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9 significant workplace violence incidents from 2019

January 14, 2020 By //  by  Bryan Strawser

Note :  This article covers workplace violence incidents from 2019. For a more up-to-date free briefing on significant workplace violence incidents for the past few years, see our free report on Notable Workplace Violence Incidents , updated annually.

According to the National Safety Council , the fourth leading cause of deaths at work is from assaults. In 2017, there were 18,400 workplace violence incidents involving assault. Of those, 458 people died. The Occupational Safety and Health Administration (OSHA) defines workplace violence as “any threat of physical violence, harassment, intimidation, or other threatening disruptive behavior” at a work site. Employers, employees and customers alike should be concerned about workplace violence. When someone who is upset with a co-worker or his or her boss, that person may assault anyone in his or her way, including shooting people in their sights.

In order to illustrate how serious workplace violence should be taken within your organization, here are 9 significant workplace violence incidents from 2019.

1. Henry Pratt Shooting, Aurora, Illinois (U.S.)

An industrial warehouse employee , Gary Martin, killed five people and injured one unidentified person and five police officers when he went on a shooting rampage after being fired from his job. Martin had worked at the plant for 15 years. Police stated that they were shot at as soon as they arrived on the scene, which was about 4 minutes after the first 911 calls. All of the fatalities were men. All of the police officers suffered injuries that were not life-threatening. The disgruntled employee was told he was being fired that day. During the meeting, Martin pulled out a gun and started firing and continued shooting as he moved through the plant.

More and more, we hear about people who are fired or laid off shooting up the workplace, whether the firing was the result of the employee’s actions or because of cut-backs or other administrative lay-offs.

About Bryan Strawser

Bryan Strawser is Founder, Principal, and Chief Executive at Bryghtpath LLC, a strategic advisory firm he founded in 2014. He has more than twenty-five years of experience in the areas of, business continuity, disaster recovery, crisis management, enterprise risk, intelligence, and crisis communications.

At Bryghtpath, Bryan leads a team of experts that offer strategic counsel and support to the world’s leading brands, public sector agencies, and nonprofit organizations to strategically navigate uncertainty and disruption.

Learn more about Bryan at this link .

PO Box 131416 Saint Paul, MN 55113 USA

[email protected]

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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.

Comments are closed.

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Workplace Violence

A study on workplace violence, including how common incidents are, whether employees feel safe at work, and how prepared employees are to respond to incidents.

Read the full report:  Workplace Violence 2019

Download the infographic

For more guidance on workplace violence see SHRM's online toolkit:  

Understanding Workplace Violence Prevention and Response

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Workplace Violence Research

In the 1980’s a series of shootings at post offices drew public attention towards the issue of workplace violence. While mass shootings receive a lot of media attention, they actually account for a small number of workplace violence events . NIOSH has been studying workplace violence since the 1980s. In 1993, NIOSH released the document Preventing Homicide in the Workplace . This was the first NIOSH publication to identify high-risk occupations and workplaces. The research revealed that taxicab establishments had the highest rate of workplace homicide–nearly 40 times the national average and more than three times the rate of liquor stores which had the next highest rate. NIOSH worked to further inform workers and employers about the risk and encourage steps to prevent homicide in the workplace in the 1996 document Violence in the Workplace which reviewed what was known about fatal and nonfatal workplace violence to focus needed research and prevention strategies. The document addressed workplace violence in various settings such as offices, factories, warehouses, hospitals, convenience stores, and taxicabs, and identified risk factors and prevention strategies.

Workplace violence is the act or threat of violence, ranging from verbal abuse to physical assaults directed toward persons at work or on duty. The impact of workplace violence can range from psychological issues to physical injury, or even death. Violence can occur in any workplace and among any type of worker, but the risk for fatal violence is greater for workers in sales, protective services, and transportation, while the risk for nonfatal violence resulting in days away from work is greatest for healthcare and social assistance workers.

There continues to be groups of workers who are disproportionately affected by workplace violence. In 2013, NIOSH researchers contributed to a publication focused on health disparities and inequalities. [i] Number and rates of homicide deaths over a 5-year span for industry and occupation groups were presented by race/ethnicity and nativity. Further analyses published in 2014 in the American Journal of Industrial Medicine controlling for other factors reported elevated homicide rate ratios for workers who are Black, American Indian, Alaska Natives, Asian, or Pacific Islanders, and those who were born outside of the United States.[ii] NIOSH researchers continue to work towards identifying disparities where they exist so we can better focus our research and translation efforts to the workforces and communities of workers that need them. See below for examples of research conducted by NIOSH on identifying disparities in specific workforces.

Health Care

In the late 1990s and early 2000s, U.S. healthcare workers accounted for two-thirds of the nonfatal workplace violence injuries in all industries involving days away from work.[iii] To address the issue of violence in healthcare, in 2002, NIOSH published Violence: Occupational Hazards in Hospitals which discussed prevention strategies in terms of environmental (installing security devices), administrative (staffing patterns), and behavioral (training).

