemic. Preliminary results from the unpublished analysis reveal:

• At least 400 WVEs related to COVID-19 were reported in the media between March 1 and October 31, 2020. Twenty-seven percent involved non-physical violence, 27% involved physical violence, and 41% involved both physical and non-physical violence. Non-physical violence is using words, gestures, or actions with the intent of intimidating or frightening an individual and physical violence is any action that leads to physical contact with the intention of injuring such as hitting, kicking, choking, or grabbing.
• A majority occurred in retail and dining establishments and were perpetrated by a customer or client. Most perpetrators were males (59%) and mostly acted alone (79%).
• The majority of COVID-19-related WVEs were due to mask disputes (72%), and 22% involved perpetrators coughing or spitting on workers.

As the COVID-19 pandemic continues to evolve, employers and employees may have to continue to enforce COVID-19 mitigation policies—which could lead to COVID-19-related WVEs. Clearly, WVEs have impacted industries and occupations differently, especially those requiring workers to be physically present at work during the pandemic. Aside from those noted above, one of the worker groups that has been negatively impacted is public health workers. Other published NIOSH research has found that nearly 12% of state, local, territorial, and tribal public health workers have received job-related threats because of their work, and an additional 23% felt bullied, threatened, or harassed. [xi] While NIOSH has a long history in workplace violence research and prevention, the COVID-19 pandemic has presented unique situations where typical workplace violence prevention strategies may not be effective. NIOSH will continue to conduct research on these events and identify possible prevention strategies to address these unique situations.

This blog is part of a  series  for the NIOSH 50 th Anniversary. Stay up to date on how we’re celebrating NIOSH’s 50 th  Anniversary on our  website .

Dawn Castillo, MPH, is the Director of the NIOSH Division of Safety Research.

Cammie Chaumont Menéndez, PhD, MPH, MS, is a Research Epidemiologist in the NIOSH Division of Safety Research.

Dan Hartley, EdD, is the former NIOSH Workplace Violence Prevention Coordinator.

Suzanne Marsh, MPA, is a Team Lead in the NIOSH Division of Safety Research.

Tim Pizatella, MSIE, is the Deputy Director of the NIOSH Division of Safety Research.

Marilyn Ridenour, BSN, MPH, is a Nurse Epidemiologist in the NIOSH Division of Safety Research.

Hope M. Tiesman, PhD, is a Research Epidemiologist in the NIOSH Division of Safety Research.

[i] CDC [2013]. CDC health disparities and inequalities report – United States, 2013. MMWR Suppl 62(3):1-187.

[ii] Steege A, et al. [2014]. Examining occupational health and safety disparities using national data: a cause for continuing concern. Am J of Ind Med 57:527-538.

[iii] BLS [2020]. Employed persons by detailed industry, sex, race, and Hispanic or Latino ethnicity. United States Department of Labor, U.S. Bureau of Labor and Statistics, http://www.bls.gov/cps/cpsaat18.pdf

[iv] Chaumont Menéndez et al. [2013]. Disparities in work-related homicide rates in selected retail industries in the United States, 2003-2008. J Safety Res 44:25-29.

[v] Davis J, Casteel C, Menendez C [2021]. Impact of a crime prevention ordinance for small retail establishments. Am J Ind Med 64:488-495, https://doi.org/10.1002/ajim23239 .

[vi] Menendez C, Socias-Morales C, Daus M [2017]. Work-related violent deaths in the US taxi and limousine industry 2003 to 2013. J Occup Environ Med 59:768-774.

[vii] [vii]Menéndez C, et al. [2013]. Effectiveness of taxicab security equipment in reducing driver homicide rates. Am J  Prev Med 45(1):1-8.

[viii] NIOSH/OSHA [2019]. NIOSH fast facts: taxi drivers—how to prevent robbery and violence. By Chaumont Menendez C, Dalsey E. Morgantown, WV: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication 2020-100 (revised 11/2019), https://doi.org/10.26616/NIOSHPUB2020100revised112019. Washington, DC: U.S. Department of Labor, Occupational Safety and Health Administration, DOL (OSHA) Publication No. 3976, https://www.osha.gov/Publications/OSHA3976.pdf

[ix] Tiesman H, et al. [2013]. Workplace violence among Pennsylvania education workers: differences among occupations. J Safety Res 44: 65–71.

[x] Konda S, Tiesman HM, Hendricks S, Grubb PL [2020]. Nonphysical workplace violence in a state-based cohort of education workers. J School Health 90: 482-491, https://doi.org/10.1111/josh.12897 .

