Scientific Papers

Contemporary evidence of workplace violence against the primary healthcare workforce worldwide: a systematic review | Human Resources for Health

We analysed the global prevalence and other vital information on WPV against HCWs who serve in the PHC setting. We identified noteworthy findings not reported in earlier systematic reviews and meta-analyses, where the healthcare setting type was not taken into primary consideration [2, 41,42,43,44,45,46,47,48,49].

Determining a definite judgement on WPV incidence against PHC workers worldwide is challenging, given that several of the studies selected for analysis were conducted using convenience sampling with low response rates. Nevertheless, notable results were obtained. WPV prevalence varied significantly, where the highest prevalence was reported in Germany (91%) and the lowest was reported in China (14%). Based on the average 1-year prevalence rate of WPV, we determined that the European and American regions had a greater WPV prevalence than others, which was consistent with a recent meta-analysis [50]. One reason might be the more effective reporting system in these regions, which facilitate more reports through a formal channel, as mentioned previously [51]. Contrastingly, opposite circumstances might cause WPV events to go unreported in other parts of the world. We also revealed a need for more evidence on WPV in the PHC context in Southeast–East Asia and African regions. The number of peer-reviewed articles from these regions could have been much higher, which inferred that the issue in these continents still requires resolution.

Various incidents of violence, including those of a criminal or domestic nature, commonly occur in the tertiary setting. The Healthcare Crime Survey by the International Association for Healthcare Security and Safety (IAHSS) reported that within a 10-year period (2010–2022), the number of hospital workers who experienced ten types of crime-related events in the workplace, such as murder, rape, robbery, burglary, theft (Type I), increased by the year [52]. In contrast, most studies conducted in PHC settings focused on providing more evidence of Type II violence, whereby other types (I and IV) were rarely detected. The scarcity of evidence does not necessarily indicate that PHC workers are not vulnerable to criminal or domestic violence. Rather, it implies that WPV is still not entirely explored in the PHC setting, which undermines the establishment of a comprehensive violence prevention strategy that encompasses all types of violence [53].

Hospital-based studies reported diverse forms of violence, where both physical and verbal violence were dominant [47, 54,55,56]. Violence as a whole and physical violence in particular tend to occur in nursing homes and certain hospital departments, such as the psychiatric department, emergency rooms, and geriatric nursing units [47, 55, 56]. Volatile individuals with serious medical conditions or psychiatric issues or who are under the influence of drugs or alcohol were mainly responsible for this severe physical aggression [53]. Similar to previous hospital-based studies, diverse forms of violence (verbal abuse, physical attacks, bullying, sexual-based violence, psychological abuse) were recorded in PHC settings. Despite this, most of the studies determined that the perpetrators’ disparate characteristics resulted in more frequent documentation of verbal violence than physical violence. Dissatisfied patients or family members were more likely to perpetrate greater incidents of verbal abuse [25, 26, 31], either due to their medical conditions or dissatisfaction with the services provided [30]. This noteworthy discovery prompted new ideas, indicating that variance in the form of violence might also be determined by the healthcare setting role [57].

Our findings demonstrated that sexual-based violence was the least frequently documented form of violence, with a regional differences pattern indicating relatively lower sexual-based violence reporting in the Middle Eastern region [13, 30]. This result contrasted with a previous systematic review of African countries that reported that sexual-based violence was one of the dominant forms of WPV. This lower incidence was possibly due to under-reporting by female employees who were reluctant to report sexual harassment aggravated by cultural sensitivities regarding sexual assault exposure [58]. Such culturally driven decision-making practices are worrying, as they could lead to underestimation of the true extent of the issues and cause more humiliating incidents and the lack of a proper response.

We identified considerable numbers of significant predisposing factors, which were determined via advanced multivariate modelling. Most factors were comparable with that in previous WPV research, especially those related to the victims’ individual socio-demographic and professional backgrounds [2, 41, 42]. Several studies consistently reported that nurses were vulnerable to WPV compared to physicians and others, which was supported by numerous prior systematic studies [19, 23, 27, 37]. This could be explained by the accessible nature of nurses as healthcare professionals to patients and families [50]. Furthermore, nurses interact first-hand with clients during treatment, rendering them more likely to become the initial victims of WPV before others. Nevertheless, this result should not necessarily suggest that other professions are not at risk for violence. Due to the shortage of evidence regarding the remaining category of PHC workers, it is impossible to provide a more conclusive and realistic assessment of the above.

The results demonstrated that many PHC clinics were built in community areas with a variety of settings, such as high-density commercial developments in urban or rural areas, resource-limited locations, or areas with a high crime concentration [27,28,29, 32, 39]. Therefore, an additional new sub-theme under predisposing factors, namely, “community and geographical factors”, was created to include all evidence on the relationship between WPV vulnerability and community social character and geo-spatial factors. Although several hospital-based studies deemed this topic less significant, several studies in the present review that examined the relationship between geographic information and the surrounding population characteristics with WPV reported valuable and constructive information for PHC prevention framework efforts.