NIOSH and its partners recognized the lack of workplace violence prevention training available to nurses and other healthcare workers. To address this need, in 2013, NIOSH and healthcare partners developed a free on-line course aimed at training nurses in recognizing and preventing workplace violence. This award-winning course, Workplace Violence Prevention for Nurses , has been completed by more than 65,000 healthcare workers. Violence remains an issue for healthcare workers. Home healthcare workers are also at risk for violence as they work closely with patients and often are in close contact with the public while they provide healthcare services to patient. The issue of violence in home healthcare will likely increase as the industry is projected to grow dramatically in the coming years.

Convenience Stores

Robbery-related homicides and assaults are the leading cause of death in retail businesses. In 2019, workers in convenience stores had a 14 times higher rate of deaths due to work-related violence than in private industry overall (6.8 homicides per 100,000 workers vs. 0.48 per 100,000 workers). With these deaths are disparities among the homicide victims. Specifically, Black, Asian, and Hispanic men have disproportionately higher homicide rates than white men. Additionally, foreign-born men have disproportionately higher homicide rates than U.S.-born men, and men 65 and older have disproportionately higher homicide rates than any other age group.[iv]

NIOSH research demonstrated that retail establishments using Crime Prevention Through Environmental Design (CPTED) programs, which suggest that environments can be modified to reduce robberies, experienced 30%–84% decreases in robberies and a 61% decrease in non-fatal injuries. A recent analysis of crime reports spanning 10 years found robbery rates decreased significantly in convenience stores and small retail establishments after a Houston ordinance based on CPTED countermeasures became effective.[v]

 Taxicab Drivers

Driving a taxi remains a dangerous job. The most serious workplace violence issues facing taxi drivers are homicide and physical assaults which are often related to a robbery. Deaths due to workplace violence among taxi drivers occur disproportionately among drivers who are men (6 times higher than women), drivers who are Black or Hispanic (double that of drivers who are Non-Hispanic and White), and drivers in the South United States (almost triple that of drivers in Northeast).[vi] NIOSH research evaluated the effect of cameras installed citywide on taxi driver homicide rates in 26 U.S. cities spanning 15 years and found those cities with camera-equipped taxis experienced a 3-fold reduction in driver homicides compared with control cities. [vii] NIOSH and the Occupational Safety and Health Administration together identified prevention measures to reduce the risk of violence including increasing visibility into the taxi, minimizing cash transactions, and security measures such as security cameras, silent alarms, and bullet-resistant barriers. [viii]

Teachers and School Staff

In 2008, NIOSH undertook a large state-wide study to measure physical and non-physical violence directed at teachers and school staff in Pennsylvania. Working with national, state, and local education unions, the study described and quantified physical workplace violence against teachers and school staff and measured the impact of violence on job satisfaction and the mental health of teachers and staff. Some of the most significant findings from that study include:

• Special education teachers were at the highest risk of all teachers and school staff for both physical and nonphysical workplace violence.
• While physical assaults were rare, non-physical violence was not. Over 34% of teachers and school staff had experienced either bullying, threats, verbal abuse, or sexual harassment. Coworkers were the most common source of the violence.
• Both physical and non-physical violence significantly impacted teachers and school workers’ job satisfaction, stress, and quality of life. Those who experienced physical violence were over 2 times more likely to report work as stressful, 2.4 times more likely to report dissatisfaction with their jobs, 11 times more likely to consider leaving the education field and had a higher mean number of poor physical health and mental health days.
• This study highlighted the need for specific prevention efforts and post-event responses that address the risk factors for violence, especially among special education workers. [ix] [x]

Workplace Violence During the COVID-19 Pandemic

Over the last 50 years, NIOSH has seen changes in the risk of workplace violence. The COVID-19 pandemic has presented unique instances of workplace violence. Since the pandemic began in early 2020, U.S. media have reported on retail workers and workers in other industries being verbally assaulted, spit on, and physically attacked while enforcing COVID-19 mitigation practices such as mask wearing or physical distancing. Several international studies have examined violence toward healthcare personnel during the pandemic. Unfortunately, the significant time-lag from the occurrence of these events to data delivery using traditional occupational safety and health surveillance sources means that COVID-19-related workplace violence data will not be available for some time. To address this lag, NIOSH has undertaken multiple studies that used media reports to provide more timely information on the number and characteristics of workplace violence events (WVEs) occurring in U.S. workplaces in the early phases of the COVID-19 pandemic. Preliminary results from the unpublished analysis reveal:

• At least 400 WVEs related to COVID-19 were reported in the media between March 1 and October 31, 2020. Twenty-seven percent involved non-physical violence, 27% involved physical violence, and 41% involved both physical and non-physical violence. Non-physical violence is using words, gestures, or actions with the intent of intimidating or frightening an individual and physical violence is any action that leads to physical contact with the intention of injuring such as hitting, kicking, choking, or grabbing.
• A majority occurred in retail and dining establishments and were perpetrated by a customer or client. Most perpetrators were males (59%) and mostly acted alone (79%).
• The majority of COVID-19-related WVEs were due to mask disputes (72%), and 22% involved perpetrators coughing or spitting on workers.

