Violence Against Healthcare Workers: A Worldwide Phenomenon With Serious Consequences

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OPINION
published: 18 September 2020
doi: 10.3389/fpubh.2020.570459
Frontiers in Public Health | www.frontiersin.org 1September 2020 | Volume 8 | Article 570459
Edited by:
Amelia Kekeletso Ranotsi,
Maluti Adventist College, Lesotho
Reviewed by:
Jacques Oosthuizen,
Edith Cowan University, Australia
Gabriele D’Ettorre,
ASL Lecce, Italy
*Correspondence:
Sandro Vento
svento@puthisastra.edu.kh;
ventosandro@yahoo.it
Specialty section:
This article was submitted to
Public Health Policy,
a section of the journal
Frontiers in Public Health
Received: 08 June 2020
Accepted: 14 August 2020
Published: 18 September 2020
Citation:
Vento S, Cainelli F and Vallone A
(2020) Violence Against Healthcare
Workers: A Worldwide Phenomenon
With Serious Consequences.
Front. Public Health 8:570459.
doi: 10.3389/fpubh.2020.570459
Violence Against Healthcare
Workers: A Worldwide Phenomenon
With Serious Consequences
Sandro Vento 1
*, Francesca Cainelli 1,2 and Alfredo Vallone 3
1Faculty of Medicine, University of Puthisastra, Phnom Penh, Cambodia, 2Raffles Medical Group Clinic, Phnom Penh,
Cambodia, 3Infectious Diseases Unit, G. Jazzolino Hospital, Vibo Valentia, Italy
Keywords: violence, healthcare worker (HCW), doctor-patient relationship, nurse-patient relationship, workplace
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

Vento et al. Worldwide Violence Against Healthcare Workers
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
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Vento et al. Worldwide Violence Against Healthcare Workers
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.
REFERENCES
1. World Medical Association. 73rd World Health Assembly, Agenda Item 3:
Covid-19 Pandemic Response. (2020). Available online at: https://www.wma.
net/wp-content/uploads/2020/05/WHA73-WMA-statement-on- Covid-19-
pandemic-response- .pdf (accessed June 7, 2020).
2. Liu J, Gan Y, Jiang H, Li L, Dwyer R, Lu K, et al. Prevalence of workplace
violence against healthcare workers: a systematic review and meta-analysis.
Occup Environ Med. (2019) 76:927–37. doi: 10.1136/oemed-2019-105849
3. Binmadi NO, Alblowi JA. Prevalence and policy of occupational violence
against oral healthcare workers: systematic review and meta-analysis. BMC
Oral Health. (2019) 19:279. doi: 10.1186/s12903-019-0974-3
4. World Medical Association Condemns Attacks on Health Care Professionals.
(2020). Available online at: https://www.wma.net/news-post/world-medical-
association-condemns-attacks-on- health-care- professionals/ (accessed June
7, 2020).
5. McKay D, Heisler M, Mishori R, Catton H, Kloiber O. Attacks
against health-care personnel must stop, especially as the world fights
COVID-19. Lancet. (2020) 395:1743–5. doi: 10.1016/S0140-6736(20)3
1191-0
6. Yao S, Zeng Q, Peng M, Ren S, Chen G, Wang J. Stop
violence against medical workers in China. J Thorac Dis. (2014)
6:E141–5. doi: 10.3978/j.issn.2072-1439.2014.06.10
7. Yang SZ, Wu D, Wang N, Hesketh T, Sun KS, Li L, et al. Workplace
violence and its aftermath in China’s health sector: implications from a cross-
sectional survey across three tiers of the health system. BMJ Open. (2019)
9:e031513. doi: 10.1136/bmjopen-2019-031513
8. Li N, Wang Z, Dear K. Violence against health professionals and facilities in
China: evidence from criminal litigation records. J Forensic Leg Med. (2019)
67:1–6. doi: 10.1016/j.jflm.2019.07.006
9. Chauhan V, Galwankar S, Kumar R, Raina SK, Aggarwal P, Agrawalet N, et al.
The 2017 Academic College of Emergency Experts and Academy of Family
Physicians of India position statement on preventing violence against health-
care workers and vandalization of health-care facilities in India. Int J Crit Illn
Inj Sci. (2017) 7:79–83. doi: 10.4103/IJCIIS.IJCIIS_28_17
10. Covid-19: Indian government vows to protect healthcare workers from
violence amid rising cases. BMJ. (2020) 369:m1631. doi: 10.1136/bmj.
m1631
11. Vorderwülbecke F, Feistle M, Mehring M, Schneider A, Linde K. Aggression
and violence against primary care physicians - a nationwide questionnaire
survey. Dtsch Arztebl Int. (2015) 112:159–65. doi: 10.3238/arztebl.201
5.0159
12. Serrano Vicente MI, Fernández Rodrigo MT, Satústegui Dordá PJ, Urcola
Pardo F. Agresiones a profesionales del sector sanitario en España, revisión
sistemática. [Aggression to health care personnel in Spain: a systematic
review]. Rev Esp Salud Publica. (2019) 93:e201910097.
13. Andy Cowper. Violence Against NHS Staff: A Special Report by HSJ
and Unison. (2018). Available online at: https://guides.hsj.co.uk/5713.guide
(accessed June 7, 2020).
14. Occupational Safety and Health Administration. Guidelines for Preventing
Workplace Violence for Healthcare and Social Service Workers (OSHA, 3148-
04R). Washington, DC: OSHA (2015) Available online at: https://www.osha.
gov/Publications/osha3148.pdf (accessed June 7, 2020).
15. Workplace violence in the health sector. World Health Organization Survey
Questionnaire ONU. Rapporto Italia. Rome (2019). Available online at:
https://portale.fnomceo.it/sanita-ricerca- oms-nursing- up-un- infermiere-
su-10- ha-subito- violenza-fisica- sul-lavoro-e-il-4-e-stato- minacciato-con-
una-pistola- nellultimo-anno/ (accessed June 7, 2020).
16. FNOMCeO. Un medico su due ha subito aggressioni.I dati preliminari dello
studio FNOMCEO. Rome (2019). Available from: https://portale.fnomceo.it/
un-medico-su-due- ha-subito- aggressioni-i- dati-preliminari-dello-studio-
fnomceo/ (accessed June 7, 2020).
17. Babiarczyk B, Turbiarz A, Tomagová M, Zeleníková R, Önler E,
Sancho Cantus D. Violence against nurses working in the health
sector in five European countries-pilot study. Int J Nurs Pract. (2019)
25:e12744. doi: 10.1111/ijn.12744
18. More than 30 SA Hospitals Report Serious Security Incidents in Past 5 Months.
(2019). Available online at: https://www.medicalbrief.co.za/archives/30-sa-
hospitals-report- serious-security- incidents-pas-5-months/ (accessed June 7,
2020).
19. Brady L, De Vries S, Gallow R, George A, Gilson L, Louw M, et al.
Paramedics, poetry, and film: health policy and systems research at the
intersection of theory, art, and practice. Hum Resour Health. (2019)
17:64. doi: 10.1186/s12960-019-0373-5
20. Sahebi A, Jahangiri K, Sohrabizadeh S, Golitaleb M. Prevalence of
workplace violence types against personnel of emergency medical services
in Iran: a systematic review and meta-analysis. Iran J Psychiatry. (2019)
14:325–34.
21. World Health Organization. Violence against Healthcare Workers. Available
from: https://www.who.int/violence,injury,prevention/violence/workplace/
en/ (accessed June 7, 2020).
22. Magnavita N, Heponiemi T, Chirico F. Workplace violence is associated with
impaired work functioning in nurses: an Italian cross-sectional study. J Nurs
Scholarsh. (2020) 52:281–91. doi: 10.1111/jnu.12549
23. D’Ettorre G, Pellicani V, Vullo A. Workplace violence against healthcare
workers in Emergency Departments. A case-control study. Acta Biomed.
(2019) 90:621–4. doi: 10.23750/abm.v90i4.7327
24. Toraldo DM, Vergari U, Toraldo M. Medical malpractice, defensive
medicine and role of the “media” in Italy. Multidiscip Respir Med. (2015)
10:12. doi: 10.1186/s40248-015-0006-3
25. Berlanda S, Pedrazza M, Fraizzoli M, de Cordova F. Addressing risks
of violence against healthcare staff in Emergency Departments: the
Frontiers in Public Health | www.frontiersin.org 3September 2020 | Volume 8 | Article 570459

