Workplace violence in a conflict zone: a study from Syria’s healthcare frontline

Workplace violence (WPV) is a growing global concern in the healthcare sector. Resident doctors, nurses, and other professionals are particularly vulnerable to various forms of violence in clinical settings, including physical assaults, verbal abuse, and threats [1, 2]. Such violence carries serious consequences—not only endangering staff well-being and performance but also straining healthcare systems, particularly in resource-limited and unstable environments [3]. Among all professions, healthcare workers face the highest risk of WPV, with the World Health Organization estimating that 8% to 38% experience it during their careers [4].

The impact of WPV often extends beyond the immediate incident. Between 5% and 32% of affected individuals may develop post-traumatic stress disorder (PTSD) [5, 6]. Yet many receive insufficient emotional or institutional support. Supportive workplace measures are essential to prevent long-term harm and aid recovery [7].

WPV also compromises patient safety. Providers under stress or working in unsafe environments are more prone to clinical errors, which can lower care quality [8]. Despite its serious consequences, most WPV cases go unreported due to fear, stigma, or lack of trust in institutional systems—leaving authorities without a clear understanding of the problem’s scope [9].

In the Arab region, research on WPV remains scarce. A few studies from Kuwait and Saudi Arabia have addressed it, but more data are needed to understand its true extent and consequences [10, 11]. In Syria, one study reported that 84.74% of resident doctors experienced verbal violence and 19.08% experienced physical violence over a 12-month period. Patients’ associates were the most common perpetrators, and both forms of WPV were significantly associated with higher depression and stress, and poorer sleep quality and overall health [12].

Following the recent drastic shifts in the political and security landscape in Syria, violence and civil unrest have sharply increased, with rising aggression across multiple sectors—including healthcare. Despite this escalation, WPV data remain limited. Unlike earlier studies that focused solely on physicians, this research also includes nurses, an often-overlooked but high-risk group. By examining the current prevalence and nature of WPV among resident doctors and nurses in public university hospitals, this study provides timely insights to inform institutional policies and protective strategies during one of Syria’s most unstable periods.

Data were collected using a self-administered electronic questionnaire created with Google Forms, requiring approximately 10–15 min to complete.

The study instrument was adapted from a pre-validated English questionnaire used in a similar Ethiopian study [13]. This original tool is based on a foundational framework developed by the International Labour Organization (ILO), the International Council of Nurses (ICN), the World Health Organization (WHO), and Public Services International (PSI) [14].

To ensure conceptual equivalence and suitability for the Syrian context, the selected sections of the original English version were translated into Arabic using a rigorous forward-backward translation process. The translated version underwent review by a senior researcher in the field for content and cultural appropriateness. The final instrument was then pilot-tested with a sample of 50 randomly selected nurses and female residents. Feedback from this pilot study was used to refine the final version, confirming the clarity and local relevance of the questions. The final English version of the questionnaire has been included as a supplementary file (S1).

The questionnaire was structured to gather information across five key domains:

The authors collected the data under mutual supervision in a quiet room attached to each unit. All eligible participants were first read an information sheet, and written consent was obtained before proceeding with the survey.

The electronic questionnaire (Google Forms) was administered using tablets and laptops provided by the research team. Despite the use of an online form, researchers were present in a quiet room adjacent to the clinical units to facilitate the process. This approach was adopted for several key reasons pertinent to the context: (1) to ensure stable internet connectivity via mobile hotspots; (2) to provide immediate technical assistance and clarify any survey questions, minimizing missing data; (3) to guarantee a private and secure environment for participants, which was not consistently available on the busy wards; and (4) to obtain witnessed informed consent and verify eligibility criteria, enhancing the rigor of the recruitment process. All participants completed the survey independently, and researchers did not view individual responses to protect anonymity.

This cross-sectional study investigated the prevalence, predictors, and institutional context of workplace violence (WPV) among physicians, residents, and nurses in three major Syrian governorates. The findings reveal a disturbingly high prevalence of violence, identify key professional and situational risk factors, and expose profound systemic failures in prevention and reporting mechanisms.

