Physical workplace violence in the health sector in Saudi Arabia

Physical workplace violence (WPV) occurs worldwide, causing psychological and physical injuries. However, reports from Saudi Arabia investigating which specialty is the most exposed are scarce. This study aimed to determine the prevalence and circumstances related to physical WPV among all healthcare providers in Saudi Arabia in 12 months, as well as the consequences for both attackers and targets of physical WPV. This cross-sectional study included all healthcare providers registered with the Saudi Commission for Health Specialties who had worked for more than 1 year in the health sector in Saudi Arabia until May 2019. Researchers distributed the questionnaire to the participants via email. Descriptive statistics were used to describe the basic features of the data. Correlations between the categorically measured variables were explored using a chi-square test of independence. Overall, 7398 healthcare workers (HCWs) voluntarily participated in the study, 51.3% being men and 48.7% being women. The mean age was 40 ± 8.62 years), and most participants were of non-Saudi origin. Overall, 9.3% HCWs had encountered physical violence. Male HCWs, pharmacists, nurses, and HCWs of non-Saudi origin were significantly more exposed to physical violence. Furthermore, those with direct physical contact with patients and those working with male patients only were more exposed to physical violence. Physical WPV is an important issue faced by HCWs, particularly those who work night shifts or have direct contact with patients. Results showed that more support, specific strategies and policies to reduce violence occurrence, and protection for healthcare providers are required.


Introduction
The World Health Organization (WHO) defines violence as "the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation." [1]Specifically, physical violence has been a well-known topic of research for many decades; however, it has received more attention recently.Physical violence is explicitly defined as "the use of physical force against another person or group that results in physical, sexual, or psychological harm.Physical violence includes beating, kicking, slapping, stabbing, shooting, pushing, biting, and pinching, among others." [2]Physical workplace violence (WPV) occurs less frequently than psychological WPV; however, it is not less important.Babiarczyk et al [3] determined that 20% of nurses from 5 European countries had been exposed to physical WPV compared with 54% who experienced psychological WPV.In previous studies, the rate of physical WPV was 12.6% in China, [4] 18.3% in Jordan, [5] and 36.8% in Ethiopia. [6][23] Globally, multiple organizations, such as the WHO, have given considerable attention to this topic.Case studies conducted in different countries, such as Brazil, Bulgaria, and Lebanon, [24] provide framework guidelines in the health sector to help workers prevent, work with, manage, and support people who have experienced WPV. [25]he Occupational Safety and Health Administration provides The authors have no funding and conflicts of interest to disclose.
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
information regarding the risk factors and strategies for preventing WPV, in addition to online training materials. [26]The National Institute for Occupational Safety and Health provides online prevention courses and resources on this subject. [27]he cause of physical violence varies worldwide.For instance, in poorly equipped hospitals, an increase in the demand will always exceed the supply within the public health system, which increases the risk of physical attacks, low reporting rates of incidents that need law enforcement interference, and stressful environments that cause anxiety in workers and make them more prone to physical violence. [28,29]Nonetheless, working in some settings (e.g., in emergency departments and with patients with psychological problems) increases the prevalence of WPV. [23]lthough previous studies have focused on WPV, to the best of our knowledge, none have covered the whole of Saudi Arabia and all specialties.Additionally, few studies have focused on the association between WPV and independent risk factors, such as hospital characteristics (i.e., clinical role and rank).
Therefore, this study aimed to determine the prevalence of physical WPV over 12 months, the circumstances related to the event, and the consequences for the attacker and target person at all healthcare provider facilities in Saudi Arabia and to identify which group of healthcare providers is most susceptible.

