Saudi Journal of Emergency Medicine

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Faisal Alhusain et al, 2020;1(1):005–014.

Saudi Journal of Emergency Medicine

Workplace violence against healthcare providers in emergency departments in Saudi Arabia

Faisal Alhusain1,2*, Maryam Aloqalaa1,2, Danah Alrusayyis3, Khalid Alshehri4, Sadaqah Wazzan5, Nouf Alwelyee2,6, Aljerian Nawfal7

Correspondence to: Faisal Alhusain

*Department of Emergency Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia.

Email: Faisalaalhusain [at] gmail.com

Full list of author information is available at the end of the article.

Received: 18 October 2019 | Accepted: 14 January 2020


ABSTRACT

Introduction:

Emergency departments (EDs) have been identified as the highest risk area within a hospital to be exposed to workplace violence (WPV). This study aimed to estimate the prevalence of WPV against healthcare providers in EDs in Saudi Arabia, to explore the experiences and attitudes of ED staff toward WPV, and to identify the possible risk factors for WPV.


Methods:

A cross-sectional survey study was conducted with physicians and nurses working in 37 EDs in three provinces in Saudi Arabia, using a convenient sampling method. Over a 1-year period, 787 ED staff members were contacted and a 60% response rate was achieved.


Results:

The 1-year prevalence of at least one violent act against ED staff was 45%. Verbal threats were the most common type of WPV (42%). The study found that the prevalence of WPV against physicians (47%) was higher than against nurses (41%). However, when comparing the physician and nurse groups, none of the types of WPV was statistically significant. More female participants were exposed to stalking compared to male participants (OR 0.38; 95% CI 0.15–0.92). Non Arabic speakers experienced more WPV in the form of verbal threats and physical assault than the Arabic speaking group (OR 0.14; 95% CI 0.03–0.75). Participants working at the Ministry of Health hospitals were more likely to be exposed to a confrontation when off-duty and to stalking.


Conclusion:

Almost half of the ED physicians and nurses experienced one or more WPV incident during a 12-month period.


Keywords:

Emergency Department, Physicians, Nurses, Violence, Saudi Arabia.


Introduction

Workplace violence (WPV) in the healthcare sector has become an alarming phenomenon globally [1,2], affecting the dignity and well-being of millions of healthcare practitioners. The healthcare profession is potentially hazardous, whether from the proximity to disease and pathogens, handling chemicals or sharp tools, or even slips and falls [3]. However, WPV has exceeded all other risks and is a significant occupational hazard for healthcare practitioners [4]. Although affecting every department, due to the frontline nature of the emergency department (ED), multiple authors have identified the ED as the highest risk area for WPV within the hospital [4,5]. Violence against healthcare practitioners occurs frequently, and this socially and ethically unacceptable phenomenon must be managed [6].

Workplace-related violence is defined as “incidents where staff are abused, threatened, or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being, or health” [7]. In the United States (US), the majority of attending emergency physicians reported experiencing at least one workplace-related violence incident, and 25% reported multiple incidents of violence in 2004 [8]. In 2005, one in four attending emergency physicians reported being attacked, with some incidents occurring outside the ED and some were stalked. One-sixth of these physicians considered to leave their department due to the fear of assault [9]. A survey of WPV in 65 US EDs found that 25% of surveyed ED staff rarely felt safe. In a 2008 US study, the majority of emergency physicians experienced at least one WPV incident in 1 year, half of the emergency medicine residents reported being physically assaulted, and ED nurses reported even more incidents [10]. Some violent events may result in healthcare practitioners paying the ultimate price. In the United States, in a period of 4 years, 69 homicides were reported in the healthcare sector, with four occurring in the ED [11].

