Violence against physicians

Hospital-Based Healthcare Workers Victims of Workplace Violence in Italy: A Scoping Review

The aim of this scoping review is to synthesize the available evidence on the prevalence rates of healthcare workers being victims of violence perpetrated by patients and visitors in Italy. PubMed, Scopus, Web of Science and CINAHL were systematically searched from their inception to April 2021. Two authors independently assessed 1182 studies. All the scientific papers written in English or in Italian reporting primary quantitative and/or qualitative data on the prevalence of aggression or sexual harassment perpetrated by patients or visitors toward healthcare workers in Italy were included. Thirty-two papers were included in the review. The data extracted were summarized in a narrative synthesis organized in the following six thematic domains: (1). Methodology and study design; (2). Description of violent behavior; (3). Characteristics of health care staff involved in workplace violence (WPV); (4). Prevalence and form of WPV; (5). Context of WPV; and (6). Characteristics of violent patients and their relatives and/or visitors. The proportion of studies on WPV differed greatly across Italian regions, wards and professional roles of the healthcare workers. In general, the prevalence of WPV against healthcare workers in Italy is high, especially in psychiatric and emergency departments and among nurses and physicians, but further studies are needed in order to gather systematic evidence of this phenomenon. In Italy, and worldwide, there is an urgent need for governments, policy-makers and health institutions to prevent, monitor and manage WPV towards healthcare professionals.

Exploring the usefulness of medical clowns in elevating satisfaction and reducing aggressive tendencies in pediatric and adult hospital wards

BACKGROUND

Most existing research on medical clowns in health care services has investigated their usefulness mainly among child health consumers. In this research we examined multiple viewpoints of medical staff, clowns, and health consumers aiming to identify the optimal audience (adult or child health consumers) for which medical clowns are most useful. We focused on exploring their usefulness in enhancing health consumers' satisfaction and, in turn, reducing their aggressive tendencies.

METHODS

We conducted three studies that examined the placement fit of medical clowns from different points of view: medical staff (Study 1, n = 88), medical clowns (Study 2, n = 20), and health consumers (Study 3, n = 397). The main analyses in Studies 1 and 2 included frequencies and t-tests comparing perceived adult and child satisfaction with clowns' performance. Study 3 used moderated-mediation PROCESS bootstrapping regression analysis to test the indirect effect of negative affectivity on aggressive tendencies via satisfaction. Exposure to the medical clown moderated this relationship differently for different ages.

RESULTS

Studies 1 and 2 show that the majority of medical clowns and medical staff report that the current placement of the medical clowns is in pediatric wards; about half (44% of medical staff, 54% of medical clowns) thought that this placement policy should change. In Study 3, data from health consumers in seven different hospital wards showed that clowns are useful in mitigating the effect of negative affectivity on satisfaction, thereby reducing aggressive tendencies among health consumers under the age of 21.6 years. Surprisingly, medical clowns had the opposite effect on most adults: for health consumers who were exposed to the medical clown and were above the age of 21.6 negative affectivity was related to decreased satisfaction, and an increase in aggressive tendencies was observed.

DISCUSSION

Medical clowns are most useful in elevating satisfaction and reducing aggressive tendencies of children. Older adults, on the other hand, exhibit lower satisfaction and higher aggressive tendencies following exposure to the performance of medical clowns.

CONCLUSION

Medical clowns should be placed primarily in children's wards.

Workplace Violence: Experiences of Internal Medicine Trainees at an Academic Medical Center

OBJECTIVES

Healthcare professionals are at higher risk for workplace violence (WPV) than workers in other sectors. This elevated risk exists despite the vast underreporting of WPV in the medical setting. The challenge of responding to this risk is compounded by limited empirical research on medical training environments. Understanding trainees' experience and educating them on workplace safety, WPV reporting, and awareness of resources are shared goals of educational and institutional leadership. In our setting, clear understanding and education were urgent after the enactment of a statewide "constitutional carry" law affording individuals a right to carry concealed firearms in all state-owned universities and hospitals, beginning in July 2017. We sought to examine the incidence of WPV affecting Internal Medicine trainees to understand the types of violence encountered, reporting rates, and the factors that influence reporting.

METHODS

We conducted a cross-sectional online survey of Internal Medicine residents and fellows in practice for the previous 12 months. Survey items included both forced choice and open-ended questions. Descriptive statistics were calculated and used to summarize the study variables. χ² tests were performed to examine whether sex differences existed for each of the survey questions. Qualitative responses were content analyzed and organized thematically.