[xi] Bryant-Genevier J, et al. [2021]. Symptoms of depression, anxiety, post-traumatic stress disorder, and suicidal ideation among state, tribal, local, and territorial public health workers during the COVID-19 pandemic — United States, March–April 2021. MMWR 70:947-952.

36 comments on “Workplace Violence Research”

Comments listed below are posted by individuals not associated with CDC, unless otherwise stated. These comments do not represent the official views of CDC, and CDC does not guarantee that any information posted by individuals on this site is correct, and disclaims any liability for any loss or damage resulting from reliance on any such information. Read more about our comment policy » .

Great blog! Thank you for shedding light on this serious problem.

is this study available in pdf. I want to use it as a reference for my master’s thesis. Thank you in advance

Thank you for your comment You asked “is this study available in pdf? ” The blog itself is not available in a PDF. The blog is a summary of various studies, most of which are included in the reference list. Let us know if you need more information on a particular study.

taxicabs are dangerous .

i did not know some these things thanks

awesome possum

the blog is very reliable. thanks for sharing

At this moment any enviroment has become dangerous. We have to be careful.

Thank you for sharing this.

very dangerous

Thanks for all this information.

thank you for that informative article.

thank you for the information

Interesting and have seen more aggressiveness from family members.

Thanks for the info.

Patient population and family members are becoming more demanding, aggressive and non compliant resulting in an increasingly tense/stressful environment. Due to HCAPS scores driving hospital decisions, these behaviors are often times overlooked to maintain patient satisfaction. Hospital staff are receiving the brunt of this bad behavior which is causing a decrease in interest in bedside nursing.

All this is Great information very helpful.

Even though I usually have good patients ,is true that patients and family members are more demanding.

unfortunately this is nursing environment , stay safe!!

Violence should never be considered part of a typical work environment. NIOSH and its partners are working to address issues related to violence in health care. For example, the creation of the online training Workplace Violence Prevention for Nurses that was referenced in this blog.

Thanks for the information it was very interesting .

Thanks for the information.

Thank you for this helpful Information .

Thanks for make us aware about a good practices on the work place.

This was great. very insightful and helpful

informative, thanks

This information is always good to know, Thank you !

Imformative Thanks

very educational article

Do you have any statistics on workplace violence in longterm care?

Thank you for your comment. This paper published from the Ohio Bureau of Workers Compensation briefly covers workplace violence in skilled nursing.

From the publicly available data from the Bureau of Labor Statistics (BLS) Survey of Occupational Injuries and Illnesses for 2021-2022, the number of nonfatal injuries associated with ‘intentional injury by other person’ were as follows ( see table for more information): • ‘skilled nursing facilities’ = 3,060 cases with days away from work (DAFW) • ‘residential intellectual and developmental disability, mental health, and substance abuse facilities’ = 4,900 cases with DAFW • ‘continuing care retirement communities and assisted living facilities for the elderly’ = 1,410 cases with DAFW

Data for comparison purposes can be extracted from the table that these numbers were extracted from.

According to the publicly available BLS Census of Fatal Occupational Injuries (CFOI) data for 2022 ( see table for more information), the number of fatalities associated with ‘violence and other injuries by persons or animals’ was not reportable. Please note that this doesn’t mean that there were no fatalities associated with violence but that the number did not meet BLS reporting requirements.

This is a great article. Thanks for providing more insight on this topic.

Very Informative

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• Original Research
• Open access
• Published: 17 June 2020

A qualitative study of workplace violence among healthcare providers in emergency departments in India

• Kevin Davey   ORCID: orcid.org/0000-0002-8350-4380 1 ,
• Veda Ravishankar 1 ,
• Nikita Mehta 1 ,
• Tania Ahluwalia 2 ,
• Janice Blanchard 1 ,
• Jeffrey Smith 1 &
• Katherine Douglass 1  

International Journal of Emergency Medicine volume  13 , Article number:  33 ( 2020 ) Cite this article

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Emergency department (ED) workplace violence is increasingly recognized as an important issue for ED providers. Most studies have occurred in developed countries with established laws and repercussions for violence against healthcare providers. There is a paucity of data on workplace violence against ED providers in less developed countries. The aim of this study was to learn more about workplace violence among healthcare providers in EDs in India.

