A cross-sectional study was conducted in Vardhman Mahavir Medical College and Safdarjung Hospital (VMMC & SJH), a tertiary care government hospital located in South district of Delhi, India over a period of 1 month in January 2016.

The study population included doctors involved in direct interaction with patients: postgraduate students, junior residents and senior residents along with interns (with an experience greater than 6 months). Under graduate students, faculties, doctors in non-clinical branches (i.e., Anatomy, Biochemistry, Physiology, Pharmacology, Microbiology, and Forensic medicine), doctors on vacations and leaves during the study period and doctors who did not volunteer to participate in the study were excluded from the study.

There were 492 eligible participants in our hospital during the period of study. The sample size was calculated to be 145 considering the prevalence of violence to be 54.9% [12] with confidence level of 95% and 15% allowable error. (Applying the formula n = 4pq/L², where p is prevalence, q=p-1 & L is the allowable error). But, 192 agreed to take part in our study and were purposively approached at their workplaces (wards, out-patients departments etc.,) so that all the departments were covered during the study. Few participants did not return the questionnaires and the final sample size obtained was 151 (response rate: 79%).

The purpose of the study was informed to each participant and they were also informed of the fact that each of them was free to withdraw any time. Assurance was given to them concerning confidentiality. A written informed consent was obtained from each participant. After this, they were handed over a pre tested self-administered semi-structured questionnaire with 49 questions under broad headings such as data related to the workplace, incidences at work, violence prevention policy of the institution, reporting of incidences and follow-up, education and training for violence management. The questionnaire was distributed to the participants by investigators during the interview, which was collected the next day. The content validity of the questionnaire was examined prior to initiation of the study. Content validity index was found to be 0.93. Cronbach’s alpha coefficient was 0.76. The study protocol was reviewed and approved by the medical superintendent of the hospital and the principal of the medical college.

Standard definitions adopted from WHO were used to define the types of violence, according to which physical violence was described as the use of physical force against another person or group that results in physical, sexual or psychological harm. This includes beating, kicking, slapping, stabbing, shooting, pushing, biting and pinching. Intentional use of power, including threat of physical force, against another person or group that can result in harm to physical, mental, spiritual, moral or social development was labelled as emotional violence and includes bullying/mobbing, harassment and threats [13]. Similarly verbal violence (also known as reviling or “verbal bullying") was defined as a negative defining statement told to the victim or about the victim, or by withholding any response, thereby defining the target as non-existent [14].

Data was compiled on a MS-Excel sheet and was analysed using appropriate statistical tests (chi-square test, Fisher-exact test) with the help of IBM SPSS (Statistical Package for Social Services) Statistics for Windows (IBM Corp. Released 2012, Version 21.0. Armonk, NY: IBM Corp). The p-value of <0.05 was considered to be statistically significant.

Out of 151 study participants, 14 (9.27%) did not mention their age, so the mean age of remaining study participants was 26.73±4.24 years. Ninety two (61%) of the participants were males, 59 (39%) were females. Eighty eight (58%) participants were unmarried, 50 (33.12%) had a work experience between 6months and 3years (i.e., this group included mostly interns, house surgeon, postgraduate students and medical officers). One hundred thirty-five (90%) among the study participants have worked in night shifts in the last one year for one or more times.

Almost half, i.e., 71(47.02%) of the doctors reported having an experience of violence during work hours in the preceding 12 months. The proportion of female doctors (51%) who suffered was higher than the male doctors (45%) as depicted in [Table/Fig-1]. Ninety percent (90%) amongst them considered it as a typical incidence of workplace violence as described in the beginning of the study.

The association of type of violence with age of the respondent doctors was assessed among 137 study participants who reported their age [Table/Fig-2]. A small number of respondents i.e., 14(9.27%) who did not disclose their age but also had a history of violence were excluded from this table.

On applying chi square or Fisher’s-exact test to different types of violence separately, it was observed that age was not significantly associated with verbal and emotional violence (p-value>0.05) but the younger doctors were more likely to report physical violence. (p-value= 0.012).

Study of occurrence of violence in various departments revealed that Department of Obstetrics and Gynecology had most number i.e., 28 (59.6%) of respondents experiencing any form of violence in last 12 months followed by the medical departments (including General Medicine, Psychiatry, Paediatrics, Dermatology and Physical medicine and Rehabilitation) with 19 (51.4%) participants and surgical departments that included General surgery, Orthopedics, ENT and Ophthalmology having 21 (42.9%); and other Departments like Casualty, Radiology, Forensic medicine and Pathology with 3 (16.7%) participants giving such a response [Table/Fig-3]. This distribution was also observed to be statistically significant (p-value 0.017) after applying chi-square test.

