Introduction

Workplace violence (WPV) among healthcare workers is well-recognized as a serious issue worldwide. Nurses, being the largest group of frontline healthcare workers and spending long working hours in hospitals, are particularly at high risk[1]. It has been reported that WPV in medical settings is four times higher than in other private sectors[2]. This occurs because healthcare workers are often tasked with communicating unpleasant news to patients and caregivers, such as deteriorating conditions or death, as well as explaining complex treatments or procedures. Consequently, patients or their relatives may sometimes respond with violence, expressed through verbal, physical, sexual, or psychological assaults against healthcare workers[3].

The prevalence of WPV in both developed and developing countries is alarming. A seven-country case study on WPV in the health sector found that more than 50% of workers experienced at least one incident of either physical or non-physical violence in the preceding year. Reported incidences included 37% in Portugal, 46% in Brazil, 54% in Thailand, 61% in South Africa, 67% in Australia, and 75% in Bulgaria[4].

A recent systematic review documented that 61% of healthcare workers globally experienced some form of WPV in the last year, with 42% encountering non-physical violence, such as verbal abuse (57%), threats (32%), and sexual advances (12%). Meanwhile, 24% reported physical violence. In Asia, 64% of healthcare workers reported WPV, with 45% experiencing non-physical violence and 24% facing physical violence. WPV rates in Asian countries are notably high, with 51% in Pakistan[5], 62% in China[6], and 63% in India[7]. These studies consistently show that nurses are more susceptible to WPV[4,5,8].

Literature puts forth that various factors linked to WPV include personal factors such as occupation, gender, age, and marital status, as well as organizational factors like work schedule, department, and position within the healthcare hierarchy[5,7-11]. In a developing country like India, where the healthcare sector serves a large and diverse population from varied cultural and socio-economic backgrounds, the risk of such incidents increases manifold. Reporting these incidents is crucial in addressing this menace, but fear of victimization often discourages nurses from openly addressing them.

Procedure

The objective of the study was to assess the extent of WPV, identify the common perpetrators, explore mitigation strategies, examine reporting mechanisms, and determine predictors of WPV among nurses employed in hospitals across India. To achieve these objectives, two null hypotheses were tested:

• H01: There are no significant predictors related to WPV among nurses in India.
• H02: There is no significant association between demographic variables (such as age, gender, marital status, years of experience, and department of employment) and the forms of WPV experienced by nurses in India.

Methods

This paper presents findings from a larger research project on WPV among nurses in India. An online cross-sectional survey was conducted among nurses employed in both private and government hospitals across the country. Prior permission was obtained from hospital administrators before sharing the survey link with nursing staff. The survey link was distributed through multiple channels, including hospital administrators, professional WhatsApp groups, hospital groups, informal networks, and referrals by participants who had already completed the survey.

The eligibility criteria required that participants be nurses who had worked for at least six months in their current hospital and voluntarily agreed to participate in the study. Regular follow-up reminders were sent to ensure a sufficient response rate. A standard tool, developed by Kumari and others[12] was employed to gather descriptive data based on the study's objectives. This tool helped in assessing the extent of WPV, identifying common perpetrators, evaluating mitigation strategies, examining reporting mechanisms, and determining potential predictors of WPV among the nurses. The data collection included questions regarding demographic variables such as age, gender, marital status, job type, hospital type (private or government), and work schedule.

Data were analyzed using logistic regression to identify significant predictors of WPV, while Chi-square tests and other statistical methods were used to explore associations between demographic variables and the different forms of violence (physical, verbal, psychological, or sexual). The results provide insights into the factors increasing the risk of WPV among nurses in India and the socio-demographic profiles most vulnerable to such incidents.

Results

Demographic Characteristics of Participants: A total of 511 nurses participated in the survey. The majority of respondents were under 25 years of age (234, 45.8%), with the predominant gender being female (371, 72.6%). In terms of marital status, more than half of the participants were married (267, 52.3%). Employment characteristics revealed that a significant proportion of nurses were employed in private hospitals (425, 83.2%), with 289 (56.6%) of them holding temporary job positions. The work schedule for the majority involved rotational duties (385, 75.3%).

Regarding work settings, most nurses were stationed in general wards (235, 46%), where they likely dealt with a broad spectrum of patients and situations. In terms of hospital infrastructure, 418 (81.8%) reported that their hospitals were equipped with security cameras, and 435 (85.1%) noted the presence of security personnel. However, when asked about the preparedness of security personnel to manage WPV, only 339 (66.3%) of the respondents felt that these security staff were adequately prepared to handle such incidents (Table 1).

Prevalence of Workplace Violence (WPV): Out of the 511 participants, 169 nurses (33.1%) reported having experienced some form of WPV, while the remaining 342 nurses (66.9%) had not encountered such incidents. Among those who experienced WPV, verbal violence was the most prevalent, with 164 nurses (97.5%) reporting it. Physical violence was also notably frequent, affecting 75 participants (44.4%), while 55 nurses (32.5%) reported experiencing sexual violence. These figures underline the high incidence of verbal aggression within healthcare settings, followed by significant levels of physical and sexual violence. The data highlights the multifaceted nature of WPV, with many nurses enduring multiple forms of violence simultaneously, further exacerbating their professional challenges and personal safety concerns.