Data collection
This study included all healthcare providers who are registered with the Saudi Commission for Health Specialties (SCFHS) and have been working for more than 1 year in the health sector (governmental or private) in Saudi Arabia by May 2019.The exclusion criteria were students, interns, employees of the administrative department, and providers who were not registered in SCFHS or had less than 1 year of work experience.Moreover, a convenient sampling technique was used where all eligible participants (i.e., physicians, pharmacists, nurses, midwives and health specialists, healthcare technicians, and technicians) were invited to participate in the study.Overall, 304,002 healthcare providers met the eligibility criteria.
The data were collected using a modified self-administered questionnaire developed by the Joint Program on Workplace Violence in the Health Sectors of the WHO, International Labor Organization, International Council of Nurses, and Public Services International.The questionnaire was translated into Arabic for staff who were not fluent in English.The questions that did not apply to Saudi Arabia were omitted.
A pilot test was conducted by distributing the questionnaire to 5 physicians, 5 dentists, 5 nurses, and 5 pharmacists who were Arabic and English speakers and had the clinical experience to validate the Arabic translation to avoid misunderstandings; these practitioners were excluded from the main study.
The questionnaire included questions related to the respondents' demographic data, workplace characteristics, the experience of violent events during the previous 12 months, risk factors contributing to WPV, personal opinions, perceptions, attitudes, experiences, and participants' knowledge of WPV.The researchers distributed the questionnaire by emailing it to the study population.To increase the response rate, the researchers sent reminder emails to the participants after 2 weeks.

Statistical analysis
Data analysis was performed using the SPSS (version 22; IBM, Armonk, NY).Descriptive statistics (frequency and table) were used to describe the basic features of the data.Continuous variables were expressed as mean and standard deviation, whereas categorical variables were expressed as frequencies and percentages.The Kolmogorov-Smirnov statistical test of normality and histograms were used to assess the statistical normality assumption of metric variables.The statistical homogeneity of variance assumption was evaluated using Levene's test of homogeneity of variance.The chi-square test of independence was used to explore the correlations between the categorical variables.An independent samples t test was used to assess the mean differences of continuous variables across the levels of categorically binary measured variables.
A multivariate binary logistic regression analysis was conducted to assess the combined and individual associations between the relevant predictors of the exposure of HCWs to recent physical violence at the workplace.The association between the measured predictor variables and their outcomes was expressed as an odds ratio with a 95% confidence interval.Statistical significance was set at P < .05.

Ethical approval
This study was conducted following the guidelines of the Declaration of Helsinki.Approval was obtained from the institutional review board of King Saud University College of Medicine (approval number: E-18-3391) before the study was started.Written informed consent for participation, publication, and confidentiality was obtained from the study participants at the beginning of the survey.

Demographic characteristics
Overall, 304,002 HCWs were recruited from the SCFHS database, and 7398 responded to the questionnaire.Among them, 51.3% and 48.7% were men and women, respectively.The participants' mean age was 40 ± 8.62 years; and 60% were of non-Saudi origin.Nurses, midwives, and health specialists accounted for 38.1% of the study population, followed by physicians at 30.91%, healthcare technicians and ambulance technicians at 25.54%, and pharmacists at 5.43%.Most participants were employed full-time (89.86%) in the public or governmental sectors (72.47%) (Table 1).

Experience of WPV
Only 9.3% of HCWs experienced a physical attack at their workplace in the last 12 months, and most (94.9%) were instigated without weapons (Table 2).Patients attacked most HCWs (48.2%); 36.2% of HCWs were attacked by patients' relatives.Moreover, most HCWs (60.6%) could not recollect the day on which the episodes of physical violence occurred; however, 8.2% of the recalled incidents occurred on Sundays.Furthermore, 37.4% of HCWs reported the incident to a senior staff member, and 33% told the offender to stop the violence (Tables 2 and 3).

Consequences of physical violence
As presented in Table 4, no injury was reported by 80.9% of HCWs because of the incident, with 21% of those who were physically offended requesting an action to be taken to explore the cause of the attack; however, 60.1% of HCWs suggested that no further investigation measures be taken.The management was the top entity that acted according to 81.5% of HCWs who were physically offended; however, 26.9% of HCWs requested police involvement.Moreover, 35.6% of HCWs who were physically attacked at their workplace stated that their supervisors offered them counseling; most of these HCWs (84%) were allowed to speak about the accident and report it, with 37.5% of HCWs also receiving another form of support.The overall satisfaction with how the management handled the physical attack incident was rated as 2.02 of the 5 satisfaction points, which is near-dissatisfactory. HCWs indicated that their primary reason for not reporting the incident was the belief that reporting the physical attack was useless (Table 5).

Witnesses of incidents of physical violence
Table 6 shows that 32.6% of HCWs witnessed at least 1 physical attack at their workplace.Among them, 50% reported these incidents to their superiors; however, 16.9% of them were penalized for reporting that their peer was subjected to physical attacks.

