Dimensions of violence against healthcare workers in emergency departments: a cross-sectional comparative study

Abstract

Background

Violence against health workers in hospital emergency departments is a global concern. The aim of this comparative study is to assess the differences in the patterns, magnitude, effects and underlying reasons for violence against health workers in the emergency departments of Palestine and Türkiye.

Methods

A cross-sectional study was conducted in 14 emergency departments in the West Bank and 3 in Isparta Province in Türkiye. A convenience sample of 377 health workers (227 in Palestine and 150 in Türkiye), consisting of 97 physicians, 198 nurses, and 82 other workers, including administrative and support health personnel, participated in the study. A self-administered survey was used to collect data between June and November 2024. Data was analyzed using SPSS with a significance level set at < 0.05. Statistical methods included, frequencies and percentages of the study variables, as well as Chi-square tests (χ2) and Fisher’s exact tests used to assess the differences between the two countries in relation to violence prevalence and related factors.

Results

A total of 68.7% of the participants reported exposure to workplace violence during the past year, which was significantly greater among Palestinian participants (84.6%) than among Türkiye participants. The prevalence rates of physical violence were 28.1%, 35.7% and 16.7% in Palestine and Türkiye, respectively; the prevalence rates of nonphysical violence were 65.3%, 81.1% and 41.1%, respectively (p < 0.05). Among the participants, physicians were the most affected by violence. The perpetrators were mainly (79.0%) patient families/companions and the patients themselves. A long waiting time to receive services, unmet expectations of patients and families and a lack of violence prevention measures were the top reported reasons. Approximately 80.0% of the events were not reported (62.1% in Türkiye, 86.3% in Palestine, p < 0.05), mainly because of a lack of follow-up and actions taken against aggressors or because the events were considered trivial/part of the job or feared consequences of reporting. The impacts of violence include significant negative psychological effects, such as hopelessness, disappointment, fear, and anxiety, in addition to effects on the delivery of care, e.g., minimizing communication and time spent with patients and companions. Violence was also associated with the intention of health care workers to leave their job in emergency services (p < 0.05).

Conclusions

Contextual differences are evident in the patterns and levels of violence in the countries studied; however, concerns are clearly common regarding and underlying reasons and impacts. The findings show that both settings suffer from considerable levels of workplace violence and negative consequences for healthcare workers and health care services with insufficient measures to combat them, which would require immediate attention. A collaborative approach among key stakeholders for developing and implementing evidence-based policies and strategies to mitigate the risks of this arduous public health problem is crucial.

Background

Workplace violence (WPV) is defined as “any activity associated with the job or any event that occurs in the work environment that involves the intentional use of physical force or emotional abuse against an employee and results in physical or emotional injury and consequences” [1].

Workplace violence negatively influences healthcare workers (HCWs) [2], such as increased stress, fatigue, job dissatisfaction and burnout, resulting in decreased productivity and quality of health care services provided to patients in addition to increased turnover [3, 4].

Hospital emergency department (ED) health workers play a crucial role in responding to health emergencies, accidents and disasters. Violence against HCWs in EDs is a common public health problem of health care systems worldwide [5, 6].

Despite increased awareness of this issue, the level of violence against health workers is still a matter of concern. The level of violence against health workers often increases during health emergencies and conflicts [7, 8].

There is a lack of adequate data on violence against health workers, which is attributed to the lack of systematic investigations, the variety of research designs used, and the underreporting of events [9]. A systematic review by Liu and colleagues [5] revealed that approximately 62% of health workers have experienced some type of WPV, and the WHO estimates that between 8% and 38% of health workers are victims of physical violence during their work life [9].

EDs are the most critical units of hospitals. Owing to the serious condition of patients seeking medical care in EDs, the stress levels of patients and their relatives are very high. Similarly, healthcare workers are also under pressure due to the nature of their work. Earlier studies have shown that health workers in emergency care are generally at greater risk for violent attacks, especially nurses and physicians, who are perpetrated mainly by patients and their relatives and companions [10, 11].

Adapting a comparative perspective is important for exploring the similarities and differences between countries and developing a better understanding of the factors related to WPV in different health care system structures and contexts. Türkiye and Palestine have some social and cultural similarities. On the other hand, Türkiye is an upper-middle income, growing economy and politically stable country; however, Palestine is a lower-middle income, burdened economy and politically unstable country due to protracted military occupation. The impact of frequent cycles of conflict on Palestinian health care system development is detrimental [12, 13]. With respect to health care, Türkiye has universal health coverage for all its citizens through a comprehensive public services delivery system. In contrast, a governmental Palestinian health insurance scheme provides coverage for more than half of the population in the West Bank through insufficient and overburdened public services [14].

