A Qualitative Systematic Review of Healthcare Practitioners’ Experience of Workplace Violence

Healthcare practitioners face significant risks of workplace violence due to various reasons such as hospital congestion, miscommunication, and aggressive behaviours of patients and relatives. Exposure to workplace violence may disrupt the workflow process and compromise patient care in healthcare facilities, ultimately affecting job performance, reducing job satisfaction, and negatively affecting the physical and mental health of healthcare practitioners. This study aimed to review all the published studies conducted on the experiences of workplace violence among healthcare practitioners. This study is a systematic review of qualitative studies. Data were collected through online databases including ScienceDirect, PubMed, MEDLINE and JSTOR were searched from the year 2015–2021. The inclusion criteria were: qualitative methods and mixed methods of data collection and analysis; studies that were carried out among healthcare practitioners who have been experience on workplace violence; scope of the primary studies included experience of workplace violence; and published in English/Malay in academic journal between 2015 and 2021. A total of 15 papers were included in the final analysis. The overall quality of the included papers was high. Of the 15 papers, 12 studies fully met the CASP criteria. The results of the 15 included studies were organised into the thematic groups of: i) verbal violence as the common workplace violence; ii) perceived causes of workplace violence and iii) seeking help. Across different countries, verbal violence was the most common type of workplace violence reported by healthcare practitioners. This review also identified that a lack of information, failure to meet patient expectations, and delayed treatment were the main contributing factors to workplace violence.


Introduction
Workplace violence is a severe occupational hazard in the healthcare industry worldwide, affecting thousands of healthcare practitioners each year (1,2).Workplace violence encompasses a spectrum of unacceptable behaviours ranging from threats and verbal abuse to physical assaults and homicides in the workplace (3).For example, workplace violence incidents can occur when staff members are abused, threatened, discriminated against or assaulted in circumstances related to their work, including when they travel to and from work.Such incidents can pose threats to their safety, health and well-being (4).
Healthcare practitioners face the significant risks of workplace violence (1,5).The annual rate of violent victimisation among nurses and physicians is 8.1 and 10.1 per 1,000 workers, which is much higher than 5.1 for all occupations (6).Workplace violence often results from congestion in healthcare facilities, miscommunication and aggressive behaviours displayed by patients and relatives.For instance, long waiting times in the emergency department can lead to impatience among patients, making them irritable and disruptive, sometimes harming healthcare staff (7).
Exposure to workplace violence may disrupt the workflow and patient care in hospitals.In the literature, doctors who suffered workplace violence have been linked with poor job performance, decreased job satisfaction and suboptimal physical health (8).Similarly, healthcare practitioners' mental health is affected by increased feelings of guilt, anger, anxiety and depression (9).Furthermore, exposure to violence can compromise work morale and the satisfaction derived from patient care (10).
Many studies have investigated the phenomenon of workplace violence among healthcare practitioners worldwide.While it is clear that the prevalence varies from country to country-for example, 67% in Italy, 75% in Australia and 4.6% in Hong Kong (11)(12)(13)-there is no consensus on the experiences of workplace violence among healthcare practitioners.Therefore, this qualitative systematic review aimed to understand the experiences of healthcare practitioners regarding workplace violence in Malaysia and other countries.

Methods
This was a systematic review of qualitative studies, also known as qualitative synthesis.This review aimed to understand the experiences of workplace violence among healthcare practitioners.A qualitative synthesis is a collection of methods for systematically reviewing and integrating the findings of qualitative studies.This approach was chosen to review all available literature and combine the findings of primary research studies to generate a comprehensive overview of the available evidence on the experience of workplace violence among healthcare practitioners.This approach is also suitable for new researchers to improve their knowledge of the subject of interest so that they can develop new research ideas and acquire critical skills by synthesising the results from the existing literature (14).
Four online databases were searched between 2015 and 2021, including ScienceDirect, PubMed, MEDLINE and JSTOR.The inclusion criteria were as follows: qualitative methods and mixed methods of data collection and analysis; studies that were carried out among healthcare practitioners who experienced workplace violence; scope of the primary studies included experience of workplace violence; factors triggering workplace violence; reported and unreported cases; and articles published in English/Malay in academic journals between 2015 and 2021.Upon eligibility assessment, 202 papers were excluded because they were not primary studies, not related to workplace violence or not conducted among healthcare practitioners.Further assessment excluded 48 papers because they were not published between 2015 and 2021 and were neither in English nor Malay.
The quality and methodology of the selected articles were assessed using the Critical Appraisal Skills Programme (CASP) (15).The following inclusion and exclusion criteria were used to screen the studies (Table 1).
An overview of the research methodology using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart is presented in Figure 1.

