Abstract
Background
Violence against health-care workers has become a great issue in health-care organizations. This study was conceptualized with the aim to know the prevalence of violence and to identify gap between rate of reporting of an incident of violence at a tertiary care hospital in India.
Methods
The study was descriptive and cross-sectional; a validated questionnaire was used as a tool. Reported incidents of violence against workers were collected. P value <0.05 was considered statistically significant in the analysis. A Z test for proportion at 95% confidence interval was applied to analyze the level of difference between prevalence, rate of reporting, and their level of awareness.
Results
Of 394 respondents, 136(34.5%) workers had experienced workplace violence in the last 12 months. It was found that total 32 incidents of workplace violence were reported to the concerned authority. The reporting rate of violence is significantly low (23.5%), in spite of high prevalence (34.5%). Level of awareness regarding the reporting mechanism and regulations for the safeguard of health-care workers against workplace violence is only 24.6 %.
Conclusion
This study concluded that the prevalence of violence among health-care workers is quite high, but the reporting rate is significantly low. The low rate of reporting is because of lack of awareness about the reporting mechanism of workplace violence. It is recommended that sensitizing workshops should be conducted to increase the level of awareness, which will result in reduction in the prevalence of violence and building a safe and secured workplace for health-care providers.
Keywords: Workplace violence, Health-care workers, Prevalence, Verbal abuse, Reporting of incidence
Introduction
Workplace violence against health-care workers (HCWs) at health-care organizations (HCOs) is spreading globally, and because of being at high risk of being a victim, it has become a leading concern for the doctors, nurses, hospital administrators, politicians, and other staff working in the hospitals.1 The consequences of workplace violence in the health sector have a significant negative impact on the health of the staff2 and the effectiveness of delivery of health services3, especially in developing countries such as India. There is an interrelationship between stress and violence in the workplace. The psychological violence of any nature in a workplace may lead to stress in employees which can adversely affect the delivery of services.
The World Health Organization (WHO) defines workplace violence as the intentional use of power against another person in work-related circumstances that can either result in injury, death, psychological harm, or maldevelopment.4 Violence occurring at any of these places comes under the ambit of workplace violence, i.e, a restaurant, office, taxi, factory, store, hospital, school, hotel, bar, or social service agency.5
HCWs are more predisposed to workplace violence than workers in other industries. Major reason for the same is that HCWs work closely with their patients and their families during the time when they are not only physically but psychologically weak. Patients may show violent behavior because of not only their medical condition but also the medication they are taking. Patients may also have the past medical history of violent behavior due to some other underlying causes.6 Although many studies have been conducted in different parts of the world which show that the prevalence of verbal and physical violence is increasing globally2, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20 furthermore, only a handful of studies12, 20, 21, 22 are there to know the level of awareness among HCWs about the proper reporting mechanism of such incidents in their organizations. The law23 provides a safeguard to HCWs against any act of violence; however, owing to lack of awareness among HCWs about their rights and privileges, these incidents are never reported; thus, the perpetrators of violence are not booked by law. Lack of any action against perpetrators not only encourages them but also other people who also engage in acts of violence which demotivates HCWs.
The aim and objective of this study were to measure the prevalence of violence and to analyze the reported cases in a tertiary care public hospital. In addition to this, awareness regarding reporting of such incidences was also estimated.
Materials and methods
A cross-sectional study was conducted over a period of 10 months, i.e, May 2014–August 2015, after clearance from the institutional ethics committee. Purpose of the study was to determine the prevalence of workplace violence among hospital staff at a tertiary super specialty care center in India and to estimate the rate of reporting of the incident. Another objective of the study was to find the gap between the reporting rate and the prevalence of violence if any. All the doctors, nurses, and group C staff (which includes the rest of the staff who are in direct as well as indirect contact with the patients such as technicians, drivers, security staff, and housekeeping staff) were included in the study.
Sample size of 394 was taken by anticipating the prevalence of every potential risk factor as 50%, confidence interval (CI) as 95%, and precision as 10% (absolute); minimum of 100 participants were required (N= 4 × P (100−P)/d2) (i.e., doctors = 100, nurses = 100, and group C = 100). These were enrolled from OPD, casualty, wards, daycare center, and so on.
Data were collected using a tool that was adapted from a validated questionnaire available on the open resource, which was designed collaboratively in 2003 by the International Labor Officethe WHO, the International Council of Nurses, and the Public Service International.24 The same questionnaire had been used in the earlier studies also12, 25. The questionnaire was translated into Hindi without any modifications. Descriptive statistics were completed relating to the respondents' characteristics. Cronbach's alpha was performed after the data collection to measure reliability and internal consistency. Cronbach's alpha score was more than 0.8.
