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org
International Journal of Medicine and
Pharmaceutical Sciences (IJMPS)
ISSN(P): 2250-0049; ISSN(E): 2321-0095
Vol. 4, Issue 2, Apr 2014, 101-112
TJPRC Pvt. Ltd.


VIOLENCE AGAINST EMERGENCY CARE STAFF IN BASRA HOSPITALS
ALAA HUSSEIN ABED
Lecturer, Department of Community Medicine, College of Medicine, University of Thi-Qar, Dhi Qar, Iraq

ABSTRACT
Introduction: Emergency care service is one of the professions affected by workplace violence. It is not a new
phenomenon but in recent years, much greater emphasis has been placed on the problem. Despite the fact that the problem
is under attention worldwide, little is known about it in emergency departments in Iraqi hospitals.
Aim: This descriptive cross-sectional study aims at investigating the problem of violence against emergency care
staff in Basra hospitals.
Method: The study was conducted in a cross-sectional methodology setting targeting the emergency care staff in
Basra hospitals to elicit doctor and paramedical staffs responses of experience to workplace violence. The study involved
198 staff members. This was divided by the 6 hospitals of Basra City. At each of the six emergency departments, the
sample from targeted population was convenience one. A pre-structured questionnaire was translated with a very limited
modification and used.
Results: About 48.7% of the respondents had faced verbal violence, 24.6% faced physical violence, and 13.6%
had faced hospital-property damage/ theft. Most victims did not take an action after the end of the violence incidents.
About 62.8% of respondent victims do not/rarely think about violence when they do not mean to, and most of them
(89.8%) do not/rarely have dreams about violence. About half of the victims do not to remove the subject from memory
and a approximately similar percentage of them do not talk about violence, while third of them avoid letting themselves get
upset when they think about/being reminded of violence incidents.
Conclusions: In emergency departments of Basra hospitals, verbal violence/ intimidation is the most common,
followed by physical violence, and the least frequent is hospital-property damage/ theft associated with violence and the
rates lie in the middle of international range. Violence, which worries the victims most, usually occurs during the daytime
work shifts and the main perpetrator is a male, who is mostly the patients family member, relative, companion or friend.
Workplace violence victims either do nothing as an immediate response to the incident or take limited actions and they,
often, do not take an action after the end of the incidents. Furthermore, violence does not leave long-term consequences in
Iraqi professionals.
KEYWORDS: Violence, Emergency Department, Basra
INTRODUCTION
The workplace violence has special relevance for the healthcare workers
(1, 2)
. Emergency care service staff is one
of the professions most affected by this risk
(1)
. Violence against emergency care staff is not a new phenomenon but in
recent years much greater emphasis has been placed on the problem
(3)
. Patients and their relatives exposed to stress caused
by accidents or illness might use violence against healthcare staff and interfere with quality healthcare
(4, 5)
. A number of
102 Alaa Hussein Abed