Forms of Workplace Violence: The participants experienced various forms of verbal, physical, and sexual violence during their professional duties.

• Verbal Violence: The most common forms of verbal violence included exaggerated arguments (61, 39.1%), followed by abuse (47, 30.1%), threats (17, 10.9%), and offensive comments (15, 9.6%). Verbal violence was often the precursor to more severe forms of aggression.
• Physical Violence: Among those subjected to physical violence, the most frequent incidents involved thrashing (23, 30.7%), slapping (19, 25.3%), beating (14, 18.7%), vandalizing (16, 21.3%), and even attacks with weapons (3, 4%).
• Sexual Violence: In terms of sexual violence, participants reported experiencing verbal offensive remarks (28, 50.9%), inappropriate physical behavior (10, 18.2%), misuse of professional authority (3, 5.5%), stalking (7, 12.7%), and rumors about their private lives (7, 12.7%).

These findings reveal the diverse and alarming nature of WPV that nurses encounter, from verbal confrontations to severe physical and sexual aggression, all of which contribute to an unsafe and hostile work environment.

Perpetrators of Workplace Violence among Participants: Majority of WPV incidents were perpetrated by patients' relatives, accounting for 26% of the reported cases. This was followed by coworkers, who were also significant contributors to the violence experienced by the participants. Other notable perpetrators included patients themselves and, in some instances, hospital staff from other departments. These findings highlight the complexity of WPV, where aggression not only comes from external sources (patients and their families) but also from within the healthcare system.

Mitigation Strategies to Control Workplace Violence: The study participants identified several mitigation strategies that were deemed effective in controlling WPV. Key strategies included controlling visits by attendants (143 participants, 84.6%), educating both patients and their attendants (152, 89.9%), and providing regular training for healthcare workers (153, 90.5%). Other significant measures highlighted were self-defence training for staff (129, 76.3%), improving healthcare infrastructure, such as increasing the doctor-patient ratio and population-bed ratio (142, 84.0%), and enhancing hospital facilities, such as ensuring the availability of medicines and diagnostic tests (154, 91.1%).

Additionally, participants emphasized the importance of upgrading infrastructure with security measures like CCTVs, metal detectors, and alarm systems (153, 90.5%). Establishing an effective complaint redressal system (145, 85.8%) and enforcing stronger legislative actions (149, 88.2%) were also identified as vital steps. Other suggestions included ensuring unbiased media reporting (122, 72.2%) and sensitizing politicians and public figures to the issue (125, 74.0%).

Association between demographic variables and types of WPV: Association was computed between demographic variables and types of WPV (verbal, physical, sexual). There was significant association found between types of workplace and demographic variables (Table 2) such as age (Χ²= 13.181, p=0.04), gender (Χ²= 8.675, p=0.013), nature of duty (Χ²= 18.257, p=0.000), availability of security personnel (Χ²= 6.772, p=0.034).

Predictors of workplace violence: The logistic regression model was evaluated based on an alpha of 0.05. The overall model was found to be significant, χ2(5) = 29.53, p < 0.001, suggesting that age, type of hospital, nature of duty, working area had a significant effect on WPV. The nursing personnel aged 36-45 years had experienced 14.578 times more WPV to the nurses above 45 years. The nursing personnel working in government hospitals had experienced 105.49 times more WPV to other hospitals. The nurses on rotatory duties had experienced 71.2 % lesser WPV to those working in fixed duties. The nurses at OPD had experienced 89.5 % lesser WPV compared to nurses working in general ward. The hospitals with security person have reduced incidence of WPV to 71.3% to their counterparts (Table 3).

Discussion

In this study we assessed the magnitude and predictors of WPV among nurses in India. In the current study, one third (33.1%) of the respondents had experienced WPV in last one year. However, our findings are lower than that reported from the studies conducted in the Amhara region, Ethiopia (58.2%)[13] North east Ethiopia (56%)[1], and Eastern Ethiopia (64%)[14], Tunisia (56.3%)[15], Rwanda (58.5%)[16], Gambia (62.1%)[17], Bangladesh (64.2%)[18], Nepal (64.5%)[19], and Istanbul, Turkey (64.1%)[20], Oromia region, Ethiopia, 82.2%[21], and China (79.39%)[22]. On the other hand, our finding was higher than research studies conducted in Hawassa, Ethiopia (29.9%), Gamo Gofa, Ethiopia (43.1%)[23,24], northwest Ethiopia (26.7%)[25,26]. The difference in the findings may be due to the differences in sample size, socioeconomic status, study duration and methodology.