As the COVID-19 pandemic continues to evolve, employers and employees may have to continue to enforce COVID-19 mitigation policies—which could lead to COVID-19-related WVEs. Clearly, WVEs have impacted industries and occupations differently, especially those requiring workers to be physically present at work during the pandemic. Aside from those noted above, one of the worker groups that has been negatively impacted is public health workers. Other published NIOSH research has found that nearly 12% of state, local, territorial, and tribal public health workers have received job-related threats because of their work, and an additional 23% felt bullied, threatened, or harassed. [xi] While NIOSH has a long history in workplace violence research and prevention, the COVID-19 pandemic has presented unique situations where typical workplace violence prevention strategies may not be effective. NIOSH will continue to conduct research on these events and identify possible prevention strategies to address these unique situations.

This blog is part of a  series  for the NIOSH 50 th Anniversary. Stay up to date on how we’re celebrating NIOSH’s 50 th  Anniversary on our  website .

Dawn Castillo, MPH, is the Director of the NIOSH Division of Safety Research.

Cammie Chaumont Menéndez, PhD, MPH, MS, is a Research Epidemiologist in the NIOSH Division of Safety Research.

Dan Hartley, EdD, is the former NIOSH Workplace Violence Prevention Coordinator.

Suzanne Marsh, MPA, is a Team Lead in the NIOSH Division of Safety Research.

Tim Pizatella, MSIE, is the Deputy Director of the NIOSH Division of Safety Research.

Marilyn Ridenour, BSN, MPH, is a Nurse Epidemiologist in the NIOSH Division of Safety Research.

Hope M. Tiesman, PhD, is a Research Epidemiologist in the NIOSH Division of Safety Research.

[i] CDC [2013]. CDC health disparities and inequalities report – United States, 2013. MMWR Suppl 62(3):1-187.

[ii] Steege A, et al. [2014]. Examining occupational health and safety disparities using national data: a cause for continuing concern. Am J of Ind Med 57:527-538.

[iii] BLS [2020]. Employed persons by detailed industry, sex, race, and Hispanic or Latino ethnicity. United States Department of Labor, U.S. Bureau of Labor and Statistics, http://www.bls.gov/cps/cpsaat18.pdf

[iv] Chaumont Menéndez et al. [2013]. Disparities in work-related homicide rates in selected retail industries in the United States, 2003-2008. J Safety Res 44:25-29.

[v] Davis J, Casteel C, Menendez C [2021]. Impact of a crime prevention ordinance for small retail establishments. Am J Ind Med 64:488-495, https://doi.org/10.1002/ajim23239 .

[vi] Menendez C, Socias-Morales C, Daus M [2017]. Work-related violent deaths in the US taxi and limousine industry 2003 to 2013. J Occup Environ Med 59:768-774.

[vii] [vii]Menéndez C, et al. [2013]. Effectiveness of taxicab security equipment in reducing driver homicide rates. Am J  Prev Med 45(1):1-8.

[viii] NIOSH/OSHA [2019]. NIOSH fast facts: taxi drivers—how to prevent robbery and violence. By Chaumont Menendez C, Dalsey E. Morgantown, WV: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication 2020-100 (revised 11/2019), https://doi.org/10.26616/NIOSHPUB2020100revised112019. Washington, DC: U.S. Department of Labor, Occupational Safety and Health Administration, DOL (OSHA) Publication No. 3976, https://www.osha.gov/Publications/OSHA3976.pdf

[ix] Tiesman H, et al. [2013]. Workplace violence among Pennsylvania education workers: differences among occupations. J Safety Res 44: 65–71.

[x] Konda S, Tiesman HM, Hendricks S, Grubb PL [2020]. Nonphysical workplace violence in a state-based cohort of education workers. J School Health 90: 482-491, https://doi.org/10.1111/josh.12897 .

[xi] Bryant-Genevier J, et al. [2021]. Symptoms of depression, anxiety, post-traumatic stress disorder, and suicidal ideation among state, tribal, local, and territorial public health workers during the COVID-19 pandemic — United States, March–April 2021. MMWR 70:947-952.

36 comments on “Workplace Violence Research”

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 » .

Great blog! Thank you for shedding light on this serious problem.

is this study available in pdf. I want to use it as a reference for my master’s thesis. Thank you in advance

Thank you for your comment You asked “is this study available in pdf? ” The blog itself is not available in a PDF. The blog is a summary of various studies, most of which are included in the reference list. Let us know if you need more information on a particular study.

taxicabs are dangerous .

i did not know some these things thanks

awesome possum

the blog is very reliable. thanks for sharing

At this moment any enviroment has become dangerous. We have to be careful.

Thank you for sharing this.

very dangerous

Thanks for all this information.

thank you for that informative article.

thank you for the information

Interesting and have seen more aggressiveness from family members.

Thanks for the info.

Patient population and family members are becoming more demanding, aggressive and non compliant resulting in an increasingly tense/stressful environment. Due to HCAPS scores driving hospital decisions, these behaviors are often times overlooked to maintain patient satisfaction. Hospital staff are receiving the brunt of this bad behavior which is causing a decrease in interest in bedside nursing.

All this is Great information very helpful.

Even though I usually have good patients ,is true that patients and family members are more demanding.

unfortunately this is nursing environment , stay safe!!

Violence should never be considered part of a typical work environment. NIOSH and its partners are working to address issues related to violence in health care. For example, the creation of the online training Workplace Violence Prevention for Nurses that was referenced in this blog.

Thanks for the information it was very interesting .

Thanks for the information.

