Inadequacy of interventions to eliminate or reduce violence against healthcare professionals by patients and/or their relatives

Abstract

Workplace violence (Type II), which is defined as verbal, physical and sexual assault behaviour directed at healthcare workers by patients and their relatives, is a complex concept arising from a variety of individual, social, economic, cultural and political factors. Despite differences in its definition, classification, and the destructive consequences it produces, workplace violence is a growing public health issue worldwide. It affects not only the healthcare worker who experiences it, but also the institution where the incident occurs, other patients and their families, and the perpetrator of the violent act. Every year, countless healthcare workers are harmed. The violence prevention strategies introduced by governments are aimed at managing violence and are still far from permanent and functional solutions. Permanent and effective solutions require a thorough and comprehensive approach to the issue. This study evaluates the effectiveness of workplace violence prevention programmes in line with the current literature. Primary, secondary and tertiary prevention interventions are addressed in depth. It is evident that intervention programmes alone, at any one level, are insufficient to eliminate workplace violence and that a comprehensive programme is required. Additionally, the necessity of eliminating the risk factors that cause workplace violence, rather than merely managing them, is discussed. The results of this study are expected to inform health policy.

Key Words: Workplace violence; Workplace violence among healthcare workers; Workplace violence intervention programmes

Core Tip: Workplace violence has become an escalating global public health concern, affecting a growing number of healthcare workers each year. Countless professionals suffer physical, psychological, and occupational harm as a result of such incidents. Government-implemented violence prevention strategies have largely focused on the management of violent episodes rather than their prevention, offering limited and short-term solutions. However, sustainable and effective outcomes require a broad and integrated approach that addresses the issue comprehensively. Intervention programs implemented at a single level-whether individual, organizational, or societal-have proven insufficient on their own. Therefore, there is a pressing need for a comprehensive, multi-level intervention framework that simultaneously targets all contributing factors. The results of such an approach are expected to inform public health policies and guide the development of evidence-based strategies to protect healthcare workers and improve workplace safety.

INTRODUCTION

There are various definitions of workplace violence. The 2019 Occupational Health and Safety Act defines it as the use of physical force by a person in a workplace against a worker that causes or could cause physical injury to the worker; an attempt to use physical force; or a threat to use physical force[1]. The European Commission defines workplace violence as harm suffered by individuals in the workplace or while commuting as a result of being threatened or attacked[2]. The International Labour Organization defines it as any behaviour deviating from reasonable conduct, including violence, harm or threats experienced by an individual during or in connection with their work[3,4]. In 2020, the World Health Organization defined workplace violence as any overt or covert behaviour that threatens the health and safety of workers, including during their commute to and from work, such as challenging behaviour, threats, and assaults[5]. While there is no single agreed definition, these definitions have one thing in common: They encompass any behaviour or incident that is deliberately carried out with the intent to cause physical and/or psychological harm to a worker in relation to their work. While previous studies have primarily focused on physical violence due to its clearer and more concrete definition, the profile of workplace violence has now shifted, with equal importance being given to non-physical violent behaviour[6]. Workplace violence is now recognised as a common issue across all societies[7]. It has been reported that healthcare workers are at a higher risk of experiencing various types of violence in the workplace[8].

Violence in healthcare institutions is defined as verbal, physical or sexual assault committed against healthcare workers by patients and/or their relatives or other individuals, posing a threat to their physical or psychological health[9]. The WHO classifies workplace violence into two main categories according to its nature: Physical and psychological. Psychological violence is categorised into four groups: Threats; abuse; harassment, which is subdivided into sexual and racial harassment; and bullying/intimidation. These types of violence are intertwined. For instance, an individual experiencing sexual violence may also experience psychological and physical violence[10]. Physical violence is the most straightforward form of violence to define; it is defined as hitting, slapping, kicking, pushing or being subjected to physical contact with the intent to hurt or harm[6,11]. Psychological (emotional) violence, on the other hand, aims to damage a person's sense of self-worth and self-respect, causing them to feel inadequate. It is used by the perpetrator to control the victim. Exploiting an individual's emotions and emotional needs is a deliberate use of power that has a negative effect on mental and emotional health[12].

