Violence, which has been ever present throughout the history of humanity, is defined as a threat or application of possessed power or strength towards another person, self, a group, or a community in order to cause injury and/or loss.1 The World Health Organization defines violence as “physical assault, homicide, verbal assault, emotional, sexual or racial harassment”.2

Workplace violence is defined as “abuse or attacks by one or more people on an employee within the workplace”.3 The health care field, which encompasses a wide range of employees, is among those in which workplace violence is common.4 Violence in the health care field is defined as “risk to a health worker due to threatening behaviour, verbal threats, physical assault and sexual assault committed by patients, patient relatives, or any other person”.3

According to the 2002 Workplace Violence in the Health Sector report, 25% of all violent incidents occurred in the health care sector.5 A study conducted in the United States determined that the risk of being subjected to violence is 16 times higher in the health care sector relative to other service sectors.6 Within the health care field, the department that is most frequently exposed to violence is the emergency department (ED).3 7 8 9 In this context, verbal and physical attacks by dissatisfied patients and their relatives are at the forefront.10 11

In this study we aimed to determine the extent of violence towards ED employees, analyse the attitude of the staff exposed to violence, and propose possible solutions.

This cross-sectional study was conducted in the EDs of Şevket Yilmaz Training and Research Hospital and Sakarya University between 1 July and 15 August 2012. Employees of ED—including doctors, nurses, health care officials, Emergency Medical Technicians (EMT), secretaries, laboratory technicians, radiology technicians, and security and cleaning staff—were included in the study. The questionnaire was prepared in accordance with previous publications3 10 11 and distributed to participants. All study participants were provided with information regarding the objectives of the study and were given instructions for completing the form. Of the 437 ED employees working in the two hospitals, 323 (73.9%) agreed to participate in the study and returned a completed questionnaire.

In addition to demographic information, the questionnaire contained questions about the number of violent incidents to which the individual had been subjected to, the type of violence, and whether the subject reported the incident or the reason for not reporting. Additional questions concerned a description of the person(s) responsible for the violence, the estimated age of the person(s) responsible for the violence, and the severity of the violence. We also asked participants about their attitude following the violent incident and suggestions for reducing violence in the ED.

This study was conducted in accordance with the principles of the 2008 Helsinki Declaration. The data were analysed using the Statistical Package for the Social Sciences (Windows version 15.0; SPSS Inc, Chicago [IL], US). Both proportions and mean ± standard deviation were used to represent the results. The Student’s t test, Pearson’s Chi squared test, and the Monte Carlo Chi squared tests were used to evaluate observed differences between groups and a P value of <0.05 was considered to represent a statistically significant difference.

Among the 323 participants included in the study, 189 (58.5%) were male and 134 (41.5%) were female. The mean age of the male participants was 31.5 ± 6.5 years (range, 18-55 years) and that of the female participants was 32.0 ± 6.9 years (range, 20-52 years). There was no significant difference in the age distribution between the male and female participants (P=0.476).

When participants were asked if they had ever been exposed to verbal or physical violence in the workplace during the course of their career, 239 (74.0%) indicated that they had been subjected to one or the other, and 57 (17.6%) reported being subjected to both verbal and physical violence. Among the participants who were subjected to violence, 162 (67.8%) reported being the victim of more than five violent incidents (Table 1).

The frequency of exposure to violence and the frequency of exposure to more than five violent incidents were similar for both men and women (P=0.185 and 0.104, respectively). Nonetheless, 25.9% of men reported both verbal and physical violence compared with only 6.0% of women, suggesting that the incidence of verbal and physical violence against men was greater than that against women (P<0.001) [Table 1].

We investigated the frequency of exposure to violence and the reported incidence of violence among various occupation groups (Table 2). The prevalence of exposure to violence was the highest among health care officials, EMTs, doctors, and security staff (P<0.001). In addition, only 102 (42.7%) out of 239 participants reported these violent incidents. It is notable that although the rate of incident reporting was 100% among security staff, none of the laboratory technicians reported the violent incidents (P<0.001).

