Workplace Violence against Health Workers: A Cross-Sectional Study from Baglung District, Nepal

Abstract

Background: Workplace violence (WPV) in the health sector is a worldwide concern with healthcare workers being at high risk of being victims. This study aimed to assess the magnitude, perpetrators and place of incidence, available violence response, reporting and prevention/control mechanism WPV in health institutions. Methods: A descriptive cross-sectional study was carried out using self-administered questionnaire to collect quantitative data on different aspects of workplace violence against health workers among 123 health workers of 14 selected health institutions of Baglung district between July-December 2013. In-depth interview was conducted among 10 respondents to collect qualitative data. Results: Almost two-thirds of respondents (64.9%) reported exposure to at least one type of violence in the previous 12 months: physical-11.3%, verbal-59.8% and sexual-11.3%. The perpetrators of all three types of violence were mostly the relatives of patients: physical-45.5%, verbal-29.3% and sexual-36.4%. Very few cases were investigated. Less than half of respondents reported the availability of violence reporting procedures in their health facilities and only one third reported any sort of encouragement for reporting. Non-reporting of violence was a concern, main reasons were lack of incident reporting policy/procedure, anti-violence measures and management support. Conclusion: There is an immediate need to address workplace violence by concerned authority though introducing appropriate policy and strategies, enhancement of incident reporting and follow up on reported events as well as providing adequate physical and psychological support to victims of health workplace violence.

Full text

International Journal of Health Sciences & Research (www.ijhsr.org) 274
Vol.5; Issue: 2; February 2015
International Journal of Health Sciences and Research
www.ijhsr.org ISSN: 2249-9571
Original Research Article
Workplace Violence against Health Workers: A Cross-Sectional Study from
Baglung District, Nepal
Roshna Rajbhandari1, Sudarshan Subedi2, Hari Prasad Kaphle2
1Public Health Scholar, 2Lecturer,
School of Health and Allied Sciences, Pokhara University, Lekhnath-12, Kaski, Nepal
Corresponding Author: Roshna Rajbhandari
Received: 05/01/2015 Revised: 24/01/2015 Accepted: 27/01/2015
ABSTRACT
Background: Workplace violence (WPV) in the health sector is a worldwide concern with healthcare
workers being at high risk of being victims. This study aimed to assess the magnitude, perpetrators and
place of incidence, available violence response, reporting and prevention/control mechanism WPV in
health institutions.
Methods: A descriptive cross-sectional study was carried out using self-administered questionnaire to
collect quantitative data on different aspects of workplace violence against health workers among 123
health workers of 14 selected health institutions of Baglung district between July-December 2013. In-
depth interview was conducted among 10 respondents to collect qualitative data.
Results: Almost two-thirds of respondents (64.9%) reported exposure to at least one type of violence in
the previous 12 months: physical-11.3%, verbal-59.8% and sexual-11.3%. The perpetrators of all three
types of violence were mostly the relatives of patients: physical-45.5%, verbal-29.3% and sexual-36.4%.
Very few cases were investigated. Less than half of respondents reported the availability of violence
reporting procedures in their health facilities and only one third reported any sort of encouragement for
reporting. Non-reporting of violence was a concern, main reasons were lack of incident reporting
policy/procedure, anti-violence measures and management support.
Conclusion: There is an immediate need to address workplace violence by concerned authority though
introducing appropriate policy and strategies, enhancement of incident reporting and follow up on
reported events as well as providing adequate physical and psychological support to victims of health
workplace violence.
Key words: Work place violence, health workers, physical violence, verbal abuse, sexual harassment
INTRODUCTION
Workplace violence (WPV) in the
health sector is a worldwide concern with
healthcare workers being at high risk of
being victims. Workplace violence in the
health sectors is defined as the incidents
where staffs 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. (1)
Both physical and non-physical
violence against health care workers is a
major problem affecting their health and
productivity. Moreover, the consequences of