Impact Factor (JCC): 5.1064 Index Copernicus Value (ICV): 3.0
official reports, media stories and international initiatives have focused attention on the problem worldwide. However, it is
not clear whether violence has in fact become more prevalent. Reported rates of violence against emergency care staff are
increasing and studies of violence and aggression to health service staff have largely focused upon accident and emergency
units
(6)
. A considerable percentage of emergency care staff report at least one incident of non-physical violence and less
percentage report at least one incident of physical violence
(7)
. The problem is international and Table (1) shows some
incidence figures of violence "an act of aggression directed toward emergency care staff at work, on duty or outside work
due to reasons relevant to job. It may range from the use of offensive or threatening language, harassing, coercive behavior
to physical assault, that causes physical or emotional harm or even homicide
(8)
" from different countries.
Table 1: Incidence Rate of Physical and/or Non-Physical Violence among
Emergency Care Staff in Some Countries
S. No Author Country Year
Incidence Rate
among Respondents
1 Galin Muoz I et al
(1)
Spain 2012 21.8%
2 Magnavita N et al
(2)
Italy 2012 One out of three
3 Fujita S et al
(4)
Japan 2012 36.4%
4 Ahmed AS
(5)
Jordan 2012 37.1%
5 Lanza ML et al
(7)
USA 2006 27.8%
6 Badger F et al
(6)
UK 2004 Just over 50%
Source: Prepared by the researcher
Although emergency care staff is one of the professions most exposed to violence, the risk distribution is not
homogeneous. Significant differences are found according to marital status, age, hospital characteristics, type of service,
profession, shift and seniority in the profession
(1, 5)
. However, the factors the staff believe most contribute to violence are
negative societal image of emergency care staff and poor support from hospital authorities
(5)
.
Currently, workplace violence is recognized as a violent crime that requires targeted responses from employers,
law enforcement, and the community
(8)
. In spite of the facts above, only about one third of the emergency care staff, whom
are exposed to violence, report it; half of those that do not, think it is useless to do so, while one third think they can handle
the incidents without help. This violence has made a considerable percentage of the affected emergency care staff report
that they consider leaving their job and feel their quality of work decreases because of the violence
(5)
. Because of a
shortage of standardized measurement and reporting mechanisms for violence in healthcare settings, data are scarce. At
present little is known about the problem in emergency departments of in Iraqi hospitals. This has motivated the researcher
to conduct this study.
OBJECTIVES
This descriptive cross-sectional study aims at investigating the problem of violence against emergency care staff
in Basra hospitals. The objectives are:
To determine the incidence and sources of different types of violence
To determine some characteristics of violence
To determine reactions of victim emergency care staff
METHODS
This study was conducted in a cross-sectional methodology setting targeting the emergency care staff in Basra
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hospitals to elicit doctor and paramedical staffs responses of experience to workplace violence. The sample size was
calculated to be 198 staff members. This was divided by the 6 hospitals of Basra City. The share of each hospital was
33 emergency department staff members. At each of the 6 emergency departments, the sample from targeted population
was convenience sample. The number of respondents was 191 (96.46%).Basra is the capital of the south of Iraq covering
approximately 19070 square kilometers with an estimated population of 2531997 million people
(9)
. The study population
included the doctors, paramedical staff, and other emergency service staff from emergency care units of the hospitals in
Basra City Centre. During the time of the study, the total population of interest composed of 306 senior house officers,
134 house officers and 187 paramedical staff, who work in the emergency rooms of the 6 governmental hospitals of the
City
(10)
. As far as workplace violence is a term refers to violence that is associated with work, all forms of hostile
behaviour occurred to the emergency staff in the emergency rooms or in other places inside the hospital or outside it were
investigated. A questionnaire used by Boyle et al
(11)
to explore staffs experience of violence was translated with a very
limited modification to fit the situation in Iraq. It investigated the workplace violence as defined by Tolhurst et al
(12)
-verbal
violence, hospital-property damage/ theft, intimidation, physical violence, sexual harassment, and sexual assault.
The questionnaire was piloted on ten of the candidate population. Following the return of the questionnaires and
comments, changes were made to the form. The major change made was that omitting the questions related to sexual
harassment and sexual assault. That was because none of the pilot study population agreed to answer the relevant
questions. Moreover, an advice was given by the Research Approval Committee in Basra Directorate of Health to remove
those questions.The questionnaire forms had been then distributed by the researcher to the targeted staff in Basra hospitals.
Respondent staff completed the questionnaire and returned it. Data analysis was undertaken using SPSS
(Statistical Package for the Social Sciences) Version 19.0. Descriptive and analytical statistics were used to analyse the
data. Chi
2
or Fishers exact tests were used to compare differences between the types of violence investigated. The results
were considered significant if the p value was <0.05. Ethics approval for this study was granted by the Research Approval
Committee in Basra Directorate of Health.
RESULTS
Table (2) presents the sociodemographic characteristics of the respondents. It shows that more than two thirds of
the respondent population were males. The age of about 73% of them was 30 years or less. About 67% of the study
population have spent 10 years or less working in the health service sector. About 90% of them were paramedical staff,
mainly nurses.
Table 2: Distribution of the Study Population According to Some Sociodemographic Characteristics
Characteristic Frequency Percent
Gender
Male 132 69.1
Female 59 30.9
Age (Years)
20 39 20.6
21 - 25 28 14.4
26 - 30 73 38.1
31 - 35 12 6.2
36 - 40 12 6.2
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Impact Factor (JCC): 5.1064 Index Copernicus Value (ICV): 3.0
Table 2: Contd.,
> 40 28 14.4
Duration of Work (Years)
5 67 35.1
6 - 10 61 32.0
11 - 15 32 16.5
16 - 20 24 12.4
> 21 8 4.1
Occupation/Academic Achievement
Nurse/ Nursing
preparatory school
104 54.6
Doctor assistant/
Technical institute
diploma
39 20.6
Doctor/ Bachelor 20 10.3
Laboratory assistant/
Diploma in lab
services
20 10.3
Pharmacy assistant/
Diploma pharmacy
8 4.1
Total 191 100.0