Hospital EDs in both countries perform the same function of providing care for urgent and trauma patients for 24 h. Similarly, violence against HCWs is a prevalent problem in both countries and requires serious attention [15,16,17,18]. Systematic assessment of violence in EDs in both countries is still insufficient. Some efforts have been made to assess the prevalence and related factors in Palestine [15, 19], while less comprehensive studies reported in Turkey [17,18,19,20,21,22]. Therefore, empirical evidence on the nature of violence in both settings is crucial. This comparative study aims to assess the differences in the patterns, magnitude, effects and underlying reasons for violence against health workers in EDs in Palestine and Türkiye. The results may help in developing and implementing effective policies and measures to mitigate the risks of violence against health workers in EDs in different contexts.

Methods

Study design and setting

A cross-sectional comparative design was adopted to study WPV against workers in EDs in Palestinian and Turkish public hospitals. In Palestine, all 14 EDs of hospitals run by the Palestinian Ministry of Health (MoH) in the West Bank were included in the study. In Türkiye, the study was conducted in 3 hospitals in Isparta Province including two hospitals run by the Turkish Ministry of Health and one public university teaching hospital. All the hospitals studied are the main providers of emergency medical services in their areas. The hospital sizes ranged from 30 to 850 beds.

Participants and data collection

The target group included workers with direct contact with patients and accompanies, including doctors, nurses, and other workers, such as administrative services, e.g., clerks and receptionists, and support health personnel. All the full-time HCWs available in the EDs of the studied hospitals at the time of study, estimated to 660 persons 424 in Palestine and 236 in Türkiye, were targeted in the data collection. Trainees were excluded from the study. A census survey approach was conducted due to the small size of the study population. This has resulted in a convenience sample of 377 of valid responses (227 in Palestine and 150 in Türkiye), consisting of 97 physicians, 198 nurses, and 82 other workers. The response rate was 53.5% in Palestine and 63.6% in Türkiye. Eight responses (5 from Palestine and 3 from Türkiye) were considered incomplete and excluded because none of the sections related to exposure to violence were answered.

Study tool

We used the same tool of an earlier study conducted to assess violence against HCWs in EDs in Palestine [15], which was prepared on the basis of a questionnaire developed by the International Labor Office, the International Council of Nurses, the World Health Organization, and the Public Services International Joint Programme on Workplace Violence in the Health Sector [1].

The survey consisted of four sections and 32 questions. The first Sect. (6 questions) related to the characteristics of the participants including gender, age, job category, education level and years of experience in EDs. The second Sect. (8 questions) is related to exposure to physical violence in the last year, type of physical aggression, perpetrator, time, place, and whether the victim has received services or support following incident as well as the perceived reason/s for exposure to the aggression. Similarly, the third Sect. (9 questions) is related to exposure to different types of non-physical violence. The fourth part (9 questions) is about the systems and measures available in EDs for preventing violence, whether violent incidents experienced have been reported, the reason if not, and if any actions have been taken against the perpetrator. This section also included a question about whether there any intention to quit work at EDs using 5-likert scale (very likely, likely, not decided, maybe, never). The survey was mostly in the form of multiple choices and close-ended questions. A translation and back translation of the survey to the Turkish language was made. The Arabic version was previously validated and used in Palestine [15].

The study survey was reviewed by 6 experts, including researchers and clinicians from the two countries. The aim was to test the content validity and the sensitivity of the tool to the local culture were assessed. The Scale Content Validity Index (S-CVI) of the instrument was calculated to equal to 0.989, indicating that most of the items in the instrument are very relevant according to the experts’ ratings (I-CVI ranged between 0.833 and 1). Then study was pilot tested in two hospitals in Palestine and Türkiye. The survey was conducted in local languages.

