Akbar Jaleel Zubairi  ( Aga Khan University Hospital, Karachi, Pakistan )
Moiz Ali  ( Aga Khan University Hospital, Karachi, Pakistan )
Sadaf Sheikh  ( Aga Khan University Hospital, Karachi, Pakistan )
Tashfeen Ahmad  ( Aga Khan University Hospital, Karachi, Pakistan )

A study was conducted to determine perceptions, attitudes and experience of workplace violence among residents and faculty at a tertiary care centre in Karachi, Pakistan. An anonymous, electronic, self-administered questionnaire was circulated among all residents and faculty members working at Aga Khan University Hospital, Karachi. A standard questionnaire was devised and used, and workplace violence and its types were defined as per World Health Organization (WHO) definitions. An overall response rate of 44.9% was achieved. A total of 53.4% of the respondents reported being victims of some form of workplace violence with verbal abuse being the most prevalent (41.6%) followed by bullying and threat. Most frequent perpetrators were found to be faculty members followed by patients or their attendants. Specialty of respondents was found to be significantly associated with verbal abuse and significantly more females were subjected to sexual harassment, while ethnicity was found to be significantly associated with racial harassment. The results correspond to previously available literature, while they also highlight some findings unique to our culture. We suggest that measures should be taken as per WHO and Joint Commission International Accreditation ( J CIA) recommendations to prevent workplace violence across the country.

Keywords: Workplace violence; Healthcare providers; Harassment.

Introduction

European Commission defines workplace violence as 'Incidents where staff is abused, threatened or assaulted in circumstances related to their work, including commuting to and from work', and this encompasses psychological, physical, verbal as well as sexual abuse.¹ With time, this has become an issue of increasing concern, and is receiving attention from various sectors including government and employers. This is because violence not only affects an individual and his or her family adversely, but can also have detrimental effects on the organization as well by affecting teamwork and morale of employees.^2,3,4 Violence can be any event ranging from a one-time physical assault by an outsider or long-term bullying by co-workers. ²  Violence is increasing in prevalence across all professions, but it is known to be substantially high in the field of healthcare. It has been suggested that healthcare workers are at a 16-fold higher risk of being exposed to violence and this can be attributed to their direct interaction with people in distress. ^4-6  Exposure to violence results in increased levels of depression, stress and subsequently desire to leave. This is particularly of greater concern amongst healthcare professionals as it leads to an adverse effect on quality of healthcare provided to patients. ⁴  Although violence in the medical profession is common around the globe, countries like Pakistan are more susceptible, because of the already prevalent ethnic and political violence and a fragile law enforcement infrastructure.⁷Studies have been conducted on emergency physicians, psychiatrists and students in Pakistan, with focus on specific aspects of workplace violence including bullying; however, there is still considerable lack of data on the overall extent of workplace violence amongst health care workers. ^8-10 The objective of this study was therefore to determine the frequency, pattern and risk factors of workplace violence among doctors involved in clinical care at our hospital.

Methodology and Results

A cross-sectional, questionnaire-based survey was conducted at a tertiary care private hospital in Karachi, Pakistan in January 2015. All faculty members, including Professors, Associate Professors, Assistant Professors, Senior Instructors and Instructors, were included in the study along with fellows and residents from all clinical departments. Exclusion criteria included non-full time faculty and medical officers. Approval was obtained from the Ethical Review Committee of our institution. A standard questionnaire developed by the International Labour Office (ILO), the International Council of Nurses (ICN), the World Health Organization (WHO), and the Public Services International (PSI) was adapted for use in our study. This was made available as a selfadministered electronic questionnaire on an online survey website (namely surveymonkey.com). The link was then emailed to all participants where they filled out the questionnaire anonymously. All participants were informed about the objectives of the study and an electronic informed consent was taken. Demographic details were obtained including sex, age, academic level, subspecialty, ethnicity, religion, sect, marital status, residential status, duration of employment and background education. Participants were initially asked if they thought the specific subtype of workplace violence was happening at their institution. They were then presented with the definitions of each subtype and asked the same again and if they thought it should be reported. In addition, they were also asked to mention qualitatively whether they had been a victim during the last 12 months, how frequent these episodes were, who the perpetrators were, and whether these incidents were reported. Frequency of episodes of violence was categorised as 'rarely', 'often', 'several times a month', 'several times a week' or 'almost daily'. Workplace violence and its subtypes were defined as per the definitions used in the WHO questionnaire. SPSS version 20 was used for data analysis. Nominal variables were represented in terms of proportions and percentages whereas continuous variables were expressed as mean ± standard deviation. Chi-square test was used to determine associations between qualitative variables while McNemar and McNemar-Bowker test was used to assess the difference in response prior to and after knowing the definitions. Collectively, 485 faculty and trainees were emailed out of which 218 (44.9%) replied and of those, 185 (38.1%) consented to participate in the study (Figure-1).



The demographic characteristics of the participants are summarised in Table 1.



Most of the participants were males (103; 55.7%), and in terms of ethnicity majority were Urdu speaking (92; 49.7%). Islam was found to be the most common religion with 179 (96.8%) participants practicing it. With regards to specialty, surgery was the most represented field with 44 (23.8%) participants belonging to surgery. The mean age of the participants was 32.6 ± 8.5 years and the mean duration of employment was 4.8 ± 5.2years. A total of 150 (81%) participants thought that one or more types of workplace violence had been happening in their institution before the definitions were given, while the frequency significantly increased to 162 (87.6%) with a p-value of 0.002 after the definitions were told. Verbal abuse was thought to be the most common type of violence occurring followed by threat and bullying as shown in Table-2.



