INTRODUCTION
In recent years, discussions on violent behavior have increased in the community, providing an opportunity for rethinking violence in the workplace in a broader way. In many studies, it has been reported that violence is more common in the area of health and the risk of assaults towards workers in health institutions is higher than in other work environments (1,2). The problem of assaults toward health care staff is global and on the increase (3,4). Assaults toward health care staff comprises behaviors that are intended to cause physical harm (physical assaults and/or the threat of assault) (5). It has been difficult to compare results on the definition and prevalence of assaults against doctors because of the difference of the research methods used.
The World Health Organization defines violence as follows: ‘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 (6).
It is difficult to gauge the extent of the problem since under-reporting of violent incidents is common (7-12) and is probably influenced by social roles or cultural factors (13). Annual rates of physical aggression towards health care workers range from a low of 3.1% (14), to higher (35-71%) levels (15-18). Non-physical aggression rates are even more difficult to evaluate; assessments range from 38% to 90% in a one-year period (14,19-23).
Although it has been emphasized that violence in society has increased in many respects, there are studies indicating a significant increase in violence against doctors in particular (24).
Although different aspects of physical and verbal attacks in healthcare have been reported in a number of studies, the reports on this topic are limited in our country (25-33). For this reason, we aimed to investigate assaults on doctors working at the Canakkale State Hospital and the Canakkale Onsekiz Mart University in Turkey.
METHOD
Sample
Participants who agreed to participate in the study were specialists at Canakkale State Hospital and residents or academics at Canakkale University. A self-administered questionaire was given face-to-face and completed questionnaires were checked for duplication. In total, 236 doctors from university and state hospitals agreed to participate to the study and response rate was 71.5% (93/130). We could not reach to all doctors due to vacation period in summer. The most common reason for non-responders was hectic working conditions and having no time to fill out the questionnaire.
Measure
Age, gender, workplace, professional position, duration of professional life, incidence of verbal and physical assaults in the past year, legal process after assaults and perception of assaults were collected by a questionnaire, which was prepared by the authors of the present study.
Statistical Analysis
Statistical analysis was performed with Statistical Package for Social Sciences (SPSS) 16 for Windows. Descriptive statistics were used for proportions and student’s t-test was used to compare the number of verbal and physical assaults during professional life. The chi-square (Fisher exact) test was used to compare nominal and ordinal variables, such as gender, work place, and professional position. Differences were considered significant at p<0.05 for all tests. All tests were two-tailed and were considered significant at p<0.05.
RESULTS
The participants in the research were consisted of 64.7% (n=84) male, 76.2% married (n=99), half of them (n=65) working in the internal medicine departments, 65.4% (n=85), (eight doctors working in the basic sciences were included into internal medicine departments to be able to do statistical evaluation) working in the university hospital, and 58.5% (n=76) working as specialists or academics. The average age of the participants was 36.7±8.3 (median 35) years. The gender distribution was not statistically significant when comparing internal medicine versus surgical departments (p=0.42), working as resident versus specialist (p=0.82) or working at the state hospital versus the university hospital (p=0.46).
We found that 59.2% (n=77) of the doctors were verbally or verbally and physically assaulted at least once in the past year. There were similar rates of assault when comparing residents, specialists or academics (p=0.05); internal medicine versus surgical units (p=0.50); or state versus university hospital (p=0.32) (Table 1). The majority of assailants consisted of relatives of patients (43.7% verbal assaults, n=31). Verbal assaults mostly occurred in the outpatient room (61.6%), while half of the physical assaults occurred in the emergency department (Table 2).
The vast majority of doctors considered that poor health policies were the most important reason for these assaults (83.3%, n=65), and nearly all of them thought that violence towards doctors has increased in recent years (97.4%). Second and third common reported reasons were condition-specific working area (n=7, 9.0%) and lack of security (n=3, 3.8%).
DISCUSSION
The average age of doctors working in the state hospital was found to be significantly higher in this study. There were no statistically significant differences in terms of exposure to assaults between the university hospital and the state hospital, or between academics and clinicians. However, it was found in a review of the literature that younger doctors and doctors working overtime were attacked more frequently (34). Similar trends have been observed in other countries, such as Canada and New Zealand (35-36).
