Introduction
Verbal and physical violence against healthcare workers (HCWs) have reached considerable
levels worldwide, and the World Medical Association has most recently defined violence
against health personnel “an international emergency that undermines the very foundations
of health systems and impacts critically on patient's health” (1). Two systematic
reviews and meta-analyses published at the end of 2019 found a high prevalence of
workplace violence by patients and visitors against nurses and physicians (2), and
show that occupational violence against HCWs in dental healthcare centers is not uncommon
(3).
Recent Studies
In the first study (2), the authors systematically searched PubMed, Embase, and Web
of Science from their inception to October 2018, and included 253 eligible studies
(with a total of 331,544 participants). 61.9% of the participants reported exposure
to any form of workplace violence, 42.5% reported exposure to non-physical violence,
and 24.4% experienced physical violence in the past year. Verbal abuse (57.6%) was
the most common form of non-physical violence, followed by threats (33.2%) and sexual
harassment (12.4%). The prevalence of violence against HCWs was particularly high
in Asian and North American countries, in Psychiatric and Emergency departments, and
among nurses and physicians (2).
In the second study (3), a systematic review and analysis of the literature was done
using PubMed, ScienceDirect, Scopus, Web of Science, Cochrane Library and ProQuest.
Original articles published between January 1992 and August 2019 and written in English
were included in the analysis. The violence experienced by dental healthcare workers
was both physical and non-physical (shouting, bullying, and threatening) and also
included sexual harassment (3), and in most cases, male patients, or coworkers were
responsible. Violent events ranged from 15.0 to 54.0% with a mean prevalence of 32%,
and physical abuse ranged from 4.6 to 22% (3).
Most recently, the World Medical Association has condemned the increasingly reported
cases of health care workers being attacked because of the fear that they will spread
SARS-CoV-2. The situation in India is particularly shocking, with health care workers
stigmatized, ostracized, discriminated against, and physically attacked, but incidents
have been reported across the world, for instance from France, Mexico, Philippines,
Turkey, UK, Australia, and USA (4, 5).
Discussion
The recent systematic reviews and meta-analyses and the World Health Organization
condemnation of the attacks against HCWs treating patients with COVID-19 have confirmed
the seriousness of the situation regarding violence against doctors and nurses worldwide.
Many countries have reported cases of violence, and some are particularly affected
by this problem. A Chinese Hospital Association survey collecting data from 316 hospitals
revealed that 96% of the hospitals surveyed experienced workplace violence in 2012
(6), and a study done by the Chinese Medical Doctor Association in 2014 showed that
over 70% of physicians ever experienced verbal abuse or physical injuries at work
(7). An examination of all legal cases on violence against health professionals and
facilities from the criminal ligation records 2010–2016, released by the Supreme Court
of China, found that beating, pushing, verbal abuse, threatening, blocking hospital
gates, and doors, smashing hospital property were frequently reported types of violence
(8). In India, violence against healthcare workers and damage to healthcare facilities
has become a debated issue at various levels (9), and the government has made violence
against HCWs an offense punishable by up to 7 years imprisonment, after various episodes
of violence and harassment of HCWs involved in COVID-19 care or contact tracing (10).
In Germany, severe aggression or violence has been experienced by 23% of primary care
physicians (11). In Spain, there has been an increase in the magnitude of the phenomenon
in recent years (12). In the UK, a Health Service Journal and UNISON research found
that 181 NHS Trusts in England reported 56,435 physical assaults on staff in 2016–2017
(13). In the USA, 70–74% of workplace assaults occur in healthcare settings (14).
In Italy, in just one year, 50% of nurses were verbally assaulted in the workplace,
11% experienced physical violence, 4% were threatened with a weapon (15); 50% of physicians
were verbally, and 4% physically, assaulted (16). In Poland, Czech Republic, Slovakia,
Turkey many nurses have been physically attacked or verbally abused in the workplace
(17). According to the South African Medical Association, over 30 hospitals across
South Africa reported serious security incidents in just 5 months in 2019 (18), and
in Cape Town violence against ambulance crews is widespread (19). In Iran, the prevalence
of physical or verbal workplace violence against emergency medical services personnel
is 36 and 73% respectively (20). The World Health Organization lists Australia, Brazil,
Bulgaria, Lebanon, Mozambique, Portugal, Thailand as other countries where studies
on violence directed at HCWs have been conducted (21).
The consequences of violence against HCWs can be very serious: deaths or life-threatening
injuries (15), reduced work interest, job dissatisfaction, decreased retention, more
leave days, impaired work functioning (22), depression, post-traumatic stress disorder
(23), decline of ethical values, increased practice of defensive medicine (24). Workplace
violence is associated directly with higher incidence of burnout, lower patient safety,
and more adverse events (25).
