workplace violence case study examples

Highlights from a New Report on Indicators of Workplace Violence

Federal agencies recently published a joint statistical report on workplace violence entitled Indicators of Workplace Violence, 2019 . The Bureau of Justice Statistics (BJS), the Bureau of Labor Statistics (BLS), and the National Institute for Occupational Safety and Health (NIOSH) examined incidents of fatal and nonfatal violence that occurred against persons at work or on duty, or violence that was away from work but over work-related issues from 1992 to 2019. The report includes data for 13 indicators of workplace violence from five federal data collections. The purpose of this report was to make summary data from a variety of sources readily available. It does not attempt to explore reasons for workplace violence.

Workplace Homicide

The study found that, over a 27-year period (1992 to 2019), 17,865 persons were killed in a workplace homicide, according to data from BLS’s Census of Fatal Occupational Injuries. Homicides in the workplace peaked at 1,080 homicides in 1994 and dropped to 454 in 2019, a decline of 58%. During a more recent period from 2014 (409 homicides) to 2019, workplace homicides increased 11%. The remainder of the report’s analysis on workplace homicide focuses on data from 2015 to 2019.

From 2015 to 2019:

21% of victims of workplace homicides worked in sales and related occupations. Protective-service occupations, notably police officers and security guards, accounted for 19% of workplace homicides. Persons in management occupations (e.g., owners or managers of restaurants and hotels) accounted for 9% of workplace homicides.
82% of victims of workplace homicide were male.
46% (1,052) of workplace homicide victims were white. White individuals also made up 66% of all workplace fatalities. Black individuals accounted for 25% (579) of workplace homicides and experienced 11% of all workplace fatalities. Hispanic individuals accounted for 16% (368) of workplace homicides and 18% of all workplace fatalities.
66% of workplace homicide victims were ages 25 to 54.
23% of victims of workplace homicides were self-employed.
79% of workplace homicides were shootings.

Nonfatal Workplace Violence

Workplace violence crimes.

In 2019, the rate of nonfatal workplace violence was 9.2 violent crimes per 1,000 workers ages 16 or older, according to the National Crime Victimization Survey (NCVS). This was a 25% increase from 2015, when the rate was 7.4 per 1,000. However, it was 70% lower than the 1994 rate of 31.0 violent crimes per 1,000 workers. The rate of total nonfatal violent crime followed a similar pattern.

From 2015-2019:

An annual average of 1.3 million nonfatal workplace violent victimizations occurred during the combined 5 years from 2015 to 2019, including about 53,000 rapes or sexual assaults, 46,000 robberies, 186,000 aggravated assaults, and 979,000 simple assaults per year.
The average annual rate of nonfatal workplace violence was 8.0 nonfatal violent crimes per 1,000 workers ages 16 or older.
Males committed the majority of nonfatal workplace violence (64%).
Strangers committed about half (47%) of nonfatal workplace violence, with male victims less likely than female victims to know the offender.
The offender was armed in 16% of nonfatal workplace violence.
Offenders were armed in about 24% of nonfatal workplace violence against workers in retail sales and in 24% of nonfatal workplace violence against those in transportation occupations.
Overall, 12% of nonfatal workplace violence involved injury to the victim. However, nearly a quarter (23%) of nonfatal workplace violence against workers in medical occupations resulted in victim injury.
Fifteen percent of victims of nonfatal workplace violence reported severe emotional distress due to the crime.
About 39% of all nonfatal workplace violence was reported to police.

Emergency department-treated workplace violence injuries

About 529,000 nonfatal injuries from workplace violence were treated in hospital emergency departments (EDs) for the combined 2015 to 2019 period, based on data from NIOSH’s National Electronic Injury Surveillance System-Occupational Supplement. This was a rate of 7.1 ED-treated injuries per 10,000 full-time equivalent (FTE) workers. Physical assaults (e.g., hitting, kicking, or beating) accounted for 83% of such injuries. The ED-treated injuries were most often contusions and abrasions (33%), followed by sprains and strains (12%) and traumatic brain injuries (12%). Beginning with workers ages 25 to 29, the rate of ED-treated injuries due to workplace violence decreased as workers’ ages increased.

Workplace violence injuries resulting in days away from work

In 2019, female workers (5.1 cases per 10,000 FTEs) had higher rates than males (2.3 per 10,000) of nonfatal injuries due to workplace violence resulting in days away from work. The same year, female workers accounted for 65% of the 37,210 nonfatal injuries due to workplace violence involving hitting, kicking, beating, or shoving that resulted in missed work. Male workers accounted for 82% of the 340 injuries involving an intentional shooting that resulted in days away from work.

Data Sources and Collections

This report uses data from five federal data collections—the National Crime Victimization Survey (sponsored by BJS), the National Electronic Injury Surveillance System – Occupational Supplement (sponsored by NIOSH and the U.S. Consumer Product Safety Commission), the National Vital Statistics System (sponsored by the National Center for Health Statistics), the Census of Fatal Occupational Injuries (sponsored by BLS), and the Survey of Occupational Injuries and Illnesses – Case and Demographics (conducted by BLS). Due to different data sources, estimates in this report could not always be presented consistently and are not always comparable.

Conclusion and Discussion

Workplace violence continues to negatively affect workers, organizations, and communities. This report provides a multi-faceted snapshot of the issue and establishes reliable indicators. Regular updating and monitoring of data on the topic remains critical in guiding law enforcement, researchers, policymakers, and occupational safety specialists in understanding the extent, nature, and context of violence in the workplace that will enable them to effectively address this problem.

Amid the ever-changing landscape of what work looks like, additional indicators may prove helpful in understanding how workplace violence continues to manifest. What additional data are needed to better understand and monitor the occurrence of workplace violence? Moreover, what effects did the COVID-19 pandemic have on workplace violence across the country? Please share your thoughts in the comment section below.

Erika Harrell of the Bureau of Justice Statistics

Jeremy Petosa and Nicole Dangermond of the Bureau of Labor Statistics

Susan Derk, Dan Hartley and Audrey Reichard of the National Institute for Occupational Safety and Health.

The Bureau of Labor Statistics of the U.S. Department of Labor measures labor market activity, working conditions, price changes, and productivity in the U.S. economy to support public and private decision making.

The National Institute for Occupational Safety and Health , part of the U.S. Centers for Disease Control and Prevention, in the U.S. Department of Health and Human Services, is a research institute focused on the study of worker safety and health, and empowering employers and workers to create safe and healthy workplaces.

The Bureau of Justice Statistics of the U.S. Department of Justice is the principal federal agency responsible for collecting, analyzing and disseminating reliable statistics on crime and criminal justice in the United States.

The Office of Justice Programs provides federal leadership, grants, training, technical assistance and other resources to improve the nation’s capacity to prevent and reduce crime, advance racial equity in the administration of justice, assist victims and enhance the rule of law.

3 comments on “Highlights from a New Report on Indicators of Workplace Violence”

Comments listed below are posted by individuals not associated with CDC, unless otherwise stated. These comments do not represent the official views of CDC, and CDC does not guarantee that any information posted by individuals on this site is correct, and disclaims any liability for any loss or damage resulting from reliance on any such information. Read more about our comment policy » .

You need to gauge the workplace violence against Healthcare workers, especially in Hospitals.

Thank you for your comment. Some of the data sources used in this document offer the ability to look at occupations within industries. We will consider that possibility for future iterations of this document.

Small-scale mining. Apply international studies (WHO, Minamata) to America. Thank you.

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True Stories of Workplace Bullying: Case Examples to Help You Understand Your Rights

Do you think you’re being bullied at work? If so, your workplace bully could be violating California and Federal law due to their harassing behaviors. While bullying itself is not unlawful, there are anti-bullying legislative measures being brought to the forefront all across the country, including the Healthy Workplace Bill. In addition to anti-bullying legislation, the Workplace Bullying Institute is also striving to eradicate bullying on the job by dedicating their efforts to anti-bullying education, research, and consulting for individuals, professionals, employers, and organizations.

Workplace bullying comes in many forms and can be unlawful if this type of harassment is based on an employee’s national origin, age, gender, disability, or other protected characteristics. Bullies also typically engage in these unlawful behaviors more than once rather than in isolated incidents.

In the spirit of the Workplace Bullying Institute’s Freedom from Workplace Bullies Week, we’ve decided to offer some insight into real workplace bullying, retaliation and discrimination cases from around the country that can help you understand your own rights when it comes to employment harassment.

Table of Contents

Real Workplace Bullying Case Examples

Microsoft to pay $2 million in workplace bullying case.

AUSTIN, TX – After seven years, Michael Mercieca finally saw the courts order Microsoft to pay for workplace bullying that almost led him to the breaking point.

The Texas employment labor law case judge, Tim Sulak, found Microsoft guilty of “acting with malice and reckless indifference” in an organized program of office retaliation against Mercieca.

“They (Microsoft Corporation) remain guilty today, tomorrow and in perpetuity over egregious acts against me and racist comments by their executive that led to the retaliation and vendetta resulting in my firing,” said Mercieca.

Previously, a jury, by unanimous agreement, found that Microsoft knowingly created a hostile work environment that led to Mercieca’s constructive dismissal. Mercieca was a highly regarded member of the tech giant’s sales department and had an unblemished record, but found himself trapped in a workplace conspiracy where his supervisors and coworkers undermined his work, falsely accused him of sexual harassment, and expense account fraud, marginalized him, and blocked his promotions. These harassing behaviors began when Mercieca ended a relationship with a woman who then went on to become his boss. Human relations at Microsoft did nothing to stop the bullying, either.

“Rather than do the right thing, the management team went after Michael by getting a female employee to file a sexual harassment complaint and a complaint of retaliation against him,” says Paul T. Morin. “Microsoft could have taken Mercieca’s charges seriously and disciplined the senior manager but instead it engaged in the worst kind of corporate bullying.”

Read the full story

King Soopers to Pay $80,000 to Settle EEOC Disability Discrimination Lawsuit

DENVER, CO – Dillon Companies, Inc., owners of the King Soopers supermarket chain in Colorado will pay $80,000 for bullying a learning-disabled employee who worked at its Lakewood, Colorado store.

According to the EEOC’s disability discrimination lawsuit, two store supervisors repeatedly subjected Justin Stringer, an employee who worked at King Soopers for a decade, to repeated bullying and taunting in the workplace because of his learning disability. The EEOC alleged that the bullying resulted in Stringer’s termination.

“Employees with disabilities must be treated with the same dignity and respect as all other members of the work force,” said EEOC Regional Attorney Mary Jo O’Neill. “The EEOC will continue to enforce the ADA to protect the rights of disabled employees and applicants.”

DHL Global Forwarding Pays $201,000 to Settle EEOC National Origin Discrimination Suit

DALLAS, TX – Air Express International, USA, Inc. and Danzas Corporation, doing business as DHL Global Forwarding, will pay $201,000 to nine employees and provide other significant relief to settle a national origin hostile environment lawsuit brought by the U.S. Equal Employment Opportunity Commission (EEOC).

The EEOC charged DHL Global with subjecting a class of Hispanic employees to bullying, discrimination, and harassment due to their national origin. According to the suit, Hispanic employees at DHL’s Dallas warehouse were bullied at work by being subjected to taunts and derogatory names such as “wetback,” “beaner,” “stupid Mexican” and “Puerto Rican b-h”. The Hispanic workers, who included persons of Mexican, Salvadoran and Puerto Rican heritage, were often ridiculed by DHL personnel with demeaning slurs which included referring to the Salvadoran worker as a “salvatrucha,” a term referring to a gangster. Other workers were identified with other derogatory stereotypes.

Robert A. Canino, regional attorney for the EEOC’s Dallas District Office, stated, “Bullying Hispanic workers for speaking a language other than English is a distinct form of discrimination, which, when coupled with ethnic slurs, is clearly motivated by prejudice and national origin animus. Sometimes job discrimination isn’t just about hiring, firing or promotion; it’s about an employer promoting disharmony and disrespect through an unhealthy work environment.”

Wal-Mart to Pay $150,000 to Settle EEOC Age and Disability Discrimination Suit

DALLAS, TX – Wal-Mart Stores of Texas, L.L.C. (Wal-Mart) has agreed to pay $150,000 and provide other significant relief to settle an age and disability discrimination lawsuit brought by the U.S. Equal Employment Opportunity Commission (EEOC). The EEOC charged in its suit that Wal-Mart discriminated against the manager of the Keller, Texas Walmart store by subjecting him to bullying, harassment, discriminatory treatment, and discharge because of his age.

According to the EEOC, David Moorman was ridiculed with frequent bullying and taunts at work from his direct supervisor, including being called “old man” and “old food guy.” The EEOC also alleged that Wal-Mart fired Moorman because of his age.

“Mr. Moorman was subjected to taunts and bullying from his supervisor that made his working conditions intolerable,” said EEOC Senior Trial Attorney Joel Clark. “The EEOC remains committed to prosecuting the rights of workers through litigation in federal court.”

Under the terms of the two-year consent decree settling the case, Wal-Mart will pay $150,000 in relief to Moorman under the terms of the two-year consent decree. Wal-Mart also agreed to provide training for employees on the ADA and the ADEA, which will include an instruction on the kind of conduct that could constitute unlawful discrimination or harassment.

Everyone deserves to work in a safe, supportive environment and workplace bullies should be dealt with accordingly. If you are being bullied at work, contact our expert California employment lawyers today for your free consultation.