International Journal of Health Sciences & Research (www.ijhsr.org) 275
Vol.5; Issue: 2; February 2015
workplace violence in the health sector have
a significant impact on the effectiveness of
health systems, especially in developing
countries. (2)
Today, there is increased evidence
that health staff especially nursing staffs are
at such a high risk of exposure to violent
behaviors in the workplace; it is now
considered to be a major occupational
hazard worldwide. (3)
Known to be a serious problem in
many countries in the industrialized world,
new research indicates that violence in the
health care workplace is actually a global
phenomenon. (4) Crossing borders, cultures,
work settings and occupational groups,
violence in the health care workplace is an
epidemic in all societies, including the
developing world. (4)
There is varying prevalence and
related factors of WPV in health sectors
according to the various studies around the
world. The country case study carried out by
World Health Organization
(WHO)/International Labor Organization
(ILO)/International Council of Nurses
(ICN)/Public Services International (PSI) in
Thailand showed 54.1% experienced
workplace violence at least once in the
previous years. The occurrences of verbal
abuse, bullying/mobbing, physical violence,
sexual harassment, and racial harassment
were reported by 47.7 %, 10.8 %, 10.5 %,
1.9 %, and 0.7 %. (5) In the United States,
health care workers face a 16-times greater
risk of violence than other service workers.
More than half of the claims of aggression in
the workplace in the US come from the
health sector. (6) More than half of the health
personnel in Bulgaria (75.8%), South Africa
(61%) and 46.7% of health workers in Brazil
have experienced at least one incident of
physical or psychological violence in 2001.
(7,8) In most countries studied, due to lack
of specific workplace policies in place to
prevent or respond to workplace violence,
resulted in under-reporting of violent
incidents, poor follow-up of reported
incidents, no sanction of the perpetrators and
dissatisfied victims. (4)
This study aimed to assess the
magnitude, perpetrators of violence and
place of incidence for different types of
workplace violence against workplace
violence against health workers working in
different health institutions of Baglung
district. It also aimed to the available
violence response, reporting and
prevention/control mechanism from health
careworker’sperspectives.
MATERIALS AND METHODS
The study was descriptive cross
sectional design using both quantitative and
qualitative approach. The study was
conducted in Baglung district. The health
care workers working Hospitals and Primary
Health Care (PHC) level were the study
population. The study was carried out during
July–December, 2013. Sampling technique
adopted in this study was non-probability
sampling. The sample size of the study was
the total number of health workers who were
employed in selected health institutions (2
Hospitals, 2 Primary Health Care Centers
and 10 Health Posts) of Baglung district i.e.
123. The study instrument was prepared
on the basis of the questionnaires prepared
by WHO/PSI/ICN (5) for the country case
study on workplace violence. The
instrument was modified to fit the objectives
of the study and was translated into Nepali.
It was reviewed by experts to enhance its
validity. Experts assessed the clarity,
relevancy, comprehensiveness, and
sensitivity of the tool to the culture. A self-
administered questionnaire was distributed
to 123 health workers to collect quantitative
data and in-depth interview was conducted
among 10 respondents to collect qualitative
data.