Definitions of the different types of violence were provided to participants in the survey. These are mainly based on the ILO/ICN/WHO/PSI Framework Guidelines for Addressing Workplace Violence in the Health Sector [1]. While physical violence can be any form of attack that has a physical component that involves exercising force against health workers e.g. hitting, kicking, slapping, choking biting, pulling, pushing that may lead to physical, sexual, or psychological harm, nonphysical violence includes all types of verbal abuse, threats and harassment [17]. Simply, verbal abuse is any oral communication that negatively affects the dignity of somebody; threat is the intent through use of words, gestures, signs, or behavior to intimidate or harm the employee and sexual harassment is any unwelcome and non-reciprocal verbal or physical conduct of sexual nature [17].

Data collection

Google Forms were used for data collection from ED workers in Palestine because of the difficulties associated with the prevailing conflict at that time. The survey link was distributed through direct contacts as well as social media platforms (WhatsApp). In Türkiye, printed surveys were administered to the participants by the researchers. Participation was anonymous, and the surveys were provided with a cover letter that included the aim of the study, survey instructions, and informed consent. Data collection took place between June and November 2024.

Statistical analysis

The data were analyzed via the Statistical Package for Social Sciences (SPSS) version 25 for Windows (Armonk, NY, IBM Corp.) [23]. Descriptive statistics were performed for the participant characteristics and exposure to violence. Chi-square tests (χ2) and Fisher’s exact tests were used to assess the differences between the two countries in relation to violence prevalence, impact, reporting, and prevention measures. p < 0.05 was considered statistically significant in all the analyses.

Results

The participant characteristics are provided in Table 1. Males accounted for 63.4% of the participants, especially among Palestinian participants (75.8%), compared with 44.7% in Türkiye. More than half of the participants (52.5%) were older than 30 years (59.9% in Palestine and 41.3% in Türkiye). Nurses were the largest group (52.5%), especially in Palestine (67.4%), followed by physicians (25.7%) and other types of workers (21.8%). The majority (79.6%) had an education level of a bachelor’s degree or above, especially among Palestinian participants (88.1%), compared with 66.7% in Türkiye. Most of the participants (63.1%) had less than 5 years of experience in EDs, which was obviously greater in Türkiye (74.0%) than in Palestine (55.9%). Finally, (81.3%) of the participants worked in EDs that received an average of 4000 visits monthly; 78.2% and 84.0% of the participants worked in Palestine and Türkiye, respectively.

Table 1 Characteristics of the participants

Prevalence of violence in EDs

Two-thirds of the participants (68.7%) reported exposure to a type of WPV in the EDs (either physical or nonphysical assault) in the last 12 months, which was significantly greater among Palestinian participants (84.6%) than among their Turkish colleagues (44.7%) (p < 0.001) (Table 2). The prevalence of physical violence was 28.1%, and it was significantly higher in Palestine (35.7%) than in Türkiye (16.7%) (p < 0.05). Among the types of physical violence, the most common type was pushing/pulling, which constituted 58.2% of the cases and was apparently more common in Palestine (66.7%) than in Türkiye (32.0%) (p < 0.05). The second category was kicking and hitting (17% of the cases), which was more common in Türkiye (32%) than in Palestine (13.6%) (p < 0.05). The third type was throwing instruments/equipment (6.6%), 16.0% in Türkiye compared to 3.7% in Palestine (p < 0.05). The fourth type was using weapons with an overall 1.9%, where one case in each country was reported (p < 0.05). Other types of physical assault constituted 16% of the total responses (p < 0.05).

Exposure to any type of nonphysical violence was more prevalent than physical violence, with overall percentages of 65.3% and 81.1% and 41.1%, respectively, in Palestine and Türkiye (p < 0.05) (Table 2). The reported exposures to types of nonphysical violence in Palestine and Türkiye were as follows: verbal abuse: 77.5% and 39.3%, threats: 52% and 30%, and sexual harassment: 7.0% and 1.3%, respectively. All these differences between the two countries are statistically significant (p < 0.05).

Table 2 Exposure to violence in the past 12 months by type and country

Violence by worker groups

When we examined the exposure to WPV by worker groups in the EDs (Fig. 1), the results revealed that physicians were the most vulnerable to aggression (77.3%). This percentage was significantly higher among Palestinian physicians, where 93.0% reported exposure to a kind of violence (36.8% to physical violence and 91.0% to nonphysical violence), than 55% of their Turkish colleagues (17.5% to physical violence and 50.0% to nonphysical violence) (χ² = 19.337, p < 0.001). Moreover, 74.2% of the nurses reported exposure to WPV, which was significantly greater (82.4%) in Palestine (35.9% to physical and 78.4% to nonphysical) than in Türkiye (16.5%, 9% to physical and 42.2% to nonphysical) (χ² = 23.157, p < 0.001). Other health workers are less exposed to violence, with an overall percentage of 45.1%, whereas 19.5% are exposed to physical violence and 42.7% to nonphysical violence; the differences between the two settings are significant (χ² = 8.511, p = 0.004). This group includes support health personnel, mainly Turkish participants, who are less in direct contact with patients and families than physicians and nurses are.

