Workplace Violence Against Healthcare Professionals A Systematic Review Mento - 2020
Workplace Violence Against Healthcare Professionals A Systematic Review Mento - 2020
Workplace Violence Against Healthcare Professionals A Systematic Review Mento - 2020
A R T I C LE I N FO A B S T R A C T
Keywords: Background: Workplace violence is defined as an aggression when staff members are abused, intimidated or
Workplace violence attacked in circumstances related to their work, including commuting to and from work, involving an explicit or
Healthcare professionals implicit challenge to their safety, well-being or health. Violence against healthcare professionals is frequent, and
Emergency departments constitutes a source of concern in the health system. Scientific literature highlights negative behavioral, emo-
tional, cognitive and physical outcomes. The aim of this review is to examine the impact that exposure to
workplace violence against healthcare professionals can produce, to improve healthcare professionals' knowl-
edge about the consequences of workplace violence, and to guide future research in identifying strategies that
could effectively reduce the incidence of workplace violence.
Method: We have conducted, in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and
Meta-Analyses) guidelines, a systematic search for the literature on PubMed. Search terms related to WPV were
(“Workplace violence”, “Aggression”, “Aggression department emergency”), and search terms related to WPV
consequences were (“Mental health”, OR “Health care workers”, OR “Burnout”).
Initial search identified 1.434 articles. One-hundred publications have been selected and the relevant pub-
lications, appropriate to the topic review, was reduced to twenty-seven.
Result: According to examined literature, workplace violence mostly occurs in psychiatric departments, emer-
gency services, polyclinics/waiting rooms, and geriatric units. Negative factors such as lack of information,
insufficient personnel and equipment, and communication breakdowns increase the risk of violent behavior in
healthcare services. Most violence in health institutions is perpetrated by patients and their relatives in the forms
of verbal abuse, psychological violence, physical assault, and sexual abuse.
Conclusion: Workplace violence might lead to various negative impacts on health workers' psychological and
physical health, such as increase in stress and anxiety levels; feelings of anger, guilty, insecurity, burnout.
1. Introduction which occurs between two or more persons on different levels of the
hierarchical system (Bayram, Çetin, Oray, & Can, 2017; Baby, Gale, &
Workplace violence (WPV) against healthcare workers consists in Swain, 2019; Seun-Fadipe, Akinsulore, & Oginni, 2019; Beattie,
abuses, intimidations, aggressions, in circumstances related to work Griffiths, Innes, & Morphet, 2019; Rafeea, Al Ansari, Abbas,
(Saragoza & White, 2016; Shea, Sheehan, Donohue, Cooper, & De Cieri, Elmusharaf, & Zeid, 2017; Shafran-Tikva, Chinitz, Stern, & Feder-Bubis,
2017; Kowalczuk & Krajewska-Kułak, 2017; Hoyle, Smith, Mahoney, & 2017; Sun et al., 2017; Volz, Fringer, Walters, & Kowalenko, 2017).
Kyle, 2018). The literature examines the concept of violence, defined as According to the World Health Organization (WHO), workplace
any aggressive act, such as yelling, snide comments, withholding per- violence can be categorized as physical, psychological (emotional),
tinent information, and rude, ignoring, and humiliating behaviors, sexual and racial (Ray, 2007). Physical and psychological violence are
⁎
Corresponding author at: Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Consolare Valeria str. 1, 98125
Messina, Italy.
E-mail addresses: cmento@unime.it (C. Mento), antonio.bruno@unime.it (A. Bruno), mmuscatello@unime.it (M.R.A. Muscatello),
clemente.cedro@unime.it (C. Cedro), gianluca.pandolfo@unime.it (G. Pandolfo), rocco.zoccali@unime.it (R.A. Zoccali).
https://doi.org/10.1016/j.avb.2020.101381
Received 29 April 2019; Received in revised form 13 January 2020; Accepted 27 January 2020
1359-1789/ © 2020 Elsevier Ltd. All rights reserved.
