Archive \ Volume.12 2021 Issue 1

Violence against Health Care Workers of Pediatric Departments in Saudi Arabia: Systematic Review

 

Hamed Salem S Albalwei1*, Nazim Faisal Hamed Ahmed2, Nasser Mufleh Saleh Albalawi3, Suad Salem Awad Albalawi4, Nujood Hamad Kashan Al-enazi4

 

1Director of the Maternal and child health center, Tabuk, Saudi Arabia. 2Consultant and head of the Department of Pediatrics, Maternal and child health center, Tabuk, Saudi Arabia. 3Pharmacist, Maternal and child health center, Tabuk, Saudi Arabia. 4Nurse, Nursing department, Maternal and child health center, Tabuk, Saudi Arabia.


Abstract

Background: Work Place Violence WPV is defined as the intentional use of physical or psychological force to injure, intimidate, or attack an individual in a work atmosphere. It is often known as any threat or physical abuse, assault, bullying, or other intimidating disrupting behavior that happens at the workplace. Method: This is a systematic review was carried out, including PubMed, Google Scholar, and EBSCO that examining randomized controlled trials, observational, and experimental studies that study violence against healthcare practitioners in pediatric departments. Results and Conclusion: The review included 6 randomized studies concerned about workplace violence against pediatric staff. Pediatric physicians and nurses are exposed to different types of violence from parents or caregivers of the attending children in their departments due to the psychological stress caused by the condition of their child. Recommendations to teach pediatric staff how to deal with violent events and how to report them must be instructed clearly.

Keywords: violence, healthcare workers, workplace violence, pediatrics departments, pediatric staff, WPV, Saudi Arabia


INTRODUCTION

Work Place Violence WPV is defined as the intentional use of physical or psychological force to injure, intimidate, or attack an individual in a work atmosphere. It is often known as any threat or physical abuse, assault, bullying, or other intimidating disrupting behavior that happens at the workplace [1]. It has been reported that 4.9–65% of health care professionals have been exposed to physical injury in their workplace and 1.2% of workplace homicide victims in the USA. Other studies reported a higher incidence of WPV [2].

HCWs are mostly vulnerable to reactive violence on the part of patients and their companions, affecting their physical and mental well-being, as patients and their families who are subject to mental stress due to hospitalization or disease may use violence against healthcare workers [3-6]. Job fatigue, customer demands, and declining patient-staff relationships have been linked with physical abuse against health care workers in the workplace [7].

 

It is categorized as physical and psychological violence. Physical abuse requires the use of physical force against someone or the use of objects to strike someone. It involves hitting, kicking, slapping, pulling, biting, pinching, wounding with sharp sticks, and sexual assault [8]. It may result in severe injury, dysfunction, permanent disability, or no harm at all. Non-physical aggression may involve bullying, slurs, threats, or sexual harassment; it does not cause physical injuries but may cause psychological damage, such as stress, anxiety, low job satisfaction, and low work performance [9].

Also, WPV has many negative effects, resulting not only in physical consequences but also in relational consequences for healthcare workers at work, correlated with the decision to leave, stress out, and minimize career success for medical practitioners [10]. These effects of aggression in the workplace can lead to a loss in efficiency and also affect the quality of treatment. Additionally, the shortage of workers and the investment of defensive tactics induced by abuse in the workplace will practically raise health costs [11].

 

In outpatient clinics, pediatrics care services are now diminishing and pediatrics outpatient clinics were even discontinued, resulting in a drastic rise in the number of outpatient clinics in children's hospitals, overworked medical personnel, inadequate quality behaviors, crowded conditions, and extended waiting times; these factors contribute to frustration and dissatisfaction among pediatrics patients' families which may lead to increased risk of violence [12].

Surveys were undertaken to examine the occurrence and intensity of physical violence toward health care workers committed by patients and tourists at the workplace. It is becoming an important research topic in Saudi Arabia, where cultural and ethical standards may vary dramatically from other locations Occupational abuse (WPV) committed by patients and tourists against nurses and doctors is a concern in adult emergency rooms (EDs), but largely unrecognized and unreported in pediatric EDs [13, 14].

 

Pediatric nurses working in hospital inpatient units have been under-studied in respect to their understanding of abuse in the workplace. Few studies were found in the pieces of literature that concentrate on occupational abuse against pediatrics nurses by patients and tourists [15].

 

Aim of the Study

Up to our knowledge; there's a lack of studies reporting violence against pediatric staff in Saudi hospitals, so the main objective of the study is to study the updates on violence against pediatric physicians and nurses.