The public and legislative bodies are unaware of the magnitude of the problem, the implications for healthcare providers, the recipients as well as the financial cost. WPV has serious consequences, such as decreased job satisfaction, job performance, and a decrease in the standard of medical care [12]. In addition, WPV lowers morale, causes of anger, loss of confidence, burnout, time off work, disability, and change in job status [1214]. The cost of WPV is becoming more apparent. Even though WPV is a global concern, literature is markedly lacking. The aim of this study was to estimate the prevalence of WPV against healthcare practitioners in EDs in Saudi Arabia. In addition, this study aimed to explore the experiences and attitudes of ED staff toward WPV and identify possible risk factors for WPV and the reasons for underreporting.


Methods

Study design and technique

The design for the study was a cross-sectional survey conducted in healthcare providers (physicians and nurses) working in EDs in three different provinces of Saudi Arabia over 1-year period. Convenient sampling was used, and all available physicians and nurses who met the inclusion criteria were invited to participate in the survey. The primary outcome of the study was the prevalence of WPV in ED staff and their experience and attitudes toward WPV. The confidence level was 95% with expected prevalence of 58% based on a previous local study [15] and 5% as a margin of error.

Study setting and subjects

The study was conducted with physicians and nurses from 37 EDs in Saudi Arabia. Participants from 12 centers in Riyadh, the Central Province in Saudi Arabia, 14 centers from the Western Province, and 11 centers from the Eastern Province were personally contacted by members of the research group in each province. They were invited to participate in the study by completing the questionnaire. In total, 787 ED physicians and nurses were contacted and a 60% response rate (163 nurses and 312 physicians) was achieved. The study included all male and female physicians at any level and nurses who had worked in an ED in Saudi Arabia for at least 1 year. Participants who reported less than 1 year of practice in an ED (10 participants) and two questionnaires with no data were excluded from the study. Healthcare providers in their internship year, a mandatory 1-year period in different specialties after medical and nursing school in Saudi Arabia, or still studying were not included in the study.

Questionnaire

A previously validated and publicly published English questionnaire by Michigan College of Emergency Physicians [9] was adopted in this study. The questionnaire was reviewed to ensure alignment with the study objectives. The questionnaire was divided into three sections with a total of 19 questions. The first section (9 questions) comprised demographic information including gender, age, nationality, level of the staff, years in practice, the center, and Emergency Medicine Board Certification. The second section focused on experiencing violence with one question with multiple parts. This section started with some basic definitions of violence-related concepts (verbal threat, physical assault, a confrontation outside the immediate patient encounter, and stalking). The last section explored the reaction of the participants to violence in EDs (10 questions).

Data management and analyses

Data management and analysis were done using the Statistical Package for the Social Sciences (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY). Categorical variables are represented as percentage and frequency. The prevalence is reported as a percentage with 95% confidence intervals (CIs). A comparison of the type of violence experienced by the physician and nursing groups was performed using a Chi-square test. An univariate logistic regression analysis was conducted to investigate the predictors of WPV against ED staff. The 95% CI, OR, and adjusted OR (aOR) were reported. A p-value < 0.05 was considered to indicate statistical significance.

Ethical considerations

The study participation was voluntary, and each participant could withdraw from the study at any time. The questionnaire was accompanied by a cover letter explaining the purpose of the study and reassuring participants of the confidentiality of the survey. Ethical approval was obtained from the Institutional Review Board, King Abdullah International Medical Research Center, National Guard Health Affairs, Riyadh, Saudi Arabia (Study number RC17/156/R).