The primary finding of this study is the high prevalence of WPV, with 64.78% of the 832 participating healthcare workers (HCWs) reporting exposure to at least one form of violence. This rate positions WPV as a significant and pervasive occupational hazard within the studied healthcare settings. This figure aligns closely with, and in some instances surpasses, prevalence rates reported in global and regional systematic reviews. For example, a comprehensive meta-analysis encompassing studies from numerous countries estimated a global WPV prevalence of 61.9% among HCWs [15], while a recent review focusing on the African continent reported a pooled prevalence of 62.3% [16].

Regionally, the prevalence observed in our study is consistent with the high rates documented across the Middle East. Studies have reported WPV prevalence rates of 80.4% in Palestine, 75% in Jordan, and 64.8% in Lebanon [17]. Our finding is somewhat higher than rates from several studies conducted in Saudi Arabia, which found prevalence rates of 57.5% in one hospital-based study [18] and 46.9% in a study focused on primary care centers [19]. The consistency of our findings with those from neighboring countries underscores that WPV is an endemic and critical issue plaguing healthcare systems throughout the region [17].

However, the interpretation of this high prevalence must be nuanced by the unique context in which this study was conducted. The participating governorates—Damascus, Aleppo, and Latakia—have been profoundly affected by over a decade of conflict, a critical, unmeasured variable that likely exacerbates the risk of WPV. Protracted conflict and societal instability can induce immense psychological stress and trauma within the general population, potentially lowering the threshold for frustration and aggression in stressful situations, such as seeking medical care [20]. Concurrently, healthcare systems in such environments are often severely strained, characterized by chronic under-resourcing, shortages of essential supplies and qualified personnel, and consequently, long waiting times and an inability to consistently meet patient expectations [21‐24]. These very conditions are well-established triggers for violence against HCWs globally [21‐24]. Therefore, the 64.78% prevalence rate in this study likely reflects not only the universal occupational hazards of healthcare but also the compounded pressures of a fragile, post-conflict societal context. This suggests that WPV in conflict-affected settings is a complex socio-occupational phenomenon. Therefore, effective prevention strategies must be system-wide, trauma-informed, and explicitly account for the heightened societal stress and institutional deficiencies that characterize these environments.

The binary logistic regression analysis identified five statistically significant predictors of exposure to WPV: professional role, hospital shift timing, direct patient contact, age, and the HCW’s level of concern about violence. A detailed examination of these factors provides insight into the specific dynamics of risk within this study.

A particularly striking finding from the regression model is that physicians and residents had 2.7 times the odds of experiencing WPV compared to their nursing colleagues (AOR = 2.723, p < 0.001). This finding is noteworthy because it appears to contradict a substantial body of literature that consistently identifies nurses as the professional group most vulnerable to WPV [25‐31]. The elevated risk for nurses is typically attributed to their frontline position, greater amount of time spent in direct patient care, and their role in enforcing hospital rules [25‐31].

However, the research landscape is complex. Some studies suggest that while nurses may experience more overall violence, physicians may be at a higher risk for more severe physical violence [20, 32, 33]. Other work has found no statistically significant difference in overall exposure between the two professions [32]. The heightened risk for physicians and residents observed in our study may be explained by their specific roles as ultimate decision-makers and primary communicators of consequential news, particularly within a severely strained healthcare system. In many healthcare hierarchies, physicians are tasked with delivering diagnoses and prognoses, explaining treatment limitations, and making final decisions about care plans and the allocation of scarce resources [32, 34]. In the Syrian context, where the healthcare system is likely characterized by significant resource constraints and potentially poorer patient outcomes due to these systemic deficiencies, the gap between patient and family expectations and the reality of what can be provided is likely immense [21, 23]. The frustration, anger, and grief stemming from this “expectation-reality gap” may be disproportionately directed toward the individual perceived to hold the most authority and responsibility: the physician [32, 33]. While nurses manage the continuous, moment-to-moment aspects of care, physicians often become the face of systemic failures or unfavorable clinical outcomes. This finding underscores that violence is often a reaction to perceived systemic failures. Institutional interventions must therefore address not only staff safety but also the communication of resource constraints and management of patient expectations across the care team.

