Professional Preparedness Implications of Workplace Violence against Medical Students in Hospitals: A Cross-Sectional Study

Abstract

Workplace violence is an increasing public health concern around the world. In Vietnam, attacks on healthcare workers have become a huge issue in recent years. Our study aims to shed more light on the issue and look at what variables affect acts of violence toward healthcare workers. We conducted this cross-sectional study by surveying 550 medical students from 3 universities in Vietnam. Following this survey on SurveyMonkey’s platform (surveymonkey.com), the participants were suggested to invite their associates who met the selection criteria to join in this online survey. The structured questionnaire included demographics and details on the violence. There were 90.5% of respondents were medical students, the mean age was 23.3, and verbal abuse had a prevalence rate of 29.3%. Women respondents are less likely to suffer from violent experiences than men (OR = 0.48, 95% CI = 0.28-0.84), and those specializing in nurse and technician also faced a lower rate of acts of aggression (physical violence: OR = 0.35; 95% CI = 0.19-0.63, sexual harassment: OR = 0.36; 95% CI = 0.15-0.87, and any type of violence: OR = 0.55, 95% CI = 0.37-0.82). Medical students working in Ho Chi Minh City (OR = 0.55; 95% CI = 0.34-0.89), and other regions (OR = 0.40; 95% CI = 0.19-0.85) were significantly less likely to face verbal abuse than those working in Hanoi. The workplace culture needs to be changed to make sure that people feel comfortable reporting, especially those who are younger. Protecting medical students also ensures patient safety since victims of assault in the workplace can have severe aftereffects affecting their ability to provide good patient care. Hence, policies need to be implemented at both the government and hospital administration levels to keep health workers safe.

• What do we already know about this topic?

• Workplace violence is an increasing public health concern around the world.

• How does your research contribute to the field?

• Our study demonstrated the prevalence of violence against medical students across Vietnam and that not only affects the victim both immediately and long-term, but also impacts education and healthcare quality.

• What are your research’s implications toward theory, practice, or policy?

• Policies need to be put in place at both the government level and hospital administration level to keep health workers safe.

Introduction

In recent years, there has been a surge in violent acts around the world.^1-3 The rise of workplace violence is considered a serious public health issue worldwide, and workplace homicide has been classified as an official public health concern by the Centers for Disease Control and Prevention (CDC). According to CDC’s report, 43% of women killed at work resulted from an act of violence. ⁴ The World Health Organization (WHO) provides 2 definitions of workplace violence depending on the means of violence. The first type, physical violence, is defined as physical forces against another, resulting in physical, sexual, or psychological harm, while psychological violence is defined as the use of power against another resulting in harm to physical, mental, spiritual, moral, or social development. ⁵

Out of all professions, healthcare workers experience the highest levels of aggression and violence in the workplace. According to WHO, between 8% and 38% of healthcare workers have and will face physical violence at some point in their careers. ⁶ The severity of violent consequences on healthcare workers is undeniable. It was found that 5% to 32% of victims of workplace violence experienced post-traumatic stress disorder (PTSD),^7,8 and stressful workplace encounters can lead to alcohol use disorder, substance use, and insomnia. ⁹ The prevalence of workplace violence leads to job dissatisfaction among health professionals and in turn, results in a high turnover rate and worse patient care.^10,11 Healthcare workers who are abused in their workplace are also more prone to errors and potentially harming patients. ¹² However, workplace violence tends to be underreported due to fear of aggressors or fear of social stigma, which prevents hospitals and health leaders from realizing the full scope of such problems. ¹³ Therefore, our study provides insights into healthcare workers’ perspectives of violence within the hospital.