Fig. 1

The percentage of exposure to violence by worker categories

Exposure to violence by gender

In general, males (72%) (Fig. 2) were more exposed to workplace violence (35.0% to physical violence and 69.0% to nonphysical violence) than females were (63.0%) (18.8% to physical violence and 58.7% to nonphysical violence) (χ² = 66.918, p < 0.001). At the country level, males among ED workers in Palestine had greater exposure to physical violence than did those in Türkiye (41.3% and 13.4%, respectively) and to nonphysical violence (83.1% and 32.8%, respectively) (χ² = 16.160, p < 0.001). While female workers in Palestine have lower exposure to physical violence than do those in Türkiye (18.2% and 19.3%, respectively), the opposite is true for nonphysical violence (74.5% and 48.2%, respectively) (χ² = 62.857, p < 0.001).

Fig. 2

The percentage of exposure to violence by worker gender

Perpetrators of violence

The order of perpetrators of violence was similar in the two settings. The families and companions of patients are the main perpetrators of both physical (79.0%) and nonphysical aggression (76.7%) against workers in EDs in the two countries (Table 3). Patients are in second place, with overall percentages of 14.2% and 14.3%, respectively, for physical and nonphysical assaults. Colleagues were the perpetrators of 2.8% and 2.4% of the physical and nonphysical violence, respectively. Other types of perpetrators were responsible for 3.8% of the physical assault and 6.5% of the nonphysical assault among ED workers. The differences between the scores of the Palestinian and Turkish EDs are significant (p < 0.05).

Timing of the violence

For the timing of the assaults, in both settings, the results (Table 3) show that the violent incidents were concentrated in the afternoon, where 62.3% of the physical (60.5% in Palestine and 68.0% in Türkiye) and 56.0% of the nonphysical (56.5% in Palestine and 54.9% in Türkiye) incidents took place in the afternoon and evening shifts. There was a statistically significant difference between the two settings in terms of the time when nonphysical violence took place (p < 0.05) but not in the case of physical assault (p > 0.05).

Place of violence

Regarding the place where violence took place (Table 3), the results show that 58.2% of the physical and 49.6% of the non-physical aggressions occurred in the treatment rooms; respectively 53.0% and 48.4% in Palestine compared to 60.0% 53.2% in Türkiye. Following that, 22.6% of the physical and 28.0% of the non-physical aggressions took place in the reception/waiting areas; 21.1% and 29.9% in Palestine compared to 28.0% and 22.6% in Türkiye. Moreover, 11.3% of the physical and 15.0% of the non-physical attacks took place in the corridors; 14.8% and 15.2% in Palestine compared to zero and 14.5% in Türkiye. No significant differences exist between the two settings in terms of the place of violence in both types of violence (p > 0.05).

Treatment/support is needed following exposure to violence

The participants were also asked how they handled the exposure to violence. The responses revealed that no treatment of any kind or support was needed following most of the physical violence cases (86.6%) (87.7% and 84.0% in Türkiye, respectively) and (88.3%) nonphysical assault cases (89.3% and 85.5% in Türkiye, respectively) (p > 0.05). However, 5.7% of the victims of physical assault (Palestine 3.7% and 12.0% in Türkiye) and 8.1% of the victims of nonphysical assault (Palestine 7.5% and 9.7% in Türkiye) did not receive the treatment or support they needed (Table 3).