The analysis confirmed two well-established, universal risk factors for WPV. Working night shifts was associated with an 82% increase in the odds of experiencing violence compared to working morning shifts (AOR = 1.824, p = 0.011), and having direct contact with patients increased the odds by 163% compared to those without such contact (AOR = 2.632, p = 0.032). These findings strongly corroborate a vast body of international research.

The association between night shifts and WPV is consistently documented and is often attributed to a confluence of factors, including reduced staffing levels, diminished administrative and security presence, a higher prevalence of patients presenting under the influence of alcohol or drugs, and increased fatigue among staff, which can impair communication and judgment [18, 35‐37]. One case-control study specifically demonstrated that an accumulation of night shifts was a significant predictor of WPV occurrence [36]. Similarly, direct interaction with patients and their families is the fundamental conduit for Type II WPV (i.e., violence from patients or visitors) [34, 38]. The risk is inherent to the nature of healthcare delivery, which necessitates frequent and close interaction with individuals who are often in physical pain, anxious, cognitively impaired, or experiencing profound emotional crises [26, 31, 34, 39].

The significance of these findings in the present study lies in their powerful confirmation that these universal risk factors remain potent drivers of violence even within the unique, conflict-affected Syrian context. It might be hypothesized that in such a setting, context-specific factors like heightened societal aggression or the availability of weapons would overshadow more traditional occupational risks. However, our data demonstrate that fundamental organizational and situational factors—namely, shift scheduling and the nature of the HCW-patient interaction—remain robust predictors. This strongly implies that evidence-based interventions proven effective in other global contexts are likely to be highly relevant and impactful here. Strategies such as optimizing night shift staffing models, implementing predictable forward-rotating schedules [36], enhancing security presence during off-hours, and providing targeted training in de-escalation and management of agitated patients should be considered primary pillars of any prevention program. This reinforces the concept that WPV, at its core, is an occupational health and safety problem that responds to targeted organizational measures, regardless of the broader geopolitical landscape.

The most powerful statistical predictor of experiencing violence in our model was the participant’s self-reported level of concern. A clear dose-response relationship was observed: compared to HCWs who were not concerned, the odds of reporting exposure to violence were 4.5 times higher for those who were moderately concerned, 9.1 times higher for those who were very concerned, and a staggering 22.7 times higher for those who were extremely concerned. While the literature extensively documents that fear, anxiety, burnout, and post-traumatic stress are severe consequences of being exposed to WPV [21, 27, 31, 40‐42], its use as a predictive variable requires cautious interpretation, given the study’s methodological design.

The primary limitation in interpreting this association is the cross-sectional nature of the study, which makes it impossible to establish the temporal sequence of events [43, 44]. A cross-sectional design provides a “snapshot in time,” measuring both the exposure (concern) and the outcome (violence) simultaneously. This precludes any definitive determination of which came first and therefore prohibits causal inference [43‐46]. To suggest that being concerned causes an individual to be victimized would be a logically flawed conclusion that risks blaming the victim.

The most parsimonious and professionally responsible interpretation is one of reverse causality. It is highly probable that individuals who have been previously assaulted, threatened, bullied, or have repeatedly witnessed violent incidents in their workplace will, as a direct result, develop a heightened level of concern for their safety. In this light, the regression model is likely not identifying a cause of violence but rather a powerful marker of prior victimization.

A complementary explanation is that “concern” may be acting as a proxy variable for working in an objectively high-risk environment. HCWs assigned to notoriously dangerous units, such as an understaffed and unsecured emergency department, will rationally report higher levels of concern because the threat of violence is real, palpable, and ever-present. Their concern is not an abstract anxiety but a realistic assessment of their daily occupational risk.

