Workplace violence against healthcare workers in China: a systematic legal analysis with reference to international labour standards

Abstract

Background

Workplace violence against healthcare workers (HCWPV) is a global public health and occupational hazard, endangering staff physical/psychological well-being and public health security. China faces strained doctor-patient relations and frequent HCWPV yet its legal framework lacks occupational safety and health (OSH) oriented regulations. The International Labour Organization (ILO)’s Violence and Harassment Convention (C190) and Recommendation (R206) provide an internationally recognized normative benchmark, structured around a three-pillar approach: defining and prohibiting violence, establishing enforcement and remedies, and mandating preventive measures. This study conducted a systematic legal analysis of legally binding national-level documents to examine how HCWPV is addressed in China. By comparing China’s national legal framework with the ILO three-pillar model, this study aims to identify regulatory gaps and inform improvements in the governance of HCWPV.

Methods

This study conducted a systematic legal analysis of legally binding national-level legal and policy instruments in China to examine how HCWPV is addressed. Documents were identified through comprehensive database searches and supplementary legal screening, and analyzed using a structured analytical framework informed by international standards.

Results

China’s relevant legal framework includes the Constitution, 10 laws, 3 administrative regulations, 3 departmental rules, and 33 other normative documents. Provisions are scattered and focusing on post-incident punishment and public order maintenance, while excluding psychological violence and failing to define HCWPV as an occupational hazard. When mapped against the C190& R206 framework, substantial gaps were observed across all 3 pillars, including narrow and incident-based definitions of violence, reliance on post-incident punitive enforcement, and limited preventive obligations for healthcare institutions.

Conclusion

China’s “public order-first” legislative paradigm prioritizes punishment over prevention, creating systemic gaps in HCWPV governance. These findings suggest that reframing HCWPV as a psychosocial occupational hazard and aligning national legislation with the preventive, worker-centered principles of C190&R206 may strengthen the coherence and public health effectiveness of China’s regulatory framework.

Introduction

Workplace Violence (WPV), with its global dimensions and gravity, has established a critical issue in the world of work [1]. Especially, WPV against healthcare workers (HCWs), which constitutes a global concern with a complex etiology, may get employees, clients, customers, and visitors involved in its alarming damages [2, 3]. Notably, HCWs experience substantially higher estimated rates of nonfatal injury due to WPV compared to workers overall [4]. Under the principle of occupational disease prevention and control, WPV is increasingly recognized as an occupational hazard embedded in the work environment, with implications extending beyond individual workers to the functioning and resilience of health systems [5]. Globally, legislation against WPV established long-standing, effective deterrents to perpetrators of violence in the workplace and elsewhere [6–8]. Provisions have been introduced into the labour laws or occupational safety and health (OSH) laws to guarantee workers’ right of free from WPV and harassment or to impose a duty on employers to prevent violence and harassment [9, 10]. Such legal protections constitute an upstream determinant of occupational health, shaping preventive capacity, accountability mechanisms, and access to remedies following violent incidents.

China has faced a strained doctor-patient relationship, increased medical disputes, and recurrent violence targeting HCWs in medical settings, with some cases escalating into criminal offenses. WPV in Chinese hospitals not only inflicts physical and psychological harm on HCWs but also poses a non-negligible threat to public health and safety. Despite these challenges, concerns remain regarding the adequacy and coherence of existing legal and regulatory protections addressing WPV in healthcare settings. The contrast between global legislative developments and China’s current regulatory landscape underscores the need for a systematic examination of the legal framework governing HCWPV.

Current Chinese studies on HCWPV have predominantly focused on risk assessment and control of WPV from meso-level, including analyzing prevalence rates, identifying risk factors, and proposing preventive measures [11–14]. While these studies have generated valuable empirical evidence, they rarely address the normative and regulatory dimensions of WPV governance. In particular, questions regarding employers’ legal obligations, the availability of enforceable remedies, and the rights of HCWs following WPV incidents remain insufficiently examined from a public health perspective.

Among existing international instruments addressing WPV, the Violence and Harassment Convention (C190) and its Recommendation (R206) represent the most comprehensive and authoritative international legal framework governing violence and harassment in the world of work. As a legally binding international labour convention, it establishes a systematic governance framework called 3-pillar approach: defining and prohibiting violence and harassment, establishing enforcement mechanisms and remedies, and mandating preventive measures [10, 15]. Moreover, they were developed through the ILO’s tripartite governance mechanism, incorporating extensive scientific evidence and international technical guidance accumulated over decades. Therefore, C190&R206 provides an appropriate normative reference for evaluating the structural completeness of domestic legal framework. Although China has not ratified C190, non-ratification does not diminish its relevance as a comparative benchmark; rather, it highlights a possible divergence between international integrated governance standards and China’s existing governance approach, making that divergence analytically valuable in itself. This divergence not only reflects China’s distinctive legislative and governance preferences but also provides an important perspective for understanding the country’s approach to transnational international labour standards.