Results

Demographic profile of study participants

From July 2018 to July 2019, 475 physicians and nurses working in EDs completed the questionnaire. Gender was equally distributed (50%, n = 238). The minimum age was 24 years. The highest age for males was 60 years compared to 49 years for females (mean 31.83 ± 6.5 years; 33.57 ± 7.4 years for males and 30.09 ± 4.9 years for females). The highest proportion (39%, n = 186) was working in the Central Province, 38% (n = 181) in the Western Province, and 23% (n = 108) in the Eastern Province. Arabic was the spoken language for 74% (n = 353) of the participants. Two-thirds of the sample (66%, n = 312) were physicians with 34% (n = 163) of nurses. Of the physicians, 27% (n = 83) were junior residents, 10% (n = 30) senior residents, 30% (n = 94) staff physicians, 8% (n = 25) assistant consultants, and 26% (n = 80) consultants. The maximum number of years of practice was 30 years for males and 22 years for females (mean 5.66 ± 4.9 years; 6.82 ± 5.8 years for males and 4.50 ± 3.6 years for females). In terms of the Emergency Medicine Board Certification, 20% of the female physicians (n = 19) and 44% of the male physicians (n = 95) were certified. Of the sample, 49% (n = 212) were working at a Ministry of Health hospital and 59% (n = 281) in a hospital with a residency program (Table 1).

Table 1. Baseline characteristics of the participants.

Variable Category N %
Gender Male 237 50
Female 238 50
Age 30-year old and less 254 54
31–40 175 37
41–50 39 8
More than 50-year old 7 2
Mean ± SD = 31.83 ± 6.5; Males = 33.57 ± 7.4; Females = 30.09 ± 4.9
Spoken language Arabic language 353 74
Other languages 122 26
Location Riyadh Province 186 39
Western Province 181 38
Eastern Province 108 23
Job Physician 312 66
Nurse 163 34
Physician level Junior resident 83 27
Senior resident 30 10
Staff physician 94 30
Assistant consultant 25 8
Consultant 80 26
Years of practice in EM 5 years and less 292 64
6–10 101 22
11–20 59 13
More than 20 years 5 1
Mean ± SD = 5.66 ± 4.9; Males = 6.82 ± 5.8; Females = 4.50 ± 3.6
EM board certified No 198 64
Yes 114 37
Hospital type Ministry of Health Hospitals 212 49
Other hospitals 223 51
Residency Program in the hospital No 194 41
Yes 281 59

EM, emergency Medicine; SD, standard deviation.

Prevalence of WPV against ED physicians and nurses for a 12-month period

As shown in Table 2, 45% of the participants (n = 213) experienced at least one violent act during the past 12 months. The prevalence of WPV for the physician group (47%, n = 147) was higher compared to the nurse group (41%, n = 44). A verbal threat was the most frequent type of WPV (42%, n = 198). Almost half (44%, n = 174) of the physician group and 37% (n = 60) of the nurse group received at least one verbal threat. A small proportion (12%, n = 56) experienced a physical assault, equally distributed between the physician and nurse groups. Similarly, 12% of the participants (n = 58) experienced a confrontation outside of patient care (14% of physicians and 10% of nurses). In terms of stalking, 10% (n = 45) of the sample was stalked (11% (n = 35) of the physician and 6% (n = 10) of the nurse groups). When comparing the physician and nurse subsamples, none of the types of WPV was statistically significant.

Table 2. Prevalence of different WPVs against ED physicians and nurses.

Variable Category All Physicians Nurses p-value
N % N % N %
At least one violent act during the past 12 months No 262 55 165 53 97 60 0.17
Yes 213 45 147 47 66 41
Verbal threat No 277 58 174 56 103 63 0.12
Yes 198 42 138 44 60 37
Physical assault No 419 88 276 89 143 88 0.81
Yes 56 12 36 12 20 12
Confrontation Outside Time of Patient Care No 417 88 270 87 147 90 0.25
Yes 58 12 42 14 16 10
Stalking No 430 91 277 89 153 94 0.07
Yes 45 10 35 11 10 6

WPV, workplace violence; EM, emergency medicine

Characteristics of the types of WPV against ED physicians and nurses for a 12-month period

A relationship between the years of practice in the ED and the incidence of some types of WPV was observed. Participants who had <5 years of practice reported at least one experience of physical assault (4.89 ± 3.8) and stalking (4.68 ± 3.9). Table 3 presents a more detailed comparison. The type of violence experienced varied according to the age of participants; the group older than 50 years was not stalked or confronted outside the time of patient care. Some types of WPV were more prevalent in certain provinces; for instance, a verbal threat was more prevalent in the Central Province as reported by 96% of the group who experienced violence. In contrast, the prevalence of a confrontation outside the time of patient care was the highest in the Eastern Province, as reported by 30% of the group who experienced violence. The Western Province had the highest overall prevalence rate (39%). The prevalence of violence varied in terms of the physician level as 31% of the staff physicians compared to 9% of the assistant consultants who experienced violence. Table 4 details the characteristics of WPV against ED staff.