Semi-structured interviews were conducted in-person with physicians, nurses, and paramedics in Indian EDs. Interviews were coded independently using the NVivo qualitative research software. A hybrid thematic analysis approach was used to determine dominant themes. Sixty-three interviews were conducted at 7 sites across India. Interview participants include attending physicians (11), resident physicians (36), nurses (10), and paramedics (5). Events were most often described as involving accompanying persons to the patient, not the patient themselves. Most events involved verbal abuse, although a significant percentage of responses described some kind of physical violence. ED factors such as busy times with high patient volumes or periods of waiting are associated with increased violence, as well as incidents with unanticipated outcomes such as patients with severe illness or death. Decreased levels of health literacy among patients often contribute as the financial stressors of paying for medical care. Providers reported negative consequences of workplace violence on quality of care for patients and their own motivation to work in the ED. Communication strategies were frequently proposed as interventions to mitigate violence in the future including both provider communication as well as public awareness campaigns.

Workplace violence is a frequent reality for this sample of Indian ED healthcare providers. Alarming levels of verbal and physical abuse and their impact on patient care are described. This qualitative study identified unique challenges to Indian ED providers that differ from those in more developed settings, including financial stressors, inadequate enforcement of rules governing behavior in the hospital, and an overwhelming frequency of violence emanating from patient family members and attendants rather than the patients themselves. Further investigation into preventive strategies is needed.

Previous studies have documented the prevalence of workplace violence against healthcare providers [ 1 , 2 , 3 , 4 ]. The ED is particularly prone to violence given the multitude of stressors present in the emergency setting including, but not limited to, high patient volume, high acuity of patient illness, rotating staff, and late hours [ 5 , 6 , 7 ]. While prior studies have examined the phenomenon of violence against emergency healthcare providers, the vast majority of these studies have been conducted in developed western countries with established laws and legal repercussions for violence against healthcare providers. Few studies have been conducted in low resources settings where regulations protecting healthcare providers are more sparse [ 8 ]. Likewise, in many low resource settings, the field of emergency medicine (EM) is still in its infancy and patient understanding of what care is available in the emergency setting may be lacking, potentially further exacerbating the risk of violence. Of those studies that have been conducted in India and other low resource settings, most have been limited in scope, either focusing exclusively on one type of provider (physicians vs nurses vs paramedics), or limited to a single institution [ 9 , 10 , 11 ].

In order to address the issues of violence against emergency healthcare providers in India and other developing emergency care systems, a greater understanding of the unique issues surrounding violence in EDs in low-resource settings is needed. The objective of this study is to gain a better understanding of issues surrounding violence against healthcare providers in Indian ED’s. To our knowledge, this represents the first multicenter, qualitative study of workplace violence among ED healthcare providers in India.

Semi-structured interviews were conducted in person with attending emergency physicians, emergency medicine residents, nurses and paramedics at seven EDs across India. Interviews were conducted by student field researchers who underwent training in proper interview techniques prior to beginning the study. The semi-structured interview guide was developed based on prior studies of violence against healthcare providers and was piloted before initiating the study (Fig. 1 ). The study was approved by the George Washington University Institutional Review Board and verbal consent was obtained from all interview participants. The interviews were conducted in English in a private hospital conference room without interruption. With the exception of the participants’ job title (i.e., physician, nurse, paramedic), no personal identifying information was collected. Interviews were recorded and transcribed.

Interview guide—workplace violence

A hybrid thematic analysis approach was used to determine dominant themes. Interviews were coded independently by two blinded researchers using the NVivo qualitative research software. The independently coded interviews were merged and discrepancies were addressed by a third researcher. The coding scheme can be found in Table 1 . The design and reporting of data were based on the consolidated criteria for reporting qualitative research (COREQ) guidelines.

Sixty-three interviews were conducted at 7 hospital ED’s across India. A map of hospital locations can be found in Fig. 2 . Interviewees include 11 attending physicians, 36 resident physicians, 10 nurses, and 5 paramedics. One interview participant did not give their job title. Common themes were described from the coding scheme and frequencies and relative frequencies of each subtheme are represented in Table 2 . Representative quotations from each theme can be found in Table 3 . Seven themes emerged from thematic analysis: types of violence, experiences of violence, causes of violence, description of violence events, consequences of violence, responsibility for the violence, and prevention strategies. Detailed discussions of each theme can be found below.

