Biomedical Research

Abstract

Background: To analyse the risk factors for severity of physical violence inflicted upon the medical staff in China.

Methods: Keywords related to physical violence against medical staff from January 2000 to December 2015 were extracted through on-line news, and risk factors for severity of physical violence against the medical staff in China were analysed.

Results: In location type, the risk for severity of physical violence was the highest in the places outside the hospital, followed by the office area, outpatient area and inpatient area. When there was a medical behavior between medical staff and attacker, the risk for severity of physical violence was higher. The ICU, emergency and outpatient clinics, other departments, internal medicine and surgery departments were the departments where the risk for severity of physical violence increased successively. Medical staff-, patient-, and illness-related factors increasingly contributed to severity of physical violence successively.

Conclusions: Risk factors for the severity of physical violence against medical staff were location where physical violence occurs, department where medical staff work, and causes underlying physical violence incidents. The study suggests that physical violence is serious in Chinese healthcare settings. Effective measures should be taken to prevent and reduce injuries of physical violence against medical staff.

Keywords

Physical violence, Severity, Risk factors, Medical staff

List of Abbreviations

NIOSH: National Institute for Occupational Safety and Health; WHO: World Health Organization; ICU: Intensive Care Unit; OR: Odds Ratio

Introduction

Workplace violence, a dangerous and complex occupational hazard in the modern health care work environment, presents challenges for nurses, other health care employees, management, labor unions, and regulators [1]. The National Institute for Occupational Safety and Health (NIOSH) defines workplace violence as “violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty [2].” According to data from the Bureau of Labor Statistics, over 23,000 significant injuries in 2013 due to assaults in the workplace, of which more than 70% were in healthcare and social service industry. In case of violence, healthcare and social service employees are almost 4 times as likely to be hurt as the average private sector employees [3]. According to the World Health Organization (WHO) report, Attacks on Health Care: Prevent, Protect, and Provide, over the 2-year period from January 2014 to December 2015, there were 594 reported attacks on healthcare workers that resulted in 959 deaths and 1561 injuries in 19 countries [4]. Suffering workplace violence can lead to many adverse outcomes, including personal safety concerns, job insecurity, fear, lower job performance, job satisfaction, reduced affective commitment, intent to turnover, psychological distress, emotional exhaustion, depression, interpersonal deviance, and organizational deviance [5].

Workplace violence is even more serious in China. The earliest written record of assaults against physicians in Chinese history dates back to History of the Three Kingdoms: Biography of Hua Tuo. Caocao, an ancient emperor in the Three Kingdom Period, killed Hua Tuo, a reputed physician. In modern society, serious assaults against medical staff in China have attracted nationwide attention. The past few years have seen frequent occurrences of hospital violence, especially pernicious incidents. According to research data for 2014 published by the Chinese Medical Doctor Association, 59.97% of medical staff has encountered verbal violence and 13.07% have suffered from physical injuries. Only 27.14% of medical staff has never experienced violence [6]. On 7 May 2016 at 12:39 pm, Chen Zhongwei, a retired doctor in the stomatology department of Guangdong General Hospital died after an emergency rescue (he was stabbed in a knife attack by a former patient (25 y earlier) in the afternoon on 5 May). This event aroused the attention of Chinese society to the critical issue of hospital violence [7].

Over the past decades, several studies have been carried out on work place violence, and much attention has been focus on causes and preventive measures [8,9]. Many countries have adopted occupational and safety legislation to prevent workplace violence [10]. However, many of the existing studies on physical violence against medical staff have focused on the causes of physical violence and the influence of gender of the attackers [11]. The factors which influence the severity of physical violence in the Chinese healthcare setting still await comprehensive analysis. The purpose of this study was to better understand the factors which affect the severity of physical assaults on medical staff in China in an effort to prevent physical violence and decrease the deleterious effects.

Methods

According to previous studies, the prevalence of non-physical or psychological aggression is higher than that for physical violence [5,12,13] and many hospital violence incidents is under-reported [1,14-16]. However the media is more concerned about the incidents of workplace violence causing severe physical injury. It is therefore likely that the assessments of severity and descriptions of physical injuries outlined in these reports are reasonably accurate [13]. So, we search for relevant media reports of physical violence against medical staff and analyse the risk factors for severity of physical violence in Chinese healthcare settings.

Study design

The study was conducted by extracting the keywords related to physical violence against Chinese medical staff from January 2000 to December 2015 through on-line news and analyse the risk factors of influence in severity of physical violence injuries.

