Prevalence and characteristics of WPV against resident doctors in Syria
To the best of our knowledge, this is the first study in Syria to shed light on WPV, its related factors, and its psychological impact.
Based on the findings of the present study, 84.74% of Syrian resident doctors had encountered at least one type of violence during their shifts in the last 12 months prior to the survey. This is much more than that reported by previous studies [
14,
24‐
27].
The diversity of assessment scales and different geographical location may explain the discrepancy between these studies. This could also be linked to the ongoing state of war that has in various ways eroded healthcare services. 57% of public hospitals are not functioning or are only partially functioning, placing a mounting burden and crowding on the surviving functioning hospitals.[
28]
Training, planning, and monitoring have been impacted by declining numbers of senior professors, leaving resident doctors with destitute preparation or guidance and under conditions that force them to work beyond their knowledge and expertise to fill the shortage of services gap [
29], and have less time to build rapport with patients, deteriorating the doctor–patient relationship.
In addition, incoherence of leadership and loss of validity of healthcare systems, due to conflict and uncertainty, are seriously undermining health policy-making frameworks themselves [
30].
Furthermore, in our study, all resident doctors were working in public institutions where long waiting time is prevailing and viewed as the key factor for violence (80.02% and 62.33%, respectively, for VA and PA). One study reported that working in a public institution was significantly associated with exposure to verbal and physical abuse [
31].
The findings demonstrated that resident doctors were more likely to experience verbal violence (84.74%) followed by physical violence (19.08%). This finding is consistent with studies done elsewhere [
19,
32,
33]. Because in intense situations, patients usually first display rage as verbal violence then switch to intimidation and eventually show physical violence.
Frequencies of physical and verbal violence were higher in male resident doctors, and this difference was statistically significant in the case of physical violence. This finding agrees with other studies [
8,
26,
34] and with literature review [
35]. This may be attributable to “
the cultural norms of avoiding ‘observed’ violence against females” [
8].
A significant association was found between the resident's doctor's young age and exposure to verbal violence. This finding is in line with a previous report [
36], and could be attributed to the fact that senior resident doctors have better communication skills and are more professional in dealing with nervous and agitated clients. Also, this patient-initiated violence might be due to the lack of medical management skills by junior resident doctors and the respect of patients for an older doctor. Senior resident doctors were slightly more exposed to physical violence, but there was no significant association.
In coherence with other studies [
19,
20,
37], the results showed that patients’ associates were the most common source of verbal (89.63%) and physical (82.79%) violence. This seems to be related to that in Syria, as in most Asian countries, the relatives unnecessarily stay in the patient’s ward close to healthcare workers interfering with doctors’ decisions and tasks. They might also request an urge of care delivery or more medical attention.
It is noteworthy that resident doctors encountered verbal violence by their colleagues (48.27%) more than by patients (35.6%), which was found to be higher than previous study [
27]. This could be attributed to the ‘pyramidal system’ of residency programs in Syria in which senior resident doctors—with the relative absence of supervisors in public hospitals—could determine juniors’ roles and comment on the lack of competency of them, which juniors may perceive as verbal violence. Besides, understaffing and the impact of stress in this very difficult working condition may be other possible factors [
10].
The level of physical and verbal violence was higher among resident doctors specialized in hospitals affiliated to the Ministry of Health and this difference was statistically significant in the case of physical violence. MoH hospitals are disseminated all around Syria, opposed to MoHE hospitals that are only located in four provinces. This would generate a disparity in the allocation of resources. According to WHO report 2018, the number of resident doctors in MoH hospitals were 3,639 compared to 2,173 at MoHE hospitals [
38]. Hence, MoH hospitals could suffer from a low doctor–patient ratio and insufficient institutional infrastructure compared to MoHE hospitals, which could increase patient dissatisfaction and set a lower threshold for WPV.
Additionally, there was a significant relationship between verbal violence and being a resident doctor in Damascus province. Damascus is the capital city of Syria and has the largest number of well-equipped hospitals which patients from other cities seek (21% of the overall Syrian health workload during 2018 was in Damascus) [
38] to get better medical management, leading to more crowding and increasing waiting time in hospital departments, therefore, conflicts arise and WPV occurs.
The negative effects of WPV on resident doctors’ psychological status
The medical residency is recognized as one of the most stressful and exhausting periods in a doctor’s life [
39]. Syrian resident doctors have a high baseline of chronic stress as demonstrated in a recent study [
40]. Moreover, due to the large number of doctors emigrating abroad [
29], the remaining ones suffer from an increased workload and long working hours to compensate for the shortage of human resources. Prolonged working hours is a known risk factor for stress [
41]. In addition, low financial income is another risk factor [
42]. In our study, only 16.95% of participants considered salary as the only income source and many of them reported having an extra job or required financial support from their families, which might make them lose their independence. That being said, workplace violence does nothing but add oil to the fire and pose an additional threat to mental well-being [
43], job performance [
44], job satisfaction [
24], and self-esteem of doctors, and they begin to question the worth of their work and profession while providing medical service.