A total of 43 (31.4%) out of the 137 study participants who had been exposed to violence but had not reported the incident provided reasons (Table 3). The most common reason for not notifying the authorities was the perception that “no resolution will be reached”. Other important reasons included the heavy workload, not wanting to deal with the legal process, disregarding verbal attacks, understanding/sympathising with the emotions of patients and their relatives, fear of the threat from patients and their relatives, and not knowing how and where to report such incidents.

A total of 248 participants responded to a question regarding the identity of the person who was to blame for the violence in ED in general (not their own experiences). Accordingly, 65.3% (n=162) stated that the patient’s relatives were responsible, 27.0% (n=67) stated that both the patients and their relatives were responsible, and 5.2% (n=13) placed sole responsibility on the patients. Six (2.4%) participants stated that they had been subjected to violence from other health care professionals.

When we asked individuals to estimate the age of the person(s) causing the violence that they had experienced, respondents who were exposed to multiple violent incidents answered this question by selecting multiple options and a total of 405 answers were obtained. As shown in Table 4, the majority (71.4%) of people responsible for violent incidents were young patients and patient relatives between the ages of 18 and 39 years.

When participants who were exposed to violence were asked who caused the violent incident, three (1.3%) participants stated that they themselves were responsible, five (2.1%) indicated that both sides were responsible, and the remaining 231 (96.7%) held the attacker responsible.

Participants were asked “What do you think is the reason for the violence?”. A total of 181 (56.0%) participants responded to this question. Some participants indicated more than one reason and a total of 188 answers were obtained. The top 10 most common responses to this question are given in descending order of frequency in Table 5. The most common cause of violence was ignorance and lack of education of patients and their relatives (28.7%), followed by the impatient attitudes and demanding priorities (23.4%) and the heavy workload and prolonged waiting time (10.6%).

Participants were asked “How do you think violence against health care workers can be reduced?”. Some participants indicated more than one reason and a total of 509 answers were obtained. They considered the most important steps suggested to reduce violence against ED employees were the enactment of deterrent legislation (42.6%), increased security measures in hospitals (28.5%), and improved public education (16.7%) [Table 5].

Participants were asked about their attitude after experiencing violence. Some respondents gave more than one answer and a total of 498 answers were obtained. There were 27.1% of participants who did not enjoy working in their current profession, 25.7% wanted to work in non–health care field, and 21.5% did not want to work in the ED (Table 6).

A total of 96.3% (n=311) of participants answered “Yes” to the question “Do you think that the violence against health care workers has increased in recent years?” Moreover, 90.7% (n=293) of the participants answered “Yes” to the question “Do news reports regarding violence against health care workers affect you?”. Then, when participants were asked “How does the news affect you?”, 64.7% (n=209) reported that they were “sad”, 44.3% (n=143) said they were “angry”, and 18.9% (n=61) said they were “scared”.

When participants were asked “Are there sufficient security measures in your workplace?”, only 66 (20.4%) participants gave a positive response, while 257 (79.6%) responded negatively. Among the 41 participants working as security staff, 33 (80.5%) found the safety measures inadequate. Thus, both the security staff and the general employee population agreed that hospital security was inadequate.

Workplace violence is the most prevalent in the health care sector.4 The ED is the health care unit with the highest frequency of exposure to violence.3 7 8 9 According to several previous studies, the proportion of health care professionals who report prior exposure to violence in the workplace ranges from 45% to 67.6%.3 8 12 13 14 The rate of violence against ED employees (79%-99%), however, is higher than the average for the health care field.15 16 17

Emergency services are high-risk areas for patients and staff with regard to workplace violence18 19 20 21; 24-hour accessibility, a high-stress environment, and the apparent lack of trained security personnel are underlying factors.22 Workplace violence negatively affects the morale of health care workers and negatively affects the health and effectiveness of presentation.23 24 25 26

Our study was conducted among ED employees of two different hospitals. We investigated the rate of exposure to verbal or physical violence. Among the participants, 239 (74.0%) stated that they had been subjected to exposure to violence, and 57 (17.6%) reported having been exposed to both verbal and physical violence. A study in Turkey found that among ED employees, including nurses, in the İzmir province of Turkey, 98.5% of respondents had been subjected to verbal violence and 19.7% were exposed to physical violence.16 In another study conducted in Turkey, 88.6% of ED employees were subjected to verbal violence and 49.4% reported having been the victim of physical violence.17

In the present study, the rate of exposure to violence by profession was 95.7% among health care officials/EMTs, 90.7% among doctors, and 80.5% among security personnel. According to Ayrancı et al,3 exposure to violence was most common among practitioners (67.6%) and nurses (58.4%). In another study, Alçelik et al27 reported that nurses were exposed to violence 3 times more often than other health care professionals. In the present study, the frequency of exposure to violence among nurses was 62.7%, which is lower than that in other professional groups.

