. 2022 Jan 22;30(8):1837–1855. doi: 10.1007/s10389-021-01689-6

Table 1.

Systematic reviewsof selected articlesand authors’ methodology, results and conclusions

Sl No.	• Authors • Year	Methods • Study setting • Study design • Year of study • Sample size • Analysis method used	Results (major findings)	Conclusions
1.	• Kitaneh M, Hamdan M. • 2012	• Five public hospitals located in the five northern districts (Tulkarem, Nablus, Jenin, Qalqilya, Salfit) in the West Bank. • Cross sectional design. • 2011 • 271 (84 licensed physician and 187 nurses) • Pearson’s chi-square analysis was used to test the differences in exposure to physical and non-physical violence according to respondents’ characteristics. Odds ratios and 95% confidence intervals were used to assess potential associations between exposure to violence (yes/no) and the respondents’ characteristics using logistic regression model	• 80.4% reported exposure to violence; 20.8% physical and 59.6% non-physical. • No statistical difference in exposure to violence between physicians and nurses was observed. • Men significantly experienced higher exposure to physical violence in comparison with women. • Logistic regression analysis indicated that less experience (OR 8.03; 95% CI 3.91–16.47) and a lower level of education (OR 3; 95% CI 1.29–6.67) among respondents meant they were more likely to be victims of workplace violence than their counterparts. • The assailants were mostly the patients’ relatives or visitors, followed by the patients themselves, and co-workers. • Consequences of both physical and non-physical violence were considerable. • Only half of victims received any type of treatment. • Non-reporting of violence was a concern, main reasons were lack of incident reporting policy/procedure and management support, previous experience of no action taken and fear of the consequences	• There is a need for intervention to protect health workers and provide safer hospital workplace environments. • The results can inform developing proper policy and safety measures
2.	• Algwaiz WM, Alghanim SA. • 2012	• 2 public hospitals in Riyadh city, Kingdom of Soudi Arabia. • Exploratory cross-sectional survey • 2011 • 383 participants composed of physians and nurses	• 67.4% reported they were victims of violence in the previous 12 months. • Nurses were more likely to be exposed to violent incidents than physicians (p < 0.001). • Men, less experienced, and younger respondents were more likely to encounter violent episodes. • Excessive waiting time, shortage of staff and unmet patients’ demands were the most common reasons for violence. • Verbal abuse was the most common type encountered. • The assailants were mostly the patients’ relatives or friends, followed by the patients themselves. • Reasons for not reporting violent events included: feel it is a part of the job, previous experience of no action and fear of consequences	• Physicians and nurses are at high risk of violent incidents. • Health decision makers need to be aware of the potential consequences of such events. • Appropriate preventive measures are needed to make hospitals safer environments
3.	• Zafar W, Siddiqui E et al. • 2013	• Emergency Departments of four of the largest tertiary care hospitals in Karachi, Pakistan. • Cross-sectional survey • 2008 • 266 participants composed of physians and nurses	• Verbal abuse (72.5%), physically attacked (16.5%) - (Among those 29.6% reported that the last incident involved a weapon) and in 64% of cases the attacker was a patient’s relative. • The last attack could have been prevented (86%), and 64% said that no action was taken against the attacker (64%). • Physicians were less likely than nurses to report physical attack (OR 0.46; 95% CI 0.2–1.0), and personnel with greater work experience (OR 4.8; 95% CI 2.0–11.7) and those who said that there were procedures to report WPV in their workplace (OR 3.2; 95% CI 1.6–6.5) were more likely to report verbal abuse. • WPV was associated with mental health effects in the form of bothersome memories, super-alertness and feelings of avoidance and futility	• WPV is an important challenge in the EDs of large hospitals in Karachi. • A majority of respondents feel that WPV is preventable, but only a minority of attackers face consequences
4.	• AbuAlRub RF, Al Khawaldeh AT. • 2014	• Public hospitals in two districs (Ma’an in the south region and Al-Mafraq in the north-east region) of Jordan. • A descriptive exploratory research design - Quantitative study. • 396 nurses and 125 physicians	• 15% of the participants were exposed to physical violence. • The factors - absence of policies, inadequate staffing and lack of communication skills. • Only 16.9% of participants indicated that there were specific policies available for dealing with physical workplace violence. • Strengthening security and providing training were some of the important factors indicated by participants for decreasing violence in the workplace	• Workplace violence is a problem in underserved areas that needs attention from administrators. • Firm policies should be implemented to tackle the problem of workplace violence
5.	• Tucker JD, Cheng Y et al. • 2015	• Seven hospitals in Guangdong Province, China. • Qualitative study using in-depth interviews focused on personal experiences of patient–physician mistrust and trust. • Between June and September 2013. • 160 patients, patient family members, physicians, nurses and hospital administrators at seven hospitals varying in type, geography and stages of achieving goals of health reform. These interviews included purposive selection of individuals who had experienced both trustful and mistrustful patient–physician relationships	• A patient perception of injustice within the medical sphere, related to profit mongering, knowledge imbalances and physician conflicts of interest. • Individual physicians, departments and hospitals were explicitly incentivised to generate revenue without evaluation of caregiving. • Physicians did not receive training in negotiating medical disputes or humanistic principles that underpin caregiving. • Patient–physician mistrust precipitated medical disputes leading to the following outcomes: non-resolution with patient resentment towards physicians; violent resolution such as physical and verbal attacks against physicians; and non-violent resolution such as hospital-mediated dispute resolution. • Policy responses to violence included increased hospital security forces, which inadvertently fuelled mistrust. • Instead of encouraging communication that facilitated resolution, medical disputes sometimes ignited a vicious cycle leading to mob violence. • However, patient-physician interactions at one hospital that has implemented a primary care model embodying health reform goals showed improved patient-physician trust	• Restructuring incentives, reforming medical education and promoting caregiving are pathways towards restoring trust. • In addition to regulatory and legal, responses are urgently needed to restore trust
