Indian Journal of Community and Family Medicine

: 2019  |  Volume : 5  |  Issue : 2  |  Page : 86--91

Changing world, changing trusts and health providers' sufferings

Shakunatala Chhabra 
 Department of Obstetrics Gynaecology, Mahatma Gandhi Institute of Medical Sciences; Aakanksha Shishugruha Sevagram,Kasturba Health Society, Wardha; Dr. Sushila Nayar Hospital, Amravati, Maharashtra, India

Correspondence Address:
Shakunatala Chhabra
Department of Obstetrics Gynaecology, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, Maharashtra; Dr. Sushila Nayar Hospital, Utavali, Melghat, Amravati, Maharashtra, India. Aakanksha Shishugruha Sevagram, Kasturba Health Society, Sevagram, Wardha, Maharashtra


Workplace violence (WPV) is a serious problem anywhere, but is one of the most complex issues in health settings. Many factors contribute to WPV is health setting, health workers functioning in stressful environment, 24-h access to many, presence of drugs, and human sufferings with limitations in care. Violence may take a variety of forms, verbal aggression to physical assault, use of deadly weapons against physicians, others, and even patients. It is, therefore, associated with a variety of risks to workers safety, as well as organizational liability. The objective was to know happenings and challenges in the prevention of violence against health providers. This simple review of available studies and opinions was done by using Uptodate, ERMED CONSORTIUM, Cochrane Library, Delnet, and MedIND, and self-experiences were added. Physical violence (PV) against doctors and other health personnel is increasingly being reported. It is believed that more than 75% of doctors face violence during their practice. Almost half of the violent incidents occur in critical care units. WPV has been categorized into physical and mental, but all types of violence are destructive, in one or other way. There is evidence that female health workers are exposed to PV more often than others. It is essential to identify risk factors in order to prevent and manage WPV against health providers. Reasons for violent outbursts include inadequate workforce, infrastructure to treat patient load, and long waiting times. Many health personnel never report exposure of violence to anyone because of various reasons including perception that reporting was useless. Though it is difficult to completely eliminate violence in health-care settings, and although there is no “one-size-fits-all” approach for prevention, there are many ways to reduce the potential for violent occurrences and to minimize the impact if violence does occur.

How to cite this article:
Chhabra S. Changing world, changing trusts and health providers' sufferings.Indian J Community Fam Med 2019;5:86-91

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Chhabra S. Changing world, changing trusts and health providers' sufferings. Indian J Community Fam Med [serial online] 2019 [cited 2021 Apr 19 ];5:86-91
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Workplace violence (WPV) is a serious problem in any setting; however, it is one of the most important and complex issues in health settings. Health workers have been reported to be 16 times more likely to experience WPV than workers in other jobs. According to the International Council of Nurses, the likelihood of health workers' exposure to violence was higher than even that of prison guards or police officers.[1] There are regular reports of doctors being abused, threatened, bullied, manhandled, and even killed. The issue is not restricted to any country but is a worldwide phenomenon. Till the end of the 20th century, the medical profession was considered the most noble of professions. The pendulum has now swayed, and the medical profession falls within the ambit of trade. The patient is considered a consumer in the commercial system. Some doctors are depicted as extortionists who extract money for treating dead bodies. Unfortunately, some have been caught on camera seeking bribes, commissions, and doing wrong to the patients as well as the society. Nobility has gradually taken a backseat, and the respect accorded to the treating doctors is disappearing. Reports of violence against doctors, sometimes leading to grievous injuries or murder, are making headlines across the world.[2],[3] High incidences have been reported from India too.[4],[5] Further, whether there is real increase in the numbers or increased awareness in the era of electronic mass media and improved telecommunication system needs further analysis.


The objective was to know the happenings and challenges about violence against health providers in health settings.

 Material and Methods

This simple review of available studies and opinions was done, and self-experiences were added.