As per the current study, from a total of 511 participants, 169 who experienced WPV, almost all 164 (97.5%) had experienced verbal violence, 75 (44.4%) physical violence and 55 (32.5%) sexual violence. The results are higher than another study conducted among nurses in public health institutions in Hawassa, where physical violence incidents were 18.22%, for verbal abuse (89.58%), and sexual harassment (13.02%)[23]. The variations in the results could be due to change in research settings, types of setting and research methodology.

In the current study, verbal abuse (97.5%) was found to be the most common type of violence experienced. The results are similar to the other studies conducted by Likassa and others[21], Magnavita and others[27], and Byon and others[28] wherein the verbal abuse was the common type of abuse experienced by the nurses. The reason for this could be that it is the easiest form in which the perpetrators can assault the health care worker without even the legal action taken against them.

This study identified that patients’ relatives (26%) were the common perpetrators of WPV followed by Senior Nurse (17.8%) and Coworker (17.2%). The findings are somewhat similar to other studies done by Fute and others and Likassa and others[21,23]. However, in the current study the colleagues and senior nursing staff was also identified as some of the other sources of WPV. This may be due to frequent interaction of patient’s relatives with nurses in stressful situations and work-related interaction with nursing colleagues and senior staff wherein arguments may result in violence incidents.

In the current study a significant association between types of workplace and demographic variables as Gender (Χ²= 8.675, p=0.013), which is consistent with another study undertaken in Jordan[29], Palestine[30], and Hawassa[23]. However dissimilar to another study conducted by Banda and others[33] wherein no significant difference was observed in the proportions of verbal violence between men and women (51% vs 50.8%; χ2: 0.02; p=0.900). The reason could be the sample size and mindset of society in developing countries where females are considered weak and helpless and thus are at higher risk of facing WPV.

In the current study a significant association between age and WPV Age (Χ²= 13.181, p=0.04). As per the logistic regression model analysis the nursing personnel with age between 36-45 years had experienced 14.578 times more WPV compared to the nursing personnel with age above 45 years. These findings are consistent to the findings of NEXT study conducted by Estryn-Behar and others[31]. However, the findings are contrary to the results by Fute and others[23], Magnavita and others[27], Weldehawaryat and others[1], where they found nurses over the age of 41 were three times more likely to face WPV than nurses under the age of 30. The difference in the findings may be due to the sample size and geographical variations. The older or more experienced nurses are well aware how to deal with a difficult situation as compared to younger nurses. The maturity in their behaviour and the societal norms also cause the older nurses to encounter less incidents of WPV.

In the present study it was found that rotatory duties (Χ²= 18.257, p=0.000) had a significant association to WPV. The findings are similar to the other studies where the HCWs who work solely in night shifts or shift work with night duties are at a higher risk of experiencing WPV, including physical and verbal violence, compared with those who work regular day shifts[31,32].

Strengths of the study: To ensure participation and representativeness of nurses from diverse backgrounds and culture the online survey technique was used. The fear of victimization and sensitivity of the research topic were the reasons given for physical non-participation.

Limitations: The current study undertook an online survey, which may be attributed to some flaws. No specific statistical technique for sampling could be used here for gathering online data as the link was shared though various methods. The nurses who do not have access to gadgets as smart phones or who could not access google survey forms or who did not know how to use it were left out, causing selection bias. Causality could not be established due to descriptive nature of study.

Conclusion

Workplace violence (WPV) is a significant and concerning issue among Indian nurses, with approximately one-third of participants reporting experiences of violence in various forms. This prevalence emphasizes the urgent need for greater awareness and intervention within the healthcare sector.

The analysis revealed several critical predictors of WPV, including variables such as age, type of hospital (private vs. government), nature of duty (temporary versus permanent positions), and specific working areas (e.g., emergency wards vs. general wards). Understanding these predictors is essential for developing targeted interventions that can help reduce the incidence of WPV. As the frontline providers of care in the healthcare system, nurses often face unique challenges that place them at a heightened risk of violence. They frequently interact with patients and their families during stressful and emotional times, which can escalate to confrontations. Therefore, it is imperative that healthcare institutions implement comprehensive training programs focused on conflict de-escalation, communication skills, and personal safety strategies. Additionally, establishing sound policies and procedures tailored to preventing WPV is crucial in creating a safer working environment. Moreover, encouraging a culture of reporting and support is vital. Nurses must feel empowered to report incidents without fear of retribution, and there should be mechanisms in place for addressing and responding to reported incidents effectively.

The findings of this study highlight the critical need for multi-faceted strategies that include training, policy reforms, and improved support systems to protect nurses. By prioritizing the safety and well-being of healthcare workers, we can not only enhance their work experience but also improve the overall quality of patient care. It is essential for policymakers, hospital administrators, and nursing organizations to collaborate in addressing this pressing issue and ensuring that nurses can perform their vital roles without the threat of violence.

Declaration:

Authors declare that this work is their original creation and has not been published / submitted for publication anywhere else.

Acknowledgement:

Trained Nurses Association of India for funding the study.

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