Table 3 Features of exposed violence in the emergency department

Reasons for exposure to violence

The reasons for both types of violence reported by the participants are very similar in the two settings (Fig. 3). The waiting time to receive services accounted for the greatest percentage (29%) of the responses in Palestine and Türkiye (32.4% and 20.5%, respectively), followed by the unmet expectations of patients and their families/companions (24.8%) (24.5% and 25.5%, respectively). Another important reason is the lack of preventive measures in the EDs, with 10.5% of the total responses (in Palestine, 9.6% and 13.1% in Türkiye), the mental health of the patients (10.3%) (9.6% and 12.4%, respectively), the anxiety/fear/stress of the patients (5.3%) (5.1% and 7.6%, respectively), the attitudes of staff members (3.3%) (2.7% and 4.8%, respectively), the influence of illness/pain (3.1%) (1.7% and 6.9%, respectively), and the influence of substances, e.g., drugs or alcohol (2.0%) (0.7% and 5.5%, respectively). The lack of medications or needed services was reported only in Palestine, with 3.4% of the responses. Other reasons/don’t know received 8.5% of the participants’ responses; in Palestine, 10.3%, and in Türkiye, 3.4%.

Fig. 3

The percentage of reasons for exposure to violence by country

Reporting violence

Only 19.9% of the participants reported the violent incident they had been exposed to in the past 12 months, and the percentage of Turkish participants (37.9%) was significantly greater than that of Palestine participants (13.7%) (χ² = 17.974, p < 0.001). Moreover, 13.6% of those who reported violence indicated that an action had been taken against preparators, which was significantly greater in Türkiye (44.4%) than in Palestine (8.0%) (χ² = 22.913, p < 0.001). Moreover, the participants were asked to indicate one or more reasons for not reporting violence. A total of 192 responses in Palestine and 60 in Türkiye were obtained. The findings show very similar responses for not reporting violence in both setting settings (Fig. 4): 40.9% indicated that there is no benefit to reporting because, from experience, no follow-up or action will be taken against perpetrators (40.6% in Palestine and 41.7% in Türkiye, respectively), 32.1% were not an important incident to report (33.3% and 28.3%, respectively), 11.1% feared consequences on themselves or jobs if they reported (10.4% and 13.3%, respectively), 4.0% did not know whom to report (4.2% and 3.2%, respectively), and 1.2% because they experienced shame from the incident, which was reported only by participants in Palestine (1.6%). Other reasons accounted for 10.7% of the total responses: 9.9% in Palestine and 13.3% in Türkiye.

Fig. 4

The percentage of reasons for not reporting violence

Violence prevention and control measures

In Türkiye, 64.2% of the participants indicated that there is a violent deterrent element, such as security, cameras, alarms, and communication systems, in their EDs, whereas 34.4% of the Palestinian participants did (Fig. 5). Moreover, 54.7% of the respondents indicated that there are policies/procedures and that they have received training on violence prevention and management, respectively 17.5% and 12.4% in Palestine compared with 54.7% and 48.6% in Türkiye. All these differences in violence prevention measures are statistically significant (p < 0.05).

Fig. 5

Percentages of availability of violence prevention measures in EDs. Note: Significance of differences in the availability of violence prevention measures between countries: χ2 = 56.330, p < 0.001; χ2 = 31.876, p < 0.001; χ2 = 59.636, p < 0.001

Impact of violence

The participants were asked to indicate whether they intend to leave working in EDs (using a 5-point Likert scale), where 59.6% of them responded as likely or very likely: 62.5% in Palestine and 50.8% in Türkiye (χ2 = 18.684, p = 0.012). Additionally, they were asked about the effect of exposure to violence (Fig. 6), whereas 27.3% of them indicated that it led to feelings of hopelessness/disappointment (27.6% and 26.6% in Palestine and Türkiye, respectively), 24.9% minimized communication and contact with patients and their families/companions (24.3% and 26.6%, respectively), 10.4% minimized time of patient care (10.3% and 10.9%, respectively), 6.8% fear and anxiety (3.8% and 15.6%, respectively), 6.4% desired revenge (8.1% and 1.6%, respectively), 4.4% avoided taking decisions that might involve medical risks (3.8% and 6.3%, respectively), and 2.5% experienced guilt (2.1% and 3.1%, respectively). Notably, 20% of the participants in Palestine indicated that violence had no impact on them, whereas 9.4% of those in Türkiye did (χ2 = 17.016, p = 0.017).

