Violence against health employees in a child health and diseases clinic: A tertiary-level hospital example.

AIM: Violence in health is an important public health problem that threatens community peace. In our study, it was aimed to examine the state of exposure to violence among employees in our clinic in the last one year and our employees' opinions and attitudes about violence.
MATERIAL AND METHODS: The study was performed cross-sectionally. In this study the Violent Incident Form developed by Arnetz (1998) was used as a data collection tool.
RESULTS: A total of 182 healthcare workers were included in the study. Of the participants, 14 (7.7%) were faculty members, 37 (20.3%) were physicians, 24 (13.2%) were interns, 70 (38.5%) were nurses, 10 (5.5%) were medical secretaries, and 27 (14.8%) were ancillary health personnel. The female/male ratio was 143/39. Seventy-nine (43.4%) of the employees had been exposed to violence at least once in the last year. Of those experiencing violence, 57 (72%) were female, 28 (35%) were nurses, 21 (27%) were residents, 16 (20%) were interns, five (6.5%) were faculty members, five (6.5%) were allied health personnel, and four (5%) were medical secretaries. Physicians were exposed to violence with a higher rate (p<0.05). Exposure to violence was observed most frequently in the pediatric emergency department. Of all the violent incidents, 58% occurred during night shifts and 46% occurred during examination/treatment/physical care. The perpetrator was a patient in only one incident, the other perpetrators were patients' relatives, and 63% of the perpetrators were men. All violent incidents involved verbal violence, seven (8.8%) incidents contained elements of physical violence, such as spitting, pushing, kicking, biting, restraining or using an object. Only 29 (36.7%) of the 79 staff reported violence, and 50 (63.3%) did not take any action after the violence.
CONCLUSION: Violence in health is a common and serious problem even in tertiary hospitals. In our study, only one-third of the affected staff reported violence after exposure to violence. The risk of violence should be reduced in order to ensure a safe work environment, which will be possible by raising awareness of healthcare workers and effective implementation of violence prevention programs. Copyright:

Introduction

Violence is an important public health problem that threatens peace in health institutions and hospitals, as well as in the whole community, and shows a gradual increase. Violence in health institutions is defined as follows: “a condition that is composed of threat behavior, verbal threat, physical assault, and sexual assault arising from patients, patients’ relatives or any person, and causing risk for healthcare workers” (1). More than 50% of healthcare workers are exposed to violence at any time in the time period during which they practice their profession (2). When addressing the negative effects of violence on healthcare workers and the service they give, providing a safe working environment is considerably important. One of the primary steps to be taken to prevent violence is obtaining valid evidence and reporting violence.

In our study, we aimed to examine our healthcare workers’ states of exposure to violence in the last one year in our clinic, and their opinions and attitudes related to violence, in order to draw attention to violence directed to healthcare workers, which is gradually increasing in our country.

Material and Methods

The study was conducted cross-sectionally with healthcare workers who were working in Pamukkale University, Faculty of Medicine, Pediatrics Clinic. Approval was obtained from the Non-interventional Clinical Research Ethics Committee for the study (Date: 05.03.2019, Number: 05). This study was conducted in accordance with the Declaration of Helsinki.

The Violent Incident Form questionnaire developed by Arnetz (1998) was given to all healthcare workers in the Department of Pediatrics (3). The participants were asked how many times they were exposed to violence in the last few years. The participants who answered “more than once” were asked to answer the questionnaire questions according to the violence incident that influenced them the most. This questionnaire, which was composed of 16 questions, included three demographic properties including sex, profession group, and age. The remaining part of the questionnaire included questions related to the type of the violent incident, place where the violence occured, if the person was alone during the incident, what the person did, characteristics of the perpetrator, the person’s reaction against the incident, and if the incident was reported.

Statistical Analysis

Statistical analysis of the data was performed using descriptive statistics and the Chi-square test using the Statistical Package for the Social Sciences for Windows program (SPSS 21, Inc., Chicago, IL, USA). A p value of <0.05 was considered statistically significant.

Results

A total of 182 healthcare workers who were working in the Pediatrics Clinic of our university were included in the study. Fourteen (7.7%) of the participants were faculty members, 37 (20.3%) were residents, 24 (13.2%) were interns, 70 (38.5%) were nurses, 10 (5.5%) were medical secretaries, and 27 (14.8%) were allied healthcare personnel. Physicians constituted 41% of the healthcare workers. One hundred forty-two (78.5%) of the healthcare workers were aged between 25 and 39 years, and the female/male ratio was 143/39 (Table 1).

