Abstract
Background:
Workplace violence (WPV) is a significant problem in both developed and developing countries, especially among healthcare workers. It has widespread implications for their overall health and well-being.
Objective:
The study was conducted to assess the problem of violence among doctors and other healthcare workers in healthcare settings.
Material and Methods:
A cross-sectional survey was conducted using a validated questionnaire from August 21 to September 18, 2021, based on purposive and snowball-sampling techniques for data collection. Appropriate statistical methods were applied to study the association between sociodemographics and characteristics of violence.
Results:
A total of 601 responses were analyzed. The results showed that approximately 75% of the participants experienced violence in some form at their workplace. These episodes lead to a significant impact on the physical and mental health of these workers. Around one-third of the participants felt uncomfortable reporting these incidents. Some of the most common risk factors and mitigation strategies were also reported by the participants.
Conclusion:
The findings of this study can be used by the legislators, administrators, and policymakers to develop strategies that can help in mitigating these episodes of violence for the better functioning of the healthcare system.
Keywords: Harassment, healthcare personnel, occupational health, physical abuse
INTRODUCTION
India is a land where doctors are deified as lifesavers, but the past few decades have seen this change drastically for the worse.[1] Today, episodes of violence against doctors seem to have become a common phenomenon, not only in India but in several other regions of the world as well.[2] The global prevalence of any form of workplace violence (WPV) has been reported up to 61.9% (out of which up to 42.5% experienced nonphysical violence and up to 24.4% experienced physical violence). While in India, approximately 75% of healthcare workers have reported some form of WPV in their career (up to 80% experiencing nonphysical violence and up to 40% experiencing physical violence).[3]
Though it is a multifaceted global problem, different countries have varied risk factors, sociobehavior characteristics, and scenarios that perpetuate WPV. The occurrence, expression, and aftermath of these episodes depend on cultures, law enforcement agencies, government policies, and the healthcare system of the country.[4] Despite the higher prevalence in recent years, these episodes are often underreported. These episodes lead to adverse psychosocial consequences, such as a decline in job performance, increased turnover intentions, reduced job satisfaction, decreased quality of life, and burnout.[5]
The characteristics, perceived risk factors, impact, and mitigation strategies to deal with the problem of violence in the healthcare setup are bound to change with time, across various cultures.[2,4] Addressing these require stringent strategies and legislation by policymakers.
There have been only a handful of studies available from India, but these studies lack comprehensiveness. They are mostly from a single department[6,7] or healthcare center,[8,9] and they fail to comprehensively assess the characteristics, perceived risk factors, impact, and mitigation strategies to deal with the problem.[9,10,11] The present study aims to assess the problem of WPV with a validated comprehensive questionnaire addressing all domains related to WPV across different healthcare settings in India.
METHODS
Operational definitions
As per the World Health Organization (WHO), Violence is “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either result in or have a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation.”[12] Whereas as per the United States Department of Labour, “Workplace violence is any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the work site. It ranges from threats and verbal abuse to physical assaults and even homicide. It can affect and involve employees, clients, customers, and visitors.”[2]
Study design
A cross-sectional survey was conducted using a prevalidated questionnaire to assess WPV across healthcare centers (primary healthcare centers, secondary healthcare centers, and tertiary healthcare centers).
Locale
The study was conducted across various healthcare centers in India.
Ethical statement
The study was approved by the Institute Ethics Committee with reference no. IEC-573/06.08.2021.
Survey questionnaire
The questionnaire was formulated by review of literature focus group discussions, expert opinions, pilot testing, and validation. The validity of the questionnaire was measured using face, content, and construct validity. The Cronbach’s alpha was 0.86 which indicated good internal consistency. The responses were marked on the Likert scale using closed scoring.[13] The original questionnaire comprised 37 items and targets healthcare workers. The questionnaire was divided into five domains:
Forms of violence (two items): This section assessed the prevalence and the spectrum of various forms of violence experienced in a healthcare setting.
Impact of violent episodes (five items): This section tried to capture the impact of violent episodes on the inter- and intrapersonal aspects of an individual.
Reporting of the Incidents (seven items): This domain apprehended the various reasons which lead to the underreporting of such episodes of violence.
Mitigation strategies (11 items): The section suggested several mitigation strategies that are effective in the literature and have been suggested by experts in various fields.
Risk factors (12 items): Several risk factors that contribute to the episodes of violence have been highlighted in this domain.
Besides, the sociodemographic details including age, gender, marital status, qualification, designation, department, and workplace setting were also reported by the participants.
Study participant
Participants were enrolled by purposive and snowball-sampling techniques.