Even with this causal ambiguity, the finding is profoundly important. An adjusted odds ratio of 22.7 signifies a deep-seated and extreme level of fear among a segment of the healthcare workforce. This intense concern is, in itself, a severe negative psychological outcome and a critical indicator of a toxic work environment. Such levels of fear are inextricably linked to adverse consequences for both the HCW and the healthcare system, including job dissatisfaction, burnout, increased absenteeism, and higher turnover intentions [21, 27, 41, 42], all of which ultimately compromise the quality and safety of patient care [23, 40].

Beyond individual-level predictors, the study’s findings point to critical failures at the organizational and systemic levels in creating a safe work environment and responding appropriately to violent incidents.

The results reveal a significant disconnect between the availability of violence reporting systems and their actual use. While a majority of workplaces (56.1%) reportedly have procedures for reporting violence, these systems are largely ineffective or ignored. Only 44.5% of workers in these institutions—equating to a mere 25.0% of the total sample—stated that they use these procedures. Compounding this issue is a lack of institutional encouragement; over half of the participants (52.3%) reported receiving no encouragement to report violent incidents.

This finding is a classic illustration of the pervasive and well-documented culture of underreporting that plagues healthcare systems globally [47, 48]. Official statistics consistently and dramatically underestimate the true scale of the problem because the vast majority of incidents are never formally reported [49‐51]. The reasons for this silence are multifaceted and deeply embedded in healthcare’s professional and organizational culture. They include a widespread belief among HCWs that violence is an inevitable and unavoidable “part of the job” [31, 42]; a pervasive fear of being blamed for the incident or facing negative repercussions from management [41]; and a cynical perception, often born from experience, that reporting is futile and that “nothing will be done” in response [19]. Furthermore, reporting procedures can be cumbersome and time-consuming, creating a significant barrier for already overburdened staff [52].

The data from this study suggest a fundamental failure of top-down safety leadership. The fact that the most cited source of encouragement to report violence comes from colleagues (17.5%), while the administration is perceived as absent or silent by the majority, points to a safety mentality that is peer-led and reactive rather than institutional, proactive, and robust. A functional safety system requires more than just a reporting form; it demands active, visible, and unwavering support from management [49]. The finding that over half of HCWs feel no encouragement to report indicates a passive, if not actively discouraging, stance from hospital leadership. This institutional passivity validates the common HCW perception that reporting is useless [19], creating a vicious cycle of silence. When incidents go unreported, the true magnitude of the WPV problem remains hidden from administrators, no data-driven preventive actions are taken, and HCWs become further demoralized and discouraged from reporting future events, perpetuating a hazardous work environment [38]. The problem is therefore not merely a lack of procedure but a profound lack of a supportive, responsive, and non-punitive safety culture, the cultivation of which is a direct responsibility of hospital management [38].

The study uncovered a critical and alarming gap in preparedness: an overwhelming majority of HCWs (87.3%) have not received any specific training on how to prevent or manage violent incidents. This finding reflects a common, yet inexcusable, deficit in occupational safety within healthcare [25]. The literature not only highlights this widespread lack of training but also increasingly questions the effectiveness of simplistic, one-off educational sessions that are not integrated into a broader organizational safety framework [52]. Research indicates that effective WPV prevention programs are multi-component, context-specific, and continuous. They combine education with practical skills development, are tailored to the specific risks of different clinical settings, and are supported by strong organizational policies and leadership commitment [51].

The near-total absence of training identified in this study represents a fundamental failure of the employer’s duty to provide a safe work environment and a massive missed opportunity for proactive risk mitigation. WPV is a known, well-documented, and foreseeable occupational hazard in the healthcare sector [38]. Providing employees with training on hazard recognition, risk assessment, verbal de-escalation techniques, and emergency response protocols is a basic and essential tenet of modern occupational health and safety [50]. The fact that nearly nine out of ten HCWs in this high-risk environment have not been equipped with these skills indicates that violence is being treated as an unavoidable occupational certainty to be endured, rather than a preventable problem to be actively managed. This institutional passivity is immensely costly, contributing directly to staff injury, psychological distress, burnout, and turnover [21, 26], which in turn degrades the quality of patient care and jeopardizes patient safety [23, 40]. Investing in effective, comprehensive, and sustained training is not just a matter of staff well-being; it is a critical component of organizational resilience, quality improvement, and risk management. Its absence constitutes a major systemic vulnerability.