 

METHODOLOGY

A systematic review was carried out, including PubMed, Google Scholar, and EBSCO using the following terms in different combinations: violence against healthcare workers, workplace violence in pediatric departments, pediatric staff and workplace violence, WPV in Saudi Arabia. Figure (1) is a flow chart that illustrates the data extraction process of the study. We included all full texts [randomized controlled trials, observational, and experimental studies which study violence against healthcare practitioners in pediatric departments. The authors extracted the data, and then the author's names, year, and region of publication, the study type, period of study, and the result were reported (Table 1).

 

Statistical Analysis

No software has been utilized to analyze the data. The data was extracted based on a specific form that contains (Author’s name, publication year, country, methodology, and results). These data were reviewed by the group members to determine the initial findings and the modalities of performing the surgical procedure.  Double revision of each member’s outcomes was applied to ensure the validity and minimize the mistakes.

 

RESULTS

The search of the mentioned databases returned a total of 66 studies that were included for title screening. 49 of them were included for abstract screening, which leads to the exclusion of 24 articles. The remaining 25 publications full-texts were reviewed. The full-text revision leads to the exclusion of 19 studies, and 6 were enrolled for final data extraction (Table 1). The included studies had different study designs.

 

Figure 1: Flow chart of the data extraction process of the study.

 

Gillespie, G. (2010) found that; both genders and all professional categories were at risk of witnessing verbal and physical WPV. Popular features of the suspects included patients undergoing a psychological examination and visitors suffering acute anxiety. Effects have been witnessed by staff, offenders, patients, and health employers [16].

Li, Zhe et al. (2017) found that; 68.6% of respondents experienced at least one WPV event in the past year. (94.9%) of offenders were family members of patients. Most of the WPV happened during the day shift (70.7%). Males were almost twice as females at risk to experience violence. As a consequence of WPV, aggression, anger, the decline in work, and work efficiency was reduced [17].

Shaw J. (2015) reported that; At least 26% of the workers shared worry about protection every week. Twenty-seven percent witnessed fear-causing conditions at least weekly. The primary causes of fear were patient or guest frustration (with the possibility of violence) and ED weapons. Respondents would be safer" with increased involvement of hospital security personnel (55%) and local police officers (71%) [18].

 Strollo, Bonnie A., et al. (2011) in New York suggested that there is violence in the workplace and a great deal needs to be done to deter and control violence in the workplace toward nurses who serve in inpatient pediatrics hospital units [19].

Hein PT, et al. (2019) reported that; the rate of occupational violence among nurses was 72.7%. More than 75% of nurses witnessed violence, and the verbal assault was the most frequent. Around 25% of participants were victims of sexual assault. The regression study found that nurses working in the emergency room and outpatient clinic were 1.92 times more likely to have verbal harassment than people working in other units. They were also 3.02 times statistically more likely to have physical abuse [20].

Alkorashy, H. et al.  (2016) reported that; about 50 % of participants had witnessed violence in the workplace during the 12 months before the study. Much of the respondents interpreted brutality in the workplace as physical harassment. Almost all nursing practitioners described patients as the leading cause. Slightly more than half of the understaffing, disagreements, long delays for service, and lack of staff preparation and crisis prevention policies have been listed as contributing factors [21].

 

Table 1: Author, country, year of publication, methodology, and results

Author, years, country

Methods and Objective

Outcomes

Gillespie, G.

(2010) [16]

 

A qualitative study included 31 pediatric ED workers to describe the WPV that occurred in a pediatric ED and the negative effects on the workers.

 

WPV is an issue in pediatric ED and strategies are required to facilitate the wellbeing of staff and patients.

Li, Zhe, et al.

(2017)

China [17]

 

A retrospective cross-sectional study included 1,932 healthcare providers to evaluate the incidence, magnitude, consequences, and potential risk factors of workplace violence against the medical staff of children’s hospitals.

 

Pediatric staff is at high risk of violence. Hospital supervisors should pay attention to the consequences of WPV. There is a necessity for defensive measures to look after medical staff and provide a safer workplace environment.

Shaw J.

(2015) [18]

 

A cross-sectional study involved 234 health care professionals explaining the ED staff's perspectives on the possibility of occupational violence to direct changes and resolve employee complaints.

 

Workplace violence is growing in pediatric hospital emergency rooms. True and potential risks to the well-being of workers must be handled. The use of workers' expectations of risk and suggestions for change is a powerful method to direct the elimination of violence at work.

Strollo, Bonnie A.,

(2011)

New York [19]

 

Qualitative research was used to describe nurses’ experience with workplace violence by directly examining their perceptions of the problem.

The findings of this research suggest that there is violence in the workplace and a great deal needs to be done to deter and control violence in the workplace toward nurses who serve in inpatient pediatrics hospital units.

Hein PT, et al.

(2019)

China [20]

 

The cross-section analysis involved 317 nurses in the period from January to December 2017 to measure the incidence of violence against nurses in the pediatric department and related factors.

The violence happened mainly in the emergency department and outpatient facilities. Verbal violations have been the most prominent.

