The Mental States of Aggressors: A Biopsychosocial Analysis of Workplace Violence Reports in Hospitals

Reports of violence and injuries to staff and patients in acute psychiatric inpatient settings have led to the development and implementation of training courses in the Prevention and Management of Violence and Aggression (PMVA). The purpose of this study was to explore the relationship between PMVA training of acute psychiatric ward nursing staff and officially reported violent incident rates. A retrospective analysis was conducted of training records (312 course attendances) and violent incident rates (684 incidents) over two-and-a-half years on 14 acute admission psychiatric wards (5,384 admissions) at three inner-city hospitals in the United Kingdom as part of the Tompkins Acute Ward Study. A positive association was found between training and rates of violent incidents. There was weak evidence that increased rates of aggressive incidents prompted course attendance, no evidence that course attendance reduced violence, and some evidence that attendance of briefer update courses triggered small short-term rises in rates of physical aggression. Course attendance was associated with a rise in physical and verbal aggression while staff were away from the ward. The failure to find a drop in incident rates after training, coupled with the small increases in incidents detected, raises concerns about the training course's efficacy as a preventive strategy. Alternatively, the results are consistent with a threshold effect, indicating that once adequate numbers of staff have been trained, further training keeps incidents at a low rate.

Workplace violence is a common experience for many health professionals. However, little is known about the experience of occupational therapists, specifically those that visit people in their own homes, and experience violence in that context. Home visiting is a fundamental component of practice for many occupational therapists and often takes place with the occupational therapist being alone. This study aimed to explore the experience of this group of occupational therapists, their responses to workplace violence such as reporting, and the impact of their experience on their wellbeing. A cross-sectional online survey was distributed among occupational therapists via NSW Health services and Occupational Therapy Australia with snowball sampling and links on Twitter, LinkedIn, and Facebook. The survey gathered information on demographics, work organisation, exposure to workplace violence, and strategies used to respond to this. Wellbeing was measured using the Abbreviated Maslach Burnout Inventory and the Kessler Psychological Distress Scale. A total of 101 surveys were returned: 97% (n = 97) were female, the mean age was 39 years, 52% (n = 52) were located in capital cities, and most worked in disability care (47%, n = 47) or aged care (46%, n = 46) and worked full time (60%, n = 60). Only 5% (n = 5) identified that they never worked alone. Of those who experienced violence at least occasionally, 74% (n = 74) reported verbal aggression, 27% (n = 27) physical aggression from clients or family members, 20% (n = 20) physical aggression using objects, 43% (n = 43) verbal sexual aggression, 46% (n = 46) unwanted sexual attention, and 3.2% (n = 3) sexual assault. Moderate to very high distress was exhibited by 26% (n = 26) of respondents, and 71% (n = 71) exhibited moderate to high emotional exhaustion. As the target participants were occupational therapists, consumer and community involvement was not sought. This study has demonstrated the exposure of occupational therapists to risks when visiting clients in their homes and identifies the need for risk management, training, and support for occupational therapists working in this environment. Occupational therapists often visit people in their own homes to assess their needs and provide interventions. The home is an important environment as this is where functional activities take place. However, occupational therapists can be at risk of workplace violence from clients and their families, especially if they visit clients alone. Clients may be upset and frustrated by their situations and could strike out. We know very little about workplace violence experienced by occupational therapists, and this study used an online survey to explore how commonly this occurs, the type of incidents experienced, the actions that occupational therapists took following the incident, and how these experiences affected their well-being. We found that workplace violence included verbal attacks and physical and sexual violence. Overall, 76.2% of participants reported any kind of violence. The most frequent type of violence was verbal abuse followed by unwanted sexual attention, verbal sexual abuse, and physical violence with and without objects. Three participants reported a sexual assault. However, fewer participants took actions following the incidents such as reporting it informally or formally. This means that workplace violence is likely to be underreported by occupational therapists. We also found that occupational therapists who were exposed to workplace violence reported higher distress, higher cynicism, and lower professional accomplishment, suggesting a risk of burnout. As employers are required to protect the health and safety of their employees, these findings are very important, and the occupational therapy profession should also address them.