We further distributed the different type of violent episodes according to departments [Table/Fig-4] and it was observed that verbal violence was the most common type of violence (n=62, 87.3%) reported from all departments followed by emotional violence (n=11, 15.5%) and physical violence (n=6, 8.5%) being the least reported type of violence from all departments. No doctor from Emergency, Radiology or other non-clinical departments reported any incident of physical violence.

Maximum events of violence took place after the main OPD hours i.e., 9 AM to 1 PM either in the afternoon (35.1%) or during the night shifts (30.1%). In most of the cases of violence, the perpetrators were either patients or their relatives. Only 2(2.8%) of such incidents took place outside the hospital (on the way back home, in the cafeteria) while remaining were reported to occur within hospital premises. We also wanted to enquire if white coat worn by doctors during the duty hours (except the Paediatrics department) have any impact on decreasing the prevalence of violence. But 60 (85%) of the respondents recalled that they were wearing white coat during the last incidence of violence faced by them.

Most of the respondents (73.5%) perceived long waiting periods as a cause of violence followed by delayed medical provision, violation of visiting hours and patient’s dissatisfaction with nursing staff and other causes as depicted in [Table/Fig-5]. Doctors also explained that while patients are very casual about their disease until complications arises, they get impatient and violent once they reach hospital. Many doctors (56.45%) were of the opinion that patient’s relatives also create such situations intentionally to evade the hospital bills.

A total of 58 (81.7%) of the respondents were encouraged (mostly by their colleagues), to report any incidence of violence to the competent authority while 13 (18.3%) were deterred to do so either by some of their own colleagues or by their seniors and in some cases even by the parents and were asked to stay silent in the name of prestige of the institution, to avoid wastage of time and not to hamper the academics. Among those who were encouraged 46 (79.3%) could do so without any fear of repression. Seventy-five percent (75%) i.e., 53 doctors said they were offered defusing, 12 (17%) said they were not offered so while 6 (8%) did not answer. Only 14.6% agreed that the head of the unit took the notice of the incidence and talked to the concerned authorities regarding the matter. No police enquiry was initiated as reported by the respondents.

Three-fourths (75.8%) of the doctors interviewed, admitted that any kind of violence during the duty hours affected their state of mind which in turn had an impact on their studies, duties and personal life. Only 5% said they were now used to this kind of behavior and it didnot bother them much. Correlation analysis showed negative correlation of frequency of violence episodes with experience in the health field. (r²: -0.861, p<0.05).

Among the participants, who faced incidents of any kind of violence 56 (78.9%) participants believed that these incidents could have been prevented. About 92(61.3%) respondents were not aware of any violence prevention policy at their workplace, 45(30%) said they had no idea whether it exists or not, while only 13 (8.7%) knew of the existence of any such policy at their workplace.

Among 151 participants only six (6.4%) said that they had received some kind of training for recognizing and preventing workplace violence, 142 (90.4%) said they never received any such training while 3(3.2%) did not answer. Out of 6 who received training, 5 said they were trained once a year and among them 4 said the training was adequate. All these participants were from the Department of Psychiatry where conflict management is a part of their curriculum, but on probing, all of them denied attending any special training program for management of workplace violence outside their department.

Among measures suggested by participants to counter such incidents, increase in security and increase in staff/doctors were suggested by 61(40.4%) and 31(20.5%) doctors respectively. Fifteen (10%) of them suggested to restrict visiting hours for relatives of the patients. Improving communication, proper compliance with the standard operating procedures, vigilant management and proper infrastructure were suggested by 6(4%) participants each. One patient–one attendant policy, strict security personal surveillance needed before, during and after the attack that helps the residents feel safer in their workplaces, not leaving junior doctors alone, training of security personals and patient relative counselling were other suggestions given by respondents to prevent incidents of violence against doctors.

This study tried to elucidate the various aspects related to episodes of violence encountered by the doctors during their working hours. This study is different from the others as we focussed only on the doctors working in tertiary care health facility where there is high patient load and low doctor-patient ratio. Also, the hospital caters mostly to the patients who are referred from the adjoining states and are seriously ill and most of them need specialized care involving specialists and super specialists. Paucity of perishable and non-perishable resources adds high stress among the patients and attendants and leads to frequent episodes of open confrontation between doctors and patients in many cases. Despite the best efforts, the frequency of episodes where doctors fall prey to violence has recently started increasing [12].