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Workplace Violence

Workplace Violence Home

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Enforcement Procedures and Scheduling for Occupational Exposure to Workplace Violence . OSHA Directive CPL 02-01-058, (January 10, 2017).
Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers ( EPUB | MOBI ). OSHA Publication 3148, (2016).
Worker Safety in Hospitals: Caring for our Caregivers, Preventing Workplace Violence in Healthcare . OSHA.
Taxi Drivers – How to Prevent Robbery and Violence . OSHA Publication 3976 (DHHS/NIOSH Publication No. 2020-100), (November 2019).
Recommendations for Workplace Violence Prevention Programs in Late-Night Retail Establishments . OSHA Publication 3153, (2009).

This workplace violence website provides information on the extent of violence in the workplace, assessing the hazards in different settings and developing workplace violence prevention plans for individual worksites.

What is workplace violence?

Workplace violence is any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the work site. It ranges from threats and verbal abuse to physical assaults and even homicide. It can affect and involve employees, clients, customers and visitors. Acts of violence and other injuries is currently the third-leading cause of fatal occupational injuries in the United States. According to the Bureau of Labor Statistics Census of Fatal Occupational Injuries (CFOI), of the 5,333 fatal workplace injuries that occurred in the United States in 2019, 761 were cases of intentional injury by another person. [ More... ] However it manifests itself, workplace violence is a major concern for employers and employees nationwide.

Who is at risk of workplace violence?

Many American workers report having been victims of workplace violence each year. Unfortunately, many more cases go unreported. Research has identified factors that may increase the risk of violence for some workers at certain worksites. Such factors include exchanging money with the public and working with volatile, unstable people. Working alone or in isolated areas may also contribute to the potential for violence. Providing services and care, and working where alcohol is served may also impact the likelihood of violence. Additionally, time of day and location of work, such as working late at night or in areas with high crime rates, are also risk factors that should be considered when addressing issues of workplace violence. Among those with higher-risk are workers who exchange money with the public, delivery drivers, healthcare professionals, public service workers, customer service agents, law enforcement personnel, and those who work alone or in small groups.

How can workplace violence hazards be reduced?

In most workplaces where risk factors can be identified, the risk of assault can be prevented or minimized if employers take appropriate precautions. One of the best protections employers can offer their workers is to establish a zero-tolerance policy toward workplace violence. This policy should cover all workers, patients, clients, visitors, contractors, and anyone else who may come in contact with company personnel.

By assessing their worksites, employers can identify methods for reducing the likelihood of incidents occurring. OSHA believes that a well-written and implemented workplace violence prevention program, combined with engineering controls, administrative controls and training can reduce the incidence of workplace violence in both the private sector and federal workplaces.

This can be a separate workplace violence prevention program or can be incorporated into a safety and health program, employee handbook, or manual of standard operating procedures. It is critical to ensure that all workers know the policy and understand that all claims of workplace violence will be investigated and remedied promptly. In addition, OSHA encourages employers to develop additional methods as necessary to protect employees in high risk industries.

Provides information on risk factors and scope of violence in the workplace to increase awareness of workplace violence.

Provides guidance for evaluating and controlling violence in the workplace.

Training and Other Resources

Provides online training and other resource information.

There are currently no specific OSHA standards for workplace violence. Also provides links to enforcement letters of interpretation.

Open access
Published: 03 October 2023

Healthcare workers’ experiences of workplace violence: a qualitative study in Lebanon

Linda Abou-Abbas ORCID: orcid.org/0000-0001-9185-3831 1 ,
Rana Nasrallah 2 ,
Sally Yaacoub ORCID: orcid.org/0000-0003-0819-1561 1 , 3 ,
Jessica Yohana Ramirez Mendoza 4 &
Mahmoud Al Wais ORCID: orcid.org/0009-0007-6138-1184 1

Conflict and Health volume 17 , Article number: 45 ( 2023 ) Cite this article

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The COVID-19 pandemic has brought unprecedented challenges to healthcare workers (HCWs) around the world. The healthcare system in Lebanon was already under pressure due to economic instability and political unrest before the pandemic. This study aims to explore the impact of COVID-19 and the economic crisis on HCWs’ experiences of workplace violence in Lebanon.

A qualitative research design with an inductive approach was employed to gather data on workplace violence through Focus Group Discussions (FGDs) from HCWs in Tripoli Governmental Hospital (TGH), a governmental hospital in North Lebanon. Participants were recruited through purposive sampling. The interviews were conducted in Arabic, recorded, transcribed, and translated into English. Thematic analysis was used to analyze the data.

A total of 27 employees at the hospital participated in the six FGDs, of which 15 females and 12 males. The analysis identified four main themes: (1) Types of violence, (2) Events witnessed, (3) Staff reactions to violence, and (4) Causes of violence. According to the interviews conducted, all the staff members, whether they had experienced or witnessed violent behavior, reported that such incidents occurred frequently, ranging from verbal abuse to physical assault, and sometimes even involving the use of weapons. The study findings suggest that several factors contribute to the prevalence of violence in TGH, including patients’ financial status, cultural beliefs, and lack of medical knowledge. The hospital’s location in an area with a culture of nepotism and favoritism further exacerbates the issue. The staff’s collective response to dealing with violence is either to submit to the aggressor’s demands or to remove themselves from the situation by running away. Participants reported an increase in workplace violence during the COVID-19 pandemic and the exacerbated economic crisis in Lebanon and the pandemic.

Interventions at different levels, such as logistical, policy, and education interventions, can help prevent and address workplace violence. Community-level interventions, such as raising awareness and engaging with non-state armed groups, are also essential to promoting a culture of respect and zero tolerance for violence.

Introduction

Acts of violence in the workplace have far-reaching consequences that can disrupt various aspects of society [ 1 ]. Healthcare workers (HCWs) are often at a higher risk of being subjected to workplace violence, with up to 38% of HCWs experiencing violence at some point during their careers [ 2 ]. The prevalence of workplace violence (WPV) against HCWs was found to be high in Asian and North American countries, psychiatric and emergency department settings, and among nurses and physicians [ 3 ].

The COVID-19 pandemic has aggravated violence against HCWs [ 4 , 5 , 6 ], increasing existing sources of violence and opening new areas of confrontation between healthcare providers, patients, and their families [ 5 ]. From February to December 2020, the International Committee of the Red Cross (ICRC) received 848 reports of violence against HCWs related to COVID-19 across 42 countries. These incidents occurred in various regions around the world, including Europe, Africa, the Americas, and Asia [ 7 ]. A review of incidents from a lower-middle-income country revealed that the reasons for the assaults are varied, including unexpected outcomes or death of a patient, unavailability of resources at the hospital due to overcrowding, miscommunication, and a lack of awareness in society [ 8 ].

A joint study by several international organizations has found that violence against doctors is widespread and has increased since the start of the COVID-19 pandemic [ 5 ]. The study received responses from over 120 organizations and found that 58% of respondents perceived an increase in violence, with all respondents reporting verbal aggression, 82% mentioning threats and physical aggression, and 27% reporting staff being threatened by weapons [ 5 ]. The study highlights the need for concrete action to end impunity for those who are violent and suggests practical solutions, such as improving relations between health personnel and patients and implementing successful strategies from countries such as Bulgaria, Colombia, Italy, Portugal, and Taiwan. The study highlights the need to better understand how violence is affecting healthcare workforce and quality of services and take action to stop it [ 5 ].

WPV is a serious issue in Lebanon, and the healthcare sector is not immune to this problem. A study conducted in 2015 found that 62% of nurses in Lebanon experienced verbal abuse in the past year, while 10% reported physical abuse, including weapon attacks [ 9 ]. The economic crisis in Lebanon, combined with the ongoing COVID-19 pandemic for the past three years, has resulted in an increase in violent acts against HCWs, with hospitals becoming a target for frustrated individuals [ 10 ]. The situation is particularly challenging for Tripoli Governmental Hospital (TGH), which is the second largest public hospital in Lebanon where citizens suffer from low incomes and poverty. Its location is critical, as many armed clashes/hostilities take place in the surrounding area of the hospital, making it more vulnerable to workplace violence [ 11 ]. As HCWs play a critical role in providing essential services to the community and deserve to work in a safe and supportive environment, it is crucial to address the issue of workplace violence and gain a deeper understanding of the issues surrounding violence against healthcare providers in TGH. This study aims to understand HCWs’ perspectives on workplace violence, explore their preferences for interventions to prevent violence, and propose feasible methods to protect HCWs from violence. This research could be a crucial step towards improving the safety and well-being of HCWs in Lebanon and other similar settings.

Study design and setting

A qualitative research design with an inductive approach was employed to gather data on WPV through Focus Group Discussions (FGDs). The decision to initiate the research with FGDs rather than individual interviews was due to several factors including resource availability, research objectives, and the nature of the research question. Starting directly with FGDs was deemed efficient in terms of time and resources, especially when seeking a broader understanding of WPV by facilitating group interactions that stimulate participants to build on each other’s ideas and experiences. Additionally, FGDs can create an environment where participants feel more comfortable sharing sensitive or personal experiences due to the shared context and the support of the group.

The study was conducted at TGH that serves about 638,000 Lebanese (including 244,000 residents of Tripoli), 233,000 Syrian refugees, and roughly 50,000 Palestinian refugees. Approximately 400 healthcare providers (doctors and nurses) work at TGH [ 11 ].

Participant recruitment

To ensure a diverse range of participants based on gender and occupations, we implemented a purposeful sampling procedure. This procedure involved contacting various categories of hospital staff and inviting them to participate in our study. Eligibility was extended to all staff members working within the hospital setting. Invitations to participate were conveyed through phone messages. Staff members who expressed their willingness to participate were subsequently contacted via phone messages to arrange the interview. Additionally, we meticulously planned the FGDs by predetermining the date, time, and location.

Our selection criteria focused mainly on individuals in direct contact with patients due to their unique vantage points and daily exposure to WP incidents providing firsthand perspectives on frontline dynamics. Additionally, administrative and support staff were included to contribute valuable insights into organizational aspects related to workplace violence, enriching our understanding of the broader context within healthcare organizations. These categories were considered most appropriate for our research, as they align closely with our research objectives, allowing us to gain comprehensive insights into WP in the healthcare setting.

The hospital staff who agreed to participate in the study were grouped according to their preferred time during the day.

Four FGDs were conducted for the study, as follows:

A group of female nurses.

Two groups of both female and male nurses.

A group of hospital administrative staff.

Two groups of other support staff including orderlies, lab technicians, cooks, housekeeping.

Data collection

In February 2022, the FGDs were conducted by two investigators in Arabic in a private room at the hospital using a semi-structured interview guide (Appendix 1). Only non-identifiable information was collected and included gender and the participants’ job title (i.e., physician, nurse, paramedic). The interview guide included open-ended questions related to WPV, such as how it is defined, the forms it takes, examples of violent incidents, and the motives of perpetrators. Other questions included the staff’s reaction to the incidents and whether they could have reacted differently or prevented the event from happening. Training of HCWs, preventing violence, and hospital safety regulations were also discussed. The interviews lasted 45 min to an hour on average.

As we progressed through the study, we observed that new information and perspectives related to workplace violence became increasingly scarce. Instead, we encountered recurring themes and insights from participants, indicating that we had comprehensively explored the topic. This consistent repetition of information across participants signaled to us that we had achieved data saturation, where further data collection would likely yield diminishing returns in terms of new insights.

Data gathering tool

The discussions were audio recorded as a means of capturing participants’ voices, experiences, and perspectives in their own words during the FGDs. Following the transcription, the original recordings were securely destroyed to uphold participants’ privacy and ensure the confidentiality of the information shared. This approach aligned with best practices in qualitative research to protect participants’ identities and uphold the integrity of the research process.

Quality control and assurance

The research team rigorously ensured objectivity and impartiality in the formulation of research questions. Questions posed during interviews were deliberately crafted to be objective, avoiding any form of intervention or bias. The primary goal was to explore diverse dimensions of workplace violence and gather information essential for the study. Crucially, the interviewers maintained a neutral stance, refraining from expressing personal opinions or influencing participant responses. Importantly, no pre-existing relationships existed between the interviewers and participants, reinforcing the integrity of the research process. Data collection was conducted in a room within the hospital premises, selected for its convenience. This choice accommodated the participation of hospital staff during their work shifts, facilitating their engagement in the study. All staff members within the hospital, irrespective of their roles, were eligible to participate due to their direct interactions with patients, which made their perspectives valuable to the research objectives. The selection of participants was unbiased, guided solely by their roles in patient care and their exposure to workplace violence incidents.

Ethical considerations

The approval of the Institutional Review Board (IRB) at American University of Beirut (AUB) (SBS-2021-0352) and the internal ethical review board at ICRC was obtained before starting the study (2109-APR). The study was conducted in accordance with ethical principles and guidelines, including informed consent, confidentiality, and the right to withdraw from the study at any time. The participants signed an informed consent form before the discussion, which emphasized the confidentiality of the information they shared. They were also informed that they could withdraw from participating in the study at any time.

Data analysis

Audio-recorded FGDs were transcribed verbatim in the Arabic language. A rigorous manual analysis was undertaken to discern recurring themes, patterns, and insights pertaining to WPV experiences among HCWs. The verbatim transcripts were meticulously reviewed to extract pertinent concepts and phrases, which were then assigned as codes. These codes were subsequently organized into categories within a matrix structure. These categories aligned with overarching themes that were deduced from the research objectives and questions, allowing for a comprehensive exploration of WPV dimensions. The themes and sub-themes identified underwent thorough discussion within the research team to ensure accuracy and robustness. Quotes used in reporting findings were translated to English language.

