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VIOLENCE AGAINST HEALTH CARE WORKERS: A RETROSPECTIVE STUDY

Article  in  International Journal of Health Services Research and Policy · January 2016

DOI: 10.23884/ijhsrp.2016.1.1.03

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 Volume 1 Issue 1 2016
International Journal of Health Science Research and Policy

VIOLENCE AGAINST HEALTH CARE WORKERS: A RETROSPECTIVE STUDY

Hacer ATAMAN1, Gökhan ABA2, *

1
Istanbul Medeniyet University, Faculty of Health Sciences, Department of Nursing İstanbul/Turkey
[email protected]

*2
Bandırma Onyedi Eylül University, Faculty of Health Sciences, Department of Health Management
Bandırma/ Turkey, [email protected]

*
Corresponding author e-mail: [email protected]

As violence in society is increasing in recent years it is an important problem

in health institutions as well. Changes in health systems, rising socio-economic
levels of people, and changes in expectations for health services led to violence
in health sector. This study was conducted for the purpose of examining work
place violence against health care workers. This retrospective-descriptive study
covers a period from December 2011 to April 2015. In this study 101
notifications about work place violence reported by health workers to quality
management unit of a hospital were investigated. In the analysis of the data,
descriptive statistics (number and percentage) were used. Research findings
show that physicians, nurses and health officials are exposed to violence most.
Additionally female health workers are more exposed to violence by relatives of
patients than male ones. Most of violence occurred by verbal abuse.
Besides verbal abuse physical violence as fist, kick, slap, bite sexual abuse,
emotional violence take place in health institutions so that health workers
have a risk in order to maintain their lives. As a result, in order to reduce /
prevent violence in work place, it is considered necessary to increase
consciousness of patients and their relatives, to increase security measures
in health institutions, to provide health workers to report work place
violence to management, to improve physical working conditions and
increase legal sanctions in terms of providing employee safety.

Key words: Health Workers, Health institution, Employee Safety, Violence

1. INTRODUCTION

The World Health Organization defines violence as "the possibility of causing or leading to
injury, death, psychological damage, impaired development or absence in one person, group or
community with intentional physical exertion, use of force” Violence can be seen everywhere and is

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becoming a serious problem affecting all professions, especially in the workplace [2]. Violence in the
workplace is defined as "events that an individual or people have been abused or attacked during
situations involving an employee's work" [2,3,4]. Violence in the workplace can be seen in many
different types as verbal harassment, physical assault, harassment, bullying, intimidation, threats and
obscene behavior [3]. Violence in the workplace, whether physical or psychological, has become a
global problem whose boundaries went beyond working environments and occupational groups.
Violence in the workplace has escalated in recent years and has now become a priority in both
industrialized and developing countries [5].
Health institutions are one of the most seen areas of violence [2]. Violence in health care
institutions refers to verbal or behavioral threats, physical attacks or sexual assaults [2], [4], [6, 7]
which creates a risk for health care workers from patients, relatives or anyone else. Health institutions
are among the places where workplace violence is mostly experienced because of environmental risk
factors. Serving vulnerable people having mental illness, drug addicts and criminals is the greatest risk
factor to be exposed to violence for health workers. Hospitals can turn into risky and dangerous
environments for them [8]. In the literature, although verbal and physical types of violence are mostly
discussed, psychological, sexual and economic violence have been included in types of violence in
recent years [6]. It has been reported that the most common type of violence among types of violence
in health institutions is verbal violence [9]. These attacks against health workers are in an increasing
trend affecting community health additionally [6]. Violence is an important public health problem in
society and workplaces, and the frequency of it is increasing [8].
Violence seen in the health sector is different from that in other sectors. Health care workers
often provide service to patients and their relatives under difficult circumstances and in close
relationships [10]. Working in a health institution is more risky than other workplaces because of
violence. The frequency of verbal violence is higher than physical violence. In different studies, it has
been stated that working in health institutions is 16 times more risky than other places of work because
of the violence. It is stated that encountering violence may be a serious problem for physicians as well
as other health personnel because of the fact that patients or patient relatives may not accept delays in
treatments due to various reasons and tend to be aggressive [11].
There are different factors that increase the risk of violence in health institutions. These include
24-hour uninterrupted health care given by health workers, the presence of stressful family members,
long waiting times for patients, and inability of health staff to maintain their care. It has also been
reported that the intensity of work, insufficient number of staff, working in an overcrowded
environment, working alone, lack of education in coping with violence, lack of sufficient security
personnel, lack of restriction on violence can be considered as factors increasing the risk of violence
[12].
The main causes of violence in health institutions are interaction between health workers and
patients, organizational factors, environmental factors and social variables. Patients and their relatives
and health workers are in a process of interaction involving complex relationships. In this process, it is
necessary for the individuals to be in contact by exchanging information in order to carry out the
communication process for a healthy interaction. However, clear and effective communication does
not generally take place between health workers and patients and their relatives, and some
communication problems arise. Organizational factors that create violence in health institutions
include lack of infrastructure and equipment, lack of personnel, extended queues, delayed

