Workplace violence against junior doctors in a tertiary care hospital in Manipur and coping strategies: A mixed-method study

INTRODUCTION

Workplace violence is a key occupational hazard faced by healthcare professionals worldwide and is defined as incidents where staff are abused, threatened or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being or health.^1,2 Healthcare professionals are particularly at risk due to their close interactions with patients, with up to 38% experiencing physical violence during their careers and 75% of doctors in India facing some form of violence. Such violence adversely affects their well-being, job motivation and the quality of care, resulting in considerable financial losses within the health sector.^3–6

The Government of Manipur released the Manipur Medicare Service Personnel and Medicare Service Institutions (Prevention of Violence and Damage to Property) Act in February 2016. The Act defined ‘violence’ as activities that caused harm or injury or endangered life or intimidation, obstruction or hindrance to medical service personnel or caused damage to property of a medical service institution. Any offence committed under this Act is cognizable, non-bailable, and punishable with imprisonment, which may extend to 3 years, and with a fine, which may extend to ₹50 000.⁷

Many incidents of strikes, the closing of emergency services and sit-in protests following the assault of a duty doctor have been reported in the media from different parts of the country, including Manipur.^8–13 Addressing workplace violence, as well as assessing how healthcare workers deal with it, has become an urgent concern. However, no studies from Manipur have addressed coping strategies for workplace violence. Therefore, we determined the prevalence of workplace violence towards junior doctors in a tertiary care hospital in Manipur and explored the coping strategies amongst those who experienced workplace violence.

METHODS

A mixed-method study was done at a tertiary care teaching institute in Imphal, Manipur, from October to November 2023, among junior doctors, including interns and non-academic residents. As per records maintained by the academic section of the institute, there were 99 interns and 39 non-academic junior residents during the study period. In a previous study at the same setting amongst postgraduate students, junior residents and interns, the prevalence of workplace violence was 50.3% (verbal violence: 47.4% and physical violence: 2.9%).⁹ Participants who had worked in clinical departments (as per National Medical Commision) for at least 4 months were included, and those who could not be contacted even after two attempts were excluded. Ethical approval was obtained from the Institutional Ethics Board.

RESULTS

Of the 128 eligible participants, 124 (96.8%) completed the questionnaire. The mean age of the participants was 24.9 (1.3) years; 63 (50.8%) were males and 86 (69.4%) were interns. The majority, 104 (83.9%), of the participants, worked in shifts and were concerned about workplace violence (76; 61.3%) cases (Table 1).

Fifty-five respondents (44.4%) had ever experienced any form of workplace violence, of which 52 (94.5%) experienced verbal and 3 (5.5%) physical violence. Relatives of patients were the main perpetrators of violence 39 (70.9%), followed by management/supervisor in 7 (12.7%) cases. Most of the events occurred between 6 p.m. and 12 a.m. (40%), followed by 1 p.m. to 6 p.m. (23.6%); 17 participants (31.1%) responded to the incident by telling the perpetrator to stop. The majority of respondents, 47 (85.4%), thought that the incident could have been prevented, and 11 (20%) had to take time off from work after being attacked (Supplementary Table 1).

Most of the participants, 94 (75.8%), had not reported any incidence of workplace violence to the authority during their internship/residency period, for which the reasons stated were: (i) they did not know whom to report 36 (38.2%); (ii) were afraid of negative consequences 24 (25.5%); (iii) found reporting to be useless 15 (15.9%); (iv) felt reporting was not important 10 (10.6%); (v) did not encounter any workplace violence 5 (5.3%); and felt ashamed of reporting 4 (4.2%).

Communication gap/misunderstanding was cited as the leading cause of workplace violence, followed by aggressiveness of bystanders of patients. As suggested by participants, common measures for preventing these issues included increasing the number of staff members, improving security measures, and limiting the number of patient attendees (Supplementary Table 2). Regarding their ability to deal with workplace violence if it were to occur in the future, 50.8% felt that they would not be able, 45.2% were less able, and only 4% of the respondents opined that they would be able.

Workplace violence had been encountered significantly more often by Junior Residents (p=0.005) and those who worked in shifts (p=0.017; Table 2).