Objective To study the workplace violence situation of hospital setting and explore its influence on the psychological health status of nurses.Methods A descriptive and correlative design was used.By cluster sampling,932 nurses from three hospitals in Shenzhen were recruited.The Workplace Violence in Hospital Setting Questionnaire and the Symptom Checklist 90 were used to measure the status of workplace violence in hospital setting and the level of psychological health status of nurses.The data were analysed with software SPSS version 12.0.Results The overall incidence rate of workplace violence was 64.3％ with psychological violence 86.0％,physical violence 20.9％,sexual violence 11.5％.The scores of psychological health and 9 dimensions score of nurses suffering from workplace violence were significantly higher than that of nurses without suffering from workplace violence ( Z =- 9.734,P ＜ 0.01 ).The more frequence of working violence they suffered,the higher the score of psychological health of nurses they have( P ＜0.01 ),and there was significantly difference in the frequence of psychological violence,the score of psychological health and its dimension(P ＜0.01 ).The frequence of physical violence and sexual violence was no correlation with the score of psychological health ( P ＞ 0.05 ).The more frequence of working violence is,the higher scores on psychological health status of nursing staff were.( P ＜ 0.05 ).Conclusions The overall incidence rate of workplace violence was high.The psychological health status of nurses suffering from workplace violence was lower than that of nurses without suffering from workplace violence.The more frequence of working violence,the poorer the psychological health status of nurses. Key words: Nurses; Violence; Hospital; Psychological health

RESUMENObjetivo.Conocer la frecuencia de la violencia, tanto física como verbal, hacia los profesionales de enfermería, a nivel mundial en los servicios de emergencias y su impacto en la salud y en el contexto laboral.Métodos.La investigación fue realizada mediante una revisión integrativa, en febrero de 2020, de las bases bibliográfícas MEDLINE, LILACS, CINAHL y SciELO, utilizando los descriptores “Nurses”, “Workplace Violence”, “Physical Aggression”, “Psychological Aggression”, “Stress, Psychological”, “Psychological Trauma”, “Aggression”, “Health Impact Assessment”, “Health Impact”, “Impacts on Health”, “Impact Assessment, Health” y “Occupational Health”.Resultados.De los artículos localizados, 18 fueron incluidos en el análisis. Los estudios confirmaron que los profesionales de la salud más afectados por la violencia eran los profesionales de enfermería y el tipo más común fueron las agresiones verbales, seguidas por la violencia física. El área intrahospitalaria más común donde ocurrían dichas agresiones era el servicio de emergencias. El impacto en la salud de los profesionales de enfermería se correlacionó con el estrés, el agotamiento emocional, la ansiedad y el miedo, entre otros síntomas. Con respecto al impacto laboral, se evidenciaron relaciones indirectas significativas vinculadas con la reducción de la productividad. Todos estos aspectos llevaban a los profesionales de enfermería a considerar el abandono de sus trabajos en los servicios de emergencias.Conclusiones.Los resultados permitieron identificar un perfil de riesgo de violencia contra los profesionales de enfermería en los servicios de emergencias evidenciado por la alta incidencia de violencia física y verbal que repercutió en la disminución de la productividad en su trabajo y la aparición de síntomas relacionados al síndrome de burnout.

Voices carry: Effects of verbal and physical aggression on injuries and accident reporting

Within the scarce literature concerning verbal aggression, there is some indication that verbal and physical aggression may have similar inhibitions conditioned to each. Two experiments were carried out to explore this possible relationship. In the first, middle and lower socioeconomic status (SES) adolescent boys were exposed to televised physical aggression with and without consequences to the victim shown. In the second experiment, middle and lower SES adolescent boys were exposed to televised verbal and physical aggression. For both studies, intensity of post-viewing verbal and physical aggression was measured. The hypothesized relationship between physical and verbal aggression was minimally supported. In only the second study was the previously well documented stimulative effect of viewing television violence clearly shown. Several questions are raised and research directions are suggested to better understand verbal aggression as it is related to physical aggression and televised violence.

The aim of this study was to investigate workplace violence by patients or their relatives towards health-care workers in Congolese hospitals. Through the autumn of 2012, a cross-sectional survey on workplace violence was conducted in a sample of 2,210 registered health-care workers (989 males and 1,221 females, aged 33 ± 8 years) from 436 hospitals located in the province of Katanga, Democratic Republic of the Congo. Verbal aggression, harassment and physical violence perpetrated by patients or their relatives within the previous year along with factors contributing to violence, were recorded, and the response rate was 99%. About 80.1% of the health-care workers had experienced one or more types of workplace violence. Overall, the severity of workplace violence varied from verbal aggression (57.4%) and harassment (15.2%) to physical violence (7.5%). Patients were the major perpetrators of verbal aggression and harassment, whereas patients' relatives were mainly involved in physical violence. The frequency of workplace violence was similar across hospitals. Male health-care workers were more likely to be victims of physical violence, whereas female health-care workers were the prime target for harassment. Only 34.3% of the violent episodes were reported to a supervisor. Furthermore, disrespect for medical deontology was the main cause of workplace violence perceived by 68.8% of the health-care workers. Although it has not been officially recognized, there has been workplace violence towards health-care workers perpetrated by patients or their relatives despite the fact that health-care workers have traditionally been highly respected in Congolese society. Further studies on this issue may suggest opportunities for combating violence in Congolese hospitals.