Experience of physical attacks and their sociodemographic and professional factors
Female HCWs were projected to be at significantly lower risk of physical attacks at the workplace within the past 12 months than male HCWs.However, no significant association was found between the nationality of HCWs and their experience of physical violence at the workplace (P = .124).Additionally, nurses, midwives, health specialists, and pharmacists were more likely to be at a significantly higher risk of being subjected to physical attacks than physicians and healthcare technicians in the last year (P < .001).Furthermore, the seniority level of HCWs showed no statistically significant association with exposure to physical abuse at the workplace in the last year; however, the junior staff was at a slightly higher risk of physical attacks than other HCWs (P = .053).Moreover, the working sector and employment type of HCWs did not significantly correlate with their recent exposure to a physical attack at the workplace (Table 7).

Working conditions and experience of physical attacks
Table 8 shows that HCWs working evening shifts and those with direct interaction and physical contact with patients were more likely to be at a significantly higher risk of recent physical violence at their workplaces (P < .001).Additionally, HCWs working with elderly patients, adults, adolescents, children, and infants were significantly more likely to be exposed to physical violence at the workplace (P < .001);however, HCWs working with newborns were not as likely to experience physical attacks.Moreover, the analysis showed that HCWs working with only male patients were more likely to be exposed to physical violence at the workplace (P < .001).The workers who spent more than 50% of their job working at hospitals were significantly more likely to have had recent physical violence in their work areas (P < .001);those spending more than 50% of their work in ambulance services and community-based jobs were significantly more likely to have had recent physical violence while working (P = .010).

Experience of physical attacks and violence reporting characteristics of the hospital
HCWs exposed to physical violence had a significantly higher anxiety level after experiencing WPV (According to the Likert rating, the mean worry = 3.94, SD = 1.13) than those who had not been recently physically attacked at work (mean worry = 2.74, SD = 1.30;P < .001).Additionally, HCWs serving at a facility with in-place guidelines for reporting violence were significantly less exposed to physical violence than those working without violence reporting guidelines, P < .001(Table 9).Furthermore, the analysis indicated that knowledge of how to use reporting guidelines did not significantly correlate with exposure to physical violence at the workplace (P = .058);however, receiving encouragement to report an incident from the administration of the facility resulted in significantly lower exposure to physical abuse among HCWs (P < .001).All sources of encouragement to report violence significantly reduced exposure to physical violence at the workplace (P < .001).

The influence of exposure to physical violence
Figure 1 shows the sources of encouragement for reporting violence.Encouragement from leaders and supervisors was associated with the greatest difference in reducing exposure to physical violence, followed by encouragement from colleagues, the SCFHS, family and friends, and the medical association.

Multivariate logistic binary regression analysis results
As presented in Table 10, on average, female HCWs were projected to be at a significantly lower risk of experiencing a recent physical attack at the workplace within the past 12 months than male HCWs (P = .023).Additionally, HCWs aged 20 to 29 years old were significantly more likely (40.2% more likely) to have been physically abused at the workplace than those aged 30 years or older (P = .40)(Fig. 2).Non-Saudi HCWs were significantly more exposed (40.6% more exposed) to physical harassment than Saudi HCWs (P = .001).Furthermore, pharmacists were predicted to be at a significantly higher (3.02 times higher or 200.2% higher) risk of being physically attacked at the workplace than physicians (P < .001);however, nurses were predicted to be at a significantly higher risk (66.9% times more) of being physically attacked at the workplace than physicians (P < .001).Conversely, the analysis model indicated that the seniority level of HCWs did not correlate significantly with their exposure to recent physical abuse at the workplace (P = .263).The presence of violence reporting guidelines did not significantly correlate with the HCWs' odds of being physically abused (P = .161),although such guidelines for managing violence predicted less (though not statistically significant) exposure to physical violence.However, working within an environment that encourages reporting violence anticipated significantly lower odds of physical abuse among HCWs.HCWs working in such environments were expected to be at a considerably lower (44% times lesser) risk of having been physically attacked recently (P < .001)than those working in environments that were not supportive/did not encourage reporting violence of any kind at the workplace, which accounted for the other predictors.