According to the correlation analysis, both verbal and physical violence threatened the psychological well-being of resident doctors, which is consistent with other findings [
45‐
47]. Interestingly, verbal violence correlated stronger than physical violence with all health outcomes variables, possibly because verbal violence occurs through a frequent basis and its intensity accumulates to become comparable with or even greater than physical violence, which occurs less frequently.
WPV also affects job motivation and contributes to less empathy and a decline in enthusiasm, which further complicates the poor relationship between Syrian doctors and patients and increases the doctors’ possibility of leaving the job. Research showed that WPV is a significant predictor of turnover intention [
48] and depressive symptoms [
49] in Chinese doctors. More than that, depressed resident doctors made significantly more medical errors than their non-depressed peers [
49] which put patient’s safety at risk. If violence persists, more resident doctors will be pressured to abandon their jobs and the safety of the public will continue to deteriorate.
Suggested strategies for tackling WPV
Efforts to limit WPV should be collaboratively built on different levels. First, at the healthcare system level, policymakers should enact more and reinforce existing legislation to protect doctors from aggressors’ behaviors, which has been the most proposed solution by resident doctors in our study (87.31%). Increasing healthcare workers’ numbers could also reduce the workload and lessen WPV. Second, at the hospital administrative level, respondents in this study articulated a desire of limiting visitors' access, the existence of a management system for reporting and controlling violence, and better security coverage such as video recording and increasing security guards inside the hospital. These solutions may reflect the personal satisfaction of resident doctors by the presence of additional security measurements inside the workplace environment.
Resident doctors depend largely on their own knowledge and skills to keep them safe. Therefore, we recommend that managers, supervisors, and coworkers should incorporate violence management educational programs as part of the Syrian residency training program. One study showed that such programs have measurable outcomes for a less violent workplace environment and better awareness of how to deal with aggressors [
50]. In addition, training in conflict management, communication skills, and de-escalating during an aggressive event is strongly recommended and need to be integrated in a structured violence prevention program, as reported in a systematic review [
51].
Third, regarding colleague-initiated violence, we strongly recommend senior resident doctors to properly use the pyramidal system to maintain its prime objective in producing well-trained junior resident doctors rather than abusing it and taking an opportunity to practice WPV against juniors. That could be strengthened if supervisors spent more time tracking the tutorial process in hospitals. Finally, since the deteriorating doctor–patient relationship is one of the key triggers of aggression towards doctors, they should devote more attention to improve their communication skills to create a more harmonious work environment [
52].
All efforts against workplace violence should be developed with the prime goal of improving patient care without compromising staff safety.
Strengths and limitations
The major strengths of this study include its large sample size in relation to the number of Syrian resident doctors. The annual Health Resources and Services Availability Monitoring System (HeRAMS) report for 2018 showed that the total number of resident doctors in MoH and MoHE hospitals from the 8 approached provinces was 5468 [
38]. Thus, we assume that our sample approximately represented 18.07% (988/5468) of the resident doctors working in MoH and MoHE hospitals. However, we could not afford reliable data regarding the number of resident doctors in MoD hospitals. Also, this is the first study in Syria to investigate workplace violence and spot a light on this issue, which may help explain the high response rate and show the interest of resident doctors in this issue. Our findings will help strengthen the Syrian health profile and offer a good guide for hospital management and policy-making, so that regulations can be adopted in this regard. Furthermore, this study investigated the association between workplace violence, and resident doctors’ health status in terms of stress, depressive symptoms, general health, and sleep quality, which has important implementations in medical training and research. However, this study also has various limitations. First, the survey used to assess WPV in this study is not a validated tool and was based on literature review. The methods of measurement of sleep quality and general health were also poor. Second, according to this study design, which was an adequate and efficient way to assess the prevalence, but restrains our ability to establish a true cause and effect relationship between variables. Third, this survey is based on self-reported data, which may have led to recall and report bias. Fourth, sexual violence was not addressed in this analysis due to cultural reasons and priorities. Hence, it avoids unrealistic data and focuses on other types of violence. Fifth, we were not able to reach all of the Syrian provinces at the time of the study due to war circumstances. Finally, despite the large sample size of participants from multiple provinces, any convenient sample is vulnerable to sampling bias that may impact the generalizability of research outcomes.