RESULTS

Of 186 trainees, 88 completed the survey. Forty-seven percent of respondents experienced WPV, with >90% of cases involving a patient, a patient's family member, or a patient's friend. Verbal assault was the most common type of incident encountered. Trainees formally reported fewer than half of the violent incidents disclosed in the survey. Major factors that influenced reporting included the severity of the incident, condition of the patient, and clarity of the reporting mechanism.

CONCLUSIONS

Previous research indicates similar amounts and types of WPV. Likewise, a large percentage of the incidents are not reported. Addressing the key factors related to why physicians underreport can inform institutions on how to make systematic changes to reduce WPV and its negative impact. Future research is needed to examine whether specific interventions can be implemented to improve reporting and reduce the incidence of WPV.

Adapting Maslow's Hierarchy of Needs as a Framework for Resident Wellness

ISSUE

Burnout in graduate medical education is pervasive and has a deleterious impact on career satisfaction, personal well-being, and patient outcomes. Interventions in residency programs have often addressed isolated contributors to burnout; however, a more comprehensive framework for conceptualizing wellness is needed.

EVIDENCE

In this article the authors propose Maslow's hierarchy of human needs (physiologic, safety, love/belonging, esteem, and self-actualization) as a potential framework for addressing wellness initiatives. There are numerous contributors to burnout among physician-trainees, and programs to combat burnout must be equally multifaceted. A holistic approach, considering both the trainees personal and professional needs, is recommended. Maslow's Needs can be adapted to create such a framework in graduate medical education. The authors review current evidence to support this model.

IMPLICATIONS

This work surveys current interventions to mitigate burnout and organizes them into a scaffold that can be used by residency programs interested in a complete framework to supporting wellness.

A Study of Workplace Violence Experienced by Doctors and Associated Risk Factors in a Tertiary Care Hospital of South Delhi, India

INTRODUCTION

The increasing incidences of violence against doctors in their workplaces are an important reason for stress among these healthcare workers. Many incidences of workplace violence against doctors have been reported in the past and are also being continuously reported from different parts of the country as well as the world.

AIM

To determine the prevalence of workplace violence among doctors and to study the associated risk factors in a tertiary care hospital of Delhi, India.

MATERIAL AND METHODS

A cross-sectional study was conducted using a self-administered semi-structured questionnaire. The contents were: data related to the workplace, incidences at work, violence prevention policy of the institution, reporting of incidences and follow-up, education and training for violence management. A total of 151 doctors participated in the study.

RESULTS

Total participants in the study were 151. The mean age of study participants was 26.73±4.24 years. Almost half (47.02%; 44.56% of males and 50.84% of females) of the doctors reported having an experience of violence during work hours in past 12 months. Among the cases, 39.4% were reported from Department of Obstetrics and Gynaecology while Surgery, Medicine and other departments reported 29.6%, 26.8% and 4.2% respectively. Patients or their relatives were perpetrators in most of the cases. Maximum (87.3%) of the reported cases were of verbal violence while 8.6% of the cases were of physical violence. Younger doctors with less work experience were more prone to physical violence. Regarding the time of violence, 35.1% of such cases occurred during afternoon while 30.1% of them took place at night.

CONCLUSION

A large number of doctors had experienced violence in past 12 months in a tertiary care hospital of South Delhi, India. Verbal violence came out to be most common form of violence experienced by the doctors. Afternoon or night hours were the timings when majority of such cases were reported.

Determinants of workplace violence against clinical physicians in hospitals

OBJECTIVES

Workplace violence in the health sector is a worldwide concern. Physicians play an essential role in health-care teamwork; thus, understanding how organizational factors influence workplace violence against physicians is critical.

METHODS

A total of 189 physicians from three public hospitals and one private hospital in Northern Taiwan completed a survey, and the response rate was 47.1%. This study was approved by the institutional review board of each participating hospital. The 189 physicians were selected from the Taipei area, Taiwan.

RESULTS

The results showed that 41.5% of the respondents had received at least one workplace-related physical or verbal violent threat, and that 9.8% of the respondents had experienced at least one episode of sexual harassment in the 3 months before the survey. Logistic regression analysis revealed that physicians in psychiatry or emergency medicine departments received more violent threats and sexual harassment than physicians in other departments. Furthermore, physicians with a lower workplace safety climate (OR=0.89; 95% CI=0.81-0.98) and more job demands (OR=1.15; 95% CI=1.02-1.30) were more likely to receive violent threats.

CONCLUSIONS

This study found that workplace violence was associated with job demands and the workplace safety climate. Therefore, determining how to develop a workplace safety climate and ensure a safe job environment for physicians is a crucial management policy issue for health-care systems.