A total of 27 employees at the hospital participated in the six FGDs, of which 15 females and 12 males. The participants were further categorized into three groups based on their occupations: nurses (14 participants), administrative staff (5 participants), and support staff (8 participants).

The analysis of the information gathered was conducted through a process of coding, sub-theme, and theme development. The coding scheme can be found in Table 1 .

In the following paragraphs, each theme is described in more detail providing sample quotes, where appropriate.

Types of violence

All participants unanimously agreed that any form of aggression experienced while performing their jobs in healthcare settings constitutes violence. This indicates a clear consensus among the participants regarding the definition of violence in the healthcare setting.

Based on the participants’ descriptions, the types of violence experienced in healthcare settings can be categorized into two main forms: verbal and physical. Verbal violence included any communication that is intended to harm or intimidate, such as shouting, swearing, or making derogatory remarks. Physical violence, on the other hand, included any intentional physical act that causes harm or injury, such as hitting, kicking, or pushing. Some participants also mentioned the potential for nonverbal or subtle forms of violence, such as body language or tone of voice, which can convey aggression or hostility. Additionally, some participants identified the use of weapons or threats as a form of violence. While most of the participants focused on the violence that they can face from the patients and their families, some mentioned that violence can be addressed from their colleagues as well. Moreover, it was acknowledged that violence in healthcare settings can also originate from staff members towards their patients.

Events witnessed

All staff members have witnessed violence at work that ranged from verbal abuse such as being threatened, shouted at, and being cursed, to being punched or slapped and sometimes even physical injury in the form of bone fractures. It is important to note that the type of violence targeting males and females differed. Males were more likely to experience physical violence. In contrast, females were often targeted with verbal abuse, though they were not immune to physical violence either. Additionally, weapons were brought into the hospital and used against the staff, further exacerbating the risk and harm faced by everyone involved.

A nurse that was working in the Emergency Department (ED) was present during an event when a family member of a patient who was seeking care for a stabbing injury in the back was threatening to blow the ED with a bomb if his relative would have died or “ does not leave the hospital walking on his legs ”. He even shot the roof of the ED with the weapon he was holding.

The participant verbalized the following words:

“ It was one of the scariest moments of my life… my colleague and I had to help the bleeding patient, but we were hiding afraid to die… If my parents knew what I went through that day, they would have not allowed me to go to work again ”.

Another participant described being punched in the face by someone who came to the blood bank asking for O negative blood units. The lab technician ended up giving him a unit of blood from any type due to his fear. He mentioned:

In times like that, all you think about is how to save yourself, your life, so that you remain available next to your family… .

Almost half of the participants recalled a recent event experienced by a nurse at the Obstetrics and Gynecology (OBGYN) unit. The family members of a patient broke the fingers of the nurse for not being able to insert an IV line directly to the patient.

Administrative staff have also been subject to violence with four out of five having experienced violent episodes. The violence they encounter is primarily in the form of shouting and damage to the health facility and equipment causing destruction of glass and equipment in their vicinity.

“ We’re used to this kind of violence, we face it daily ”, they said.

Violence has been observed by staff across all categories, including those who do not have direct contact with patients and their families. For example, a cook working in the hospital’s kitchen was shouted at by a patient’s family member for not providing food, even though the patient was under medical orders not to eat due to a recent surgical operation. Additionally, a pharmacist was threatened with physical harm in the pharmacy department if they did not provide narcotics to an aggressive individual.

Some participants mentioned that verbal aggression between staff members may occur, but they are usually resolved immediately without further escalation. Additionally, one participant noted that in some cases, staff members may raise their voices and behave inappropriately towards patients and their families, which could be attributed to the high levels of stress they are experiencing.

“ We are all stressed, sometimes we shout at patients’ families or our colleagues due to the stress we are enduring inside and outside the hospital environment ”.

Causes of violence

Staff reported the causes that could potentially lead to violent incidents in hospitals which can generally be divided into two categories: hospital-related and patient-related.

Hospital-related

One of the main causes that staff members at the hospital cited for potential violence was the inadequate number of security guards. With only two guards stationed at the entrance of the hospital, there was concern that they would not be able to effectively respond to any violent incidents that might occur. Additionally, even though at the hospital’s parking premises there is an army checkpoint; they are not authorized to intervene in such situations, further exacerbating the security issue.

Another reason mentioned by the administrative staff was the laborious and protracted billing procedure for outpatients. To bill the patients, the paperwork needs to be physically transported across several departments, such as pharmacy, laboratory, and imaging, which is a manual process. This process is time-consuming which adds frustration to the patient and his family and can sometimes escalate into violence.

The lack of a clear visitation policy was also a concern raised by nurses at the hospital. Without clear restrictions on who can visit patients and when, anyone can enter the hospital at any time, including individuals who may be carrying weapons.

Patient-related

According to the TGH staff, the main reason of violence in the hospital is attributed to the financial status of the patients. As a public hospital, many patients expect to receive free treatment. However, when informed of the costs associated with their care by the admitting department, they become overwhelmed and agitated, which can escalate to violent behavior. Additionally, the hospital’s location in an area with a culture of favoritism contributes to some patients’ belief that they can obtain special treatment by shouting and threatening, which may also contribute to incidents of violence in the hospital.

One of the staff said that “ the clients of the hospital know that if they shout and threaten, they will get whatever they want ”.

The insufficient medical knowledge of patients and their families is identified by almost all participants as a significant factor contributing to violence in TGH. Due to their limited understanding of the disease, patients and their families have unrealistic expectations of the healthcare staff’s ability to maintain the patient’s life, which can escalate to violent conduct. Furthermore, the COVID-19 pandemic has worsened this situation, as participants noted that the lack of comprehension of this novel disease has also played a role in violent incidents.

“ Families and patients do not understand why they cannot see their relative at isolation, and that makes them aggressive ”.

Staff reactions to violence

The staff collectively agreed that the best way to deal with violence is to either submit to the aggressor’s demands to avoid being subjected to violence or to physically remove themselves from the situation by running away. Two nurses working at the pharmacy department described how nurses from the Obstetrics and Gynecology department ran away from their unit to the pharmacy department when they were aggressed by a patient’s family.

Staff members in hospitals often avoid reacting or intervening in violent situations due to their fear of not only being attacked at work but also being followed and harassed on their way to and from work, as they mentioned:

“ In these situations, we just need to protect ourselves… we agree with whatever the aggressor says and do whatever he asks for ”.

The response to violence differs between males and females. Males tend to face the perpetrator and confront them directly, possibly reflecting societal expectations of male protectiveness or assertiveness. In contrast, females tend to prioritize escape and avoidance, preferring not to engage with the perpetrators directly. They may even respond to the perpetrators’ needs, even if those needs are not relevant or urgent, as a means of defusing the situation. Some female staff members mentioned that when a perpetrator attacks the nursing station or arrives angry at a department, their aggression often subsides upon realizing that the entire staff present is female. This observation suggests that the gender composition of the staff can have an impact on the dynamics of the situation, potentially leading to a de-escalation of the aggression.

In cases of violence, staff members seek assistance by calling the few available security guards at the hospital or asking for help from the police, recognizing the importance of external support in managing violent incidents and ensuring the safety of all involved parties.

The study conducted sheds light on the alarming issue of violence against HCWs in TGH. According to the interviews conducted, all the staff members, whether they had experienced or witnessed violent behavior, reported that such incidents occurred frequently, ranging from verbal abuse to physical assault, and sometimes even involving the use of weapons. The study findings suggest that several factors contribute to the prevalence of violence in TGH, including patients’ financial status, cultural beliefs, and lack of medical knowledge. The hospital’s location in an area with a culture of clout and favoritism further exacerbates the issue. The staff’s collective response to dealing with violence is either to submit to the aggressor’s demands or to remove themselves from the situation by running away. In this discussion section, we will examine the implications of these findings and propose recommendations to address this problem.

Our findings are consistent with a recent meta-analysis of 38 studies involving 63,672 healthcare workers (HCWs), which reported high prevalence rates of workplace violence (WPV) among HCWs. The analysis revealed significant rates of physical violence (9%), verbal violence (48%), and emotional violence (26%) among HCWs. Furthermore, the meta-analysis indicated an escalation of WPV, physical violence, and verbal violence during the mid- to late-stages of the COVID-19 pandemic [ 12 ]. These findings emphasize the critical need to address WPV and prioritize the well-being and safety of HCWs. The patients’ financial status appears to be a significant contributor to violent behavior, as many patients expect to receive free treatment at TGH, being a public hospital. However, they become agitated when informed of the costs associated with their care, which can escalate to violent conduct. The cultural beliefs and attitudes of patients towards the hospital staff also play a role in the occurrence of violence. Patients who believe that shouting and threatening will give them preferential treatment may become violent when their expectations are not met. The lack of medical knowledge among patients and their families is also a significant factor contributing to violent behavior. Patients and their families may have unrealistic expectations of the healthcare staff’s ability to maintain the patient’s life due to their limited understanding of the disease. The COVID-19 pandemic has further exacerbated the issue of violence in the hospital, with participants reporting that the lack of knowledge about the new disease has contributed to violent incidents. Working with people infected with COVID-19 is also a factor for violence [ 6 ]. The weakness of the security logistics at the hospital has also been a major reason for violence. The issues of corruption in Lebanon have also affected violence in the TGH. Many participants mentioned that people who commit violence against HCWs at the hospitals are usually covered by political parties. They threat with weapons and use them in the hospital knowing that eventually, there will be no punishment for their actions. The fact that TGH is a public hospital makes it a “punching bag” for the Lebanese patients that are frustrated from the Lebanese Government, so they pour their anger against the corrupted system in Lebanon on the healthcare workers at the hospital.

Differences were observed between males and females in terms of the types of violent incidents witnessed and the corresponding reactions exhibited. Males are more likely to witness and experience physical violence, such as being punched, slapped, or sustaining physical injuries. This could be attributed to societal expectations of male dominance and the perceived need for physical confrontation. On the other hand, females are more likely to encounter verbal abuse and emotional violence. When faced with violence, males tend to confront the perpetrators directly, possibly driven by societal norms of masculinity and the desire to protect themselves or others. In contrast, females often prioritize their safety by opting for escape and avoiding direct confrontation. They may comply with the aggressor’s demands to de-escalate the situation or minimize the risk of harm. These gender-specific responses may be influenced by social conditioning and self-preservation instincts, highlighting the complex interplay between societal expectations, gender roles, and individual coping mechanisms in the face of violence. However, it is important to note that these findings should not overshadow the fact that violence can affect individuals of all genders and that the experiences of individuals may vary widely. Each case should be considered on its own merits, and it is crucial to avoid making broad generalizations based solely on gender. Addressing violence requires comprehensive efforts that focus on prevention, support for survivors, and challenging harmful societal norms and behaviors.

It’s important to note that not all HCWs initially approached for participation in our study agreed to participate to the study. Possible reasons are unavailability during the study period or may be concerns related to the sensitivity of the topic, given that workplace violence is a complex and sensitive issue. We recognize that their non-participation introduces certain limitations and potential biases as their perspectives and experiences, which could have enriched our findings, are not represented. Consequently, we have taken great care to accurately present the data collected from willing participants in a manner that faithfully reflects their experiences within the study’s scope.

Interventions should be implemented promptly to enhance the security measures in hospitals, given the severity of the issue of violence against staff members. To improve security measures at hospitals, various interventions can be implemented at the organizational level. Logistical interventions, policy initiation interventions, and staff education can help prevent workplace violence. One effective logistical intervention is to install metal doors with access restricted to staff ID cards at hospital entrances and unit doors. Additionally, increasing the number of security guards and placing at least one guard on each hospital floor can help limit the number of visitors and prevent unwanted access. Metal detectors at the main entrance can also help prevent visitors from entering the hospital with weapons. At the policy level, visitation restrictions can be implemented, such as limiting visits to two family members per patient. Staff education and training programs can be conducted to prevent and manage workplace violence. Research has shown that staff training for violence prevention and management can reduce the consequences of violence [ 13 ]. Healthcare organizations, policymakers, and the government should work together to implement these interventions to ensure that healthcare workers can provide care safely and without fear of violence. Staff have shown willingness to participate in such training during focus group discussions.

At the community level, raising awareness among the adjacent population about the importance of respecting the hospital’s facilities and staff is one such intervention. This can help the community understand the crucial role of healthcare workers in treating and preventing diseases and promote their protection instead of violation. Another important intervention is to engage with non-State armed groups in the area to prevent violence against healthcare workers. The International Committee of the Red Cross (ICRC) has set an example in 2014 by counseling and meeting with them and signing an agreement to avoid interfering in the hospital’s work and protecting healthcare workers [ 7 ]. These interventions involve all stakeholders in the problem and have shown positive impacts in reducing violence against healthcare workers in recent studies [ 13 ].