Thank you for this helpful Information .

Thanks for make us aware about a good practices on the work place.

This was great. very insightful and helpful

informative, thanks

This information is always good to know, Thank you !

Imformative Thanks

very educational article

Do you have any statistics on workplace violence in longterm care?

Thank you for your comment. This paper published from the Ohio Bureau of Workers Compensation briefly covers workplace violence in skilled nursing.

From the publicly available data from the Bureau of Labor Statistics (BLS) Survey of Occupational Injuries and Illnesses for 2021-2022, the number of nonfatal injuries associated with ‘intentional injury by other person’ were as follows ( see table for more information): • ‘skilled nursing facilities’ = 3,060 cases with days away from work (DAFW) • ‘residential intellectual and developmental disability, mental health, and substance abuse facilities’ = 4,900 cases with DAFW • ‘continuing care retirement communities and assisted living facilities for the elderly’ = 1,410 cases with DAFW

Data for comparison purposes can be extracted from the table that these numbers were extracted from.

According to the publicly available BLS Census of Fatal Occupational Injuries (CFOI) data for 2022 ( see table for more information), the number of fatalities associated with ‘violence and other injuries by persons or animals’ was not reportable. Please note that this doesn’t mean that there were no fatalities associated with violence but that the number did not meet BLS reporting requirements.

This is a great article. Thanks for providing more insight on this topic.

Very Informative

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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.

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.”

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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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• 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.

Peer Review reports

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 in healthcare settings: The risk factors, implications and collaborative preventive measures

Mei ching lim.

a Department of Public Health Medicine, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Jalan UMS, Kota Kinabalu, 88400, Sabah, Malaysia

Mohammad Saffree Jeffree

Saihpudin sahipudin saupin, nelbon giloi, khamisah awang lukman.

b Centre for Occupational Safety & Health, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia

Violence at work refers to acts or threats of violence directed against employees, either inside or outside the workplace, from verbal abuse, bullying, harassment, and physical assaults to homicide. Even though workplace violence has become a worrying trend worldwide, the true magnitude of the problem is uncertain, owing to limited surveillance and lack of awareness of the issue. As a result, if workplace violence, particularly in healthcare settings, is not adequately addressed, it will become a global phenomenon, undermining the peace and stability among the active communities while also posing a risk to the population's health and well-being. Hence, this review intends to identify the risk factors and the implications of workplace violence in healthcare settings and highlight the collaborative efforts needed in sustaining control and prevention measures against workplace violence.

• • Workplace violence needs to be addressed more comprehensively, involving shared responsibilities from all levels.
• • Emphasis on healthcare management's commitment, assurance, and clearly defined policy, reporting procedures, and training.
• • The healthcare workers' commitment to update their awareness and knowledge regarding workplace violence.
• • The provision of technical support and assistance from professional organizations, NGOs, and the community.

1. Introduction

Violence affects people at all levels of society and can occur anywhere; at home, on the streets, in schools, workplaces, and institutions. Violence had previously been overlooked as a Public Health issue due to the lack of a clear definition, undeniably a complex and diffused matter. It is not as simple as relating violence to scientific facts to define it; instead, it is a matter of judgment of appropriate and acceptable behaviors influenced by culture, values, and social norms. Violence is determined by the World Health Organization (WHO) as the deliberate use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that has consequences or has a high probability of resulting in injury, death, mental distress, mal-development, or deprivation.

Occupational Safety and Health Administration (OSHA) defines workplace violence as any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at work [ 1 ]. While physical violence (which includes beating, biting, kicking, pushing, slapping, stabbing, and shooting) in the workplace has been acknowledged, little has been done to address the presence of psychological violence until recent years [ 2 ]. Psychological violence is the intended use of power, including the threat of physical force against another person or group with the potential to impair the affected individual's physical, mental, spiritual, moral, or social development [ 2 ]. Besides, harassment which is also categorized as a type of violence, is defined as any behavior that degrades, humiliates, irritates, alarms, or verbally insults another person, including abusive words, bullying, gestures, and intimidations [ 3 ]. This review aims to determine the risk factors and consequences of workplace violence in healthcare settings, as well as emphasizing the joint efforts required to enhance the control and preventative measures of workplace violence.

2. Workplace violence in healthcare settings

Although violence in the workplace affects almost all sectors and groups of workers, it is apparent that violence in healthcare settings provides a significant risk to public health and an occupational health issue of growing concern. The healthcare and social service industries have the greatest rates of workplace violence injuries, with workers in these industries being five times more likely to be injured than other workers [ 4 ]. In addition, workplace violence in the health sector is estimated to account for about a quarter of all workplace violence [ 5 ]. Workplace violence is constantly on the rise in the health industry due to rising workloads, demanding work pressures, excessive work stress, deteriorating interpersonal relationships, social uncertainty, and economic restraints [ 5 ].