6.	• Kvas A, Seljak J. • 2015	• Slovenia. • Survey- Quantitative. • 2010–2011 • 692 nurses	• Verbal violence (60.11%) and physical violence (26.01%). • The most frequent perpetrators of verbal violence were patients (listed as a source of violence by 39.3% of the respondents) and peers (39.6%), with the most forceful identified as physicians and patients. • Physical violence against nurses was most often initiated by patients (20.8%) who were also the most forceful source in this category. • Nurse leaders were found to be the most frequent and forceful sources of violence in terms of leadership level. • A positive correlation between external (patient and relatives) and internal (physician and nurse) sources of violence was determined	• Development of action-oriented violence management strategies required
7.	Park M, Cho SH et al. 2015	• University hospital in Seoul, South Korea. • Cross sectional study. • 2013 • 970 female nurses. • Relationships among variables were examined by conducting multiple logistic regression analyses with multilevel modelling	• Verbal abuse (63.8%), threats of violence (41.6%), physical violence (22.3%), sexual harassment (19.7%) and bullying (9.7%). • Physical violence, threats of violence and verbal abuse occurred most frequently in ICUs, whereas sexual harassment and bullying were highest in operating rooms. • The main perpetrators were patients, followed by physicians and patients’ families. • Nurses perceiving greater work demands and less trust and justice were more likely to have been exposed to violence	• Reduction of violence will contribute to creating a better nursing work environment
8.	• Hamdan M, Abu Hamra A. • 2015	• Main 14 hospitals having Emergency Departments (8 from the West Bank (WB) and 6 from the Gaza Strip (GS). • Cross sectional study. • 2013 • A total of 444 participants (response rate 74.5%): 161 (32.0%) nurses, 142 (32%) physicians and 141 (31.7%) administrative personnel. • Multivariate regression analysis was performed	• 76.1% experienced a type of WPV: physical (35.6%) and 71.2% to non-physical assaults (69.8% verbal abuses, 48.4% threats and 8.6% sexual harassments). • Perpetrators of physical and non-physical violence were mainly patients’ families/visitors (85.4% and 79.5%, respectively). • Waiting time, lack of prevention measures and unmet expectations of patients and their families are the main reasons for WPV. • The multivariate regression analysis showed that younger personnel (OR = 2.29 CI 95% 1.309–4.036), clinicians (nurses and physicians) (OR = 1.65 CI 95% 0.979–2.797) compared with administrative and less experienced ED personnel (OR = 2.39 CI 95% 1.141–5.006) are significantly at higher risk of exposure to WPV (P < 0.05). • Low level (40%) of violence reporting is evident, largely attributed to not enough actions being taken and fear of consequences. • Violence has been shown to have considerable consequences for workers’ well-being, patient care and job retention	• Internal-system-related factors are the most amenable to change. • Attention should be given to strengthening violence prevention policy and measures and improving incident-reporting system
9.	• Pompeii LA, Schoenfisch AL et al. • 2015	• Two large hospital systems in Texas (TX) and North Carolina (NC); each system included one large medical centre hospital and two community hospitals- Total 6 Hospitals. • Cross sectional survey. • 11,000 hospital workers	• 39% experienced violence; 2098 of 5385 workers experienced 1180 physical assaults, 2260 physical threats and 5576 incidents of verbal abuse. • Direct care providers were at significant risk. • Perpetrator circumstances attributed to violent events included altered mental status, behavioural issues, pain/medication withdrawal and dissatisfaction with care. • Fear for safety was common among worker victims (38%). Only 19% of events were reported into official reporting systems	• This pervasive occupational safety issue is of great concern and likely extends to patients for whom these workers care for
10.	• Abed M, Morris E et al. • 2016	• Eight government-owned primary care clinics in Barbados. • Cross sectional study. • 2014 • 102 participants	• 63% of nurses and physicians reported at least one episode of violence in the past year. • Verbal abuse (60%) and bullying (19%), sexual harassment (7%), physical violence (3%) and racial harassment (3%). • Patients emerged as the main perpetrators of violence (64%). • Significant associations between gender and workplace violence. Women and nurses were more predisposed to experience violent incidents than men and physicians	• Female gender being a significant predictor of abuse. • Adequate documentation and implementing clear policies and violence prevention programmes in health institutions are crucial steps towards addressing this issue