Table (3) shows that about 48.7% of the respondents answered they had faced verbal violence/ intimidation,
13.6% had faced hospital-property damage/ theft associated with violence, and 24.6% faced physical violence.
These differences were found to be statistically significant. Also, regarding the frequency of exposure to each type of
violence during the last 12 months, it can be noticed that verbal violence/ intimidation is more frequent than
hospital-property damage/ theft associated with violence or physical violence. Again, these differences were found to be
statistically significant.
Table 3: Answers of Respondents to Questions about Exposure to
Workplace Violence during the Last 12 Months and its Frequency
Variables
Type of Violence
Chi
2
P-Value
Verbal

Property Damage^ Physical

History of exposure:
Yes
No

93 (48.7%)
98 (51.3%)

26 (13.6%)
165 (86.4%)

47 (24.6%)
144 (75.4%)
59.758

0.0001
Frequency of violence:
Once a year
Few times
About once/ month
About once/ week
Almost every day

4 (4.3%)
9 (9.7%)
21 (22.5%)
26 (28.0%)
33 (35.5%)

18 (69.2%)
6 (23.1%)
2 (7.7%)
0 (0.0%)
0 (0.0%)

35 (74.5%)
4 (8.5%)
8 (17%)
0 (0.0%)
0 (0.0%)

99.239

0.0001





Almost all respondents linked intimidation to verbal violence incidents. Answers were mostly the same.
Therefore, intimidation is joined to verbal violence in the results.
^ Answers relevant to this type of violence, in the following results, represent the characteristics of
hospital-property damage only. Respondents could not answer questions related to hospital-property
stealing.


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Table (4) shows that during the verbal violence/ intimidation incidents, the level of fear was mostly (47.3%) mild
apprehension, the hospital-property damage/ theft associated with violence incidents mostly (34.6%) quite apprehension,
and physical violence incidents mostly (49%) fright. These differences were found to be statistically extremely significant.
No any statistically significant difference between the 3 types of violence could be noticed for the other
characteristics tested. Table (5) shows the answers to the questions relevant to these characteristics. It can be noticed that
Violence occurred during the daytime work-shifts more than the nighttime ones;
Most of incidents occurred in the usual work location;
In most of the incidents, the perpetrator was the patients family member, relative, companion or friend;
The gender of the main perpetrator in the worried most violence incident was male;
Most respondents do not think that there was any underlying factor that participated in the occurrence of the
incident; and
About half of the respondents, who faced violence, did nothing as an immediate response to the incident.
Table 4: Answers of the Victims to the Question What was your Level of
Fear during the Worried-Most Incident?
Variables
Type of Violence
Chi
2
P-Value
Verbal

Property Damage^ Physical

None
Mildly apprehensive
Quite apprehensive
Frightened
Very frightened
23 (24.7%)
44 (47.3%)
20 (21.5%)
2 (2.2%)
4 (4.3%)
6 (23.1%)
7 (26.9%)
9 (34.6%)
2 (7.7%)
4 (7.7%)
0 (0.0%)
0 (0.0%)
19 (40.4%)
23 (49%)
5 (10.6%)
64.603 0.0001

Table 5: Answers of the Victims to the Questions of the Workplace Violence
Question No. %
When did a worried-most incident, of each of
the following types of violence, occur?
During daytime work
During nighttime work


103
63


62.05%
37.95%
Where did a worried-most incident, of each
of the following types of violence, occur?
Usual work location
Other place inside the hospital
Others


149
11
6


89.76%
06.63%
03.61%
Who was the main perpetrator of the worried
most violence incident?
Service user
User's family, relative, companion or friend
Other professional or work colleague
Others


34
119
1
12


20.48%
71.69%
0.60%
7.23%
What was the gender of the main
perpetrator?
Male
Female

