Healthcare Victims of Workplace Violence: Comparison
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Please note this is a comparison between Version 2 by Enzi Gong and Version 1 by Cristina Civilotti.

The aim of this entry is to synthesize the available evidence on the prevalence rates of healthcare workers being victims of violence perpetrated by patients and visitors in Italy.

  • workplace violence
  • hospital
  • healthcare workers
  • nurses
  • physicians
  • Italy

1. Overview

The aim of this entry is to synthesize the available evidence on the prevalence rates of healthcare workers being victims of violence perpetrated by patients and visitors in Italy. PubMed, Scopus, Web of Science and CINAHL were systematically searched from their inception to April 2021. Two authors independently assessed 1182 studies. All the scientific papers written in English or in Italian reporting primary quantitative and/or qualitative data on the prevalence of aggression or sexual harassment perpetrated by patients or visitors toward healthcare workers in Italy were included. Thirty-two papers were included in the review. The data extracted were summarized in a narrative synthesis organized in the following six thematic domains: (1). Methodology and study design; (2). Description of violent behavior; (3). Characteristics of health care staff involved in workplace violence (WPV); (4). Prevalence and form of WPV; (5). Context of WPV; and (6). Characteristics of violent patients and their relatives and/or visitors. The proportion of studies on WPV differed greatly across Italian regions, wards and professional roles of the healthcare workers. In general, the prevalence of WPV against healthcare workers in Italy is high, especially in psychiatric and emergency departments and among nurses and physicians, but further studies are needed in order to gather systematic evidence of this phenomenon. In Italy, and worldwide, there is an urgent need for governments, policy-makers and health institutions to prevent, monitor and manage WPV towards healthcare professionals. 

2. Background

Compared to other forms of violence, the interest shown in workplace violence (WPV) has grown over the years [1,2][1][2]. In particular, violence against healthcare workers perpetrated by patients or visitors presently has the traits of an emergency. Paradoxically, taking care of suffering people may become a risky duty; hospitals may become violence-prone workplaces, and health workers are often “assaulted and unheard” [3,4][3][4]. WPV threatens, in fact, the well-being of both the workers and the organization they belong to, negatively influencing the rights of millions of people to work in a safe environment and affecting the organization with absenteeism and low productivity, among other things. For these reasons, worldwide, several international organizations [5,6[5][6][7],7], along with many different research groups [8,9,10,11,12][8][9][10][11][12], are underlining the importance of having specific guidelines to monitor and prevent the spreading of this phenomenon. In the last two decades, the number of scientific publications on this topic has grown. Literature is organized into primary studies and meta-analytical reviews. In primary studies, data are collected in order to describe the phenomenon of violence in a specific context (e.g., emergency or psychiatric departments) [13[13][14],14], toward a target population (e.g., oral health-care workers) [15], in a particular geographical area (e.g., African or European Countries) [16,17][16][17] or in specific countries (such as China, Spain or Iran) [18,19,20][18][19][20]. Meta-analytical reviews e.g., [21[21][22],22], allowing a general perspective in the evaluation of the phenomenon, by merging and/or re-reading the data or the conclusions drawn from previous works. This paper pertains to the second category, consisting of a scoping review aimed at describing the prevalence of healthcare staff (physicians and nurses and technicians) who have been subject to violence or aggression by patients or visitors in Italy.