Which are the most at-risk services and what are the underlying factors of this growing
violence? Emergency Departments, Mental Health Units, Drug and Alcohol Clinics, Ambulance
services and remote Health Posts with insufficient security and a single HCW are at
higher risk. Working in remote health care areas, understaffing, emotional or mental
stress of patients or visitors, insufficient security, and lack of preventative measures
have been identified as underlying factors of violence against physicians in a 2019
systematic review and meta-analysis (26).
In public hospital/services, insufficient time devoted to patients and therefore insufficient
communication between HCWs and patients, long waiting times, and overcrowding in waiting
areas (27), lack of trust in HCWs or in the healthcare system, dissatisfaction with
treatment or care provided (26), degree of staff professionalism, unacceptable comments
of staff members, and unrealistic expectations of patients and families over treatment
success (28) are thought to contribute. Indeed, in public hospitals worldwide, staff
shortages prevent front-line HCWs from adequately coping with patients' demands. In
private hospitals/services, too extended hospital stays, unexpectedly high bills,
prescription of expensive and unnecessary investigations are key factors. Finally,
the media frequently report extreme cases of possible malpractice and portray them
as representative of “normal” practice in hospitals (24).
What can be done to reduce the escalating violence against HCWs? HCWs worldwide generally
advocate for more severe laws, but harsher penalties alone are unlikely to solve the
problem. Importantly, evidence on the efficacy of interventions to prevent aggression
against doctors is lacking, and a systematic review and meta-analysis found that only
few studies have provided such evidence (29). Just one randomized controlled trial
indicated that a violence prevention program decreased the risks of patient-to-worker
violence and of related injury in hospitals (30), whereas contrasting results in violence
rates after implementation of workplace violence prevention programs have been observed
from longitudinal studies (29). There is no evidence on the effectiveness of good
place design and work policies aimed to reduce long waiting times or crowding in waiting
areas (29). More studies are clearly needed to provide evidence-based recommendations,
and interdisciplinary research with the involvement of anthropologists, sociologists,
and psychologists should be encouraged. However, certain measures have to be taken
and can be corrected, should they be shown as ineffective in properly conducted studies.
Security measures have been advocated for years (31) and should be taken to safeguard
particularly the most at-risk services. First, staff shortages, so common in public
hospitals worldwide, should be acted upon, and increased funding should be allocated
to employ more doctors and nurses. Hence, the duration of each patient encounter would
be augmented, particularly in overburdened public hospitals, allowing the (often young)
(32) doctors to develop a meaningful relationship with the patient. Second, healthcare
organizations and universities should considerably improve the communication skills
of current and future HCWs to reduce unrealistic expectations or misunderstanding
of patients and families. Third, HCWs who denounce any verbal or physical violence
should be fully supported by their healthcare organizations; this would reduce the
huge issue of under-reporting of workplace violence (33, 34). Good courses should
be organized for HCWs to learn how to identify early signs that somebody may become
violent, how to manage dangerous situations, and how to protect themselves.
Prompt communication about delays in service provision should be given to patients
and their relatives when waiting times are long because certain conditions are prioritized.
Alarms and closed-circuit televisions should be placed in the higher-risk departments
and in areas where doctors and/or nurses work in isolation. Sanctioning of violence
by patients, relatives or visitors must be imposed. Staff should be increased and
security officers should be placed, particularly at night, in remote Health Posts
and Emergency Departments and at particular times (violence tends to happen in the
evenings/nights, when more patients under the influence of drugs and alcohol present);
the number of night shifts should be limited (23). Efforts should be made to improve
job satisfaction of HCWs (25). Finally, media should cease to contribute to the general
public's distrust toward HCWs and institutions. Many patients report their negative
experiences of medical care to news or media outlets which are highly interested in
these stories and very often do not check the information before publishing it (24).
These biased media reports may exacerbate the tension.
All workers have a right to be safe on their job, and healthcare workers are no exception.
The idea that violence is inherent to doctors and nurses' work, especially in certain
departments, needs to be fought; urgent measures must be implemented to ensure the
safety of all HCWs in their environment, and the needed resources must be allocated.
Failure to do so will worsen the care that they are employed to deliver and will ultimately
negatively affect the whole healthcare system worldwide.
Author Contributions
SV had the idea of writing the manuscript and drafted it. FC co-drafted the manuscript.
AV contributed to the drafting, and reviewed the manuscript. All the authors approved
the final version.
Conflict of Interest
The authors declare that the research was conducted in the absence of any commercial
or financial relationships that could be construed as a potential conflict of interest.