The researchers collected online news reports about workplace violence by searching Chinese keywords, such as “violence against doctors,” “hospital violence,” and “assaults against doctors” on Baidu (www.baidu.com) and reviewing recorded workplace violence cases on www.dxy.cn, www. medlive.cn and other well-known medical websites. Cases involved in this research occurred in China between January 2000 and December 2015. Hospital violence referred to in the current study was 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” [17]. A total of 320 cases of physical violence incidents were included.

Chinese keyword extraction and value assignment

The severity of physical violence against Chinese medical staff was classified according to the Investigation on hospital violence during 2003 to 2012 in China [18] and the standards used in previous studies [16,19]. For each reported incident, the information extracted was as follows: severity of physical violence inflicted upon the medical staff; city level; time of occurrence; level of hospital; department of occurrence; location where physical violence occur; causes of physical violence; whether or not there was a medical behavior between medical staff and attacker; professional title of the medical staff being attacked; response to physical violence; age of patient involved in the incident; treatment outcome of the patient; gender of the attacker; age of the attacker; relationship between the attacker and patient; occupation of the attacker; risk factors of the attacker himself; whether or not medical disputes occurred; and whether or not professional hospital violators were involved. Firstly, two researchers manually performed keyword extraction from the 320 reported cases. Then, the extracted information was classified and the value was assigned (Table 1). Finally, based on Python language, a logic check was carried out from two aspects, number and value of variables, concerning the manually extracted keywords.

Table 1. Classification and value assignment of extracted information.

Conversion of extracted information to values assigned

Value conversion: After value assignment for extracted information of each reported case, then conduct numeric conversion and input into Excel software, re-checked.

Statistical analysis

SPSS Windows (version 20.0) was used for data statistical analysis, α 0.05 significance level was used. Severity of physical violence was classified into 5 levels, with level 1 indicating the lowest severity and level 5 the highest severity (i.e., no injury, mild injury, moderate injury, severe injury, and death). The frequencies were counted, then the Kruskal-Wallis rank-sum test was used to compare statistical difference of different risk factors to the severity of physical violence. The ordinal logistic regression model was fitted according to univariate analysis. Risk factors to the severity of physical violence were selected with the forward procedure.

Results

Keyword frequencies and constituent ratios are shown in Table 2.

Table 2. Keyword frequencies and constituent ratios.

Risk factors for severity of physical violence

Deleting some of the missing independent variables: As shown in Exhibit 2, a large proportion of data regarding professional titles of the medical staff being attacked, patient age, attacker age, attacker occupation, and the attacker-related factors were not available. Therefore, these five variables were excluded in the fellow-up study.

Univariate analysis of the risk factors for severity of physical violence

The Kruskal-Wallis rank-sum test was used to evaluate the differences among the groups of the risk factors for severity of physical violence. There were statistical significant differences in the following factors: time of the occurrence; department where the medical staff work; location where physical violence occur; causes of physical violence; whether or not a medical behavior between medical staff and attacker; treatment outcome of the patient; relationship between attacker and patient; and whether or not a medical dispute occurred. Other variables, such as city level, level of hospital, response to physical violence, gender of the attacker, and whether or not professional Hospital Violators were involved , have no significant difference for the severity of physical violence (Table 3).

Table 3. Univariate analysis of risk factors impact on the severity of physical violence.

Multi-collinearity analysis

Spearman’s correlation analysis was used to test the level of correlation between the independent variables. As r>0.3 was considered to be collinear. The r values of some independent variables in Spearman’s correlation test are shown in Table 4 (r>0.3).

Table 4. Variables with r>0.3 in Spearman’s correlation test.

Ordinal logistic regression analysis of risk factors for severity of physical violence

Proportional odds assumption was adopted and held true (χ²=28.271, P=0.249), thus ordinal logistic regression analysis was used. Variables with a P<0.1 in the univariate analysis were included in the ordinal logistic regression model. Variables were selected using forward method. Considering the multiple collinearity effect, variables with strong correlation were selected sequentially with adjustification. Variables selected are shown in Table 5.

Table 5. Ordinal logistic regression of risk factors for severity of physical violence.