Univariate logistic regression analysis of the predictors of WPV against emergency medicine physicians and nurses

Gender was associated with stalking in the univariate analysis, with female participants more exposed than male participants (OR 0.38; 95% CI 0.15–0.92). There was no association between age, location of hospital, physician level, years of practice in emergency medicine, and board certification. However, spoken language was significantly associated with experiencing WPV in the past 12 months, specifically verbal threats and physical assault. The non Arabic speaker group experienced more WPV in the past 12 months than the Arabic speaking group (OR 0.14; 95% CI 0.03–0.75), received more verbal threats (OR 0.14; 95% CI 0.03–0.75), and experienced more physical assaults (OR 0.12; 95% CI 0.02–0.64). The group working in the Ministry of Health hospitals was more likely than the counter group to be exposed to a confrontation outside the time of patient care (OR 3.20; 95% CI 1.33–7.73) and to stalking (OR 2.78; 95% CI 1.03–7.47). In addition, the group working in hospitals without a residency training program in emergency medicine experienced significantly more physical assault and stalking (OR 23.91; 95% CI 3.93–145.60, and OR 4.81; 95% CI 1.31–17.66, respectively) (Table 5).

Physician and nurse reaction to WPV in EDs

Due to violence within the workplace, 19% of the sample considered leaving their current hospital position and 14% considered leaving the practice of emergency medicine. Only 1% sought psychological counseling, with 5% obtaining legal counsel. A substantial proportion of the WPV was committed by family members: 43% of the verbal threats, 43% of the confrontation outside of patient care, and 39% of stalking. However, almost half of the physical assaults were received from patients (47%). The sample indicated that 15% of the verbal threats were perpetrated by patients believed to be intoxicated and 13% from mentally disturbed patients. When questioned whether they fear to become a victim of violence in the ED, almost half (46%) indicated being occasionally fearful of WPV, 24% were frequently fearful, and 12% were constantly fearful. In terms of protecting themselves from the violence, one-third (33%) tried to have any form of protection. The majority (68%) requested assistance from the hospital security. When questioned whether they desired additional resources to cope with the threat of violence in their ED, one-third (32%) indicated information regarding their legal rights, 24% indicated information on personal protection orders and how to obtain them, and 22% indicated training courses or presentations to manage threatening and violent patients. Figures 1 and 2 display the physicians’ and nurses’ reactions to WPV in the ED.

Table 3. The difference between the mean age and years of practice between the types of WPV.

Variable Category Age (mean ± SD) Years of practice (mean ± SD)
Having at least one violent act during the past 12 months Yes 32.42 ± 6.7 5.81 ± 4.9
No 31.34 ± 6.3 5.53 ± 4.9
Verbal threat Yes 31.34 ± 6.3 5.53 ± 4.9
No 32.27 ± 6.2 5.51 ± 4.9
Physical assault Yes 30.95 ± 5.9 4.89 ± 3.8
No 31.94 ± 6.6 5.7 ± 5.1
Confrontation outside the time of patient care Yes 31.86 ± 5.9 5.32 ± 4.5
No 31.82 ± 6.6 5.7 ± 4.9
Stalking Yes 31.4 ± 5.8 4.68 ± 3.9
No 31.87 ± 6.6 5.8 ± 5.0

WPV, workplace violence

Table 4. Characteristics of different types of WPV against EM department staff.