All of these workplace violence incidents range from simple arguments affecting the daily routine or psychological health of healthcare workers, to incidents resulting in loss of life. At a workshop held in 2024, the Turkish Medical Association categorised workplace violence into five levels. The first level includes arguments, shouting, obscene gestures, and emotional blackmail. Such incidents affect the psychological well-being of healthcare workers and disrupt their daily routine. The second level involves severe verbal abuse, such as swearing, death threats and aggressive comments. The third level involves physical assault. This causes psychological distress to healthcare workers, but does not result in physical injury. The fourth level involves physical assault behaviours that cause serious injury and psychological distress, such as vision impairment, fractures or dislocations, and other injuries and disabilities. The fifth and final level is the most destructive, involving death or permanent functional disability, which is irreversible[13].

Incidents of workplace violence have consequences that extend beyond the moment of the incident itself. These consequences affect not only the healthcare worker, but also their family members and individuals in their social circle. Workers exposed to physical and/or psychological violence experience anger and fear in the short term, and burnout, depression, anxiety, social withdrawal, eating and sleeping disorders, a desire to leave the profession and a decline in work performance in the long term[8,14,15]. They may also experience post-traumatic stress disorder, which is characterised by feelings of resentment and emotional arousal when the event is recalled. This event is perceived as unjust, a personal insult, and a violation of fundamental beliefs and values. Workers may also exhibit risky behaviours such as smoking, alcohol use, use of anxiolytic medications, and decreased physical activity[5]. Other common consequences include changes in attitudes and decision-making, increases in defensive medical behaviour (e.g. overprescribing medication, conducting unnecessary tests and making inappropriate referrals and consultations)[16], and a general lack of empathy towards patients. This can lead to decreased job satisfaction and a dislike of work, or even a refusal to work[17,18]. Other consequences include tension-type headaches, gastritis-type stomach pains and heart problems[19].

Incidents of violence negatively affect the physical, psychological and mental health of healthcare personnel, as well as their motivation to work. This can manifest as repeated absenteeism or lateness, increased staff turnover, decreased productivity, and increased insurance costs. Workplace violence negatively affects employees' motivation, organisational commitment and work environment, thereby causing indirect costs for organisations. In the United States, it is estimated that workplace violence results in an annual staff turnover rate of between 15% and 36% among nurses[1,20]. The financial burden resulting from compensation claims filed following violent incidents is also among the organisational-level impacts on healthcare institutions[21].

Workplace violence also has societal implications. It leads to reduced service effectiveness, compromised quality of patient care, lower clinical care[22,23], poorer work performance and increased neglect, impaired cognitive functioning among employees and defensive medical practices[3,24], early retirement of healthcare workers who are victims of violence[25], production losses due to reasons such as leaving work as a result of injuries caused by violence[26], personnel turnover costs, treatment of injuries caused by workplace violence, and time spent away from work due to violence[27] are among the social and financial consequences. There are no complete statistical data on the prevalence of workplace violence in healthcare institutions. Therefore, it is not possible to make a realistic assessment of direct and indirect costs such as the number of lost workdays and treatment costs in cases of mental or physical trauma[28]. However, worse than all the costs and financial losses is the impact of high workplace violence rates in the healthcare sector on the mental health of healthcare workers and the declining quality of care in healthcare services day by day[29].