In the present study, the estimated age distribution of patients and patient relatives responsible for violent incidents showed that the majority (71.4%) were between 18 and 39 years of age. Other studies have reported that individuals prone to violence are generally younger than 30 years.28

Health care workers are often subjected to verbal and physical attacks from patients and their relatives who are dissatisfied with the services provided.10 11 In the present study, the most common cause of violence was the lack of education and ignorance of the patients and their relatives. Heavy workload was identified as another cause of workplace violence. Factors such as patient stress and anxiety regarding their condition, high expectations of the patients and their relatives, lack of effective institutional and legal arrangements aimed at preventing violence, and the failure to effectively document the extent of workplace violence contribute to the high frequency of violence.12 There are several factors that increase the risk of violence in health care institutions, including 24-hour service, long waiting time for patients, poor access to health care services, heavy workload, limited staff, inadequate employee training, and lack of security personnel.29 30

Previous studies conducted in Turkey revealed that 60% of ED employees who were exposed to violence did not report the incident. Among the reasons for not reporting was a lack of confidence in health care and executive leadership as well as the justice system.12 In the present study, the incident reporting rate was also low (42.7%) and the most important reason (34.9%) for not reporting was the perception that “no resolution will be reached”. Indeed, a study found that there were no repercussions for the attacker in 77% of instances.12 This suggests the perception that “no resolution will be reached” is a valid one.

A heavy workload consumes the energy of employees and reduces their ability to empathise with patients and tolerate violent situations. Sometimes verbal or physical conflicts may arise between a stressed patient who may be subject to long waiting times and exhausted and stressed health care workers. Training regarding communication with patients helps health care professionals to avoid these problems.31 Effective communication alone, however, is not sufficient and additional steps must be taken to reduce waiting time of patients. Previous studies have indicated that the most important reason for patient dissatisfaction in the ED is the waiting time.32 33 Yet, the most important reason for long waiting times is the heavy workload caused, in part, by the discourteous attitude of patients and their relatives. Studies have also shown that more than half of patients who present to the ED are not ‘emergency patients’.34 35 36 Further education regarding the definition of “emergency” and the practice of effective triage may reduce the heavy workload in the ED and associated violent incidents.

One previous study reported that verbal and physical attacks by patients and their relatives are the most important factors contributing to stress among ED employees.37 Consistent exposure to high-stress conditions resulting from exposure to verbal and physical violence results in both physical and mental exhaustion. As a result, a situation known commonly as ‘burnout syndrome’ emerges.38 39 The burnout syndrome is defined as holding a negative view of current events, frequent despair, and lost productivity and motivation.40 Reluctance among physicians to work in the ED is one consequence of burnout syndrome.41 In the present study, among the participants who were subjected to violence, 21.5% indicated that they wanted to work in a department other than the ED, while 25.7% stated a desire to work outside the health care field. In a study conducted in Canada, 18% of participants who had been exposed to violence stated that they did not want to work in the ED, and 38% wanted to work outside the health care field.9 Others indicated that they had quitted their jobs because of workplace stress.9 In the present study, 10.4% of ED employees stated that they were afraid of patients and their relatives. In the same Canadian study, 73% of respondents stated that after experiencing violence they were afraid of patients.9 In our study, 96.3% of respondents thought that there had been an increase in violence against ED health care workers in recent years. Moreover, 79.6% of respondents stated that the safety measures in their institutions were insufficient. The participants in the present study suggested that the preparation of deterrent legislation, increased security measures, and efforts to better educate the general population regarding the appropriate use of ED resources will help to reduce violence against health care workers.