Background and Aim: Occupational violence increasingly has been known as a problem in health care system. Emergency personnel, because of direct contact with patients and their relatives are exposed of the most invasions. Multiple refers to emergency unit than other hospital parts increase threat occurrences, physical and verbal violence and cause to physical and mental injury in medical personnel. In Gerberich et al viewpoint, working in ICU (intensive care unit), psychological and emergency unit is of important factors for exposure of violence. This study aims to determine the vulnerable factors of occupational violence against practitioner medical personnel in the emergency units of training hospitals of Arak city. Materials and Methods: In this descriptive-sectional study, 108 of practitioner medical personnel of the emergency units were studied in verbal and physical violence in 1394. Studied society were practitioner medical personnel of emergency unit of training hospitals of Vali-Asr, Amir- Almumenin and Amir-Kabir of Arak. Entry measures were self-desire of personnel in all educational levels and occupational grades with one year work experience in current unit in turning shift. In order to collect information of violence in work place questionnaire in health units were used which include four parts (demographic information, threat, verbal and physical violence). This questionnaire is derived from standardized questionnaires of international labor office, WHO, international council of nurses, public services international which are balanced based on environmental and social conditions and its reliability and validity were confirmed. Data were analyzed by SPSS software version 21. Ethical Considerations: This paper is a part of issued investigational plan of medical sciences of Arak University, by ethical committee confirmation of IR.ARAKMU.REC.1394.148. The goal of study was explained for participants and secrecy and anonymity were ensured to them. Also, verbal satisfaction was obtained from medical personnel for contribution in study. Findings: Participants had average age of 31.45±6.26 years, total work experience mean 6.85±5.09 years and work experience mean 3.49±3.22 years in emergency unit. 28.7% of medical personnel were exposed of physical violence and 77.1% of them were exposed of verbal violence. 17.9% of participants reported verbal violence very much, 20.2% moderate and 36.9% low or very low. The most motivating reason of violence was crowdedness of unit and the most factors resulted to physical and verbal violence was patient's relatives. The most physical violence factor (856.4%) and verbal (60.5%) were for relatives. Conclusion: Findings showed high prevalence of violence, especially verbal violence against medical personnel. According to occupational characteristics of practitioner personnel in emergency unit, it can be said that violence emergence in work place is inevitable and impossible work. Therefore, the best approach is to identify amount and vulnerable factors in regions violence and to program for reducing its occurrences as low as possible. It should be noted that workplace violence is a multidimensional problem which its destructive dimensions has adverse effects on emergency personnel performance and also on hospital performance. Thus, creating a supportive environment, preparing continual training programs, financial resources and enough human force, restricting visit hours, also observation and answering in patients care are recommended in order to successful performing care programs. In this study, violence was forced from patient relatives more which can be prevented by managing, planning and public training. Please cite this article as: Harorani M, Varvanifarahani P, Yazdanbakhsh SA, Pakniyat AG, Sadeghi H, Norozi M, Golitaleb M. Evaluation of the vulnerable factors of occupational violence against practitioner medical personnel in the emergency units of training hospitals of Arak city. Med Ethics J 2017; 11(39): 55-61.

This study examined the construct validity of the Direct & Indirect Aggression Scales (DIAS) (Finland: Abo Akademi University) [Björkqvist et al., 1992c] in 653 adolescents aged 14 to 17 in four Spanish high schools. This paper also examined sex and age differences in aggression. The factor structure of scales was assessed using exploratory factor analysis. Varimax rotation was used, with a factorial structure of three factors: physical aggression, verbal aggression and indirect aggression. The results showed that, compared with girls, boys reported a more frequent use of physical and verbal aggression. However, for indirect aggression no differences were found between boys and girls. A specific examination of sex differences on individual items of the DIAS showed that boys used physical, verbal and indirect aggression more often than girls. The findings also indicated that, as expected, adolescents in lower courses (14-15 years old) rated higher in all types of violence than adolescents in higher courses (16-17 years old). Also, we found that boys used physical and verbal aggression more often than girls did in all age groups studied. This study provided a better understanding of female aggression in the Spanish context and it enhanced our understanding of how aggression is expressed by Spanish girls. Aggr. Behav. 00:1–11, 2005. © 2005 Wiley-Liss, Inc.