Healthcare workers accounted for 73% of all nonfatal workplace injuries and illnesses due to violence in 2018 [ 4 ]. According to World Health Organization (WHO), it is estimated that between 8% and 38% of health workers suffer physical violence at a certain point in their careers. At the same time, many more are exposed or threatened with verbal aggression [ 6 ]. Most violent cases are committed by patients’ family members or friends and followed by patients themselves [ 4 , 7 ]. Violence in healthcare settings worsens when there is a crisis, emergency, or disaster which involves large groups of people who are even more overwhelmed with panic attacks, shock, uncertainties, fears, and worries of the conditions they or their family members are going through [ 6 ]. As a result, healthcare workers become the targets to vent their anger or frustrations. The most vulnerable healthcare workers victimized are staff at emergency departments, especially nurses and paramedics, and staff directly involved with in-patient care [ 5 , 6 ].

Furthermore, the Healthcare Crime Survey conducted by International Association for Healthcare Security and Safety Foundation's (IAHSSF) in 2019 reported the assault rates against healthcare workers increased from 9.3 incidents in 2016 to 11.7 per 100 beds in 2018, which is the highest rate that IAHSSF has ever recorded since 2012 [ 8 ]. 85% of workplace violence occurrences were classified as National Institute for Occupational Safety and Health (NIOSH) Type II Customer/Client Workplace Violence, which involves violence directed at employees by customers, clients, patients, students, inmates, or anybody else for whom an organization provides services [ 9 ]. According to a meta-analysis of 47 observational studies, the overall prevalence of workplace violence against healthcare professionals was 62.4%, with verbal abuse accounting for the highest majority (61.2%), followed by psychological violence (50.8%), threats (39.5%), physical violence (13.7%), and sexual harassment (6.3%) [ 10 ].

Even though some institutions may have a proper formal incident reporting system, there are still many incidents, especially in the forms of bullying, verbal abuse, and harassment, unreported [ 11 ]. Lack of reporting guidelines or policy, lack of trust in the reporting system, and fear of retaliation are among the many reasons for underreporting [ 12 , 13 ]. For example, in Malaysia, with the launching of the guidelines and training modules to address and prevent violence against healthcare workers, more cases were reported with a drastic 159% increase from 167 cases in December 2017 to 432 cases in December 2018 [ 14 ]. The Emergency Department and the Psychiatry and Mental Health Departments were high-risk areas, as they were in other countries, with the most common perpetrators being patients, their relatives, or visitors [ 14 ]. While verbal violence, physical assault, intimidation, and sexual harassment were among the types of workplace violence documented [ 14 ], cyberbullying has been on the rise in recent years, with humiliation, defamation, and unlawful video recording in healthcare settings.

3. Risk factors of workplace violence in healthcare settings

The etiology of workplace violence can be pretty complex, and many risk factors are related to both the perpetrators and the healthcare workers assaulted. The environments under which care and services are provided in healthcare settings contributed to healthcare workers being more prone to occupational violence. Many studies were conducted, and some of the risk or associating factors that contributed to the amplified incidence of violence towards healthcare workers over the recent years are: (i) attitudes and behaviors of patients, family members, friends, or visitors who are often under intense emotional charge and expectations [ [15] , [16] , [17] ]; (ii) healthcare workers and work factors which include shortage of staffs, inexperienced or anxious staffs, poor coping mechanism and lack of training [ [18] , [19] , [20] , [21] , [22] ]; and (iii) system or environmental factors (overcrowded areas, long waiting hours, inflexible visiting hours, lack of information as well as difference of language and culture) [ 15 , 17 , 19 , 20 , 23 , 24 ].

4. Effect of workplace violence in healthcare settings

Violence against healthcare workers in any situation is inexcusable, especially when they are working around the clock to ensure that everyone receives the best treatment possible. The effect of violence harms healthcare employees' physical and psychological well-being of healthcare workers [ 6 ]. Victims of violence are more likely to experience demoralization, depression, loss of self-esteem, ineptitude as well as signs of post-traumatic stress disorders like sleeping disorders, irritability, difficulty concentrating, reliving of trauma, and feeling emotionally upset [ 7 , 17 , 24 , 25 ].

Furthermore, the negative implications of such widespread violence in healthcare sectors have a significant impact on the delivery of health care services, including a decline in the quality of care delivered, increased absenteeism, and health workers' decision to leave the field [ 5 , 15 , 17 , 19 , 25 ]. As a result, the number of health services available to the general public will be limited, resulting in increased healthcare costs due to resource constraints. In addition, if healthcare workers leave their employment due to harassment and threats of violence, equal access to primary health care would be threatened, particularly in developing countries where the number of healthcare workers is insufficient to meet the needs and demands of the population.

Many healthcare employees mistakenly feel that workplace violence is just part and parcel of their jobs [ 26 , 27 ] and that they were unlucky enough to be in the wrong location at the wrong time. Many employees believe no action will be taken against the perpetrators [ 28 ], or they refuse to endure the stigmatization and the inconvenience of filing reports and following through on legal proceedings [ 29 , 30 ]. They are typically concerned that if they speak up about what has occurred to them, they will be shamed or labeled incompetent with a lack of supervisory support [ 12 , 29 ]. Furthermore, the harassed healthcare workers are even more concerned that the offenders may inflict additional harassment, violence, or threats on them and their family members if reports are made [ 31 ].

Hence, it further implies the need for proper awareness and recognition followed by clearly defined control and prevention measures of workplace violence in healthcare settings to prevent the negative impact of workplace violence to both the healthcare staffs and services. These measures are also vital to ensure that all healthcare workers, especially the front liners, are well protected in a safe working environment so that health care services can be continued to run smoothly without any interruptions for the benefit of the community.