Violence against healthcare workers is a critical issue that affects the quality of healthcare services and the safety of both HCWs and patients. Our findings, derived from the perspectives of healthcare workers (HCWs), suggest that the problem of violence against HCWs is multifaceted, with various factors contributing to its occurrence. These factors include patient-related, organizational, and community-related factors. Interventions at different levels, such as logistical, policy, and education interventions, can help prevent and address workplace violence. Community-level interventions, such as raising awareness and engaging with non-state armed groups, are also essential to promoting a culture of respect and zero tolerance for violence. It is crucial for all stakeholders, including healthcare organizations, policymakers, the government, and the community, to work together to implement these interventions to ensure that healthcare workers can provide care safely and without fear of violence or harm.

The authors confirm that the views and opinions expressed in this publication do not in any way constitute the official view or position of the ICRC. Every effort has been made to comply with our duties of discretion regarding activities undertaken during our employment/missions with the ICRC.

Data Availability

The data collected for this qualitative study is not publicly available due to the confidential nature of the information shared by participants. Access to the data is restricted to the research team to maintain privacy and ensure compliance with ethical guidelines.

Abbreviations

Coronavirus disease-2019

Health care workers

Focus group discussion

Tripoli Governmental Hospital

International Committee of the Red Cross

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Acknowledgements

We thank the staff of the TGH who consented to participate in this study and for sharing their stories during such troubled times in Lebanon. We also thank the nursing director who helped with the recruitment and logistics.

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International Committee of the Red Cross (ICRC), Beirut, Lebanon

Linda Abou-Abbas, Sally Yaacoub & Mahmoud Al Wais

American University of Beirut, Beirut, Lebanon

Rana Nasrallah

Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and Statistics (CRESS), Paris, France

Sally Yaacoub

International Committee of the Red Cross, Geneva, Switzerland

Jessica Yohana Ramirez Mendoza

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Contributions

MAW and SY conceived the study idea and designed the study protocol. RN and SY conducted the interviews. RN conducted the transcription, translation, and drafted the manuscript. LAA contributed to the qualitative analysis of the data and assisted with editing the article. JM reviewed the article for important intellectual content. All authors approved the final version submitted.

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Correspondence to Mahmoud Al Wais .

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This study received ethical approval from the Institutional Review Board (IRB) at the American University of Beirut (AUB) and the internal ethical review board at ICRC (DP_DIR 21/14 - FTY/abg). Informed consent was obtained from participants, who were assured of confidentiality, the right to withdraw, and the destruction of audio recordings after transcription.

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Interview Topic guide .

Introduce yourself, provide the consent form .

Collect Demographic information: Gender & job title .

Workplace Violence .

How do you define occupational violence (i.e., workplace violence)? In what forms does it occur? Can you give examples from your experience (whether you witnessed violence or got exposed to it)?

Have you ever been exposed to violence at work/healthcare setting?

Why do you think such aggressive incidents take place? What are the motives of the perpetrator?

How did you react to the incidents that you got exposed to or witnessed? And do you think you could have reacted differently or maybe prevented the event from happening?

Do you think training of healthcare workers in communication/counseling skills, training in managing violence … would help prevent violent incidents?

Do you think it would be useful to increase resources in combating violence; specifically, by increasing security personal and facilities, working conditions and incentives for healthcare workers, and adequate facilities (equipment/medicines/ healthcare workers)?

What rules and regulations are needed to ensure that the environment is safe at the hospital?

How willing are you to engage in specific programs to combat violence? Why are you encouraged and why not?

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Abou-Abbas, L., Nasrallah, R., Yaacoub, S. et al. Healthcare workers’ experiences of workplace violence: a qualitative study in Lebanon. Confl Health 17 , 45 (2023). https://doi.org/10.1186/s13031-023-00540-x

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Conflict and Health

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Published: 13 October 2023

Contemporary evidence of workplace violence against the primary healthcare workforce worldwide: a systematic review

Hanizah Mohd Yusoff 1 ,
Hanis Ahmad ORCID: orcid.org/0000-0001-6657-8698 1 ,
Halim Ismail 1 ,
Naiemy Reffin 1 ,
David Chan 1 ,
Faridah Kusnin 2 ,
Nazaruddin Bahari 2 ,
Hafiz Baharudin 1 ,
Azila Aris 1 ,
Huam Zhe Shen 1 &
Maisarah Abdul Rahman 3

Human Resources for Health volume 21 , Article number: 82 ( 2023 ) Cite this article

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Violence against healthcare workers recently became a growing public health concern and has been intensively investigated, particularly in the tertiary setting. Nevertheless, little is known of workplace violence against healthcare workers in the primary setting. Given the nature of primary healthcare, which delivers essential healthcare services to the community, many primary healthcare workers are vulnerable to violent events. Since the Alma-Ata Declaration of 1978, the number of epidemiological studies on workplace violence against primary healthcare workers has increased globally. Nevertheless, a comprehensive review summarising the significant results from previous studies has not been published. Thus, this systematic review was conducted to collect and analyse recent evidence from previous workplace violence studies in primary healthcare settings. Eligible articles published in 2013–2023 were searched from the Web of Science, Scopus, and PubMed literature databases. Of 23 included studies, 16 were quantitative, four were qualitative, and three were mixed method. The extracted information was analysed and grouped into four main themes: prevalence and typology, predisposing factors, implications, and coping mechanisms or preventive measures. The prevalence of violence ranged from 45.6% to 90%. The most commonly reported form of violence was verbal abuse (46.9–90.3%), while the least commonly reported was sexual assault (2–17%). Most primary healthcare workers were at higher risk of patient- and family-perpetrated violence (Type II). Three sub-themes of predisposing factors were identified: individual factors (victims’ and perpetrators’ characteristics), community or geographical factors, and workplace factors. There were considerable negative consequences of violence on both the victims and organisations. Under-reporting remained the key issue, which was mainly due to the negative perception of the effectiveness of existing workplace policies for managing violence. Workplace violence is a complex issue that indicates a need for more serious consideration of a resolution on par with that in other healthcare settings. Several research gaps and limitations require additional rigorous analytical and interventional research. Information pertaining to violent events must be comprehensively collected to delineate the complete scope of the issue and formulate prevention strategies based on potentially modifiable risk factors to minimise the negative implications caused by workplace violence.

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Introduction

Events where healthcare workers (HCWs) are attacked, threatened, or abused during work-related situations and that present a direct or indirect threat to their security and well-being are referred to as workplace violence (WPV) [ 1 ]. Violence in the health sector has increased over the last decade and is a primary global concern [ 2 ]. Recent statistical data demonstrated that HCWs were five times more likely to experience violence than workers in other sectors and are involved in 73% of all nonfatal violent work incidents [ 3 ]. The experience of WPV is linked to reduced quality of life and negative psychological implications, such as low self-esteem, increased anxiety, and stress [ 4 , 5 , 6 ]. WPV is often linked to poor work performance caused by lower job satisfaction, higher absenteeism, and reduced worker retention [ 7 , 8 ], which may disrupt patient care quality and other healthcare service productivity [ 9 ]. Decision-makers and academics worldwide now recognise the seriousness of WPV in the health sector, which has been extensively examined in tertiary settings, particularly emergency and psychiatric departments. Nonetheless, understanding of WPV in primary healthcare (PHC) settings is minimal.

The modern health system has experienced a fundamental shift in delivery systems while moving towards universal health coverage and Sustainable Development Goals (SDGs) [ 7 ]. Despite the focus on tertiary-level individual disease management, the healthcare system recently moved towards empowering primary-level patient and community health needs [ 10 ]. Robust PHC system delivery provides deinstitutionalised patient care, which includes health promotion, acute disease management, rehabilitation, and palliative services, via primary health units in the community, which are referred to with different terms across countries, such as family health units, family medicine and community centres, and outpatient physician clinics [ 11 , 12 , 13 ]. In developing and developed countries, PHC services are associated with improved accessibility, improved health conditions, reduced hospitalisation rates, and fewer emergency department visits [ 14 ]. The backbone of this health system delivery is a PHC team of family physicians, physician assistants, nurses, laboratory technicians, pharmacists, social workers, administrative staff, auxiliaries, and community workers [ 15 ].

Nevertheless, the nature of PHC service, which delivers essential services to the community, requires direct interaction with patients and family members, thus increasing the likelihood of experiencing violent behaviour [ 10 ]. Understaffing occurs mainly due to the lack of comprehensive national data that could offer a complete view of the PHC workforce constitution and distribution, which results in increased responsibilities and compromised patient communication [ 15 ]. Considering the current worldwide employment patterns, a shortage of approximately 14.5 million health workers in 2030 is anticipated based on the threshold of human resource needs related to the SDG health targets [ 16 ]. Other challenges at the PHC level recently have also been addressed, including long waiting times, dissatisfaction with referral systems, high burnout rates, and limited accessibility in rural areas, which exacerbate existing WPV issues [ 14 ].

As PHC system quality relies entirely on its workers, the issue of WPV requires more attention. WPV issues must be examined separately between PHC and other clinical settings to support an effective violence prevention strategy for PHC, given that the violence characteristics and other relevant factors can vary by facility type. In addition, PHC workers also have distinct services, work tasks, and work environments [ 11 ]. Since the Alma-Ata Declaration of 1978, interest in conducting empirical studies investigating WPV in the PHC setting has increased worldwide [ 17 ]. Nevertheless, a comprehensive systematic review summarising the results from previous studies has never been published. Understanding this issue among workers who serve under a robust PHC system would be equally essential and requires attention to critical dimensions on par with WPV incidents in other clinical settings, especially hospitals. Therefore, this preliminary systematic review of WPV against the PHC workforce analysed and summarised the current information, including the WPV prevalence, predisposing factors, implications, and preventive measures in previous research.

Literature sources

This systematic review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 review protocol [ 18 ]. A comprehensive database search of the Web of Science, Scopus, and PubMed databases was conducted in February 2023 using key terms related to WPV (“violence”, “harassment”, “abuse”, “conflict”, “confrontation”, and “assault”), workplace setting (“primary healthcare”, “primary care”, “community unit”, “family care”, “general practice”), and victims (“healthcare personnel”, “healthcare provider”, “medical staff”, “healthcare worker”). The keywords were combined using advanced field code searching (TITLE–ABS–KEY), phrase searching, truncation, and the Boolean operators “OR” and “AND”.

Eligibility criteria

All selected studies were original articles written in English and published within the last 10 years (2013–2023) on optimal sources or current literature. The articles were selected based on the following criteria:

Inclusion criteria

Described all violence typology (Types I–IV) and its form (verbal abuse, physical assault, physical threat, racism, bullying, or sexual assault);

The topic of interest concerned every category of PHC personnel (family doctor, general practitioner, nurse, pharmacist, administrative staff).

Exclusion criteria

The violence occurred in a tertiary or secondary setting (during training/industrial attachment at a hospital);

Case reports or series, and technical notes.

Study selection and data extraction

All research team members were involved in screening the titles and abstracts of all articles according to the inclusion and exclusion criteria. All potentially eligible articles were retained to evaluate the full text, which was conducted interchangeably by two teams of four members. Differences in opinion were resolved with the research team leader’s input. Before the data extraction and analysis, the methodological quality of the finalised article was assessed using the Mixed-Methods Appraisal Tool (MMAT). Based on the outcomes of interest, the information obtained from the included articles was compiled in Excel and grouped into the following categories: (i) prevalence, typology, and form of violence, (ii) predisposing factors, (iii) implications, and (iv) preventive measures. Figure 1 depicts the article selection process flow.

PRISMA flow diagram

General characteristics of the studies

Forty-three articles were potentially eligible for further consideration, but only 23 articles provided information that answered the research questions (Table 1 ) [ 13 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 ]. The studies mainly covered 16 countries across Asia, Europe, and North and South America, thus providing good ethnic or cultural background diversity. All included articles were observational studies. Sixteen studies were quantitative descriptive studies conducted through self-administered surveys using different validated local versions of WPV study tools (response rate: 59–94.47%). Four qualitative studies collected data through in-depth interviews and focus group discussions. The remaining studies were mixed-method studies that combined quantitative and qualitative research elements. Of the 23 studies, 15 involved various categories of healthcare personnel, seven involved primary clinicians, and one involved pharmacist.

Prevalence, typology, and form of violence

14 studies focused on the prevalence of patient- or family-perpetrated violence (Type II), three studies focused on co-worker-perpetrated violence (Type III), while six studies reported on both type II and III violence (Table 2 ). Evidence of domestic- and crime-type violence (Types I and IV) was not found in the literature. In most studies, the primary outcome was determined based on recall incidents over the previous 12 months. The reported prevalence of violence against was 45.6–90%. The incidence rate of verbal abuse was 46.9–90.3%, which rendered it the most commonly identified form of violence, followed by threats or assault (13–44%), bullying (19–27%), physical assault (15.9–20.6%), and sexual harassment (2–17%). The reported prevalence of violence against doctors was 14.0–73.0%, followed by that against nurses (6.0–48.5%), pharmacists (61.8%), and others (from 40% to < 5%). Patients and their families were the main perpetrators of violence, followed by co-workers or supervisors (Table 2 ).