For all types of workplace violence except racial harassment, the number of participants replying as yes significantly increased after they were told the definitions. In response to whether workplace violence should be reported, an alarming 20 (10.8%) participants replied in negative for verbal abuse, 29 (15.7%) for bullying, 32 (17.7%) for threat, 39 (21.1%) for racial harassment, 38 (20.5%) for sexual harassment and 32 (17.7%) for physical abuse. Overall, 99 (53.4%) participants had experienced one or more types of workplace violence. The most common type of violence experienced was verbal abuse by 77 (41.6%) participants followed by bullying by 52 (28.1%) respondents, threat by 46 (24.9%) respondents and racial harassment by 14 (7.6%) participants. On the other hand, sexual harassment and physical abuse were found to be the least experienced types with 5 (2 .7%) respondents experiencing each of them. When assessed separately for faculty and trainees, 118 (63.0%) trainees were exposed to workplace violence overall compared to 67 (37.9%) faculty members. This difference was found to be statistically significant (p0.01). With respect to specific types, significantly higher percentage of trainees were found to experience verbal abuse (p0.01), bullying (p0.01), racial harassment (p=0.04) and physical abuse (p=0.04).



Figure-2 summarises the percentage of faculty and trainees experiencing each type of violence. Overall, the most common perpetrators of workplace violence were found to be faculty members with 109 (28%) responses against them, followed by patients or their attendants (107;27%) and trainees (82;21%). Patients or their attendants were found responsible for majority of verbal abuse and threats to faculty as well as trainees, while faculty was reported as the most common perpetrators of bullying as shown in Figures-3 and 4.



In terms of reporting workplace violence, 76 (41.3%) participants experiencing a specific type of violence said that they had reported the incidents while the rest denied reporting any incident of violence. A lesser percentage of trainees reported their experiences of violence (31; 39.7%), compared to faculty (12; 46.2%), with the difference not being statistically significant (p=0.57). It was noted that significantly higher percentage of females (5; 6.1%) were exposed to sexual harassment as compared to males (0;0%) with a p value of 0.04. Specialty of the respondents was also found to be significantly associated with exposure to verbal abuse (p0.01) with participants from emergency medicine being exposed the most (8;88.9%). None of the other types of violence was found to be significantly associated with specialty. Another important finding was that ethnicity was found to be significantly associated with racial harassment (p=0.04) with respondents belonging to Pakhtoon ethnicity experiencing the highest percentage of harassment (4; 30.8%), followed by Sindhis (3; 18.8%). Religion of the participants and whether they had completed their MBBS degree from a government or private college had no significant effect on any type of violence. When faculty and trainees were separately assessed, racial harassment was found to be significantly higher amongst male trainees compared to females (p0.01) and amongst outstation trainees compared to locals (p=0.03). A significantly less percentage of trainees in paediatrics were found to experience verbal abuse (p0.01), bullying (p=0.03) and threat (p=0.02). In comparison, amongst faculty members, being married was found to significantly reduce bullying (p=0.01) and racial harassment (p0.01) but was associated with an increased exposure to sexual harassment (p0.01).

Conclusion

An important finding noted in the current study is regarding awareness of healthcare professionals about workplace violence. Significantly higher percentage of participants changed their response after being informed of the WHO definitions of different types of violence. This suggests that better awareness should be created amongst all healthcare providers so that incidents of violence are better identified and appropriate actions are taken. Another interesting point to note is that only around 20% of the participants felt that racial and sexual harassment incidents should be reported (21.1% and 20.5%, respectively), the reason for which should be further investigated. Significantly higher percentage of trainees were found to be exposed to workplace violence compared to faculty, and faculty members were identified as the most common perpetrators of violence followed by patients or their attendants. Trainees also identified faculty as most common perpetrators for bullying and second most common for verbal abuse. This finding corresponds to the observation that on occasion, comments by seniors on lack of competency of juniors are thought of as bullying by the juniors while seniors think of them as a necessary part of their relationship. Such disagreements are even more pronounced at teaching institutions such as the one where this study was conducted. ⁴ However it should be noted that such disagreements can have a negative effect on the overall environment of the workplace. ⁴ Emergency department (ED) is considered to be a highly stressful place therefore contributing to high violence rates and the results of this study also demonstrated a significantly higher prevalence of violence in ED, thereby supporting the previous evidence. ⁸ Previous studies conducted in Pakistan have also shown the prevalence of verbal and physical abuse in ED to be as high as 76.9% and 72.5% amongst trainees and healthcare providers respectively.^7-10 There is limited literature available to evaluate the prevalence of racial harassment within people of different ethnic backgrounds amongst medical professionals. In this study, Pakhtoons were shown to be the most exposed to racial harassment. As The Aga Khan University caters to staff from all over Pakistan as well as from other countries, this finding should be looked upon with serious intent and measures should be taken to avoid this in future. The major limitation of the study is that it was a single centre study which can lead to selection bias and therefore skewed results. A low response rate of participants also adds to the limitation. However, no other study has been conducted in Pakistan so far which evaluates the prevalence of all the various types of workplace violence as described by WHO and amongst all healthcare professionals from all specialties. The results show a clear divide between faculty and trainees at our institution in terms of exposure to workplace violence but further multi centre studies are warranted to reach a definite conclusion and prospective studies should be conducted to devise strategies to prevent further

exposure to violence.

Disclaimer: None.

Conflict of Interest: None.
Funding Sources: None.

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