This study examined the social-ecological correlates of aggressive behavior in 120 youths with autism spectrum disorder. Youths were divided into three groups based on caregiver reports of the youth's aggressive acts: youths who engaged in acts of both physical and verbal aggression, youths who engaged only in acts of physical aggression, and nonaggressive youths. Caregivers and youths completed self-report instruments and behavior rating inventories that assessed youth individual functioning, family relations, and extrafamilial factors (i.e., peer relations, academic performance). Results showed that youths who engaged in both verbal and physical aggression were characterized by poor sleep quality and victimization by peers, and their caregivers evidenced high levels of distress and avoidant coping. In contrast, youths who were physically but not verbally aggressive were distinguished by difficulties in social interaction and communication. In general, each group of youths who were aggressive experienced more problems with repetitive behaviors, family relations, and academic performance than did their nonaggressive counterparts. The implications of these findings for theory, research, and treatment are discussed. Autism Res 2019. © 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: The present study demonstrated that youths with autism spectrum disorder may be classified by the types of aggressive behaviors that they exhibit: youths who are verbally and physically aggressive, physically aggressive only, or not aggressive. Compared to the nonaggressive group, both groups of youths who were aggressive experienced difficulties in their individual, family, peer, and academic functioning. Youths with both verbal and physical aggression showed the most problems in their functioning.

In 27 preschoolers observed social activity was significantly and positively correlated with physical, verbal, direct, and indirect aggression in girls (physical and direct aggression, 2A.05; verbal and indirect aggression, EL .01), but negatively correlated with all but verbal aggression in boys (all g's .01) . Boys had high physical aggression scores more frequently than girls .003); girls showed more verbal than physical aggression (2.< .01). Direct predominated over indireCt aggression in both sexes (both est.01). Sex differences in relationships of social activity to aggressions were attributed to differences in physical aggression, which was hypothesized to discourage interactions. Murphy's (1937) study demonstrated a relationship between social interaction and aggression in preschoOlers but failed to find sex a relevant variable; though sex differences in aggression have been occasionally reported elsewhere in the literature, there have been few attempts to clarify them. Comparing verbal and physical modes of aggression, Durrett (1959) found girls more verbally aggressive than boys. In Feshbach'i (1969) study, adolescent TImmq girls were more indirectly aggressi4e than boys, suggesting the importance of a yawl style dimension. However, none of these studies included dominance or non,compliance under the rubric of aggression. This omission seems to be important since these.forms of aggression are more culturally acceptable in females than are the more explicit aggressions. The present study investigated whether sex differences in frequency of aggressing among preschool children are related to differences in rates of social interaction, and whether girls manifest aggression in different ways than boys do. InclUded was consideration of differences in

WORKPLACE VIOLENCE IN HEALTH CARE: A CONTINUOUS GLOBAL PROBLEM AND ITS CHARACTERISTICS IN CHINA Workplace violence is a persistent problem in health care worldwide. The victims are usually nurses and workers in the emergency department.[12345678] The academic debate, as it develops overtime, would allow us to gain an integral insight about this problem. The author searched the related research and debate articles in English in PubMed (www.pubmed.com) dated from 1990 to 2016 [Figure 1]. In total, 1899 items with the keywords of "workplace violence," 600 items with "workplace violence healthcare," 786 items with "workplace violence nursing," and 279 items with "workplace violence emergency" (there is some overlap between these four groups) have been published.Figure 1: Workplace violence papers searched by keywords in PubMed from 1990 to 2016. Papers included in http://www.pubmed.com. Here shows the account of items from 1990 to 2016 when searched with "workplace violence" (blue), "workplace violence healthcare" (red), "workplace violence nursing" (green), and "workplace violence emergency" (violet), respectively.Workplace violence in health care has become a prominent social problem in China in the recent years. A survey conducted by the China Hospital Association in 2012 showed that 96% of the hospitals investigated had verbal violence and as much as 60% had experienced physical violence.[9] Another survey in 2012 showed that more than 50% of the 2464 respondents in 12 hospitals from 2 provinces had experienced workplace violence and the rate of physical assault was 11%.[10] According to a survey conducted in 2014, 12.6% of 840 respondents admitted being physically attacked at their workplace in that past 12 months.[11] Direct care providers, including physicians and nurses, are more prone to suffer from physical assaults.[11] However, violence, including fatal physical assault, affects nearly all Chinese health-care professionals.[121314] In addition, "medical mobs"–a group of people gathered at health care facilities threatening medical staff and create chaos for large compensation instead of the settlement of medical disputes–disturb medical working environment, although more often than not, they do not resort to violence.