2.1. Critical Issues on Definitions and Complexity Elements in Studying the Concept of Violence and Workplace Violence

A first element of complexity in studying WPV pertains to the definition of “violence” itself. To overcome this problem, the solution accepted by most scholars is to use a definition of violence that is generalized and generalizable, since the components and declination of violence are multiple and variegate [23]. For the aim of this paper, we refer to the World Health Organization [24], which describes violence as, “The intentional use of power, threatened or actual, against another person or against a group, in work-related circumstances, that either results in or has a high degree of likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation”. Two fundamental aspects emerge from this definition. First of all, violence is considered an intentional act, committed by an agent who actively wants to harm another person. The second key point is that the idea of violence as a mere physical injury has been replaced by a broader concept that includes also psychological harm [25].
Although the concept of WPV is more specific than the concept of violence, for it encompasses a narrower field, there is not a unique definition in the literature. It is described using a wide range of words and situations that differ from each other, from physical and sexual aggression to verbal, mental and/or moral abuse [25,26,27,28,29,30,31][25][26][27][28][29][30][31]. A further complexity in identifying and classifying WPV is related to the contextual influences, as pinpointed by Waddington and colleagues [23]. The concept of violence cannot be detached from the socio-cultural context in which it is embedded. As stated by Escribano and colleagues [3], “workplace aggression does not occur in a social vacuum”, but it emerges in an interconnected framework that includes both organizational and psychosocial factors [32,33,34][32][33][34].
Since the socio-cultural context may play a significant role in studying the WPV phenomenon, as already done previously in other studies, e.g., [19,20][19][20], the aim of the present scoping review is to give a comprehensive picture of it in a European country, namely Italy.

2.2. Legal Aspects of WPV in Italy

For a long time in Italy, there has not been a specific law regarding violence in the workplace, nor any law concerning violence specifically designed for the health sector. The only existing protocol to control violent behavior in the health area was the one developed in 2005, initially on an experimental basis, by the Ministry of Labor, Health and Social Policies, named Protocol for Sentinel Events Monitoring. The latest version of this document dates back to 2009. It is a ministerial circular, a regulatory act that encourages and promotes good practices through the analysis of violent behavior. Its purpose, in fact, was to observe and monitor the so-called “sentinel events”, with the aim of defining this type of events in the same way at a national level. The objective of the Protocol for Sentinel Events was to have the same vision and the same line of action between Regions, Provinces and local health authorities operating in the area, to guarantee an Essential Level of Assistance. In recent years, to evaluate WPV in health sectors and contain its effects, various guidelines, good practices and recommendations have been issued by trade associations, the Ministry of Health, etc. However, these tools did not favor a systemic and quantitative approach to risk assessment or to identifying in an organic way the prevention and protection measures for the health care workers. Only very recently, with the law no. 4 (15 January 2021), the first in Europe, the Italian President of the Republic ratified the Convention of the International Labor Organization (n. 190) on the elimination of violence and harassment in the workplace, initially adopted in Geneva on 21 June 2019. The Convention may become an important tool in combating violence and sexual harassment in the workplace. First, as we did in this study, it provides the broad, internationally approved definition of violence of the World Health Organization (harassment or violence is any behavior likely to cause physical, psychological and economic harm). Furthermore, explicit reference is made to discrimination based on gender, recognizing that women are particularly exposed to physical, economic and psychological aggression in the workplace.
The aim of this work is to deepen the knowledge of violence in the workplace in healthcare settings within the Italian context, in order to lay the foundations for the structuring and the implementation of future prevention and containment interventions. For the purpose of this paper, we adopted the widely used classification in four main categories proposed by the University of Iowa Injury Prevention Research Center [35] (Westlawn, Iowa, with a specific focus on Type II workplace violence (in Type II, a customer, a patient, a client or an inmate is responsible for it, and the staff is the victim).

3. Conclusions

Based on the results of our scoping review, we can conclude that workplace violence is a phenomenon present among healthcare workers in Italy. Between 11.9 and 93.3% of HCWs reported having been victims of verbal aggressions and threats, while 27.5–50.3% claim to have been victims of physical violence. Considering the detection difficulties and the large methodological heterogeneity in monitoring the problem, it is recommended that the registers of aggression be standardized throughout the Italian territory and an adequate policy be structured in order to promote a greater awareness of HCW on the issues of violence in the workplace. More training would be needed, as well as carrying out targeted periodic dissemination campaigns, underling the importance of reporting all aggressions and providing specific information on the definition of the concept of “workplace violence”. In this way, it could be possible to obtain more information, to better monitor the phenomenon and implement more effective prevention and intervention protocols.

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