Discussion
31] To the best of our knowledge, no studies have focused on HCWs from all cities in Saudi Arabia.This comprehensive study with many participants focused on physical violence against all healthcare providers across Saudi Arabia.
Few participants had experienced physical violence in the last 12 months.Comparatively, the extent of physical violence was less than that reported by Mohamed [31] and more than that reported by Alharthy et al, [7] Al-Turki et al, [8] and El-Gilany et al [9] However, the study by Mohamed [31] only included nurses working in Riyadh City with most working in emergency and psychiatric units, thus the higher reporting rates.][34][35][36] The results from Egypt were consistent with this result, with the same percentage of incidence of physical abuse. [37]Additionally, the result is consistent with the systematic review and meta-analysis conducted by Binmadi et al [22] The variation between the countries may be due to the different perceptions of violence between different cultures, under-reporting, or due to some studies focusing on certain specialties that had a higher incidence of physical abuse.
Physical attacks usually originated from the patients and their relatives, similar to the findings of Mohamed, [31] Fallahi-Khoshknab et al, [32] Binmadi et al, [22] and others. [8,38]However, some studies, such as those conducted by Alharthy et al, [7] El-Gilany et al, [9] and Duan et al, [39] reported the opposite; these studies determined that attacks originating from patients' relatives were more frequent than physical attacks originating from the patients themselves.Approximately half of all HCWs registered in the SCFHS are of non-Saudi origin.Attacks originating from patients against non-Arabic-speaking HCWs could be due to a misunderstanding between the patient and healthcare provider, may not speak Arabic, or have a different language that could cause communication barriers. [40,41]Consistent with the results of this study, those of previous studies revealed that most incidents occurred outside the institution [7] and inside the institution. [8,32,42]ble 8 Association between healthcare workers' experience of physical attacks at the workplace and their working conditions factors.

Variable
Hospice 5 (0.4) 0 Home for the elderly/nursing home 5 (0.4) 2 (1.9) Community service (e.g., home care, outreach service, health visiting) 85 (6.1) 9 (8.4) Table 9 Association between healthcare workers' experience of physical attacks at the workplace and their hospital violence reporting guidelines characteristics.We found that HCWs working in the public and private sectors have the same risk of encountering physical violence.In contrast, governmental HCWs in Ethiopia had a higher risk of experiencing physical violence than those in the private sector. [33]The lack of differences in our results may have been due to patients seeking treatment in both private and public hospitals in Saudi Arabia equally, as all hospitals are generally wellequipped and have well-trained staff, which increases healthcare provider loads at all times and, consequently, patient waiting times.