Data collection
The data were gathered from healthcare workers including doctors, nurses, and other allied paramedical staff across North India from August 21st to September 18th, 2021. The participants who refused to provide consent were excluded from the study. The questionnaire was self-administered, and data were collected in both offline and online modes. Participants were informed about the purpose of the study and consent was obtained before enrolment. The anonymity and confidentiality of the participants were ensured. Any identifiable information was eliminated while cleaning the data for analysis.
Sample size
The sample size is calculated using a single population proportion formula (N * [Z2* p * (1 − p)/e2]/[N – 1+ (Z2* p * (1 − p)/e2]), where N is the population size, Z is the critical value of the normal distribution at the required confidence level, P is the sample proportion, and e is the margin of error. Thus, by considering the following assumption, P = 75% prevalence of workplace in India, e = margin of error taken as 5%, Zα/2 = 1.96 at 99% confidence level, and by adding 20% nonresponse rate, the final sample was 600.
Bias
The study may have the possibility of recall bias.
Data and statistical analysis
The response pattern of the participant was found using descriptive statistics. Mean and standard deviations were calculated for continuous variables and the association between sociodemographics, and study variables were calculated using Chi-square. Multivariable analysis was done by using a logistic regression model. For all analyses, P ≤ 0.05 was considered statistically significant. All statistical analyses were performed by using STATA/SE version 14.2 (StataCorp LP, College Station, TX, USA).
RESULTS
Sociodemographic profile of the participants
A total of 601 healthcare workers completed the survey. The mean age was found to be 30.7 ± 5.81, with a fairly equal representation of males (n = 327, 54.41%) and females (n = 274, 45.59%). Half of the participants were pursuing MD/MS/M.Sc. (n = 303, 50.58%), and the majority were from government hospitals (n = 502, 83.52%). Among the participants, a slight majority (n = 306, 50.92%) were resident doctors, followed by nursing officers (n = 186, 30.95%), consultant or faculty (n = 102, 16.97%), and other paramedical staff (n = 7, 1.16%). One-third of the participants belonged to medicine and allied fields (n = 228, 37.94). The complete description of sociodemographic details is presented in Table 1.
Table 1.
Sociodemographic profile of the participants
| Characteristics | n | % |
|---|---|---|
| Age | M=30.7 and SD=5.81 | |
| Gender | ||
| Male | 327 | 54.41 |
| Female | 274 | 45.59 |
| Professional qualification | ||
| MBBS/B.Sc. | 238 | 39.60 |
| MD/MS/M.Sc. | 304 | 50.58 |
| DM/Ph.D. | 59 | 9.82 |
| Workplace setting | ||
| Government hospital | 502 | 83.52 |
| Corporate hospital | 48 | 7.98 |
| Private nursing home | 29 | 4.82 |
| Private clinic | 22 | 3.66 |
| Area | ||
| Metropolitan | 322 | 53.67 |
| Urban | 228 | 38.00 |
| Rural | 50 | 8.33 |
| Designation/Job | ||
| Consultant/Faculty | 102 | 16.97 |
| Resident doctor | 306 | 50.92 |
| Nursing officer | 186 | 30.95 |
| Other paramedical staff | 07 | 1.16 |
| Number of years of experience after completion of MBBS/B.Sc. (count internship as first year of experience)* | M=7.00 and SD=5.40 | |
| Department of residency/specialization/working | ||
| Medicine and Allied | 228 | 37.94 |
| Surgery and Allied | 62 | 10.32 |
| Obstetrics and Gynecology | 90 | 14.98 |
| Pediatrics | 63 | 10.48 |
| Trauma and Emergency | 87 | 14.48 |
| Anesthesia and Critical Care | 22 | 3.66 |
| Others | 49 | 8.15 |
| Marital status | ||
| Single | 290 | 48.25 |
| Married | 307 | 51.08 |
| Others | 04 | 0.67 |
*(Count Internship as First Year of experience)
Forms of violence
The findings indicate that approximately three-quarters (n = 457, 76.04%) of the participants experienced violence in healthcare settings. About 61.4% of the participants reported that they faced verbal altercations such as threats, abuse, exaggerated arguments, offensive comments, and so on. about once a month, and about half of the participants (n = 288, 47.92%) reported that they face such episodes of violence every week and 23.29% experience them daily. These altercations were significantly associated with pursuing postgraduation (P < 0.05), being a junior and senior resident (P < 0.01), and working in government hospitals (P < 0.05). It was also found that 39.93% of the participants had encountered physical violence such as slapping, beating, thrashing, vandalizing, attack with weapons, and so on at least once in their lifetime. Around one-fourth of the participants undergo such incidents every year, while about a fifth face it every 6 months and about 6.32% every month. These incidents were found to be significantly associated with being male (P < 0.001), junior and senior residents (P < 0.01), working in rural regions (P < 0.001), and departments such as Medicine and Allied specialties (P < 0.01).
