Workplace violence among healthcare providers in India: a mixed-method study

Abstract

Introduction

Workplace violence (WPV) against healthcare workers is a growing concern globally. This study aims to determine the prevalence and risk factors associated with WPV among healthcare workers in South India. The study also aims to evaluate the effects and potential solutions for reducing it.

Methodology

The study adopted a mixed-methods approach (convergent parallel). A cross-sectional survey with a pre-tested questionnaire was conducted among 243 healthcare workers, which included doctors, nurses and paramedics, to assess demographics, occupational characteristics, WPV experiences, consequences and prevention. 20 in-depth interviews and thematic analysis were carried out using an inductive approach.

Results

62.6% of participants experienced WPV at some point in their lives. Verbal abuse (62.1%) was more common than physical assault (13.6%). Younger, less experienced and unmarried healthcare workers were more likely to experience WPV. Thematic analysis revealed factors contributing to WPV, including communication gaps and patient/bystander behaviour, systemic issues, cultural factors, personal issues of healthcare staff, hospital-associated factors, etc. WPV consequences included fear, mental trauma, defensive medicine practices and potential migration.

Conclusions

This study highlights the significant prevalence of WPV and its negative impact on healthcare workers in India. The findings suggest a need for multifaceted interventions to address WPV, including improved communication strategies, patient/bystander education and organisational changes to enhance safety in the workplace.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Violence is the second-leading cause of death in the workplace.

• The impact on the social and mental well-being of healthcare workers can be significant.

WHAT THIS STUDY ADDS

• Younger, less experienced, unmarried and female healthcare workers are most vulnerable to workplace violence.

• Communication gaps, patient and bystander behaviours, systemic issues and cultural factors drive violent incidents.

• Consequences include psychological trauma, defensive medical practices and workforce migration.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• Better communication, patient education, enhanced staffing, surveillance and stronger policies will ensure safety and security.

Introduction

Workplace violence (WPV) among healthcare workers has emerged as a global issue that has gotten worse in many regions of the world.¹ The estimated prevalence of WPV in healthcare in a developing country such as India is approximately 60–78%. The true magnitude of this event is believed to be significantly greater due to the problem being largely ignored and inadequately reported.2,4

WPV has been defined as “violent acts including physical assault and threats of assault directed towards personnel at work or on duty.”⁵ These events may involve verbal or physical violence perpetrated by patients, attendants or even co-workers.⁶ The WHO recognises healthcare providers globally as being highly vulnerable to WPV, which significantly affects staff well-being, retention and service delivery.⁷ These violent events result in adverse physical and psychological outcomes, reduced workplace morale and compromised healthcare quality.⁸ Victims often suffer from symptoms such as anxiety, depression, sleep disturbances and burnout, which may lead to absenteeism, job dissatisfaction and even attrition.^{9 10}

Recent studies emphasise the pervasive effects of WPV on healthcare delivery.11,13 For instance, a 2021 study in India reported that nearly 75% of resident doctors experienced verbal abuse, and 20% encountered physical violence, leading to substantial emotional stress and defensive medical practices.¹⁴ Behera et al emphasised that WPV is strongly associated with poor mental health outcomes and reduced job satisfaction among nurses.¹⁵ Moreover, in a multicentre study from 2023, healthcare providers expressed a heightened intent to leave the profession altogether following recurrent WPV incidents.¹³ The impact of violence on the psycho-social well-being of healthcare providers and its influence on critical decision-making in patient management is grossly under-researched and under-reported in India. By addressing these issues, potential solutions can be found to improve doctor-patient relationships and enhance patient care.²

Though this concept of WPV is known, limited studies have explored both the prevalence and experience of the healthcare professionals.¹ Along with the increasing WPV incidents in India, it also has long-term consequences such as provider burnout, rise in the healthcare expenditure and patient dissatisfaction.

This study was conducted as a mixed-method study to determine the prevalence and risk factors contributing to WPV among healthcare workers and evaluate the effects and potential solutions for reducing it.