[1516] Statistical analysis by the Ministry of Health showed that more than 17,000 violent affairs had occurred in 2010.[17] In 2015, the Supreme People's Procuratorate summarized features of violence at hospitals as follows: occur frequently and suddenly with serious consequences, have a wide impact on the public, need urgent attention and handling, cause serious damage, and pose continuous potential dangers.[18] Thus, being employed as a hospital staff, especially as a direct care provider, is now considered a dangerous job in China. NEGATIVE EFFECTS OF WORKPLACE VIOLENCE ON THE STAFF AND PATIENT OUTCOMES Frequent instances of workplace violence have direct and indirect negative consequences on both the staff and patients, including compromised patient care.[19] Violence and inadequate managerial care after violent incidents may reduce nurses' proficiency, which could have negative implications for patient care.[20] Physical violence against care providers has been associated with patient falls, medication errors, and late administration of medications.[2021] Numerous studies have documented experiences of violent incidents resulting in severe psychological distress, increased work stress, and reduced work efficiency.[2223242526] Violence in the health sector is also associated with job dissatisfaction and turnover intention among care professionals.[2728] Both bullying and physical violence have led to increased turnover intention. Shortage of physicians and long waiting time for visits and treatment are challenges faced by China's health care, and these are also some of the reasons for workplace violence.[17] Chinese medical staff faces heavy workload, providing service to one-fourth of the world's population. An investigation by the Chinese Medical Doctor Association in 2009 showed that more than 60% of the registered physicians were not satisfied with the working environment. The Ministry of Health statistics in 2008 showed that 1 million people had acquired physicians' license in the past 6 years; however, 40% of them did not register.[17] If this situation continues, Chinese patients will have to face a further shortage of physicians.[29] Moreover, the practice of defensive medicine among physicians in Chinese hospitals has been reported for years. This may also have negative implication for doctor–patient relationship and subsequently contribute to the incidences of violence against health-care professionals. The author conducted a survey in 13 hospitals of Beijing from July 2007 to March 2008 that showed most of the respondents' (83.0%, n = 811) practiced defensive behavior, and defensive practices were significantly associated with their experience of complaints (P = 0.0318) and medical negligence claims (P < 0.0001). Notably, even in emergency cases, a surprisingly high percentage of the physicians (43.3%, n = 811) had a negative attitude toward first aid when the patient was not accompanied by any family member; they would not implement invasive treatment without the consent in writing from the patient's families, even if the patient needs the treatment as prompt first aid. Instead, they chose to wait for the signed consent or followed the manager's decision. Defensive behavior is becoming more widespread due to the frequency of violent incidents. A written informed consent by the patient or his family for any operation, special examination, or special treatment is required by Tort Law of China, making the situation even worse. When the author gave lectures during Beijing resident training on courses of law and regulations from 2015 to 2016, a rough statistical analysis of the emergency question showed that less than 20 of the 1200 residents who attended the courses showed no hesitation to provide prompt invasive treatment to the patients on basis of the patients' interests rather than a written consent form. Ultimately, it is the patients who end up paying for the violence. GOVERNMENT EFFORTS TO PREVENT WORKPLACE VIOLENCE AND THE RESULTING OUTCOMES The Chinese government has been exploring various ways to prevent workplace violence in health care, especially in the recent years. For example, the Ministry of Health and the Ministry of Public Security had called for the protection of health-care professionals from suffering violence in a joint notice as a response to the fatal violence at the First Affiliated Hospital of Harbin Medical University.[30] In addition, the Supreme Court, on April 24, 2014, announced the decision to work together with four-related departments to penalize those responsible for workplace violence in hospitals. The notice listed six kinds of violent behaviors that hurt doctors or disturb/disrupt the daily operation of hospitals, including carrying dangerous materials or threatening medical staff. Despite the presence of security officers in some hospitals for assistance, the situation has continued to deteriorate in the recent times. Wei Xiao, a spokesperson of the Supreme People's Procuratorate, stated on June 24, 2015 that more than 10 cases of violence against doctors were reported by the media within 20 days in China, only 2 days before the fifth Chinese Doctor's Day.[31] Under the Amendment of Criminal Law in effect from October 1, 2015, those who organize or participate in medical mobs will face criminal penalties if their violent behavior disturbs work order seriously and causes heavy losses. However, preventive measures for workplace violence have not proved to be entirely effective. Bullying, physical assault, and serious personality insult still occur occasionally.[13151632] Recently, Li Baohua, a pediatrician of Shandong Laiwu Steel Group Hospital, was stabbed 27 times and killed by a patient's family member causing serious injuries.