Violence against doctors and other health personnel is increasingly being reported. More than 75% of doctors face violence during their practice. Multiple reviews and studies have been published in contemporary literature, with the largest numbers originating from China.[6],[7],[8] In a study, it was revealed that 23.5% of the participants were exposed to PV in the 12 months prior to the day of interview. Nurses were the main victims of PV (78%), and patients' families were the main perpetrators (56%) of violence. A survey of violence against general practitioners (GPs) in Birmingham found that 63% had suffered abuse or violence in the previous year and 0.5% suffered serious injuries. Another survey of GPs had found that over 60% of GPs experienced abuse or violence by patients or their relatives over 1-year period and nearly 20% reported some sort of abuse at least once a month.[9] A German survey revealed that 50% of GPs were confronted with aggressive behavior, 10% of them experiencing critical to violent attacks, such as criminal damage to property and/or physical assault.[10] About 87% of respondents, in a survey in China, reported an increasing trend of violence against doctors.[7] In a study, 78.3% of nurses stated that they had been victims of physical aggression, over the previous 12 months, compared with 45.5% of those employed in pedagogic positions and 55.6% of those working in other fields.[11] In verbal aggression, there were no significant differences between the various professional groups. Results of studies conducted during 2009–2010 in Italy revealed that 13.4% of nurses reported at least one physical attack during the past year.[12],[13] In Iran, the results of a systematic review revealed that the prevalence of PV was between 9.1% and 71.6%.[14] Rahmani et al. reported that the PV against emergency medical workers in East Azerbaijan was 37.7%.[15] The majority of the physical incidents occurred inside the hospitals (90.1%) against female health workers (67.5%), who were of 30–40 years of age (39.5%). The results showed that the health workers' exposure to PV was 23.5%. The result of a study in Jordan revealed that 22.5% of hospital nurses were exposed to WPV.[16] Abualrub[17] reported that 15.93% of emergency staff reported PV during the past 3 months. The incidence of PV in another study was 21%.[18] In some studies,[19],[20] between 46% and 70% of participants reported PV. This may be due to cultural differences between countries or underreporting of violence because of some or other factors. Rahmani et al. reported that the frequency of pushing and punching was 71.4% and 20.4%, respectively.[15] Talas et al. reported hitting, pushing, or shoving by 73.9% of victims, and the main perpetrators were patients' families, which is consistent with the findings of other studies.[21],[22] Merecz et al. reported that overall 64% of psychiatric nurses and more than 16% of other nurses had frequently been subjected to PV by patients' families.[22] In another study, patients were the main perpetrators of PV and threats to attack.[23] The results showed that female health workers, especially between 30 and 40 years of age, were exposed to PV more than other workers. Health personnel, especially nurses, should identify the risk factors in order to prevent and manage such violence. Khoshknab et al.[24] also reported that nurses were the main victims of PV. Pich et al. reported that nurses were at the highest risk of patient-related violence in psychiatrists clinics and 83.9% in nursing homes.[25] This is thought to be due to their close contact with patients and/or their families.[10] The majority of the violent incidents, however, occurred in public hospitals, where treatment is free. The reported numbers of verbal and physical aggression toward health-care staff ranged from 0.4% to 91%.[21],[26],[27],[28] It has been reported that female medical trainees reported vastly higher rates of sexual harassment than trainees in the science or engineering.[29],[30],[31]

Types of violence

Violence in health care may take variety of forms, such as verbal aggression and physical assault, including the use of deadly weapons against physicians, other workers, and the patients. It is, therefore, associated with a variety of risks to workers' safety, even patients as well as organizational liability. In addition to physical harm, individuals who experience or witness violence in the health-care workplace are at the risk of emotional consequences that can lead to time away from work, burnout, job dissatisfaction, and decreased productivity. However, many healthcare workers consider violence “part of the job.”