International Journal of Health Sciences & Research (www.ijhsr.org) 276
Vol.5; Issue: 2; February 2015
Written permission to conduct the
study was obtained from the Public Health
Programme of Pokhara University and
District Public Health Office, Baglung.
Written consent was also obtained from each
participant after explaining the aim and
assuring the confidentiality of the study. Of
the 123 questionnaire distributed; 97 (non
response rate 21.1%) questioners were
returned with adequately completed.
Descriptive analysis was applied to perform
statistical output for quantitative data.
Analysis was performed using Statistical
Package for Social Sciences version 16. For
the analysis qualitative data code was used.
RESULTS
General characteristics of respondents:
Majority of the respondents was aged 25-29
years (24.7%), female (52.5%) and married
(71.1%). Moreover majority of the
respondents were working in primary health
care (PHCC) level (62.9%); paramedical
(51.5%) and having work experience 1-5
years (30.9%). (Table 1)
Exposure to violence: In the 12 months
prior to the survey; 64.9% of the
respondents reported exposure to workplace
violence of any type at least once. Of the
total respondents; 11.3% reported exposure
to physical violence, 59.8% reported
exposure to verbal abuse and 11.3%
reported exposure to sexual harassment
respectively.
Table 1: General characteristics of respondents
Characteristics
Frequency(n=97)
Percentage(%)
Age of respondents
20 -24 years
15
15.5
25- 29 years
24
24.7
30 - 34 years
15
15.5
35- 39 years
19
19.6
40 - 44 years
16
16.5
45 and above
8
8.2
Sex of respondents
Male
47.4
Female
51
52.6
Marital Status
Single
28
28.9
Married
69
71.1
Working health institution
Hospital level
36
37.1
PHC level
61
62.9
Professional Group
Doctor
9
9.3
Nurses
9
9.3
Midwives
29
29.9
Paramedical
50
51.5
Working experience
< 1 years
10
10.3
1-5 years
30
30.9
6-10 years
17
17.5
11-15 years
19
19.6
16-20 years
12
12.4
> 20 years
9
9.3
Perpetrators of violence and place of
incidence: The perpetrators of all three
types of violence were mostly the relatives
of patients (physical violence-45.5%, verbal
abuse-29.3% and sexual harassment-36.4%)
followed by staff members and external
colleagues as shown in Table 2. Incidents
took place mostly inside the health
institution for verbal abuse (84.5%) and
sexual harassment (81.8%), whereas for
physical violence, it took place mostly
outside the health institution (54.5%). (Table
2)
Table 2: Perpetrators of violence and place of incidence
Characteristics
Physical violence n=11
Verbal abuse n=58
Sexual harassment n=11
Perpetrators
Patients
0 (0.0)
9 (15.5)
1 (9.1)
Relatives of patients
5 (45.5)
17 (27.3)
4 (36.4)
Staff members
1 (9.1)
21 (36.2)
3 (27.3)
External colleague
2 (18.2)
5 (8.6)
0 (0.0)
General public
1 (9.1)
2 (3.4)
0 (0.0)
Political parties
2 (18.2)
4 (6.9)
0 (0.0)
Management/supervisor
0 (0.0)
0 (0.0)
3 (27.3)
Place of Incidence
Inside health institution
5 (45.5)
49 (84.5)
9 (81.8)
Outside health institution
6 (54.5)
7 (12.1)
2 (18.2)
Inpatient’shome
0 (0.0)
2 (3.4)
0 (0.0)

International Journal of Health Sciences & Research (www.ijhsr.org) 277
Vol.5; Issue: 2; February 2015
Respondent’s response to violence: In
response to the violence; most of the victims
of physical violence reported that they told
the perpetrators to stop (72.7%), most
victims of verbal violence took no actions
(36.2%) and most of victims of sexual
violence sought counseling (36.4%).
Moreover, no action was taken to investigate
most of the cases of violence. (Table 3)
Table 3: Respondent’s response to violence
Characteristics
Physical violence n=11
Verbal abuse n=58
Sexual harassment n=11
Response to the incident
Took no action
1 (9.1)
21(36.2)
3 (27.3)
Tried to pretend it never happened
0 (0.0)
5 (8.6)
0 (0.0)
Told the person to stop
8 (72.7)
16 ( 27.7)
3 (27.3)
Told friends/family
0 (0.0)
2 (3.4)
1 (9.1)
Sought counseling
0 (0.0)
3 (5.2)
4 (36.4)
Told colleagues
1 (9.1)
7 (12.1)
0 (0.0)
Told senior staffs
1 (9.1)
4 (6.9)
0 (0.0)
Action to investigate incident
Yes
1 (9.1)
6 (10.3)
0 (0.0)
No
10 (90.9)
52 (89.7)
11 (100.0)
Reporting procedures and anti-violence
strategies: The availability of reporting
procedures and various anti-violence
policies andstrategiesfromtherespondent’s
perspectives were also assessed and were
further confirmed by observation and in-
depth interview. More than half of the
respondents indicated absence of procedures
for reporting the violence (54.6%) in their
health institution. Those with the presence
of violence reporting procedure in their
health institution (45.5%); majority knew
how to report (79.5%). Two-third of the
total respondents indicated that there was
absence of encouragement to report violence
(66%). Among one-third said there was
encouragement (34%);
managements/employers were reported to
encourage more than three-quarter (78.8%)
and colleagues (15.2%), own family/friends
(3%) and others (3%) respectively.
The result of an in-depth interview
with one victim stated: “…I don’t know
where to report this kind of incidence. I
wasn’t ever being oriented by the reporting
procedures of WPV before my job or during
my job. It isn’t that a big issue to call the
police. I wish management had some sort of
procedures to address these kinds of day to
day incidences happening in our health
facility. If I ignore this, I know the
perpetrators will get encouraged to repeat
this sort of violence. I just wish there would
be a proper reporting system…”
Table 4: Existing measures for violence prevention and control
at health facilities
Anti-violence measures
Frequency
(n=97)
Percentage
(%)
Security measures (e.g. guards,
alarms, portable telephones)
95
97.9
Improve surroundings (e.g. lighting,
noise, heat, access to food, cleanliness,
privacy)
42
43.3
Restrict public access
38
39.2
Patient screening (to record and be
aware of previous aggressive
behavior)
0
0.0
Restrict exchange of money at the
workplace (e.g. patient fees)
26
26.8
Check-in procedures for staff
(especially for home care)
0
0.0
Reduced periods of working alone
24
24.7
Training (e.g. workplace violence,
coping strategies, communication
skills, conflict resolution, self-defense)
0
0.0
Measures for prevention and control:
Among various measures for workplace
violence prevention and control explored in
this study, the availability of security
measures, improvement of workplace
surrounding were reported the most.
Maximum respondents reported that there
were “security measures” (97.9%), more
than half reported the availability of
“improved surroundings” in their