In Vietnam, there has been a recent increase in violence against healthcare workers. Multiple news has reported physicians being attacked in hospital settings by their colleagues or even by patients. However, as there is no law protecting healthcare workers in Vietnam from workplace violence, many physicians have chosen not to report assaults.^14,15 Therefore, immediate policy adjustments should be made to tackle this issue and create a safe space for health professionals. Despite the increasing prevalence of healthcare workplace violence in Vietnam, there has been a serious shortage of research on the issue. Our study aims to investigate the prevalence, and types of workplace violence and the experience among medical students in hospitals and its implications for their professional preparation. To achieve these aims, the research question had been: (1) What is the prevalence and types of workplace violence experienced by medical students in hospitals and (2) How does this experience impact their professional preparedness?”

Methods

Study Design

A cross-sectional approach was chosen for this exploratory study. All of the participants were medical students aged above 18 from December 2019 to February 2020 at the beginning of the study. Snowball sampling techniques were employed. The initial sample consisted of 3 core groups in 3 universities (Hanoi Medical University, University of Medicine and Pharmacy at Ho Chi Minh City, and Hue University of Medicine and Pharmacy). Following this survey on SurveyMonkey’s platform (surveymonkey.com), the participants were suggested to invite their associates who met the selection criteria to join in this online survey.

Participants

Participation criteria were: (1) living in Vietnam, (2) studying or working at the hospital/medical universities in Vietnam, (3) having either an email account or an account on social networking sites to invite their peers, (4) agree to participate in the study. Participants who had major diseases or were unable to answer questions were excluded from the recruiting procedure.

The sample size was calculated using the formula to estimate the proportion of violence against health workers with α = .05; the proportion of workplace violence against healthcare workers is 62.4%, ¹⁶ and the relative error = 0.065. Apply the formula, the required sample size n = 548, it is expected that 10% of the participants refused to participate, so we set the final sample size n = 603. A total of 608 health workers were eligible to participate in the study, but 550 participants completed the questionnaire. Therefore, the response rate is 90.46%.

Variables

Our approach toward constructing research tools involved a systematic methodology to ensure the robustness and consistency of the resulting data. Initially, we examined existing literature on workplace violence, as well as referred to the Workplace Violence in the Health Sector Country Case Study Questionnaires (WPVHS) Geneva 2003, ¹⁷ to identify crucial areas of inquiry and gaps in current research. Upon completion of this initial step, we formulated a comprehensive instrument that integrated all pertinent subjects and was tailored to the Vietnamese context. Subsequently, we sought the expertise of professionals spanning various disciplines, including public health, psychology, health services, and policymaking, who represented our target audience. Collaborating with these specialists, we refined, translated, tested, and simplified the questionnaires. Finally, we employed the questionnaire that comprised 2 parts after completing this rigorous process:

• (1) Demographic variables: age, gender (male, female), area (Urban, Town/rural/mountainous), major in university (physicians/dentists, nurses/technicians), and city (Hanoi, Ho Chi Minh City, others).

• (2) Experience of violence: corresponding to each type of violence:

1. Physical violence was behaviors that cause physical injury, trauma or pain, or bodily harm.

2. Verbal abuse was the act of cursing and scolding others.

3. Sexual harassment was the process of taking advantage of one’s position to entice or coerce another to engage in sexual activity.

The first question was designed to ascertain whether you have witnessed or experienced violence. The next 7 questions elicited information on:

1. The attacker (Patient; Health worker; Patient’s Relatives; Agency leader)

2. Place of violence (Clinic; Emergency department; Inpatient department; Corridor waiting)

3. Time of violence (In of office hours; Out of office hours; Others)

4. The consequences of being assaulted (Minor injury; Major injury; Stress; Felt scared; Felt guilty; Felt hurt about honor; None)

5. Act when being attacked or witness the assault (Took no action; Tried to defend me physically; Told the person to stop; Sought counseling; Told friends/relatives; Told colleagues; Transferred to another position; Sought help from the association; Reported these case

6. Investigate the case (Investigated by facility manager/leader; Investigated by the union; Investigated by police; No)

7. Solution of medical facilities (No further implementation; Strengthening security; Changing the medical examination and treatment process; Self-defense training for health workers; Communication to increase awareness of people and health workers about violence in health)

Statistical Methods

All analyses were carried out using Stata software (version 15). With missing data, we used the Listwise Deletion method to clean data before analyzing it. Percentages of variables of interest, mean and standard deviation of continuous variables were calculated. Statistical significance was analyzed using the Wilcoxon rank-sum test and Chi-square test as appropriate.