Methodology

Study design and setting

The cross-sectional study, which used a mixed-method design (convergent parallel approach), was conducted from January to May 2024 in selected tertiary healthcare hospitals in two cities of southern state of Karnataka to capture the variation of study findings across the region.¹⁶ These cities fall under urban and semiurban areas, serving a mixed socioeconomic population.

Data collection and questionnaire design

The eligible study participants were approached and informed about the purpose of the study. Upon obtaining their informed consent, data were collected from them.

The study tool was pre-validated by subject experts and pilot-tested among 5% of the sample, which helped to enhance the quality and feasibility of the study tool. The study used a semistructured questionnaire which was validated by public health experts (face and content validation).

The participants were selected through purposive sampling technique. Medical, nursing or paramedical graduates who had ≥6 months of work experience in the current setting and who provided informed consent were included for study participation. Healthcare interns, non-clinical and administrative staff, and staff on probation or who were on temporary appointment were excluded.

The quantitative part of the study was an interviewer-administered survey in healthcare settings, which collected data on basic sociodemographic factors, workplace details and assessments of WPV. Variables for violence at work such as type of violence, frequency and timings of incidents, location, consequences and action taken after the incident were collected. For recording the profile of healthcare professionals, age, gender, marital status, educational qualification, designation, type of facility, years of work experience and area of posting were recorded (online supplemental material 1)

The qualitative data were collected through a semistructured, in-depth interview guide developed based on prior studies of violence against healthcare providers. 20 in-depth interviews were conducted among the participants. Interviews were conducted in private settings with the hospital, ensuring privacy and comfort of the participants. Each interview lasted between 45 min to 1 hour and was conducted in English or local language, as preferred by the participant. Interviews were audio recorded, transcribed and later translated (online supplemental material 2).

The privacy and confidentiality of the study participants were ensured throughout the data collection period. Except for the participants’ job titles, no other personal identifying information was collected.

Study participants

The study was conducted among medical consultants/physicians, nurses and paramedics to provide multidirectional and in-depth data on violence among healthcare providers and their experiences and perceptions regarding the same. Healthcare providers with at least 6 months of experience were considered for study participation. No patients or members of the general public were involved in the planning, execution, reporting or distribution of our study.

Sample size

Assuming a prevalence of 80.4% for verbal abuse based on a study conducted by Debnath et al,⁹ at a CI of 95% and an absolute precision of 5%, the sample size was calculated as 243.

$${\displaystyle {\displaystyle \mathrm{S}\mathrm{a}\mathrm{m}\mathrm{p}\mathrm{l}\mathrm{e}\mathrm{s}\mathrm{i}\mathrm{z}\mathrm{e},n=\frac{Z^{2}pq}{d^2}}}$$

where Z=1.96, p=80.4% for the survey response rate, q= (100−p) and d=5%.

Sampling

The study participants were chosen purposively from the selected healthcare settings upon satisfying the inclusion criteria for participation for both the quantitative and qualitative part of the study.

Data analysis

The quantitative data were entered into Microsoft Excel, and then, data cleaning and coding were done. SPSS software V.26 (Statistical Package for Social Science, Windows, V.26.0, IBM Corp. Released 2019. IBM SPSS Statistics, Armonk, New York, USA) was used to analyse the data. WPV was considered the primary outcome variable in the quantitative analysis.

The continuous variables were expressed as mean and standard deviation. Categorical variables were represented as frequency and proportions. Associations between WPV and categorical predictors were examined using the χ² test (or Fisher’s exact test where applicable). Crude OR (cOR) with 95% CI were calculated using univariate logistic regression to assess the strength of associations.

To adjust for potential confounders, multivariate logistic regression analysis was performed, including variables found significant at the bivariate level (p<0.10) and those considered epidemiologically relevant. Adjusted OR (aOR) with 95% CI were reported to identify independent predictors of WPV. Qualitative data obtained from in-depth interviews were transcribed, and codes were generated using an inductive approach. Data collection was continued until thematic saturation was reached, defined as the point at which no new themes or insights were observed in three consecutive transcripts.¹⁷

Similar codes were placed under suitable subthemes and themes, and analysis was done. Thematic analysis using an inductive approach was used for qualitative data analysis (Braun and Clarke’s six-phase framework). Two independent researchers coded the data. Participant status was de-identified and verbatims were represented to describe the appropriate findings. The analysis was performed manually.