Vento et al. Worldwide Violence Against Healthcare Workers
effects of job satisfaction and attachment style. Biomed Res Int. (2019)
5430870. doi: 10.1155/2019/5430870
26. Nowrouzi-Kia B, Chai E, Usuba K, Nowrouzi-Kia B, Casole J. Prevalence
of type II and type III workplace violence against physicians: a systematic
review and meta-analysis. Int J Occup Environ Med. (2019) 10:99–
110. doi: 10.15171/ijoem.2019.1573
27. Alsaleem SA, Alsabaani A, Alamri RS, Hadi RA, Alkhayri MH, Badawi
KK, et al. Violence towards healthcare workers: a study conducted in
Abha City, Saudi Arabia. J Family Community Med. (2018) 25:188–
93. doi: 10.4103/jfcm.JFCM_170_17
28. Shafran-Tikva S, Chinitz D, Feder-Bubis P. Violence against physicians and
nurses in a hospital: how does it happen? A mixed-methods study. Isr J Health
Policy Res. (2017) 6:59. doi: 10.1186/s13584-017-0183-y
29. Raveel A, Schoenmakers B. Interventions to prevent aggression
against doctors: a systematic review. BMJ Open. (2019)
9:e028465. doi: 10.1136/bmjopen-2018-028465
30. Arnetz JE, Hamblin L, Russell J, Upfal MJ, Luborsky M, Janisse J,
et al. Preventing patient-to-worker violence in hospitals: outcome of a
randomized controlled intervention. J Occup Environ Med. (2017) 59: 18–
27. doi: 10.1097/JOM.0000000000000909
31. Nelson R. Tackling violence against health-care workers. Lancet. (2014)
383:1373–4. doi: 10. 1016/s0140-6736(14)60658-9
32. Madhivanan A, Venugopal V, Dongre AR. Physical violence against
doctors: a content analysis from online Indian newspapers. Indian
J Community Med. (2020) 45:108–9. doi: 10.4103/ijcm.IJCM_
215_19
33. Kvas A, Seljak J. Unreported workplace violence in nursing. Int Nurs Rev.
(2014) 61:344–51. doi: 10.1111/inr.12106
34. Arnetz JE, Hamblin L, Ager J, Luborsky M, Upfal MJ, Russell J, et al.
Underreporting of workplace violence: comparison of self-report and actual
documentation of hospital incidents. Workplace Health Saf. (2015) 63:200–
10. doi: 10.1177/2165079915574684
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.
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