Potential covariates for full models of violent experience in health facilities included several individual characteristics such as age, gender, specialty, level of health facilities, and city/province. Multivariate logistic regression modeling was performed to examine the possibility of experiencing each type of violence concerning the socio-economic status of the medical workers. Finally, a stepwise forward model strategy was applied using a log-likelihood ratio test at a P-value of .2 to select variables for the reduced models. Significance levels were set at the 5% level.

Ethical Considerations

All participants were kept private about their information. Information obtained is for research purposes only. The study was carried out in compliance with the Institutional Review Board of Vietnam YRI (decision 177 QĐ/TWĐTN-VNCTN dated 28/12/2018). Participants were asked to give online informed consent if agreeing to participate in the study. The study’s participants were provided with a clear explanation of the research goals, scope, and potential advantages of participation. The collected information was treated in a confidential manner and used solely for research purposes and secured via encryption to safeguard individual privacy. It is crucial to emphasize that voluntary participation was integral to the study, wherein participants could opt out at any point, and withdraw their involvement if they felt uneasy with the research process.

Results

Workplace Violence in the Previous 12 Months Regarding Individual Characteristics

The results of different types of violence sorted by characteristics are shown in Table 1. Over half of the participants surveyed reported that they studied physician and dentist majors. The mean age of the group that experienced a violent act against them was 23.3, which was higher than that of the group that did not experience a violent act against them. There are significant differences between the 2 groups (have been violent or have not been violent) when accounting for gender, specialty, and occupation. The results regarding the different types of violence by characteristics are shown in Table 1. Overall, the prevalence of verbal abuse was the highest at 29.3% while sexual harassment was 6.4%. Men are also more likely to suffer from violent experiences than women. In addition, the experience of violence by physicians and dentists was higher than that experienced by nurses and technicians. There are more cases of medical violence in town/rural/mountainous areas than in urban areas.

Table 1.

Univariate Chi-Square Test Results of Workplace Violence in the Previous 12 months.

Characteristics	Overall		Physical violence			Verbal abuse			Sexual harassment			Any type of violence
	n	%	n	%	P	n	%	P	n	%	P	n	%	P
Total	550	100	72	13.1		147	26.7		27	4.9		174	31.6
Gender					<.001			.36			.58			.08
Male	138	25.1	31	22.5		41	29.7		8	5.8		52	37.7
Female	412	74.9	41	10		106	25.7		19	4.6		122	29.6
Specialty					<.001			<.001			.01			<.001
Physician, dentist	279	50.7	54	19.4		90	32.3		20	7.2		109	39.1
Nurse, technician	271	49.3	18	6.6		57	21		7	2.6		65	24
Living area					.35			.92			.51†			.67
City	495	90.0	67	13.5		132	26.7		26	5.3		158	31.9
Town/rural/mountainous	55	10.0	5	9.1		15	27.3		1	1.8		16	29.1
Levels of health facilities					.09			.27			.44			.28
National hospital	51	9.3	12	23.5		18	35.3		2	3.9		21	41.2
Provincial/city hospital	66	12.0	8	12.1		14	21.2		4	6.1		16	24.2
University hospital	406	73.8	47	11.6		110	27.1		18	4.4		129	31.8
Other	27	4.9	5	18.5		5	18.5		3	11.1		8	29.6
City/Province					.42			.24			.61			.25
Hanoi	124	23.2	18	14.5		40	32.3		5	4		43	34.7
Ho Chi Minh city	339	63.4	46	13.6		87	25.7		18	5.3		110	32.4
Others	72	13.5	6	8.3		16	22.2		2	2.8		17	23.6
	Mean	SD	Mean	SD		Mean	SD		Mean	SD		Mean	SD
Age	21.5	4.6	25.0	7.4	<.001 *	23.4	6.4	<.001 *	23.8	7.4	.45	23.3	6.4	<.001 *

^†Fisher’s exact test.

