International Journal of Emergency Mental Health and Human Resilience
Open Access

According to the definition of The National Institute for Occupational Safety and Health (NIOSH), Work Place Violence (WPV) is described as violent acts directed toward persons at work or on duty (CDC, 2002). The main types of WPV are known to be physical/verbal/sexual assaults, mobbing and bullying. Emergency Department (ED) is one of the most common places for WPV in the hospital setting (Kansagra, et al. 2008). Even if patients, their relatives and friends are the main perpetrators, co-workers and managers of the health care workers may, as well, be the source of violence (Gerberich, et al. 2004). Since majority of violence in the ED setting is underreported, true incidence of violence is unknown (Fernandes, et al. 1999). Workplace violence towards health care providers results in anger, anxiety, fear, and decreased job satisfaction (Kansagra, et al. 2008). In this article, we aimed to identify the incidence and characteristics of WPV and compare public and private hospitals in respect to WPV.

Samsun is a large city with a population of about 605000 in the city center located in the Black Sea Region in Turkey. In this cross-sectional study, 4 private hospitals and 3 public hospitals (including the university hospital) in Samsun were investigated. After obtaining necessary permits from the Ministry of Health, a survey including 11 questions was performed to identify incidence and characteristics of WPV against ED workers. The survey was based on a combination of Employee Risk Assessment Questionnaire Workplace Violence by The Industrial Accident Prevention Association (2007) and Workplace Violence Survey by Ontario Safety Association for Community and Healthcare (2010). The ED staff was divided into two subgroups in respect to their institution (private vs public hospital). Ten specialist doctors, 22 practitioner doctors, 20 ED residents, 63 nurses, 42 paramedics, 18 health officers, 24 cleaning staff, 34 secretaries and 8 transport staff were involved into the study as volunteers (241 workers in total). Among the participants, 65 were working in private hospitals, while 176 were working in public hospitals. In the survey, demographical properties of the staff, whether they were exposed to violence in the last month, type, source and number of assault, whether they feel secure in the workplace were asked.

Statistical analyses were performed with SPSS 15.0 for Windows. Descriptive data were presented as numbers and percentages. The Shapiro–Wilk test was used to analyze normal distribution assumption of the quantitative outcomes.

The Mann-Whitney U test was used for non-normal data. Pearson Chi-square test was used to compare frequency. p<0.05 was accepted as statistically significant in comparisons.

Of the participants, 131 were male (54.4%) and 110 were female (45.6%). Majority of the workers were in age range of 30-39 years (44%). This study revealed that 63% of the ED workers were exposed to workplace violence at least once within a month (n=176). Characteristics of the participants and assaults are summarized in Table 1. Among the workers, practitioners had the highest incidence of exposure to WPV (95.5%), followed by resident doctors (80%). With a rate of 50%, specialist doctors had the lowest incidence and this finding was found to be statistically significant (p=0.01). The most common type of assault was verbal (n=68, 38.6%). Assailants were commonly relatives of the patients (n=105, 59.7%) followed by both patient and their relatives (n=46, 26.1%) and patients (n=14, 8%). While the most common type of verbal violence was found to be shouting (n=53, 30.2%), followed by swearing (n=22, 12.5%), the most common type of physical assault was found to be pushing and/or pulling (n=30, 68.1%). Of the participants who were exposed to verbal violence, 72.6% expressed that violence occurred more than once. Physical violence occurred more than once in 40.2%. While all participants who were sexually assaulted (n=3) were working in public hospitals, all participants exposed to violent acts from their managers (n=3) were from private hospitals. Our study also revealed that majority of the workers (92%) do not inform necessary authorities about the assaults and majority of the cases remained underreported.

Table 1: Characteristics of the participants and violent acts aiming them.

A 5-point Likert scale was applied (never, rarely, sometimes, most of the time, or always) to measure the feeling of workplace safety. When all the participants are considered, 138 (57.2%) employers expressed that they do not feel safe in the workplace, while 22 of them expressed that they feel safe. Remainings stated that they feel safe partially.

When public and private hospitals are compared according to type and frequency of the violence, any statistical significance could not be determined. In both institutions, the most common type of assault was verbal and relatives of the patients were the most common source of workplace violence. When the staff was questioned whether they felt safe in the workplace, it was determined that workers in the ED of private hospital felt safer when compared to those in public hospitals (24.6% and 3.4%, respectively). This finding was also found to be statistically significant (p<0.05). Comparison of public and private hospitals in respect to WPV in the ED is summarized in Table 2.

Table 2: Comparison of public and private hospitals in respect to workplace violence.

