Workplace violence against the healthcare workers – call to action

Workplace violence against health workers is common within the healthcare system and yet there seems to be significant underreporting of workplace violence in healthcare. The most common type of workplace violence is verbal abuse. However, there seems to be a significant proportion of physical violence. Perpetrators vary, from patients and their families to co-workers, although less frequently. This article aims to present what workplace violence is, its prevalence, types, consequences, and possible interventions to reduce workplace violence.

INTRODUCTION

Workplace violence (WPV) is defined as: “any act or threat of physical violence, harassment, intimidation or other threatening disruptive behavior that occurs at the work site” [1]. In Serbia, workplace violence is defined as: “any repeated active or passive behavior towards an employee or a group of employees aimed at injuring the dignity, reputation, personal or professional integrity, health, and status of the employee, that causes fear or creates a hostile, humiliating, or offensive environment, deteriorates the working conditions and leads to the isolation of the employee or to his/her self-initiated termination of the employment contract or other contracts” [2]. Different modalities and levels of severity of workplace violence range from threats, including verbal abuse, to physical abuse, and sometimes even homicide [3].

Workplace violence in healthcare – types and prevalence

Workplace violence seems to be especially frequent in healthcare settings, and workers in healthcare appear to have as much as a five times higher likelihood of being the victims of workplace violence, as compared to other sectors [1],[3],[4]. Even more worryingly, there seems to be very significant underreporting of workplace violence, and the actual prevalence is likely even higher [4]. The lifetime prevalence of exposure to workplace violence in China is 95%, while the reported prevalence of exposure to workplace violence among healthcare workers in primary care in Serbia is 52.6% [4],[5]. The most common type of violence the healthcare workers are exposed to is verbal abuse, however, there seems to be a significant proportion of physical violence as well, ranging from 6.4%, in Brazil, to 71.1%, in South Africa [6],[7],[8]. Furthermore, almost one in ten nurses reported exposure to sexual violence at the workplace in Nepal, China, and Ethiopia [9],[10],[11]. The most common perpetrators of workplace violence against healthcare workers worldwide are the patients’ family members, patients’ friends, and the patients themselves [12].

Types of workplace violence in healthcare

According to the US National Institute for Occupational Safety and Health (NIOSH) workplace violence in healthcare settings can be classified into four types:

• Type 1 comprises criminal intent, and it accounts for situations wherein the perpetrator is committing a crime accompanied by violence;
• Type 2 is the most common form of WPV in healthcare settings, and it is based on the client relationship between the victim and the perpetrator;
• Type 3 WPV includes acts of violence perpetrated by a co-worker, commonly manifested as offensive or demeaning behavior towards a colleague;
• Type 4 is violence stemming from a personal relationship with the perpetrator [13].

Factors associated with exposure to workplace violence

Factors associated with WPV can be personal factors related to the employee, organizational factors related to the healthcare institution, and factors associated with the individual or health characteristics of the perpetrators.

Personal employee characteristics associated with exposure to workplace violence in healthcare include younger age, female sex, and the profession of a nurse, as they are more often exposed to workplace violence than doctors [4],[8]. Sometimes, healthcare workers can be exposed to violence as a consequence of the treatment provided not meeting the expectations of the patients or waiting times being longer than expected [4],[14].

Additional risk factors of exposure to workplace violence are related to work organization and include job demand, job insecurity, and social support [8],[15].

Factors associated with workplace violence committed against healthcare workers are sometimes caused by the patient’s health status, specifically the presence of conditions like delirium, various psychiatric conditions, alcohol or substance intoxication [12],[14]. For example, almost 90% of all physical assaults against assistants in nursing homes are associated with dementia in patients [16].

Consequences

The consequences of workplace violence are personal and organizational [17],[18],[19]. The consequences for the healthcare institution and the work process include loss of trust between the workers and the managers and the development of a toxic workplace environment [18]. This affects the work process as well, through absenteeism, low productivity or complete loss of productivity, or dissatisfaction with one’s job. A little over one in eight days of absenteeism in healthcare is associated with exposure to workplace violence [17].

The consequences of exposure to workplace violence to the workers include acute and chronic consequences, physical injuries and psychological trauma, and sometimes even death [17],[19].

Interventions

Interventions aiming to reduce workplace violence in healthcare can be directed towards the prevention of workplace violence and the reduction of its impact [20],[21]. The efforts towards the prevention of workplace violence in healthcare settings aim to decrease the possibilities for its occurrence and can be environmental, organizational, and behavioral.

Environmental efforts include improving the working environment, such as improving lighting, patient waiting areas, and camera surveillance [20]. Another possibility is setting up alarm systems [22], although some studies have shown an increase in the recording of workplace violence cases [22].

Proper staffing, an appropriate number of physicians and nurses, including the appropriate number of staff in night shifts, improvement of communication, and development of work guidelines, are some of the organizational efforts towards the prevention of workplace violence in healthcare [20]. Behavioral measures include training the workers in de-escalation methods and self-defense [20], including online training programs, classroom training programs, or hybrid programs [20]. Although there is still not enough evidence on the effectiveness of all the interventions, it seems that a multidimensional approach, i.e., using all types of interventions, may be the most effective approach [20]. Policy responses, including guidelines issued by the ministries of health, and policy support for the allocation of security guards can be effective in settings wherein other preventive measures have failed [23].

On the other hand, interventions aimed at reducing the impact of workplace violence often rely on cognitive behavioral therapy and have been shown to reduce the effects of exposure to workplace violence on the quality of provided services and overall work performance [21].

CONCLUSION

Workplace violence in healthcare is significantly more prevalent than in other sectors, and a huge majority of healthcare workers have reported at least one such incident in their careers. The most common perpetrators of workplace violence in healthcare are patients’ relatives and the patients themselves. There is a need for the development and rigorous assessment of preventive and coping interventions aiming to protect healthcare workers against workplace violence.