This study conducts a systematic analysis of legally binding national-level documents in China and benchmarks them against the ILO C190&R206 framework to identify regulatory gaps and inform improvements in the governance of HCWPV. This study aims to complement existing empirical research and contribute to the development of a more coherent and preventive framework for HCWPV protection.

Methods

A systematic legal analysis was adopted because HCWPV is governed through a complex legal framework involving multiple parties, including healthcare institutions, regulatory authorities, and judicial bodies. Because these actors operate within a structured legal framework, examining the legal architecture that defines responsibilities, rights, and governance mechanisms is essential for understanding how workplace violence is regulated and addressed.

The conceptual framework and search strategy proposed by Liu, et al. [11], which emphasizes systematically identifying legally binding national-level documents through law database retrieval and supplementary official government website searches were used in this article. Following that, a comprehensive search of legally binding national-level Chinese documents was conducted using the PKULAW Database (Beida Fabao), supplemented by searches of official websites of the Central Government and Departments of the State Council of the People’s Republic of China. Full-text search utilized the keywords “workplace violence,” “medical violence,” “medical disputes”, “doctor-patient conflicts,” “hospital violence” or “healthcare order” with no start date restriction and an end date of June 10, 2025. In addition to keyword-based searches, documents that did not explicitly contain these terms were also included if they conferred protections related to personal security, occupational health, or human rights of HCWs. Given the legal nature of the research question, document hierarchy and legally binding force were prioritized over empirical evidence grading in the selection and analysis of materials. This study focuses on national-level legal instruments because they establish the overarching regulatory framework governing WPV prevention in China. In China, national legislation establishes binding rights, regulatory obligations, and institutional responsibilities across sectors. In addition, ratification and implementation of international labour conventions occur at the national level. Local policies often function as implementation measures but vary across regions and therefore cannot provide a consistent basis for national-level legal comparison. Although local governments have adopted various measures addressing WPV in healthcare settings, these policies primarily function as implementation tools and vary considerably across regions therefore cannot provide a consistent legal basis for general application across the whole country [16]. Importantly, WPV is not limited to healthcare but occurs across multiple sectors of work. Addressing WPV systematically therefore requires a national framework capable of coordinating prevention, monitoring, and enforcement across industries. Therefore, national legislation represents the most appropriate level for comparative legal analysis with international labour standards.

The inclusion criteria were defined as: (1) legally binding national-level laws, administrative regulations, judicial interpretations, or normative policy documents with legally binding force that were currently in force; (2) documents that explicitly establish fundamental rights, guiding principles, or concrete regulatory measures aimed at preventing, responding to, or addressing WPV in healthcare; and (3) documents applicable to healthcare institutions or HCWs.

The exclusion criteria were: (1) duplicate records; (2) invalid, repealed, or non-effective documents; (3) documents of lower legal hierarchy or without general legally binding force, including internal working papers, Party regulations, military normative documents, industry self-regulatory rules, and group rules; and (4) documents not substantively related to WPV, healthcare order, or protection of HCWs.

The search yielded 952 records from the PKULAW Database and 8 additional documents through supplementary legal analysis, including manual screening of cross-referenced legal provisions (n = 960). After removal of 513 duplicates, 23 invalid or non-effective documents, and 223 documents of lower legal hierarchy (including 211 working papers, 7 Party regulations, 1 military normative document, 3 industry rules, and 1 group rule), 201 records remained for screening. Following full-text screening, 133 irrelevant documents were excluded. A further 18 documents (16 irrelevant documents and 2 working reports identified at the eligibility assessment stage) were excluded at the eligibility assessment stage. Ultimately, 50 legally binding national-level documents explicitly establishing essential rights, principles, or specific measures to address WPV in healthcare settings were included in the final analysis. The search strategy is presented in Fig. 1.

Fig. 1.

Flow diagram of the search process for the review

For comparative purposes, the International Labour Organization (ILO) C190&R206, which serve as the primary analytical framework for addressing WPV and harassment, were retrieved from the ILO Normlex database [10, 15]. The selection of these instruments is grounded in both their legal hierarchy and substantive content. First, as international conventions, they represent a formal source of international law, establishing legally binding obligations for member states upon ratification. Although China has not yet ratified C190, it is significant that within the Chinese legal system, ratified international conventions hold a legal status equivalent to national legislation. This potential for domestic legal effect underscores the relevance of these instruments as a benchmark. This characteristic distinguishes them from other soft laws such as resolutions, technical guidelines and standards of other international organizations, which primarily function as political commitment or technical/policy guidance. Second, C190&R206 are unique in international law for providing a comprehensive, cross-sectoral framework to address violence and harassment in the world of work. They are inclusive, gender-responsive, and prevention-oriented, covering all sectors including healthcare—a scope unmatched by other international instruments. Therefore, C190&R206 serve as the most appropriate benchmark for evaluating the comprehensiveness of China’s current regulatory framework against an authoritative international standard.