5. Collaborative efforts in prevention and management of workplace violence in healthcare settings

The detrimental effects, mainly the psychological impact of workplace violence on affected healthcare employees, are one of the most critical reasons it must be handled before it escalates to higher absenteeism rates or further affects healthcare workers' overall performance. It will have even more negative implications for the healthcare sector when staffing is already scarce, and patient loads continue to rise inexorably.

Nonetheless, there is still much room for improvement in workplace violence awareness and abilities. There is an essential need to have a strong collaborative effort, support, and commitment from top management and the workers to protect themselves. There is no single guideline that is suitable for all settings. Hence, the management of each healthcare setting needs to create or adapt and establish a practical, acceptable and sustainable workplace violence prevention program. It should be according to the needs of their respective environments, using the available guidelines or recommendations by WHO, ILO, DOSH, and evidence-based research.

In non-emergency settings, interventions to prevent violence against healthcare professionals focus on techniques to better manage aggressive patients and high-risk visitors while in emergency circumstances, interventions are more focused on assuring the physical security of healthcare facilities [ 6 ]. Among some of the prevention and control measures in the sequence of effectiveness include; (i) substitution by transferring a client or patient with a history of violent behaviour to a more suitable secure facility or area [ 13 ]; (ii) engineering control measures which include installing barrier protection, metal detectors and security alarm systems, allocating conducive patients or visitors areas and clear exit routes [ 1 , 13 ]; (iii) administrative and work place practise controls which include implementing workplace violence response and zero-tolerance policies [ 1 , 17 , 24 , 32 ], ability to resolve conflict situation [ 33 ], establishing mandatory timely reporting system [ 34 ], ensuring employees are not working alone [ 35 ], flowchart for assessing and response in emergency situations [ 1 , 35 ]; (iv) post-incident procedures and services that include trauma-crisis counselling, critical-incident stress debriefing and employee assistance programs [ 35 ]; (v) safety and health training in order to ensure that all staff members are aware of potential hazards and how to protect themselves and their co-workers through established policies and procedures [ 32 , 35 , 36 ].

Aside from that, international or regional professional organizations, councils, and associations play essential roles in supporting, participating in, as well as contributing to initiatives and mechanisms aimed at minimizing and eliminating the potential risks of workplace violence in healthcare settings [ 5 , [37] , [38] , [39] ]. It includes but is not limited to (i) actively advocating on the awareness and training for workplace violence; (ii) incorporating in their codes of practice, codes of ethics, and clauses concerning the unacceptance of any form of workplace violence; (iii) integrating accreditation procedures in healthcare institutions on the requirement of measures aimed at preventing workplace violence; (iv) establishing workplace violence surveillance by mandatory and guided data collection procedures on the incidents of violence in all healthcare settings; and (v) offering support for victims of workplace violence, specifically in the form of legal aid if necessary.

In addition, participation and contribution from community groups, non-governmental organizations (NGOs), as well as business corporations in terms of technical support and financial assistance, play an essential part in curbing and preventing workplace violence in the healthcare settings [ 5 , 35 , [37] , [38] , [39] ]. Among the initiatives and activities which are highlighted include (i) creating and maintaining a strong network of information and expertise in workplace violence; (ii) assisting in promoting awareness of the risks of workplace violence; (iii) participating in training and educational programs; (iv) assisting in the support structure for the prevention and management of workplace violence; as well as (v) incorporating and emphasizing the importance of good communication skills and coping mechanism among the healthcare workers.

Summary of the risk factors, effects as well as the collaborative efforts which are important in the control and prevention measures for workplace violence in healthcare settings are tabulated in Table 1 .

Summary of risk factors, effects and collaborative management of workplace violence in healthcare settings.

6. Conclusion

It is undeniable that workplace violence needs to be addressed more comprehensively, involving shared responsibilities from all levels. These include (i) government's legislations; (ii) healthcare management's dedication, firm support, assurance, and clearly defined policy, reporting procedures, and training; (iii) the healthcare workers' commitment to update their awareness and knowledge regarding workplace violence; and (iv) the provision of technical support and assistance from professional organizations, NGOs, and the community.

Sources of funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Ethical approval

No ethical approval is required for this review.

Not applicable as it is a review and does not involve any new data collection from healthcare workers.

Author contribution

Mei Ching Lim drafted the initial manuscript and was involved in the literature search. Mohammad Saffree Jeffree was responsible for conceptualizing the study, facilitating manuscript writing, and approving the final manuscript. Saihpudin @ Sahipudin Saupin, Nelbon Giloi, and Khamisah Awang Lukman contributed expert input in literature search and facilitated manuscript writing. All authors have seen and approved the final manuscript.

Registration of research studies

Not applicable as it is a review and does not involve any new data collection from healthcare workers .

Dr Mei Ching Lim.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Declaration of competing interest

The authors report no conflict of interest nor proprietary or commercial interest in any product mentioned or concept discussed in this article.

Acknowledgements

Unit 9: Introduction to Case Studies and Case Study 1: Psych Patient in ED

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• 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.

No funding was received.

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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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The authors declare no competing interests.