Alkorashy, H. et al.

(2016)

Saudi Arabia [21]

A quantitative cross-sectional study on a sample of 370 nursing personnel to determine the prevalence rate of workplace violence against nursing professionals

The prevalence rate of WPV against nurses is extremely high among nurses in the studied sample

 

DISCUSSION

Violence against health care providers has been increasing in many countries. Exposure of pediatric staff to violence while carrying out their duties negatively affect nurses and physicians which may lead to loss of concentration while performing their duties and other negative consequences.  Physicians are also a victim of occupational violence. Around a fifth of the emergency room physicians announced that they were victims of physical violence in the last year [22, 23]. Understanding the association between WPV and its effect on patient care is relevant because the results of the study could inspire hospital management to implement violence reduction initiatives. Gillespie's study findings indicate that all patients and visitors should be treated as though they have the potential to be violent. Employers must make sure the influence that violence has on employees' abilities to deliver patient care and debriefing and to learn how violence impacts patient care, how necessary it is to call for assistance when violence happens, and measures to avoid violence [16].

Several studies have reported high levels of WPV among health workers [24-29]. In a 2009 survey in Germany, 70.7 percent of healthcare professionals reported exposure to physical abuse, while 89.4% reported verbal violence, the repeated incidence of accidents and inadequate social assistance raised tension [30]. In Egypt, in the Ismailia Governorate report, the incidence of physical or verbal violence in nurses was 69.5% and 9.3% respectively [31]. The majority of the current study in China reports on tertiary and county-level hospitals emergency departments in general hospitals; research indicates that emergency departments have a high rate of WPV [32-35]. Several significant reports have suggested that nurses are at high risk of having WPV. The incidence rate of physical violence for nurses during the past 12 months,  in Ethiopia, South Korea, Jordan, Germany ranged from 18.22 percent to 56.0 percent, the verbal abuse rate being from 63.8 percent to 89.58 percent, and the sexual harassment rate from 4.7 percent to 19.7 percent [36-41]. In a US report, approximately 25% of nurses serving in emergency departments were confronted with more than 20 physical violence incidents and 20% were confronted with more than 200 verbal violence incidents between 2006 and 2009. Many that were met with physical and/or verbal abuse also pointed to their fear of counterattack and lack of support for hospital management and ED management barriers to disclosing violence [42]. 88.1% of nurses reported verbal abuse from patients in a major mental health facility in Israel and 58.4% reported physical violence in the last year [43].

Research at Mansoura University Emergency Hospital has shown that only 7.4% of doctors did not experience abuse. Physical abuse was the most common with 76.5 percent followed by physical violence at 60.3 percent and sexual assault at 30.9 percent. Most physical and verbal aggressors are relatives/visitors to the patient. Hospital protection mechanisms are not available and there is no monitoring mechanism or survivor counseling for abuse of any sort [44]. In another survey performed in Ismailia in the emergency room, 59.7% of HCWs reported abuse. The bulk (58.2 percent) of verbal abuse was reported, while 15.7 percent reported physical violence. The investigators also found that inability to satisfy the needs of the patient and his families, and the amount of time they wait, are the key causes of abuse [45].

Study on the experience of nurses in these departments in the USA. Switzerland and Jordan have shown that they experience a greater rate of WPV than nurses in other units [46-48]. In a Palestinian government hospital, 80.4 percent of nurses reported having been subjected to abuse in the previous year; 20.8 percent were violent and 59.6 percent were non-physical [49]. A retrospective analysis in Australia found that verbal harassment (71%) was more common than physical abuse (29 percent) [50]. Research further indicates that 7.8% of nurses reported physically abusive experiences and 71.9% reported non-physically violent events in the previous year (a total of 588 nurses) [51]. Of the few population-based studies undertaken, a study of 1,404 health staff from Community Health Centers in Guangzhou and Shenzhen found that 51.64 percent witnessed WPV [52].

In previous research, 89% of violent cases were patients, 9% were family members, and 2% were patients' relatives [53]. In a nationwide survey conducted in the United States, 78% of emergency room physicians indicated that they had been the victim of occupational abuse in the previous year. Of these, 75 percent were in direct assaults, 21 percent were physical assaults, 5 percent were off-site confrontations, and 2 percent were abuse [54].

CONCLUSION

Pediatric physicians and nurses are exposed to different types of violence from parents or caregivers of the attending children in their departments due to the psychological stress caused by the condition of their child. Recommendations to teach pediatric staff how to deal with violent events and how to report them must be instructed clearly. Holding health education sessions to increase the public knowledge about the important and critical rules of pediatric staff as they deal with that delicate and vulnerable group of patients must be considered. Physicians and nurses also need to be well trained and acknowledged the anxiety and stress of parents about their children and how to break the bad news.