Qualitative Appraisal
Of the 15 studies, all but three fully met the CASP criteria, indicating that the overall quality of the included studies was high.This was derived from the CASP quality assessment (Table 2).

Inclusion
Exclusion criteria • Qualitative method and mixed method of data collection and analysis.
• Peer review publication.
• Studies were carried out among healthcare practitioners with previous experience of workplace violence.
• The scope of the primary studies included the experience of workplace violence, factors that triggered workplace violence, reported and unreported cases.
• Published in English/Malay in academic journals between 2015 and 2021.
• Full paper available.

Approach to Analysis
The selected papers reviewed and analysed using thematic synthesis which is used to identify, analyse and interpret the patterns of various themes (31).Thematic analysis can be used when working as a research team to analyse large qualitative datasets.It is a step-by-step approach that provides a detailed explanation and practical approach for conducting thematic analysis.Thematic analysis is also useful in summarising the key features of large datasets by ensuring that researchers adopt a wellstructured approach to deal with data so that clear and well-organised final reports can be generated (32).
Thematic analysis began by coding the text findings and reading the article's findings lineby-line.Subsequently, 'descriptive themes' were developed and compared among the selected articles.Next, the 'descriptive themes' were refined to introduce a higher level of abstraction.
In this step, some initial themes were retained, whereas others were grouped at an abstract level as the analysis progressed.

Results
Fifteen studies were included in the meta-analysis.These studies were conducted worldwide in Malaysia, Indonesia, Thailand, Saudi Arabia, India, Iran, Turkey, Australia, Sweden, Italy and the United States of America.Nine studies employed face-to-face in-depth interviews (IDI), two involved focus group discussions (FGD), two used a combination of IDI and FGD, and two involved openended surveys.Studies were conducted among various groups of healthcare practitioners, with nurses being the major group of participants.A summary of the included studies is presented in Table 3.Based on thematic analysis, the results of studies included in this review can be categorised into the following three themes: i) verbal violence is the most common workplace violence, ii) perceived causes of workplace violence and iii) seeking help.

Verbal Violence is the Most Common Workplace Violence
According to Fisekovic et al. (33), verbal abuse is a behaviour that shows humiliation, degradation or a lack of respect for a person's dignity and worth.Analysis of the selected studies revealed that the most common type of workplace violence among healthcare practitioners was verbal violence (34).The abusive words reported in the studies included 'prostitute', 'body fat' and 'husband snatcher'.Some were insulted through blackmail.
Henderson et al. ( 18) conducted a qualitative study by interviewing 19 nurses using snowball sampling to investigate their perspectives on violence caused by patients and visitors.The IDI lasted approximately 45 min-60 min.Nurses reported being verbally abused by patients and visitors, describing how they were shouted at, cursed at or sworn at.Additionally, Vrablik et al. ( 21) interviewed 23 healthcare practitioners, including nurses, advanced nurse practitioners, physicians and medical students, in three emergency departments in Washington.They reported that workplace violence occurred every day and felt that many people were loud and vocal toward healthcare practitioners.They also commented that workplace violence was a common phenomenon, noting that it was a 'standard package' that accompanied their jobs.

Perceived Causes of Workplace Violence
Based on the 15 studies, workplace violence was perceived as a result of a lack of information, failure to meet patient expectations, refusal of unreasonable requests, delayed treatment/long waiting, poor management, workload pressure and a high number of visitors/patients.Najafi et al. (29) conducted a qualitative study of workplace violence among 22 nurses in nine hospitals in Iran.Five categories of factors causing workplace violence were identified: i) unrealistic expectations from patients/relatives; ii) poor organisational management; iii) poor professional communication; iv) factors related to nurses; and v) factors related to patients, sick relatives and colleagues.In the category of unmet expectations of patients/relatives, one of the common triggers of workplace violence was patient-related; for example, when they received inadequate information or became anxious after finding out about the high treatment cost, especially in private hospitals.
Second, inefficient organisational management can cause workplace violence because of poor organisation, workload pressure or crowding (high patient and visitor volumes).One common example is how healthcare practitioners may not be able to handle patients and their caregivers effectively in overcrowded situations, a common scenario in emergency departments.Similarly, Kueanongkhun et al. (26) reported that workplace violence frequently occurred at the front desk of the emergency department because of the high number of patients and relatives there.
The third most commonly cited factor of workplace violence is inappropriate or nonprofessional communication, including verbal and nonverbal communication with patients/ relatives or written reports in patient case notes.A similar study conducted in Italy by Ramacciati et al. (22) highlighted the role of weak communication among nurses in causing workplace violence.One participant said that nurses could trigger violence if they were hostile toward patients and visitors.Miscommunication in the workplace, whether between doctors and nurses or between nurses, can also indirectly result in workplace violence.Better communication between healthcare practitioners and patients/relatives can reduce anxiety and aggression.
Additionally, some participants reported that managers and doctors experienced violence and tension because of medical and nursing errors.Some nurses reported that communication between patients and relatives upon admission to the emergency department or other departments played a major role.In Turkey, Bahadir-Yilmaz and Kurşun (17) found that workplace violence encountered by nurses commonly arose due to poor communication skills, lack of information provided to patients, fatigue due to intense work pressure, job pressure and low job satisfaction.Most of these factors are closely associated with nurses' responsibilities in patient care provision.
Finally, workplace violence can also be related to patient, relative or colleague factors.Patients who experienced pain or anxiety, hallucinations, restlessness, substance abuse (alcohol and drugs), had a history of suicide, or had an antisocial personality were more to commit workplace violence toward healthcare professionals.Some nurses pointed out that patients/relatives often become irritable because of the stress caused by their illness, consequently leading to tension and violence.
Nowrouzi-Kia et al. (35) conducted an IDI with 17 registered nurses from nine hospitals in Iran who had experienced workplace violence.The results showed that the factors contributing to workplace violence were lack of time to answer all questions from patients and relatives, insufficient information from doctors, and patients' unrealistic expectations for nurses to fulfil all their demands.