The findings of this study have profound and urgent implications for healthcare policy and hospital management in Syria and other conflict-affected regions. The high prevalence of WPV, compounded by systemic failures in reporting and prevention, necessitates a multi-pronged, top-down, and bottom-up approach to create a safer healthcare environment.

At the policy level, national and regional health authorities must formally recognize WPV as a critical occupational health and safety issue. Mandating the development and enforcement of clear, system-wide, zero-tolerance policies is essential to protect all healthcare personnel. Enacting and enforcing legal frameworks that criminalize violence against all healthcare workers would send a powerful message that such acts are unacceptable and will be prosecuted, aligning with international norms. Furthermore, mandating a standardized, national incident reporting system is crucial. Such a system would allow for the accurate tracking of WPV trends, the identification of high-risk settings and populations, and the rigorous evaluation of the effectiveness of implemented interventions.

At the hospital management level, the implications are more direct and demand immediate action. First, institutional leaders must actively cultivate a culture of safety. This requires moving beyond the passive availability of reporting forms to actively and visibly championing a non-punitive environment where reporting is encouraged, supported, and demonstrably leads to investigation and tangible action. A culture of safety is characterized by open communication, management support, and a commitment to learning from adverse events to prevent their recurrence.

Second, hospitals must implement multi-component interventions. It is clear from extensive research that simple, isolated solutions are ineffective. A comprehensive WPV prevention strategy must be layered, incorporating environmental modifications (e.g., improved lighting, controlled access, installation of panic buttons, enhanced security presence), administrative controls (e.g., ensuring adequate staffing levels, particularly on night shifts; implementing policies to reduce wait times), and robust training programs.

Third, institutions must invest in tailored, evidence-based training. Generic, one-time training sessions have shown limited efficacy. Hospitals must commit resources to ongoing, recurring training programs that are specific to the unique risks encountered in different departments. Training must be role-specific and context-aware. For example, curricula should include verbal de-escalation for emergency staff, structured communication protocols for delivering difficult news, and techniques for managing agitated patients for ward staff, ensuring all team members have competencies relevant to their patient interactions. This training must include opportunities for hands-on practice and skills reinforcement to ensure that knowledge can be effectively applied under pressure.

Finally, organizations must establish clear and accessible procedures for post-incident support. Employees who experience a violent event require immediate and sustained support, including access to medical treatment for physical injuries, confidential psychological counseling to address emotional trauma, and administrative assistance with the reporting and, if necessary, legal processes.

This study provides compelling and sobering evidence that workplace violence is a crisis-level occupational hazard for healthcare workers in Syria. The finding that nearly two-thirds of the healthcare workforce report exposure to violence is a stark indictment of the conditions under which they must work. This epidemic of violence is not random; it is systematically associated with identifiable risk factors—such as being a physician or working a night shift—and dangerously enabled by a culture of silence and a near-total lack of preventive training. The powerful, dose-dependent association between experiencing violence and being concerned about it underscores the profound and lasting psychological toll this hazard takes on the workforce, turning fear into a daily feature of their professional lives.

These results issue an urgent and unequivocal call to action. Protecting the healthcare workforce is not a secondary concern; it is an absolute prerequisite for a functioning, resilient, and effective healthcare system. The failure to act is not a neutral choice; it is a decision that actively degrades the quality of patient care, accelerates the burnout and departure of essential personnel, and undermines the very foundation of the healthcare system. It is imperative to move beyond passive acknowledgment of the problem and to design and implement robust, multi-faceted, and evidence-based interventions. Fostering a genuine culture of safety—through visible leadership, supported reporting, tailored training, and targeted risk mitigation—is not merely an administrative task. It is an ethical and organizational imperative. Ultimately, protecting the healthcare workforce is not a secondary concern; it is an absolute prerequisite for a functioning, resilient, and effective healthcare system capable of serving the Syrian people.