Results

Overview of legal documents of China

Under China’s legislative system, the legal normative framework can be divided into two primary structures: national legislation and local legislation. This study focuses specifically on the national-level legal instruments for they establish the overarching legal framework governing WPV prevention in China. Within China’s current legislative framework, national legislation comprises the following four primary legal basis: (1) The Constitution, which serves as the supreme legal and normative source within the entire legal system, occupying the highest position and possessing ultimate authority; (2) Laws, which are divided into two tiers: basic laws enacted by the National People’s Congress (NPC) and other laws enacted by the Standing Committee of the National People’s Congress (NPCSC); (3) Administrative regulations, formulated by the State Council (SC); (4) Departmental rules, issued by the ministries and commissions under the State Council.

After the comprehensive review of the current Chinese law database and Chinese official government websites, the national legally binding documents concerning the prevention of violence against HCWs were examined and collected. As a result, the constitution, 10 laws, 3 administrative regulations, 3 departmental rules (Table 1), 33 other legal normative documents are involved [17–33]. Notably, there are no specific laws, regulations or rules, which are of relatively high hierarchy, mainly for neither the WPV nor the WPV against HCWs, with relevant provisions scattering in different documents. At the national level, China lacks specialized legislation on WPV through a perspective of occupational safety and health. Overall, the identified legal provisions were fragmented across multiple legal instruments and could be analytically grouped into three domains: (1) protection of personal dignity and physical safety, (2) maintenance of medical and public order through punitive measures, and (3) limited employer-related obligations concerning workplace safety. Notably, preventive and psychosocial risk-oriented provisions were largely absent.

Table 1.

Content of selected Chinese national legally binding documents (except other normative documents)

Legislative Hierarchy	Title	Issuing Authority	Effective Date	Relevant articles	Brief Summary
Constitution	Constitution (2018 Amendment) [17]	NPC	2018.03.11	Article 33,38,42	The Constitution establishes fundamental principles concerning human rights protection, personal dignity, and labor protection, thereby providing a general normative basis for safeguarding HCWs’ personal safety and working conditions, while not explicitly addressing HCWPV.
Law	Penalties for Administration of Public Security (2025 Amendment) [18]	NPCSC	2026.01.01	Article 26	This law regulates acts that disrupt public order in medical institutions through administrative penalties, treating violence against HCWs primarily as a public security issue rather than an occupational safety and health risk.
	Criminal Law (2023 Amendment) [19]	NPC	2024.03.01	Article 290	The Criminal Law criminalizes serious acts of violence and disorder that disrupt medical services, emphasizing punitive responses to extreme incidents and addressing WPV against HCWs mainly from a criminal justice perspective.
	Law on Safeguarding the Rights and Interests of Women (2022 Revision) [20]	NPC	2023.01.01	Article 20,21,25	This law provides specific protections against sexual harassment and violence, including preventive obligations imposed on employers, which may apply to female HCWs but are not specifically tailored to HCWPV as an occupational hazard.
	Medical Practitioners Law [21]	NPCSC	2022.03.01	Article 22,49,50	The Medical Practitioners Law recognizes HCWs’ rights to personal dignity, personal safety, and a secure practicing environment, and assigns responsibilities to governments and medical institutions to maintain medical order and protect practitioners, with a primary focus on post-incident protection.
	Civil Code [22]	NPC	2021.01.01	Article 109,110,990,1002,1003,1004,1010,1228	The Civil Code establishes comprehensive civil protections for personal rights, health, and dignity, and provides a legal basis for tort liability in cases where medical order is disrupted or HCWs’ legitimate rights are infringed.
	Work Safety Law (2021 Amendment) [23]	NPCSC	2021.09.01	Article 3	The Work Safety Law sets out general principles of work safety and prevention-oriented risk control, but does not explicitly classify WPV or psychosocial risks in healthcare settings as regulated occupational safety hazards.
	Law on Basic Medical and Health Care and the Promotion of Health [24]	NPCSC	2020.06.01	Article 23,33,46,57,79,96	This law frames violence in healthcare settings mainly as a threat to medical order and public safety, affirming the protection of HCWs’ personal safety while prioritizing the maintenance of orderly medical services.
	Labor Law (2018 Amendment) [25]	NPCSC	2018.12.29	Article 3,52,54	The Labor Law confirms workers’ general rights to occupational safety and health and imposes employer obligations for workplace safety management, without explicitly incorporating WPV or psychosocial hazards into labor protection mechanisms.
	Law on the Prevention and Control of Occupational Diseases (2018 Amendment) [26]	NPCSC	2018.12.29	Article 4,20,39	This law establishes a comprehensive framework for occupational disease prevention and employer responsibility, but remains focused on traditional physical, chemical, and biological hazards, thereby excluding WPV from the defined scope of occupational hazards.
	Mental Health Law (2018 Amendment) [27]	NPCSC	2018.04.27	Article 15,71	The Mental Health Law requires employers to promote psychologically healthy working environments and provides specific protections for mental health professionals, offering indirect relevance to psychological harm arising from WPV.
Administrative Regulations	Nurses Regulation (2020 Revision) [28]	SC	2020.03.27	Article 3	The Nurses Regulation explicitly protects nurses’ personal dignity and personal safety during professional practice, reinforcing legal recognition of protection needs while lacking detailed preventive or enforcement mechanisms for WPV.
	Regulation on the Prevention and Handling of Medical Disputes [29]	SC	2018.10.01	Article 1,6,29	This regulation establishes administrative and public security mechanisms for responding to medical disputes and violent incidents, emphasizing rapid intervention and the restoration of medical order rather than the systematic prevention of WPV.
	Regulation on the Handling of Medical Accidents [30]	SC	2002.09.01	Article 1,6,29	This regulation focuses on the management of medical accidents and dispute resolution, indirectly addressing safety concerns in medical settings without directly regulating WPV against HCWs.
Departmental Rules	Provisions on the Administration of Occupational Health at Workplaces [31]	NHC	2021.02.01	Article 1	These provisions clarify employers’ primary responsibility for occupational health management and hazard control, but do not explicitly recognize WPV or psychosocial risks as occupational health hazards.
	Measures for Complaint Management of Medical Institutions [32]	NHC	2019.04.10	Article 3,4	These measures require medical institutions to establish complaint-handling and risk-management mechanisms aimed at reducing disputes and maintaining medical order, with limited emphasis on protecting HCWs from violence.
	Measures for the Administration of Medical Quality [33]	NHFPC (dissolved)	2016.11.01	Article 7,8,9,14,15	These measures promote medical safety and risk management through institutional governance and dispute prevention mechanisms, addressing WPV only indirectly as part of broader medical quality and safety management.