C. Mento, et al. Aggression and Violent Behavior 51 (2020) 101381
both common, but psychological violence appears to be more popular. damage)- and 8% had been victim of serious physical violence and
Psychological violence can be defined as the intentional act against a sexual assaults (Vorderwülbecke et al., 2015).
person or collective force that results in physical, mental, spiritual, Violence against healthcare professionals is similarly an important
moral, and social harm, including insults, threats, attacks, verbal abuse problem in Turkey, with one study finding that 44.7% of all healthcare
(Ray, 2007; Peng et al., 2018). The health sector has the highest risk personnel are subjected to violence every year. Although nurses are the
(Schablon, Wendeler, Kozak, Nienhaus, & Steinke, 2018; Kleissl-Muir, highest at-risk group for violence in many parts of the world, physicians
Raymond, & Rahman, 2018; Kim et al., 2019; Bloom, 2019). The Na- and dentists were reported as the highest at-risk groups for workplace
tional Institute for Occupational Safety and Health (NIOSH) notes that violence in the health sector in Turkey (Bayram et al., 2017). Although
the public place where most violence towards employees can be ob- healthcare providers are increasingly concerned about the escalating
served is the hospital; healthcare workers are the most vulnerable incidents of workplace violence, there is a lack of evidence to support
professionals to workplace violence (Vorderwülbecke, Feistle, Mehring, this concern due to low reporting rates. A study found that only around
Schneider, & Linde, 2015; Sun et al., 2017; Shea et al., 2017; Volz et al., 15% of workplace violence cases were reported to police or public se-
2017). curity authorities. In addition, sometimes these cases were reported as
A shocking finding in international studies is that aggressive beha- negligence of physicians without proper investigation by the concerned
vior towards doctors is a usual occurrence (Vorderwülbecke et al., authorities (Ahmed, Memon, & Memon 2018).
2015); the reported cases of violence form the tip of the iceberg, Authors showed that almost every primary care physician had faced
whereas non-reported cases of violence remain as the submerged por- at least one violent event, be it mild, in the preceding 12 months of their
tion of the iceberg (Shea et al., 2017; Nico, Volz, Fringer, Walters, & work. In contrast, other international studies documented high per-
Kowalenko, 2017; Pinto, Radon, & van Dijk, 2018; Niu et al., 2019). centages of violence, although in those cases some participants were
In recent years, many doctors have been assaulted, seriously spared such mistreatment. One such study carried out in Japan from
wounded and even murdered by patients or relatives; consequently, 2007 indicated that 84.8% of the doctors had experienced violence
doctors and healthcare assistants are at high risk of serious injury or during their practice, 72.1% were verbally abused, whereas alcohol-
death in hospital settings due to attacks by patients (Tian & Du, 2017; associated harassment accounted for 51.8% (Ahmed et al., 2018).
Volz et al., 2017; Strickler, 2018; Schablon et al., 2018; Jeong & Kim, Studies undertaken in America in 2004 and 2015 have demon-
2018). Over the last two decades the percentage of assaults on strated that verbal abuse is the most frequent type of violence reported
healthcare assistants has been increasing across the globe. The in- by physicians and nurses (39–99%). Also, in a study in Pakistan, more
cidence of WPV against physicians was also reported to vary among than two-thirds of the respondents (n = 121/164, 73.8%) had been
departments and was substantially higher in emergency medicine and victims of violence in the preceding 12 months, with verbal abuse
psychiatry departments (Wu et al., 2015; Volz et al., 2017; Pinto et al., (n = 104/121, 86%) being the main type of aggression.
2018; Li, Zhang, Xiao, Chen, & Lu, 2019), which more often treat pa- In Jordan, the prevalence of verbal abuse by patients and visitors
tients with problems of substance abuse or mental illness (Pekurinen was approximately 63.9%, for physical abuse, 7.2% was committed by
et al., 2017). patients and 3.1% by visitors (Peng et al., 2018). In both the private and
Several recent studies have identified physicians' characteristics public sectors in Hong Kong, non-physical violence was found to occur
associated with the experience of WPV; for example long waiting lists, more frequently than physical violence; in addiction, there is a reported
perceived emergency, anxiety for the disease, or doctors being unable lack of readiness of many organizations in dealing with violence (Peng
to extend sick leave, or not willing to comply with patients' desires for et al., 2018).