Workplace violence is a worldwide public health problem[30]. According to the World Medical Association, rates of violence vary from country to country. Although violence is more prevalent in developing countries, it is also common in high-income, industrialised nations such as France, the United Kingdom, Australia and the United States[1]. Reports from the Federal Bureau of Labor Statistics indicate that approximately 75% of the 24000 workplace assaults that occurred each year between 2011 and 2013 took place in the healthcare sector[5]. This suggests that violence from patients poses a serious occupational hazard in general hospitals in the United States. Studies indicate that workplace violence is prevalent in 78% of healthcare institutions in the United States[31], and that the annual nurse turnover rate due to workplace violence ranges from 15% to 36%[1,20]. In Canada, the prevalence of workplace violence in healthcare institutions is 75% for verbal violence and 39% for physical violence[32]. A 2014 study by Edward et al[8] stated that nurses are generally exposed to verbal violence, with a ratio of 3:1 between verbal and physical violence. The frequency of verbal violence can reach 94.1% in Canada, with an overall average ranging between 94% and 97%. A systematic study conducted by Njaka et al[33] in 2020 examined violence data from Africa between 2000 and 2019. It was found that the prevalence of workplace violence against healthcare workers ranged from 9% to 100%. The highest rates were found in South Africa (54%-100%) and Egypt (59.7%-86.1%), while the lowest rate was found in Ghana (9%-73.99%). A 2021 study in Ethiopia found that workplace violence prevalence was 64%, with patients and their relatives being the main perpetrators of all types of violence[18]. The first study of its kind to focus on workplace violence against nurses, conducted in The Gambia in 2017, reported a violence rate of 62%, with verbal abuse being the most common form. According to Gambian law, nurses account for a significant proportion of those who write prescriptions in public secondary healthcare institutions, and participants reported that when prescribed medications are insufficient, the situation often escalates into violence against nurses[34]. As in the rest of the world, a rise in violence against healthcare workers has been observed in Asian countries in recent years. A study by Alsuliman et al[35] attributed the increase in violence to the pandemic. During this period, Asian medical students and healthcare workers reported experiencing violence in real life and cyberbullying because they were perceived as the source of the virus. The prevalence of physical violence in Asian countries has been reported to have risen from 19.6% between 2000 and 2009, to 25.0% between 2010 and 2018[36]. In China, a country with one of the lowest murder rates in the world, 29 murders were reported in hospitals[37]. Nearly 40%-50% of medical school graduates in China do not begin their careers due to violence[38]. Another study reported that 24 healthcare workers (doctors and nurses) died as a result of workplace violence in China between 2003 and 2013[39]. Workplace violence was reported to be prevalent in Japan (84.8%), Pakistan (51%), and India (63%)[18,40]. A study conducted in Hong Kong included 850 nurses. It reported that 44.6% of nurses had experienced workplace violence in the previous year, finding that shift work, job satisfaction, conflicts with colleagues, intentional self-harm and anxiety symptoms were significantly associated with it[23]. A study of 11095 healthcare personnel in Japan found that 36.4% had been exposed to workplace violence by patients or their relatives in the previous year[41]. A 2020 study in Syria involving 1226 assistant doctors found that 84.74% had encountered at least one type of violence during their shifts in the 12 months prior to the survey, which was much higher than previously reported[42]. In India, more than 90% of healthcare workers are exposed to violence in the workplace[43]. In a tertiary hospital in Delhi, 40.8% of assistant doctors have experienced violence in the workplace in the last 12 months[44]. In Germany, 70.7% of healthcare workers have experienced physical violence, and 89% have experienced verbal violence, 4% have experienced verbal violence[45]. In Italy, the annual prevalence of violent incidents among healthcare workers ranges from 48.6% to 65.9%, and in Australia, verbal violence most frequently occurs in emergency department triage areas, with 9% of nurses experiencing it on a weekly basis[46]. The situation is similar in other countries. For example, a 2015 study in Greece found that 83.4% of healthcare workers had previously experienced workplace violence, but 52% did not report it to hospital management. Verbal violence was the most common type of violence reported[47]. A study of 12944 healthcare workers in Turkey found that 44.7% had experienced violence in the workplace in the past 12 months, including 6.8% physical violence, 43.2% verbal violence, 2.4% bullying and 1% sexual violence[48]. Another study involving 1209 healthcare workers from 34 centres found that 49.5% had been subjected to verbal, physical, or both verbal and physical violence[49]. While the national and international studies cited above provide some insight into workplace violence in healthcare, it is challenging to determine accurate figures due to under-reporting and differences in definitions of violence. Nevertheless, the high incidence of violence reported in the available data demonstrates the imperative of prioritising the prevention of workplace violence.

Research on workplace violence experienced by healthcare workers shows that violence is a significant problem across all professions in the healthcare sector. Almost all healthcare workers experience at least one type of violence during their professional lives, with verbal violence being the most common form[50]. Women healthcare workers are particularly affected by this issue, with general practitioners and nurses being the most frequent victims of violence, perpetrated most often by patients and/or their relatives. Healthcare workers who experience violence derive less satisfaction from working directly with patients or providing care. Consequently, violence reduces the quality of healthcare, so more effective strategies must be developed to prevent it[19]. This is because workplace violence affects not only the victims, but also their colleagues, families, employers and social circles[51]. Furthermore, studies show that a significant proportion (75.4%) of healthcare workers who have experienced workplace violence believe that it can be prevented[15]. Studies emphasising the need to shift the focus from equipping healthcare workers with tools to manage violence, to targeting perpetrators and developing prevention standards focusing not only on physical attacks, but also on non-physical behaviours undermining a culture of safety, such as verbal abuse and harassment[22], show that healthcare workers believe in the effectiveness of violence prevention.