Results

A total of 243 participants took part in this study. The mean age of the participants was 27.4±5.4 years. The majority of the participants were women (70.4%) and belonged to the age group of <30 years (77.8%). 69.5% of participants were unmarried. Most participants were employed in corporate settings (67.1%) and urban areas (77.4%). 57.6% of healthcare workers in this study had a postgraduate degree, while 42.4% were graduates. The median duration of experience of the participants was 2 years (IQR: 1–4) (tables1 2).

Table 1. Sociodemographic and occupational characteristics of the participants.

Variables	WPV faced (N=152)	WPV not faced (N=91)
Age (in years)
<30	115 (75.7%)	74 (81.3%)
≥30	37 (24.3%)	17 (18.7%)
Gender
Male	57 (37.5%)	15 (16.5%)
Female	95 (62.5%)	76 (83.5%)
Marital status
Married	53 (34.9%)	21 (23.1%)
Unmarried	99 (65.1%)	70 (76.9%)
Divorced/widowed/others	0 (0%)	0 (0%)
Area
Urban	112 (73.7%)	76 (83.5%)
Rural	40 (26.3%)	15 (16.5%)
Educational qualification
Graduate	73 (48%)	30 (33%)
Postgraduate	79 (52%)	61 (67%)
Workplace
Government hospital	21 (13.8%)	12 (13.2%)
Corporate hospital	100 (65.8%)	63 (69.2%)
Private clinic	31 (20.4%)	16 (17.6%)
Years of experience
≤1 year	31 (20.4%)	41 (45.1%)
1–5 years	84 (55.3%)	30 (33%)
>5 years	37 (24.3%)	20 (21.9%)

Table 2. Association of sociodemographic and occupational characteristics of the participants with the WPV.

Variables	WPV faced (N=152)	WPV not faced (N=91)	χ2 value	P value
Age (in years)
<30	115 (75.7%)	74 (81.3%)	1.055	0.304
≥30	37 (24.3%)	17 (18.7%)
Gender
Male	57 (37.5%)	15 (16.5%)	12.058	0.001*
Female	95 (62.5%)	76 (83.5%)
Marital status
Married	53 (34.9%)	21 (23.1%)	3.737	0.036*
Unmarried	99 (65.1%)	70 (76.9%)
Area
Urban	112 (73.7%)	76 (83.5%)	3.143	0.076
Rural	40 (26.3%)	15 (16.5%)
Educational qualification
Graduate	73 (48%)	30 (33%)	5.286	0.021*
Postgraduate	79 (52%)	61 (67%)
Workplace
Government hospital	21 (13.8%)	12 (13.2%)	0.350	0.840
Corporate hospital	100 (65.8%)	63 (69.2%)
Private clinic	31 (20.4%)	16 (17.6%)
Years of experience
≤1 year	31 (20.4%)	41 (45.1%)	17.850	<0.001*
1–5 years	84 (55.3%)	30 (33%)
>5 years	37 (24.3%)	20 (21.9%)

Bold p value indicate statistically significant results.

^*Significant p (χ2 test).

WPV, workplace violence.

Gender was significantly associated with the outcome, with women showing higher odds (OR 3.040, 95% CI 1.597 to 5.787, p=0.001) compared with men. Marital status showed that unmarried individuals had increased odds (OR 1.785, 95% CI 0.988 to 3.222), but the association was borderline significant (p=0.055). Regarding educational qualification, postgraduates had significantly higher odds (OR 1.879, 95% CI 1.094 to 3.226, p=0.022) than graduates. Years of experience demonstrated a protective effect: those with 1–5 years of experience had significantly lower odds (OR 0.270, 95% CI 0.144 to 0.505, p<0.001), and those with more than 5 years also had reduced odds (OR 0.409, 95% CI 0.200 to 0.837, p=0.014) compared with those with less than 1 year of experience (table 3).