prescription of certain types of drugs, in Countries where essentially all
these are freely available, but doctors are supposed to justify their ac- 2. Methods
tions to higher authorities (Bayram et al., 2017). This situation may be
highly distressing for healthcare assistants and entails a series of ne- 2.1. Research strategy
gative consequences, since psychological and physical violence among
health care workers is associated with decreased job satisfaction, in- This systematic review was conducted according to PRISMA
creased occupational strain, and poor patient care outcomes. Ad- (Preferred Reporting Items for Systematic Reviews and Meta-Analyses)
ditionally, WPV negatively influences health care workers' organiza- guidelines (Moher et al., 2009). PubMed database was searched from
tional commitment (Peng et al., 2018). January 1, 2014, to January 1, 2019, using 3 key terms related to WPV
The negative consequences of such widespread violence heavily (“Workplace violence”, “Aggression”, “Aggression department emer-
affect the delivery of healthcare services, calling upon the quality of gency”), and 3 key terms related to WPV consequences (“Mental
care. Moreover, in developing Countries equal access of care seekers to health” OR “Health care workers” OR “Burnout”). The electronic search
primary health care may be threatened if already scarce healthcare strategy used for PubMed is described in Table 1. Articles have been
workers abandon their profession because of the threat of violence; selected by title and abstract; the entire article was read if title/abstract
recent reports have shown that, in Bangladesh, violence against phy- was related to the specific issue of exposition to workplace violence
sicians perpetrated by patients or patients' attendants has increased,
and the severity has simultaneously intensified both in emergency and Table 1
indoor departments (Peng et al., 2018; Jalil, Huber, Sixsmith & Dickens, List of search terms entered into the PubMed search.
2017).
Number Search term
Recent studies have found out that people who experience psy-
chological violence are seven times as likely to be victims of physical 1 WORKPLACE Violence [all fields]
violence. In a study on hospital violence in China, the incidence of 2 AGGRESSION [all fields]
3 AGGRESSION DEPARTMENT EMERGENCY [all fields]
violence in hospitals has reached as high percentages as 95%, in-
4 MENTAL HEALTH [all fields]
dicating that physical and verbal abuse of medical staff is common 5 HEALTH CARE WORKERS [all fields]
(Peng et al., 2018). 6 BURNOUT
A study from Canada concluded that 29% of all participating pri- 7 1 OR 2 OR 3
mary care physicians had been exposed to aggressive behavior in the 8 4 OR 5 OR 6
9 7 AND 8
month preceding the survey: almost each one had experienced milder
10 English [language]
aggressive events, such as verbal insults and verbal abuse; 26% had 11 2014/01/01 to 2019/01/31 [publication date]
experienced moderate aggression - damage to property (criminal
2
C. Mento, et al. Aggression and Violent Behavior 51 (2020) 101381
Identification
Records identified through Records identified through
database searching other sources
PubMED (n=1.434) (n=0)
Records excluded
Records screened according to inclusion/
(n=1.334) exclusion criteria
(n=1.234)
Eligibility
Studies included in
qualitative synthesis
(n=27)
against health care workers, and if the article potentially met the in- duplicate articles, data derived from our research of articles included
clusion criteria. References of the selected articles were also examined study author names, publication dates, study aims, sample size and
in order to identify additional studies meeting the inclusion criteria. characteristics, type of measurement.
Articles were included in the review according to the following in- Fig. 1 summarizes the flowchart of articles selected for the review.
clusion criteria: English language, publication in peer reviewed jour- The search of PubMed database provided a total of 1434 citations; no
nals, quantitative information on workplace violence against healthcare additional studies meeting inclusion criteria were identified by
workers, and year of publication at least 2014. Articles were excluded checking the reference list of the selected papers. After adjusting for
by title, abstract, or full text for WPV against workers other than duplicates, 1334 records were screened. Of these,
healthcare, and for irrelevance to the topic in question. Further exclu- 1234 studies were excluded according to inclusion and exclusion
sion criteria were review articles, editorial comments, and case reports/ criteria.
series. Furthermore, we arbitrarily decided to start our research from After the screening, a total of 27 studies assessing the workplace
2014 to give a more recent view of “WPV against healthcare workers” violence against healthcare workers met the inclusion criteria and were
findings. included in the systematic review (Table 2); in particular 20 studies
focused on workplace violence and investigated the impact of training
2.3. Data extraction on more broadly aggressive accidents, which included verbal aggres-
sion and violence towards objects, and 8 studies focused on the ag-
Two authors (MCS, AB) performed the initial search, independently gression-related psychological vulnerability of healthcare professionals.