Variable Category An incident of WPV in the last year N = 213 Verbal threat N = 198 Physical assault N = 56 Confrontation outside time of patient care N = 58 Stalking N = 45
N % N % N % N % N %
Gender Male 108 51 104 96 29 27 32 30 20 19
Female 105 49 94 90 27 26 26 25 25 24
Age 30 and less 102 48 93 91 32 31 27 26 26 25
31–40 87 41 81 93 19 22 25 29 14 16
41–50 19 9 19 100 4 21 6 32 5 26
More than 50 5 2 5 100 1 20 0 0 0 0
Spoken language Arabic language 157 74 147 94 40 25 46 29 38 24
Other languages 56 26 51 91 16 29 12 21 7 13
Location Riyadh Province 79 37 76 96 18 23 21 27 14 18
Western Province 84 39 75 89 25 30 22 26 21 25
Eastern Province 50 24 47 94 13 26 15 30 10 20
Job Physician 147 69 138 94 36 24 42 29 35 24
Nurse 66 31 60 91 20 30 16 24 10 15
Physician level Junior resident 31 21 29 94 9 29 9 29 11 35
Senior resident 17 12 17 100 4 24 5 29 5 29
Staff physician 46 31 42 91 13 28 14 30 10 22
Assistant consultant 13 9 13 100 2 15 3 23 2 15
Consultant 40 27 37 93 8 20 11 28 7 18
Years in practice in Emergency Medicine 5 years and less 130 63 122 94 37 28 39 30 34 26
6–10 47 23 42 89 13 28 12 26 7 15
11–20 26 13 25 96 4 15 5 19 3 12
More than 20 years 3 2 3 100 0 0 1 33 0 0
Emergency Medicine board certified No 88 60 83 94 25 28 27 31 25 28
Yes 59 40 55 93 11 19 15 25 10 17
Hospital type Ministry of Health Hospital 98 51 91 93 30 31 34 35 28 29
Other hospitals 96 50 91 95 21 22 20 21 14 15
Residency Program in the hospital No 93 44 85 91 31 33 30 32 26 28
Yes 120 56 113 94 25 21 28 23 19 16

WPV, workplace violence; EM, emergency medicine.

Table 5. Univariate logistic regression analysis of the predictors of WPV against EM physicians and nurses.