In general, we identified a similar correlation between work-related factors and WPV as in hospital-based studies, particularly on healthcare system delivery and organisational support elements [40,41,42,43,44,45,46,47,48]. Nonetheless, the evidence on operational service was vastly distinct. As several PHC services are expanded outside facilities, there is increased potential for violence against HCWs when they provide out of clinic services, for example, during home visits and school health services [21, 37, 39]. Such situations might require more comprehensive prevention measures compared to violent events that occur within health facilities. Unfortunately, the available literature that describes and assesses the safety elements of HCWs in PHC settings mainly focused on services inside the health facilities, indicating that WPV prevention and management should be expanded to outdoor services [21].

The studies included in this review comprehensively described the observed implications on WPV victims in PHC settings. Nonetheless, additional vital information on the adverse effects on organisational elements remains lacking, especially regarding the quality of patient care involving potential near-miss events, negligence, and reduced safety elements [31]. The economic effect is another important aspect that requires further consideration. Recent financial expense data were only available from hospital-based research. A systematic review revealed that WPV events resulting in 3757 days of absence at one hospital over 1–3 years involved a cost exceeding USD 1.3 billion that was mainly due to reduced productivity [43].

The magnitude of under-reporting among HCWs was concerning, as most respondents admitted that they declined to report WPV cases through formal reporting channels, such as via electronic notification systems, supervisors, or police officers [13, 30, 36, 39]. Although the included articles mentioned several impediments to reporting, such as fear of retaliation, fear of missing one’s job, and feelings of regret and humiliation, [13, 30, 36], the main reason for under-reporting was a lack of trust in existing WPV preventive institutional policies. Most respondents perceived that reporting the case would not lead to positive changes and were dissatisfied with how the policy was administered [13, 30]. Despite much evidence on proactive coping mechanisms utilised by the HCWs, which were either behaviour change technique or conflict resolution style, we did not obtain additional crucial information on existing regional WPV policies or specific intervention frameworks at institutional level [31, 40]. Furthermore, reports of the mediating functions of federal- or state-level central funding and legal acts or regulatory support in establishing effective regional violence policies were also absent in primary settings. Further discussion in this area is crucial as significant federal or state government support would improve HCWs’ perceptions of regional prevention program and would potentially reduce the rate of violence against HCWs.

Opportunities for future research

Only a few studies discussing WPV in the PHC setting have been published over the 10 years covered in this review. Local researchers and stakeholders should define and prioritise important areas of study. Given the heterogeneity of the forms of violence, it might be advantageous to conduct additional observational research in the future to describe the situation and investigate the associations between the rate of violence and its multiple predictors using Poisson regression analysis [59]. At the present stage, quasi-experimental evidence is ambitious. Therefore, more longitudinal studies are required to evaluate the efficacy of any newly introduced violence prevention and management measures designed in primary healthcare settings [60].

A comprehensive investigation of WPV occurrences beyond Type II violence is required to accurately reflect the breadth of the issue and focus on prevention efforts. In the present study, the association pattern between the consequences of WPV for specific perpetrators was not investigated as in prior research due to the scarcity of evidence on Type I, III, and IV violence. For example, Nowrouzi-Kia et al. revealed that the victims of inter-professional perpetuation (Type III) experienced more severe consequences involving their professional life (low job satisfaction, increased intention to quit) than those who experienced patient or family-perpetrated violence (Type II), which involved psychological and emotional changes [61, 62]. In addition, the study scope must also be expanded to include assaults against both healthcare personnel and patients in primary settings. A hospital-based investigation by Staggs 2015 revealed a significant association between the number of staff at psychiatric patient units and the frequency of violent incidents. Surprisingly, this rigorous investigation determined that higher levels of hospital staffing of registered nurses were associated with a higher assault rate against hospital staff and a lower assault rate against patients [63].

Despite universal exposure to WPV, the incidence rates and types of violence vary between regions. Thus, the primary investigation focus should be tailored to specific violence issues in a particular setting. Our results highlighted the need for further research into strengthening WPV policy, particularly concerning the reporting systems in regions outside European and American countries. Compared to other regions, local academicians in Southeast Asia and Africa are encouraged to increase their efforts to perform more epidemiological WPV studies in the future to better understand the WPV issue. It is crucial to identify the underlying causes of low prevalence of sexual harassment, particularly in the Middle East, which might be caused by under-reporting influenced by culture or gender bias. Although it is asserted that sexual-based violence is likely to occur commonly in cultures that foster beliefs of perceived male superiority and female social and cultural inferiority, the reported prevalence rate of such violence in certain regions [64], particularly in the Middle East, was low, possibly due to under-reporting. Thus, to address this persistent problem, the existing reporting mechanisms must be improved and sexual-based violence should be distinguished from other forms of violence to encourage more case reporting. Simultaneously, sexual-based violence should also be defined differently across countries and various social and cultural contexts to reduce impediments to reporting [64].