Table 1

Demographic charcateristics of the employees

Occupation	n	%
Faculty member	14	7.7
Resident	37	20.3
Intern	24	13.2
Nurse	70	38.5
Medical Secretary	10	5.5
Allied heath personnel	27	14.8
Sex
Female	143	78.5
Male	39	21.5
Age
25–39 years	142	78
40 years and above	40	22
Total	182	100

Seventy-nine (43.4%) of the healthcare workers were exposed to violence at least once in the last one year. Thirty-two (40%) of the subjects who were exposed to violence reported that they were exposed to violence once in the last one year, 16 (20%) reported that they were exposed to violence twice, 10 (13%) reported that they were exposed to violence three times, and 21 (27%) reported that they were exposed to violence four times or more in the last one year.

Twenty-two (28%) of the subjects who were exposed to violence were male and 57 (72%) were female (p>0.05). Twenty-eight (35%) of the subjects who were exposed to violence were nurses, 21 (27%) were residents, 16 (20%) were interns, five (6.5%) were faculty members, five (6.5%) were allied healthcare workers, and four (5%) were medical secretaries (p<0.05). Sixty-four (81%) of the subjects who were exposed to violence were in the 25–39 years’ age group (Table 2). Twenty-eight (40%) of 70 nurses, 21 (56.8%) of 37 residents, 16 (66.7%) of 24 interns, 5 (35.7%) of 14 academic members, 5 (18.5%) of 27 allied healthcare workers, and 4 (40%) of 10 medical secretaries were exposed to violence. Among all physicians, the rate of esposure to violence was found as 56% (42/75). It was observed that physicians were exposed to violence with a higher rate compared with the other healthcare workers (p<0.05) (Table 3).

Table 2

Demographic characteristics of the subjects who were exposed to violence

Occupation	n	%
Academic member	5	6.5
Resident	21	27
Intern	16	20
Nurses	28	35
Medical secretary	4	5
Allied health personnel	5	6.5
Sex
Female	57	72
Male	22	28
Age
25–39 years	64	81
40 years and above	15	19
Total	79	100

Table 3

Exposure to violence by occupation and unit of work

	Violence absent		Violence present		Total n	p
	n	%	n	%
Occupation
Physician	42	56	33	44	75	<0.05
Other	37	36	70	64	103
Unit of work
Emergency	45	62.5	27	37.5	72	<0.05
Wards	12	31.5	26	68.5	38
Outpatient clinics	11	35.5	20	64.5	31
Intensive care	1	6	16	94	17
Neonatal intensive care	10	42	14	58	24

Most incidents of violence were experienced in the pediatric emergency department (n=28, 35%). Nineteen (24%) incidents occured in wards, 21 (27%) occured in outpatient clinics, and 11 (14%) occured in intensive care units. It was observed that 45 (62.5%) of 72 individuals who were working in pediatric emergency department were exposed to violence (p<0.05) (Table 3). When the hours of the incidents of violence were examined, it was found that 42% occured between 08:00 and 18:00 during daytime working hours, 38% occured between 18:00 and 24:00, and 20% occured between 24:00 and 08:00.

The assault occured in an examination room in 37 incidents (47%), in a corridor in 16 incidents (20%), in a patient room in 15 incidents (19%), in the physician’s room in three incidents (4%), and in the waiting room in three incidents (4%). Thirty-six (46%) incidents of violence occured during examination/treatment/physical care, 15 (19%) occured during patient admission procedures, 15 (19%) occured at the end of examination/treatment, three (4%) occured during discharge procedures, and one (1%) incident occured during patient transportation.

The perpetrator was a relative in 78 incidents (99%), and a male patient himself aged 17 years, in one incident (1%). Fifty (63%) of the perpetrators were male and 29 (37%) were female. When the perpetrator’s ages were examined, it was found that 51 (64.5%) were in the 31–50 years’ age group, 21 (26.5%) were in the 19–30 years’ age group, three (4%) were in the 51–65 years’ age group, 2 (2.5%) were aged 65 years and above, and two (2.5%) were aged 18 years and below.

All staff afffectedby violence were exposed to verbal violence. In addition to verbal violence, elements of physical violence including spitting, pushing, kicking, biting, pressure, and throwing objects were present in seven incidents (8.8%). Four (57%) of seven healthcare workers who were exposed to physical violence were nurses, two (29%) were residents, and one (14%) was an intern; all were female.