11.	• Ferri P, Silvestri M et al. • 2016	• A general hospital in northern Italy. • Cross sectional study. • 2015 • 419 health professionels who worked in 15 departments. • Logistic regression was performed	• 45% of professionals reported WPV. Nurses (67%), nursing assistants (18%) and physicians (12%). • The first two categories were correlated, in a statistically significant way, with the risk of WPV (p = 0.005, p = 0.004, multiple logistic regression). • The violent incidents more frequently occurred in the psychiatry department (86%), emergency department (71%) and in geriatric wards (57%). • The assailants more frequently were men whereas assaulted professionals more often were women. Men committed physical violence more frequently than women, in a statistically significant way (p = 0.034, chi-squared test). • Verbal violence (51%) was often committed by people in a lucid and normal state of consciousness; physical violence (49%) was most often perpetrated by assailants affected by dementia, mental retardation, drug and substance abuse, or other psychiatric disorders. • The variables positively related to • WPV were ‘calling for help during the attack’ and ‘physical injuries suffered in violent attack’ (p = 0.02, p = 0.03, multiple logistic regression)	• This study suggests that violence is a significant phenomenon and that all health workers, especially nurses, are at risk of suffering aggressive assaults. • Prevention programmes tailored to the different care needs are necessary to promote professional awareness for violence risk
12.	• Bilici R, Sercan M et al. • 2016	• Locked Psychiatric Clinics of Turkey. • Cross sectional survey. • 137 participants (62 nueses, 50 physicians and 25 health officers). • Chi squre test was performed	• 87.6% of staff members viewed security measures insufficient. • Preventive actions should be taken to reduce the risk of exposure to violence against the staff members working at the locked psychiatric clinics	• Preventive actions should be taken to reduce the risk of exposure to violence against the staff members working at the locked psychiatric clinics
13.	• Sun T, Gao L. • 2017	• 30 provinces of China. • A cross-sectional online survey study. • 2016 • 2617 doctors. • Pearson correlation & multiple hierarchical linear regression was done	• Verbal abuse (76.2%), made difficulties (58.3%), smear reputation (40.8%), mobbing behaviour (40.2%), intimidation behaviour (27.6%), physical violence (24.1%) and sexual harassment (7.8%). • WPV significantly affected the psychological stress, sleep quality and self-reported health of doctors. • Psychological stress partially mediated the relationship between work-related violence and health damage	• A safer work environment for Chinese healthcare workers needs to be provided to minimise health threats, which is a top priority for both government and society
14.	• Shafran-Tikva S, Chinitz D et al. • 2017	• Hadassah University Medical Center, Kiryat, Hadassah, Jerusalem, Israel. • Mixed method study (Qualitative- FGD, IDI) • 2010 • Participants- For quantitative 676 (230 physicians, 446 nurses), Qualitative – Focus group discussion 20 (Head nurses-5, Physician-5, Staff nurses-5, Sequrity personel-5), In depth interview-18, Open ended questions- 676	• Important factors - staff behaviour (39%), patient behaviour (26%), hospital setting (17%), professional roles and waiting times (10%). • Patients and staff reported similar perceptions and emotions regarding the episodes of violence. 35% of the staff responded that paients contributed to the creation of the most severe violent episode, 48% stated that staff behaviour contributed to violent episodes. • According to physicians and nurses- 50% of violence was related to patient dissatisfaction with the quality of service, the degree of staff professionalism, or an unacceptable comment of a staff member. • Other reasons- lack of understanding of the hospital system on the part of patients, together with poor communication between patients and providers and expectations gaps	• Staff and patients share conditions of overload, pressure, fatigue, and frustration. Lack of coping tools to prevent violence. • Self-conscious awareness regarding potential interacting factors required to coping with hospital violence
15.	• Rafeea F, Al Ansari A et al. • 2017	• Emergency Department of the Defence Force (BDF) Hospital, Bahrain. • Cross sectional exploratory study. • 100 workers of Emergency departments	• Participants experienced verbal abuse (78%), physical abuse (11%) and then sexual abuse (3%). • Violence against ED workers occurred during night shifts (53%), while physical abuse was reported to occur during all the shifts. • 40% of the staff in the ED of the hospital were not aware of the policies against workplace violence, and 26% of the staff considered leaving their jobs at the hospital	• The results clearly demonstrate the importance of addressing the issue of workplace violence in EDs in Bahrain and can be used to demonstrate the strong need for interventions
16.	• Wong AHW, Combellick J. • 2017	• Urban, tertiary care public hospital in New York City, New York. • Focus group discussion and individual interviews using a phenomenological approach. • 31 participants (9 hospital police officers, 10 nurses, 6 patient care technicians and 6 emergency medicine resident physicians)	• Emergency Department’s healthcare workers provide high-quality care to a marginalised patient population that concurrently poses safety threats, creating a patient care paradox. • Teamwork is critical to safely managing this population, but hierarchy and professional silos hinder coordinated care between healthcare professionals. • Environmental challenges and systems issues both in and outside the ED exacerbate threats to safety	• The experience of ED staff members while caring for agitated patients is complex and multidimensional. • Study identified issues that coalesced into four tiers of healthcare delivery at the individual, team, environment and system levels
17.	• Alsaleem SA, Alsabaani A et al. • 2018	• Two government hospitals and ten primary healthcare centres of Abha city, Saudi Arabia. • Cross sectional study. • 738 workers (151 were selected from ten PHCs and 587 from two government hospitals) • A multiple logistic regression modelling was done to identify the predictors of violence against healthcare workers	• 64.9% participants were females and 69.4% were Saudis. • 57.5% participants had experienced some workplace violence at least once. • Verbal assaults and slaps were the most common form of workplace-related violence (58%)	• The reasons need to be explored in order to set and develop policies, regulations and interventions to prevent violence against workers