Table 3. Univariate logistic regression analysis showing cOR with 95% CI for factors associated with WPV.

Variables	Category	cOR	95% CI	P value
Gender	Male (Ref)	1	–	–
	Female	3.040	1.597 to 5.787	0.001
Marital status	Married (Ref)	1	–	–
	Unmarried	1.785	0.988 to 3.222	0.055
Educational qualification	Graduate (Ref)	1	–	–
	Postgraduate	1.879	1.094 to 3.226	0.022
Years of experience	≤1 year (Ref)	1	–	–
	1–5 years	0.270	0.144 to 0.505	<0.001
	>5 years	0.409	0.200 to 0.837	0.014

Bold p values indicate statistically significant results.

cOR, crude OR; WPV, workplace violence.

In the multivariate model, after adjusting for potential confounders, gender remained a strong and significant predictor of WPV, with women having nearly three times higher odds (aOR 2.799, 95% CI 1.419 to 5.522, p=0.003) compared with men. Educational qualification did not retain statistical significance in the adjusted model: although postgraduates had higher odds than graduates (aOR 1.644, 95% CI 0.924 to 2.925), the association was not statistically significant (p=0.091). Years of experience showed a protective effect: those with 1–5 years of experience had significantly lower odds of WPV (aOR 0.275, 95% CI 0.144 to 0.524, p<0.001). Those with more than 5 years of experience also showed lower odds (aOR 0.494, 95% CI 0.231 to 1.044), though this result was not statistically significant (p=0.065) (table 4).

Table 4. Multivariate logistic regression analysis showing aOR with 95% CI for factors associated with WPV.

Variables	Category	aOR	95% CI	P value
Gender	Male (Ref)	1	–	–
	Female	2.799	1.419 to 5.522	0.003
Educational qualification	Graduate (Ref)	1	–	–
	Postgraduate	1.644	0.924 to 2.925	0.091
Years of experience	≤1 year (Ref)	1	–	–
	1–5 years	0.275	0.144 to 0.524	<0.001
	>5 years	0.494	0.2314 to 1.044	0.065

Bold p values indicate statistically significant results.

aOR, adjusted OR; WPV, workplace violence.

Out of the 243 participants, 62.6% reported having experienced WPV during their lifetime. 33 (13.6%) participants reported having experienced physical violence, while 151 (62.1%) had experienced verbal altercations.

5.8% of the healthcare workers reported facing verbal abuse daily. In comparison, 39 (16%), 54 (22.2%) and 44 (18.1%) participants reported having experienced it at least once a week, once a month and once every 6 months, respectively. On assessing the physical violence faced by healthcare workers, three (1.2%) participants reported facing it at least once a month or more, six (2.5%) participants at least once every 6 months and eight (3.3%) participants at least once a year.

Among the 72 male participants in our study, 79.2% experienced WPV, compared with 55.6% of all female participants in our study. Similarly, out of the 103 graduates, 70.9% experienced violence, compared with 56.4% of the total postgraduates. The prevalence of WPV was also found to be higher among unmarried individuals (p=0.036) and workers having experience between 1 and 5 years (p=<0.001)

Qualitative domains

The in-depth interview among the participants revealed multiple perceptions and experiences regarding WPV. Four main themes that emerged are explained below.

Precipitating factors leading to violent situations in a healthcare setting

The participants elaborated on numerous factors that might lead to violence in the healthcare setting. The major subthemes that emerged included communication and knowledge issues, behavioural factors, external and systemic issues, patient-related issues, cultural and social factors, and personal issues of healthcare staff.

Most of the time, bystanders are apprehensive. Especially in cases of patients with critical conditions, the bystanders or patients show rude behaviour due to a lack of awareness about medical procedures and a hesitancy to understand the situation. Even the doctor-patient communication issues may play a major causative role in WPV, when combined with illiteracy and lack of awareness among bystanders.