Variable(s) An incident of WPV in the last year Verbal threat Physical assault Confrontation outside the time of patient care Stalking
OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)
Age
30 years old and less 0.13 (0.01–1.74) 0.09 (0.01–1.29) 1.03 (0.02–44.79) N/A N/A
31–40 0.19 (0.02–2.46) 0.19 (0.01–2.46) 0.33 (0.01–10.58) N/A N/A
41–50 0.17 (0.01–2.13) 0.19 (0.02–2.53) 0.20 (0.01–4.91) N/A N/A
More than 50 years old 1 1 1 1 1
p-value 0.35 0.203 0.53 N/A N/A
Gender
Male 0.68 (0.38–1.21) 0.69 (0.39–1.25) 0.92 (0.36–2.34) 0.92 (0.39–2.14) 0.38 (0.15–0.92)
Female 1 1 1 1 1
p-value 0.188 0.221 0.857 0.837 0.032
Spoken language
Arabic language 0.14 (0.03–0.75) 0.14 (0.03–0.75) 0.12 (0.02–0.64) 0.29 (0.06–1.44) 0.35 (0.06–1.99)
Other languages 1 1 1 1 1
p-value 0.022 0.022 0.014 0.131 0.234
Location
Riyadh Province 1.06 (0.43–2.60) 1.01 (0.41–2.50) 4.92 (0.84–28.84) 0.71 (0.19–2.61) 5.56 (0.96–32.28)
Western Province 0.92 (0.44–1.91) 0.68 (0.32–1.42) 1.34 (0.44–4.07) 0.80 (0.29–2.17) 3.81 (0.94–15.39)
Eastern Province 1 1 1 1 1
p-value 0.916 0.305 0.161 0.863 0.123
Physician level
Junior resident 0.80 (0.21–2.98) 1.20 (0.31–4.54) 0.23 (0.03–1.92) 0.49 (0.08–2.90) 0.84 (0.10–7.30)
Senior resident 1.93 (0.45–8.29) 2.86 (0.66–12.46) 0.81 (0.08–8.28) 1.48 (0.20–10.78) 2.03 (0.19–22.27)
Staff physician 0.86 (0.25–2.93) 1.09 (0.32–3.76) 0.17 (0.02–1.24) 0.30 (0.06–1.57) 0.39 (0.05–3.36)
Assistant consultant 0.99 (0.34–2.91) 1.38 (0.47–4.08) 0.10 (0.01–1.15) 0.81 (0.17–3.93) 0.78 (0.12–5.23)
Consultant 1 1 1 1 1
p-value 0.507 0.162 0.174 0.321 0.404
Years in practice in Emergency Medicine
5 years and less 0.73 (0.05–10.79) 0.60 (0.04–9.02) N/A 0.07 (0.00–1.73) N/A
6–10 0.66 (0.05–9.73) 0.53 (0.04–7.92) N/A 0.06 (0.00–1.69) N/A
11–20 0.32 (0.02–4.29) 0.25 (0.02–3.46) N/A 0.05 (0.00–1.30) N/A
More than 20 years 1 1 1 1 1
p-value 0.368 0.302 N/A 0.355 N/A
Emergency Medicine Board certified
No 0.60 (0.20–1.78) 0.62 (0.21–1.84) 0.66 (0.12–3.62) 0.82 (0.20–3.42) 0.63 (0.12–3.35)
Yes 1 1 1 1 1
p-value 0.36 0.39 0.628 0.782 0.584
Hospital type
Ministry of Health Hospital 1.24 (0.68–2.24) 1.23 (0.68–2.24) 1.76 (0.65–4.81) 3.20 (1.33–7.73) 2.78 (1.03–7.47)
Other hospitals 1 1 1 1 1
p-value 0.482 0.495 0.268 0.01 0.043
Does your hospital have a residency training program in EM?
No 1.55 (0.68–3.52) 1.47 (0.64–3.38) 23.91 (3.93–145.60) 2.24 (0.71–7.06) 4.81 (1.31–17.66)
Yes 1 1 1 1 1
p-value 0.298 0.367 0.001 0.167 0.018

WPV, workplace violence; EM, emergency medicine; OR, odds ratio; CI, confidence interval.


Discussion

WPV in EDs is a serious phenomenon that affects the patient experience as well as the quality of practice for healthcare providers. The aim of this study was to estimate the prevalence of WPV against healthcare providers in EDs in three provinces of Saudi Arabia, to emphasize the seriousness and extent of the problem, and to highlight the need for immediate intervention. In addition, the risk factors for WPV and the experiences and attitude of ED healthcare providers were explored. The findings provide evidence of a relatively high prevalence of WPV (physical, verbal, confrontations outside the workplace, or stalking), in the past 12 months against physicians and nurses working in 37 EDs (45% in total, 47% for the physician group, and 41% for the nurse group) in the three provinces in Saudi Arabia.

Figure 1. Perpetrators of different violent assaults.

Figure 2. Characteristics of WPV-related questions among EM physicians and nurses.

A study conducted in Abha, Saudi Arabia, targeting all healthcare providers, reported a WPV prevalence of 58%, which was higher for the nurse group (63%) [15]. In the Middle East, several studies reported WPV in the ED [1618]. In Egypt, the prevalence of WPV against healthcare workers in the ED was 59.7% [8]. This was even higher in Palestinian EDs with 76% of staff experiencing a type of WPV in the past 12 months [19]. Furthermore, Çıkrıklar et al. [18] conducted a study in Turkey to compare various professional groups working in the ED, and they concluded that 74% of the participants had been subjected to WPV [18]. These findings are higher compared to this study. Several other studies reported varying prevalence rates of WPV against ED staff, for example, New York City (66%), Michigan State (76%), Hong Kong (76%) and Tehran City (90%) [5,9,16]. These differences could be related to different ethnicities, culture-related factors as well as unmeasured biological, social, and environmental characteristics that could play a role in WPV.