The response rate of our study was 79%, indicating that the study population was propelled to participate in a research, on an issue of cardinal significance to them. The reason of non–response was the high patient load in the OPD, wards and emergency department.

A study reported that the mental health service personnel are at highest risk of violence [15]. In our study we observed that Emergency/Radio-diagnosis/Para-clinical departments had minimum proportion of individuals (16.7%) who had experienced a violence episode as they have better security measures as compared to other departments and they have an equally high chance of confrontations during working hours, as evident from the responses depicted in [Table/Fig-3]. Alexander and Fraser also studied occupational violence in an Australian healthcare setting and found no statistically significant differences among different allied health professional disciplines [16].

Type of violence has always been an important factor of interest. In our study about 87.32% of the incidents were of verbal violence while 8.4% were of physical violence. These results are comparable to a study by Jego Ori et al., conducted among postgraduate students of tertiary care hospital of Manipur and another study among British Physicians, where verbal abuse was more frequent as compared to physical violence [17–19]. But the higher proportions of verbal abuse as compared to physical and other kind of violence is not a universal phenomenon as depicted from the study conducted by J Farooq et al., where majority of the cases (52.2%) were of physical assault and verbal abuse was found among 43.5% of the cases [20]. The reason for verbal abuse turning into a physical one can be explained by the lack of safety measures in the hospital premises where the patients or their relatives feel dominant when they are more in numbers compared to the staff on duty as commonly seen in evening and night shifts.

Involvement of either patients or their attendants as perpetrators of violence was another important result we found in our study as 84.5% incidents had involvement of both. This finding was similar to the results observed by J. Farooq et al., (81.8%) [20].

A variety of causes responsible for instigating a violent episode have been revealed in different studies. Study by T Ciluz, et al., (Israel) observed that the most common causes of violence were long waiting time (46.2%), dissatisfaction with treatment (15.4%) and disagreement with the physician (10.3%) [21,22]. Koukia E et al., (Greece) also observed violation of visiting hours by the visitor (88.8%), long waiting periods 86.4%), visitors’ psychological problems (83.2%), and smoking prohibition in the waiting areas (82.4%) as the precipitating factors [23].

Similarly, long waiting periods (73.5%), delayed medical provision (45.6%), violation of visiting hours and patient’s dissatisfaction with nursing care (41%), psychological stress (38.4%) and denial of hospital admission due to limited availability of beds in the wards (31.1%) were pointed out to be possible causes of violence in our study.

Most of the times, these incidents are overlooked, but in the long run increases the level of dissatisfaction among the healthcare workers. Farooq J et al., reported that the formal preliminary investigation was done in 47.8% episodes of violence, detailed enquiry in 13% and non-formal investigation done in 13% episodes [20]. Effective measures were not taken to avoid future instances of violence in 82.6% cases, whereas, some steps were taken in 13% cases. Similarly, 75% of the doctors who participated in our study said they were offered defusing and only 14.6% agreed that the head of the unit took the notice of the incidence and talked to the concerned authorities regarding the matter. This calls for a need of setting up of violence management committees which should meet regularly and where each and every case of violence that had occurred in the institution since the last meeting should be discussed and effective remedial measures should be suggested with proper follow-up to ensure compliance.

Our study also points towards the unmet need of training for effectively handling stressful situations without instigating any violent episodes as 78.9% of the participants were of the opinion that these incidents could have been prevented. Similar results were seen in the study by Koukia E et al., where health care staff reported that they lack the knowledge and the skills to handle violent visitors. Proper training would make them more confident and equipped to deal with particularly stressed patient and/ or attendants [23].

The study was conducted in a tertiary care government hospital with a small sample size, though it was statistically justified. A similar study can be done with a bigger sample size, by taking equal number of participants in all the departments. We can also include participants from the non-clinical departments. We should involve doctors working in both the government and private hospitals. This will help us to elucidate different factors that are responsible for episodes of violence in government and private hospitals as they are also not spared.

It is important that healthcare workers are protected from the risks and incidence of occupational violence both for their own health and safety and to protect the continuity and quality of healthcare services provided to the community. Workplace violence is definitely not a part of the job.