Behavioural factors from the patient and bystander’s side, like alcohol intoxication, arrogance, non-compliance, unrealistic expectations and emotional upsurge, may lead to WPV.

The environment under which care and services are provided in hospitals contributes to WPV, where healthcare workers are more prone to them. Some other crucial factors that may cause WPV are internal and systemic factors such as treatment delay, hierarchical issues, negligence, high treatment cost and service delay from the hospital.

Even when the doctor-patient ratio is low, it leads to longer waiting time and triaging delay, irritating the patient and bystanders.

For a patient who is diagnosed with a critical condition (pain or possibility of sudden and worse health outcome) and poor prognosis, the situation may invite agitated and angry mobs as they expect ‘godly healing’ from the doctor.

In this note, one participant stated,

Violent situations in healthcare settings can arise due to a combination of factors such as patient aggression stemming from pain, confusion, or mental health issues, breakdowns in communication among staff or with patients, long wait times leading to heightened frustration, and becoming stressful.

Experience with workplace violence and violence-prone situations

One significant subtheme that emerged was patient-bystander-related incidents. Healthcare workers frequently face violence from intoxicated individuals. Similarly, managing mentally unstable patients often leads to challenges. Demanding patients and their bystanders, patients with non-compliance with medical advice, and dissatisfaction can also trigger aggressive situations. Sometimes, repeated information seeking from family members irritates and interrupts the healthcare workers from their duty, and the patient information, if not conveyed to each bystander when they seek it, will trigger the aggressive bystanders, which worsens the situation.

In this note, a participant stated, “Once, an individual under the influence of alcohol visited my clinic and forcefully grabbed my hand, insisting that I examine him.”

Along with patient-bystander incidents, hospital-associated factors and situation-specific incidents are also prone to violence. Limited resources, admission denial when patients demand it and ethical dilemmas are other sources of dispute and violence. Billing disputes, treatment delays, wrong diagnosis and irritation caused by repeated investigations are additional factors that provoke the mob. Specific situations like night shifts, critical emergencies and the triage process are particularly prone to violent incidents.

One of the participants said that,

When one of my colleague’s patients was unexpectedly shifted to the ICU from wards following complications of malaria, the Patient’s relatives, who were very agitated, gathered in huge numbers and were searching for the treating physician all around the wards.

Grief is another emotional factor that provokes the crowd. Sometimes, a death, especially of a newborn, leads to aggressive, violent reactions from relatives. A strange scenario arises sometimes when death is declared following road traffic accidents or suicide attempts, and emotionally unstable relatives may start blaming the healthcare professionals.

A similar scenario was faced by another participant who stated that,

Once, while working as a junior doctor in the casualty department of a renowned hospital, I encountered violence. A patient arrived in hypovolemic shock after delivering a fetus at home. Despite our timely interventions, we were unable to save the mother and newborn, who were both declared dead. The attendees, forming a mob, mistakenly believed we had not provided proper treatment. They stormed the casualty ward, assaulted the senior resident, the chief medical officer, and me.

Possible consequences of healthcare violence

Possible consequences can be either for the HCP or for the patients. Fear might arise, making them hesitant to take the necessary risk while treating patients, mental trauma from stressful incidents can have long-lasting effects on their professional as well as personal life. Doctors opined they might adopt defensive medicine as a consequence of such violent experiences. This includes the practice of advising tests or treatment in order to avoid any liability.

Nowadays, fear of violence forces healthcare workers to practice ‘defensive medicine’. This approach often results in delayed procedures, extensive investigations, and expensive imaging, as no one wants to take any risks.

Doctors might migrate to other countries when they feel insecure in their work environment. Physical harm, property damage and hospital service interruption are other potential losses with WPV.

Patients might experience a lack of mutual respect from healthcare providers, which can affect the quality of care received. The doctor-patient relationship may change, resulting in reduced communication and trust. Delayed care is a potential consequence, where necessary treatments are postponed, possibly worsening the health outcomes. There could be long-term health consequences due to a combination of the above factors, affecting the patient’s overall well-being and health.