Fifty-one (65%) of the total 79 healthcare workers could not predict that an assault would take place. Twenty-three (29%) of 79 subjects who were exposed to violence were alone during the incident, whereas 56 incidents (71%) occured in crowded places. When the staff were asked the reason of assault, 27 subjects (34%) reported that it might be related with the perpetrator’s mental illness, one subject (1%) reported that the perpetrator might have been under the influence of alcohol/narcotics, and 51 subjects (65%) gave the answer “I don’t know.”

When the reactions against violence were examined, it was found that 50 of the affected staff (63.3%) reacted by defending themselves verbally, and 16 (20.3%) asked for help, and people around came for help for 12 (15.4%) of the subjects. As a result of the incident, 66% of the stff reported that they felt anger, 53% reported discomfort, 38% reported anxiety, 27% reported disappointment, 25% reported fear, and 23% reported humiliation.

Fifty (63.3%) of 79 healthcare workers did not take legal action after the incident of violence, and only 29 (36.8%) made an official report. Sixteen (55%) of 29 healthcare workers who made an official report wrote a statement alone, nine (31%) called the police, and four (14%) both wrote a statement and called the police. Twenty-one (72.4%) of the staff who made an official report were female and eight (27.6%) were male. Seventeen (58.6%) were physicians. Three of a total of seven healthcare workers who were exposed to physical violence did not make an official report, even though they were exposed to physical violence.

The Arnetz Violent Incident Form was administered to the healthcare workers in our study and the data obtained are shown in Table 4.

Table 4

Arnetz Violent Incident Form applied to healthcare workers who were exposed to violence and the data obtained

	n	%
How many times have you been exposed to violence in the last one year
1 time	32	40
2 times	16	20
3 times	10	13
4 and above	21	27
The unit in which you were working during the incident Pediatric emergency department	28	35
Pediatrics wards	19	24
Pediatrics outpatient clinics	21	27
Pediatric and neonatal intensive care unit	11	14
Incident time
08:00–18:00	33	42
18:00–24:00	30	42
24:00–08:00	16	20
By whom were you exposed to assault or violence?
Patient	1	1
Patient’s relative	78	99
What do you assumably associate the individual’s assault with?
Mental disease	27	34
Dementia/mental disability	–	–
Being under anesthesia	–	–
Intensive treatment	–	–
Being under the effect of alcohol or narcotics	1	1
I don’t know	51	65
Perpetrator’s sex
Male	50	63
Female	29	37
Perpetrator’s age
Below 18 years	2	2.5
19–30 years	21	26.5
31–50 years	51	64.5
51–65 years	3	4
Above 65 years	2	2.5
Where were you exposed to assault?
Patient’s room	15	19
Physician’s room	3	4
Examination room	37	47
Waiting room	3	4
Corridor	16	20
Other	5	6
When did the incident happen?
At the time when the patient’s admission procedure was being performed	15	19
During examination/treatment/physical care	36	46
At the end of examination/treatment	15	19
During patienta’s transport	1	1
During discharge procedure	3	4
Other	9	11
Did you feel beforehand that you would be exposed to assault?
Yes	28	35
No	51	65
Were you working alone at the time when the incident happened?
Yes	23	29
No	56	71
Type of the incident of violence
Verbal threat/assault	79	100
Spitting	3	4
Biting	1	1
Kicking	1	1
Pressure	1	1
Slapping	–	–
Pushing	3	4
Use of tool or weapon	1	1
Other	–	–
What was reaction against the incident?
I reacted by defending myself verbally	50	63.3
I asked for help	16	20.3
Other people came for help	12	15.4
No procedure was needed	1	1
What happened as a result of the incident?
Physical injury	–	–
I was afraid	20	25
I was angry	52	66
I felt uncomfortable	42	53
I experienced anxiety	30	38
I felt humiliated	18	23
I experienced disappointment	21	27
I felt helpless	11	14
Nothing happended	–	–
Other	–	–
What did you do during the incident?
I made an official report	20	25
I called the police	13	16
I both made an official report and called the police	4	5

Discussion

Violence is frequently experienced in the healthcare sector as well as in every segment of society. The conduction of healthcare services in close communication with society and the fact that healthcare workers give service to all segments of society increase the risk of violence in the healthcare sector. The frequency of violence was found as 49.5% in a study conducted by Ayrancı et al. (4) with 1209 heatlhcare workers, and 44.7% in a study conducted by Pınar et al. (5) with 612 639 healthcare workers. There are only two studies related to exposure to violence in pediatrics clinics in our country. In a study conducted with a total of 95 pediatric nurses working in six centers in the province of Konya, the rate of exposure to violence was found as 77.9% (6). In the other study, an “employee satisfaction questionnaire” was administered to 253 healthcare workers who were working in a children’s hospital and it was reported that 17% of the healthcare workers were exposed to physical assaults in the last six months (7). In our study, the frequency of exposure to violence was found as 43.5%, similar to the study conducted by Pınar et al. (5).