The study was carried out in only two hospitals in Turkey that may not be representative of all hospitals. In addition, participants could decide whether or not to answer all questions and some questionnaires were incomplete. The response rate was only 74% and this might give rise to self-selection bias, that is, those who did not respond may have had a higher (or lower) exposure to violence than those who responded. Hence, the various percentages reported in this paper might be over- or under-estimated.

The results of the current study as well as those of earlier studies indicate that the prevalence of violence against ED employees is high. Factors such as patient and stress of health care provider, prolonged waiting times due to overcrowding in the ED, negative attitude of discourteous patients and their relatives, insufficient security measures, and the lack of sufficiently dissuasive legal regulations may contribute to increased violence in the ED. These factors in turn increase stress among ED employees, reduce job satisfaction, and lower the quality of services provided. Measures to decrease the workload in the ED and shorten waiting time of patients, the adoption of legal policies that deter violent behaviour, and increased security measures in health care facilities should be reassessed. Steps should be taken to educate the public in order to reduce violence against health care workers.

All authors have disclosed no conflicts of interest.

1. Kocacik F. On violence [in Turkish]. Cumhuriyet Univ J Econ Adm Sci 2001;2:1-2.

2. Violence and injury prevention. Available from: http://www.who.int/violence_injury_prevention/violence/activities/workplace/documents/en/index.html. Accessed Nov 2012.

3. Ayrancı Ü, Yenilmez Ç, Günay Y, Kaptanoğlu C. The frequency of being exposed to violence in the various health institutions and health profession groups. Anatol J Psychiatry 2002;3:147-54.

4. Wells J, Bowers L. How prevalent is violence towards nurses working in general hospitals in the UK? J Adv Nurs 2002;39:230-40. Crossref

5. Workplace violence in the health sector. Framework guidelines for addressing workplace violence in the health sector. Available from: http://www.ilo.org/wcmsp5/groups/public/---ed_dialogue/---sector/documents/publication/wcms_160912.pdf. Accessed Nov 2012.

6. Kingma M. Workplace violence in the health sector: a problem of epidemic proportion. Int Nurs Rev 2001;48:129-30. Crossref

7. Gülalp B, Karcıoğlu, Köseoğlu Z, Sari A. Dangers faced by emergency staff: experience in urban centers in southern Turkey. Ulus Travma Acil Cerrahi Derg 2009;15:239-42.

8. Lau J, Magarey J, McCutcheon H. Violence in the emergency department: a literature review. Aust Emerg Nurs J 2004;7:27-37. Crossref

9. Fernandes CM, Bouthillette F, Raboud JM, et al. Violence in the emergency department: a survey of health care workers. CMAJ 1999;161:1245-8.

10. Yanci H, Boz B, Demirkiran Ö, Kiliççioğlu B, Yağmur F. Medical personal subjected to the violence in emergency department—enquiry study. Turk J Emerg Med 2003;3:16-20.

11. Sucu G, Cebeci F, Karazeybek E. Violence by patient and relatives against emergency service personnel. Turk J Emerg Med 2007;7:156-62.

12. Çamci O, Kutlu Y. Determination of workplace violence toward health workers in Kocaeli. J Psychiatr Nurs 2011;2:9-16.

13. Stirling G, Higgins JE, Cooke MW. Violence in A&E departments: a systematic review of the literature. Accid Emerg Nurs 2001;9:77-85. Crossref

14. Sönmez M, Karaoğlu L, Egri M, Genç MF, Günes G, Pehlivan E. Prevalence of workplace violence against health staff in Malatya. Bitlis Eren Univ J Sci Technol 2013;3:26-31.

15. Stene J, Larson E, Levy M, Dohlman M. Workplace violence in the emergency department: giving staff the tools and support to report. Perm J 2015;19:e113-7. Crossref

16. Senuzun Ergün F, Karadakovan A. Violence towards nursing staff in emergency departments in one Turkish city. Int Nurs Rev 2005;52:154-60. Crossref

17. Boz B, Acar K, Ergin A, et al. Violence toward health care workers in emergency departments in Denizli, Turkey. Adv Ther 2006;23:364-9. Crossref

18. Joa TS, Morken T. Violence towards personnel in out-of-hours primary care: a cross-sectional study. Scand J Prim Health Care 2012;30:55-60. Crossref

