Workplace violence (WPV) is defined as any incident in which a person is abused, threatened, or assaulted in circumstances related to their work, including verbal abuse and threats as well as physical or sexual assaults. WPV has been reported to be common in hospital settings.
A review of WPV in health-care settings over the last two decades demonstrated that most studies on this topic have focused on the occurrence rate, risk assessment, and management, while fewer studies have focused on assessing the psychological consequences of WPV. WPV may result in a lack of job satisfaction, issues with recruitment and retention, and lowered health-related quality of life. In particular, trainee doctors in psychiatry feel less safe at work, probably because of less experience, high clinical exposure, out-of-hours service, and difficulties in accessing colleagues to carry out joint assessments.
Most of the studies on health-care WPV are from North America and Western Europe. Of the studies carried out in Asia, most are from East Asian countries, and the focus has been on the WPV experienced by nurses. So far, such studies focusing on mental health professionals from Asia have not been carried out.
The objectives of this study were (a) to explore the extent of violence against psychiatric trainees in Asian countries; (b) to identify the common settings in which this violence occurs, its physical and psychological impact, and trainee-reported individual and institutional management of violent episodes; and (c) to explore the potential differences in violence experienced related to victim’s characteristics such as gender, psychiatry specialty, and training experience.
MATERIALS AND METHODS
Study design: The study was a part of a larger international online survey entitled “Violence Against Psychiatric Trainees (VAPT) study.” The VAPT survey was a cross-national survey designed by trainees of the European Federation of Psychiatric Trainees (EFPT) Research Working Group and distributed across all continents.
Study instrument: The survey was conducted using a bespoke tool for the purpose of this project [Appendix 1]. The tool consisted of 15 close-ended multiple-choice questions. The questions sought to gather demographic, training-related, and assault-related variables. Based on previous studies, assaults were subclassified into three types: physical, sexual, and verbal (definitions provided in the appendix). The survey tool was not pretested and validated. However, the usability and functionality of the tool were tested before the actual data collection started. In addition to English, this survey was disseminated in Chinese (after a translation–back translation process) to improve acceptability in mainland China.
Study procedure: Those physicians who were currently in psychiatry training in countries of the United Nations region of Asia were included in the study after an electronic consent was obtained from them. The study followed a convenience snow-ball sampling method. The survey followed an open survey approach. No personal information of the participants was collected or stored. SurveyMonkey platform was used for data collection purposes, except in mainland China, where manual collection through email was used. As per the local needs, we adjusted the data collection method. The survey was disseminated among psychiatric trainees in Asian countries through various online communication channels, including email, Facebook, Twitter, and other messaging apps, harnessing the reach of the World Network of Psychiatric Trainees. Participation in the study was voluntary, and no incentive was provided. The 15 questionnaire items were not randomized and were presented in the same screen. However, to reduce the number/complexity of the questions, adaptive questioning of items and a skip pattern was used. Completeness check was performed before submission. However, respondents were not allowed to review and change their answers. The survey platform would prevent users from re-entering the form using the same navigator and user. Data were collected over 2 years, between June 2018 and August 2020. The results are being reported in accordance with the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) of the Enhancing the QUAlity and Transparency Of health Research (EQUATOR) network.
Data analysis: Data were analyzed using Statistical Package for the Social Sciences (SPSS) V20.0. Descriptive analysis was performed using mean, standard deviation, frequency, percentage, median, and interquartile range (IQR), as appropriate. Group comparisons were performed using the Chi-square test, Fisher’s exact test, independent sample t-test, or Mann–Whitney U (MWU) test, as appropriate. A P value of <0.05 was considered significant.
Ethical aspects: The study was reviewed and approved by the Research Ethics Committee of the University of Navarra (Pamplona, Spain; ID 2019.083). Participants’ identities were maintained confidential, and no personal identifying details were collected. No one except the investigators had access to the data. The study protocol is registered at the Open Science Framework (osf.io/6z4qy).
A total of 467 responses were obtained from psychiatric trainees in 16 countries in Asia (data on view, participation, or completion rates are not available). Around 59.32% of total responses were received from India, Bangladesh, and the People’s Republic of China [Table 1]. The participants’ characteristics are summarized in Table 1.
Characteristics of WPV
Characteristics of WPV are summarized in Table 1. A total of 325 (69.59%) participants reported a history of assault. Psychiatry inpatient wards/units were the most common setting where assaults took place (n = 239, 73.54%).
The majority of participants did not report the assault to any authority (n = 182, 56.00%), while 53 (16.31%) participants reported the assault, and measures were taken. Feelings of anxiety, rage, and sadness were the most commonly reported consequences of the assault (n = 165, 50.77%). Only a minority of participants reported that training was being provided in their respective hospitals to prevent and manage episodes of aggression, or that there was an established protocol for aggression prevention and management in their hospitals [Table 1].