It has been reported that rates of exposure to violence in healthcare workers are higher in women, and young women with small physical structure and worried appearance are exposed to violence with a higher rate (4, 8, 9). Women constituted the majority of healthcare workers who were exposed to violence, also in our study. The belief that women have less strength for defence in our society may be the reason for the fact that violence in the healthcare sector is mostly directed to women.

In studies conducted in our country, it has been reported that physicians are exposed to violence most frequently among healthcare workers and this might be associated with the fact that physicians are in the frontline in the healthcare system in Turkey (5, 10). On the other hand, it has been shown that young and inexperienced healthcare workers have significant risk in terms of exposure to violence (11). Similarly, physicians, interns, and residents who had less professional experience among the physicians, constituted the majority of healthcare workers who were exposed to violence in our study. These findings suggest that regulations and training directed to the prevention of violence in the healthcare sector should be activated to a greater extent for inexperienced healthcare workers who are at higher risk in terms of violence.

When the place and time of incidents of violence were examined, it was found that incidents of violence most frequently occured in emergency departments, followed by psychiatry clinics. Incidences of violence occured during nightshifts more frequently compared with day shifts (12, 13). Incidents of violence are expected to occur more frequently in emergency departments because there is a higher probability of having contact with angry patients and relatives who have drug/alcohol addiction and psychiatric diseases and a higher risk in terms of engaging in violence in emergency departments. The fact that incidents of violence mostly occured during nightshifts in our clinic, supports the view that exhausted healthcare workers are more prone to exposure to violence comitted by individuals who have a tendency to violence, after long and intense working hours. Increasing safety precautions in the working environment, improving working conditions and training healthcare workers in crisis management and communication skills, will markedly reduce the risk of exposure to violence.

Verbal violence is the most common type of violence found in studies related to violence in the healthcare sector with a frequency of 29–74% (14). The finding that almost half of our healthcare workers were exposed to verbal violence and incidents of violence mostly occured in crowded environments might be associated with the fact that perpetrators were accustomed to violence, did not consider verbal violence as violence or thought that they would not be punished when they displayed verbal violence.

When the characteristics of individuals with a tendency to violence are examined, it can be observed that these individuals are generally men aged below 30 years with low socioeconomic status who may carry weapons and have previously experienced legal problems or a history of arrest. Most of these individuals have a history of alcohol or substance abuse (15). Studies have reported that there is a prodromal period before physical assault. In this period, there may be signs such as increased anxiety, raised voice, postural change, doubtful looks, increased physical activity, and fidgeting (16). In our study, it was observed that most of our healthcare workers did not sense violence beforehand because of their busy schedule. Observing the signs in the prodromal period before violence and training healthcare workers in terms of appropaches recommended to control individuals who suddenly become aggressive are considerably important.

Violence causes multiple negative outcomes for the individual affected by the violence. Many negative effects such as growing disheartened with the profession, anger, fear, sorrow, and depression emerge, and this influences working lives of individuals negatively (17). The emotions experienced extensively by the healthcare workers who were exposed to violence in our study were similar to the literature, and the most common negative emotion experienced was anger. Receiving professional support with regular intervals may enhance coping with these emotions for healthcare workers.

When the report status following violence was examined generally, it was observed that most healthcare workers did not report violence (10, 18). The finding that only one-third of violent incidents in our clinic were reported, might have arisen from the avoidance of healthcare workers from legal procedures, the thought that they could not spare time for legal procedures in their busy schedule and possibly not getting a result, and considering being attacked as part of the profession. Healthcare workers should be encouraged to report violence to relevant institutions in order to reduce violence in the healthcare sector.

As in all areas of healthcare, providing a safe environment, increasing awareness of workers, applying violence prevention programs efficiently, and reducing the risk of violence are considerably important in the area of pediatrics. The results may be the tip of the iceberg. Reporting violence is the first step in prevention of violence.

A limitation of our study was the fact that it was conducted in a single clinic with a small number of samples. Future multi-dimensional studies measuring experiences of violence in different environments and using a valid criterion appropriate for comparison will contribute to the establishment of more efficient programs for the prevention of violence.