NHC, National Health Commission; NHFPC, National Health and Family Planning Commission (dissolved); NPC, National People’s Congressp; NPCSC, Standing Committee of the National People’s Congress; SC, State Council

Content analysis of legal documents of China

Legal basis of WPV against HCWs

Analysis of national-level legal documents indicates that protections against HCWPV in China are primarily derived from general constitutional and civil rights provisions, rather than from explicit occupational safety and health laws. Pursuant to the theory of application of analogy, such right can be interpreted through extended application of legal provisions within Chinese legal system (Table 1).

Firstly, HCWs, as citizens, are legally entitled to the right to life, which includes protection from unlegitimate violent infringement. The right to life is the most fundamental and paramount human right, and citizens are legally entitled to protection against illegal infringement of their lives.

Secondly, the state and employers bear the obligation to strengthen labour protection and improve working conditions, while workers have the right to occupational safety and health protection. From the perspective of occupational disease prevention, employers are responsible for preventing occupational diseases, creating sound work environments and conditions that comply with national occupational health standards and requirements, and fulfilling their primary responsibility to take measures to ensure workers’ occupational health protection.

Ultimately, HCWs serve as the core pillar of China’s health and wellness sector, playing a pivotal role in safeguarding public health and advancing the “Healthy China” initiative [34]. Their legitimate rights and interests deserve and should be protected. Article 1,228 of Part VII: Tort Liability in the Civil Code stipulates tort liability for disrupting medical order, hindering the work and lives of HCWs, and infringing upon their legitimate rights and interests [22]. The Law on Medical Practitioners explicitly grants physicians the right to personal dignity and inviolability of personal safety [21]. The Basic Healthcare and Health Promotion Law set forth legal consequences for disrupting order in healthcare institutions, threatening or endangering the personal safety of healthcare personnel, and violating their personal dignity, thereby achieving effective coordination between administrative, civil, and criminal laws [24].