Despite this belief, examining the phenomenon of violence from a multifaceted perspective that encompasses cultural, social and organisational factors, and developing a simple, universally applicable solution to reverse the increasingly widespread and disturbing trend of violence worldwide, is not an easy or feasible task[5]. While it is extremely difficult to develop a single intervention programme targeting this issue, the World Health Organisation, in collaboration with the International Labour Office, the International Council of Nurses and the International Public Services, published a set of guidelines addressing workplace violence in the health sector in 2002. While some governments have not implemented these recommendations, others have introduced initiatives to prevent workplace violence. For instance, in 2016, the Western Australian government adopted an organisational approach to violence as part of its employment policy framework, updated in 2019. This approach provides support to employees experiencing violence and adopts a zero-tolerance policy towards it[35]. The United States Occupational Safety and Health Administration has outlined five key elements that should be present in healthcare institutions as part of workplace violence prevention programmes. The first element is the support of the institution's management and the participation of its employees. The second is analysing work areas and identifying potential hazards. This involves a step-by-step evaluation of the workplace to identify existing or potential hazards that could lead to incidents of workplace violence. The third element is the process of preventing and controlling hazards. The fourth element is safety and health training. The fifth element refers to record-keeping and programme evaluation. Different reporting systems for acts of violence are used around the world. Ascension hospitals in the United States have a digital infrastructure called the Dynamic Online Event Reporting System, which can be accessed from any computer connected to the hospital's automation system. Through this portal, healthcare workers can enter relevant situations as reports into the system. These reports are then forwarded directly to the hospital's occupational health personnel, security director and human resources department[52]. In Turkey, violent incidents have been recorded since 2012 in accordance with a circular published that year using the White Code system. Incidents reported to the legal authorities are recorded using this system.

Intervention programmes aimed at preventing workplace violence against healthcare workers are implemented at three levels: First, second and third level.

LEVEL ONE: INDIVIDUAL INTERVENTION PROGRAMMES

These interventions focus on the personal attitudes, beliefs and behaviours of each employee that can reduce their risk of victimisation. They focus on healthcare workers' interactions with patients and their families. The first step in proposing solutions is establishing good communication and a positive culture. This can be achieved by fostering harmonious relationships between employees and patients based on respect, tolerance, and cooperation.

Studies have emphasised the need to implement these programmes alongside mandatory in-service training on workplace violence. These training programmes should include communication skills, conflict management and reducing tension during aggressive incidents[42], as well as service psychology and service behaviour[34]. It is also recommended that these programmes include training to teach all employees how to protect themselves and their colleagues from violence by being aware of potential dangers[38]. In the United States, a study by the National Institute for Occupational Safety and Health involved new and experienced healthcare workers who had not received any training. They participated in online programmes involving case study simulations, and after completing the training, they expressed positive views about it in focus group interviews[53]. There are also studies in the literature showing that first-level individual intervention programmes are effective. One such study, which involved a total of 1688 participants from the United States, Switzerland, the United Kingdom, Taiwan and Sweden, aimed to evaluate the effectiveness of education and training interventions aimed at preventing workplace violence. The study reported that educational programmes had a short-term impact on violence[4]. Although first-level individual intervention programmes are widely used to prevent violence among healthcare workers, there is currently no evidence that they are successful[29]. It is important to note that these programmes are only conducted with healthcare workers and exclude the perpetrators of violence (patients and their relatives), which is why they are ineffective. However, community-based violence prevention education programmes are necessary to raise awareness of workplace violence. Including patients and their relatives in individual-level prevention programmes would achieve the goal of establishing good communication and a positive culture at both the individual and societal levels.