In this study, it was determined that a great proportion of health care workers in the ED face WPV. It is known that WPV in the ED is a growing problem with its increasing incidence all over the World. It is also known that as the level of development of a country decreases, frequency of WPV aiming health care workers increases. A study in Lebanon revealed that 4 in 5 ED employees were verbally abused and 1 in 4 were physically abused in a 12-month-period (Alameddine, et al. 2011). High rate of WPV in hospitals in Turkey, as a developing country, is not surprising.

There are reports in the literature indicating that nurses have the highest rate of exposure to WPV (Fernandes, et al. 1999; Magnavita, et al. 2012). Also, it was reported that, when compared to the other workers in the ED, nurses were 5 times less likely to feel safe in the workplace. The reason of this finding is linked to their close association with patients in the ED setting (Kansagra, et al. 2008; Gillespie, et al. 2013). Besides, nurses are known to spend greater amount of time providing patient care. However, studies have shown that, contrary to what we know, physicians are also at a significant risk of aggression. In some cases, it was also observed that the rate of aggression was higher for doctors when compared to nurses. Our study also revealed that practitioner doctors had higher rate of violence exposure when compared to other staff. Magnavita et al. reported that this might be due to the role and decisionmaking power of doctors. Also, the fact that nurses are less likely to report WPV might contribute to this result (Magnavita, et al. 2012). Accordingly, Canbaz et al. reported that, when ambulance staff was considered, doctors were more frequently exposed to either verbal or physical assaults when compared to nurses (Canbaz, et al. 2013). We think that as the managers of the ED, doctors are thought to be responsible for everything supposed to be inaccurate and they become the target of violence. Interestingly, in our study, emergency specialist had the lowest incidence of exposure to violence. This finding may be linked to their knowledge and experience in approaching the patients and their relatives.

Verbal abuse is the most common type of violence in the ED (Fernandes, et al. 1999). Exposure to verbal abuse is known to cause distraction of the staff from patients care. It also causes loss of time for the staff before returning to their normal functions (Alameddine, et al., 2011). The reasons for verbal violence were reported to be long waiting times, drug/alcohol abuse and mentally ill patients. In our study, we also determined that the most common type of WPV is verbal assault. Verbal abuse commonly occurred in the form of shouting. This finding is compatible with the literature (Alameddine, et al. 2011).

Physical violence may be seen in various ways. Minor physical injuries, serious physical injuries, temporary and permanent physical disability, psychological trauma, and death may occur (Canbaz, et al. 2013). Physical violence is often associated with alcohol abuse (Ng, et al. 2009). There are also reports revealing that physical threats or assaults are more commonly seen in the ED (Fernandes, et al. 1999). In our study, physical abuse took the second place in violence spectrum and the most common type of physical assault was found to be pushing and/or pulling. No serious harm was reported in one-month-period. Compatible with the literature, a great proportion of the cases were underreported. According to our view, this finding carries the risk to contribute to increase WPV in the ED. Emergency department staff must be encouraged to report every incident regardless of its magnitude. Assaults in the ED should not be considered a part of their job by ED staff (Baydin, et al. 2014).

As far as is known, this study is the first to compare public and private hospitals in respect to WPV. In a study with 65 EDs and 3518 participants, it was found that 73% of staff reported they felt safe most of the time or always. Another 19% said they sometimes felt physically safe; the remaining 8% of ED staff reported that they never or rarely felt physically safe while working in the ED (Kansagra, et al. 2008). In our study, however, 57.2% of the staff was found not to feel safe in the workplace. This difference may be explained with the socio-economic and cultural variations between different countries. Also, adequacy of measurements taken to reduce WPV by the governments may be the reason of reduction in WPV in developed countries. Although any difference was not obtained according to the frequency and severity of WPV among hospitals, staff in private hospitals stated that they felt safer in the ED setting. This may be linked to differences in viewpoints of administrators to employees. Workers in public hospitals are more likely to feel unprotected against patients and visitors prone to violence.

Due to design of the study, only voluntary healthcare providers in the city were involved into our study. The persons exposed to WPV may be more enthusiastic to answer the survey. So, generalization of our results may be objectionable.

Workplace violence is a growing problem in healthcare settings, particularly in EDs. Emergency department is a stressful and challenging workplace complicated with both patients and patients’ relatives. Our study revealed that specialists of ED are less likely to experience WPV. Employment of more specialists instead of practitioners in the ED may help reduce WPV to doctors. Since the most common source of violence is relatives of the patients, removal of crowd from ED may be another method. In addition; structure of the ED, number of security staff and mechanisms to take legal action for workers must be constructed to reduce WPV. Governments may also take measures to reduce misuse of EDs resulting in overcrowding. This study revealed that staff in the public hospitals are more likely to feel insecure. Elimination of this feeling is essential to increase productivity and intensity of the staff.

The authors declare no potential conflicts of interest with respect to the research, authorship and/or publication of this article.