157
9

94.58%
5.42%
Do you think there were any underlying
factors that participated in the occurrence of
this incident? (e.g. alcohol intoxication,






106 Alaa Hussein Abed

Impact Factor (JCC): 5.1064 Index Copernicus Value (ICV): 3.0
psychological health problem, etc)
Yes
No
67
99
40.36%
59.64%
What was your immediate response to the
violence?
Did nothing
Called the Hospital security/ police
Asked for colleagues help
Others

81
74
8
3

48.79%
44.58%
4.82%
1.81%
Total 166 100%

From Table (6), it is clear that most of respondent victims of violence did not take an action after the end of the
violence incidents.
Intermediate-Term Consequences
Table 6: Answers of the Victims to the Question How did you Respond to
Work-Associated Violence Incidents, Which you Exposed to, after they Ended?
Response
Percent
Never
One-Few
Times
Mostly Always Total
Submitted a claim to the hospital management/
Directorate of Health headquarter
63.4 26.8 00.0 09.8
100.0
Submitted a claim to the police 51.2 34.9 09.3 04.7
Used the tribal law to deal with the incident 73.3 08.9 08.9 08.9
Took days off work 77.8 08.9 13.3 00.0
Moved to an other job/ position in the hospital or
another hospital
86.7 13.3 00.0 00.0

It can be seen in Table (7) that about 62.8% of respondent victims do not/rarely think about violence when they do
not mean to, and most of the (89.8%) do not/rarely have dreams about violence. In the same time, about half of the
respondents answered that they do not to remove the subject from memory and a approximately similar percentage of them
do not talk about violence, while third of them avoid letting themselves get upset when they think about/being reminded of
violence incidents.
Long-Term Psychological Consequences
Table 7: Long-Term consequences
Consequence
Percent
Never Rarely
Some
Times
Mostly Total
I usually think about violence when I do not mean to 31.4 31.4 13.7 23.5
100.0
I usually have dreams about violence 74.4 15.4 10.3 00.0
I used to try to remove the subject from memory 48.9 12.8 12.8 25.5
I try not to talk about violence 47.5 20.0 07.5 25.0
I usually avoid letting myself get upset when I think
about/being reminded of violence incidents
29.3 13.8 25.9 31.0

DISCUSSIONS
Violence against Emergency Care Staff in Basra Hospitals 107

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Regarding the sociodemographic characteristics of the respondents, the percentage of males reflects the fact that
there is a shortage in female nursing-staff in Basra hospitals during the period of study. The considerable percentage of
young junior staff may be a facilitating factor for entering in conflicts that can lead to violence; when the candidate to work
in emergency rooms are not trained efficiently on communication skills. They acquire these skills gradually during their
work as a part of the hidden training curriculum. Because the sample was a convenience (non-probability) one, the
distribution of the respondents, according to occupation/ academic achievement, differs greatly from the distribution of the
emergency department staff population.
In the last 12 months, the rates of emergency department staff, who answered that they were subjected to violence,
are 48.7% verbal violence/ intimidation, 13.6% hospital-property damage/ theft associated with violence and 24.6%
physical violence. Considering representativeness, Basra, certainly, does not represent Iraq. But, the results of the study
can give a rough idea about the size of the problem in the country. The rate lies in the middle of international range above.
Regarding exposure of emergency department staff to verbal violence, it was stated that its rate internationally
varies from 2182.4%
(11)
. The rate reported in the current study lies nearly in the middle.
When physical violence is considered, researchers from the Middle East found that its incidence in the 6 months
proceeded the study was 18.3 %
(5)
, in Turkey 8.5%
(13)
and in Hong Kong it was reported as 18%
(14)
.
No data relevant to violence-associated hospital property damage/theft were found in the literature for
comparison. The available data are relevant to the victims property damage/theft. Amendment from victims property to
hospital property was done in the light of the results of pilot study.
Figures in this study seem to be lower than many figures in other places in the world. This is probably due to
difference in culture, where the staff of emergency department in other countries may remember or document simple
violence incidents more than the respondents in the current study do.
The differences in the incidence of these types were found to be statistically significant (P= 0.0001). That is to
say, Workplace violence against emergency department staff in Basra hospitals is significantly more frequently verbal,
followed by physical, and the least frequent is hospital property damage/theft. A sequence that seems to be expected and
does not differ from the trend of these types of violence in other countries
(2, 4, 5, 7)