18.	• Wang N, Wu D et al. • 2018	• Eight county hospitals in four counties, two each from developed counties, Shengzhou and Ninghai, and developing counties, Jiangshan and Kaihua, Zhejiang province, eastern China. • Cross sectional survey. • 2016–2017 • 1388 Health worker. • Odds ratio and Pearson’s correlation was performed	• Physical attacks (7.8%), physical threats (21.2%), 51.6% experienced (medical disturbance created by gangs using extreme means to obtain compensation from a hospital) at least once in the past year. • Physical attacks were significantly more in physicians (10.9%) than in nurses (5.9%). Physicians were threatened at 27.1%, followed by nurses at 20.2%. • Compared with general medicine, health workers working in emergency were significantly more likely to suffer physical attacks ( OR = 2.7, 95% CI = [1.4, 5.2], p < .01) and WPV (physical attacks or threats; OR = 2.5, 95% CI = [1.6, 4.1], p < .001). • Being encouraged to tolerate WPV was correlated with physical attacks (OR = 6.1, 95% CI = [3.5, 10.4], p < .001) and WPV (OR = 6.7, 95% CI = [4.6, 9.8], p < .001)	• This highlights the need for a focused systematic prevention concerning health workers’ safety and governmental regulations and the need for hospitals to encourage their employees to report the WPV
19.	• Honarvar B, Ghazanfari N et al. • 2019	• Three main university-affiliated public hospitals in Shiraz, southern Iran—Faghihi, Nemazee and Rajaei Hospitals. • Quantitative study. • 2017–2018 • 405 nurses	• 89.6% nurses had experienced at least one kind of violence; 68.4% suffered from more than one type of violence. • Verbal abuse (83.9%), verbal threats (27.6%), physical violence (21.4%), sexual abuse (10.8%) and ethnical harassment (6.1%). • Patients’ companions, patients and physicians were reported as the sources of violence in 70.6%, 43.1% and 4.1% of cases, respectively. • Nurses with non-official employment status and non-Farsi ethnicity, having a disease, with non-evening shift work, and those with short or long employment period were more affected. • Unrealistic expectations by patients’ companions and long working hours were the most common attributing factors	• Violence against nurses, as a strenuous and health-threatening crisis, should be investigated to shot out the problem
20.	• Sachdeva S, Jamshed N et al. • 2019	• Tertiary care hospital in Delhi, India. • Cross sectional survey. • 2017 • 235 (123 doctors, 112 nurses) • Chi-square and Fisher’s exact tests were used for bivariate analysis while logistic regression analysis was to analyse the impact of violence with participant characteristics	• Verbal abuse (67%), physical assault (17%) was reported by 17% (40/235), while confrontation (11%). • Family members were the main perpetrator for VA (75%) and PA (35%). • Regarding reporting, the violent incidences were mostly reported to ED security and ED faculty. • Individuals who are younger, less experience, and male gender were more exposed to abuse both VA and PA at p < 0.05. • Nurses and junior residents reported more abuse than senior residents (p < 0.05). • Majority of the participants had reported lack of job satisfaction due to verbal abuse (p = 0.01)	• Work place violence is common in Emergency Departments of the current setting. • It results in significant physiological and psychological effects on healthcare providers
21.	• Demirci Ş, Uğurluoğlu Ö. • 2020	• A public hospital in Ankara, Turkey • Cross sectional survey • 347 (104 physicians, 93 nurses and 150 other medical staff) • A logistic regression analysis was performed to determine the effects of sociodemographic features on violence	• Physicians (96.2%), nurses (95.7%) and other medical personnel (80.7%) reported verbal violence at least once in their professional life. • Physicians were identified as a source of violence among other healthcare professionals. • Nurses are exposed to sexual violence more than other medical personnel are (OR = 3.11, 95% CI [1.29, 7.49]). • Nurses were more exposed to verbal (OR = 5.08, 95% CI [1.54, 16.75]) and physical (OR = 3.68, 95% CI [1.15, 11.80]) violence compared with other medical personnel	• This study shows that a great majority of healthcare professionals are subjected to violence ranging from verbal violence in particular to physical and sexual violence
22.	• Davey K, Ravishankar V et al. • 2020	• 7 hospital Emergency Department’s across India. • Qualitative- Semi-structured interviews and hybrid thematic analysis approach was used to determine dominant themes. • 63 participants (11 attending physicians, 36 resident physicians, 10 nurses, and 5 paramedics, 1 interview participant did not give their job title)	• Most events involved verbal abuse, although a significant percentage of responses described some kind of physical violence. • ED factors such as busy times with high patient volumes or periods of waiting are associated with increased violence, as well as incidents with unanticipated outcomes such as patients with severe illness or death. • Decreased levels of health literacy among patients often contribute as well as the financial stressors of paying for medical care. • Providers reported negative consequences of workplace violence on quality of care for patients and their own motivation to work in the ED. • Communication strategies were frequently proposed as interventions to mitigate violence in the future, including both provider communication as well as public awareness campaigns	• Alarming levels of verbal and physical abuse and their impact on patient care are described. • Indian ED providers that differ from those in more developed settings, including financial stressors, inadequate enforcement of rules governing behaviour in the hospital, and an overwhelming frequency of violence emanating from patient family members and attendants rather than the patients themselves