The trend indicated that the majority of the resident doctors experienced violence during their duty hours. Males were found to be more vulnerable to physical assault in comparison to females and those working in the urban areas experienced more violence in comparison to those working in metropolitan followed by rural areas. The complete description is presented in Table 2.
Table 2.
Frequency of responses by participants and their sociodemographic correlates
| S. no. | Domain | Frequency of responses by participants (%) |
Association with sociodemographic correlates |
|||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 2 | 3 | 4 | 5 | 6 | Gender | Qualification | Designation | Workplace setting | Area | Department | Marital status | ||
| Forms of violence | ||||||||||||||
| 1. | Verbal altercations | 81 (13.48) | 148 (24.63) | 140 (23.29) | 88 (14.64) | 144 (23.96) | – | n.s. | P<0.05 | P<0.01 | P<0.05 | n.s. | n.s. | n.s. |
| 2. | Physical violence | 38 (6.32) | 71 (11.81) | 51 (8.49) | 80 (13.31) | 361 (60.07) | – | P<0.001 | n.s. | P<0.01 | n.s. | P<0.001 | P<0.01 | n.s. |
| Impact of violence | ||||||||||||||
| 1. | Feelings regarding the violence | 121 (20.13) | 262 (43.59) | 80 (13.31) | 110 (18.30) | 22 (3.66) | 06 (1.00) | P<0.01 | P<0.01 | P<0.001 | P<0.05 | n.s. | n.s. | P<0.01 |
| 2. | Personal well-being | 147 (24.46) | 246 (40.93) | 155 (25.79) | 45 (7.49) | 08 (1.33) | – | n.s. | n.s. | P<0.05 | n.s. | P<0.01 | n.s. | P<0.001 |
| 3. | Family life | 197 (32.78) | 198 (32.95) | 155 (25.79) | 40 (6.66) | 11 1.83 | – | n.s. | n.s. | n.s. | n.s. | n.s. | n.s. | n.s. |
| 4. | Social life | 167 (27.79) | 214 (35.61) | 169 (28.12) | 37 (6.16) | 14 (2.33) | – | n.s. | n.s. | n.s. | P<0.05 | n.s. | P<0.05 | P<0.001 |
| 5. | Mental and psychological well-being | 90 (14.98) | 218 (36.27) | 197 (32.78) | 77 (12.81) | 19 (3.16) | – | n.s. | n.s. | n.s. | n.s. | P<0.01 | n.s. | n.s. |
| Reasons for not reporting of the incidences of violence | ||||||||||||||
| 1. | Would you be comfortable in reporting the incidences of violence to competing authorities | 35 (5.82) | 57 (9.48) | 121 (20.13) | 120 (19.97) | 268 (44.59) | – | n.s. | P<0.05 | n.s. | n.s. | P<0.05 | n.s. | P<0.001 |
Verbal altercations: 1Nearly daily, 2about once a week, 3about once a month, 4about once every 6 months, 5about once a year or less. Physical violence: 1About once a month or more, 2about once every 6 months, 3about once a year, 4less than once a year, 5never. Feeling regarding violence: 1did not affect, 2motivation or efficiency reduced, 3felt like changing workplace, 4opting for alternate career, 5felt like not working, 6self-harm/suicidal ideations. Personal/family/social/psychological well-being: 1not affected, 2mildly affected, 3moderately affected, 4severely affected, 5very severely affected. Reporting of incidences: 1strongly disagree, 2disagree, 3neither agree nor disagree, 4agree, 5strongly agree
Impact of violent episodes
Study findings revealed that the majority of the participants (n = 474, 79.87%) were negatively impacted by these incidents of violence. Results indicated that the personal well-being, family life, social life, and psychological and mental well-being of the participants were found to be affected by 75.54%, 67.22%, 72.21%, and 85.02% of the participants, respectively. The endorsement of the negative impact of the incidents of violence was found to be significantly associated with females (P < 0.01), postgraduates (P < 0.01), resident doctors (P < 0.001), and Government hospital setting (P < 0.05), and unmarried P < 0.01). Personal well-being was found to be severely affected for the married individuals and social life was more severely impacted for those who were single (P < 0.001). Participants who were in their residency (P < 0.01) and were working in the metropolitan cities (P < 0.05) were negatively impacted by these episodes.