Prevention of healthcare violence

The participants opined that to prevent any incidents of WPV, the majority of the factors that cause it have to be managed, and it has to come mutually from the patient and HCP’s side. Communication from both parties can enhance the transparency and reduce most of the confusions and misunderstandings, and any situation can be handled well in this case.

Media also plays a very important role in disseminating information to the mass audience and impact on their awareness and trust levels. One of the participants, in this line, mentioned that,

We should prevent the delivery of half knowledge to the common people through social media, which is creating most issues. The common people believe this news as fact, and the ones that are shared by the doctors as a misconception. Also, we should take steps to gradually raise awareness among the people about common diseases.

The present study has adopted a convergent parallel mixed-method study design to provide a comprehensive understanding of WPV among healthcare providers.

Findings from the quantitative component identified the prevalence and predictors of WPV, showing that younger age, lesser work experience and employment in emergency departments were associated with higher odds of experiencing WPV. This was supported by qualitative findings that described how junior staff and those working in high-stress areas such as emergency rooms felt more vulnerable and lacked organisational support when facing aggression.

The quantitative data showed gender-based differences in WPV exposure, which was further explored in interviews. Female healthcare providers reported more frequent verbal abuse and expressed feelings of insecurity, highlighting how gender roles and expectations shape the WPV experience.

Additionally, while statistical analysis highlighted limited reporting of WPV, qualitative data provided that many participants feared retaliation, loss of reputation or administrative inaction, leading to under-reporting. This convergence underscores the need for institutional mechanisms that not only record but also act upon WPV incidents.

By integrating both datasets, this study offers a richer, contextualised understanding of WPV and emphasises the value of mixed-method research in exploring complex healthcare phenomena.

Discussion

This study employed a mixed-method approach to determine the prevalence and factors associated with WPV among healthcare personnel, as well as to evaluate the effects and potential solutions for reducing it.

62.6% of the participants indicated that they had encountered WPV at some point in their lives. The results of our investigation far exceeded the 35% reported by Kumari et al in their 2021 study conducted in New Delhi.¹ Other studies undertaken by Grover et al, Sharma et al and Anand et al have also found a decreased occurrence of WPV among doctors in comparison to our study.^{10 14 18} Other studies conducted in more developed countries have found higher rates of violence directed at healthcare professionals, ranging from 80% to 100%. Changes in the duration of exposure to the phenomenon, the specific definition of WPV, and the geographical location of the study population can account for the discrepancies in the prevalence rates of WPV among different studies.^{18 19}

Although the majority of reported violence is verbal abuse, accounting for 62.1%, around 13.6% of healthcare personnel claimed direct experience with physical assault. This finding aligns with previous research carried out in more affluent environments, which also shows comparable occurrences of both verbal and physical abuse. The absence of adequate safety protocols on hospital grounds is the primary cause of the progression of verbal abuse into physical violence.19,21

Our study found a statistically significant association between sociodemographic factors and the occurrence of WPV among healthcare workers. Out of the 72 male participants in our study, 79.2% experienced WPV, compared with 55.6% of all female participants. Similarly, out of the 103 graduates, 70.9% experienced acts of violence, compared with 56.4% of all postgraduates. The prevalence of WPV was greater among unmarried individuals (p=0.036) and those with 1–5 years of experience (p = <0.001) in healthcare settings. Consistent with our results, a study in Lebanon also reported that single healthcare workers are more likely to have experienced verbal abuse than married workers.²² Furthermore, Wei et al and Pich and Roche showed that young and inexperienced healthcare professionals were comparatively more susceptible to violence.^{23 24} At the same time, Spelten et al highlighted the challenges young and inexperienced nurses face in managing aggressive patients.²⁵

The interviewed participants reported that attendees are often anxious, especially around critical patients, and act violently due to a lack of medical knowledge and unwillingness to understand the issue. Even if the doctor has communication challenges with bystanders, illiteracy and lack of understanding may cause WPV. Similar findings of low health literacy among patients were also identified as a common cause of violence in prior studies in higher resource settings.^{21 26}