To achieve the principles outlined above, relevant national authorities have successively issued supporting normative documents that echo the zero-tolerance stance toward violence against HCWs, proposing more actionable implementation requirements. At the national level, in response to the high incidence of offenses and crimes against medical institutions, in September 2021, the NHC and seven other departments jointly issued the Guiding Opinions on Promoting the Management of Hospital Safety and Order (hereinafter referred to as the Guiding Opinions) [35]. The Guiding Opinions emphasizes the dual mechanisms of improving management mechanism and legal system, advocating a “two-pronged approach” that combines crackdowns on illegal and criminal offenses targeting HCWs with the establishment of long-term mechanisms for preventing and handling medical disputes [36]. These efforts aim to enhance the management structure of hospital security, standardize safety management systems, optimize risk early-warning mechanisms, improve emergency response protocols, and gradually build a systematic, scientific, efficient, and intelligent high-level hospital security prevention system [35]. Additionally, ahead of the Guiding Opinions, a series of normative legal documents and judicial interpretation documents had been introduced, enhancing the competence to actively prevent and address offenses and crimes against HCWs and medical order and reaffirming the zero-tolerance position [37]. After years of efforts, according to the Supreme People’s Procuratorate’s working reports, the number of individuals prosecuted for intentional violence against HCWs and gatherings that disrupt medical order decreased from 3,202 in 2018 to 467 in 2022. By 2023, this figure further dropped to 226, representing a year-on-year decrease of 51.6% compared to 2022 [38, 39]. However, these trends reflect changes in criminal prosecution statistics rather than comprehensive indicators of WPV prevention effectiveness, as they do not capture unreported incidents or psychosocial forms of violence.

Definition and characteristics

The review shows that existing Chinese legal documents adopt an incident-based and behavior-specific approach to WPV, lacking a unified and inclusive definition that captures cumulative, psychological, and internal forms of violence. Though there is no clear legal definition of WPV in Chinese legal system, several serve violent acts targeting at HCWs were listed in some legally binding documents whose legal hierarchy are mostly lower than rules. For instance, in accordance with the Opinions of Punishing Illegal Acts and Crimes against Medical Staff in accordance with Law and Maintaining the Normal Medical Order [37], illegal acts and crimes against HCWs are described as follows:

• Beating, intentionally injures or kills HCWs, or intentionally damages public or personal property in a medical institution;

• Setting up mourning halls without permission, lay wreaths, burn joss paper, hang banners, block the gates or disrupt medical order by other means in a medical institution;

• Placing a dead body in a hospital ward, emergency room, intensive care unit or any other facility in a medical institution or in the public open space of a medical institution in violation of regulations, affecting medical order, but does not cease the act upon persuasion or warning.

• Illegally restricting personal freedom of any HCW by prohibiting him or her from leaving the workplace or by other means;

• Openly insulting or intimidating HCWs;

• Entering a medical institution illegally carrying a firearm, ammunition or a tool subject to regulation, or any explosive, radioactive, toxic or corrosive substance;

• Intentionally escalating a matter and instigates another person to commit an illegal act or a crime against a medical institution or any HCW, or engaging in extortion, picking quarrels and making trouble, or committing another act in the name of handling a medical dispute with the authorization of another person.

Such kind of categories’ limitations are evident. First, it overlooks the complexity in the sources of WPV. Research has confirmed that WPV in medical institutions originates from diverse sources, which may include external perpetrators such as patients and their families or strangers, as well as internal hospital personnel such as colleagues or supervisors [7]. Second, it fails to account for the variety of manifestations of WPV. These range from acute and overt physical violence such as pushing and beating, to psychological violence including bullying, exclusion, and threats [13]. Notably, psychological violence among HCWs is widely recognized as more common than physical violence [13]. While such psychological violence may not cause significant disruption to medical or operational order, it leads to chronic and latent occupational health harm such as post-traumatic stress disorder (PTSD) and burnout among HCWs that cannot be overlooked [14].

The definition of WPV should not be limited to acute, overt physical acts of high severity that may endanger public order. Also, preventive methods in normative documents are narrowly confined to safety mechanism aiming at prohibiting severe physical violence by external perpetrators, which shows the imbalance on post-incident punitive method and systemic WPV prevention mechanism, resulting in neglecting the profound and complex internal socioeconomic, human resource management, and organizational factors that may contribute to WPV.

Rather, from an occupational health perspective, it should also encompass all unacceptable and invisible forms of psychological and sexual violence. Although these may be less severe in immediate intensity, they exert cumulative effects on workers’ physical and mental health.

Nature in legal practices

Based on the analysis of China’s normative legal documents, it is revealed that in Chinese legislative practice, WPV against HCWs is primarily regulated from the perspectives of public security management and post-incident punitive measures under criminal law. WPV incidents are treated as isolated events, with more severe and harmful cases being addressed as violations of the Public Security Administration Punishment Law or the Criminal Law. However, criminal law as the last resort to protect legal interests, only when the high threshold of incrimination is satisfied, it can play its protective role. Thus, merely relying on this way to regulate WPV against HCWs is far from enough.