Sl No.

• Authors
• Year

Methods
• Study setting
• Study design
• Year of study
• Sample size
• Analysis method used

Results (major findings)

Conclusions

• Kitaneh M, Hamdan M.

• 2012

• Five public hospitals located in the five northern districts (Tulkarem, Nablus, Jenin, Qalqilya, Salfit) in the West Bank.

• Cross sectional design.

• 2011

• 271 (84 licensed physician and 187 nurses)

• Pearson’s chi-square analysis was used to test the differences in exposure to physical and non-physical violence according to respondents’ characteristics. Odds ratios and 95% confidence intervals were used to assess potential associations between exposure to violence (yes/no) and the respondents’ characteristics using logistic regression model

• 80.4% reported exposure to violence; 20.8% physical and 59.6% non-physical.

• No statistical difference in exposure to violence between physicians and nurses was observed.

• Men significantly experienced higher exposure to physical violence in comparison with women.

• Logistic regression analysis indicated that less experience (OR 8.03; 95% CI 3.91–16.47) and a lower level of education (OR 3; 95% CI 1.29–6.67) among respondents meant they were more likely to be victims of workplace violence than their counterparts.

• The assailants were mostly the patients’ relatives or visitors, followed by the patients themselves, and co-workers.

• Consequences of both physical and non-physical violence were considerable.

• Only half of victims received any type of treatment.

• Non-reporting of violence was a concern, main reasons were lack of incident reporting policy/procedure and management support, previous experience of no action taken and fear of the consequences

• There is a need for intervention to protect health workers and provide safer hospital workplace environments.

• The results can inform developing proper policy and safety measures

• Algwaiz WM, Alghanim SA.

• 2012

• 2 public hospitals in Riyadh city, Kingdom of Soudi Arabia.

• Exploratory cross-sectional survey

• 2011

• 383 participants composed of physians and nurses

• 67.4% reported they were victims of violence in the previous 12 months.

• Nurses were more likely to be exposed to violent incidents than physicians (p < 0.001).

• Men, less experienced, and younger respondents were more likely to encounter violent episodes.

• Excessive waiting time, shortage of staff and unmet patients’ demands were the most common reasons for violence.

• Verbal abuse was the most common type encountered.

• The assailants were mostly the patients’ relatives or friends, followed by the patients themselves.

• Reasons for not reporting violent events included: feel it is a part of the job, previous experience of no action and fear of consequences

• Physicians and nurses are at high risk of violent incidents.

• Health decision makers need to be aware of the potential consequences of such events.

• Appropriate preventive measures are needed to make hospitals safer environments

• Zafar W, Siddiqui E et al.

• 2013

• Emergency Departments of four of the largest tertiary care hospitals in Karachi, Pakistan.

• Cross-sectional survey

• 2008

• 266 participants composed of physians and nurses

• Verbal abuse (72.5%), physically attacked (16.5%) - (Among those 29.6% reported that the last incident involved a weapon) and in 64% of cases the attacker was a patient’s relative.

• The last attack could have been prevented (86%), and 64% said that no action was taken against the attacker (64%).

• Physicians were less likely than nurses to report physical attack (OR 0.46; 95% CI 0.2–1.0), and personnel with greater work experience (OR 4.8; 95% CI 2.0–11.7) and those who said that there were procedures to report WPV in their workplace (OR 3.2; 95% CI 1.6–6.5) were more likely to report verbal abuse.

• WPV was associated with mental health effects in the form of bothersome memories, super-alertness and feelings of avoidance and futility

• WPV is an important challenge in the EDs of large hospitals in Karachi.

• A majority of respondents feel that WPV is preventable, but only a minority of attackers face consequences

• AbuAlRub RF, Al Khawaldeh AT.

• 2014

• Public hospitals in two districs (Ma’an in the south region and Al-Mafraq in the north-east region) of Jordan.

• A descriptive exploratory research design - Quantitative study.

• 396 nurses and 125 physicians

• 15% of the participants were exposed to physical violence.

• The factors - absence of policies, inadequate staffing and lack of communication skills.

• Only 16.9% of participants indicated that there were specific policies available for dealing with physical workplace violence.

• Strengthening security and providing training were some of the important factors indicated by participants for decreasing violence in the workplace

• Workplace violence is a problem in underserved areas that needs attention from administrators.

• Firm policies should be implemented to tackle the problem of workplace violence

• Tucker JD, Cheng Y et al.

• 2015

• Seven hospitals in Guangdong Province, China.

• Qualitative study using in-depth interviews focused on personal experiences of patient–physician mistrust and trust.

• Between June and September 2013.

• 160 patients, patient family members, physicians, nurses and hospital administrators at seven hospitals varying in type, geography and stages of achieving goals of health reform. These interviews included purposive selection of individuals who had experienced both trustful and mistrustful patient–physician relationships

• A patient perception of injustice within the medical sphere, related to profit mongering, knowledge imbalances and physician conflicts of interest.

• Individual physicians, departments and hospitals were explicitly incentivised to generate revenue without evaluation of caregiving.

• Physicians did not receive training in negotiating medical disputes or humanistic principles that underpin caregiving.

• Patient–physician mistrust precipitated medical disputes leading to the following outcomes: non-resolution with patient resentment towards physicians; violent resolution such as physical and verbal attacks against physicians; and non-violent resolution such as hospital-mediated dispute resolution.

