Workplace violence against hospital healthcare workers in China: a national WeChat-based survey

Convenience sampling was used to collect data. From January 10th to February 5th, 2019, this survey was conducted using a self-designed anonymous WeChat-based questionnaire. First, 40 nurses and doctors were selected as “original deliverers” from our university hospital. A link to our questionnaire survey was sent to them via social media (WeChat). The introduction of the study was shown on the first page of the questionnaire and participants chose “agree” to continue the survey or “disagree” to quit. Completing the survey questionnaire implied consent to join the study. Then, the colleagues or classmates of “the original deliverers” were invited to participate in the online survey (we encouraged the transfer of questionnaires among them, but no compensation was given). The questionnaire links were also distributed among the respondents’ friends and the WeChat groups. Subsequently, the size of the sample increased. The target group consisted of China’s front-line medical staff across different departments in the hospitals.

The survey included sociodemographic information, such as gender, age, marital status, level of education, and occupational questions, including the level of hospital care, work department, profession, professional title, work schedule (shift or non-shift), weekly working hours and years of experience. Respondents also answered two questions regarding career choice: “Knowing all the risks, would you still have chosen the medical profession?” and “Would you want your child to become a healthcare worker?”

The frequency of WPV against Chinese healthcare workers in the previous 12 months was measured using the Chinese version of the Workplace Violence Scale (WVS), a scale with proven good reliability and validity (the Cronbach’s coefficient was 0.92) among healthcare workers in China [33]. The scale was composed of five dimensions, including PA, EA, T, VSH and SA. The score for each item ranged from 0 to 3, reflecting the frequency of the respondents’ exposure to WPV (0 = zero times, 1 = 1 time, 2 = 2 or 3 times, 3 = more than 3 times) in the past year. The total score was the sum of grades from each item, ranging from 0 to 15. The level of violence was divided into four categories according to the grades (none = 0, low = 1–5, intermediate = 6–10, high = 11–15). The survey provided specific definitions of each type of violence. Details about the questionnaire in this study are presented in the Additional file 1.

A total of 3706 healthcare workers from all provinces in mainland China responded to the questionnaire, 22 of whom were excluded because of incomplete data. Among the 3684 respondents (74.6% nurses and 25.4% physicians), 65.8% were married, 34.2% were single, 84.9% were female, 69.0% worked in tertiary-level hospitals, 61.6% held a primary professional title and 73.3% were shift workers. The respondents were aged 18 to 72, and 50% of them were below the age of 30, with a mean age of 31.6 ± 7.7 years. The distribution of participants by demographic and occupational characteristics is shown in Table 1.

The rate of WPV among healthcare workers was 56.4% (2079/3684). EA had the highest rate (48.6%), followed by T (27.0%), VSH (16.2%), PA (15.9%), and SA (8.1%). The five types of WPV showed significant differences in their one-year prevalence by demographic and occupational characteristics (Table 1). Male healthcare workers had a higher prevalence of PA (24.1% vs. 14.5%, χ² = 38.9, p < 0.01), EA (55.4% vs. 47.3%, χ² = 12.2, p = 0.01), T (38.1% vs. 25.0%, χ² = 41.1, p < 0.01), VSH (20.5% vs. 14.5%, χ² = 45.3, p < 0.01) and SA (12.9% vs. 7.2%, χ² = 21.1, p < 0.01) than their female colleagues. Bachelor’s degree holders had the highest prevalence of PA (17.6% χ² = 17.9, p < 0.01), EA (50.2% χ² = 10.2, p < 0.01) and SA (8.7%χ² = 7.6, p < 0.01) compared to the other groups classified by the level of education. Among the three levels of hospital care, medical staff in secondary hospitals had the highest prevalence of all five types of WPV (PA, EA, T, VSH and SA were 19.3, 54.2, 29.9, 17.3 and 10.0%, respectively). Mental health professionals were most vulnerable to all five types of violence (PA, EA, T, VSH, and SA were 48.6, 63.9, 44.1, 30.2 and 20.7%, respectively), followed by healthcare workers in emergency departments, in outpatient clinics and finally in paediatric departments. Shift workers appeared to be more vulnerable to PA (17.7% vs. 10.9%, χ² = 24.4, p < 0.01), EA (52.4% vs. 37.9%, χ² = 61.0, p < 0.01), VSH (17.0% vs. 14.0%, χ² = 4.7, p = 0.03) and SA (9.3% vs. 4.8%, χ² = 19.6, p < 0.01) than non-shift workers. Healthcare workers working more than 50 hours per week were more vulnerable to EA (58.8% χ² = 30.2, p < 0.01), T (31.8% χ² = 7.5, p = 0.02) and VSH (21.6% χ² = 15.0, p < 0.01).

The correlation between WPV levels and career choice is shown in Table 2. A total of 880 (23.9%) of the respondents reported that they still would have chosen the medical profession even if they had been more aware of the risks, and 90.7% (3341/3684) indicated that they would not support their children becoming healthcare workers. Healthcare workers who had experienced higher levels of WPV were less likely (P < 0.01) to say “yes” when asked the above two questions. A total of 549 (14.9%) of the healthcare workers who had experienced high levels of WPV in the previous year reported that they still would choose a career in health care, while only 103 (2.8%) would support their children becoming healthcare workers.