International Journal of Health Sciences & Research (www.ijhsr.org) 278
Vol.5; Issue: 2; February 2015
workplaces (56.7%). More than one-third
reported the availability of restriction of
public access (39.2%). Only around one-
fourth of the respondents reported the
presence of restriction in exchange of money
at the workplace e.g. patient fees (26.8%)
and reduced periods of working alone
(24.7%). Other measures like patients
screening, check-in procedures and training
were reported completely unavailable on
those health facilities. (Table 4)
Additional information about various
measures obtained through in-depth
interviews with the managers/in-charges of
the health facilities and observation showed
that only hospital had guards at the entrance
and all other health facilities didn’t have
guards. Likewise all the health facilities had
availability of telephone either landline or
personal cell phone. In general, offices of
the government sector, including health
settings, are restricted areas but members of
the public were found eligible to enter.
Cleanliness of the surrounding was
maintained regularly according to the in-
charge on one Health post.
Screening procedures for aggressive
patients were unavailable and there were no
written guidelines and screening was not a
routine practice in these health facilities.
“…Individual personnel had to be alert and
watchful depending on their own knowledge
and experience…” said one of the senior
doctors.
One health worker working in Health
Post said, “…no trainings on WPV is given
and is overlooked when there is lack of
budget for essential trainings related to
health procedures…”
Opinions of respondents on workplace
violence: According to the opinions given
by the respondents, the three most important
and frequently addressed contributing
factors for physical violence in health care
settings were: lack of awareness,
information and education regarding WPV;
lack of proper implementation of rules and
laws against WPV; and absence of reporting
system. Likewise the three important and
frequently addressed contributing factors for
verbal abuse and sexual violence were: lack
of awareness, information and education on
WPV; misuse of power by supervisors and
staff members; and male domination and
conservative thinking. Besides these factors,
respondents also addressed negative attitude
and distrust of patients, bad companion,
alcoholism, workload, misunderstandings,
communication gap between supervisor and
co-ordinates, and political reasons as
contributing factors of violence in work
setting. Since awareness, information and
education regarding WPV were both the
problem and solution in many cases, many
subjects suggested the opportunities of
awareness programmes, information
dissemination and trainings regarding WPV.
Provision of strict laws and moreover
implementation of existing laws is essential
for prevention and control of violence as
suggested by many of the subjects.
Likewise, improving the workplace
atmosphere and cultivating a non-violence
tradition as well as social and recreational
activities among personnel were also
suggested. Counselors and violence
reporting facilities should be provided.
These are the most frequently suggested
measures for violence prevention and
control. Nevertheless, positive attitudes,
gender equality, reward and punishment
system, control of alcoholism and political
stability were other measures suggested by
few respondents.
DISCUSSION
The main finding of the study was
that 64.9% of the participants indicated
exposure to workplace violence of any type
at least once in the past 12 months. Despite
some differences in the definition of