• Policy responses to violence included increased hospital security forces, which inadvertently fuelled mistrust.

• Instead of encouraging communication that facilitated resolution, medical disputes sometimes ignited a vicious cycle leading to mob violence.

• However, patient-physician interactions at one hospital that has implemented a primary care model embodying health reform goals showed improved patient-physician trust

• Restructuring incentives, reforming medical education and promoting caregiving are pathways towards restoring trust.

• In addition to regulatory and legal, responses are urgently needed to restore trust

• Kvas A, Seljak J.

• 2015

• Slovenia.

• Survey- Quantitative.

• 2010–2011

• 692 nurses

• Verbal violence (60.11%) and physical violence (26.01%).

• The most frequent perpetrators of verbal violence were patients (listed as a source of violence by 39.3% of the respondents) and peers (39.6%), with the most forceful identified as physicians and patients.

• Physical violence against nurses was most often initiated by patients (20.8%) who were also the most forceful source in this category.

• Nurse leaders were found to be the most frequent and forceful sources of violence in terms of leadership level.

• A positive correlation between external (patient and relatives) and internal (physician and nurse) sources of violence was determined

• Development of action-oriented violence management strategies required

Park M, Cho SH et al.

2015

• University hospital in Seoul, South Korea.

• Cross sectional study.

• 2013

• 970 female nurses.

• Relationships among variables were examined by conducting multiple logistic regression analyses with multilevel modelling

• Verbal abuse (63.8%), threats of violence (41.6%), physical violence (22.3%), sexual harassment (19.7%) and bullying (9.7%).

• Physical violence, threats of violence and verbal abuse occurred most frequently in ICUs, whereas sexual harassment and bullying were highest in operating rooms.

• The main perpetrators were patients, followed by physicians and patients’ families.

• Nurses perceiving greater work demands and less trust and justice were more likely to have been exposed to violence

• Reduction of violence will contribute to creating a better nursing work environment

• Hamdan M, Abu Hamra A.

• 2015

• Main 14 hospitals having Emergency Departments (8 from the West Bank (WB) and 6 from the Gaza Strip (GS).

• Cross sectional study.

• 2013

• A total of 444 participants (response rate 74.5%): 161 (32.0%) nurses, 142 (32%) physicians and 141 (31.7%) administrative personnel.

• Multivariate regression analysis was performed

• 76.1% experienced a type of WPV: physical (35.6%) and 71.2% to non-physical assaults (69.8% verbal abuses, 48.4% threats and 8.6% sexual harassments).

• Perpetrators of physical and non-physical violence were mainly patients’ families/visitors (85.4% and 79.5%, respectively).

• Waiting time, lack of prevention measures and unmet expectations of patients and their families are the main reasons for WPV.

• The multivariate regression analysis showed that younger personnel (OR = 2.29 CI 95% 1.309–4.036), clinicians (nurses and physicians) (OR = 1.65 CI 95% 0.979–2.797) compared with administrative and less experienced ED personnel (OR = 2.39 CI 95% 1.141–5.006) are significantly at higher risk of exposure to WPV (P < 0.05).

• Low level (40%) of violence reporting is evident, largely attributed to not enough actions being taken and fear of consequences.

• Violence has been shown to have considerable consequences for workers’ well-being, patient care and job retention

• Internal-system-related factors are the most amenable to change.

• Attention should be given to strengthening violence prevention policy and measures and improving incident-reporting system

• Pompeii LA, Schoenfisch AL et al.

• 2015

• Two large hospital systems in Texas (TX) and North Carolina (NC); each system included one large medical centre hospital and two community hospitals- Total 6 Hospitals.

• Cross sectional survey.

• 11,000 hospital workers

• 39% experienced violence; 2098 of 5385 workers experienced 1180 physical assaults, 2260 physical threats and 5576 incidents of verbal abuse.

• Direct care providers were at significant risk.

• Perpetrator circumstances attributed to violent events included altered mental status, behavioural issues, pain/medication withdrawal and dissatisfaction with care.

• Fear for safety was common among worker victims (38%). Only 19% of events were reported into official reporting systems

• This pervasive occupational safety issue is of great concern and likely extends to patients for whom these workers care for

10.

• Abed M, Morris E et al.

• 2016

• Eight government-owned primary care clinics in Barbados.

• Cross sectional study.

• 2014

• 102 participants

• 63% of nurses and physicians reported at least one episode of violence in the past year.

• Verbal abuse (60%) and bullying (19%), sexual harassment (7%), physical violence (3%) and racial harassment (3%).

• Patients emerged as the main perpetrators of violence (64%).

• Significant associations between gender and workplace violence. Women and nurses were more predisposed to experience violent incidents than men and physicians

• Female gender being a significant predictor of abuse.

• Adequate documentation and implementing clear policies and violence prevention programmes in health institutions are crucial steps towards addressing this issue

11.

• Ferri P, Silvestri M et al.

• 2016

• A general hospital in northern Italy.

• Cross sectional study.

• 2015

• 419 health professionels who worked in 15 departments.

• Logistic regression was performed

• 45% of professionals reported WPV. Nurses (67%), nursing assistants (18%) and physicians (12%).

• The first two categories were correlated, in a statistically significant way, with the risk of WPV (p = 0.005, p = 0.004, multiple logistic regression).

• The violent incidents more frequently occurred in the psychiatry department (86%), emergency department (71%) and in geriatric wards (57%).

