Impact of violence against medical professionals: An online survey of medical practitioners in India

INTRODUCTION

Healthcare professionals (HCPs) in India, historically respected for their services, now face escalating incidents of workplace violence (WPV), with more than 75% doctors witnessing some form of violence at work.^1,2 Similar issues are reported globally. In the USA, over a hundred HCPs died from WPV between 1980 and 1990,³ and 57% of emergency room staff at university hospitals have been threatened with a weapon in the past 5 years.⁴ In the UK, a third of HCPs have experienced verbal or physical attacks, though many incidents go unreported.⁵

The causes of WPV are multiple, including poor communication, negative public perception of doctors, low health literacy, high healthcare costs, lack of security, etc.² Even the consequences are varied, leading to mental health issues (e.g. sleep disturbance, depression), which subsequently may contribute to absenteeism and impact healthcare delivery. This could burden the already strained healthcare system.^6,7

Limited research exists on the perceived impact of WPV on HCPs in India, underscoring the need for studies exploring the nature and causes of such violence, as well as its effects on medical practice. We aimed to fill that gap by investigating the violent incidents faced/witnessed by doctors and their implications at both personal and professional levels.

METHODS

Study participants included doctors registered with the Medical Council of India or the State Medical Councils. A validated semi-structured questionnaire, based on existing literature about WPV in the health sector⁸ was used, divided into 4 subsections: demographic and workplace details, incidents of violence, perceived reasons for violence, and its impact. Questions were presented in multiple-choice or on a Likert scale from 1 to 4, with options for additional comments. Participant anonymity was preserved, though medical registration numbers were collected for authenticity and randomly verified. Following institutional ethics committee approval, a pilot survey with 10 doctors ensured question clarity. The final questionnaire, distributed via email and WhatsApp groups across the country, remained open for 4 weeks. Descriptive statistics and chi-square tests were used for data analysis.

RESULTS

We received 439 responses. The largest subgroup of responders was aged 50 years and above; 335 (76.2%) were males, 249 (56.8%) mentioned having no reporting system for WPV. 352 (80.2%) had experienced or witnessed WPV, with verbal assaults being the most common (325, 92.3%), followed by physical (161, 45.6%), and a few experiencing sexual violence (5, 1.4%). 188 (53.4%) reported incidents occurring at the emergency department, and the main perpetrators were relatives or persons accompanying the patients (324, 92%) Nearly half the respondents had experienced WPV more than once, with 8.2% experiencing 7–10 occurrences and 11.6% more than 10.

Incidents of WPV led to physical injuries in 42.9% cases; of which 7.8% were grievous. ‘How worried are you about violence in your current workplace?’ was answered by 53.3% to be deeply worried (Table 1). Of 345 respondents, 91% reported a major impact on mental health. Many of them had repetitive, disturbing thoughts, avoidance, excessive vigilance, etc., persistent for variable durations (Table 2).

On the issue of preventive measures, 65.2% reported adequate security, 40.1% reported restricted public access, and 32.8% received proper training at their workplaces. The most valued prevention strategies included training in soft skills (72%), restricting public access (70%), and enhancing security measures.

In response to WPV, 63.8% demanded improved preventive measures, 85.4% supported or participated in strikes, 27.3% protested within their hospitals, 58.3% joined efforts organized by doctors’ associations, 53% approached professional bodies like the Indian Medical Association, and 23.3% participated in online forums.

Participants perceived ‘mob mentality’ (73.5%), unrealistic expectations (73.5%), and negative media portrayal (71.4%) as leading contributors to WPV (Fig. 1). 66.8% participants believed that WPV contributes to the avoidance of treating critically ill patients at primary centres (65.1%) and promoting a defensive practice of medicine (61.6%). Many reported loss of job satisfaction and interest in patient care (52.5% said highly likely and 41.4% found it moderately likely), indicating burnout and compassion fatigue (according to 44.3% highly likely and 48.4% moderately likely; Fig. 2).

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FIG 1. Perception of respondents about the probability of the above factors contributing towards violent incidents

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FIG 2. Perception of respondents about the probable impacts of violent incidents on medical practice

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DISCUSSION

As per WHO, ‘WPV is defined as situations where staff are ill-treated, intimidated or attacked in conditions linked to their workplace, including commuting to and from the workplace, involving an explicit or implicit challenge to their safety, well-being or health’. It can be physical, psychological or a combination of both.³ Though well-known, reports of doctors being attacked have recently gained global attention. In our study, of 439 responses, 46.9% had faced WPV, while 80.2% had witnessed such incidents. Previous studies from India reported the prevalence of such incidents between 40.8% to 78%, results about WPV in relation to the gender of the professionals vary in different studies.^9–16

Analysing details of the incidents, verbal violence was the most common form, followed by physical, with several respondents reporting both in a single incident. Similar findings have been reported by others in the past.^9,10,17,18 The rates of physical violence are variable, and our finding falls somewhere midway.^9,16,18–21 Several studies suggest that these incidents are not isolated events.^9,21 Emergency departments were the most common sites for WPV, particularly between 6 p.m. and 12 a.m. This area often has very ill patients, increasing anxiety and tensions among their companions, who may react strongly to minor provocations.