Predisposing factors of WPV

Victims’ personal characteristics

Several socio-demographic factors were identified as predictors of WPV. Male gender and female gender were associated with risk of physical violence [ 21 , 22 , 23 ] and non-physical violence [ 12 , 19 , 24 , 32 , 35 , 39 ], respectively. Nevertheless, a specific form of non-physical violence, such as coercion, was also reported less frequently among women [ 34 ]. A minority group of HCWs with individual sexual identities perceived a severe form of intra-profession violence, such as threats to their licenses [ 24 ]. Being young presented a higher risk for violence, especially sexual harassment, and was frequently complicated by physical injury [ 23 , 27 , 34 ]. A personality trait study demonstrated a significant association between aggression incidents with “reserved” and “careless” personality types [ 20 ]. Regarding professional background, medical workers were more vulnerable to physical violence compared to non-medical workers [ 12 , 22 , 34 ]. Nurses faced a higher risk of WPV than others [ 19 , 23 , 27 , 37 ]. Nevertheless, non-medical staff were also vulnerable to physical violence [ 35 ]. Due to less work experience, certain HCWs were identified as vulnerable to violence [ 22 , 26 , 35 ]. Furthermore, violent clinic incidents could occur due to poor professional–client relationships triggered by workers’ attitudes, such as a lack of communication and problem-solving skills [ 25 , 26 ] (Table 3 ).

Perpetrators’ personal characteristics

Patients and their family members mainly triggered WPV, and some exhibited aggressive behaviours, such as psychiatric disorders or drug influence [ 20 , 23 , 28 ]. Female patients in a particular age group were noted as being at risk of causing both physical and non-physical violence [ 34 ]. WPV was also prevalent in clinics, which was attributable to poor patient–professional relationships triggered by the perpetrator’s inappropriate attitude, such as being excessively demanding, or when clients did not fully understand the role of HCWs or used PHC services for malingering [ 25 , 26 , 31 ] (Table 3 ).

Community/Geographical factors

We identified the role of the local community, where WPV was prevalent among HCWs who served at PHC facilities in drug trafficking areas [ 27 ] and that were surrounded by a population of lower socio-economic status [ 28 ]. Furthermore, WPV was increased in clinics in urban and larger districts, which have a lower HCW density per a given population compared to the national threshold of human resource requirement [ 29 , 32 , 39 ], whereas WPV reduced in rural areas, where medical service was perceived more accessible due to lower population density [ 39 ] (Table 3 ).

Workplace factors

The operational service, healthcare system delivery, and organisational factors were identified as the three major sub-themes of work-related predictors of WPV. Specific operational services increased the likelihood of WPV, for example, during home visit activities, handling preschool students, dealing with clients at the counter, and triaging emergency cases [ 27 , 36 , 37 , 38 , 39 ]. WPV was more prevalent if the service was delivered by HCWs who worked extra hours with multiple shifts, particularly during the evening and night shifts [ 30 , 36 , 37 , 39 ]. HCWs who worked in clinics with poor healthcare delivery systems due to ineffective appointment systems, uncertainty of service or waiting times, and inadequate staffing [ 25 , 26 , 27 , 31 , 33 , 36 , 37 ] faced higher potential exposure to aggressive events compared to those working in clinics with better systems. WPV was also linked to a lack of organisational support, mainly in fulfilling workers’ needs, such as providing sufficient human resources, capital, and on-job training, or equal pay schedule and job task distribution, or ensuring a safety climate and clear policy for WPV management [ 22 , 26 , 27 , 29 , 30 , 33 , 35 , 36 , 37 ]. We also determined that the lack of a multidisciplinary work team and devalued family medicine speciality by other specialists caused many HCWs to remain in poor intra- or inter-profession relationships and be vulnerable to co-worker-perpetrated incidents in PHC settings [ 24 , 26 , 33 , 39 ] (Table 3 ).

Effects of WPV

The most frequently reported implications by the victims of WPV involved their professional life, where most studies mentioned reduced performance, absenteeism, the decision to change practice, and feeling dissatisfied or overlooked in their roles. This was followed by poor psychological well-being (anxiety, stress, or burnout), and emotional effects (feeling guilty, ashamed, and punished) [ 13 , 21 , 24 , 30 , 31 , 34 , 35 , 38 ]. Three studies reported on physical injuries [ 13 , 21 , 34 ], while only one study reported a deficit in victims’ cognitive function, which might lead to near-miss events involving patients’ safety elements, and social function defects, where some victims refused to deal with patients in the future [ 31 ]. Only one study reported the WPV implication of being environmentally damaged [ 34 ] (Table 3 ).

Victims’ coping mechanisms and organisational interventions

The coping strategies adopted by HCWs varied depending on the timing of the violent events. Safety approaches such as carrying a personal alarm, bearing a chevron, and other similar steps were used, especially by female HCWs, as a proactive coping measure against potentially hazardous incidents [ 21 ]. “During an aggressive situation triggered by patients, certain workers used non-technical skills, which included leadership, task management, situational awareness, and decision-making [ 31 ]. During inter-professional conflict (physician–nurse conflict), the most predominant conflict resolution styles were compromise and avoiding, followed by accommodating, collaborating, and competing [ 40 ]. Avoiding conflict resolution was most common among nurses, whereas compromise was most common among doctors [ 40 ]. Post-violent event, most HCWs chose to take no action, while some utilised a formal reporting channel either via their supervisors, higher managers, police officers, or legal prosecution. Some HCWs also utilised informal channels by sharing problems with their social network members, such as colleagues, friends, or family members [ 13 , 30 , 36 , 39 ]. Only one article mentioned health managers’ organisational preventive interventions, which included internal workplace rotation, staff replacement, and writing formal explanation letters [ 34 ] (Table 3 ).

We analysed the global prevalence and other vital information on WPV against HCWs who serve in the PHC setting. We identified noteworthy findings not reported in earlier systematic reviews and meta-analyses, where the healthcare setting type was not taken into primary consideration [ 2 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 ].

Determining a definite judgement on WPV incidence against PHC workers worldwide is challenging, given that several of the studies selected for analysis were conducted using convenience sampling with low response rates. Nevertheless, notable results were obtained. WPV prevalence varied significantly, where the highest prevalence was reported in Germany (91%) and the lowest was reported in China (14%). Based on the average 1-year prevalence rate of WPV, we determined that the European and American regions had a greater WPV prevalence than others, which was consistent with a recent meta-analysis [ 50 ]. One reason might be the more effective reporting system in these regions, which facilitate more reports through a formal channel, as mentioned previously [ 51 ]. Contrastingly, opposite circumstances might cause WPV events to go unreported in other parts of the world. We also revealed a need for more evidence on WPV in the PHC context in Southeast–East Asia and African regions. The number of peer-reviewed articles from these regions could have been much higher, which inferred that the issue in these continents still requires resolution.

Various incidents of violence, including those of a criminal or domestic nature, commonly occur in the tertiary setting. The Healthcare Crime Survey by the International Association for Healthcare Security and Safety (IAHSS) reported that within a 10-year period (2010–2022), the number of hospital workers who experienced ten types of crime-related events in the workplace, such as murder, rape, robbery, burglary, theft (Type I), increased by the year [ 52 ]. In contrast, most studies conducted in PHC settings focused on providing more evidence of Type II violence, whereby other types (I and IV) were rarely detected. The scarcity of evidence does not necessarily indicate that PHC workers are not vulnerable to criminal or domestic violence. Rather, it implies that WPV is still not entirely explored in the PHC setting, which undermines the establishment of a comprehensive violence prevention strategy that encompasses all types of violence [ 53 ].

Hospital-based studies reported diverse forms of violence, where both physical and verbal violence were dominant [ 47 , 54 , 55 , 56 ]. Violence as a whole and physical violence in particular tend to occur in nursing homes and certain hospital departments, such as the psychiatric department, emergency rooms, and geriatric nursing units [ 47 , 55 , 56 ]. Volatile individuals with serious medical conditions or psychiatric issues or who are under the influence of drugs or alcohol were mainly responsible for this severe physical aggression [ 53 ]. Similar to previous hospital-based studies, diverse forms of violence (verbal abuse, physical attacks, bullying, sexual-based violence, psychological abuse) were recorded in PHC settings. Despite this, most of the studies determined that the perpetrators’ disparate characteristics resulted in more frequent documentation of verbal violence than physical violence. Dissatisfied patients or family members were more likely to perpetrate greater incidents of verbal abuse [ 25 , 26 , 31 ], either due to their medical conditions or dissatisfaction with the services provided [ 30 ]. This noteworthy discovery prompted new ideas, indicating that variance in the form of violence might also be determined by the healthcare setting role [ 57 ].

Our findings demonstrated that sexual-based violence was the least frequently documented form of violence, with a regional differences pattern indicating relatively lower sexual-based violence reporting in the Middle Eastern region [ 13 , 30 ]. This result contrasted with a previous systematic review of African countries that reported that sexual-based violence was one of the dominant forms of WPV. This lower incidence was possibly due to under-reporting by female employees who were reluctant to report sexual harassment aggravated by cultural sensitivities regarding sexual assault exposure [ 58 ]. Such culturally driven decision-making practices are worrying, as they could lead to underestimation of the true extent of the issues and cause more humiliating incidents and the lack of a proper response.

We identified considerable numbers of significant predisposing factors, which were determined via advanced multivariate modelling. Most factors were comparable with that in previous WPV research, especially those related to the victims’ individual socio-demographic and professional backgrounds [ 2 , 41 , 42 ]. Several studies consistently reported that nurses were vulnerable to WPV compared to physicians and others, which was supported by numerous prior systematic studies [ 19 , 23 , 27 , 37 ]. This could be explained by the accessible nature of nurses as healthcare professionals to patients and families [ 50 ]. Furthermore, nurses interact first-hand with clients during treatment, rendering them more likely to become the initial victims of WPV before others. Nevertheless, this result should not necessarily suggest that other professions are not at risk for violence. Due to the shortage of evidence regarding the remaining category of PHC workers, it is impossible to provide a more conclusive and realistic assessment of the above.

The results demonstrated that many PHC clinics were built in community areas with a variety of settings, such as high-density commercial developments in urban or rural areas, resource-limited locations, or areas with a high crime concentration [ 27 , 28 , 29 , 32 , 39 ]. Therefore, an additional new sub-theme under predisposing factors, namely, “community and geographical factors”, was created to include all evidence on the relationship between WPV vulnerability and community social character and geo-spatial factors. Although several hospital-based studies deemed this topic less significant, several studies in the present review that examined the relationship between geographic information and the surrounding population characteristics with WPV reported valuable and constructive information for PHC prevention framework efforts.

In general, we identified a similar correlation between work-related factors and WPV as in hospital-based studies, particularly on healthcare system delivery and organisational support elements [ 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 ]. Nonetheless, the evidence on operational service was vastly distinct. As several PHC services are expanded outside facilities, there is increased potential for violence against HCWs when they provide out of clinic services, for example, during home visits and school health services [ 21 , 37 , 39 ]. Such situations might require more comprehensive prevention measures compared to violent events that occur within health facilities. Unfortunately, the available literature that describes and assesses the safety elements of HCWs in PHC settings mainly focused on services inside the health facilities, indicating that WPV prevention and management should be expanded to outdoor services [ 21 ].

The studies included in this review comprehensively described the observed implications on WPV victims in PHC settings. Nonetheless, additional vital information on the adverse effects on organisational elements remains lacking, especially regarding the quality of patient care involving potential near-miss events, negligence, and reduced safety elements [ 31 ]. The economic effect is another important aspect that requires further consideration. Recent financial expense data were only available from hospital-based research. A systematic review revealed that WPV events resulting in 3757 days of absence at one hospital over 1–3 years involved a cost exceeding USD 1.3 billion that was mainly due to reduced productivity [ 43 ].

The magnitude of under-reporting among HCWs was concerning, as most respondents admitted that they declined to report WPV cases through formal reporting channels, such as via electronic notification systems, supervisors, or police officers [ 13 , 30 , 36 , 39 ]. Although the included articles mentioned several impediments to reporting, such as fear of retaliation, fear of missing one’s job, and feelings of regret and humiliation, [ 13 , 30 , 36 ], the main reason for under-reporting was a lack of trust in existing WPV preventive institutional policies. Most respondents perceived that reporting the case would not lead to positive changes and were dissatisfied with how the policy was administered [ 13 , 30 ]. Despite much evidence on proactive coping mechanisms utilised by the HCWs, which were either behaviour change technique or conflict resolution style, we did not obtain additional crucial information on existing regional WPV policies or specific intervention frameworks at institutional level [ 31 , 40 ]. Furthermore, reports of the mediating functions of federal- or state-level central funding and legal acts or regulatory support in establishing effective regional violence policies were also absent in primary settings. Further discussion in this area is crucial as significant federal or state government support would improve HCWs’ perceptions of regional prevention program and would potentially reduce the rate of violence against HCWs.

Opportunities for future research

Only a few studies discussing WPV in the PHC setting have been published over the 10 years covered in this review. Local researchers and stakeholders should define and prioritise important areas of study. Given the heterogeneity of the forms of violence, it might be advantageous to conduct additional observational research in the future to describe the situation and investigate the associations between the rate of violence and its multiple predictors using Poisson regression analysis [ 59 ]. At the present stage, quasi-experimental evidence is ambitious. Therefore, more longitudinal studies are required to evaluate the efficacy of any newly introduced violence prevention and management measures designed in primary healthcare settings [ 60 ].

A comprehensive investigation of WPV occurrences beyond Type II violence is required to accurately reflect the breadth of the issue and focus on prevention efforts. In the present study, the association pattern between the consequences of WPV for specific perpetrators was not investigated as in prior research due to the scarcity of evidence on Type I, III, and IV violence. For example, Nowrouzi-Kia et al. revealed that the victims of inter-professional perpetuation (Type III) experienced more severe consequences involving their professional life (low job satisfaction, increased intention to quit) than those who experienced patient or family-perpetrated violence (Type II), which involved psychological and emotional changes [ 61 , 62 ]. In addition, the study scope must also be expanded to include assaults against both healthcare personnel and patients in primary settings. A hospital-based investigation by Staggs 2015 revealed a significant association between the number of staff at psychiatric patient units and the frequency of violent incidents. Surprisingly, this rigorous investigation determined that higher levels of hospital staffing of registered nurses were associated with a higher assault rate against hospital staff and a lower assault rate against patients [ 63 ].