While WPV has been categorized into physical and mental violence, all types of violence are destructive, in one or other way.[32] PV involves use of physical force against an individual or a group, and can lead to physical, psychological, or sexual harm and includes punching, kicking, slapping, shouting, pushing, biting, pinching, and wounding using sharp objects.[33] In a study, the most common types of PV were pushing or pitching, experienced by 43% of the health providers.[26] Erkol et al. also reported that hitting, kicking, and scratching were the most frequent types of PV.[34] A study from India revealed that 87% of violent incidents were verbal and 8.4% were physical.[35] In the 12 months prior to the survey, verbal aggression was experienced by 89.4% of the participants and physical aggression by 70.7%. Employees in the workshop for people with disabilities (41.9%) were less affected by physical aggression than employees in other health-care settings (78.7%).[11] In a study by Franz et al.,[11] 70.7% of the people interviewed experienced physical and 89.4% verbal aggression. In the majority of the cases (60%–70%), such violence took the form of either verbal abuse or aggressive gesture.

Causes of violence

Many factors contribute to the violence in health settings. Health-care workers have to function in typically stressful environments. There is 24-h access to health settings. There are some unexpected tragedies. Also, the presence of drugs makes them attractive targets. Almost half of the violent incidents occur in critical care units. Those working in intensive care units face violence almost every day. In a study, lack of people's knowledge of health providers tasks was the most common contributing factor to PV (49.2%).[36] The researchers reported that most of the people did not have a clear concept of the medical staff's duties and in most of the cases, they expected treatments and prescriptions of different medicines by whosoever was available and if their expectations were not met, they behaved violently. Patients are becoming more aggressive in their demands and are much more likely to resort to aggression if not satisfied with care. Poor quality of medical services and increased awareness among patients have resulted in an increase in medical disputes and at times violence against health-care professionals. People attending private hospitals expected exceptional quality of services than in public hospitals.[37] Major reasons for violent outbursts include inadequate workforce and infrastructure to treat the patient load. Long waiting times and short consultation times also contribute. The doctor–patient relationship, historically defined as the legendary Hippocratic Oath, is now unfortunately reduced to a commercial transaction. Poor doctor–patient communication can easily trigger tension whenever doctors fail to meet patients' high expectations. Lack of proper staff training programs for preventing and managing violence and lack of appropriate legislation and policy for pursuing received reports and managing violence in health-care settings are real problems. In a study in New Delhi, 73.5% of doctors attributed long waiting periods as a major cause of violence. Other causes perceived were visiting-hours violation and dissatisfaction with service providers. Doctors reported that patients reported to the hospitals when the disease was advanced and when complications set in, they got impatient and violent. Nursing staff in particular were exposed to physical aggression frequently.[35] Very often, those who abused a medical person were patients themselves who were under the influence of alcohol and drug and were delirious or were in the psychiatry wards.[38] Increased risk of violence was also recorded when a general physician was on house calls, particularly at night.[39] Sometimes, political parties take the law in their hands in such situations. Anxiety, long waiting period before the patient could speak to a doctor, and the feeling that doctor is not giving enough attention to his/her patient lead to frustration giving rise to violence. For government hospitals and primary health centers across the country, money is not the reason, but anxiety, long waiting period, nonavailability of crucial investigations, inordinate delay in referral, and unhygienic and extremely crowded conditions in the emergency and other wards are some of the reasons.[4],[5] Assaults by psychiatric patients against mental health-care providers are both a reality and a concern, as the effects of violence can be devastating to the victim. In most of the European countries and in Canada, the health-care cost is borne by the government, and often, the first contact of the patient with medical service is with designated GPs who take house calls day and night; hence, there is no financial anxiety for medical treatment in these countries.[39] In the USA, although the standard of medical care may be high, this comes at a cost mostly through payment to insurance companies or direct cost out of pocket. More often than not in India, patients by themselves are not violence makers, but their relatives are. Sometimes, unknown, apparently sympathetic individuals political leaders also cause violence.[40]