^*Wilcoxon rank-sum test.

Detail of Violent Experience Regarding the Type of Violence

As shown in Table 2, the contextual characteristics, consequences, and resolution of the experience of violence are presented. The majority of those who abuse healthcare workers were found to be relatives of the patient. The number of physical violence occurring in the emergency department was highest while the clinic or corridor was the most common area for verbal abuse. Most victims experience post-traumatic stress disorder and it was also found that no follow-up investigation took place after the medical students were assaulted.

Table 2.

Detail of Violent Experience.

Characteristics	Physical violence		Verbal abuse		Sexual harassment
	N	%	N	%	N	%
Attacker
Patient	18	25.0	57	38.8	7	25.9
Health worker	17	23.6	39	26.5	8	29.6
Patient’s relatives	48	66.7	101	68.7	12	44.4
Agency leader	4	5.6	9	6.1	3	11.1
Place of violence
Clinic	22	30.6	52	35.4	11	40.7
Emergency department	30	41.7	38	25.9	6	22.2
Inpatient department	5	6.9	39	26.5	6	22.2
Corridor waiting	32	44.4	62	42.2	9	33.3
Time of violence
During office hour	50	69.4	108	73.5	14	51.9
Office hour	31	43.1	58	39.5	14	51.9
Consequences when the victim is attacked
Minor injury	29	40.3	N/A	N/A	5	18.5
Major injury	18	25.0	N/A	N/A	4	14.8
Stress	42	58.3	83	56.5	14	51.9
Felt scared	42	58.3	63	42.9	10	37
Felt guilty	6	8.3	14	9.5	2	7.4
I felt hurt about the honor	26	36.1	63	42.9	7	25.9
None	6	8.3	21	14.3	2	7.4
Respond to the incident
Took no action	8	11.1	37	25.2	2	7.4
Tried to defend myself physically	20	27.8	N/A	N/A	N/A	N/A
Told the person to stop	19	26.4	29	19.7	5	18.5
Sought counseling	7	9.7	14	9.5	5	18.5
Told friends/relatives	10	13.9	36	24.5	8	29.6
Told colleagues	4	5.6	14	9.5	4	14.8
Transferred to another position	0	0.0	5	3.4	0	0.0
Sought help from the association	27	37.5	32	21.8	4	14.8
Reported these case	20	27.8	34	23.1	4	14.8
Investigate the case
Investigated by facility manager/leader	20	27.8	37	25.2	6	22.2
Investigated by union	10	13.9	13	8.8	7	25.9
Investigated by police	13	18.1	17	11.6	7	25.9
No	31	43.1	80	54.4	6	22.2
Solution of medical facilities
No further implementation	17	23.6	53	36.1	8	29.6
Strengthening security	29	40.3	43	29.3	9	33.3
Changing the medical examination and treatment process	6	8.3	20	13.6	N/A	N/A
Self-defense training for health workers	22	30.6	38	25.9	10	37
Communication to increase awareness of people and health workers about violence in health	16	22.2	44	29.9	2	7.4

N/A = not applicable.

Multivariate Logistic Regression to Identify Factors Associated With Violent Experiences in Health Facilities

Table 3 reports odd ratios (ORs) and 95% CI from the multiple logistic regression analysis of relationships between each type of violence and their socio-economic status. After adjusting for other factors in the model, the statistically significant correlates of type of violence were: (1) Age: Older people were significantly associated with higher odds of physical violence (OR = 1.26, 95% CI: 1.07-1.48), verbal abuse (OR = 1.43, 95% CI: 1.24-1.64), (2) Gender: Female was significantly associated with lower odds of physical violence (OR = 0.48, 95% CI: 0.28-0.84); (3) Specialty: nurse, the technician was significantly associated with lower odds of all violence; (4) Levels of health facilities: university hospitals are less likely to be involved in physical violence than national hospitals (OR = 0.44, 95% CI: 0.20-0.99), respectively; (5) City/Province: Ho Chi Minh city, other regions have significantly associated with lower odds of verbal abuse (Ho Chi Minh City vs Hanoi: OR = 0.55, 95% CI: 0.34-0.89), (Others city vs Hanoi: OR = 0.40, 95% CI: 0.19-0.85).