Despite universal exposure to WPV, the incidence rates and types of violence vary between regions. Thus, the primary investigation focus should be tailored to specific violence issues in a particular setting. Our results highlighted the need for further research into strengthening WPV policy, particularly concerning the reporting systems in regions outside European and American countries. Compared to other regions, local academicians in Southeast Asia and Africa are encouraged to increase their efforts to perform more epidemiological WPV studies in the future to better understand the WPV issue. It is crucial to identify the underlying causes of low prevalence of sexual harassment, particularly in the Middle East, which might be caused by under-reporting influenced by culture or gender bias. Although it is asserted that sexual-based violence is likely to occur commonly in cultures that foster beliefs of perceived male superiority and female social and cultural inferiority, the reported prevalence rate of such violence in certain regions [ 64 ], particularly in the Middle East, was low, possibly due to under-reporting. Thus, to address this persistent problem, the existing reporting mechanisms must be improved and sexual-based violence should be distinguished from other forms of violence to encourage more case reporting. Simultaneously, sexual-based violence should also be defined differently across countries and various social and cultural contexts to reduce impediments to reporting [ 64 ].

In existing studies, the main focus of work-related predisposing factors is based on superficial situational analysis, which is identified using the local version of the standard WPV instrument tool via a quantitative approach. Nevertheless, this weak evidence would not support a more effective preventive WPV framework. This issue should be addressed in more depth and involve psychosocial workplace elements that cover interpersonal interactions at work and individual work and its effects on employees, organisational conditions, and culture. Qualitative investigations that complement and contextualise quantitative findings is one means of obtaining a greater understanding and more viewpoints.

Implications of WPV policies

The results had major effects on WPV prevention and intervention policies in the PHC setting. The results highlighted the importance of enacting supportive organisational conditions, such as providing adequate staffing, adjusting working hours to acceptable shifts, or developing education and training programmes. As part of a holistic solution to violence, training programmes should focus on recognising early indicators of possible violence, assertiveness approaches, redirection strategies, and patient management protocols to mitigate negative effects on physical, psychological, and professional well-being. While previous WPV studies focused more on physical violence and inspired intervention efforts in many organisational settings, our results necessitate attention on non-physical forms of violence, which include verbal harassment, sexual misconduct, and intimidation. The increased potential of domestic- and crime-type violence in PHC settings necessitates expanded prevention programmes that address patients, visitors, healthcare providers, the surrounding community, and the general population.

Our results demonstrated that under-reporting of violent events remains a key issue, which is attributable to a lack of standardised WPV policies in many PHC settings. The initial action that should be implemented in accordance with human resource policy is to establish a system that renders it mandatory for victims, witnesses, and supervisors to report known instances of violence to HCWs. Unnecessary and redundant reporting processes can be reduced by an advanced system for rapidly recording WPV incidents, such as in hospital settings, where WPV is reported via a centralised electronic system. However, healthcare professional and organisational advocacy remains necessary. These parties must promote the value of routine procedures to ask employees about their encounters with patient violence and to foster an environment, where the organisation encourages reporting of violent incidents.

In addition to insufficient reporting, it is crucial to draw attention to the manner in which violent incident investigations are currently conducted in most workplaces. In reality, the incident reporting focuses on the violence itself and its superficial or circumstantial analysis, as opposed to an in-depth examination of the causes of violence, which are due to workplace psychosocial hazards, poor clinic environment, or poor customer service. For example, if any patient-inflicted violence occurred as a result of unsatisfactory conditions caused by poor clinic service, such as unnecessary delay, the tendency is to report on the perpetrator’s behaviour or on the violence itself rather than the unmet health service provision issue. In the long-term, however, the findings of such an investigation would not support the development of a violence prevention and management guideline, as it focuses on addressing aggressive patients rather than enhancing clinic service quality. Therefore, the relevant authorities should formulate a proper plan to improve the existing reporting and investigations mechanism to ensure that it is more comprehensive, structured, and detailed, either by providing proper training for the investigators or conducting institutional-level routine root cause analysis discussions, so that the violence hazard risk assessment can be framed effectively to resolve the antecedent factors in the future.

Nonetheless, there remains much room for primary-level improvement in WPV awareness and abilities. Reports on the mediating roles of federal- and state-level central funding and regulatory support for efficient local WPV policies at primary level have not been found. Therefore, more studies will be necessary to fill these gaps and concentrate on examining the relationship between regional WPV policies and national support. Possibly, more central funding and state regulation following new positive results can be made available to aid local preventive programs. A strong central financial support is essential to support regional preventive programmes, such as employing security guards, enhancing the physical security of health facilities buildings, and research grants. Awadalla and Roughton strongly suggested that adequate national-level financial support is one of the essential components of successful regional policies that would alter HCW perceptions [ 65 ]. In terms of law and regulation, for example, Ferris and Murphy firmly supported the role of the Occupational Safety and Health Act (OSHA) via the issuance of the “Enforcement Procedures for Investigating or Inspecting Workplace Violence” instructions to institutional-level officers as one of the essential components of local WPV prevention strategies [ 66 ].

Study strength and limitations

The present study is a preliminary systematic review that explored evidence of WPV against all PHC workers in empirical studies worldwide. The breadth of the review was achieved by incorporating numerous peer-reviewed high-quality published studies, which enabled us to derive a solid conclusion. The approach relied on the authors’ prior knowledge of the study topic, the standard review technique, and specialised keywords.

It is also important to emphasise several potential limitations. First, recall bias was introduced in most studies as the authors used self-reporting to recall previous incidents either up to 12 months prior or after a lifetime. As most of the included studies involved small sample sizes, a few studies with low response rates restricted the generalisability of the findings. Several studies were descriptive and were cross-sectional; consequently, extra caution should be applied when making inferences pertaining to the risk factor interactions with violence. Variability in the instrument used, data collection and analysis methods, the notion of violence, and the general study objective might account for the heterogeneity across studies, which limited comparisons across studies. As PHC health system delivery between countries is described by different terms or names or might be identified by names besides those used in the present study, studies that use such terms might have been overlooked during the database search.

WPV in the PHC setting is a common and growing issue worldwide. Many PHC workers reported experiencing violence in recent years, strongly suggesting that violence is a well-recognised psychosocial hazard in PHC comparable to hospital settings. HCWs are highly susceptible to violence perpetrated by patients or their families, which results in considerable negative consequences. With various predisposing factors, this complex issue indicates a need for more serious consideration of a resolution on par with that in the tertiary setting. Several research gaps and limitations necessitate additional rigorous analytical and interventional research in the future. Information on violent events must be comprehensively collected to delineate the complete scope of the issue and formulate prevention strategies based on potentially modifiable risk factors. Thus, a new interventions framework to mitigate violent events and control their negative implications can be established. The results presented here were derived from literature on diverse cultures worldwide, and, therefore, can be used as a data reference for policymakers and academicians for future opportunities in the healthcare system field.

Availability of data and materials

All data generated or analysed during this study are included in this published article.

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Acknowledgements

We are grateful to the Dean of the Universiti Kebangsaan Malaysia (UKM) School of Medicine for granting permission to publish this work. We also thank the head of the UKM Community Health Department and its staff for their excellent cooperation during this study.

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Yusoff, H.M., Ahmad, H., Ismail, H. et al. Contemporary evidence of workplace violence against the primary healthcare workforce worldwide: a systematic review. Hum Resour Health 21 , 82 (2023). https://doi.org/10.1186/s12960-023-00868-8

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Workplace violence: A nurse tells her story

It’s not okay, and it is a big deal..

By Lillee Gelinas, MSN, RN, CPPS, FAAN

“Personal boundary violation is not part of our job description. That statement is powerful because boundary setting is a part of our job. I believe that if we fail to establish and maintain personal boundaries, then we’ve compromised the safe and therapeutic environment in which we’re able to truly care and advocate for our patients. We have an obligation to stand up against that which is unsafe, and I believe that ending nurse abuse is critical.”

That’s how my conversation began with Karen*, an emergency department (ED) nurse who recently experienced on-the-job violence. I promised her that her story is not over. Nor is the story of thousands of nurses who have been harmed by patients while at work. The importance of the American Nurses Association (ANA) #EndNurseAbuse movement became very real for me the day I spoke with Karen.

Out of the blue

Karen worked as a nurse extern for 4 years, volunteering in the ED and in other settings to get real-world experience before becoming an RN. She’s the type of nurse I try to hire as frequently as I can because she’s enthusiastic about the profession, worked hard to become a nurse, and strives to be the best she can be. But this shining star in the nursing universe has lost some of the glow after her experience.

Out of the blue, a patient hit her hard in the jaw while she was trying to perform an electrocardiogram. The violence was so unexpected that she immediately left the bedside in disbelief. Karen says she was “overwhelmed by my feelings of being hurt.”

Karen says “it’s the aftermath” that’s so important. Being angry with the patient at first is easy, but Karen says, “I can’t stress enough how much this event hurt my feelings, and I’m still not fully over it months later.” The physical injury may have healed, but the emotional injury still stings.

Our role as nurses is to establish a trusting relationship with patients, and when that relationship is compromised after an assault, we may be left with a lasting fear for our personal safety. When you walk into a patient’s room, you enter with a sense of confidence. But this type of event jars that confidence. Getting back to the level of how it felt pre-assault takes a long time and may require long-term support systems that healthcare facilities may not yet have in place.

In addition to ANA’s call to action ( read the American Nurse Today article ), The Joint Commission issued a Sentinel Event Alert to bring more awareness to the seriousness of the issue and outline seven actions every healthcare setting must implement to create safer workplaces. ( Read the alert .)

According to the Occupational Safety and Health Administration, 75% of nearly 25,000 workplace assaults reported annually occur in healthcare and social service settings. But we know that number is grossly underreported because only about 30% of nurses report violent incidents. ANA President Pam Cipriano, PhD, RN, NEA-BC, FAAN, states the urgency best: “Abuse is not part of anyone’s job and has no place in healthcare settings. Time’s up for employers who don’t take swift and meaningful action to make the workplace safe for nurses.”

I agree. And Karen agrees. We add the following: It’s not okay, and it is a really big deal.

Lillee Gelinas, MSN, RN, CPPS, FAAN Editor-in-Chief [email protected]

*Name has been changed.

2 Comments .

I was assaulted in 2015 while working inpatient behavioral health. It occurred in an area where there had been previous problems. In order to discredit me and a co-worker who came to my aid, we were fired. I was never given an opportunity to tell my story. I was blamed for the incident and reported to my Board of Nursing. My employer presented falsified documentation and lied. I spent $10,000 and over a year fighting for keep my license (which I eventually did). I suffered a head and neck injury which has caused me permanent difficulty. My four top front teeth and my glasses were broken. Compared to the emotional hell I went through because of my employer and the Board’s “investigation,” my injuries were nothing. Oh, the Board’s investigator had just started her position and was a former associate of my employer. I live in a small state. My employer has a lot of clout and there is little protection for workers in any field. I never felt to alone.

Thank you for the editorial. A similar incident occurred early in my practice while I was performing a bedside cardiac assessment. Shock is probably the best way to describe my initial reaction. I took a step back, rubbed my jaw in disbelief and actually wondered out loud, “Why would you do that?” Many years have come and gone and I no longer remember the answer, as if it could possibly have made any sense. I don’t remember being angry, I felt, if anything a bit foolish that a 100 pound little lady well into her 80s, who was so sweet earlier in the shift, took me off guard, and hit me so squarely with such force. It did, however, make me realize that it was important to be vigilant in assessing the potential for physical violence at ALL times – even from those that might not fit the standard profile. Looking back and having heard many similar stories from my colleagues that resulted in more significant injury (both physical and emotional), I realize that I was fairly lucky to learn such a valuable lesson for no more cost than both a bruised ego and jaw.

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J Occup Health
v.63(1); Jan-Dec 2021

Workplace violence in nursing: A concept analysis

Mahmoud mustafa al‐qadi.

1 University of Connecticut School of Nursing, Storrs CT, USA

To clarify the concept of workplace violence in nursing and propose an operational definition of the concept.

The review method used was Walker and Avant's eight‐step method.

Identification of the key attributes, antecedents, consequences, and empirical referents of the concept resulted in an operational definition of the concept. The proposed operational definition identifies workplace violence experienced by nurses as any act or threat of verbal or physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the worksite with the intention of abusing or injuring the target.

Conclusions

Developing insights into the concept will assist in the design of new research scales that can effectively measure the underlying issues, provide a framework that facilitates nursing interventions, and improve the validity of future studies.