Discussion

Unlike previous studies, we focused on the risk factors for the severity of physical violence inflicted upon Chinese medical staff by examining 320 physical violence cases reported in online news from 2000-2015. The results showed as the following: 52.5% of the medical staff have had moderate injuries; 44.4% of the physical assaults occurred in first-tier cities; 47.2% of the assaults occurred during day shifts; 54.7% of the assaults occurred in tertiary hospitals; 38.4% of the assaults occurred in the outpatient clinic, emergency department, and Intensive Care Unit (ICU); 52.8% of the violence incidents occurred in the outpatient area; 38.8% of the incidents were caused by illness-related factors; 35.6% of the medical staff been assaulted have a medical behavior with attacker; 53.8% of the medical staff being attacked coped with assault were called the police or securities; 58.8% of the patients involved in the physical violence with the treatment outcome is cured or improved; 89.1% of the attackers were males; 55.6% of the attackers were patients’ relatives; 79.4% of the incidents were not combined with medical disputes or complaints; and 85.9% of the incidents did not with professional hospital violators.

At this time, very few guidelines for preventing physical violence in hospitals are available, especially those for coping with unexpected physical assaults against doctors. To our knowledge, this is the first study on the risk factors for severity of physical violence against the medical staff in China. According to previous studies, the most common locations where hospital violence happen are emergency rooms and psychiatric departments [20,21]. Physical assaults occur more frequently in psychiatric and geriatric departments, and ICUs [22,23]. In our study, however, the risk factors for severity of physical violence against Chinese medical staff included location where physical violence occur, whether or not there was a medical behavior between medical staff and attacker, the department where the violence occurred, and causes of physical violence. As to the type of location, the risk for severity of physical violence increased successively for the medical staff in the inpatient area, outpatient area, office area, and places outside the hospital. When the medical staff had been assaulted have a medical behavior with attacker, the risk for severity of physical violence was higher. As to the type of department, the ICU, emergency and outpatient clinics, other departments, internal medicine and surgery departments were the departments where the risk of physical violence increased successively. As to the type of causes of physical violence, medical staff-, patient-, and illness-related factors were the causes contributing to severity of physical violence with an increasing significance.

Location is an independent risk factor. Compared with the risk for physical violence outside the hospital, the severity of physical violence increased successively in the inpatient, outpatient, and office areas (Odds Ratio (OR)=0.38, 0.41, 0.64; OR=1 for outside the hospital). Thus, the risk for severity of physical violence outside the hospital was the highest. Outside the hospital area including patient’s home or on the way to emergency aid which the environment is comparatively uncontrolled [23,24]. The reasons for high risk of physical violence in the office area were as follows: the office area is where the physician-patient communication takes place and where the physicians are closest to the patients or relatives who may undergo significant mood swings [25]; and medical staff are busy with work and less ready to cope with sudden violence. In the outpatient area, such as the consulting rooms, the medical staff spends longer time with the patients alone, which increases the risk for physical violence [3]. Compared with the outpatient area, the inpatient area, such as the ward, implements stricter regulations that specific the time of visit and the number of visitors permitted and this effectively reduces the risk of physical violence.

Whether or not there was a medical behavior between medical staff and attacker is another independent risk factor. The risk for severe injury when medical staff being attacked is directly involved in the treatment of patient is 1.9 times higher than medical staff being attacked is not directly involved in the treatment of the patient (OR=1.90, 1). This is especially true the doctor or nurse in charge is taking care of the patients for prolonged periods. Therefore they are more exposed to the negative physical and psychological impact of illness and treatment that affect the patients [26]. If the treatment outcome falls short of the patients’ expectation, physical violence is even more likely to occur.

Previous studies on hospital violence indicate that physical violence is most likely to occur in psychiatry [27] and emergency departments [28] and the ICU [23]. Similarly, we found that department is one independent risk factor for severity of physical violence. Internal medicine and surgery departments have the highest risk of physical violence, followed by other departments. The outpatient clinic, emergency department, and the ICU have the lowest risk of physical violence (OR=0.65 for the outpatient clinic, emergency department, and ICU; OR=1.10 for internal medicine and surgery departments; OR=1 for other departments). Compared with other departments, internal medicine department receives patients with chronic, critical, and refractory diseases who require treatment or nursing care for longer periods of time. Therefore, the risk for severity of physical violence is higher in the internal medicine department [29,30]. The surgery department also has a higher risk for physical violence due to the fact that the effect of surgical treatment is more intuitive, it is easier to detect negative consequences [31]. Other departments as gynecology and obstetrics department, pediatrics department are at low risk for severity of physical violence because there are fewer male adults in these areas [23]. The ICU is unattended severe ward, thus reducing the risk and severity of physical violence. According to existing studies, a crowded environment and inadequate medical staff in the emergency department and outpatient clinic are major reasons for physical violence in these areas [28]. To solve the above problems, a reasonable allocation of medical resources is very important.