reviewed and selected the references based on the inclusion and ex- This review investigated the impact of workplace violence and
clusion criteria, and clarified any disputes in the presence of a third found that major violence is shown at emergency and psychiatric de-
expert reviewer (CM). The results were subsequently reevaluated by the partments. This situation is associated with negative consequences in
auditors, and the salient results were shown. After having discarded healthcare workers, such as increases in anxiety, anger, and depression
3
Table 2
Characteristics of the studies included in the review.
References Aims Sample size and characteristics Group characteristics Type of measurement
C. Mento, et al.
(Author, place)
Babanataj, Mazdarani, The aim of this study was to determine the effect of 30 nurses This study is an almost experimental The pretest-posttest approach was used in this
Hesamzadeh, Gorji, and training for resilience on nurses working in the unit intervention done by recruiting 30 nurses who study, and the nurses completed the Connor-
Cherati (2019) of intensive care and on their occupational stress were selected from critical care units of an Davidson Resilience Scale, and Expanded
and resilience levels. educational hospital in Sari City, Iran. Nursing Stress Scale, before and 2 weeks after
the training program.
Baby et al. (2019) This study aimed to evaluate the effect of an The participants were healthcare support workers The criteria of partecipants were as must be a The first questionnaire included demographic
intervention (communication skill training) to working in mental health services of the District healthcare support worker working for an NGO, data, Perception of Patient Aggression Scale-
reduce the experience of aggression for healthcare Health Board (DHB) and nongovernmental District Health Board, or Aged Care facility; aged New Zealand (POPAS-NZ), Kessler Psychological
support workers. organizations (NGOs) from 14 organizations 18 years and above; must be fluent in English; Distress Scale (K10), Impact of Events Scale-
across the Otago and Southland regions and able to provide informed consent; Revised (IES-R), and Interpersonal
Auckland region of New Zealand. Communication Competence Scale (ICCS).
Bayram et al., 2017 The aim of this study is to determine the prevalence 713 physicians Physicians currently practicing in EDs in Turkey. -Workplace Violence in the Health Sector
of violence directed at emergency department (ED) Country Case Studies Research Instruments-
physicians in Turkey and confirm the factors Survey Questionnaire, Geneva 2003, which was
influencing such violence. prepared by a joint programme by the
International Labour Office, International
Council of Nurses, WHO and Public Services
International.
Beattie et al. (2019) This paper examines the relationship between WPV Managers, directors, health/safety staff, nurses The partecipants worked in occupational health Semistructured, individual or group interviews
perpetrated by clients, their innate and educators (n = 99). and safety (OHS) or coordinated the hospital were conducted taking into account the
neurophysiological response to disease and the aggression management plan were invited to preferences of the participants for type of
resulting interactions with healthcare providers. participate. interview, time and place.
Seun-Fadipe et al. (2019) The objectives were to evaluate workplace violence 380 health workers. The participants were stratified according to The questionnaire was developed by
and risk for psychiatric morbidity, as well as their profession and the number of participants to be International Labour Organization/
4
correlates, among health workers in a tertiary recruited per profession was determined by International Council of Nurses/ World Health
healthcare setting in Nigeria. proportionate sampling to ensure proportional Organization/ Public Services International
representation of all professional groups as (ILO/ICN/WHO/PSI) joint programme on
follows: 99 doctors, 200 nurses, 11 pharmacists, workplace violence in the health sector (ILO/
16 workers from professions allied to medicine, ICN/ WHO/PSI, 2003) General Health
23 technical staff and 31 support staff. Questionnaire (GHQ-12).
de Looff et al. (2018) This study explored the association between type 114 forensic nursing. Nursing staff members worked in four Dutch -Maslach Burnout Inventory
and severity of aggressive behavior as experienced forensic psychiatric hospitals for clients with -Modified Overt Aggression Scale+
by nursing staff and staff's burnout symptoms. intellectual disabilities and severe challenging -The Modified Overt Aggression Scale.
behavior, such as aggressive behavior.