Table 3.

Factors Associated with Violent Experiences in Health Facilities.

Variables	Physical violence	Verbal abuse	Sexual harassment	Any type of violence
	OR (95% CI)	OR (95% CI)	OR (95% CI)	OR (95% CI)
Age (per year)	1.26** (1.07-1.48)	1.43** (1.24-1.64)
Gender
Male	Ref.
Female	0.48* (0.28-0.84)
Specialty
Physician, dentist	Ref.	Ref.	Ref.	Ref.
Nurse, technician	0.35** (0.19-0.63)	0.67 (0.44-1.02)	0.36* (0.15-0.87)	0.55** (0.37-0.82)
Levels of health facilities
National hospital	Ref.
Provincial/city hospital	0.40 (0.13-1.26)
University hospital	0.44* (0.20-0.99)
Other	0.88 (0.23-3.41)
City/Province
Hanoi		Ref.		Ref.
Ho Chi Minh City		0.55* (0.34-0.89)		0.69 (0.43-1.11)
Others		0.40* (0.19-0.85)		0.39* (0.19-0.81)

^**P < .01. *P < .05.

Discussion

Our study showed that medical students in Vietnam face significant violence, physically, verbally, and sexually. It also showed the factors most associated with violence were setting, gender, age, and main assailants. Our study also showed that hospital corridors were the main location of verbal abuse. These findings were critical in identifying interventions suitable for Vietnam to stop the prevalence of attacks against medical students.

We found that most medical students faced violence from patients. This trend is in line with most previous studies,^18-20 where violence against healthcare workers occurred in psychiatric or emergency department settings, and perpetrators were generally patients and their relatives. ²¹ A study by Qi et al ²² discussed how patients felt justified in displaying aggressive behavior toward nurses if they felt that the nurses were not providing adequate care. Another research in China hospitals showed that when the system was overloaded, patients became upset due to long waiting times. ²³ However, as Lanctôt and Guay ²⁴ have highlighted, it is important to reframe what counts as justification for aggression in the workplace setting. This is partly because the legislation does not adequately protect healthcare workers and students. ²⁵ In general, healthcare professionals in rural/town/mountainous hospital settings were more likely to face violence. A WHO report demonstrates that there is a smaller number of physicians in the Central Highlands and Northwest mountainous regions of Vietnam than in Northern cities. In addition, most of the physicians available in those regions only received the 4-year training program, a shortened and less qualified version of the standard 6-year medical education. ²³ Other healthcare workers such as pharmacists and nurses working in the Central Highlands and Northwest mountainous regions also only had entry-level experience. ²³ Not just in Vietnam, it is also common worldwide for better-trained professionals to work and study in major and populated cities, making the retention rate in rural areas a problem.^26,27 The Vietnamese government has implemented several policies to encourage the enrollment of healthcare workers and students in mountainous and rural regions such as salary raise or working contract guarantees. However, new incentives need to be developed and more effectively implemented as the problem of workforce scarcity in these regions has not been alleviated. ²⁶

Findings from our regression models showed that men are more likely to face aggression in the workplace. This finding differs from previous studies, most of which stated that female healthcare was more prone to workplace violence.^28,29 In Vietnam, while there are more female healthcare workers than males in total, the majority (83.1%) of specialty physicians are male.^26,30 This provides a potential explanation for our findings as most abuses were found among physicians who specialize in clinical medicine, where males account for the larger proportion. A study done in Vietnam also highlighted the power imbalance between younger female professionals and their older superiors. The superior-inferior workplace dynamic, where younger workers often feel prohibited from expressing true feelings to their older counterparts, can cause extreme occupational stress. ³⁰ However, cultural and contextual factors may explain why male medical students in Vietnam are more vulnerable to violence than their female counterparts. Gender norms in Vietnamese society dictate that men should be strong and assertive, while women should be passive and submissive. ³¹ This can lead to male medical students being viewed as more authoritative and therefore more likely to become targets of violence when challenging authority figures or making decisions that are perceived as threatening. Additionally, male medical students may be perceived as more threatening due to their physical stature and perceived power, making them more vulnerable to aggression from patients and their families, particularly in high-stress environments such as emergency departments.