To estimate the rate of reporting of violence in the hospital, all the reported incidents for violence against HCWs in the last two years were collected from different administrative authority (Office of medical superintendents, chief nursing officer, duty officers, etc.) and record keeping sections of the hospital.
Data were analyzed using the Statistical Package for Social Sciences, version 19. The P value < 0.05 was considered statistically significant in the analysis. The Z test for proportion at 95% CI was applied to analyze the level of difference between prevalence and rate of reporting, prevalence, and level of awareness about reporting mechanism.
Results
The response rate was 90% (405 filled questionnaires were received). Of which, 11 questionnaires were rejected for being incomplete, and the rest were analyzed. The sociodemographic profile of respondents is shown in Table 1.
Table 1.
Sociodemographic profile of respondents, N = 394.
| Parameter | Doctors, 123 (32.1%) | Nurses, 125 (31.7%) | Group C, 146 (36.2%) |
|---|---|---|---|
| Female | 36 (29.3%) | 89 (71.2%) | 09 (6.2%) |
| Male | 87 (70.7%) | 36 (28.8%) | 137 (93.8%) |
| <20 yrs of age | Nil | 04 (3.2) % | 12 (8.2%) |
| 20–30 yrs of age | 72 (58.5%) | 69 (55.2%) | 74 (50.7%) |
| 30–40 yrs of age | 40 (32.5%) | 29 (23.2%) | 52 (35.6%) |
| 40–50 yrs of age | 09 (7.3%) | 12 (9.6%) | 04 (2.7%) |
| >50 yrs | 02 (1.6%) | 11 (8.8%) | 04 (2.7%) |
| Married | 75 (61.0%) | 73 (58.4%) | 77 (52.7%) |
| Unmarried | 48 (39.0%) | 52 (41.6%) | 69 (47.3%) |
Out of 394 respondents, 136 (34.5%, 95% CI, 29.94–39.31) of HCWs experienced workplace violence in the last 12 months and 50 (12.7%, 95% confidence interval 9.67–16.25) were those who had experienced physical violence. Category-wise prevalence of workplace violence (WPV) among HCWs is shown in Table 2. Knowledge regarding the reporting mechanism for violence was significantly low among all the categories of staff. Formal reporting of cases of workplace violence is significantly low at 23.5% with lowest by doctors (16.7%) and highest by nurses (33.3%) (Fig. 1).
Table 2.
Category-wise prevalence of WPV among HCWs N = 394.
| Category of staff | No. of responses | Prevalence of violence | Prevalence of physical violence |
|---|---|---|---|
| Doctor | 123 | 48 (39.0%) | 9 (7.3%) |
| Nurses | 125 | 45 (36.0%) | 3 (2.4%) |
| Group C | 146 | 43 (29.5%) | 38 (26.0%) p = .001 |
| Total | 394 | 136 (34.5%) | 50 (12.7%) |
HCW, health-care worker.
Fig. 1.
Awareness on the reporting mechanism among different categories of staff.
Regarding reported incidence of workplace violence in the hospital for the last 2 years (yr 2013–14), it was found that total 32 incidents of workplace violence were reported through proper channel to the concerned authority. Of the 32 reported incidents, 8 (25%) were associated with physical violence and 24 (75%) were non-physical or verbal (Table 3). It was also found that the maximum numbers of reported cases were from the nursing staff. In these 32 reported cases, eight incidents were also associated with physical violence in the last two years, of which six were against group C, one with a doctor, and one with a nursing staff.
Table 3.
Distribution of the category of staff who had reported workplace violence in the last 2 years.
| Category of staff | No. of incidents reported |
|---|---|
| Doctors | 8 (25%) |
| Nurses | 15 (46.8%) |
| Group C | 9 (28.1%) |
| Total | 32 |
The difference between the prevalence of violence and rate of reporting among different categories of staff (Table 4) shows that the reporting rate of violence among all the categories of staff is significantly low (23.5%), despite high prevalence (34.5%). Although the difference between prevalence and awareness of reporting of incidents of violence shows that HCWs faced violence, they are not aware of the reporting mechanism through a proper channel. There is a statistically significant difference (p-value 0.002) between the prevalence of violence and rate of reporting, with a Z score of −2.801. There is a statistically significant difference (p-value 0.00) between a level of awareness and rate of reporting, with a Z score of −3.923. It is also revealed from the descriptive analysis and retrospective data that nurses are more aware of the reporting mechanism than other categories of staff (Table 5, Table 6).
Table 4.