The cause of physical violence is also an independent risk factor for severity of physical violence. Studies have shown that main causes of hospital violence include the following: treatment outcome falling short of patients’ expectation; overcrowded environment; inadequate medical resources; and intentional violence and aggressive behaviors without perpetrators being under influence of disease or substances [12]. In this study, illness-, medical staff-, and patient-related factors were associated with an increasing risk for severity of physical violence (OR=1.55, 0.90, and 1, respectively). In china, distrust between physicians and patients, many patients go to the hospital with unrealistic expectations [32], high medical expenses, and poor doctor-patient communication [15] all lead to hospital violence. In previous surveys, low educational level and poverty are the most common features shared by attackers. Approximately 40% of attackers are introverts and have eccentric and bigoted disposition and 30% of the attackers have histories of mental diseases. Many of the attackers are faced with the dilemma of an inability to pay medical expenses or an incurable disease [18]. As compared with medical staff-related factors which are easier to improve, patient-related factors, if not properly controlled, can lead to a higher risk for severity of physical violence.

Limitations

We research only focused on the hospital violence incidents in China between 2000 and 2015 and the data collected are limited. Some physical assaults occurring in the hospital might be missing from this study. Cases recorded and analysed in this research may not covered all those recorded by the government. Moreover, due to a lack of standards for news reports covering hospital violence, some important information or details may be missing.

Conclusions

Chinese medical staff are now facing the danger of physical violence, the severity of which is affected by location, whether or not there was a medical behavior between medical staff and attacker, department, and causes of physical violence.

According to the law published in 2015, Professional Hospital Violators are now considered illegal in China [33], however our study suggested that physical violence is still serious in Chinese healthcare settings. Many countries have issued guidelines for preventing workplace violence [34], however general prevention strategies for preventing physical violence are not enough. Along with the understanding of the risk factors for severity of physical violence in Chinese healthcare settings, more effective countermeasures will be released to protect the medical staff.

Acknowledgments

The paper is sponsored by a research fund of NSSFC. We highly appreciated Prof. Juan Wang and Prof. Hengying Fang for their invaluable comments on the framework and the draft paper.

Funding

A project supported by The National Social Science Fund of China (NSSFC, 13BGL143).