1. INTRODUCTION

Violence against nurses in their workplace is a major global problem that has received increased attention in recent years. 1 Approximately 25% of registered nurses report being physically assaulted by a patient or family member, while over 50% reported exposure to verbal abuse or bullying. 2 Nurses, who are primarily responsible for providing life‐saving care to patients are victimized at a significantly higher rate than other health‐care professionals, 3 and it is estimated that workplace violence causes 17.2% of nurses to leave their job every year. 4

In the United States, workplace violence increased by 23% to become the second most common fatal event in 2016, 5 accounting for 1.7 million nonfatal assaults and 900 workplace homicides each year. 6 In addition, there has been an increase in workplace violence in US hospitals, increasing from 2 events per 100 beds in 2012 to 2.8 events per 100 beds in 2015. 5 In 2016, hospitals and health‐care facilities invested $1.1 billion in security and training to prevent violence and had to spend $429 million on insurance, staffing, and medical care due to workplace violence. 7

The absence of a universal definition for workplace violence within health‐care settings and the ambiguity about what constitutes a violent event currently compromise research on the prevalence and magnitude of this phenomenon. Furthermore, varying definitions and unclear criteria may lead to nurses failing to identify their experience as a form of workplace violence, which prevents it from being reported.

Applying the concept analysis method to better understand the violence to which nursing staff are subjected in the workplace will demystify the factors at play, with the underlying intention of preventing such violence. Using concept analysis to address the theoretical background to such violence will aid the development of an operational definition that increases the validity of the concept. This study aims to elucidate the nature and form of workplace violence experienced by nurses and develop a precise operational definition of the concept in conjunction with a set of criteria that can be used to identify the phenomenon.

2. BACKGROUND AND SIGNIFICANCE

Violence is defined by the World Health Organization in the World Report on Violence and Health as “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either result in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation.” 8 This definition emphasizes that a person or group must intend to use force or power against another person or group for an act to be classified as violent.

University of Iowa Injury Prevention Research Center 9 classified workplace violence into four basic types: Type I, Type II, Type III, and Type IV. Type I involves “criminal intent.” In this type of workplace violence, “individuals with criminal intent have no relationship to the business or its employees.” Type II involves a customer, client, or patient. In this type, an “individual has a relationship with the business and becomes violent while receiving services.” Type III involves a “worker‐on‐worker” relationship and includes “employees who attack or threaten another employee.” Type IV involves personal relationships. It includes “individuals who have interpersonal relationships with the intended target but no relationship to the business.” Types II and III are the most common in the health‐care industry.

Verbal abuse is the most common type of abuse directed toward nurses in health‐care settings. It is three times more likely to occur than physical violence. 10 In one study, 82% of nurses reported verbal abuse as being the most common type of abuse, 11 while 63.9% of nurses had been subjected to some form of verbal abuse by patients. 12 Behaviors such as swearing, shouting, or cursing have been identified as the most common form of verbal abuse 13 and have also been reported as the most violent type of verbal aggression. 14 Data collected from 349 nurses indicated that 79.5% had been subjected to verbal violence, while 28.6% had been exposed to physical violence. 15 Physical abuse often co‐exists with verbal abuse, suggesting that the latter might act as a predictor for potential physical abuse. 10 Of these behaviors, “being pushed or hit” has been identified as the most common type of physical abuse, 13 while the use of lethal weapons has been shown to occur mostly during night hours. 16

Many studies indicate that violence against nurses is underreported. 17 Emergency departments have been highlighted as locations where violent incidents are likely to be significantly underreported; the reasons given are: (a) nurses are not satisfied with how their previous violent events were handled as some cases were not treated with appropriate seriousness 15 ; (b) nurses’ belief that violence is part of the job 18 ; (c) nurses are discouraged from reporting such events as even if they do, there are no policies guaranteeing justice 19 ; (d) insufficient time 20 ; (e) nurses' belief that no harm was inflicted on them and they can handle it 21 ; and (f) nurses' ability to defend themselves by changing how they treat that particular patient. 12

Previous studies have reported that nurses consider the absence of assertive legislation, poor management of violent incidents, a lack of resources, such as insufficient equipment, medical errors, and a poor environment to contribute significantly to workplace violence. 22 Also, a lack of proper communication skills, lack of experience, lack of quality care, and shortage of nursing staff can also lead to workplace violence. 15 The shortage of nursing staff is a pertinent issue that has affected the majority of countries. The reviewed literature underlines how health‐care settings have witnessed high turnover rates among nurses. 23

The experience of workplace violence has physical, personal, emotional, professional, and organizational consequences that impact individuals and organizations. We argue that a definition to aid the recognition of workplace violence and the understanding of its attributes, antecedents, and consequences will assist in optimizing recognition and facilitate the formation of strategies to address the problem.

3. CONCEPT ANALYSIS METHOD

This study used Walker and Avant's 24 eight‐step method, which is commonly applied in the nursing context (see Table Table1). 1 ). The concept analysis process helps to validate current nursing understanding, as well as support strategies for nursing interventions. Hence, this approach was utilized to analyze the current understanding of the workplace violence to which nurses are subjected as it offers an interactive process that can facilitate the development of an operational definition of a concept.

Walker and Avant's 24 eight‐step method

4. DATA SOURCES

Walker and Avant 24 suggest that all data sources should be fully utilized to ensure a thorough inventory of the relevant characteristics and variables is compiled. Studies were identified via a search of four key databases: Cumulative Index of Nursing and Allied Health Literature (CINAHL), PubMed, PsycINFO, and Scopus using the following single and/or combined keywords: “nurses”; “nursing”; “nurse”; “violence”; “workplace violence”; “abuse”; and “assault.”

The eligibility of the studies was assessed based on the aims of the concept analysis. The following inclusion criteria were utilized: (a) studies published in peer‐reviewed journals between 2000 and 2020; (b) studies that are relevant to the topic and fit with the content of the analysis; (c) studies that included nurses experience of workplace violence; and (d) studies published in English. Papers were excluded if the study primarily focused on violence against nurses working in mental health settings on the basis that these had different and unique considerations (see Figure 1 ).

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PRISMA diagram of search strategy adapted for use from Moher et al 25

Initially, 383 papers were identified. Once duplicates were removed, the titles and abstracts of the papers were reviewed. This resulted in 227 papers, which were reviewed in full against the inclusion criteria, after which a further 193 papers were excluded. Thus, a total of 34 papers met the inclusion criteria and were included in the concept analysis; see Figure 1 for a Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) flow diagram of the process. 25

The results of the concept analysis are presented according to the eight steps of Walker and Avant's 24 method.

5.1. Select a concept

According to Walker and Avant, 24 before a concept is selected its significance should be scrutinized across a variety of settings. The selected concept should reflect the area of interest addressed in the research question. Workplace violence experienced by nurses is the selected concept for this analysis.

5.2. Purpose of the analysis

The aims of the current analysis were to (a) clarify the concept of workplace violence experienced by nurses by defining its essential attributes, antecedents, consequences, and empirical referents; and (b) propose an operational definition of workplace violence.

5.3. Identifying uses of the concept

Under the next step in Walker and Avant's 24 method, the available literature is searched to outline the primary attributes of the concept and identify how it is used. Reviewing the existing studies generates an evidence base in relation to the essential attributes underpinning the concept; hence, it facilitates and validates the outcomes of the analysis.

5.3.1. Literature definitions

Violence in health care has been defined “as any incidents where the staff are abused, threatened, or assaulted in circumstances relating to their work involving an explicit or implicit challenge to their safety, well‐being, or health.” 26 This definition includes “any threatening statement or behavior which gives a worker reasonable cause to believe they are at risk.” 27 It also encompasses a broad range of behaviors 28 from physical assault or direct violence to nonphysical forms of violence such as verbal abuse and sexual harassment. 29 Workplace violence can be defined as any physical assault, threatening behavior, or verbal abuse that occurs in a work setting. 30

The Center for Disease Control and Prevention, 31 World Health Organization, 32 and Occupational Safety and Health Administration 33 define workplace violence as any act occurring in the workplace with the intention to harm someone physically or psychologically including attacks, verbal abuse, and both sexual and racial harassment. 34 Also, workplace violence is defined as, “Incidents where staff are abused, threatened, or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well‐being, or health.” 31 , 32 , 33

5.4. Defining attributes

The defining attributes are those critical qualities and characteristics that often emerge within a concept. Such attributes differentiate the concept from closely related notions, and elucidate its meaning. The literature review revealed that the three distinguishing qualities of the workplace violence experienced by nursing staff can be classed in distinct categories: (a) working relationship; (b) power and powerlessness; and (c) behavior.

5.4.1. Working relationship

One of the considered attributes is the working relationship, which is one of the contributors to violence against nurses. It involves the relationship between nurses and patients, nurses and the patient's family, physician and nurses, management and nurses, and nurses and other nurses, any of which can trigger violence. 35 Human beings differ in their response to emotions, 36 and dealing with them requires a certain level of discipline.

5.4.2. Power and powerlessness

Power is another defining factor. In any normal working environment, there should be someone superior who guides and directs the normal operations of the day. 37 However, misuse of this power can result in conflicts within the organization. 38 , 39 For example, conflicts tend to arise when multiple people want to wield power or when a superior rule in an unjust manner. Similarly, there may be others within the organization who intend to disempower the one bestowed with power. Such an intention results in organizational politics, which can have serious consequences for workplace performance. 40 Moreover, when members of one gender believe that they should rule over others, this destabilizes the unity within a health facility. In general, unequal power relationships contribute to violence against nurses. 41

5.4.3. Behavior

The final attribute is the behavior of the perpetrator. Behavior is defined as how a person acts or does things, whereby in this context the causative agent of the violence comes from an outside source. It can be in the form of physical or emotional violence. 42

6. CONSTRUCTED CASES

The defining attributes identified within the concept analysis can also be narrowed down through the identification of model, borderline, contrary, illegitimate, and invented cases. 24 The constructed cases facilitate efforts to delineate between the characteristics that represent key attributes and those that do not.

7. MODEL CASE

The model case should be a real example that, ideally, presents all the critical attributes. 24 Sarah went to see Julia, the charge nurse in her unit. Sarah reported that the workload in her assignment was becoming unsafe and unacceptable for practice and quality of care. Julia became defensive saying that Sarah was over‐dramatic and her noncompliance with following policies and procedures in the unit contributed to unsafe practice within the unit. This case is an example containing all the defining attributes of workplace violence: That is, a formal working relationship exists between Sarah and Julia, with Julia in a position of power. Julia's response to verbal abuse and horizontal violence professionally degraded Sarah and is again consistent with workplace violence.

8. BORDERLINE CASE

Borderline cases are those that present some, but not all, of the key attributes associated with the concept. They shed light on ideas related to the main attributes of the concept of interest by providing insights into how often it is misconstrued. 24 John was due for his surgery and was observed continuously pacing throughout the corridor looking very agitated and anxious. Jessica, a nurse, asked him if he was alright. John did not say anything and went back to his room but showed signs of autonomic arousal by continuing pacing throughout the hallway. However, while anxious and agitated, he has not acted abusively toward Jessica (the nurse), and therefore this cannot be considered workplace violence.

9. CONTRARY CASE

A contrary case is one that does not represent the defining attributes of the concept. In addition, it represents attributes that are not features of the concept. 24 A contrary case can give insights into the primary characteristics of the concept by highlighting contrary ideas.

9.1. Antecedents

Walker and Avant 24 describe antecedents as events or incidents that precede the concept's occurrence (see Figure 2 ). These can be defined as the fundamental and underlying factors that initialize violence against nurses. 43 For any form of violence to occur, there must be two parties; one party is the perpetrator, who aims to harm the other party, and the other is the recipient, who is on the receiving end of the act. Other contributors are the internal factors and the external factors.

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Antecedents, empirical referents, attributes, and consequences of workplace violence

9.1.1. Two parties (perpetrators and nurses)

Two parties must be present in order for violence to occur, namely the perpetrator and the recipient. In this study, the recipient is the nurse, while the perpetrator could be a family member of the patient, the patient, management, other nurses, or even a physician.

Nurses are more vulnerable to violence as they communicate directly with patients and their families. 44 Sometimes, physicians use violence to achieve power, maintain their prestige, and abuse nurses to force them to perform better in their handling of not only patients but also the physicians themselves. 12

9.1.2. External factors (policies and workplace environment)

Some policies that are imposed within health‐care settings lead to nurses being subject to stress and can even affect patients negatively. For example, in some instances, nurses are expected to work long hours without rest 45 ; however, increasing the working hours impairs the performance of nurses. Similarly, restricting the visitation hours makes patients’ family members experience distress and resentment. They feel alienated and unvalued by the administration. A stressful situation also arises when patients are involved in painful invasive procedures. 46 All these situations can precipitate violence against nurses. Hence, the physical setting is important when it comes to health care, whereby the accessibility of working instruments and a good working atmosphere play a key role. If there is not enough medicine or if staffing levels are low, both nurses and patients may be negatively affected. The working environment can also discourage patients and even staff from being associated with the health facility as they feel that the quality of services is being compromised. Moreover, there is a lack of well‐structured policies, which contributes significantly to the violence experienced by nurses. 23 The result is conflict among different parties.

9.1.3. Internal factors (perpetrator or recipient characteristics)

Anything that causes stress can serve as a contributor to violence against nurses. These factors are not contributed externally but rather emanate from the thinking of individuals. Some of the causes for such behaviors are substance and drug abuse, feelings of powerlessness, frustration, fear, disorder, mental illness, and others. 44 These can affect the minds of individuals, which in turn impairs individual judgments. A perpetrator can become directly violent toward a recipient if he or she falls into one of the identified categories. The above behaviors are associated with perpetrators, who in this context are generally patients or their relatives. 47 On the other hand, the recipients, who are nurses, may display poor communication and a failure to perform, making them more vulnerable to violence. 22 For example, a nurse who fails to accomplish his or her task is prone to verbal violence from a senior nurse.