Difference between prevalence of violence and rate of reporting of incidents.
| Category of staff | No. of responses | Prevalence of violence (n = 394) | No. of incidents reported (n = 136) | P value | Z score |
|---|---|---|---|---|---|
| Doctors | 123 | 48 (39.0%) | 8 (16.7%) | 0.322 | −0.464 |
| Nurses | 125 | 45 (36.0%) | 15 (33.3%) | 0.005 | −5.216 |
| Group C | 146 | 43 (29.5%) | 9 (20.9%) | 0.000 | −3.673 |
| Total | 394 | 136 (34.5%) | 32 (23.5%) | 0.002 | −2.801 |
Table 5.
Difference between prevalence and level of awareness.
| Category of staff | No. of responses | Prevalence of violence (n = 394) | Level of awareness (n = 394) | P value | Z score |
|---|---|---|---|---|---|
| Doctors | 123 | 48 (39.0%) | 30 (24.6%) | 0.02 | 2.034 |
| Nurses | 125 | 45 (36.0%) | 52 (41.4%) | 0.25 | −0.685 |
| Group C | 146 | 43 (29.5%) | 15 (10.4%) | 0.00 | 3.404 |
| Total | 394 | 136 (34.5%) | 97 (24.6%) | 0.18 | 1.343 |
Table 6.
Difference between level of awareness about reporting and number of reported cases.
| Category of staff | No. of responses | Level of awareness (n = 394) | No. of incidents reported (n = 136) | P value | Z score |
|---|---|---|---|---|---|
| Doctors | 123 | 30 (24.6%) | 8 (16.7%) | 0.02 | −2.060 |
| Nurses | 125 | 52 (41.4%) | 15 (33.3%) | 0.00 | −4.703 |
| Group C | 146 | 15 (10.4%) | 9 (20.9%) | 0.00 | −6.535 |
| Total | 394 | 97 (24.6%) | 32 (23.5%) | 0.00 | −3.923 |
Discussion
Workplace violence against HCWs by patients and their relatives is a big problem in health-care organizations. From the study, it was found that prevalence of verbal violence is 34.5% and 12.7% of respondents reported being physically attacked. As compared with other studies conducted in Australia, Mid-Atlantic region of the US, Brazil, Bulgaria, the UK, Palestinian, Hong Kong, China, Japan, Kuwait, and Taiwan, our neighboring countries such as Pakistan and Nepal found that the annual prevalence rates of physical violence ranged from 3% to 21% and verbal abuse 27.4% to 73%.2, 22, 26, 27.
It is also revealed through the study that the group C faces high levels of physical violence (26%), although only 1.8% said they were injured because of physical violence. It was also found by collecting retrospective data from reported cases in the last two years that magnitude of reported incidents of verbal violence is more than the physical violence in the hospital, and doctors and nurses are almost equally affected by verbal violence, but physical violence is more in group C employees.
Hence, workplace violence is prevalent in this tertiary care hospital, but reporting of incidents through proper channel or awareness about the reporting system is very less because 75% of HCWs think that there is no procedure of reporting in the hospital; of this, 89.6% are the group C employees. It was found in this study that in the hospital, the HCWs are not aware of the reporting system of violence incidents and also found that among HCWs, nurses are more aware of the reporting system than any other category of staff. Maximum reports (46.86%) which were received were from the nursing staff, and the prospective study also revealed that 41.4% of nursing staff have awareness about the reporting mechanism. It was found in other health-care settings also that HCWs assaulted from patients and their visitors never reported the incidents to hospital authorities or there is lack of coordination between them with reporting authorities28, 29. If these incidents were reported, the staff felt unsatisfied with the manner of handling which caused HCWs to be humiliated.30
Limitation
Findings of the study are limited to the HCWs of public hospitals only. Private Health Care Organizations (HCOs) including nursing homes and clinics were excluded.
Conclusion
This study has concluded that the prevalence of violence among HCWs is quite high, but the reporting rate is significantly low level of awareness regarding reporting system, and regulations for the safeguard of HCWs against workplace violence is only 24.6% with the highest among nurses (41.4%) and the lowest among group C employees (10.4%).
The low rate of reporting of WPV is because of lack of awareness about the reporting system. Low reporting also creates a false sense of security in the hospital authorities, and they often fail to initiate necessary remedial measures to curb this menace of violence against health-care providers. Sensitizing workshops should be conducted in all the health-care organizations for different categories of staff to increase their level of awareness regarding reporting mechanism and to know their rights and laws regarding the safeguard of health-care providers.
As this study was limited to the public sector hospital only, it is recommended that further studies among private HCOs may also be conducted to measure the prevalence and associated risk factors in private sector hospitals.
Conflicts of interest
The authors have none to declare.
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