Farah et al. (2018) Aggression and Violence against primary care 769 primary care physicians aged 31. 769 doctors, 524 allowed to participate in the -The demographic data
physicians is reportedly common in Pakistan but survey. -the questionnaire included questions regarding
there is no documented study to-date on this the level of safety that primary care physicians
burning issue. felt during their work setups and on-call duties,
along with the experience of aggression against
them by the perpetrators & the support provided
by the hospital management in such cases.
Foster et al. (2018) The aim of this study was to evaluate the feasibility 24 nurses. The nurses were recruited from the two -Mental health was measured with the DASS 21
of a workplace resilience education programme for inpatient units. scale (Depression, Anxiety and Stress)
nurses in high-severity adult mental health settings. -Satisfaction with Life Scale
Jalil et al. (2017) To identify relationships between mental health Sixty-eight mental health nurses. Nurses who were designated keyworkers for -Positive and negative affect schedule –
nurses' exposure to patient aggression, their patients enrolled into a related study. expanded form.
emotions, their attitudes towards coercive -Perception of prevalence of aggression scale.
containment measures, and their involvement in -The attitudes to containment measures
incidents involving seclusion and restraint. questionnaire.
-Novaco anger scale provocation inventory.
Kowalczuk and Krajewska- The aim of this study was to assess exposure of 1624 healthcare workers. 493 nurses, 504 midwives, 501 physicians and - MDM Mobbing Questionnaire.
Kułak (2017) various professional groups of healthcare personnel 126 medical rescue workers.
to
(continued on next page)
Aggression and Violent Behavior 51 (2020) 101381
Table 2 (continued)
References Aims Sample size and characteristics Group characteristics Type of measurement
(Author, place)
C. Mento, et al.
5
distributed. prevalence of physical violence, and the
demographic
characteristics of perpetrators, attack time,
attack tools, and consequences;
-psychological violence,
including prevalence, response of healthcare
workers,
and workers' methods of dealing with
psychological
violence;
-organizational measures, including
incident reporting, supervisor support, and
training programmes.
Rafeea et al. (2017) This study explored workplace violence towards 120 people work in ED. The study included responses from 100 staff in -Demographic and professional background (15
emergency staff in the Ed of the BDF Hospital in the Ed of the BDF Hospital in Bahrain (doctors, questions)
Bahrain. nurses, and support personnel). The majority of -Exposure to violence (22 questions)
the participants were nurses. -Levels of burnout assessed by Maslach Burnout
Inventory (MBI).
Ramacciati et al. (2019) To analyze the dimensions and characteristics of 668 EDs in Italy. For the sample size calculation, they referred to - Questionnaire as the survey instrument
Violence towards Emergency Nurses in a national the survey findings of Becattini, Bambi, Palazz, -
context (Italy). Lumini, 2007 in 14 Italian regions in 2007, when
90% of emergency nurses declared to have
suffered from violence in the previous year of
work.
Schablon et al. (2018) The objective of the survey was to study the 181 workplaces. A total 81 workplaces participated in the study -The Interview topics included the description of
frequency and nature of violence and the handling with a potential of around 5000 employees who the specific violent event, the roles played by all
of aggressive behavior by facility management. met the required patient/client/resident/ involved, its contributing factors, and emotions
contact for a study participation. that arose during the episode.
Shafran-Tikva et al. (2017) 678 physicians, and nurses. -In-depth interviews
(continued on next page)
Aggression and Violent Behavior 51 (2020) 101381
Table 2 (continued)
References Aims Sample size and characteristics Group characteristics Type of measurement
(Author, place)
C. Mento, et al.
The aims of the study was to identify and describe Comprising 34% nurses and 66% physicians
the perceptions of staff and patients regarding the (93% response rate).
factors that lead to violence on the part of patients
and those accompanying them.
Shea et al. (2017) This study also examines the relative contributions The nursing and caring profession. The nursing and caring professions in Victoria, -Demographic questions for gender, age, job.
of demographic characteristics and workplace and Australia, Neary all respondents were female -Two items measures to examine respondent
individual safety factors in predicting OVA. and between the ages of 46 and 65 years. Most experience of Ova.
had been employed in the nursing and caring -The quantitative workload inventory
profession for more than 10 years. -individual safety factors were measured using
three scales: Safety motivation, safety
compliance, safety participation.