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appointments, excessive workload, adverse working conditions, lack of time to hospitalization, lack of
empty beds and lack of safety. Factors such as culture, level of crime in the community, level of
poverty, level of drug use, population density is among the environmental factors of violence in health
institutions. [13].
Violence in the workplace damages the physical, psychological and social structure of health
workers and can lead to many disorders such as increasing stress and medical errors, decreasing of
work efficiency and quality of life, anxiety and concentration difficulties, withdrawing from social
relations besides the initial effects [12]. It can also cause adverse consequences, both physically and
psychologically. These negative results may lead to a rise in emotional reactions, anger, shock, fear,
depression, and anxiety and sleep disorders. Occupational accidents, injuries and even suicides can be
seen in workplaces exposed to violence frequently [10].

2. METHOD

This retrospective-descriptive study covers a period from December 2011 to April 2015,
when the "White Code" application launched at a Training and Research Hospital for work place
violent in health care facilities begins. In this study 101 notifications about work place violence
reported by health workers to quality management unit of a hospital were investigated. In the analysis
of the data, descriptive statistics (number and percentage) were used in the SPSS 19.0 program.
Permission was obtained from the Institution's Clinical Research Ethics Committee and the institution
before starting work.

3. FINDINGS

The findings obtained from analysis of data regarding health workers exposed to violence in the
health institution are given below.
Table 1. Distribution of Health workers exposed to violence according to professions (n=101)
Job N %
Physician 45 45
Nurse, Health Officer 39 38.3
Service Purchaser Personnel 16 15.5
Other 1 1.2
Total 101 100

Table 1.shows that 45% of the victims of violence were physicians, 38.3% were nurses and
health workers, 15.5% were service purchasers and 1.2% were from other professions.

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Table 2.Distribution of people inflicted violence to health workers (n=101)

People Inflicted Violence N %
Patient 48 47.7
The relatives of the patients 53 52.3
Total 101 100

It can be seen from Table 2 that health workers were exposed to violence by 47.7% of the
patients and by 52.3% of their relatives.

Table 3. Distribution of people inflicted violence and health workers exposed to violence by
gender (n=101)

People applied violence Health workers exposed to violence

Female Male Female Male
n % n % n % n %
30 30,3 71 69,7 60 59,4 41 40,6

69.7% of the people inflicted violence is male and 30.3% are females. 60.6% of the health
workers exposed to violence were women, 41% were male. Findings can be seen in Table 3.

Table 4. Distribution of reported cases according to place of action of violence (n=101)

Place of Action of Violence n %
Inpatient services 40 39.6
Polyclinics 30 29.7
Emergency 29 28.7
Intensive Care Unit 1 1.0
Medical Supply Warehouse 1 1.0
Total 101 100

In Table 4 it can be seen that when the distribution according to the incident place was
examined, it was found that 39.6% of work place violence occurred in inpatient services, 29.7% in
policlinics, 28.7% in emergency services, 1% in intensive care unit and 1% in medical supplies.

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Table 5. The Time of the Action of Violence (n=101)

The Time of the Action of Violence n %
During Working Hours 75 74.3
Out of working hours 26 25.7
Total 101 100

Table 5, it is obvious that 74.3% of the incidents of violence were during working hours and
25.7% of them were out of working hours.
Table 6. Distribution of violence according to types (n=101)
Type of Violence Action n %
Verbal Violence 65 64.3
Physical Violence 25 24.8
Verbal and Physical Violence 11 10.9
Total 101 100

When the distribution of the violence according to the type is examined, 64.3% of the violence
was verbal, 24.8% was physical, and 10.9% was verbal and physical. Findings are in Table 6.