Our study participants also reported that violence may be caused by patients’ and bystanders’ alcohol intoxication, arrogance, non-compliance, unrealistic expectations and emotional upheaval. Internal and systemic causes like treatment delay, hierarchy issues, neglect, expensive treatment costs and hospital service delays can also cause WPV. With a reduced doctor-patient ratio, longer waiting time, and triage can annoy patients. Hospital-related causes and situation-specific incidents, in addition to patient-bystander occurrences, are responsible for inciting violence. The participants cited several reasons for violence, including limited resources, admission denials and ethical difficulties. Repeated investigations, billing disputes, treatment delays, erroneous diagnoses and frustration also ignite the mob. In the study done by Joshi et, doctors expressed that the combination of rising denial of care for non-paying patients and a reluctance to accept unsatisfactory results by the patients or bystanders was undermining the essential foundations of the doctor-patient relationship.²⁷ The findings are consistent with the responses of many interview participants, who repeatedly mentioned instances of violence related to unexpected negative results, as well as family members unhappy with the expense of healthcare.²⁸

The participants believed that these violent events can create a lack of courage or fear while treating patients, leading to mental trauma that can affect both their professional and personal lives, which could be a reason why doctors migrate to other countries. One participant even cited adopting defensive medicine as a consequence of such violent experiences. They also felt that the lack of mutual respect between the patient and the doctor can make the care patients receive less effective, resulting in reduced communication and trust. In a study by Davey et al, the participants reported the adverse effects of WPV on both the quality of patient care and their job motivation.²⁹ Our results align with previous research, which establishes a correlation between WPV and higher levels of burnout, absenteeism and job dissatisfaction.^{18 30}

The majority of the participants opined that to reduce WPV, there should be effective communication between both healthcare providers and patients to increase transparency and minimise confusion and misunderstandings, thereby enabling the successful handling of any circumstances. Furthermore, the media is essential in informing the public and shaping their levels of knowledge and trust; it is important to use the media responsibly rather than disseminating false information. A comprehensive analysis of nine studies confirms that implementing appropriate training on aggression management and communication skills leads to enhanced communication and effective handling of patient hostility, thereby reducing WPV.³⁰ Literature also suggests that training in communication skills can increase confidence in dealing with such behaviour.³¹

The present study has certain limitations that should be considered when interpreting the findings. First, we conducted this study using a self-reported technique, which depends on the participants’ ability to recall events. Second, healthcare professionals from various parts of Southern India participated in the survey. Even though most of these hospitals are considered tertiary-level, there could be variations in the number of patients seeking medical attention at these specific institutions. Thus, future research should incorporate specific information on the patients who visit these facilities to account for the potential confounding factors. Moreover, the bulk of interviewees consisted of doctors, predominantly residents or consultants. Potential selection bias may exist when the replies provided disproportionately reflect doctors’ perspectives and concerns.

Conclusion

WPV against healthcare professionals remains a significant concern nowadays, with many incidents being reported throughout India. The problem still goes under-researched and under-reported. This mixed-method study highlights the prevalence, risk factors and consequences of WPV among healthcare workers. The study reveals that a substantial number of healthcare workers experience verbal and physical violence. Key risk factors include gender, educational background and years of experience, with younger, less experienced and unmarried workers being more vulnerable to violence.

The qualitative findings emphasise the complexity of WPV, which is influenced by communication gaps, patient and bystander behaviour, systemic issues and cultural factors. The consequences of such violence extend beyond physical harm to include psychological trauma, reduced job satisfaction and impaired patient care. The study revealed long-term consequences, such as that they may adopt defensive medical practices or sometimes choose to migrate due to safety concerns.

Addressing the WPV requires a multifaceted approach, inculcating improved communication strategies, better patient and bystander education methods, and organisational level changes to ensure safety and security. Also, the interventions should be directed through a gender-sensitive approach and focus on early career professionals for conflict resolution and staff protection.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.