Workplace violence against nurses in Chinese hospitals: a cross-sectional survey

OBJECTIVES

To determine the prevalence of workplace violence that Chinese nurses have encountered, identify risk factors and provide a basis for future targeted interventions.

SETTING

Heilongjiang, a province in northeast China.

METHODS

A cross-sectional survey.

PARTICIPANTS

A total of 588 nurses provided data. There were also in-depth interviews with 12 nurses, 7 hospital administrators and 6 health officials.

RESULTS

A total of 7.8% of the nurses reported physically violent experiences and 71.9% reported non-physically violent experiences in the preceding year. Perpetrators were patients or their relatives (93.5% and 82%, respectively), and 24% of nurses experienced non-physical violence that involved Yi Nao (gangs specifically targeting hospitals). Inexperienced nurses were more likely to report physical (13.2%) or non-physical (89.5%) violence compared with experienced nurses. Graduate-level nurses were more likely to perceive and report non-physical violence (84.6%). Nurses who worked rotating shifts were 3.668 times (95% CI 1.275 to 10.554) more likely to experience physical violence, and 1.771 times (95% CI 1.123 to 2.792) more likely to experience non-physical violence compared with nurses who worked fixed day shifts. Higher anxiety levels about workplace violence and work types were associated with violence. Interviewees perceived financial burdens, unsatisfactory treatment outcomes and miscommunications as influencing factors for workplace violence.

CONCLUSIONS

Preplacement education should focus on high-risk groups to reduce workplace violence. Increased awareness from the public and policymakers is necessary to develop effective control strategies at individual, hospital and national levels.

Violence against physicians in training. A Romanian perspective

The main purpose of this study was to assess whether there are differences between perceived and actual aggressions directed towards medical trainees from different medical specialties and different stages of medical training, and to characterize various types of aggressions against physicians in training in Romania. A multi-institutional survey was conducted in order to assess the prevalence of perceived and actual violence during medical residents; it included a total number of 384 medical residents from various specialties. Thirty two cases declared perceived physical aggression, most often in psychiatry. Actual physical aggression was 48% higher compared to perceived physical aggression. A similar situation occurred for sexual harassment, with only 9 perceived and 65 actual cases (an increase of 722%). Psychological abuse was the easiest to identify by the physicians in training, as the difference between perceived and actual aggression was minimal (202 and 205 respectively). The degree of perceived violence against physicians in training was much lower than the actual prevalence of the phenomenon, especially for physical and sexual types. This decreased awareness may lead to a failure in taking necessary safety measures and may subsequently increase the severity and consequences of the violent acts directed towards them.

Sources of distress during medical training and clinical practice: Suggestions for reducing their impact

BACKGROUND

Medical students and doctors experience several types of professional distress. Their causes ("stressors") are commonly classified as exogenous (adapting to medical school or clinical practice) and endogenous (due to personality traits). Attempts to reduce distress have consisted of providing students with support and counseling, and improving doctors' management of work time and workload.

AIM

To review the common professional stressors, suggest additional ones, and propose ways to reduce their impact.

METHOD

Narrative review of the literature.

RESULTS AND CONCLUSION

We suggest adding two professional stressors to those already described in the literature. First, the incongruity between students' expectations and the realities of medical training and practice. Second, the inconsistencies between some aspects of medical education (e.g., its biomedical orientation) and clinical practice (e.g., high proportion of patients with psychosocial problems). The impact of these stressors may be reduced by two modifications in undergraduate medical programs. First, by identifying training-practice discrepancies, with a view of correcting them. Second, by informing medical students, both upon admission and throughout the curriculum, about the types and frequency of professional distress, with a view of creating realistic expectations, teaching students how to deal with stressors, and encouraging them to seek counseling when needed.

Identification of violence in Turkish health care settings

This study sought to investigate the contributing factors to and frequency of violence against health care workers (HCWs) working in western Turkey. The population is composed of a random sample of 1,209 HCWs from 34 health care workplaces. Written questionnaires were given to HCWs at all sites, where staff were instructed to register all types of violence they had experienced. In all, 49.5% of HCWs reported having experienced verbal, physical, or verbal and physical violence, with this total being made up of 39.6% men and 60.4% women. A larger percentage (69.6%) of general practitioners reported experiencing verbal abuse and physical violence by patients and patients' family members or friends. Younger workers, inexperienced staff, and those in emergency services were more likely to report violence. Violence directed toward HCWs is a common occupational hazard. Public health authorities should plan preventive interventions based on the findings of this study.