19. Magnavita N, Heponiemi T. Violence towards health care workers in a Public Health Care Facility in Italy: a repeated cross-sectional study. BMC Health Serv Res 2012;12:108. Crossref

20. Arimatsu M, Wada K, Yoshikawa T, et al. An epidemiological study of work-related violence experienced by physicians who graduated from a medical school in Japan. J Occup Health 2008;50:357-61. Crossref

21. Taylor JL, Rew L. A systematic review of the literature: workplace violence in the emergency department. J Clin Nurs 2011;20:1072-85. Crossref

22. Gacki-Smith J, Juarez AM, Boyett L, Homeyer C, Robinson L, MacLean SL. Violence against nurses working in US emergency departments. J Nurs Adm 2009;39:340-9. Crossref

23. Kowalenko T, Gates D, Gillespie GL, Succop P, Mentzel TK. Prospective study of violence against ED workers. Am J Emerg Med 2013;31:197-205. Crossref

24. Position statement: violence in the emergency care setting. Available from: https://www.ena.org/government/State/Documents/ENAWorkplaceViolencePS.pdf. Accessed Nov 2012.

25. Workplace violence. Washington, DC: United States Department of Labor; 2013. Available from: http://www.osha.gov/SLTC/workplaceviolence/index.html. Accessed Nov 2012.

26. Adib SM, Al-Shatti AK, Kamal S, El-Gerges N, Al-Raqem M. Violence against nurses in healthcare facilities in Kuwait. Int J Nurs Stud 2002;39:469-78. Crossref

27. Alçelik A, Deniz F, Yeşildal N, Mayda AS, Ayakta Şerifi B. Health survey and life habits of nurses who work at the medical faculty hospital at AIBU [in Turkish]. TAF Prev Med Bull 2005;4:55-65.

28. Young GP. The agitated patient in the emergency department. Emerg Med Clin North Am 1987;5:765-81.

29. Stathopoulou HG. Violence and aggression towards health care professionals. Health Sci J 2007;2:1-7.

30. Hoag-Apel CM. Violence in the emergency department. Nurs Manage 1998;29:60,63.

31. Yardan T, Eden AO, Baydın A, Genç S, Gönüllü H. Communication with relatives of the patients in emergency department. Eurasian J Emerg Med 2008;7:9-13.

32. Al B, Yıldırım C, Togun İ, et al. Factors that affect patient satisfaction in emergency department. Eurasian J Emerg Med 2009;8:39-44.

33. Yiğit Ö, Oktay C, Bacakoğlu G. Analysis of the patient satisfaction forms about Emergency Department services at Akdeniz University Hospital. Turk J Emerg Med 2010;10:181-6.

34. Kiliçaslan İ, Bozan H, Oktay C, Göksu E. Demographic properties of patients presenting to the emergency department in Turkey. Turk J Emerg Med 2005;5:5-13.

35. Ersel M, Karcıoğlu Ö, Yanturali S, Yörüktümen A, Sever M, Tunç MA. Emergency Department utilization characteristics and evaluation for patient visit appropriateness from the patients’ and physicians’ point of view. Turk J Emerg Med 2006;6:25-35.

36. Aydin T, Aydın ŞA, Köksal Ö, Özdemir F, Kulaç S, Bulut M. Evaluation of features of patients attending the Emergency Department of Uludağ University Medicine Faculty Hospital and emergency department practices. Eurasian J Emerg Med 2010;9:163-8. Crossref

37. Kalemoglu M, Keskin O. Evaluation of stress factors and burnout in the emergency department staff [in Turkish]. Ulus Travma Derg 2002;8:215-9.

38. Ferns T, Stacey C, Cork A. Violence and aggression in the emergency department: Factors impinging on nursing research. Accid Emerg Nurs 2006;14:49-55. Crossref

39. Keser Özcan N, Bilgin H. Violence towards healthcare workers in Turkey: A systematic review [in Turkish]. Turkiye Klinikleri J Med Sci 2011;31:1442-56. Crossref

40. Maslach C. Burned-out. Hum Behav 1976;5:16-22.

41. Dwyer BJ. Surviving the 10-year ache: emergency practice burnout. Emerg Med Rep 1991;23:S1-8.