9.2. Consequences

Walker and Avant 24 refer to consequences as events or incidents which follow the occurrence of workplace violence. These consequences can be psychological, emotional, physical, organizational, or professional.

9.2.1. Emotional and psychological consequences

The emotional and psychological consequences are largely experienced by nurses, whereby psychological violence is the most common type of abuse reported by nurses in health‐care facilities. 48 They include, but are not limited to, stress, lack of sleep, and anger. Emotional and psychological consequences are more prevalent than physical consequences and represent the highest percentage of experienced consequences. Such consequences eventually affect the quality of work performed as a stressed nurse will not deliver as per the expected standards. 49 Violence also evokes feelings of humiliation, which can lead to an increase in absenteeism. 50

9.2.2. Physical consequences

Physical consequences are the result of an assault on nurses from external sources and include broken bones, headaches, wounds, and other injuries that are associated with physical harassment. 35 Nurses in the health‐care setting have reported being subjected to incidents of physical abuse, including the use of weapons, whereby most of the perpetrators of these violent incidents were patients. 3 Physical attacks on nurses within the health‐care setting have been reported to include lethal weapons, and most of these attacks occur between the afternoon and night time. 16 This is due to the fact that the majority of clinics do not accept patients after 4 PM, and the managers and administrators also finish work at that time. This results in a large number of patients visiting hospitals and requiring attention from nurses. 47 Pushing and hitting have been reported to be the most common forms of physical attacks. 13

9.2.3. Organizational consequences

Workplace violence is associated with a high turnover rate, lack of proper communication skills, lack of experience, and lack of quality care, 15 and thus it incurs additional operating costs. 7 It is expensive to replace a nurse as the new staff needs to be trained so that they can become acquainted with the normal operations of the health‐care setting. 51 The organization is thus negatively affected in terms of running costs. Furthermore, it can be difficult for the administration to source new and skilled nurses.

9.2.4. Professional consequences

The professional consequences of workplace violence are related to the delivery of services, manifested through increased sick leave, decreased job satisfaction, a high turnover rate, very low productivity, and an increase in error frequency by staff. 23 A nurse who feels threatened will not be inspired to work better. Instead, their motivation to work will decrease and they may opt to venture into other areas to find safety. 35 In addition, violence by perpetrators disrupts teamwork, thereby reducing the efficiency of service delivery.

9.3. Empirical referents

Empirical referents are categories of actual phenomena that may indicate the occurrence of the concept in its contextual framework and enable one to recognize or measure the defining attributes of the concept. 24 Although empirical referents are not themselves instruments for measuring the concept, they can be employed in the development of new measurement instruments or evaluation of existing ones. Empirical referents can be correlated to the theoretical foundations of the concept and contribute to the content and construct validity of the new measurement tool.

These are symptoms signifying that violence has occurred or might occur at any time and can be combined to form a tool that is used as part of the concept under discussion. Such observable cues are (a) humiliation, (b) verbal abuse, (c) physical abuse, and (d) horizontal violence and bullying. 23

9.3.1. Humiliation

Humiliation is an act aiming to belittle an individual as well as a failure to acknowledge achieved success. It may be presented in the form of words or actions directed at the victim. This mostly happens when a member of staff fails to appreciate the role of another or when someone is the subject of malicious rumors circulated by their colleagues. 13

9.3.2. Verbal abuse

Verbal abuse is also a sign of impending danger. 52 Patients or other staff members can decide to use abusive language against nurses. Family members of a patient can also become perpetrators by subjecting a nurse to verbal abuse.

9.3.3. Physical abuse

Physical abuse refers to the use of physical force, such as wounding a nurse or inflicting other forms of injury. This indicates the presence of violence. As stated earlier, this can come from patients who are angry with the nurse or even from the family members. The worst‐case scenario involves the use of weapons and the throwing of objects. 20

9.3.4. Horizontal violence and bullying

Horizontal violence can be an indicator of violence. This is mostly directed at vulnerable groups within the health‐care setting, 53 for example, when these are sidelined from major activities and are not consulted. Horizontal violence might involve the withholding of resources, exclusion from the organization's activities, and the belittling of nurses.

10. PROPOSED OPERATIONAL DEFINITION

The following is a proposed operational definition of workplace violence generated from the current concept analysis:

Workplace violence is any act or threat of physical violence (beating, slapping, stabbing, shooting, pinching, pushing, smashing, throwing objects, preventing individuals from leaving the room, pulling, spitting, biting or scratching, striking, or kicking; including sexual assault), harassment (unwanted behavior that affects the dignity of an individual), intimidation, or other threatening disruptive behavior that occurs at the worksite with the intention of abusing or injuring the target. It ranges from threats and verbal abuse (swearing, shouting, rumors, threatening behavior, nonserious threats, or sexual intimidation) to physical assaults and even homicide that creates an explicit or implicit risk to the health, well‐being, and safety of an individual, multiple individuals, or property.

11. DISCUSSION AND IMPLICATIONS

It is important to keep the working environment safe, cooperative, and respectful. 47 The relationships experienced among nurses, patients, and family members have a significant impact on cases of violence. 35 , 54 Failure to have a good working environment makes the professionals suffer, which can affect the organization negatively. Physical, emotional, and verbal violence are the most prevalent forms in health‐care settings. 46 Of the three, verbal abuse is the most frequent one and primarily affects the emotional strength of nurses. The consequences of workplace violence are classified as physical, professional, or organizational. Organizational consequences are by far the most detrimental to the running of a health‐care facility 16 because they range from cutting staffing levels to affecting the finances of the organization. They also result in an increased turnover rate and low retention of employees.

Workplace violence against nurses has been likened to other forms of violence like domestic violence and child abuse, although the element of sexual harassment does not feature greatly in workplace violence, 55 unlike in child abuse. Nevertheless, the consequences of the two are similar. Furthermore, the effects felt by the nurse due to humiliation are the same as those elicited by domestic violence, 49 indicating that there is a strong relationship between the two. Some scholars even argue that workplace violence is an extension of domestic violence.

Much has been written on horizontal violence, which refers to nurses exposing other nurses to violence. Power struggles largely contribute to this form of violence. Nurses often use abusive language to insult other nurses with the intention of lowering their morale. 51 Horizontal violence is also applied when there is a need to implement certain strategies. For instance, senior nursing staff impart a lot of pressure on juniors if they want certain standards to be attained, 36 and this trend is often maintained once the achievement has been made.

Workplace violence affects not only nurses but also the entire health‐care system. It may cause stress among the staff, which affects their performance, which in turn results in poor services. This also has an effect on recruitment as it becomes more difficult for the health‐care service provider to attract suitably skilled workers. Furthermore, the effects of workplace violence are sometimes felt directly or indirectly. Nurses who have experienced violence report symptoms related to stress, whereby some experienced trauma while others had difficulty sleeping. In addition, the majority of nurses who report their violent incidents are not satisfied with the way these are handled by their employers, with some of these cases not being treated with appropriate seriousness, meaning the nurses' claims are often swept under the carpet in favor of the patients and their families. 15 Identifying the factors that contribute to violence is necessary for policymakers as well as health‐care center administrators as this would help them develop strategies to address this phenomenon. To do so, they would also need to be aware of the concerns of the staff, who are in the firing line and thus subject to the consequences of workplace violence.

Violence against nurses can be reduced by addressing the factors contributing to the occurrence of this violence. For instance, researchers suggest that when there are enough staff and adequate training programs, abuse and violence can be greatly reduced by adding facilities like beds and other medical equipment, encouraging teamwork, and assigning work fairly. 15 They also recommend controlling the access of the public and limiting visitation hours, which would stabilize the situation in the hospitals and thereby ensure the safety of nurses. Implementing certain policies and legislation would also minimize workplace violence. For example, some of the studies reviewed here showed that withholding information from the family of a patient can trigger violence. 10 , 12 , 13 , 16 , 23

Some of the studies considered in this paper argue that the absence of legislation is one of the major contributing factors in violence against nurses. Most of the nurses who were asked why they did not come forward when abused reported that they are aware that nothing would be done. In other words, the absence of policies means the absence of justice. The weakness in this argument, however, is that there is no clear reason for the lack of policies on the abuse of nurses in health‐care settings. Hence, more research is necessary to determine why such policies are not being implemented. Enforcing security measures has also been suggested as one of the solutions to curb violence against nurses. 48

The proposed operational definition can be used in nursing research addressing the concept of workplace violence. The outcomes of this concept analysis could facilitate future research by providing insights that prompt new research avenues. Researchers need to conduct mixed‐method, qualitative studies to discern relationships between the concept and real‐life events as a means of better understanding the relationships between the key attributes in various nursing specialties which experience violence in the workplace.

One of the limitations of Walker and Avant's 24 concept analysis method is that it does not recommend a specific strategy to identify multiple uses of a given concept. The breadth of the articles studied in the literature review increased the rigor of the current analysis and was an attempt to overcome this limitation by enabling consideration of numerous examples of the concept. A further limitation associated with the concept analysis carried out for this study was that the cases presented were artificially constructed, which may limit their application in a real‐world setting. However, this concept analysis had many strengths. At the time this paper was written, the concept analysis presented herein was, to the best of the author's knowledge, the first of its type to use Walker and Avant's 24 method to assess workplace violence in the nursing setting.

“Nursing personnel play the vital role by together with other workers in the field of health, in the protection and improvement of the health and welfare of the population, and emphasize the need to expand health services through co‐operation between governments and employers' and workers' organizations concerned in order to ensure the provision of nursing services appropriate to the needs of the community, and recognizing that the public sector as an employer of nursing personnel should play a particularly active role in the improvement of conditions of employment and work of nursing personnel and noting that the present situation of nursing personnel in many countries, in which there is a shortage of qualified persons and existing staff are not always utilized to best effect, is an obstacle to the development of effective health services, and recalling that nursing personnel are covered by many international labor Conventions and Recommendations laying down general standards concerning employment and conditions of work, such as instruments on discrimination, on freedom of association and the right to bargain collectively, on voluntary conciliation and arbitration, on hours of work, holidays with pay and paid educational leave, on social security and welfare facilities, and on maternity protection and the protection of workers' health, and considering that the special conditions in which nursing is carried out make it desirable to supplement the above‐mentioned general standards by standards specific to nursing personnel, designed to enable them to enjoy a status corresponding to their role in the field of health and acceptable to them.” 56

Finally, social learning theory 57 is a theoretical framework that suggests that new behaviors are learned from other people. The theory is based on the hypothesis that people learn new behaviors through imitation and observation. 58 It is applied in understanding social behavior and learning processes. The social learning theory can also be used to understand health behaviors among individuals or members of a group. 59

Social learning theory indicates that responses to social stimuli or situations are motivated by prior experience. 60 Thus, nurses who appreciate social learning theory are likely to engage actively in collaborative learning and teamwork, which develop values such as participative decision‐making, communication, and cooperation in promoting the interests of patients. 61 According to the social learning theory, learning occurs best within social environments. 57

12. CONCLUSION

Workplace violence can take multiple guises and can be defined in a myriad of ways. In light of this, the objective of this paper was to delineate a clear definition of workplace violence that is derived from its prevailing characteristics. Acts of workplace violence can take various forms, including verbal and physical abuse, bullying, harassment, exclusion, and intimidation, and can be targeted at and perpetrated by a range of individuals, including patients, colleagues, patients’ family and friends, and management. Regardless of the form it takes, workplace violence can have far‐reaching emotional, professional, physical, and psychological consequences. The extant studies highlight the extent to which workplace violence remains an issue for members of the nursing workforce. However, addressing this issue will require a collaborative effort that involves a range of stakeholders, including administrators, nurses, leaders, educators, and other practitioners at both the community and national levels. The failure to address the prevalence of workplace violence in health‐care settings will have major ethical, legal, and moral implications for the industry and will ultimately undermine the quality of care provided.

The outcomes of this analysis provide the conceptual basis and standardized language required to develop and implement effective interventions in workplace violence as well as valuable insights that can guide future studies. As the main goal of the concept analysis was to develop an operational definition, the next step involves developing study instruments that accurately reflect the primary attributes of the concept. This will add to the validity of future studies.

Approval of the research protocol : N/A. Informed Consent : N/A. Registry and the Registration No. of the study/trial : N/A. Animal studies : N/A. Conflict of Interest : N/A.

ACKNOWLEDGMENTS

Al‐Qadi MM. Workplace violence in nursing: A concept analysis . J Occup Health . 2021; 63 :e12226. 10.1002/1348-9585.12226 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

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Congo (DRC): Solidarité Syndicale des Infirmiers du Congo (SOLSICO) - ( Download PDF ) Video: Interviews SOLSICO (DRC) activists in health care (on YouTube ) – in French, subtitled in English
Argentina: Asociación Sindical de Profesionales de Salud de la Provincia de Buenos Aires (CICOP) - ( Download PDF ) Video: Workshop on Violence in the Workplace (on YouTube ) – in Spanish, subtitled in English
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ILO, ICN, WHO, PSI Framework Guidelines: Framework guidelines for addressing workplace violence in the health sector available for download in English - French - Russian - Spanish
ILO : Towards a standard against violence and harassment in the world of work

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Highlights from a New Report on Indicators of Workplace Violence

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Contemporary evidence of workplace violence against the primary healthcare workforce worldwide: a systematic review

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