[33] This heinous violent behavior happened exactly 1 year after the Amendment of Criminal Law was in effect. A female physician was also stabbed for no reason,[14] only a few days after, "the Opinion on Performing the Procuratorial Functions Fully to Provide a Strong Judicial Support for Promoting healthy China" was published on September 29, 2016.[34] In this opinion, the Supreme People's Procuratorate stresses that they will intensify the crackdown on criminal behavior against medical staff to ensure normal medical order and safety of medical personnel. It appears that the government's efforts were not very effective. LEGAL AND ETHICAL REASONS BEHIND FAILURE OF PREVENTIVE MEASURES Even criminal penalty has been unable to prevent violence in health care. Insufficient investment in the health system, lack of communication between health professionals and patients, negative media reports, and unrealistic patient expectations from treatments may be the reasons for this. However, the government may not have realized that the factors described below are important reasons that directly cause and worsen workplace violence and promote medical mobs as well. Unfair and time-consuming litigation process of medical negligence claims Many people prefer not making claims due to the fear of failure and prolonged course for arbitration of disputes; instead, they sort to medical mobs and behaviors alike. If people suffer an injury during treatment under a medical service, they can allege medical negligence. However, litigation procedure for medical negligence is a time-consuming process that usually lasts several years, especially for complicated disputes. As a part of structured retrospective reviews, Li et al. analyzed 1086 medical dispute lawsuits from 1998 to 2011 from a nationwide database in China.[35] Results suggested that the average time span between the occurrence of disputes and issue decision was 3 years;[35] nearly 76% of the claims in negligence received compensation under civil judgment (640 of 841) although fault liability was not confirmed in 7% of these claims (43 of 640).[35] In general, the judges cannot make a decision by themselves about the professional problems of medical disputes, and they usually arrive at a decision based on the conclusions issued by a judicial authentication of the claims. Thus, the patients and their family have to wait for a long time for the compensation through litigation. Such legal proceedings are not established under patient-centered ethical considerations. Apparently, patients in urgent need of subsequent treatment cannot benefit from compensations through litigations. Moreover, patients who fail in the court do not get compensation and end up paying the litigation costs. "Successful" resolution of negligence claims by medical mobs Research shows that only about 5.4–25.3% of medical disputes have been solved by litigation.[35363738] Many of the "successful" negligence claims are the result of medical mobs. This factor not only contributes to workplace violence but also to the origin of medical mobs. There are several reasons for the popularity of medical mobs. First, the staff, including some managers in China's hospitals, has always adopted an evasive and conciliatory attitude and preferred to resolute disputes with money when they encounter disputes with patients. Such an attitude invited medical mobs, which had been proven quite effective in medical disputes–amount of compensation or indemnity depends on the extent of trouble caused by the mobs rather than the extent of the medical damage.[39] This has gradually led to the proliferation of medical mobs. From the year 2000 to 2012, at least 150 medical violence cases that caused more than 30 deaths have been reported by the media. However, it is regrettable that most of the hospitals chose to terminate the disputes monetarily.[35] The staff prioritizes quick resolution of disputes, and consequently, they often pay a substantial amount of money for little or even no negligence. Second, through communication with physicians and managers, the author found that some hospitals have even formulated some unfair rules to avoid disputes, such as "a doctor or nurse will be punished for a complaint or dispute, no matter whether he or she is at fault." Such unjustified rules ignore feelings of medical staff. When patients and their families realize they can obtain more money quickly by threats and violence, litigation became less popular. The tolerance and forgiveness for patients and their families worsen the situation Palliative attitudes of the Supreme People's Procuratorate and Public Security Forces and misleading media reports worsen the situation. On June 24, 2015, the Supreme People's Procuratorate stated that they would treat medical mobs differently–"Procuratorate at all levels will try to promote reconciliation when the medical mobs are patients or their relatives; on the contrary, they will attack professional mobs." The Supreme People's Procuratorate's statement shows different attitudes to violence from medical mobs and patients' families. That difference and the weakness of security personnel are mistakenly attributed to the government's tolerance of violence from patients and their families. A survey showed that only 28% of public security personnel provided active help to resolve violent incidents resulting from medical disputes[35] despite a cross-sectional survey showed 22.6% and 62.3% of the perpetrators of physical assaults were patients and their relatives, respectively.[11] In addition, forgiveness and tolerance of the patients and their family's violent behavior showed in the media reports are looked on as an encouragement of the future violence. Media reports on violence also mislead people–these reports seldom discuss the truth behind the violence and the potential legal liability of such behaviors, which directly worsen the medical working environment. SUGGESTIONS FOR PREVENTION OF VIOLENCE AND MEDICAL MOBS It is important for the Chinese government to evaluate and implement alternative strategies to address workplace violence. Stringent guidelines may play a significant role in preventing workplace violence and fatal assaults.