References

1. Mcphaul KM, London M, Lipscomb JA. A framework for translating workplace violence intervention research into evidence-based programs. Online J Issues Nursing 2013; 31; 4.
2. Healthcare facilities, healthcare personnel, violence prevention, risk factors, work practices, injury prevention. Violence: occupational hazards in hospitals. National Institute for Occupational Safety and Health 2002.
3. Labor D. OSHA updates guidance for protecting healthcare and social service workers from workplace violence 2015.
4. Organization WH. Attacks on Health Care: Prevent-Protect-Provide 2016.
5. Piquero NL,Piquero AR,Craig JM, Clipper SJ. Assessing research on workplace violence, 2000-2012. Aggress Viol Behav 2013; 18: 383-394.
6. Lado CMDA. Full text of white paper of chinese doctors practice situation 2015.
7. South China Doctor Killed by Former Patient [http://english.cri.cn/12394/2016/05/07/3521s926839.htm]
8. Gillespie GL, Gates DM, Mille M, Howard PK. Workplace violence in healthcare settings: risk factors and protective strategies. Rehab Nurs 2010; 35: 177-184.
9. Nowrouzi B, Huynh V. Citation analysis of workplace violence: A review of the top 50 annual and lifetime cited articles. Aggress Viol Behav 2016; 28: 21-28.
10. Pich J, Hazelton M, Sundin D, Kable A. Patient-related violence against emergency department nurses. Nurs Health Sci 2010; 12: 268-274.
11. Guay S, Goncalves J, Jarvis J. A systematic review of exposure to physical violence across occupational domains according to victims sex. Aggress Viol Behav 2015; 25: 133-141.
12. Kitaneh M, Hamdan M. Workplace violence against physicians and nurses in Palestinian public hospitals: a cross-sectional study. BMC Health Serv Res 2012;12: 469.
13. Cashmore AW, Indig D, Hampton SE, Hegney DG, Jalaludin BB. Workplace violence in a large correctional health service in New South Wales, Australia: a retrospective review of incident management records. BMC Health Serv Res 2012; 12: 245.
14. Speroni KG, Fitch T, Dawson E, Dugan L, Atherton M. Incidence and cost of nurse workplace violence perpetrated by hospital patients or patient visitors. J Emerg Nurs 2014; 40: 218-228.
15. Hogarth KM, Beattie J, Morphet J. Nurses attitudes towards the reporting of violence in the emergency department. Australasian Emerg Nurs J 2015; 19: 75-81.
16. Sato K, Wakabayashi T, Kiyoshi-Teo H, Fukahori H. Factors associated with nurses reporting of patients aggressive behavior: A cross-sectional survey. Int J Nurs Studies 2013; 50: 1368-1376.
17. Workplace violence in the health sector (http: //www.who.int/violence_injury_prevention/injury/en/WVsynthesisreport.pdf)
18. Jia X, Zhou H, Zhao Y, Zheng L, Wei Q, Zheng X, Association CH.Investigation on hospital violence during 2003 to 2012 in China. Chinese Hosp 2014; 18: 1-3.
19. Chen ZH, Wang SY. Prevalence of workplace violence in staff of two hospitals in Guangzhou. Chinese J Prev Med 2003; 37: 358-360.
20. Gackismith J, Juarez AM, Boyett L, Homeyer C, Robinson L, Maclean SL. Violence against nurses working in US emergency departments. J Healthcare Protect Manag Publ Int Assoc Hosp Secur 2010; 26: 81-99.
21. 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: 127-139.
22. Donatella C, Madeleine EB, Paul Maurice C, Hans-Martin H. Work-related factors and violence among nursing staff in the European NEXT study: a longitudinal cohort study. Int J Nurs Studies 2008; 45: 35-50.
23. Fujita S, Ito S, Seto K, Kitazawa T, Matsumoto K, Hasegawa T. Risk factors of workplace violence at hospitals in Japan. J Hosp Med 2012; 7: 79-84.
24. Phillips JP. Workplace violence against health care workers in the United States. N Engl J Med 2016; 374: 1661-1669.
25. Sun T, Wang S, Wang N, Wang F, Fan LH, Cao DP. Epidemiological characteristics and variance analysis of workplace violence in public hospitals. Pract Prev Med 2014; 21: 478-480.
26. Hahn S, Muller M, Hantikainen V, Kok G, Dassen T, Halfens RJG. Risk factors associated with patient and visitor violence in general hospitals: Results of a multiple regression analysis. Int J Nurs Studies 2013; 50: 374-385.
27. Zeng JY, An FR, Xiang YT, Qi YK, Ungvari GS, Newhouse R, Yu DSF, Lai KYC, Yu LY, Ding YM. Frequency and risk factors of workplace violence on psychiatric nurses and its impact on their quality of life in China. Psych Res 2013; 210: 510-514.
28. Touzet S, Cornut PL, Fassier JB, Pogam MAL, Burillon C, Duclos A. Impact of a program to prevent incivility towards and assault of healthcare staff in an ophtalmological emergency unit: study protocol for the PREVURGO On/Off trial. BMC Health Serv Res 2014; 14: 643-646.
29. Sabine H, Marianne M, Ian N, Theo D, Gerjo K, Halfens Ruud JG. Factors associated with patient and visitor violence experienced by nurses in general hospitals in Switzerland: a cross‐sectional survey. J Clin Nurs 2010; 19: 3535-3546.
30. Findorff MJ, Mcgovern PM, Wall M, Gerberich SG, Alexander B. Risk factors for work related violence in a health care organization. Inj Prev 2004; 10: 296-302.
31. Cui X, Liu Y, Cheng YM, Yue DL, Lin J. Data analysis on 962 reported cases of Major medical negligence incident and malpractice. Soft Sci Health 2009; 12: 673-676.
32. Pan Y, Yang XH, He JP, Gu YH, Zhan XL, Gu HF, Qiao QY, Zhou DC, Jin HM. To be or not to be a doctor, that is the question: a review of serious incidents of violence against doctors in China from 2003-2013. J Publ Health 2015; 23: 111-116.
33. YINAO and creating scandal on the Internet are now behaviors that will be penalized according to law. (http: //news.163.com/15/1101/02/B7A643UU00014Q4P.html)
34. Wiskow C. Guidelines on workplace violence in the health sector 2003.