Variable
Nurses, midwives, and healthcare specialists (except pharmacists) are the top groups among all other professional groups to encounter physical violence.It was impossible to compare this study's results to those of other studies because most studies did not include all HCW specialties; some studies categorized HCWs into physicians and nurses, whereas others investigated a single specialty.El-Gilany et al [9] included more than 5 categories and determined that physicians rather than pharmacists were more prone to experience physical violence, whereas Al-turki et al [8] found that clerks rather than pharmacists experienced physical violence more frequently.Nurses frequently experience WPV owing to their vital role in the hospital setting. [43]Nurses are usually the first healthcare providers to interact with patients, patients' family members, or caregivers.[45][46] This study showed that physical attacks usually occurred between 0700 and 1300 on the first day of the week (Sunday in Saudi Arabia).This finding was similar to those of Al-turki et al, [8] El-Gilany et al, [9] and Ferri et al, [15] but differed from those of Abbas et al [37] and Kitaneh et al, [35] who reported that most attacks occurred during night shifts.In our study, most  attacks may have occurred on the first day of the week as more people sought treatment after weekends, which may have led to overcrowding, increased waiting time, and increased workloads of HCWs.Conversely, most of the victims were working night shifts; this could be explained by the under-reporting of night attacks, as fewer staff are available to take time off for reporting.
The participants responded to the incident by reporting it to a senior staff member; some informed the attacker to stop, while others took no action.Very few pursued prosecution or completed a compensation claim.In a study by Alharthy et al, [7] the participants usually asked the aggressors to stop, then attempted to physically defend themselves, while only a few took no action.
The participants in most studies stated that violence could be prevented. [8,13,37]Availability of security personnel, liaison with police, and a penalty for perpetrators are the most frequent suggestions to prevent and control violence. [9]Physical violence incidents caused injuries to some of the victims, and half of them consequently needed treatment, whereas others experienced psychological changes after the attack.Physical violence may lead to HCWs taking some time away, as over one-fifth of the participants took at least 1 day off from work after the incident.This may lead to a shortage of staff and financial loss for the institution. [39,47]WPV negatively affects workers' job satisfaction and leads to more job burnout. [37,39]Work performance was diminished, and some participants felt sad, stressed, ashamed or guilty, bothered, suspicious, and angry after a WPV incident. [8,9,35]WPV also causes psychological consequences, [15] such as mental stress, which results in sleep disturbance and deteriorated health. [34] high proportion of physical violence incidents occurred with no action taken to investigate the causes of the events. [13,32,42]n this study, only a few respondents reported an investigation, most of which were performed by the management or employer of the institution.This finding is similar to that of El-Gilany et al, [9] who stated that most of the time, no action was taken; only 4 perpetrators were issued a verbal warning by the directors of primary health care centers.
A high percentage of victims did not report the incident, similar to previous studies' findings, [7,15,32,35,38] indicating that the rules or their implementation were inadequate or that there was a lack of knowledge regarding the rules.Another explanation for not reporting the attacks may be a lack of encouragement to report, having a previous fruitless experience, or fear of revenge from the attacker or their families. [10]Gacki-Smith et al [48] mentioned that having no physical injury as evidence of physical violence could prevent nurses from reporting the incident or that they wanted to protect their image by not giving the impression of being weak or unqualified.Lu et al [29] reported that nurses would report more cases of WPV when there was a reporting system in the hospital, possibly because the abovementioned study was performed at psychiatric hospitals that had more violent events or because workers were more aware of when and how to report them because they knew the system. [29]Some HCWs who reported the incidents were victimized or disciplined/penalized for reporting the incident, which highlighted a substantial amount of blame for reporting healthcare workplace physical abuse, which may be another contributing reason for not reporting any future accidents.
HCWs exposed to physical violence reported a significantly higher worry level from their WPV than those who had not recently been physically attacked at work. [3,4]Additionally, HCWs serving at a facility with in-place guidelines for reporting violence were, on average, significantly less likely to be exposed to physical violence than those working in facilities without violence reporting guidelines.Though knowledge of how to use reporting guidelines did not significantly correlate with exposure to physical violence at work, encouragement to report violence by facility administration significantly reduced exposure to physical abuse among HCWs.
Therefore, further studies are needed, mainly of a longitudinal nature, to explore the reasons for physical violence and to implement solutions accordingly.Educational programs are required for HCWs, patients, and their relatives, and increasing awareness through the media is important.A more encouraging environment to report every violent incident with strict consequences for the attackers should be implemented.More importantly, new regulations (e.g., more staff members, shorter waiting times, and more support, such as prevention programs) are necessary.The main limitation of this study is its use of a retrospective self-report questionnaire, which might cause recall bias.Additionally, although this study had a sufficiently large number of participants to be considered a convenient sample, the results cannot be generalized to the population.The strength of this study involves all HCWs in both government and private institutions in Saudi Arabia, unlike previous studies that mainly focused on emergency departments or nurses.
In conclusion, the rate of physical WPV in Saudi Arabia is lower than what has been reported in previous literature in other countries; however, it remains a risk faced by HCWs, particularly those working night shifts and having direct contact with patients.The prevalence was the highest among pharmacists, nurses, midwives, and healthcare specialists, followed by healthcare technicians and physicians.This result shows that more support and specific strategies and policies to reduce the occurrence of WPV, protect healthcare providers, and prevent the event are required.Under-reporting the attacks may give an incorrect indication of the magnitude of the problem; therefore, more education and additional research in the Kingdom of Saudi Arabia are needed.

Figure 1 .
Figure 1.The percentage difference (i.e., decline) in exposure to physical violence, broken down by sources of violence reporting encouragement at the workplace.

Figure 2 .
Figure 2. The association between the health workers' age groups and sex with their mean predicted probability of being physically attacked at work.

Table 1
Descriptive analysis of healthcare worker's sociodemographic and professional characteristics (N = 7398).

Table 2
Healthcare workers' perceptions and experience of physical workplace violence.

Table 3
Incidence of experience of physical workplace violence.

Table 4
Consequences of the physical violence.

Table 5
Reasons for not reporting the physical violence.

Table 6
Witness of incidents of physical violence.

Table 7
Association between the healthcare workers' experience of physical attacks at the workplace and their sociodemographic and professional factors.

Table 10
Multivariate logistic binary regression analysis of the predictors of healthcare workers' exposure to recent physical violence at the workplace (n = 7398).