[40414243] Active postviolence management for relieve the pressure on the staff is as important. However, continuing violence has highlighted that the policies and actions taken by the government cannot entirely resolve the problem. Following are a few suggestions for resolving this issue: A law- and evidence-based process for medical disputes should be established It is usually the patients or their families who are responsible for most physical assaults and fatal violence incidents.[11] Although the aim of medical mobs is to create chaos at workplaces and exert pressure and they seldom cause fatal harm to the staff, the tolerance of violence stemming from patients is a barrier to preventing workplace violence. The medical staff deserves protection by the law as citizens. The Supreme People's Procuratorate's statement on treating mob violence differently is a breach of the principles of law. The Procuratorate has a criminal law in place for violent behavior, and treating physical assaults and fatal violence in hospitals differently is, thus, a breach of criminal law. To prevent workplace violence effectively, the government should change this attitude. The Procuratorate and courts need to treat all physicians, patients, and medical mobs as citizens, and address violence and mob incidents under a common principle of law. In addition, the media should report impartially and encourage people to resolve disputes through negotiation and legally prescribed ways. Moreover, tracking reports are needed to inform people of the investigated results and the subsequent penalty for the violence. Alternative dispute resolutions should be introduced in medical disputes Besides building a law- and evidence-based dispute resolution process and environment, the government should develop multiple alternative dispute resolutions (ADRs), such as arbitration and mediation, which have been confirmed to be successful in settling medical disputes in other countries.[4445] Meditation is the most common method of ADR, and it has been confirmed to be the most effective method when supported by organizational commitment and conducted by independent, experienced, and qualified mediators in workplace conflict[46] and has successfully addressed a part of the medical disputes in China in the recent years.[47] Arbitration, which has more advantages than mediation, however, is commonly applied only in economic disputes in China. Arbitration can address a dispute quickly and make decisions through a team of professional experts and lawyers. Choice of arbitration authority can help in reaching an agreement between the parties easily. Moreover, the decision is legally enforceable. Thus, arbitration can resolve medical disputes effectively and efficiently. Arbitration is a potentially feasible pathway for medical disputes resolution. A survey conducted in 2008 showed that both medical staff (83%) and patients (67.69%) considered that a fair and reasonable decision of medical disputes should be made by a group, which comprised multi-field professionals, especially including both medical professionals and lawyers (74.61% of doctors and 55.26% of patients).[45] In addition, the majority of doctors and patients (57.6%, 51.3%) chose to resolve the dispute through a variety of ways; nearly 28.40% of doctors and 15.86% of patients chose arbitration to solve the disputes, even when arbitration was not a very popular option for the people.[45] Face high-risk in medical work with active managements and attitudes Healthcare worksites should develop specific plans to minimize and prevent workplace violence. Hospital managers and front-line health-care workers should actively participate in implementing such programs. To eradicate medical mobs, the medical staff must change their attitude and principles during a dispute resolution process, which will also benefit the establishment of law- and evidence-based process to solve disputes. Violence, especially by medical mobs, will reduce and finally stop when they can obtain nothing except punishment. In addition, the medical staff should be encouraged to discuss high-risk medical treatment with the patients. They should explain the potential risks to the patients and also share undesirable prognosis and outcomes with them. Even when things do not go well as expected, hospital and staff should tell the truth. Most patients or relatives often simply want the truth and an explanation. The staff should not be afraid of sharing their failure with the patients and the public. The staff should not expect patients to face the risk of medicine and the possible adverse results when they would not want to face and accept the risks. The patients and the public can understand the position of the medical staff only if they understand the limitations of medicine. Media should play a positive role in the patient–physician relationship Media should undertake their due social responsibility. Fundamentally, three tasks are imperative for the media to carry out. First, workplace violence incidents should be reported objectively, with the background of medical technology and legal provisions, thus improving the medical knowledge of law among the masses. Second, subsequent processes of the violent incidents, especially the legal consequences of medical violence and the court verdict, should be reported promptly, thus letting people know the legal responsibilities and consequences of violent behavior against health-care professionals. Third, promoting the popularization of medical science among the public through self-media, such as microblogging platforms and messaging resources, should be