• The assailants more frequently were men whereas assaulted professionals more often were women. Men committed physical violence more frequently than women, in a statistically significant way (p = 0.034, chi-squared test).

• Verbal violence (51%) was often committed by people in a lucid and normal state of consciousness; physical violence (49%) was most often perpetrated by assailants affected by dementia, mental retardation, drug and substance abuse, or other psychiatric disorders.

• The variables positively related to • WPV were ‘calling for help during the attack’ and ‘physical injuries suffered in violent attack’ (p = 0.02, p = 0.03, multiple logistic regression)

• This study suggests that violence is a significant phenomenon and that all health workers, especially nurses, are at risk of suffering aggressive assaults.

• Prevention programmes tailored to the different care needs are necessary to promote professional awareness for violence risk

12.

• Bilici R, Sercan M et al.

• 2016

• Locked Psychiatric Clinics of Turkey.

• Cross sectional survey.

• 137 participants (62 nueses, 50 physicians and 25 health officers).

• Chi squre test was performed

• 87.6% of staff members viewed security measures insufficient.

• Preventive actions should be taken to reduce the risk of exposure to violence against the staff members working at the locked psychiatric clinics

13.

• Sun T, Gao L.

• 2017

• 30 provinces of China.

• A cross-sectional online survey study.

• 2016

• 2617 doctors.

• Pearson correlation & multiple hierarchical linear regression was done

• Verbal abuse (76.2%), made difficulties (58.3%), smear reputation (40.8%), mobbing behaviour (40.2%), intimidation behaviour (27.6%), physical violence (24.1%) and sexual harassment (7.8%).

• WPV significantly affected the psychological stress, sleep quality and self-reported health of doctors.

• Psychological stress partially mediated the relationship between work-related violence and health damage

• A safer work environment for Chinese healthcare workers needs to be provided to minimise health threats, which is a top priority for both government and society

14.

• Shafran-Tikva S, Chinitz D et al.

• 2017

• Hadassah University Medical Center, Kiryat, Hadassah, Jerusalem, Israel.

• Mixed method study (Qualitative- FGD, IDI)

• 2010

• Participants- For quantitative 676 (230 physicians, 446 nurses), Qualitative – Focus group discussion 20 (Head nurses-5, Physician-5, Staff nurses-5, Sequrity personel-5), In depth interview-18, Open ended questions- 676

• Important factors - staff behaviour (39%), patient behaviour (26%), hospital setting (17%), professional roles and waiting times (10%).

• Patients and staff reported similar perceptions and emotions regarding the episodes of violence. 35% of the staff responded that paients contributed to the creation of the most severe violent episode, 48% stated that staff behaviour contributed to violent episodes.

• According to physicians and nurses- 50% of violence was related to patient dissatisfaction with the quality of service, the degree of staff professionalism, or an unacceptable comment of a staff member.

• Other reasons- lack of understanding of the hospital system on the part of patients, together with poor communication between patients and providers and expectations gaps

• Staff and patients share conditions of overload, pressure, fatigue, and frustration. Lack of coping tools to prevent violence.

• Self-conscious awareness regarding potential interacting factors required to coping with hospital violence

15.

• Rafeea F, Al Ansari A et al.

• 2017

• Emergency Department of the Defence Force (BDF) Hospital, Bahrain.

• Cross sectional exploratory study.

• 100 workers of Emergency departments

• Participants experienced verbal abuse (78%), physical abuse (11%) and then sexual abuse (3%).

• Violence against ED workers occurred during night shifts (53%), while physical abuse was reported to occur during all the shifts.

• 40% of the staff in the ED of the hospital were not aware of the policies against workplace violence, and 26% of the staff considered leaving their jobs at the hospital

• The results clearly demonstrate the importance of addressing the issue of workplace violence in EDs in Bahrain and can be used to demonstrate the strong need for interventions

16.

• Wong AHW, Combellick J.

• 2017

• Urban, tertiary care public hospital in New York City, New York.

• Focus group discussion and individual interviews using a phenomenological approach.

• 31 participants (9 hospital police officers, 10 nurses, 6 patient care technicians and 6 emergency medicine resident physicians)

• Emergency Department’s healthcare workers provide high-quality care to a marginalised patient population that concurrently poses safety threats, creating a patient care paradox.

• Teamwork is critical to safely managing this population, but hierarchy and professional silos hinder coordinated care between healthcare professionals.

• Environmental challenges and systems issues both in and outside the ED exacerbate threats to safety

• The experience of ED staff members while caring for agitated patients is complex and multidimensional.

• Study identified issues that coalesced into four tiers of healthcare delivery at the individual, team, environment and system levels

17.

• Alsaleem SA, Alsabaani A et al.

• 2018

• Two government hospitals and ten primary healthcare centres of Abha city, Saudi Arabia.

• Cross sectional study.

• 738 workers (151 were selected from ten PHCs and 587 from two government hospitals)

• A multiple logistic regression modelling was done to identify the predictors of violence against healthcare workers

• 64.9% participants were females and 69.4% were Saudis.

• 57.5% participants had experienced some workplace violence at least once.

• Verbal assaults and slaps were the most common form of workplace-related violence (58%)

• The reasons need to be explored in order to set and develop policies, regulations and interventions to prevent violence against workers

18.

• Wang N, Wu D et al.