Effects of violence

Effects of violence have been reported to be variable. The consequences for the employees in health settings include reduction of working spirit, anger, reduction of self-confidence, being absent from work, changing job, and even death.[41] In addition to the immediate harms caused by violence, the number of times one faces violence at work can have cumulative impact on him/her; the more the frequency and the intensity of the incidence, the more the probability of trauma. The other consequences included negative behavioral manifestations. The professional violence could lead to burnout, resulting in the loss of physical and emotional capacity and cause negative behaviors and attitudes toward himself/herself and the others. In a study in China, 49% of doctors even said that they intended to leave the profession.[6] Health-care workers suffered from job dissatisfaction,[23] low self-esteem, and poor quality life.[42],[43] In another study, 76% of doctors felt that they would not choose the profession, if given another chance, and 78% did not want their children to be doctors.[44]

Action taken

In a study by Fallahi-Khoshknab,[45] it was revealed that the most common reaction of victims to PV was asking the aggressor to stop violence (45%). More than half of the participants did not report WPV to anyone and considered reporting useless. Furthermore, more than 60% of participants stated that there were no guidelines for reporting violence in their workplace, and more than half of them said that no action was usually taken to pursue the incidence of violence. In a study, AbuAlRub[46] reported that most participants said that no specific policy was thought of for dealing with violence. In another study, the most important reasons for not reporting included the belief that reporting was useless and there was fear of being stigmatized as a troublesome and incompetent person.[24] Franz et al.[11] reported that most often interventions to stop the aggression took the form of discussions with the patient (81.0%), requests to change behavior (58.6%), withdrawal from the patient (56.0%), requests for personal support (49.1%), and quite removal of the patient (47.4%). However, more rigorous interventions were performed, too like medication to the patient (46.6%), physical restraint (37.9%), forcible detention of the patient (33.6%), forcible removal of the aggressive person (31.0%), and 18.1% of the respondents asked for help from the police. The study by Rahmani et al.[15] revealed that 60.5% did not report violence to any one and the most common reason for not reporting was the perception that reporting was useless (52%).


The world is getting more violent with violence in all walks of life. However, the medical profession is increasingly facing PV at workplaces. violence is much more common in health-care places than in other industries, and violent events in health care are perpetrated by patients, family members of patients and visitors, employees, and criminals. The notion that the practice of medicine is a social service, and not a profession, aggravates the situation. Patients' perceptions of societal injustice and commercialization of medicine lead to patient–physician mistrust. Over the years, physician training has lacked core humanistic components that nurture empathy and caregiving. The patient–physician relationship is founded on trust entered by mutual consent.[47] Violence is generally dismissed as the effects on physicians as simply a hazard of the job that should be handled by physician resilience. At the physician's discretion, the patient's care can be transferred to different providers.[48] Medical councils and medical institutions have an obligation to support the decision of the physician while caring for the patient. While it is an offense to assault a public servant, there are no laws for the protection and safety of the medical community. Assaulting medical personnel on duty should be made a serious cognizable offense. Concealed closed circuit televisions with video recording may serve as a deterrent, as well as be used to record evidence. Hospitals and clinics must have panic alarms and all threats/episodes of violence should be recorded in a critical incident book. There must be a zero tolerance policy for WPV which must be embraced as a universally applied core institutional value rather than an imposed bureaucratic requirement. Risk managers committed to decreasing risk of violence in their organizations will need to convene stakeholders from various disciplines and collaborate to implement strategies, individualized according to identified risks, across the organization. Systematic approaches are needed to ensure that clinicians, especially women can safely treat patients in populations where sexism is common. In some places in developed countries, there is existence of transparent policies, appropriate legislation, and reporting mechanisms.[45] Results of a study in Australia revealed that nearly 70% of health workers were satisfied with WPV control policies and reporting mechanisms.[49] The World Health Organization has drawn out a global action plan to prevent violence in health setting.[50] To combat the problem of WPV the United Kingdom, the National Health Service has issued “Zero tolerance” guidelines.[51]


Though it is difficult to completely eliminate violence in health-care settings, and although there is no “one-size-fits-all” approach for prevention, there are many ways to reduce the potential for violent occurrences and to minimize the impact if violence does occur.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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