Fig. 6

The percentage of reported impact of exposure to aggression

Discussion

The main aim of this study was to compare the patterns of workplace violence in EDs in two different countries. Our findings revealed significantly greater exposure of HCWs in Palestinian EDs to WPV (Fig. 1), which was greater than the levels previously reported [15] and twice as high as those reported by their Turkish colleagues (p < 0.05). Moreover, the prevalence of violence in Turkish EDs is lower than that reported in earlier studies [20,21,22]. Although both countries, like other countries [5, 24], suffer from overcrowding due to nonurgent visits [14, 25, 26], the studied EDs in Türkiye have triage processes in which patients are assessed and prioritized according to their clinical conditions; however, in Palestinian hospitals, this system is not functional. It has been also reported that long waiting time is the main reason for aggression against HCWs in Turkish hospital EDs [26]. The higher prevalence of WPV in Palestinian EDs can be explained by the reality that these serve as the primary source for emergency services in the cities of the West Bank; they are also under resourced, their staff lack specialized training that they need, and they are often overcrowded with sick patients in addition to the flux of injuries and traumas caused by the ongoing conflict [27]. These conditions contribute to the vulnerability and exposure of HCWs to workplace violence [7, 28].

The most reported form of violence was nonphysical, especially verbal assaults, which reached 77.5% in Palestine and 39.3% in Türkiye (p < 0.05). Sexual harassment was the least reported, accounting for 16 cases (7%) in Palestine and 2 cases (1.7%) in Türkiye, but this number was lower than that previously reported in both countries [15, 22]. The degree of physical aggression toward HCWs in Türkiye (16.7%) is lower than that in Palestine (35.7%) and previously reported (41.1%) [22]. However, the most aggressive mode of physical violence that can have harmful effects on victims, such as throwing instruments/equipment and the use of weapons/sharps against HCWs, was considerably greater in Türkiye (20%) than in Palestine (3.5%) (p < 0.05) and those previously reported [21]. Generally, the prevalence of physical violence especially aggression using weapons and sharps in Turkish society has been on rise in recent years [29]. In relation to that, our findings showed that only in 13.6% of the cases, 8% in Palestine and 44.4% in Türkiye, actions were taken against the perpetrators of violence. The lack of effective punitive actions against perpetrators is a major factor for increasing physical violence against health workers [5].

Physicians are exposed to violence, whether physical or nonphysical, in both countries, followed by nurses and other workers (Fig. 1). This is consistent with international studies [5] as well as with the previous studies in both settings that showed that physicians are the most targeted ED workers in aggression [15, 17, 21]. In the two countries’ cultures, attitudes toward physicians as the primary entity very often target the aggression of anxious patients and/or their families/companions when their expectations are not fulfilled. Nurses in both settings are also seriously targeted by violence, especially physical violence (31.1%) and, noticeably, violence in Palestine (35.9%) compared with Türkiye (16.5%) (p < 0.05). This is probably because most of the nurses (70.6%) in Palestinian EDs are males. Moreover, exposure to violence (both physical and nonphysical) is greater among females in Türkiye than among males, whereas the opposite is true for Palestine (p < 0.05), which is clearly inconsistent with the findings of previous studies in Türkiye [20,21,22] and might be due to the social vulnerability of females in the region of study. Liu and colleagues [5] systematic review study findings showed that females have lower risk of exposure to both physical and non-physical violence than males, but the differences were not found statistically significant (p > 0.05). However, Maguire and colleagues [30] reported higher exposure among female ED workers than males in their review.

In our findings like in other earlier [15, 22] and international studies [6, 31], the main perpetrators of violence were patients’ families and companions as well as the patients themselves. The high stress and anxiety of the patients and their families and their expectation of prompt attention to their needs together with inadequate information provided about their situation are the key reasons for aggressive behavior against HCWs in EDs. Effective communication with patients and families plays a crucial role in the prevention and control of violence in EDs. In this sense, health personnel providing brief information about the care process for patients and their relatives can significantly reduce the degree of violence that may occur in EDs. The person who receives the information he/she might need about the patient’s condition can remain calm; otherwise, as the anxiety level increases, the tendency to perpetrate violence can also increase.

While serious incidents of colleague aggression are minimal in both settings, other group aggression is obvious in Palestine (4.9% of the physical and 8.1% of the nonphysical assaults). This would probably include the occupation of military forces raiding health care institutions during times of conflict. Health care institutions and workers are at an increased risk of aggression in conflict zones [7, 28]. For the timing of assaults (Table 3), the results show that incidents were concentrated in the morning and afternoon, probably when the EDs become overcrowded with patients seeking care after the work hours of the primary health care centers in the two settings. Patients and their families become frustrated due to prolonged waiting times and are more aggressive when their expectations are not met by the care team [15, 16]; evidently, approximately half of the incidents in both settings took place in the treatment and examination rooms. Another important system-related factor is inadequate measures to prevent and control WPV in both settings (Fig. 3).