In this study, the most frequent type of violence against ED physicians and nurses was verbal threats (42%), which is lower than the results from Zafar et al. [20] reporting a prevalence rate of 72.5% [20]. In this study, 44% of the physician group reported experiencing verbal threats, which is similar to a study conducted in Egypt (45.3%) [17] and lowers than the prevalence rate reported in Pakistan (72.5%), the United States (75%), and Iran (90.7%) [8,16,20]. In terms of the nurse group, 37% received at least one verbal threat during the past 12 months, which is low compared to an Egyptian study (65.7%) [17]. The prevalence of physical assaults in this study was 12%, which is comparable with two studies reporting a prevalence of 16.5% and 15.1%, respectively [17,20], but lowers than a national survey conducted in the US (21%) [8]. A concerning finding in an Iranian study indicated a prevalence of 68.6% for physical assaults against physicians [16]. In the present study, 12% of the participants experienced a confrontation outside the ED and 10% experienced being stalked compared to 5% (a confrontation outside the ED) and 2% (stalking) from the national survey in the USA [8].

The majority of the violent acts in this study were committed by family members; the finding is supported by a previous study conducted in Riyadh [21], indicating that the patient’s family/friends were the most frequent perpetrators of all forms of violence combined and identified by more than 70% of the respondents. Another local study [22], investigating WPV against emergency medical services workers in Riyadh, reported that the majority of the attackers were the patients’ relatives (80%), followed by patients themselves (51%). These findings correlate with other studies in the region [2326], providing evidence that the most violent acts in EDs were committed by the patients’ relatives or friends. In contrast, a Chinese [27] study indicated that most perpetrators were the patients themselves. A possible explanation could be that the patients’ relatives misunderstood the triaging system or other conditions encountered when visiting the ED, which highlights an area for further research. Perpetrators, who were believed to be impaired due to intoxication or mental illness, comprised a relatively small proportion in this study, 13% and 15%, respectively, for verbal threats which are low compared to 47% reported in another study [9]. This could be explained by the conservative behavior of the Saudi society and the illegality of alcohol and other substances causing intoxication in Saudi Arabia.

The reactions of the participants who encountered any type of violence in the ED were variable. The majority of violated healthcare providers requested assistance from the police or security (31%); the finding is supported by Bayram study [28] which reports that 54.1% of the participants implemented Code White, the Ministry of Health’s official emergency code for WPV against healthcare providers in Turkey. Similarly, Esmaeilpour et al. study [25] indicated that in 50% of the physical violence incidents, a report was handed to the police. Fear of being a victim of violence has been closely related to EDs as reported in this study by 46% of the participants who “occasionally” felt that they could be a victim of WPV. This was consistent with another local study [29] in Al-Hassa reporting 38% for the same context. Abou-ElWafa et al. [23] compared the difference of being worried between emergency nurses and nonemergency nurses, and 54.7% of the emergency nurses expressed being worried about violence compared with only 6.8% of nonemergency nurses.

Regardless of the high prevalence of WPV incidents and the harmful effects on the healthcare providers in our society, only 1% sought psychological counseling. The finding is noteworthy as Qunhong Wu et al. [27] who highlighted that 13% of WPV victims suffered from posttraumatic stress disorder symptoms.