Sun, Gao, et al. (2017) This research aimed to determine the prevalence of 1899 healthcare workers. The healthcare workers from Heilongjiang, a The questionnaire they used to measure WPV
workplace violence (WPV) against province was developed in 2003 by an International
healthcare workers, explore the frequency in Northeastern China, completed the Labour
distribution of violence in different occupational questionnaire. Of the respondents, 83.3% Office (ILO), International Council of Nurses
groups, reported exposure (ICN), WHO, and Public Services International
and determine which healthcare occupation suffers to workplace violence, and 68.9% reported non- (PSI) joint
from WPV most frequently. physical violence. programme to measure workplace violence.
Sun, Zhang, et al. (2017) This study had three objectives: 2617 doctors. The survey was conducted among 1740 doctors In the present survey they used a 6-point Likert
-to identify in tertiary hospitals, 733 in secondary hospital scale, with ‘never’, rarely’, ‘occasionally’, ‘often’,
the incidence rate of WPV against doctors under a and 139 in primary hospital across 30 provinces ‘frequently’
new of China. and ‘every day’, to reflect the frequencies of
classification, work-related violence against doctors.
-to examine the association between
exposure to WPV, psychological stress, sleep quality
6
and
subjective health of Chinese doctors and
-to verify the partially mediating role of
psychological stress.
Jia Tian & Li Du (2017) In this paper, they explore how perspectives on the 661 chinese-language. In this study using the Sina Weibo's built-in The content analysis was conducted in two
LCPH incident and related opinions on stopping search tool, they established a dataset of 661 stages. They first conducted an exploratory
hospital violence is presented on the Weibo, or Chinese-language micro-blogs containing the thematic analysis on 10% of the dataset.
micro-blogs. search terms.
Volz et al. (2017) This pilot study investigates the prevalence of HV 67 physicians. 67 physicians residents (n = 25), and MLPs The survey consisted of 18 questions that asked
among emergency department (ED) (n = 24) in three unique EDs within a single participants to indicate with what frequency
attending physicians, residents, and mid-level multi-hospital medical system. (never, once, a few
providers (MLPs). Times, monthly, weekly, or daily) they have
witnessed or experienced a particular behavior
in the previous
12 months. Seven additional questions aimed to
elicit the impact of HV on the participant, the
work
environment, or the patient care.
Vorderwülbecke et al. (2015) To gauge the general sense of personal safety in 1500 primary care physicians. The total study population consisted of all The four-page questionnaire was developed after
primary care physicians in the surgery, on house resident primary care physicians who were an
visits and visits to homes, and during on-call active in Inspection of the original questionnaires from
duties (practice based or house visits). Germany in October 2013. several
International sources
Pekurinen et al., 2017 The aim of this study was to estimate and compare 5288 nurses. A sample of 5288 nurses (923 psychiatric nurses, The measure has been
the prevalence of patient aggression and the 4070 medical and surgical nurses, 295 used previously to assess the occurrence of
associations between patient aggression and the emergency aggression at work, not only regarding
wellbeing nurses) participated in the study. healthcare workers.
of nurses in psychiatric and non-psychiatric
(continued on next page)
Aggression and Violent Behavior 51 (2020) 101381
C. Mento, et al. Aggression and Violent Behavior 51 (2020) 101381
Environment (NRCWE).
as stressful environments and the care context can be perceived as a
Type of measurement
psychological harm.
days of absence and work-related accidents.
and improve their general health, reduce
reduced quality of life, since both physicians and nurses usually suffer
189 physicians
health (Baby et al., 2019; Foster et al., 2018; Kowalczuk & Krajewska-
Kułak, 2017; Nico et al., 2017; Shafran-Tikva et al., 2017; Tian & Du,
References
2017).
In conclusion, workplace violence can lead to various negative
psychological and physical outcomes in health workers; furthermore,
7
C. Mento, et al. Aggression and Violent Behavior 51 (2020) 101381
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senteeism, burnout, decreased job satisfaction, all factors that strongly with substance abuse and patient-related violence in the emergency department: A
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