DISCUSSION

Workplace violence has become an alarming issue worldwide. Our study revealed that 44.4% of the junior doctors experienced workplace violence during their work in the tertiary care hospital, which is more than compared to studies conducted by Rajkumari et al.¹⁴ (32.8%) and Anand et al.¹⁵ (40.8%). This could be because our participants were less experienced and younger, making them more vulnerable to workplace violence. This is much less than reported by Ori et al.¹⁶ in 2014 in Manipur, where 78.3% of postgraduate students had faced at least one form of violence during their entire residency period. This could be due to the implementation of better security measures and the enactment of laws over time. More than 75% of our study participants expressed concern about workplace violence, which emphasizes that it is a pressing issue in the healthcare sector.

Verbal abuse (41.9%) was more common than physical (2.5%), which is similar to studies across the country.^9,14,15,17 However, the higher proportions of verbal abuse as compared to physical abuse are not a universal phenomenon, as depicted in the study conducted by Kumar et al.,¹⁷ where the majority of cases (52.2%) were physical. Verbal abuse could turn into physical violence when patients or relatives feel dominant, and when they are more in numbers compared to the staff on duty, as commonly occurs in evening and night shifts.

Amongst those who experienced workplace violence, the main perpetrators were relatives of patients (70.9%), which is similar to other studies.^14,15 Some experienced violence from seniors and hospital staff, too, which highlights the need for comprehensive measures to promote a culture of respect, safety and accountability within the organization. The majority of events happened between 6 p.m. and 12 a.m. (40.0%), followed by 1 p.m. to 6 p.m. (23.6%), which may be due to fewer number of doctors and staff on duty during evening and night shifts. The affected participants mainly responded to the abuse by telling the perpetrator to stop (31.1%), and the majority (85.4%) of them believed that the incident could have been prevented, which is similar to a study by Vanlalduhsaki et al.⁹ and 11 (20%) of them took time off after the event.

While 70% of the participants were satisfied with how they handled the incident, nearly half (50.9%) were not satisfied with the way the authorities handled it. Half of the participants opined that they will not be able to deal with workplace violence if it occurs in the future, which highlights a crucial need for training and preparedness efforts both at the individual and organizational levels.

Different studies^9,14 have described various contributing factors for violence, such as communication gap, aggressiveness of patients or associates, lack of awareness and trust and hospital-related factors such as lack of infrastructure and security and low staff numbers, which were also found in our study. Participants’ suggestions to prevent workplace violence include increasing the number of staff members, increasing security measures, limiting the number of patient attendants and improving communication.

There was no significant difference in the proportion of participants who experienced violence based on gender and domiciliary state. Non-academic junior residents were more commonly affected by workplace violence than interns (p=0.005), which may be due to non-academic junior residents having more direct responsibility for interacting with patients than interns. Experience of workplace violence was higher amongst those who worked in shifts (p=0.017), which highlights the importance of proper communication and handoff practices.

The in-depth interviews explored how the participants who had faced workplace violence dealt with it. The thematic analysis highlighted two major aspects. A lack of logistics compromises timely, quality care and increases out-of-pocket expenditures, leading to patient frustration and annoyance, fostering resentment among healthcare workers.^18–20 Poor communication leads to mismatched expectations, underscoring the importance of training in communication skills. Lack of health literacy and patient awareness affects their perspective towards doctors and the healthcare delivery system.²¹ High attendee-to-patient ratios and intoxicated patient associates can trigger violence, which is preventable with protocols, security and surveillance. Enhanced signage, pamphlets and videos in waiting rooms inform patients, foster understanding and reduce incidents.⁴ A positive workplace environment fosters collaboration, respect and open communication amongst colleagues and encourages productivity, leading to higher job satisfaction and should be prioritized so that junior doctors feel motivated.

During a crisis, healthcare workers often self-restrain or seek support, as seen in other studies conducted in Asia.^1,22 Participants generally maintained a calm and professional demeanour, opting for silence or moving away to prevent escalation. Seeking assistance from security and senior colleagues was crucial in managing incidents. Post-incident coping strategies included seeking emotional support through sharing feelings with peers and relying on spiritual faith. Taking short breaks helped participants recover and regain motivation. Preparation through discussions with colleagues and enhancing skills in managing violence is vital for handling such situations effectively in the future.

Both phases of coping are equally crucial as violence can affect healthcare workers on many levels, including psychological, physical, emotional and work function.