Ethics approval and consent to participate

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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Received : 19 June 2023

Accepted : 15 September 2023

Published : 03 October 2023

DOI : https://doi.org/10.1186/s13031-023-00540-x

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Workplace Violence

• Workplace Violence Home

Risk Factors

Prevention programs.

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Enforcement

• Workers' Rights
• 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.

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• Violence and Harassment in the Workplace

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What is workplace violence and harassment, is there specific workplace violence prevention legislation, when conducting a workplace assessment, what work-related factors increase the risk of violence, which occupational groups tend to be most at risk from workplace violence, how do i know if my workplace is at risk, what can be done to prevent violence in the workplace, what are some advantages of having a written policy about workplace violence, harassment and other unacceptable behaviour, what are some examples of preventive measures.

Most people think of violence as a physical assault. However, workplace violence and harassment is a much broader problem. It can be defined as any act in which a person is abused, threatened, intimidated or assaulted in his or her employment.

While exact definitions vary in legislation, generally speaking, workplace violence or harassment includes:

• Threatening behaviour – such as shaking fists, destroying property or throwing objects.
• Verbal or written threats – any expression of an intent to inflict harm.
• Verbal abuse – swearing, insults or condescending language.
• Physical attacks – hitting, shoving, pushing or kicking.

Some jurisdictions include harassment as a form of violence, while others define harassment separately. Harassment can be thought of as any behaviour that demeans, embarrasses, humiliates, annoys, alarms or verbally abuses a person and that is known or would be expected to be unwelcome. These behaviours include words, gestures, intimidation, bullying , or other inappropriate activities.

Generally speaking, any action or behaviour – from spreading rumours, swearing, verbal abuse, pranks, arguments, property damage, vandalism, sabotage, pushing, theft, physical assaults, inflicting psychological trauma, anger-related incidents, rape, arson to murder – are all examples of workplace violence or harassment.

Also, note that workplace violence or harassment is not limited to incidents that occur within a traditional workplace. Work-related incidents can occur at off-site business-related functions (conferences, trade shows), at social events related to work, in clients' homes, or away from work but resulting from work (a threatening telephone call to your home from a client).

NOTE: In this document, we use the term violence also to include bullying and harassment.

Yes, all jurisdictions in Canada have legislation specific to harassment and violence. Please see the OSH Answers titled  Violence and Harassment in the Workplace – Legislation  for more details. Contact your  local authorities  in your jurisdiction for specific information.

Please refer to the following OSH Answers documents for information:

• Bullying in the Workplace
• Internet Harassment or Cyberbullying
• Violence and Harassment in the Workplace – Family (Domestic) Violence
• Violence and Harassment in the Workplace – Legislation
• Violence and Harassment in the Workplace – Dealing with Negative Interactions
• Violence and Harassment in the Workplace – Parking Lot Safety
• Violence and Harassment in the Workplace – Warning Signs
• Violence and Harassment in the Workplace – Working Late

Certain work factors, processes, and interactions can put people at increased risk of workplace violence. Examples include:

• Working with customers or the public.
• Handling money, valuables or prescription drugs (e.g., cashiers, pharmacists, veterinarians).
• Carrying out inspection or enforcement duties (e.g., government employees).
• Providing service, care, advice or education (e.g., health care staff, teachers).
• Working with unstable or volatile persons (e.g., social services or criminal justice system employees).
• Working in premises where alcohol is served (e.g., food and beverage staff).
• Working alone, in small numbers (e.g., store clerks, real estate agents), or isolated or low-traffic areas (e.g., an isolated reception area, washrooms, storage areas, utility rooms).
• Working in community-based settings (e.g., nurses, social workers, and other home visitors).
• Having a mobile workplace (e.g., taxicab, salesperson, public transit).
• Working during periods of intense organizational change (e.g., strikes, downsizing).

The risk of violence may be greater at certain times of the day, night or year. For example:

• late hours of the night or early hours of the morning
• tax return season
• overdue utility bill cut-off dates
• during the holidays in the retail sector when demand for service is higher
• Friday or Saturday nights in establishments that serve alcohol
• report cards or parent interviews
• performance appraisals

The risk of violence may increase depending on the geographic location of the workplace. For example:

• near buildings or businesses that are at higher risk of violent crime (e.g., bars, banks)
• in areas isolated from other buildings or structures

In other situations, workplaces might be exposed to family (domestic) violence, such as a family member repeatedly phoning or e-mailing an employee, which interferes with their work, or showing up at the employee's workplace and disrupting co-workers (e.g., asking many questions about the employee's daily habits).

Certain occupational groups tend to be more at risk from workplace violence. These occupations include:

• healthcare employees or those who dispense pharmaceuticals
• veterinary practices
• police, security, or correctional officers
• social services employees, including crisis intervention and counselling services
• teachers or education providers
• municipal housing inspectors
• public works employees
• retail employees
• sellers of alcohol (sale or consumption on the premises)
• taxi or transit drivers

Conduct a workplace assessment to determine which hazards are present and the risks they represent. This assessment may involve conducting an inspection of the workplace. When conducting this assessment:

• Consider internal factors such as culture, conditions, activities, organizational structure, etc.
• Consider external factors such as location, clients, customers, family violence, etc.
• Any measures in place to protect the psychological health and safety of the workplace include factors like how much control over the work an individual has, excessive workload, tight deadlines, etc.
• Ask employees about their experiences and whether they are concerned for themselves or others.
• Review any incidents of violence by consulting existing incident reports, first aid records, and health and safety committee records.
• Determine whether your workplace has any of the risk factors associated with violence.
• Obtain information from any organizations with which you are associated, e.g., your industry association, workers' compensation board, occupational health and safety regulators, or union office.
• Seek advice from local police security experts.
• Review relevant articles or publications.