Table 7. Distribution of Reactions after the event (n=101)

Reactions after violence event n %
Initiated a criminal case 63 62.3
Victim didn’t want legal aid 25 24.7
Reported to Public Prosecutor's Office 10 9.9
Other 3 2.9
Total 101 100

According to Table 7, in 62.3% of violence incidences a criminal case was initiated, 24.7% of
victims did not want legal help and 9.9% were reported to the Office of the Prosecutor.
When the types of physical violence were analyzed, erythromatosis around the left umbilicus
(face, eye, nose, chest, ear, head), bite-tightening, bleeding in the mouth, kicking (arm, hand), erosion
image, slapping, hair pulling, broken in the knee, throwing a hard object in the face, biting the chest,
pushing, squeezing the throat and throwing shoulder in the chest were seen most.

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4. DISCUSSION

Akca and his colleagues found that 47.4% of the victims of violence in a health institution were
medical secretary or patient advisor, 36.8% were physicians, 10.5% were administrative personnel and
5.3% were health technicians. It was observed that 45.5% of the violence against health workers was
inflicted by the patient and 40.9% of the violence was inflicted by the patient relatives. A majority of
the violence exposers were male with a rate of 76.2%. 85.7% of the victims were women, 14.2% were
males. It was observed that the place of violence of most seen was examination room with a rate of
45.5%. That was followed by the corridor with a rate of 22.7%. All of the staff that was exposed to
violence explained their violence as verbal threat or aggression [11].
In study of Ayrancı and his friends, 48.4% of men and 52.5% of the women were found to have
experienced violence among health workers. According to profession, the rates of abuse are 53.7% in
physicians, 58.4% in nurses and 43.5% in assistant personnel. Violence occurred most in emergency
department (63.1%) and clinical services. In 1071 health workers, the rate of violence was 50.8%
[14].
Gülalp and colleagues found that there was a significant relationship between physical violence
and gender, age, occupation, and experience at work [15].
In the "Health Workers Violence Survey" conducted by the Health and Social Workers' Union
in 25 provinces and 1300 health workers it was found that there were more risky groups for exposure
to violence. Participants were asked what extent they were exposed to violence throughout your
career; 86.8% of the respondents stated that they were exposed to verbal, psychological or physical
violence at least once. 23.7% of the respondents stated that they were exposed to physical violence in
the last year. The proportion of people who have been exposed to psychological / verbal abuse within
the past year is 98.3%. 56.9% of those exposed to violence stated that the violence was committed by
patient relatives and 31.8% were performed by patients. When we look at the sex of the people who
applied violence, we see that 68.33% is male and 31.67% is female. The time of the violence is
widespread, both during working hours and during the seizure. While the rate of participants who
reported violence during working hours was 64.5%, 33.9% stated that they were exposed to violence
during the seizure. In the question "Where did the violence occur?” 25% of the participants answered
the hospital corridor, 23.8% the emergency service, and 11.7% the polyclinic [16].
Arcak and Kasımoğlu found that 21% of nurses were exposed to violence at in last one year of
working [17]. Winstanley and Whittington reported that 68.3% of participants were exposed to verbal
violence in a study conducted in a general hospital in the UK [18].
In Demir's study, it was found that 60.3% of the nurses were exposed to violence in a hospital.
The percentage of physical violence was 11.9%, verbal violence was 51.6% and sexual violence was
% 9.5. It was found that 65.1% of cases of violence were committed by relatives of the patient [3].
In a study conducted in Kocaeli, the rate of exposure to violence in the last 12 months was
72.4%; the type of violence most exposed during work life was verbal violence with a rate of 98.5%.
14.3% of the health workers were exposed to workplace violence on weekdays; 30.1% were occurred
during the visiting, and 37.2% were exposed during outpatient services [2].
Özcan and Bilgin systematically addressed violence against health workers in Turkey and
reported that attacks were observed more frequently during the daytime than nighttime. In this
systematic review, all types of violence towards healthcare workers were found to be high, and
violence was performed by the majority of the patients' relatives and patients [19].

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5. RESULT

This study focused on reported violence incidences, so it can be said that there may be a lot of
violence victims who are not recorded official. The findings of the study show that among health
workers physicians and nurses are most exposed to violence. Violence in workplace decreases
performance of health workers and destroys quietness of environment. Besides verbal assault other
kinds of violence as well as fist, kick, slap, bite occurs so that health workers have a risk in order to
maintain their lives. Health professionals who work for enhancing the health of the people can
unfortunately lose their own health when performing their duties. The underlying reason for violent
acts against health workers is that individuals think that their or their relatives' health status is more
important and urgent than all issues. Patients and / or relatives of patients are also subjected to
violence as a result of their claim without knowing their responsibilities. In this case, the motivation of
health personnel working in difficult conditions decreases and burnout occurs.
As a result, in order to reduce / prevent work place violence, it is considered necessary to
increase consciousness of patients and their relatives, to increase security measures in health
institutions, to provide health workers to report work placed violence against them to their institutions,
to improve physical working conditions and increase legal sanctions against violence.