• 2018

• Eight county hospitals in four counties, two each from developed counties, Shengzhou and Ninghai, and developing counties, Jiangshan and Kaihua, Zhejiang province, eastern China.

• Cross sectional survey.

• 2016–2017

• 1388 Health worker.

• Odds ratio and Pearson’s correlation was performed

• Physical attacks (7.8%), physical threats (21.2%), 51.6% experienced (medical disturbance created by gangs using extreme means to obtain compensation from a hospital) at least once in the past year.

• Physical attacks were significantly more in physicians (10.9%) than in nurses (5.9%). Physicians were threatened at 27.1%, followed by nurses at 20.2%.

• Compared with general medicine, health workers working in emergency were significantly more likely to suffer physical attacks ( OR = 2.7, 95% CI = [1.4, 5.2], p < .01) and WPV (physical attacks or threats; OR = 2.5, 95% CI = [1.6, 4.1], p < .001).

• Being encouraged to tolerate WPV was correlated with physical attacks (OR = 6.1, 95% CI = [3.5, 10.4], p < .001) and WPV (OR = 6.7, 95% CI = [4.6, 9.8], p < .001)

• This highlights the need for a focused systematic prevention concerning health workers’ safety and governmental regulations and the need for hospitals to encourage their employees to report the WPV

19.

• Honarvar B, Ghazanfari N et al.

• 2019

• Three main university-affiliated public hospitals in Shiraz, southern Iran—Faghihi, Nemazee and Rajaei Hospitals.

• Quantitative study.

• 2017–2018

• 405 nurses

• 89.6% nurses had experienced at least one kind of violence; 68.4% suffered from more than one type of violence.

• Verbal abuse (83.9%), verbal threats (27.6%), physical violence (21.4%), sexual abuse (10.8%) and ethnical harassment (6.1%).

• Patients’ companions, patients and physicians were reported as the sources of violence in 70.6%, 43.1% and 4.1% of cases, respectively.

• Nurses with non-official employment status and non-Farsi ethnicity, having a disease, with non-evening shift work, and those with short or long employment period were more affected.

• Unrealistic expectations by patients’ companions and long working hours were the most common attributing factors

• Violence against nurses, as a strenuous and health-threatening crisis, should be investigated to shot out the problem

20.

• Sachdeva S, Jamshed N et al.

• 2019

• Tertiary care hospital in Delhi, India.

• Cross sectional survey.

• 2017

• 235 (123 doctors, 112 nurses)

• Chi-square and Fisher’s exact tests were used for bivariate analysis while logistic regression analysis was to analyse the impact of violence with participant characteristics

• Verbal abuse (67%), physical assault (17%) was reported by 17% (40/235), while confrontation (11%).

• Family members were the main perpetrator for VA (75%) and PA (35%).

• Regarding reporting, the violent incidences were mostly reported to ED security and ED faculty.

• Individuals who are younger, less experience, and male gender were more exposed to abuse both VA and PA at p < 0.05.

• Nurses and junior residents reported more abuse than senior residents (p < 0.05).

• Majority of the participants had reported lack of job satisfaction due to verbal abuse (p = 0.01)

• Work place violence is common in Emergency Departments of the current setting.

• It results in significant physiological and psychological effects on healthcare providers

21.

• Demirci Ş, Uğurluoğlu Ö.

• 2020

• A public hospital in Ankara, Turkey

• Cross sectional survey

• 347 (104 physicians, 93 nurses and 150 other medical staff)

• A logistic regression analysis was performed to determine the effects of sociodemographic features on violence

• Physicians (96.2%), nurses (95.7%) and other medical personnel (80.7%) reported verbal violence at least once in their professional life.

• Physicians were identified as a source of violence among other healthcare professionals.

• Nurses are exposed to sexual violence more than other medical personnel are (OR = 3.11, 95% CI [1.29, 7.49]).

• Nurses were more exposed to verbal (OR = 5.08, 95% CI [1.54, 16.75]) and physical (OR = 3.68, 95% CI [1.15, 11.80]) violence compared with other medical personnel

• This study shows that a great majority of healthcare professionals are subjected to violence ranging from verbal violence in particular to physical and sexual violence

22.

• Davey K, Ravishankar V et al.

• 2020

• 7 hospital Emergency Department’s across India.

• Qualitative- Semi-structured interviews and hybrid thematic analysis approach was used to determine dominant themes.

• 63 participants (11 attending physicians, 36 resident physicians, 10 nurses, and 5 paramedics, 1 interview participant did not give their job title)

• Most events involved verbal abuse, although a significant percentage of responses described some kind of physical violence.

• ED factors such as busy times with high patient volumes or periods of waiting are associated with increased violence, as well as incidents with unanticipated outcomes such as patients with severe illness or death.

• Decreased levels of health literacy among patients often contribute as well as the financial stressors of paying for medical care.

• Providers reported negative consequences of workplace violence on quality of care for patients and their own motivation to work in the ED.

• Communication strategies were frequently proposed as interventions to mitigate violence in the future, including both provider communication as well as public awareness campaigns

• Alarming levels of verbal and physical abuse and their impact on patient care are described.

• Indian ED providers that differ from those in more developed settings, including financial stressors, inadequate enforcement of rules governing behaviour in the hospital, and an overwhelming frequency of violence emanating from patient family members and attendants rather than the patients themselves