Map of hospital locations

Types of violence

Interview participants described the types of violence they experienced in the ED. The most commonly reported type of violence against healthcare providers was verbal abuse (81.4%), although a significant percentage of respondents also reported experience with physical abuse (18.5%). Participants reported almost daily episodes of being shouted at or degraded by patients and their family members or attendants, as well as several who described episodes in which they or their colleagues were physically assaulted.

Experiences of violence

Interview participants described their personal experiences with workplace violence. Over 90% of interview participants ( n = 57) reported personal experience with workplace violence. The most common descriptions were between a patient’s family members or attendants and doctors (54.8%), nurses (12.7%), and other hospital staff (12.7%). Overall, family members or attendants were identified as the most common perpetrators of violence against ED staff. Reported frequencies of violence by patients’ family members or attendants outnumbered violence by patients by more than 4:1. As one resident put it, “It’s mostly the bystanders, and the more number of bystanders, the more likely.” [sub-theme: between attendants/bystanders and doctors].

Causes of violence

Interview participants described what they perceive to be the most common precipitants of workplace violence in the ED. ED dependent factors, such as crowding or wait times, were reported as the most common precipitant of violence against ED providers (27.8%), followed by a lack of health literacy among patients (23.6%), and patients’ financial concerns (13.2%). Interviewees identified that many patients are unfamiliar with the idea of an acuity based triage system, and expect to be seen immediately when they present to the ED. As lower acuity patients are forced to wait they are more likely to become agitated and engage in violence. As one participant described, “The patients don’t understand. In western countries the expected waiting time is 3-4 h. That’s not the case in India. If you ask the patient to wait hardly 10-15 min or 30 min, things go berserk.” [sub-theme: health literacy]. Interview participants also identified the importance that financial implications can play in precipitating workplace violence in the ED. These issues may be exacerbated at private hospitals which may charge more for services. As one participant described, “See India is a developing country, perception is actually different here. What the general public thinks is this hospital charges more, they work like the corporate sector, they don’t bother about patients, they bother only about money.” [sub-theme: financial issues].

Interviewees report that a lack of basic health literacy among patients may serve to exacerbate violence in the ED. As one participant stated “People come with lots of expectations, and the patients are at such critical conditions or at the end stage, that they expect from us that we’ll do some magic. That within a few minutes or an hour or so, their patient will be in better condition. But when eventually that doesn’t happen or the condition of the patient deteriorates they don’t accept it.” [sub-theme: health literacy]. Other common precipitating factors identified by interviewees included emotional factors, such as unanticipated patient outcomes or death (10.6%), communication challenges (11.7%), factors relating to the patient’s age (4.5%), and factors relating to the gender of the patient or the provider (3.8%). Participants stated that violence was more likely to occur with a pediatric patient. As one interview participant described, “If the patient is a child then the parent tends to get angry fast.” [sub-theme: age factors]. Interview participants also observed that gender factors may play a role in ED violence. As one participant noted, “Sometimes the relatives don’t think, seeing a female doctor, that she is confident or she is good enough to treat the patients… They are okay getting treated by a first year who is a male, but not a female doctor who in her second or final year.” [sub-theme: gender factors]. Participants noted that intoxication may play a role in ED violence (3.4%); however, it was identified with relatively little frequency as compared with other common precipitants.

Description of events

Interview participants were asked to describe the circumstances surrounding their experiences with workplace violence in the ED. Common themes that emerged were the involvement of family members or attendants in violent events (51.2%) and the role that timing may play in precipitating events (15%). Many interview participants noted that violent events were more likely to take place at night, when lower ED staffing may result in longer wait times. Furthermore, many interviewees stated that hospital security staffing is also decreased during night shifts and perpetrators of violence against ED providers may feel emboldened by the lack of security personnel.

Consequences

Interview participants were asked to identify the consequences of workplace violence in the ED. Participants overwhelmingly believed that healthcare providers suffered the greatest adverse consequences of ED violence (59.5%), but also identified patients and patient care (30%) as well as society at large (10.5%) as suffering adverse consequences. Interview participants reported a decrease in morale as a result of violent events and acknowledged that fear of violence may affect their medical decision-making, causing them to treat patients in the manner least likely to result in a violent outcome, rather than doing what is medically indicated. As one resident described “Definitely it will affect our work pattern and work efficiency, because we will have to concentrate more time on solving that issue rather than taking care of patients. Other patients will be affected and they will be kept unattended so that also becomes a problem.” [sub-theme: on doctors and providers].