6. REFERENCES

[1] Krug, E. G., et al., World Report on Violence and Health, World Health Organization, Geneva,
2002
[2] Çamcı, O., Kutlu, Y., Kocaeli’nde Sağlık Çalışanlarına Yönelik İşyeri Şiddetinin Belirlenmesi,
Psikiyatri Hemşireliği Dergisi, 2 (2011) 1, pp. 9-16
[3] Demir, G., Bir Üniversite Hastanesinde Çalışan Hemşirelerin Şiddete Maruz Kalma Durumlarının
İncelenmesi, İnönü Üniversitesi Sağlık Bilimleri Dergisi, 3 (2014), 1, pp. 25-28
[4] İlhan, M. N., et al., Toplum Gözüyle Sağlık Çalışanlarına Şiddet: Nedenler, Tutumlar,
Davranışlar, Gazi Medical Journal, 24 (2013), pp. 5-10
[5] International Labour Organization (ILO), et al., Framework Guidelines For Addressing Workplace
Violence in The Health Sector. International Labour Office, Geneva, 2002
[6] Al, B., et al., Sağlık Çalışanlarına Yönelik Artan Şiddet, The Journal of Academic Emergency
Medicine, 11 (2012), pp. 115-24
[7] Annagür B., Sağlık Çalışanlarına Yönelik Şiddet: Risk Faktörleri, Etkileri, Değerlendirilmesi ve
Önlenmesi, Psikiyatride Güncel Yaklaşımlar, 2 (2010), 2, pp. 161-173
[8] Cinoğlu, A., Sağlık Kurumlarında Şiddet, Dönem Projesi, Pamukkale Üniversitesi, Denizli,
Türkiye, 2015
[9] Kahriman İ., Hemşirelerin Sözel ve Fiziksel Şiddete Maruz Kalma Durumlarının Belirlenmesi,
Psikiyatri Hemşireliği Dergisi, 5 (2014), 2, pp. 77-83
[10] Pınar, T., Pınar G., Sağlık Çalışanları ve İşyerinde Şiddet, TAF Preventive Medicine Bulletin,
12 (2012), 3, pp. 315-326

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[11] Akca, N., et al., Sağlık Çalışanlarına Uygulanan Şiddet: Özel Bir Tıp Merkezi Örneği, Ankara
Sağlık Hizmetleri Dergisi, 13 (2014), 1, pp. 1-12
[12] Durak, T. Ç., et al., Bozyaka Eğitim ve Araştırma Hastanesi Sağlık Çalışanlarına Hasta ve
Hasta Yakınları Tarafından Uygulanan Şiddetin Değerlendirilmesi, Genel Tıp Dergisi, 24 (2014),
pp. 130-137
[13] Sarcan, E., Toplumun Sağlık Çalışanlarına Uygulanan Şiddete Bakış Açısı, Uzmanlık Tezi,
Gazi Üniversitesi, Ankara, Türkiye, 2013
[14] Ayrancı, Ü., et al., Çeşitli Sağlık Kurumlarında ve Sağlık Meslek Gruplarında Şiddete Uğrama
Sıklığı, Anadolu Psikiyatri Dergisi, 3 (2002), pp. 147-154

[15] Gülalp, B., et al., Dangers Faced By Emergency Staff: Experience In Urban Centers In
Southern Turkey, Turkish Journal of Trauma&Emergency Surgery, 15 (2009), 3, pp. 239-242
[16] Sağlık ve Sosyal Hizmet Çalışanları Sendikası, Sağlık Çalışanları Şiddet Araştırması, Sağlık-
Sen Yayınları-20, Ankara, 2013
[17] Arcak R. Kasımoğlu; E., Diyarbakır Merkezdeki Hastane ve Sağlık Ocaklarında Çalışan
Hemşirelerin Sağlık Hizmetlerindeki Rolü ve İş Memnuniyetleri, Dicle Tıp Dergisi,1 (2006), 3, pp.
323-330.
[18] Winstanley, S., Whittington, R., Aggression Towards Health Care Staff In A UK General
Hospital: Variation Among Professions and Departments, Journal of Clinical Nursing, 13 (2004),
1, pp. 3-10
[19] Özcan, N. K., Bilgin, H., Türkiye’de Sağlık Çalışanlarına Yönelik Şiddet: Sistematik
Derleme. Türkiye Klinikleri Tıp Bilimleri Dergisi, 31 (2011), 6, pp. 1442-56

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