International Journal of Health Sciences & Research (www.ijhsr.org) 279
Vol.5; Issue: 2; February 2015
violence, targeted professional groups, and
methodology used, the study results are
comparable with previous regional and
international studies. In general, health
workers in the Baglung district have similar
rate of exposure to workplace violence of
any kind (64.9%) to some studies. (9) On the
other hand it has lower rate to violence of
any kind (64.9%), both physical (11.3%)
and verbal violence (59.8%) than many
other country studies. (2,7,10-12)
The fact that the majority of
respondents were exposed to some type of
violence is also a matter of concern.
According to the perceived reasons for
violence investigated by this study, the high
level of violence against health workers can
be explained by the current state of public
services including understaffing and
inadequate working conditions, delays in
receiving care as well as unmet patient
needs/expectations, workload, lack of
information, education and communication
regarding workplace violence, indecorous
use of power by supervisors and mainly the
lack of reporting procedures in health
facilities. Furthermore, this situation is
exacerbated, as the study results indicated,
by lack of violence preventing strategies
such as policy/procedures, training, and lack
of adequate safety measures to protect health
workers from violence in health facilities of
Baglung district. Evidence from other
studies showed that such conditions and
factors can result in violence against health
workers. (13-16) The dominant political
instability of the country could be other
important causative factors.
Similar to many of the previous
studies the patient’s relatives and patients
were frequently reported as the main source
of violence. (2,9,14,16,17) Nevertheless, a matter
of concern was the proportion of violence
created by colleagues or supervisors. About
36.2% of respondents encountered verbal
violence incidents from their co-workers.
This was found to be similar with one
previous study (2) and more than some other
studies. (2,9,18,19)
Taking no action was the most
common individual response towards work
place violence reported in this study which
may one of the causes for low self reporting.
Availability of violence reporting procedure
in this study (45.4%) was found less than
previous studies. (2,9,13,15) Lack of anti-
violence measures and policies in various
health sectors can be the source of de-
motivation for the victims to report violence
in workplace. From the qualitative findings,
the respondents attributed their reluctance to
report due to lack of clear procedures for
reporting and management encouragement
to report. Respondents believed that
reporting is useless because hospital
management will not take any action
besides, the fear of consequences such as
blame or revenge of perpetrators. However,
it is believed that socio-cultural norms and
values of Nepalese society have a great
impact. From experience it is known that in
many cases incidents are not formally
reported and disputes are settled through the
tribal system rather than going to the court.
Moreover, in many cases health workers
consider this as part of the job, therefore
tolerate the assailants, and do not feel that
they should support reporting the events.
The Ministry of Health and Population
should strengthen the incident reporting
system in public hospitals and enforce laws
to deter assaults against health workers as
well as raising awareness in the community,
and empower staff to cope with and report
violence.
CONCLUSION
The presence of workplace violence
in the health facilities of Baglung district is a
matter of concern. The inadequacy in
reporting procedures and anti-violence
policies and strategies in those health