In China’s judicial practice, judicial precedents demonstrate that WPV can be deemed a work-related injury in litigation. Theoretically, Article 14, Item 3 of the Regulations on Work-Related Injury Insurance [40], covers the situation that “an employee suffers from violence or other unexpected injury within the working hours and working place due to implementation of his duties.“ [40]. Then the identification of injuries follows the national standard outlined in the “Standard for identify work ability-Gradation of disability caused by work-related injuries and occupational diseases“(hereinafter referred to as the Standard) [41]. Notably, this regulation does not explicitly limit the injuries to physical harm but also encompasses psychological harm, as reflected both in the Regulations on Work-Related Injury Insurance and the Standard. This interpretation was judicially affirmed in Changsha Bureau of Human Resources and Social Security v. Wang J. (2020), This case involved a nurse who developed fecal/urinary incontinence, bilateral temporal lobe atrophy, and social dysfunction and received a diagnosis of “adjustment disorder with prolonged depressive reaction” after being sexually assaulted while on duty. The court found that this injury satisfied the elements of work-related injury for the assault happening at work time during her duty at workplace. Meanwhile, there was a nexus between the injury and the assault. Altogether, the fact was deemed sufficient to establish work-related injury. The appellate court recognized psychological harm from WPV as work-related injury. In result, regardless of whether the injuries are physical or mental resulting from WPV, as long as they satisfy the criteria for recognition as work-related injuries, the victim is eligible to receive remedies through work-related injury insurance [42]. Nevertheless, it is often very difficult to provide evidence of a direct causal nexus between the injury and the conduct. As a result, in cases involving WPV or bullying leading to consequences such as suicide or addictive behaviors like drug abuse, it is challenging to establish such a connection and obtain remedy.

China’s latest 2024 Classification and Catalogue of Occupational Diseases (hereinafter referred to as the Catalogue) has recently incorporated Occupational Mental and Behavioral Disorders, encompassing work-related PTSD [43]. Emerging research has shown that WPV significantly increases PTSD risks among HCWs [44–47], with one study revealing that approximately 10% of WPV victims developed PTSD within six months post-incident [44]. While this development seemingly presented a potential avenue for addressing WPV as an occupational hazard and the resulting work-related PTSD as an occupational disease, may not be sufficient. In fact, the application of PTSD in the Catalogue is strictly limited to emergency responders handling emergency events, including police, firefighters and HCWs [43]. This exclusionary scope, combined with the legal definition of emergency events which renders PTSD from routine WPV ineligible for occupational disease status. Moreover, China’s occupational hazard classification remains fixated on traditional occupational hazards like physical, chemical and biological etc., entirely omitting psychosocial hazards like WPV and their chronic harm [43].

Above all, under Chinese current legal context, WPV is recognized as a work-related injury rather than an occupational hazard. This recognition focuses solely on the abrupt, unforeseen, and immediate aspects of violent incidents, overlooking their potential for persistence and cumulative effects. By reclassifying WPV as an occupational hazard, it would be recognized as a prolonged or recurrent hazard that workers are exposed to, which would facilitate the identification, assessment, and control of WPV through the hierarchy of occupational disease prevention and control. Such a shift would be essential for implementing proactive measures to prevent WPV.

Content analysis of C190 and R206

Overview of C190 and R206

C190 is the first international legally binding instrument that specifically recognizes the right of everyone to a world of work free from violence and harassment. C190 requires ratifying countries to ensure protection from and prevention of violence and harassment in the world of work through a two-handed framework. This encompasses a set of rights-based principles for the prevention and elimination of violence and harassment in the world of work and an inclusive, integrated and gender-responsive approach (Table 2). The latter includes a spectrum of different obligations which can be summarized as 3-pillar approach, such as defining and prohibiting violence and harassment in domestic labour law system, establishing enforcement and remedies mechanism, adopting appropriate measures to prevent it, which requires employers to take specific measures.

Table 2.