Organize and review the information you have collected. Look for trends and identify the occupations and locations that you believe are most at risk. Record the results of your assessment. Use this document to develop a prevention program with specific recommendations for reducing the risk of violence within your workplace.

The most important component of any prevention program is management commitment. Management commitment is best communicated in a written policy. The policy should:

• Be developed by management and employee representatives, including the health and safety committee or representative and union, if present.
• Apply to management, employees, clients, independent contractors and anyone with a relationship with your company.
• Define what you mean by workplace violence, harassment, and bullying in precise, concrete language.
• Provide clear examples of unacceptable behaviour (e.g., making threats) and working conditions (e.g., working alone without appropriate safeguards).
• State clearly your organization's view toward workplace violence and harassment and its commitment to prevention.
• Precisely state the consequences of making threats or committing violent acts.
• Outline the progressive discipline procedure that will be used to hold individuals accountable for unacceptable behaviour to ensure fair and consistent treatment.
• Outline the process by which preventive measures will be developed and implemented.
• Encourage reporting of all incidents, including reports from witnesses.
• Outline the confidential process by which employees can report incidents and to whom.
• Assure no reprisals will be made against reporting employees who make reports in good faith (sincere and honest).
• Outline the procedures for resolving or investigating incidents or complaints.
• Describe how information about potential risks will be communicated to employees.
• Make a commitment to provide support services to targets of violence.
• Offer a confidential Employee Assistance Program (EAP) to allow employees to seek help.
• Make a commitment to fulfill the prevention training needs of different levels of personnel within the organization.
• Make a commitment to monitor and regularly review the policy.
• State applicable regulatory requirements.

A written policy will inform everyone about:

• What behaviour (e.g., violence, intimidation, bullying, harassment, etc.) your organization considers inappropriate and unacceptable in the workplace.
• What to do when incidents occur.
• Contact information for reporting incidents.
• The procedure that will be followed when an incident is reported.

A written policy will also encourage employees to report such incidents and show that management is committed to fairly addressing incidents involving violence, harassment, and other unacceptable behaviour.

Preventive measures generally fall into three categories: workplace design, administrative practices, and work practices.

Workplace design considers factors such as workplace layout, use of signs, locks or physical barriers, lighting, and electronic surveillance. Building security is one instance where workplace design issues are very important. For example, you should consider:

• Positioning the office furniture, reception area, or sales or service counter so that it is visible to fellow employees or members of the public passing by.
• Positioning office furniture so that the employee is closer to a door or exit than the client so the employee cannot be cornered.
• Installing surveillance cameras in the public spaces of the workplace, such as entrances, parking lots, waiting rooms, etc.
• Installing physical barriers, e.g. pass-through windows or bullet-proof enclosures.
• Minimizing the number of entrances to your workplace.
• Using coded cards or keys to control access to the building or certain areas within the building.
• Using adequate exterior lighting around the workplace and near entrances.
• Strategically placing fences to control access to the workplace.

Administrative practices are decisions you make about how you do business. For example, certain administrative practices can reduce the risks involved in handling cash. You should consider:

• Keeping cash register funds to a minimum.
• Using electronic payment systems to reduce the amount of cash available.
• Varying the time of day that you empty or reduce funds in the cash register.
• Installing and using a locked drop safe.
• Arranging for regular cash collection by a licensed security firm.
• Keeping other valuables safely stored and secure, such as firearms, tools, opiates, medicines, etc.

Administrative practices may also include education and training for employees. This education and training would include not only information about the workplace's policy and process to respond to incidents but may also include the following:

• What civility and respect mean in the workplace.
• How to respond to customers or members of the public who may be angry or frustrated, such as how to exit a confrontational interaction or de-escalate a conflict safely.
• How to respond to an incident of violence (e.g., emergency response, when to contact security or police, etc.).
• Knowledge about discrimination, family violence, diversity and cultures.
• How to respond to individuals who may be impaired.

Work practices include all the things you do while you are doing the job. They may include management functions such as making sure the performance evaluation process is fair and transparent or “checking in” with employees to determine their workload or stress level and make reasonable adjustments where possible.

People who work away from a traditional office setting, for example, those working from home, salespeople, real estate agents, or home care providers, can adopt many different work practices that could reduce their risk. For example,

• Identify a designated contact at the office and a backup contact.
• Prepare a daily work plan and share it with your designated contact so they know where you are expected to be throughout the day in case of an incident.
• Keep your designated contact informed of your location and consistently adhere to the check-in schedule.
• Verify the credentials of clients.
• Use the "buddy system", especially when you feel your personal safety may be threatened.
• DO NOT enter any situation or location where you feel threatened or unsafe.
• Fact sheet last revised: 2023-10-31