International Journal of Health Sciences & Research (www.ijhsr.org) 280
Vol.5; Issue: 2; February 2015
facilities might be a challenge to address
such problems. There is an immediate need
to address workplace violence by concerned
authority though introducing appropriate
policy and strategies, enhancement of
incident reporting and follow up on reported
events as well as providing adequate
physical and psychological support to
victims of health workplace violence.
REFERENCES
1. Kamchuchat C, Chongsuvivatwong
V, Oncheunjit S, Yip TW,
Sangthong R. Workplace violence
directed at nursing staff at a general
hospital in southern Thailand. J
Occup Health. 2008;50(2):201-7.
2. 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.
3. Abbas MA, Fiala LA, Abdel
Rahman AG, Fahim AE.
Epidemiology of workplace violence
against nursing staff in Ismailia
Governorate, Egypt. J Egypt Public
Health Assoc. 2010;85(1-2):29-43.
4. World Health Organization. New
Research shows workplace violence
threatens health services. [Accessed:
2013 Aug 7]; Available from:
http://www.who.int/mediacentre/new
s/releases/release37/en/.
5. Sripichyakan K, Thungpunkum P,
Supavititpatana B. Workplace
Violence in the Health Sector: A
Case Study in Thailand. Chiangmai,
Thailand. 2003.
6. Martino VD. Workplace violence in
the health sector - Country case
studies (Brazil, Bulgaria, Lebanon,
Portugal, South Africa, Thailand,
and an additional Australian study),
Synthesis report, ILO, WHO, ICN.
2002.
7. Alameddine M, Kazzi A, El-Jardali
F, Dimassi H, Maalouf S.
Occupational violence at Lebanese
emergency departments: prevalence,
characteristics and associated factors.
J Occup Health. 2011;53(6):455-64.
8. Abualrub RF, Al-Asmar AH.
Physical violence in the workplace
among Jordanian hospital nurses. J
Transcult Nurs. 2011 Apr;22(2):157-
65.
9. Algwaiz WM, Alghanim SA.
Violence exposure among health
care professionals in Saudi public
hospitals. A preliminary
investigation. Saudi Med J. 2012
Jan;33(1):76-82.
10. Esmaeilpour M, Salsali M, Ahmadi
F. Workplace violence against
Iranian nurses working in emergency
departments. Int Nurs Rev. 2011
Mar;58(1):130-7.
11. Franz S, Zeh A, Schablon A,
Kuhnert S, Nienhaus A. Aggression
and violence against health care
workers in Germany: A cross
sectional retrospective survey. BMC
Health Serv Res. 2010;10:51.
12. Carmi-Iluz T, Peleg R, Freud T,
Shvartzman P. Verbal and physical
violence towards hospital- and
community-based physicians in the
Negev: an observational study. BMC
Health Serv Res. 2005;5:54.
13. Erkol H, Gokdogan MR, Erkol Z,
Boz B. Aggression and violence
towards health care providers--a
problem in Turkey? J Forensic Leg
Med. 2007 Oct;14(7):423-8.
14. Adib S, Al-Shatti A, Kamal S, El-
Gerges N, Al-Raqem M. Violence
against nurses in healthcare facilities
in Kuwait. Int J Nurs Stud. 2002; 39:
469-78.
15. Ayranci U, Yenilmez C, Balci Y,
Kaptanoglu C. Identification of

International Journal of Health Sciences & Research (www.ijhsr.org) 281
Vol.5; Issue: 2; February 2015
violence in Turkish health care
settings. J Interpers Violence. 2006;
21:276–96.
16. El-Gilany A, El-Wehady A, Amr M.
Violence against primary health care
workers in Al-Hassa,Saudi Arabia. J
Interpers Violence. 2010;25:716-34.
17. Gillespie GL, Gates DM, Miller M,
Howard PK. Workplace violence in
healthcare settings: risk factors and
protective strategies. Rehabil Nurs.
2010 Sep-Oct;35(5):177-84.
18. Deeb M. Workplace Violence in the
Health Sector – Lebanon Country
Case Study, Geneva:
ILO/ICN/WHO/PSI Joint
Programme on Workplace Violence
in the Health Sector. 2003.
19. AbuAlRub RF, Khalifa MF, Habbib
MB. Workplace violence among
Iraqi hospital nurses. J Nurs
Scholarsh. 2007;39(3):281
*******************
How to cite this article: Rajbhandari R, Subedi S, Kaphle HP. Workplace violence against health
workers: a cross-sectional study from Baglung district, Nepal. Int J Health Sci Res. 2015; 5(2):274-
281.
International Journal of Health Sciences & Research (IJHSR)
Publish your work in this journal
The International Journal of Health Sciences & Research is a multidisciplinary indexed open access double-blind peer-
reviewed international journal that publishes original research articles from all areas of health sciences and allied branches.
This monthly journal is characterised by rapid publication of reviews, original research and case reports across all the fields
of health sciences. The details of journal are available on its official website (www.ijhsr.org).
Submit your manuscript by email: editor.ijhsr@gmail.com OR editor.ijhsr@yahoo.com