Content analysis of C190 and relevant R206 provision

Summary	Right/Obligation	Relevant articles	Brief Summary	Relevant paragraphs	Brief Summary
Rights-based framework for the prevention and elimination of violence and harassment in the world of work	Right to be free from Violence and harassment	Article 4	It establishes the right of all persons in the world of work to be free from violence and harassment and requires States to adopt an inclusive and integrated regulatory approach that treats WPV as a systemic labor and occupational safety issue rather than isolated misconduct.	Para.2	It adopts an integrated and gender-responsive approach by addressing violence and harassment across labour, occupational safety and health, equality, and criminal law frameworks, emphasizing comprehensive coverage of all relevant legal domains.
	Fundamental principles and rights at work; Decent work	Article 5	It links the prevention of violence and harassment to fundamental principles and rights at work, positioning a violence-free working environment as an essential component of decent work.
	Equality and non-discrimination for all	Article 2	It adopts an inclusive scope of protection covering all workers and persons in the world of work, regardless of contractual status or sector, with particular attention to groups disproportionately exposed to violence and harassment.	Para.5	It calls for regulatory alignment between measures addressing violence and harassment and existing international instruments on equality, non-discrimination, and fair employment conditions.
		Article 6	It mandates equality and non-discrimination protections for women and vulnerable groups disproportionately affected by violence and harassment, ensuring targeted legal coverage for at-risk populations.
The pillars of the inclusive, integrated and gender-responsive approach	Prevention and protection	Article 7	It requires States to legally define and prohibit violence and harassment in the world of work, explicitly recognizing physical, psychological, sexual, and gender-based forms of violence.	Para.6 ~ 13	It promotes preventive and protective measures for all workers, including vulnerable and high-risk groups, integrating OSH standards, participatory policies, risk assessments, and protections without restricting access to employment.
		Article 8	It requires members to implement preventive measures by identifying high-risk sectors, recognizing the role of public authorities in informal work, and providing protections for exposed workers, emphasizing proactive risk management.
		Article 9	It requires employers to adopt preventive measures proportionate to their degree of control, including workplace policies, training, and the integration of WPV into OSH management systems.
	Enforcement and remedies	Article 10	It requires States to establish enforcement mechanisms, accessible complaint procedures, and effective sanctions, ensuring that victims of WPV can obtain timely and appropriate remedies.	Para.14 ~ 22	These provisions emphasizes an integrated, victim-centred response that combines legal redress, workplace protection, and support measures to mitigate the work-related consequences of violence and harassment.
	Training, guidance and awareness raising	Article 11	It calls for the integration of WPV prevention into national policies and for the provision of guidance and training for employers, workers, and relevant authorities.	Para.23	It advances prevention through state-supported training, guidance, public awareness, and institutional capacity-building across the world of work, promoting a sustained culture of safety and non-violence.

Definition and nature

Instead of applying a closed or uniform definition, the C190 described “violence and harassment” in the world of work as an inclusive concept encompassing a spectrum of unacceptable behaviors and practices, or threats thereof, whether a single occurrence or repeated, that aim at, result in, or are likely to result in physical, psychological, sexual or economic harm, and includes gender-based violence and harassment [15]. This definition consists of two fundamental elements [48]. The first is the prohibited conduct, which describes “a range of unacceptable behaviors and practices, or threats thereof”, which indicates that violence and harassment may consist of isolated incidents or cumulative and escalating behaviors based on both subjective experiences and objective standards. For conduct to be considered unacceptable, it must aim to cause, be likely to lead to, or actually result in physical, psychological, sexual, or economic harm. The explicit incorporation of “economic harm” alongside other forms ensures a comprehensive coverage of all types of harms of violence and harassment. Notably, the definition does not treat intent as a constitutive element, which reflects a victim-centered perspective, indicating the emphasis on the impact of the behaviour and its unacceptability [48].

As for the nature of WPV under the C190&R206, the states parties should engage in extending or adapting existing OSH measures to cover violence and harassment and developing specific measures where necessary [15]. Also, in Article 9 of C190, the employers should be required to take appropriate steps commensurate with their degree of control to prevent WPV, applying the OSH method where the WPV will be defined as an occupational hazard. The OSH method consists of identifying hazards and assessing the risks of WPV with the participation of workers and their representatives, taking measures to prevent and control them; and providing to workers and other persons concerned information and training, in accessible formats as appropriate, on the identified hazards and risks of WPV and the associated prevention and protection measures, including on the rights and responsibilities of workers and other persons concerned in relation to the Workplace OSH policy [15]. This framework establishes a clear and standardized international law methodology to address diverse spectrum of WPV and harassment.

Discussion

Insights from the comparison of Chinese and ILO legal frameworks concerning prevention and control of WPV

The present analysis focuses primarily on the legal definition and nature of WPV which form the foundation for the development of systematic prevention and monitoring mechanisms at the national level. In China, systematic monitoring, surveillance, and institutional data collection can only be effectively initiated once WPV is formally recognized as an occupational hazard within the OSH framework. So additional discrepancies such as in the scope of workers covered, requirements for risk assessment and so on will not be discussed in detail here.

Under the analysis, it can be concluded that China’s existing national legally binding documents governing WPV exhibit a distinct “public order-first"orientation, prioritizing the maintenance of medical order over the protection of HCWs’ OSH rights. Moreover, the Criminal Law and other legal documents place greater emphasis on punishing extreme physical violence, while preventive measures and proactive risk management remain limited.

This orientation contrasts sharply with the ILO framework, which considers WPV as an occupational safety and health hazard and embeds prevention, protection, and remedy within an integrated, worker-centered approach. Prevention at the workplace level represents the lowest-cost and most effective entry point for intervention allowing risks to be identified and addressed before escalation into serious incidents, yet it cannot be activated without hazard recognition in national OSH law. The absence of such a OSH-oriented framing in China’s legal system constitutes a critical structural gap, helping to explain why existing responses remain largely reactive and punitive rather than preventive.