Verbal violence/ intimidation was faced by respondents from once/ week to daily in a percentage of about 63.5%,
while hospital-property damage/ theft associated with violence and physical violence were faced from once to few times
per year in 92.3% and 83% respectively. These differences were found to be statistically significant (P= 0.0001).
Again this finding seems to be logical, when the relatively mild form of violence occurs more frequently than the relatively
more sever form. These results differ from the findings of Malcolm Boyle et al
(11)
, who found most of the study
respondents who experienced verbal abuse and intimidation a few times in the last 12 months. Just over 3% of paramedics
reported experiencing verbal abuse on a daily basis and approximately 12% about once a week.
In all types of violence, which worried the victim most, incidents occurred during the daytime work shifts more
than the nighttime work shifts. This has been explained to be because of the fact that daytime work shifts represent the time
of high activity and interaction with patients
(15)
. These findings do go with Waleed Zafar et als findings
(16)
. Most of the
violence incidents occurred at the place of work other than other places, inside or outside the hospital. This is expected as
far as it is assumed that the incidents occur as an immediate temporary reaction to mutually unmet behavioral expectations.
108 Alaa Hussein Abed

Impact Factor (JCC): 5.1064 Index Copernicus Value (ICV): 3.0
This assumption is supported by the finding that most respondent victims do not think that there was any underlying factor
that participated in the occurrence of incident in all types of violence. A similar finding was reported by Cassie B. Barlow
and Anne G. Rizzo, earlier at the end of last century, that attacks were more likely to occur in the emergency room than in
any other section of the hospital
(17)
.
The main perpetrator, in the incidents that worried the respondents most, was the emergency care service users
family member, relative, companion or friend. The service user themselves come in the second degree. This what was
stated by Waleed Zafar et al that emergency department healthcare workers are relatively frequent victims of violence
perpetrated mainly by patients relatives (69.9% in verbal and 63.6% in physical violence) and then by the patients
themselves (16.1% in verbal and 20.4% in physical violence)
(16)
.
The main perpetrator in the worried most incidents was male in all types of violence. This finding goes with the
belief that men are responsible for the vast majority of violence. The findings here differ from those reported by Terry
Kowalenko et al that men perpetrated only 52% of assaults and 63% of physical threats
(18)
. This difference is probably can
be attributed to sociological and cultural differences between the two communities; where in Iraq, men are socially
dominant. However, Mohamad Kitaneh and Motasem Hamdan found, in spite of that males were the main perpetrator in
physical violence (76%), females were the main perpetrator in verbal violence (63.6%)
(19)
.
It was stated by Needham I et al that despite differing countries, cultures, research designs and settings, staff's
responses to patients aggression are similar
(20)
. In this study, almost all respondents, who faced violence, either did
nothing as an immediate response to the incident or they called the hospital security/ police, which in fact is a very limited
action, when the security guards/ police officers role, only, stop violent behaviours without any consequences.
This probably refers to that even if the incident may seem worrying to the victim staff, it does not lead them to take a
serious action to stop/ deal with it. It can be due to the perception, by the staff, that exposure to workplace violence is part
of the nature of their job. This finding goes with what Cheshin Arik et als. They found that victim staffs response ranged
from ignoring the incident, giving in to the violence, or calling security
(21)
. They also reported that the higher the
perception of threat, the more likely the staff was to give in to the perpetrators anger and/or the higher the likelihood that
the response would be to call security, i.e. the staff recognizes perpetrators anger at varying levels and responds
accordingly
(21)
.
The graduation in the level of fear during the incidents, reported in this study, was consistent to the graduation in
the level of violence. This seems to be logical and agrees Cheshin Arik et al, who reported that the expressions and
magnitudes of the perpetrators anger were directly correlated with the victim staff's fear level, hence with their response to
violence
(21)
.
Most of respondent victims of violence did not take an action after the end of the violence incidents. This finding
agrees what was found by Terry Kowalenko et al; they stated that for the violent events, 42% of the incidents reported to
hospital authorities and only 5% of assaults were reported to police
(18)
. It was reported that the reason behind this
underreporting was because there are barriers to reporting violent events exist and include confusion about what events
should be reported, lack of time to complete reports, and lack of feedback from management and administration about the
reported event
(22)
. Respondent victims in the Kitaneh and Hamdans study answered that they did not take an action