SECOND LEVEL: ORGANISATIONAL/INSTITUTIONAL INTERVENTION PROGRAMMES

These programmes can be implemented at the administrative level of hospitals. They include increasing the number of healthcare workers and improving their working conditions. The literature shows that effectively implementing these programmes plays an important role in preventing violence. Strategies such as increasing the number of employees, investing in hospital human resources, improving staff-to-patient ratios to reduce shortages, regulating healthcare workers' workload, preventing consecutive night shifts and long hours, and reducing employees' workload are important[42]. Within the scope of engineering measures, strengthening security structures such as assistance or panic buttons, telephone lines that connect directly to security and the police, lighting and mirrors[5], installing security cameras and video surveillance systems[34], restricting companion access and using metal detectors and security alarm systems are reported to be important in preventing violence[38]. In addition, according to those who report it, violence occurs significantly more frequently in facilities where reporting procedures and culture are lacking. Therefore, reducing waiting times at all stages of service[54], informing patients about the reasons for waiting and paying attention to comfort are among the factors that can contribute to reducing workplace violence[5]. Furthermore, measures such as utilising assessment teams (through existing joint occupational health and safety committees) to enhance safety in vulnerable areas[29] and establishing comprehensive institutional guidelines and clear, reliable procedures for the mandatory reporting of violent incidents using simple, fast and user-friendly technologies can contribute to reducing workplace violence[18]. Studies have examined the opinions of healthcare workers on the content of secondary prevention programmes. In a study conducted in Balgledaş, healthcare workers reported that safety measures were the most common, but these were reactive rather than proactive, only being effective in preventing physical violence rather than workplace violence as a whole. Participants also reported that restricting perpetrators' access to health services in public institutions and organisations, as well as restricting financial transactions in hospitals, could be effective[55]. A study conducted in five participating countries (Turkey, Spain, Poland, the Czech Republic and Slovakia) indicated that there were statistically significant differences between countries in terms of reported perpetrators. Unlike the other four participating countries, it was reported in Turkey that healthcare workers were mostly subjected to attacks by patients' relatives[56]. In this context, controlling attendants is also important.

THIRD LEVEL: COMMUNITY INTERVENTION PROGRAMMES

These programmes focus on addressing workplace violence against healthcare workers at a legal level. In these programmes, policymakers aim to enact more laws to protect healthcare workers and strengthen existing legislation. Useful and powerful strategies include strengthening the law, defining violence as a crime that cannot be ignored, implementing relevant laws completely, continuing the important role of the media without interruption and organising public campaigns[22]. The correct use of mass media such as newspapers, magazines, books, radio, television and the internet is important for public campaigns. It has been stated that the effective use of mass media can influence decision-making processes, facilitate the creation of deterrent legislation against perpetrators of violence, and thus contribute to reducing violence[57].

Examining the literature reveals that many intervention programmes have been developed, ranging from zero-tolerance approaches to violence to getting close to the perpetrator. However, it is reported that there is no evidence that any of these interventions prevent violence on their own[1,4,22]. A holistic approach that incorporates first, second and third level intervention programmes is required to prevent violence. Existing interventions generally focus on proposals to manage existing violence rather than prevent violent events, and aim to eliminate risk factors. While it is rational to assume that programmes targeting risk factors would provide a more permanent solution than managing violence, interventions regarding the elimination of risk factors should be implemented holistically at individual, institutional, and societal levels. Programmes implemented separately and without a holistic approach are ineffective. Research on this subject also proves this. A 2024 study analysed intervention programmes for preventing violence against healthcare workers and evaluated the effect of a 60-minute training programme for healthcare workers. Contrary to expectations, however, no difference was found in terms of events before and after training[58]. Another study from 2023, which included a variety of studies ranging from pharmacological interventions for aggressive patients to training programmes for healthcare professionals, concluded that the success of a single intervention programme could not be determined[59]. A cross-sectional study on the prevention of workplace violence in Thai emergency services found no relationship between hospitals having security systems and physical violence[60]. A 2020 Italian study emphasised that psychosocial working conditions should be considered alongside other factors to prevent workplace violence. It also stated that social support is a protective factor and that stress experienced by healthcare professionals at work may make them more vulnerable to third-party violence. The study concluded that improving psychosocial working conditions could help prevent violence and its consequences in the workplace[61]. The results of the study stated that practical, acceptable and sustainable workplace violence prevention programmes and procedures should be created and established according to the needs of healthcare professionals[38]. These results should be taken into consideration.

CONCLUSION

Programmes designed to prevent workplace violence to which healthcare workers are exposed are inadequate. Such programmes require a holistic guide that acknowledges that workplace violence is caused by personal, organisational and social factors, and that it occurs as a result of complex interactions between parties, organisational and environmental factors, and social variables. The guide must also recognise that there are many risk factors, such as the cultural structure of society and the inadequate functioning of the justice system, and that laws and the judiciary can produce incomplete or undesirable outcomes. Creating a single guide for the joint implementation of individual, institutional and social intervention programmes could provide a holistic understanding. This holistic understanding could be the key to a permanent solution.