Workplace Violence: A Survey of Emergency Physicians in the State of Michigan

STUDY OBJECTIVE

We seek to determine the amount and type of work-related violence experienced by Michigan attending emergency physicians.

METHODS

A mail survey of self-reported work-related violence exposure during the preceding 12 months was sent to randomly selected emergency physician members of the Michigan College of Emergency Physicians. Work-related violence was defined as verbal, physical, confrontation outside of the emergency department (ED), or stalking.

RESULTS

Of 250 surveys sent, 177 (70.8%) were returned. Six were blank (3 were from retired emergency physicians), leaving 171 (68.4%) for analysis. Verbal threats were the most common form of work-related violence, with 74.9% (95% confidence interval [CI] 68.4% to 81.4%) of emergency physicians indicating at least 1 verbal threat in the previous 12 months. Of the emergency physicians responding, 28.1% (95% CI 21.3% to 34.8%) indicated that they were victims of a physical assault, 11.7% (95% CI 6.9% to 16.5%) indicated that they were confronted outside of the ED, and 3.5% (95% CI 0.8% to 6.3%) experienced a stalking event. Emergency physicians who were verbally threatened tended to be less experienced (11.1 versus 15.1 years in practice; mean difference -4.0 years [95% CI -6.4 to -1.6 years]), as were those who were physically assaulted (9.5 versus 13.1 years; mean difference -3.6 years [95% CI -5.9 to -1.3 years]). Urban hospital location, emergency medicine board certification, or on-site emergency medicine residency program were not significantly associated with any type of work-related violence. Female emergency physicians were more likely to have experienced physical violence (95% CI 1.4 to 5.8) but not other types of violence. Most (81.9%; 95% CI 76.1% to 87.6%) emergency physicians were occasionally fearful of workplace violence, whereas 9.4% (95% CI 5.0% to 13.7%) were frequently fearful. Forty-two percent of emergency physicians sought various forms of protection as a result of the direct or perceived violence, including obtaining a gun (18%), knife (20%), concealed weapon license (13%), mace (7%), club (4%), or a security escort (31%).

CONCLUSION

Work-related violence exposure is not uncommon in EDs. Many emergency physicians are concerned about the violence and are taking measures, including personal protection, in response to the fear.

Medical workplace violence

Dr. Z., an obstetrician-gynecologist, refused to refill a narcotic prescription for a drug-seeking patient while on emergency room back-up call. For the next 6 months, he and his family were threatened and harassed by this patient. The constant fear of danger to his family dramatically affected Dr. Z., who questioned, "Is this the price of practicing medicine?"After months of being stalked and threatened by an angry former patient, Dr. A., an obstetrician/gynecologist, sought and was granted a court restraining order, which further infuriated the patient. When the threats became more pernicious, Dr. A. consulted a security expert, who evaluated her daily routine and advised her to dramatically revamp her life by changing where she shopped, continually altering her driving routes, learning self-defense skills, and constantly scanning her environment for the former patient. Despite making these striking changes, her life became unbearable as she loathed the practice of medicine that she once loved. Dr. A. stated, "Life will never be the same!"

A survey of threats and violent acts by patients against training physicians

OBJECTIVES

The primary purpose was to determine the prevalence of various types of threats or assaults by patients against training physicians and to determine the psychological impact of the most distressing incidents. Differences between specialty of training and gender were examined.

DESIGN

An anonymous mailed questionnaire.

SETTING

The Medical School of the University of Auckland, New Zealand.

SUBJECTS

All 160 postgraduate trainees in psychiatry, general medicine, surgery, and obstetrics and gynaecology. A response rate of 84% (n=135) was obtained.

RESULTS

The majority of trainees had been verbally threatened (n=91, 67%) or physically intimidated (n=73, 54%) at some time during specialty training, while another 41% (n=55) had witnessed Health Board property being damaged in their presence and 39% (n=53) had been physically assaulted. Psychiatry trainees were significantly more likely to experience the various types of threat or violence. Females (n=20, 38%) were significantly more likely than men (n=8, 10%) to report having been sexually harassed (chi2=14, d.f.=1, P < 0.001). The overall mean on the Impact of Event Scale for those who described the most distressing incident was 8. On only one occasion was a training director directly informed about a trainee's most distressing incident and most trainees (n=95, 70%) had not had training on protecting against assault or on managing violence.

CONCLUSION

These findings underscore a priority for developing programmes which effectively reduce threats and violence against trainees and which lessen the psychological sequelae of these incidents.