encouraged; however, information about the deficiency and limitation of the existing clinical diagnoses and treatment technologies should be predominantly provided. Thus, the patients and their family can gradually realize the truth that what the doctors can do for treating human diseases is limited. Conclusively, workplace violence in health care has had a negative influence on patient safety and progress of health care in China. The government needs to explore strategies and plans for effective prevention of violence and medical mobs in health care. The government and hospitals should realize the underlying reasons behind the violence and find ways to address them. Most importantly, the government should establish a law- and evidence-based dispute resolution process and environment and develop effective ADRs, which include introducing arbitration into medical disputes to provide fairness and justice to both medical staff and patients. The patients and their families should be provided opportunities to understand the limitations of medicine. The patients, public, and government will be the ultimate beneficiaries of a safe health-care environment. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Workplace violence (WPV) is a prevalent phenomenon, especially in the healthcare setting. WPV against healthcare workers (HCWs) has increased during the COVID-19 epidemic. This meta-analysis determined the prevalence and risk factors of WPV. A database search was conducted across six databases in May 2022, which was updated in October 2022. WPV prevalence among HCWs was the main outcome. Data were stratified by WPV/HCW type, pandemic period (early, mid, late), and medical specialty. WPV risk factors were the secondary outcome. All analyses were conducted through STATA. Newcastle Ottawa Scale evaluated the quality. Sensitivity analysis identified effect estimate changes. A total of 38 studies (63,672 HCWs) were analyzed. The prevalence of WPV of any kind (43%), physical (9%), verbal (48%), and emotional (26%) was high. From mid-pandemic to late-pandemic, WPV (40-47%), physical violence (12-23%), and verbal violence (45-58%) increased. Nurses had more than double the rate of physical violence (13% vs. 5%) than physicians, while WPV and verbal violence were equal. Gender, profession, and COVID-19 timing did not affect WPV, physical, or verbal violence risk. COVID-19 HCWs were more likely to be physically assaulted (logOR = 0.54; 95% CI: 0.10: 0.97). Most healthcare employees suffer verbal violence, followed by emotional, bullying, sexual harassment, and physical assault. Pandemic-related workplace violence increased. Nurses were twice as violent as doctors. COVID-19 healthcare employees had a higher risk of physical and workplace violence.

Workplace violence is a prevalent phenomenon in the health-care sector globally, but few studies have examined its impact on nurses' use of prescribed and/or over-the-counter medications to manage signs and symptoms. The purpose of this study was to examine the direct and indirect effect of workplace violence, through the pathway of psychological stress responses, on nurses' frequencies of medication intake. An occupational stress and health outcomes model was tested in this study. A secondary analysis of cross-sectional survey data from 551 medical-surgical nurses in British Columbia was conducted. Both emotional and physical workplace violence were examined. Emotional exhaustion and posttraumatic stress disorder were psychological stress responses to workplace violence. Emotional and physical violence from patients and/or families were the most prevalent sources of workplace violence. Physical violence and psychological stress responses increased the frequency of medication intake after controlling for nurse characteristics. Emotional violence was not related to medication intake over and above the effect of psychological stress responses. Physical and emotional violence elicited psychological stress responses resulting in increased medication use. Workplace violence triggers psychological stress responses with adverse outcomes on nurses' health and well-being.

Workplace violence (WPV), such as physical violence, harassment, intimidation, or other threatening behavior, commonly occurs within healthcare settings including dentistry. The objective of this study was to analyze the behavioral and environmental factors contributing to WPV, determine its prevalence within one dental institution, and develop a WPV prevention and management protocol that is dental specific. To identify factors that impact WPV occurrence, the PRECEDE-PROCEED planning model was employed. A pilot cross-sectional survey was then conducted among faculty, staff, and dental learners (students/residents) to evaluate the prevalence of WPV incidents experienced and witnessed over the past year. The survey also assessed the locations where incidents took place, their type, and the strategies employed to manage them. A comprehensive protocol aimed at preventing and managing WPV in dental settings was subsequently developed. Multiple factors influence the occurrence of WPV. The prevalence of experienced and witnessed WPV incidents was 22% and 24% among faculty/staff and 7% and 5% among learners, respectively. Verbal aggression was the most common type of WPV. Most respondents lacked awareness of the available reporting mechanisms for WPV. A WPV prevention and management protocol was developed, consisting of five steps: intervene, report, document, access support services, and resolve (IRDAR). Administrators must have a comprehensive understanding of the prevalence of violence in their workplace and the underlying factors that contribute to it in order to take appropriate action. IRDAR is a clearly defined and easily implemented protocol designed for preventing and managing WPV in dental learning environments.