because it was useless (from their experience no action would be taken), it was not important, they were afraid of negative
consequences or fear of feeling guilty or ashamed, or they did not know to whom they should report
(19)
.
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The researcher here does not believe that this is the reason in the underreporting findings of the current study; it
simply may be because the victim staff consider violence incidents as a part of their work.
Respondent victims answers about long-term psychological consequences of exposure to workplace violence
showed that a considerable percentage of them do not/rarely think about violence, do not/rarely have dreams about it, do
not/rarely try to remove the subject from memory, do not/rarely talk about violence, and mostly/ sometimes avoid letting
themselves get upset when they think about/being reminded of violence incidents. The situation here differs, to some
extent, from findings reported by other researchers. Magnavita and Heponiemi documented psychological impacts of
violence. These included anger, disappointment, anxiety, distress, intention to move to another place of work or to perform
professional duties in a different way, and high psychological disorders scores
(2)
. Kitaneh and Hamdan stated that the
impact of workplace violence and its potential threat was an issue that most of the study respondents contemplated at least
occasionally. There were forms of protection sought. These include obtaining a gun, a knife, a concealed weapon license,
and carrying mace or a club and most used a security escort. Considering leaving the hospital, emergency medicine, or
location of practice because of being a victim of workplace violence were found to be impacts. One percent sought
psychological support, and 16% went to a course on violent patients because of their experience with violence in the
workplace
(18)
. Needham I, et al. reported that the most frequent psychological consequences of violence were anger,
depression, fear or stress, headache/ fatigue, and frustration. A considerable percentage of victims sought some sort of
treatment (including psychological), reported persistent health problems, and reported subsequent changes in their work
status including restrictions in work, work absences, or transferred to another location
(19)
. This difference, probably,
belongs to the fact that Iraqi people have faced variable work, social, and domestic types of violence of considerable levels
during the last 35 years that has made such workplace violence does not leave long-term psychological consequences in
Basra emergency department staff victims .
CONCLUSIONS
In emergency departments of Basra hospitals, verbal violence/ intimidation is the most common, followed by
physical violence, and the least frequent is hospital-property damage/ theft associated with violence and the rates lie in the
middle of international range. Violence, which worries the victims most, usually occurs during the daytime work shifts and
the main perpetrator is a male, who is mostly the patients family member, relative, companion or friend. The graduation in
the level of fear during the incidents, reported in this study, is consistent to the graduation in the level of violence.
Workplace violence victims either do nothing as an immediate response to the incident or take limited actions and
they, often, do not take an action after the end of the incidents. Furthermore, violence does not leave long-term
consequences in Iraqi professionals.
LIMITATIONS
It was assumed that respondents in this study responded to the questionnaire in a reliable manner. There is no way
at the disposal of the investigator, however, to verify such assumption. It might be biased by the potential
inaccuracy of self-reported data compared to objectively verified one.
The respondents who answered the questionnaire might not have a clear recollection of all the incidents during the
year preceded the study. If the respondent was unable to recollect all incidents, the questionnaire may not have
been answered in a credible and factual manner. People usually tend to remember important events.
110 Alaa Hussein Abed

Impact Factor (JCC): 5.1064 Index Copernicus Value (ICV): 3.0
The retrospective nature of the study may mean, because of the respondents recall accuracy, that the results are
not a true representation of the problem in Basra. Memories, especially regarding events like a verbal attack,
might be less memorizable, leading to distorted time perception: events that happened more than a year ago might
be misremembered to have occurred more recently.
The sample was not randomly selected. So, from education level and type of occupation points of view, the
sample was not representative. This could make the generalizability of the study results limited.
RECOMMENDATIONS
The problem needs more detailed investigation in Iraq to determine its frequency, distribution, and determinants.
Training, on how to deal with workplace violence, is a topic that needs to be added to the initial and continuous
training curriculum of emergency department staff in Iraq.
More legislations need to be put to prevent workplace violence against health staff in general and specifically the
emergency department staff.
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