Variables associated with WPV
Participants with a history of an assault (n = 325, 69.59%) were compared with participants with no history of assault (n = 142, 30.41%) [Table 2]. Those with a history of assault were more advanced in their psychiatry training (MWU = 18140, P < 0.001). However, a relatively lower proportion of study participants from the East Asian countries reported an assault (χ2 = 13.41, P = 0.001) compared to participants from other countries.
Gender differences in assault characteristics
The number of assaults was similar across men (46.77%) and women (53.23) participants (χ2 = 4.83, P = 0.09). Sexual assault history was more commonly reported by the women participants (χ2 = 0.94, P = 0.002). Significantly more women participants reported anxiety, rage, and sadness after an assault (χ2 = 9.93, P = 0.002).
This is the first multinational study exploring the phenomenon of violence against psychiatric trainees in Asia. This study was carried out concomitantly in Europe (and globally) by the same research group. Despite its pilot nature, our results showing that around 70% of psychiatric trainees experienced violent assault, while 62% reported recent violence in the past 12 months warrant both further study and immediate action. As expected, verbal WPV was the most common form experienced, similar to previous studies from Western Europe and North America.[5,7,8] It is also in line with a recent meta-analysis which reported a 64.9% 12-month prevalence of WPV among (all) health-care workers in Asian countries.
Almost 48% of the trainees reported a physical assault. This is again in line with previous studies reporting that 25%–56% of trainees experience physical WPV. The rates were similar across genders, similar to what is reported in the existing literature. However, sexual assault was more commonly reported by female trainees, consistent with a previous study. Psychiatric inpatient units and emergency units were the most common settings where the assault occurred. This is again in concurrence with previous studies, and the evidence is similar for WPV experienced by other clinical professionals.[4,8]
Only one in five trainees reported an established protocol being in place in their respective hospitals for reporting violence. Only around 17% of trainees reported the assault to the authorities. Previous studies have also highlighted the lack of existence/awareness of training and reporting protocols for WPV. This is compounded by the popular misconception that WPV is a “normal” experience in mental health service provision. Similarly, lack of training for staff and aggression management plans at their institutions or being unaware of their existence was cited as a common theme among mental health trainees in Europe.
Of interest is the high proportion of psychiatric trainees experiencing WPV in South/South-East Asia. Differences in psychiatric training pathways, service models in mental health, and cultural differences might explain this significant variation. However, it is possible that the heterogeneity in recruitment and the sampling framework might be the contributing factors.
This study has some inherent limitations in methodology and scope. Our non-probabilistic sampling design based on an online survey may have contributed to selection bias and, therefore, lack of representativeness. The lack of cross-national databases and publicly available figures of psychiatric trainees’ workforce in Asia precluded random sampling. The survey tool, which was used in European countries, was not prevalidated in Asia. Also, the distribution of responses across countries in Asia was heterogeneous and lacked statistical power for comparisons. The cross-sectional design is vulnerable to recall bias, and hence, we cannot infer causal associations. We did not explore the characteristics of perpetrators or the variable intensity of abuse episodes. The questionnaire was designed and disseminated only in English and Chinese, which might have limited participation. Within Asia, there are significant regional and national differences in psychiatric training, which have not been considered while interpreting our data. Data about the view rate, completion rate, and participation rates are not available. Notwithstanding these limitations, we were able to obtain one of the largest and widest samples of psychiatric trainees in Asia. Our findings are consistent with previously referenced studies.[13,14] The low proportion of trainees reporting abuse and the lack of protocols around institutional training for staff are possible areas for improvement.
Future research should obtain accurate prevalence figures with probabilistic samples and validated instruments. The consequences of violence among victims, specific individual differences in the impact of violence, and risk/protective factors should be longitudinally studied. To address the systemic factors perpetuating violence against trainees, national psychiatric associations and the Asian Federation of Psychiatric Associations (AFPA) can take the lead in formulating policies and mandating action at hospitals employing psychiatric trainees, particularly around reporting and training related to handling workplace-based violence. This includes a need for mandatory processes and protocols in place as relevant to VAPT. An open and dynamic process of reporting and acting on concerns will significantly mitigate the risk of violence against psychiatric trainees.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
The authors want to manifest their gratitude, first and foremost, to all survey participants, as well as to the colleagues who contributed to survey dissemination and translation, to the colleagues involved in other ramifications of the VAPT Study, to the European Federation of Psychiatric Trainees for hosting the initiative, and to the World Network of Psychiatric Trainees and national trainees’ associations and networks involved in data collection.
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