Responsibility

Interview participants were asked to identify whom they believe were responsible for workplace violence in the ED. A variety of different groups were identified including society (25.2%), patient family members or attendants (17.6%), hospitals (16.8%), patients (16%), and doctors (14.5%). Participants acknowledged that much of the violence against healthcare providers in the ED may result from misunderstandings and distrust between patients, their family members, and providers. Participants believe that the root of this misunderstanding is multifactorial, resulting from a lack of basic medical education among the general ED population as well as poor communication between providers and their patients. Many participants also blamed hospitals for failing to provide adequate security as well as failure to enforce hospital rules limiting the number of patient attendants allowed in the ED.

Prevention strategies

Interview participants were asked to offer prevention strategies to mitigate violence against ED providers. Proposed strategies included improved communication between healthcare providers and patients (27.7%), hospital-based interventions (26.3%), and improved patient and society education (20%). Improved communication between patients, their attendants, and providers was repeatedly suggested as a way to decrease incidence of violence in the ED. Participants also called on hospitals to improve security, suggesting measures like increasing the number of security personnel in the ED, adding hospital metal detectors, and greater enforcement of hospital rules on the number of attendants allowed in the ED. Public outreach to improve the medical knowledge of the general population was also seen as an important step. Participants also called for greater government enforcement of laws prohibiting violence against healthcare providers.

Violence against ED healthcare providers is an unfortunate yet common occurrence in Indian EDs. Over 90% of ED healthcare providers interviewed described personal experience with workplace violence. This is consistent with prior studies conducted in more developed countries, which have found a prevalence of violence against ED healthcare providers between 80% and 100% [ 5 , 12 , 13 , 14 ]. With the caveat that existing ED workplace violence data in India is extremely limited, the prevalence found in this study is somewhat higher than previously reported. In the only prior published study to address the issue, a survey of ED residents at a single institution, 89% of respondents said they had witnessed some form of workplace violence, but only 70% reported having been the victim of violence themselves [ 9 ]. The reason for this difference is difficult to ascertain given the dearth of data, but highlights the need for continued research into the issues surrounding ED workplace violence in India.

Several common patterns of violence emerged throughout the course of these interviews. While most of the reported violence is verbal abuse, almost one in five providers reported experience with physical abuse. This is also consistent with prior studies conducted in higher resource settings, which demonstrate similar incidents of both verbal and physical abuse [ 5 , 13 , 14 ]. The commonalities between the patterns of workplace violence in India as compared with higher resource settings can likely be attributed to factors that make the ED especially prone to violence in general. Long wait times, high patient volumes, rotating staff, and a high acuity of illness have all been linked to increases in workplace violence in the ED in more developed countries [ 14 , 15 ]. In our study, interview participants cited ED related factors, such as wait times and unexpected patient outcomes, as the most frequent precipitants of violence against ED providers. Low health literacy among patients was also identified as a common precipitant of violence, similar to findings from prior studies in higher resource settings [ 14 , 15 ].

The findings from these interviews differ from those conducted in higher resource settings in several important ways. One precipitant of violence frequently cited by interview participants that differs substantially from more developed countries was financial concerns. While access to health insurance is increasingly common in India, many people must still pay out of pocket for healthcare expenses [ 16 ]. Unlike in more developed countries, where bills for hospital expenses arrive weeks to months later, in India many patients are presented with a bill at the time of their visit and required to pay before leaving the hospital. In a prior qualitative study conducted at a single hospital in central India, doctors identified growing distrust in the doctor-patient relationship, which they in part attributed to “high payments and high expectations.” In the study, doctors stated that a combination of increasing denial of care for non-paying patients, as well as a refusal to accept poor outcomes by the “buyer of costly healthcare,” were eroding the fundamental building blocks of the doctor-patient relationship [ 10 ]. These observations are consistent among responses of several interview participants who repeatedly cited experiences of violence around unanticipated poor outcomes, and family members upset by the cost of care. Findings from studies in other low-income settings also cite a growing public distrust of medical professionals and the perception that doctors and hospitals are abusing their positions, accepting bribes and providing lower-quality care to poorer patients [ 17 ]. Couple this strained sense of trust with the already fraught ED environment, and it is easy to envision how adding financial stressors, like presenting a patient with a bill, may serve to exacerbated ED workplace violence.