Reporting of the incidents
The statistical analysis showed that approximately one-third (n = 213, 35.43%) of the participants were hesitant about reporting the incident to the competent authorities. Participants who were pursuing a Doctorate in Medicine (MD) were more hesitant in reporting followed by those who were in graduation or Bachelor of Medicine and Bachelor of Surgery (MBBS) (P < 0.05). Those who were married reported that they were not comfortable reporting their experience in comparison to those who were single (P < 0.001). Some of the major factors that contributed to the underreporting of these incidents were lack of organizational support (56.41%), belief that no action will be taken (55.74%), and the time-consuming nature of the entire process (51.25%), followed by other factors.
Mitigation strategies
Participants were asked to rate the effectiveness of the strategies that could be used to mitigate the episodes of violence in healthcare settings. Some of the strategies that were found to be most useful by the majority of the participants were improving healthcare facilities (84.36%), and strong legislature (80.03%), controlling the number of attendants (78.54%), an active complaint redressal system (78.37%), countering negative remarks by public figures toward the healthcare workers (76.54%), and by improving infrastructural facilities (76.04%). Some of the other strategies have also been presented in Table 3.
Table 3.
Frequency of responses for underreporting, mitigation strategies, and risk factors
| S. no. | Domain | Frequency of responses by participants (%) |
||
|---|---|---|---|---|
| 1 | 2 | 3 | ||
| Reasons for underreporting | ||||
| 1. | Felt ashamed | 136 (22.63) | 307 (51.08) | 158 (26.29) |
| 2. | No action will be taken | 335 (55.74) | 214 (35.61) | 52 (8.65) |
| 3. | Lack of organizational support | 339 (56.41) | 206 (34.28) | 56 (9.32) |
| 4. | No provision to report | 292 (48.59) | 239 (39.77) | 70 (11.65) |
| 5. | Time-consuming process | 308 (51.25) | 227 (37.77) | 66 (10.98) |
| 6. | Appraisal or promotion will be affected | 262 (43.59) | 218 (36.27) | 121 (20.13) |
| Effective mitigation strategies | ||||
| 1. | Controlling number of attendants | 472 (78.54) | 121 (20.13) | 08 (1.33) |
| 2. | Educating about limitations | 437 (72.71) | 150 (24.96) | 14 (2.33) |
| 3. | Soft-skills training | 427 (71.05) | 165 (27.45) | 09 (1.50) |
| 4. | Self-defense training | 341 (56.74) | 216 (35.94) | 44 (7.32) |
| 5. | Improving healthcare facilities | 507 (84.36) | 86 (14.31) | 08 (1.33) |
| 6. | Improving facilities within hospitals | 446 (74.21) | 136 (22.63) | 19 (3.16) |
| 7. | Improving infrastructural facilities | 457 (76.04) | 127 (21.13) | 17 (2.83) |
| 8. | Active complaint redressal system | 471 (78.37) | 120 (19.97) | 10 (1.66) |
| 9. | Strong legislature | 481 (80.03) | 111 (18.47) | 09 (1.50) |
| 10. | Unbiased media reporting | 454 (75.54) | 124 (20.63) | 23 (3.83) |
| 11. | Negative remark toward healthcare workers | 460 (76.54) | 126 (20.97) | 15 (2.50) |
| Risk factors | ||||
| 1. | Unrealistic expectations | 428 (71.21) | 126 (20.97) | 15 (2.50) |
| 2. | Inappropriate knowledge | 436 (72.55) | 139 (23.13) | 26 (4.33) |
| 3. | Poor communication skills | 381 (63.39) | 173 (28.79) | 47 (7.82) |
| 4. | Lack of resources | 432 (71.88) | 129 (21.46) | 40 (6.66) |
| 5. | Overcrowding | 462 (76.87) | 92 (15.31) | 47 (7.82) |
| 6. | Long waiting time | 413 (68.72) | 143 (23.79) | 45 (7.49) |
| 7. | Inadequate security | 447 (74.38) | 110 (18.30) | 44 (7.32) |
| 8. | Inadequate action taken | 421 (70.05) | 141 (23.46) | 39 (6.49) |
| 9. | Lack of respect for authority | 430 (71.55) | 124 (20.63) | 47 (7.82) |
| 10. | Negative and inappropriate media reporting | 456 (75.87) | 96 (15.97) | 49 (8.15) |
| 11. | Lack of punishment | 443 (73.71) | 114 (18.97) | 44 (7.32) |
Reasons for underreporting: 1significantly, 2somewhat significantly, 3insignificantly. Mitigation strategies: 1Very useful, 2somewhat useful, 3not useful. Risk factors: 1very important, 2somewhat important, 3not important
Risk factors
Perceived risk factors were found in the literature and were suggested by the experts. Some of the risk factors that were found to be most prominent by the participants were overcrowding (76.84%), negative and inappropriate reporting by the media (75.87%), inadequate security (74.38%), lack of punishment for offenders (73.71%), inadequate knowledge about the disease or health condition (72.55%), and several others, which have been mentioned in Table 3.