The reason for the lack of difference between the age groups in our study may be that violence may not depend on the experience of the doctor or attitude toward the patient, but may depend on high expectations of the patient from the doctor, unsuitable environments for health care services, and overcrowded treatment environments.
There were no significant differences observed for attacks in comparing the gender of doctors. There are conflicting reports in the literature on this subject. It has been found that men were significantly more exposed to physical violence then women (37-40) and this is thought to be attributable to the dominant cultural norms that do not accept a lack of respect for women in these communities. However, in other studies, women were found to be more affected by violence than men (41).
The vast majority of attackers were relatives of the patient in our study (verbal attack 40.8%, n=31). Also in the literature, most attacks were reported to be carried out by patients and their relatives (42,43). The reason for this might be the anxiety of the patients’ relatives for their family members, the lack of adequate attitudes for coping with stress, and negative discourses directed against doctors in oral and written media. A large proportion of verbal attacks were found in an outpatient setting (61.5%); physical attacks were found in the emergency department in our study. These settings are often used by aggressive and stressed patients/visitors. The tendency to violence toward healthcare professionals was carried out mostly by patients affected by drug addiction (20,44,45).
Non-physical attacks occurred mostly face to face (86%), in places such as outpatient clinics, patient rooms, and waiting rooms, where staff, patients and their families were in direct communication (60%), as found in Kitaneh and Hamdan’s study. This is an indicator of poor communication skills between caregivers and receivers and it points out a weakness in the approach to patients and their families in controlling violent behavior (37). Psychiatric units (15,46) or emergency units (19,32,47-49) were investigated in most of the studies.
Patients in emergency settings, such as out-of-hours primary care, have acute illnesses or are in acute need of help, and some patients are intoxicated with drugs or alcohol. This may produce volatile situations for health care workers (50). Patients wait a long time in the ED and are under stress regarding their underlying medical condition. These factors, concomitantly with substance abuse and psychiatric comorbidities, also contribute to violence toward staff (3,9,51). Emergency departments appear to be especially problematic. Some studies reported that 1 in 3 emergency department doctors were physically assaulted during the previous year, and 75% of all US emergency department (ED) doctors experienced at least one verbal threat (52). Psychiatrists and other doctors whose practice includes many patients with mental illness and addiction problems are at higher risk of being assulted (34,53,54). In our study, 59.2% of doctors (n=77) had been verbally and/or physically attacked at least once in the past year. The literature reports rates of 35-71% (15-18), which are compatible with our study. Verbal attack rates were 67%, and physical attack rates were 16% in a similar study conducted in Turkey. In this study, they reported no gender difference in attack rates (31), as in our study. Although Acik et al. (31) reported that attacks were mostly observed in surgical units, there was no difference between medical and surgical clinics in terms of exposure to attack in our study. However, this might be due to todays changing health policies, ease of access to doctors in both surgical and internal branches, and increased expectations from doctors. Considering these factors, both from our results and from the literature, we see the importance of preventing violence against doctors through comprehensive studies and the introduction of precautions to decrease violence.
Our study has some limitations, such as the relatively small sample size, lack of information about emotional and psychiatric reactions to the assailants and the legal process after the assaults. Sufficient information could be obtained about the properties of the assailant because of the retrospective design of the study. We could not reach to all doctors due to vacation period in summer. Thus, our study sample does not reflect all Canakkale. However, further studies in this area would force health policies to be re-evaluated to provide preventive precautions to protect workers in workplaces and, in the end, to help decrease the number and severity of the assaults.
In conclusion, the high rate of violence against doctors is noteworthy. We found that physical and verbal attacks occur in emergency departments and outpatient examination rooms in an environment of close communication between doctors and patients. We suggest that health policies can play an important role in influencing violence against doctors. There is a need to have further more detailed studies on this topic in order to examine the causes and to develop suggestions for solutions.