Seeking for Help
Although workplace violence is prevalent among health care practitioners, many cases remain unreported.Many seek comfort from their colleagues after the incident or dismiss the situation altogether, as they feel unsupported by the administrator.Some victims of workplace violence shared their experiences of seeking help after the incident.
In another study, 13 students from the medical, surgical and emergency departments of Shahid Beheshti Hospital in Kashan, Iran, were recruited using purposive sampling.One participant asked for help from hospital security when she encountered workplace violence, but they refused to get involved.Another participant claimed that the security team arrived only when the conflict had been settled (19).
In Malaysia, Salim et al. (24) conducted a study on workplace violence in the Emergency and Trauma Department of a tertiary government hospital.All healthcare practitioners with previous experience of workplace violence were interviewed.Incident reports were also reviewed.According to the participants, they considered themselves as being 'immune' to workplace violence and they believed that no help would be necessary.However, some sought help from colleagues to help them cope with their situation.

Discussion
This review found that workplace violence has been reported across many countries, including Malaysia, Indonesia, Thailand, Saudi Arabia, India, Iran, Turkey, Australia, Sweden, Italy and the United States.The most commonly reported type of violence was verbal abuse, whereas the least common was physical violence.Factors triggering workplace violence included gender, patients under the influence of drugs and alcohol, communication challenges, long waiting times and overcrowded waiting rooms.According to Berkowitz (36), disinhibition occurs because of the lack of negative consequences following an aggressive act.In other words, apart from causing negative emotions, stress can lead to violence.Frustration is another unpleasant negative effect that can provoke violent actions in the workplace.
The three themes of workplace violence derived from the qualitative analysis were verbal violence as common workplace violence, perceived causes of workplace violence and seeking help.It is important to acknowledge that workplace violence should not be regarded as 'part of the job' (37).A safe, secure and productive work environment must always be maintained.Employers must take the necessary actions to minimise and prevent workplace violence.Moreover, specific policies to facilitate risk assessment and prevention should be implemented in the workplace to tackle this issue.
Most workplace violence was committed by patients and their relatives, with eight studies showing that the abuser was a patient and seven studies reflecting that the abusers were patients and relatives.
A recent study proposed recommendations to prevent workplace violence by increasing the number of security personnel and providing basic training to staff (38).According to the Occupational Safety and Healthcare Act (OSHA), policies and procedures must be put in place to prevent workplace violence, including the identification of risk factors and violent behaviour, comprehensive strategies for interacting with patients and dealing with violence, training programmes to equip employees with knowledge of operating safety equipment such as systems alarms, and ways of protecting themselves and colleagues during violent episodes (39).

Conclusion
In summary, this study established three key findings.First, most violence experienced by healthcare practitioners at work is verbal.Second, the most commonly perceived causes of workplace violence included a of information, failure to meet patients' expectations and long waiting times for treatment.Third, few qualitative studies on workplace violence among healthcare practitioners have been conducted in Malaysia.Therefore, further research is required to explore how Malaysian healthcare practitioners perceive their experiences of workplace violence to obtain more information about its impact on the Malaysian healthcare sector.

Limitation
The limitation of the review was that there were few studies in Malaysia, especially qualitative studies.Therefore, the awareness of workplace violence in Malaysia remains low and needs to be emphasised to strengthen existing policies.

Table 2 .
Quality appraisal outcome using CASP

Table 3 .
Summary of the included studies