Factors leading to the episodes of WPV
Logistic regression analysis was done to establish/find out the factors leading to the episodes of WPV [Table 4]. Findings of the model indicate that only gender and experience emerged as significant factors for WPV. Based on the findings, it can be interpreted that male healthcare workers were more likely to be subjected to WPV (1.8 (1.19–2.81)) than females, especially if they were working as residents or with less experience (0.95 (0.92–0.99)).
Table 4.
Multivariable analysis
| Variables | Nonadjusted | Adjusted |
|---|---|---|
| OR (95% CI) | OR (95% CI) | |
| Gender | ||
| Male | 1.7 (1.1–2.6) | 1.8 (1.19–2.81) |
| Years of experience | 0.96 (0.92–0.99) | 0.95 (0.92–0.99) |
| Professional qualification | ||
| M.D./M.Sc. | 1.15 (0.7–1.8) | – |
| D.M./Ph.D. | 0.72 (0.3–1.4) | – |
| Workplace setting | ||
| Government hospital | 1.5 (0.6–3.8) | – |
| Corporate hospital | 1.4 (0.48–4.18) | – |
| Private hospital | 0.7 (0.27, 2.14) | – |
| Area of work | ||
| Urban | 1.2 (0.7–1.8) | – |
| Rural | 1.4 (0.6–3.4) | – |
| Designation/Job | ||
| Resident | 1.7 (1.03–3.09) | – |
| Nursing officer | 1.4 (0.8–2.6) | – |
| Other paramedical staff | 0.8 (0.14–4.4) | – |
DISCUSSION
The present study cohesively assessed the characteristics, perceived risk factors, impact, and mitigation strategies for WPV in healthcare settings. The findings divulged some significant insights into the paradigm of WPV in the North Indian healthcare setup.
In the present study, all participants encountered verbal altercations at least once in their career physical violence was experienced by 40% of participants. These findings are synergistic with other Indian studies to an extent as they report the prevalence of verbal altercations up to 90% and physical violence up to 40%.[9,14] The most common causes leading to such occurrences were found to be overcrowding at the hospitals, inappropriate media reporting, inadequate security, and the inability to take action against the offenders by competent authorities.[15] Consequently, this leads to a significant impact on the physical and mental health of the individual causing absenteeism, low productivity, and burnout which is positively associated with low doctor–patient relationships and decreased quality of care.[16]
Despite the high prevalence and serious impact on the lives of the affected individuals, participants were hesitant in reporting the episodes of violence. Similar findings have been reported across the globe. The most common reasons for not reporting were lack of support from the organization, the belief that no action would be taken, the time-consuming nature of the process, and fear that promotion or appraisal would be affected.[17,18]
Even though India has strong laws and legislation for general violence, laws concerning WPV are largely missing. The safeguarding of “at-risk” healthcare workers is not completely done especially in rural and peripheral healthcare settings. This calls for employing appropriate strategies from the individual to the policy level. The healthcare system should be strengthened to decrease overburdening and cater to the staff shortage. Healthcare workers should be trained to identify the early signs of the violent perpetrator and appropriate skills must be imparted to build a meaningful relationship of trust and care. The curriculum should also teach navigation through such episodes and motivate them to report. Along with this, the healthcare system should increasingly support healthcare workers denouncing WPV.[19]
An understanding of WPV based on real experiences is a way forward. The primary limitation of the study is the collection of the sample using the purposive and snowball techniques, which restricts the generalizations of results to the entire population. Related to it, there is a possibility of sampling or response bias as the majority of the data were collected using an e-survey. No proxy measures were used to assess the violence or to measure the severity of the violence. Apart from this, the sample had a relatively lower representation of other paramedical staff including nurses and orderlies. There is still scope to further investigate the perpetrator of the violence to better understand the complexity of the problem.
CONCLUSION
WPV is a prevalent problem in the healthcare settings of North India. The factors from individual to policy levels are accountable for the perpetuation of the problem. The findings of this study should be used to advocate mitigation strategies including not just the healthcare workers but by improving healthcare infrastructure, devising policies, and improving legislature to counteract the perpetrating factors of WPV. This would help in strengthening the healthcare system and will reduce WPV in healthcare settings.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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