In existing studies, the main focus of work-related predisposing factors is based on superficial situational analysis, which is identified using the local version of the standard WPV instrument tool via a quantitative approach. Nevertheless, this weak evidence would not support a more effective preventive WPV framework. This issue should be addressed in more depth and involve psychosocial workplace elements that cover interpersonal interactions at work and individual work and its effects on employees, organisational conditions, and culture. Qualitative investigations that complement and contextualise quantitative findings is one means of obtaining a greater understanding and more viewpoints.

Implications of WPV policies

The results had major effects on WPV prevention and intervention policies in the PHC setting. The results highlighted the importance of enacting supportive organisational conditions, such as providing adequate staffing, adjusting working hours to acceptable shifts, or developing education and training programmes. As part of a holistic solution to violence, training programmes should focus on recognising early indicators of possible violence, assertiveness approaches, redirection strategies, and patient management protocols to mitigate negative effects on physical, psychological, and professional well-being. While previous WPV studies focused more on physical violence and inspired intervention efforts in many organisational settings, our results necessitate attention on non-physical forms of violence, which include verbal harassment, sexual misconduct, and intimidation. The increased potential of domestic- and crime-type violence in PHC settings necessitates expanded prevention programmes that address patients, visitors, healthcare providers, the surrounding community, and the general population.

Our results demonstrated that under-reporting of violent events remains a key issue, which is attributable to a lack of standardised WPV policies in many PHC settings. The initial action that should be implemented in accordance with human resource policy is to establish a system that renders it mandatory for victims, witnesses, and supervisors to report known instances of violence to HCWs. Unnecessary and redundant reporting processes can be reduced by an advanced system for rapidly recording WPV incidents, such as in hospital settings, where WPV is reported via a centralised electronic system. However, healthcare professional and organisational advocacy remains necessary. These parties must promote the value of routine procedures to ask employees about their encounters with patient violence and to foster an environment, where the organisation encourages reporting of violent incidents.

In addition to insufficient reporting, it is crucial to draw attention to the manner in which violent incident investigations are currently conducted in most workplaces. In reality, the incident reporting focuses on the violence itself and its superficial or circumstantial analysis, as opposed to an in-depth examination of the causes of violence, which are due to workplace psychosocial hazards, poor clinic environment, or poor customer service. For example, if any patient-inflicted violence occurred as a result of unsatisfactory conditions caused by poor clinic service, such as unnecessary delay, the tendency is to report on the perpetrator’s behaviour or on the violence itself rather than the unmet health service provision issue. In the long-term, however, the findings of such an investigation would not support the development of a violence prevention and management guideline, as it focuses on addressing aggressive patients rather than enhancing clinic service quality. Therefore, the relevant authorities should formulate a proper plan to improve the existing reporting and investigations mechanism to ensure that it is more comprehensive, structured, and detailed, either by providing proper training for the investigators or conducting institutional-level routine root cause analysis discussions, so that the violence hazard risk assessment can be framed effectively to resolve the antecedent factors in the future.

Nonetheless, there remains much room for primary-level improvement in WPV awareness and abilities. Reports on the mediating roles of federal- and state-level central funding and regulatory support for efficient local WPV policies at primary level have not been found. Therefore, more studies will be necessary to fill these gaps and concentrate on examining the relationship between regional WPV policies and national support. Possibly, more central funding and state regulation following new positive results can be made available to aid local preventive programs. A strong central financial support is essential to support regional preventive programmes, such as employing security guards, enhancing the physical security of health facilities buildings, and research grants. Awadalla and Roughton strongly suggested that adequate national-level financial support is one of the essential components of successful regional policies that would alter HCW perceptions [65]. In terms of law and regulation, for example, Ferris and Murphy firmly supported the role of the Occupational Safety and Health Act (OSHA) via the issuance of the “Enforcement Procedures for Investigating or Inspecting Workplace Violence” instructions to institutional-level officers as one of the essential components of local WPV prevention strategies [66].

Study strength and limitations

The present study is a preliminary systematic review that explored evidence of WPV against all PHC workers in empirical studies worldwide. The breadth of the review was achieved by incorporating numerous peer-reviewed high-quality published studies, which enabled us to derive a solid conclusion. The approach relied on the authors’ prior knowledge of the study topic, the standard review technique, and specialised keywords.

It is also important to emphasise several potential limitations. First, recall bias was introduced in most studies as the authors used self-reporting to recall previous incidents either up to 12 months prior or after a lifetime. As most of the included studies involved small sample sizes, a few studies with low response rates restricted the generalisability of the findings. Several studies were descriptive and were cross-sectional; consequently, extra caution should be applied when making inferences pertaining to the risk factor interactions with violence. Variability in the instrument used, data collection and analysis methods, the notion of violence, and the general study objective might account for the heterogeneity across studies, which limited comparisons across studies. As PHC health system delivery between countries is described by different terms or names or might be identified by names besides those used in the present study, studies that use such terms might have been overlooked during the database search.

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