Further, it was found that two-fifths had sustained physical injuries, including 7.8% sustaining grievous injuries. Ahmad et al. reported that 38.1% respondents in their study suffered severe forms of aggression (including physical attacks, weapon attacks).²² A recent study from India presented similar observations.²³

Merely one-third reported the incident to higher authorities, hospital administration, or any professional medical agency; and nothing was done nearly half the time. This portrays an inconsiderate response of authorities, which would further discourage such reporting. Kaur et al. found that only half of such cases get reported, and that too, which involve major physical injuries.²³

The primary reasons for not reporting WPV cited in the survey were ‘had no faith in the existing system,’ followed by ‘feeling ashamed’ and ‘did not know whom to report.’ This highlights the critical need for a respon-sive, empathetic, and well-publicized grievance system. Among those who reported, only a minority felt their issues were resolved satisfactorily, reflecting findings from other Indian studies.^9,23

The survey also explored the mental health consequences of WPV. A vast majority experienced mental health issues for weeks to months, with many ‘being super-alert or watchful and on guard,’ experiencing frequent recollections of the trauma, and depressive symptoms. Despite mental health often being an overlooked aspect in trauma victims, earlier studies have reported loss of self-esteem, feelings of shame, defeat, stress, and emotional exhaustion.^12,16Therefore, mental health and counselling services are crucial, yet our study found that only a few respondents received such support.

Many respondents reported a lack of preventive measures, such as security, restricted public access, and training against WPV. They engaged in various activities, including strikes and protests, to raise awareness among the public and the authorities. Often, these efforts ended with unfulfilled promises or threats under the Essential Services Maintenance Act (ESMA), which allows action against employees in essential services who strike.²⁴ Despite efforts, the Healthcare Service Personnel and Clinical Establishments (Prohibition of Violence and Damage to Property) Bill, 2019, was not enacted, leading to the passage of the Epidemic Diseases (Amendment) Act, 2020, by the Union Government of India to address such violence.²⁵ Yet, reports of violence against HCPs persist nationwide, even during critical times like the Covid-19 outbreak.

Several factors contributing to WPV were identified, including social aspects like ‘mob mentality’ and ‘media portrayal of doctors’, educational issues such as ‘unrealistic expectations’, and governance issues like ‘lack of faith in judicial process’ and ‘insufficient health insurance’ from the government. Hospital-related factors such as ‘lack of unity among medical professionals’ were also noted. Respondents suggested that enhancing doctors’ communication skills and improving security could prevent such incidents. Previous Indian studies classified causes as patient care-related issues, poor infrastructure, and inadequate clinician communication skills, particularly in conflict resolution.^9,10,23 Recent curriculum changes emphasize better communication and empathy to reduce gaps between patients and clinicians.²⁶ Issues like inadequate infrastructure and high out-of-pocket healthcare costs remain important, exacerbated by limited healthcare funding. International studies highlight increased patient rights awareness and a readiness to pursue legal actions against HCPs as contributing factors.^27–31

According to respondents, WPV has led clinicians to adopt defensive practices and has reduced job satisfaction. Shi et al. linked WPV to emotional exhaustion and increased workloads among HCPs.³⁰ In India, excessive referrals to tertiary centres delay treatments and burden the system. Additionally, over-caution, like over-prescription or extensive testing, strain patients financially due to inadequate health insurance, further increasing distrust and disputes.³²

We recommend improving reporting systems, integrating communication and conflict resolution into medical training, and rigorously enforcing protective policies (Fig. 3).

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FIG 3. Framework representing the key issues of WPV against doctors and possible levels of intervention traumatic stress disorder

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The strengths of our study include a detailed, anonymized questionnaire on WPV, broadly disseminated via social media. Its limitations include potential recruitment bias due to social media use and the slight chance that non-health professionals’ responded, though verification of respondents’ medical registrations helped reduce this.

Conclusion

WPV against doctors is common, highlighting inadequate preventive measures and a major impact on clinicians’ physical and mental health, often leading to dissatisfaction and burnout. Effective response requires analysing causes and enhancing preventive strategies.