Our regression model also indicated age as a huge factor. The average age of participants that experienced workplace abuse was 23.3, meaning most victims are still medical students. Previous studies also suggested that young and inexperienced healthcare workers or students were the most assaulted age group in workplace settings.^32,33 A reason underlying this inconsistency may be that students and young healthcare workers feel prohibited and are less likely to report the assault for fear of future tension and hostility from their senior staff. ²¹ A study also conducted in Vietnam found that because of societal values of collectivism and Confucianism, younger employees are more likely to be silent even when assaulted. ³⁴ Moreover, workplace abuse in hierarchical professions like medicine is mainly caused by power imbalances. A qualitative exploration study conducted in Australia revealed that senior doctors often mistreat junior doctors and medical students by exercising their power and authority, leading to verbal abuse, public humiliation, and personal attacks. ³⁵ Similarly, another study found that senior faculty members were more prone to harassing medical students. ³⁶ Additionally, long and irregular working hours for medical students and junior doctors often lead to burnout and fatigue, making them more vulnerable to mistreatment. ³⁷ This is exacerbated in the context of a severe shortage of human resources in Vietnam.

To address workplace violence in hospitals, Vietnam Government has implemented policies and programs such as Article 26 of the Law on People’s Health Protection also clearly stipulates: All organizations and citizens have the responsibility to help and protect doctors and medical staff when they are on duty. ³⁸ Despite the implementation of policies to regulate workplace violence, it is still prevalent in healthcare facilities in Vietnam. Therefore, more measures are required to improve the situation for medical students in hospitals.

Several implications arise from our study. First, more protections must be put in place for healthcare students in school and hospital settings, especially in mountainous areas. While it helps in preventing attacks, security technology also increases racial and religious biases.^39,40 Therefore, the interventions should come from policy adjustments, specifically stricter financial fines for assailants or better compensations for students who are abused. Moreover, hospitals should raise awareness of workplace violence to create an environment where reporting acts of violence and aggression toward healthcare workers and students is considered vital. According to the American College of Emergency Physicians (ACEP), 70% said they faced acts of violence, but only 3% reported them.^41,42 A study also found that society tended to justify attacks against nurses and sympathize with the aggressor. ⁴³ We also found that for the majority of the violence reported cases, no investigation was implemented Therefore, serious investigations need to take place where violent acts are reported, and appropriate punishments for the assailants should be provided. Furthermore, while not stated in this study, it is critical to increase awareness regarding workplace violence among medical students, hospital administrators, and policymakers. This may be accomplished through training programs and seminars that focus on detecting and reporting incidences of workplace violence, as well as preventative and mitigation techniques. Finally, further study is required to better understand the reasons of workplace violence against medical students in hospitals, as well as the efficacy of various preventative initiatives. This can aid in the formulation of evidence-based policies and treatments adapted to the unique setting of Vietnamese hospitals.

There are several limitations to this study. First, as it is a self-reported study, answers may be subject to personal bias. In addition, because most questions are about past experiences, recall bias may occur. Nevertheless, our study was able to highlight existing problems and propose valuable policy implications.

Conclusion

Our study demonstrated the prevalence and severity of violence against medical students across Vietnam. Violence and aggression against medical students not only affect the victim both immediately and long term but also impact education and healthcare quality. To effectively tackle this problem, university leaders should raise awareness of workplace violence within their institutions and encourage reports of assaults. Furthermore, policymakers need to develop stricter regulations regarding safety in hospital settings.