Table 3 shows the results of the multivariate logistic regression analyses on the associated factors for the five types of WPV. Male sex and shift work were two significant factors associated with all five types of WPV (p < 0.01). Bachelor’s degree education emerged as a significant factor associated with PA (p < 0.01), EA (p < 0.01) and SA (p < 0.01). The strongest correlate for PA (p < 0.01), EA (p < 0.01) and T (p < 0.01) was working in secondary hospitals, with odds ratios of 3.6 (95% CI: 1.79–7.31), 2.6 (95% CI: 1.76–3.75) and 3.3 (95% CI: 1.91–5.54), respectively. Holding a senior professional title was a factor associated with T (p = 0.01) and VSH (p = 0.01), and working more than 50 h per week [OR = 1.64 (95% CI: 1.32–2.05)] was a factor associated with EA (p < 0.01).

This study showed that the overall prevalence of WPV among healthcare workers in mainland China (56.4%) was higher than Hong Kong’s WPV prevalence of 44.6% reported in a recent (2017) cross-sectional study of 850 healthcare workers [31] and lower than the overall national prevalence of 62.2% reported in a recent meta-analysis of 44 observational surveys [34]. The prevalence was also much lower than the prevalence of 76% reported in a national survey conducted among emergency nurses in Italy [35] and 67% among nurses and midwives in Australia [36].

Our results showed that the rate of WPV was higher in male healthcare workers than in females. This finding is consistent with those reported by previous studies [31, 32]. We found that work schedule (shift or non-shift work), working time and professional title also influenced the odds of exposure to WPV. These results are also consistent with findings from previous studies [32, 37]. Several reasons could explain the effects of shift work on the odds of experiencing the five types of WPV, including the shortage of staff on night shifts, staff exhaustion [38], and the consequent effect on patient satisfaction. In China, a normal hospital ward usually has only one or two nurses with one doctor on night shift, and they must take care of more than 40 patients. Healthcare workers working more than 50 h per week were found to be 1.64 times more likely to experience EA compared to those working less than 40 h per week. One possible explanation for this finding could be the increase in patient contact associated with longer weekly working hours, which increases the likelihood of encountering WPV. Healthcare workers with a senior professional title reported more T and VSH than those with primary titles. In China’s 3-tier responsibility system for doctors and nurses, a senior professional title usually brings greater responsibility and a heavier workload. According to Wu et al. [34], many senior doctors must see more than 100 outpatients on a given day, which may affect their health and the quality of their services. In addition, studies have revealed that patients tend to have higher expectations of physicians who hold senior professional titles [39], and unmet expectations constitute a major risk for assaults [40].

Our findings showed a significant correlation between the level of hospital care and the risk of WPV. Healthcare workers in secondary-level hospitals had a higher risk of all five types of WPV than those working in primary- and tertiary-level hospitals. Previous studies have identified several factors that could contribute to this finding. First, the number of both outpatients and inpatients in China’s secondary-level hospitals is increasing due to hierarchical diagnosis and treatment reform, which aims to manage simple diseases at the township level and in secondary-level hospitals [41]. Furthermore, in China, secondary-level hospitals suffer greater staff shortages than tertiary-level hospitals [42]. The increasing patient load and staff shortage lead to higher workload and higher risk of burnout for healthcare workers in secondary-level hospitals, which may subsequently result in negative outcomes for patients [43]. In addition, secondary-level hospitals are less advanced relative to the staff’s level of education and the sophistication of medical equipment than tertiary-level hospitals [42, 44], which causes discrepancies in the quality of medical services and may lead to more medical disputes as well as a higher level of dissatisfaction among patients and their family members. The majority of workplace aggression was performed by patients who suffered negative clinical outcomes and by their dissatisfied family members [40, 45]. However, healthcare workers in primary-level hospitals suffered less WPV than those in secondary- and tertiary-level hospitals. A possible explanation for this finding is that primary-level hospitals provide fundamental medical services in relatively smaller areas where staff tend to know their clients better and tend to develop better patient-physician relationships, making them less likely to suffer from WPV.

This study showed that the higher the level of violence, the less likely healthcare workers were to answer “yes” to the two questions regarding career choice. WPV may adversely affect the physical and mental health of healthcare workers [4‐8], resulting in decreased job satisfaction [46], poorer quality of life [9] and an increased risk of staff burnout and employee turnover [47]. This situation is worsened by the lack of condemnation from the public towards the perpetrators following the news of doctors murdered due to WPV [48]. These negative effects and citizens’ attitudes towards hospital WPV may have decreased the victims’ confidence in the healthcare system, leading them to say “no” when asked the two questions.

This study has several limitations. First, the data were collected retrospectively. This method depends on the respondents’ ability to recall events that occurred in the previous 12 months, potentially resulting in recall bias. Second, this study was a national online cross-sectional survey, and although 3706 doctors and nurses from all provinces in mainland China responded, the sample was small and disproportionately distributed compared to the large number of Chinese health care workers. Therefore, the sample has limited representativeness, and the prevalence measures in this study cannot fully represent the current status of WPV among Chinese healthcare workers. Nevertheless, the significant risk factors of WPV found in this study have the potential to mitigate WPV towards healthcare workers in China.