Workplace violence prevention and control measures must be considered in the context of the health care system via a holistic approach [5, 32]. According to our findings, Palestinian EDs obviously lack violence deterrent measures, training on violence prevention and control methods, and incident reporting systems (Fig. 4). The same shortages have also been reported by less than half of the participants in the Turkish EDs. Essential components of a violence prevention system are an adequate legal structure and an efficient incident reporting mechanism that provides the data needed for developing prevention and control strategies that can prevent future attacks [1]. In Türkiye, in light of the growing debate, laws are better established to protect against violence against health workers, and a violence reporting system called the “White Code” was inaugurated in 2016 to allow the reporting of aggression against health workers in public and teaching hospitals [33]. The system also provides legal support for victims per request, while reported cases are automatically investigated and transferred to the judiciary system [33]. In Palestine, however, adequate laws are very weak, and systematic violence reporting mechanisms in hospitals are still lacking. This makes it very difficult to sue aggressors, and cases are mostly settled out of the judiciary system. Moreover, our findings revealed a very low level of incident reporting, which was significantly lower (13.7%) in Palestine than in Türkiye (37.9%). The major reasons behind this are the belief that it is a useless process and that no action would be taken against aggressors, seeing incidents, particularly nonphysical incidents, as unimportant and probably unavoidable parts of the job, in addition to the fear that reporting would produce undesired consequences on them and on their job (Fig. 5). These findings and findings on reporting behavior are supported by earlier evidence [6, 15, 22, 34, 35].

The implications of physical and nonphysical exposure for HCWs and the delivery of health care services are immense [24, 36]. WPV occurrence is associated with increases of stress, fatigue, job dissatisfaction and consequently turnover of HCWs resulting in decreased productivity and quality of health care services they provided to patients as well as [6,7,8, 37, 38]. Our findings in both settings equally showed significant negative psychological effects, such as hopelessness, disappointment, fear, anxiety and sometimes feeling or guilt, among the victims of violence in EDs (Fig. 6). Moreover, the negative effects on the delivery and quality of health care services, such as minimizing communication, contact and the time patients spend with patients, avoiding decisions of a risky nature, and even sometimes feeling revenge, have also been reported by the participants (Fig. 6). Exposure to violence makes it difficult to retain staff in emergency services. Our results show that more than half of HCWs exposed to violence seriously consider leaving work in EDs. This poses a significant challenge for health care systems and undermines their ability to retain human resources that are essential for delivering needed emergency services [39].

Limitations

This study has employed a retrospective cross-sectional approach that may entail some limitations that need to be considered when interpreting the findings. Biases in recalling violent events that happened one year and possible socially desirable responses to sensitive questions. Moreover, using face-to-face data collection in one country and online surveys in another is another issue that should be considered. The use of an online survey in Palestine might have potential for selection bias, limiting participations to individuals with familiarity with the platform and internet access.

Conclusions

Contextual differences are evident in the patterns and levels of violence in the studied countries; however, concerns are clearly common regarding the underlying reasons and impacts. The findings show that both settings suffer from considerable levels of workplace violence and negative consequences for HCWs and health care services as well as insufficient measures to combat them. The findings of the study highlight the need for actions to reduce the risks of violence against HCWs in EDs in the studied countries and in other similar settings. A major solution to alleviate overcrowding and decrease the waiting time to receive emergency services, especially in Palestine, is establishing an efficient triage system and increasing the capacity of EDs with adequate staffing levels and training. Moreover, hospitals need to strengthen their measures to prevent and control aggression and protect workers, including security precautions and training, to improve the communication skills of workers with patients and families and their ability to manage violent patients and companions. The importance of incident reporting systems is crucial, and hospitals need to address barriers to reporting and increase staff awareness through providing necessary education, time and support. Deterrent laws against aggressors and suing mechanisms need to be enforced, and public awareness raising and media campaigns are also needed to curb violence against HCWs. Proper actions also need to be taken against perpetrators to curb the aggression against HWCs in Palestine and Türkiye. A collaborative approach among policy makers, hospital administrations, researchers, staff and the public for developing and implementing evidence-based policies and strategies to mitigate the risks of this arduous public health problem is crucial.