Another major difference reported between ED violence in India and that of more developed countries is the perpetrators of violence. Interview participants overwhelmingly identified those who accompany the patient to the ED, commonly referred to as bystanders or attendants, rather than the patients themselves, as the main perpetrators of violence against ED healthcare providers. This stands in stark contrast to other studies in more developed countries, which have shown that patients are directly involved in up to 90% of all violent events, while friends or family members are implicated in only 11% of violent episodes [ 5 ]. Likewise, while in more developed settings, the vast majority of violent perpetrators have dementia, decompensated mental illness, or intoxication, our interview participants only rarely cited the presence of these factors [ 14 , 18 ]. The reasons for this distinction may be a result of both cultural and regulatory differences. In India, it is extremely uncommon for a person to present to a healthcare setting unaccompanied by a friend or family member. In fact, many hospitals require that patients have an attendant with them in order to be admitted [ 19 ]. These attendants may act as a patient advocate, and even assist with minor nursing duties like basic hygiene and medication administration. While some hospitals have rules limiting the number of attendants, our interview participants report that these rules are rarely enforced. As one participant stated “If we receive a trauma patient, like 10 to 15 attenders will be there. All attenders will be very aggressive.” [theme: description of events; sub-theme: involving bystanders]. Violence perpetrated by patient attendants is also complicated by the tools available to mitigate that violence. While intoxicated or mentally unstable patients can be medicated, violent family members frequently cannot.

Interview participants frequently faulted a lack of adequate security for exacerbating violence in the ED. Participants also reported an increase in violent incidents at night, when there is less security available and when it may be slower to respond. These findings have not been previously described in India, though they are similar to findings from other studies in low resource settings, where providers cited a lack of confidence in the capacity and ability of security staff to provide a safe environment [ 20 ].

Providers reported negative consequences of workplace violence on the quality of care for patients and their own motivation to work in the ED. These findings match those from prior studies in higher resource settings, which link ED workplace violence to increased rates of burnout, missed workdays, and job dissatisfaction [ 5 , 7 , 21 ].

Solving the problem of workplace violence will require a multifaceted approach, addressing the perpetrators of violence, the considerations of healthcare workers, government intervention, law enforcement, and healthcare organizations. Interview participants identified a number of strategies for mitigating the incidence of violence against ED providers. Improved communication strategies, as well as public outreach campaigns to improve societal education and awareness, were frequently proposed interventions. While many strategies have been proposed for combating ED workplace violence in higher resource settings, few have any supporting evidence. The use of filmed vignettes as well as de-escalation training for healthcare workers has been proposed, but evidence for their efficacy is currently lacking [ 17 , 22 ]. Hospital -based interventions like increased security, the use of hospital metal detectors, and better enforcement of laws limiting the number of attendants allowed in the ED were also frequently proposed in this study. While the increased use of metal detectors has been shown to aid in confiscation of dangerous weapons, there is little evidence to suggest that it actually decreases the incidence of violence [ 23 ]. Ultimately, decreasing workplace violence against ED providers will require a combined approach that utilizes multiple strategies and is customized to unique aspects of each environment.

Limitations

This study was completed in private hospitals. Private hospitals in India may charge higher rates than public hospitals and thereby may exacerbate the role of financial factors in precipitating workplace violence in the ED. Additionally, the majority of interview participants were doctors, either residents or attendings/consultants. There may be a selection bias that the responses given overly represent the points of view and issues of physicians.

Workplace violence is an unacceptable, although frequent, reality for ED physicians and staff in India, with alarming rates of verbal and physical abuse. This qualitative study identified unique challenges to Indian ED providers that differ from those in more developed settings, including financial stressors, inadequate enforcement of rules governing behavior in the hospital, and an overwhelming frequency of violence emanating from patient family members and attendants rather than the patients themselves. Further investigation into preventive strategies must be a priority.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Emergency department

Emergency medicine

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KJD, KD, JB, and JS conceived the study and designed a structured interview guide. Medical students VR and NM conducted and transcribed the interviews. KJD, TA, KD, and medical student VR developed the coding scheme and coded the interviews using the NVivo qualitative research software. TA and KJD provided statistical advice on study design and analyzed the data. KJD drafted the manuscript, and all authors contributed substantially to its revision. KJD takes responsibility for the paper as a whole.

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Davey, K., Ravishankar, V., Mehta, N. et al. A qualitative study of workplace violence among healthcare providers in emergency departments in India. Int J Emerg Med 13 , 33 (2020). https://doi.org/10.1186/s12245-020-00290-0

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Received : 17 April 2020

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DOI : https://doi.org/10.1186/s12245-020-00290-0

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