Several studies evaluated the characteristics and predictors of WPV against ED physicians. Regarding gender, this study revealed no difference in overall violence against ED staff of both the genders, which is consistent with a prospective cross-sectional survey reporting a similar prevalence of violence against female and male participants (79% vs. 75%) [8]. In contrast, Algwaiz et al. [21], investigating violence against healthcare providers in Saudi Arabia, reported that the male gender was found to be a risk factor for WPV in the health sector (73.7% vs. 63.2) [21]. Stalking was the only violence subtype that was more likely to be experienced by females. This finding was not observed in other studies. The abovementioned study also investigated the age as a risk factor for violence, revealing that an age younger than 35 years was a risk factor for violence [21]. This is not consistent with this study, which found that age was not associated with an increased risk of violence against the ED healthcare provider.

The language used by ED staff was a predictor for WPV in this study, reporting that non Arabic speakers were more likely to experience WPV. No other studies in the literature considered fluency in the native language of the patient population as a predictor for WPV in EDs. The finding could be related to cultural behavior in Arab countries. If the patient speaks loudly and in a high-pitched voice when talking to the staff, it may be interpreted as verbal violence because they do not understand the patient’s language. It could be also related to miscommunication between non Arabic staff and the patient due to the language.

Some studies associated a higher level of physician and longer experience in the ED with a lower prevalence of WPV [9,30]. In this study, the level of the physician and the years of practice were not identified as risk factors for WPV. In addition, hospital location, Emergency Medicine Board Certification, and presence of an emergency medicine residency program were not predictors of WPV, supporting the findings of a Michigan State study [9]. Community hospitals (i.e., Saudi Ministry of Health hospitals) were risk factors of confrontations outside the time of patient care and stalking, which can be attributed to lower levels of security services and more overcrowding with limited resources.

This study was conducted in three provinces in 37 EDs in Saudi Arabia. The questionnaire was distributed to participants by research team members, and they were asked to complete the questionnaire anonymously, increasing the chance of honest responses. However, the results of this study should be interpreted taking into consideration some limitations. A response rate of 60% is relatively low which may have affected the statistical analysis. However, contacting ED staff was not easy due to the overcrowding in the departments. In addition, asking the participants to report experiencing violence over 12 months is susceptible to recall bias. Self-reported answers may be affected by the sensitivity of the questions. Physicians and nurses may choose not to disclose some information due to a fear of stigmatization.


Conclusion

Managing the consequences of violence occurring external to the ED has always been a major part of the ED staff workload. However, violence is also committed in the cubicles and hallways of the ED presenting a risk to ED staff and their well-being. This study highlighted that there is a high prevalence of WPV against physicians and nurses working in EDs in three provinces in Saudi Arabia. Being a female, non Arabic speaker, who working in a Saudi Ministry of Health hospital, or who working in a hospital that does not have an Emergency Medicine Residency Program are associated with an increased risk of WPV. Therefore, developing prevention policies and measures and improving the reporting system should be prioritized to improve the working environment, the safety of healthcare providers, and the quality of practice in EDs.


List of Abbreviations

ED Emergency Department
US United States
WPV Workplace violence

Conflict of interest

The authors declared that they have no conflict of interest.


Funding

None.


Consent for publication

Written consent was obtained from all the participants.


Ethical approval

Ethical approval was granted by the Institutional Review Board of King Abdullah International Medical Research Center, National Guard Health Affairs, Riyadh, Saudi Arabia (Study number RC17/156/R).


Author details

Faisal Alhusain1,2, Maryam Aloqalaa1,2, Danah Alrusayyis3, Khalid Alshehri4, Sadaqah Wazzan5, Nouf Alwelyee2,6, Aljerian Nawfal7

  1. Department of Emergency Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia
  2. King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
  3. College of Medicine, Imam Abdulrahman bin Faisal University, Dammam, Saudi Arabia
  4. Department of Neurology, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
  5. Department of Emergency Medicine, Alnoor Specialist Hospital, Makkah, Saudi Arabia
  6. College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
  7. Medical referrals Center, Ministry of Health, Riyadh, Saudi Arabia

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