Under the “public order-first” paradigm, employers’ responsibilities are constrained. Hospitals often address WPV through post-incident punitive measures or risk mitigation rather than systemic OSH interventions. In practice, some hospitals have failed to play their due role, addressing WPV in a simplistic and peremptory manner as isolated incidents or even ignoring it entirely, resulting in HCWs being dissatisfied or highly dissatisfied [12, 14]. In contrast, C190 explicitly requires employers to identify psychosocial risks, adopt preventive policies, and account for sector-specific vulnerabilities—elements that are largely absent from China’s current regulatory framework [48].

Further, within this framework, the legal practice of defining medical order as public order empowers public authorities to regulate external violence sources through top-down administrative oversight, emphasizing post-incident resolution while neglecting root causes like socioeconomic determinants, human resource management deficiencies, and organizational risk factors. If this situation persists, and the root causes of WPV are not adequately addressed, a hostile work environment will develop, which is likely to become a breeding ground for abuse of a power relation.

Compared with OSH approaches centered on workers’ rights, this paradigm neglects proactive prevention at the source, prioritizes post-incident resolution, and fails to identify and address the complex socioeconomic factors, human resource management deficiencies, and organizational dynamics contributing to WPV. Apart from that, the WPV has not yet been incorporated into the OSH legal network as the C190 requiring, representing systemic gaps in addressing WPV of Chinese healthcare sector existing in limited legislation paradigm, exclusion from occupational disease prevention network.

Overall, the comparison with C190&R206 demonstrates that the key challenge is not merely the absence of individual legal provisions, but a systemic regulatory gap in which WPV is governed primarily as a public order issue rather than as a preventable occupational health hazard.

Suggestions for future work of WPV prevention

The comparative analysis highlights structural gaps between the current Chinese regulatory framework and the comprehensive governance approach established by C190&R206. Ratification of C190&R206 could provide a systematic legal basis for integrating WPV prevention into occupational safety and health governance systems, thereby strengthening preventive mechanisms and improving protection for healthcare workers. As indicated in the legal review above, the preparation of the ratification of C190 is largely adequate, with solid legal basis and substantial scientific evidence. This alignment would also signal China’s commitment to global health governance, as outlined in the Accelerating Actions to Advance the Global Health and Care Workforce by 2030 Resolution and Global Health and Care Worker Compact [49, 50], which calls for legal frameworks to prevent and address WPV against HCWs for their safety and well-being. By integrating international standards with domestic needs, China’s HCWPV legislation can serve as a model for low- and middle-income countries, contributing to global efforts to cultivate safer, equitable, and dignified working environments for HCWs worldwide.

Domestically, legislative reforms should adopt a hierarchical two-pronged approach to ensure coherence between foundational laws and specialized rules. Revise foundational laws to establish a more explicit and preventive-first legal basis through amending the Labor Law, Law on the Prevention and Control of Occupational Diseases and other highly relevant Laws to clearly define WPV as a psychosocial occupational hazard, integrate WPV prevention into occupational health services, which allows for the establishment of systematic risk identification and monitoring mechanisms, including incident reporting systems, occupational risk assessments, and institutional prevention measures. Strengthening data collection and monitoring systems is particularly important for improving the evidence base for policy development and enabling early identification of WPV risks. Also, if appropriate, developing specialized legislation for prevention and control of WPV in Healthcare, which describes stakeholder responsibilities, prevention standards, enforcement mechanism, victim remedies etc.

Conclusion

Comparative analysis reveals that China’s current legislation paradigm prioritizes public security order over occupational health protection, simplistically categorizing WPV consequences as workplace injuries while neglecting widespread psychosocial occupational hazard. To address these systemic gaps, China must build a preventive-first occupational health legal system responsive to practical demands, accelerate ratification of C190 while selectively integrating international best legal practices. Ultimately, these measures will advance comprehensive protections for over 15 million HCWs, thereby cultivating safer, equitable, and dignified working environments free from violence.

Abbreviations

C190

Violence and Harassment Convention

HCW

Healthcare Workers

HCWPV

Healthcare Workplace Violence

ILO

International Labour Organization

NHC

National Health Commission

NHFPC

National Health and Family Planning Commission (dissolved)

NPC

National People's Congress

NPCSC

Standing Committee of the National People's Congress

OSH

Occupational Safety and Health

SC

State Council

WPV

Workplace Violence

Authors’ contributions

Conceptualization: M.Z. and X.W.; Methodology: X.W.; Formal analysis: X.W.; Writing—original draft preparation: X.W.; Writing—review and editing: X.W., M.Z., Y.H., F.W., Y.T., C.H., X.F., Y.Z., K.L. and S.X.; Supervision: M.Z.; Project administration: M.Z.

Funding

This work was supported by the Project to Carry Out International Expert Consultation and Promote the Alignment of China’s Occupational Health with International High-Standard Technical Rules (2024–2025) which is funded by the Ministry of Human Resources and Social Security of the People’s Republic of China (Grant No. H20240785).

Data availability

Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.