Causes of workplace violence and preventive strategies in a tertiary care hospital in North India

For nursing students

Study summary

Workplace violence against healthcare staff is a serious and growing problem worldwide, and emergency departments are among the highest-risk areas because they combine high stress, long waits, and frightened or frustrated patients and families. This study, conducted at a tertiary care hospital in North India (affiliated with PGIMER Chandigarh), set out to measure how common workplace violence is among emergency department staff and to understand its impact on their wellbeing.

The researchers recruited 389 participants, enrolling them consecutively as they obtained informed consent, which is a practical way to study a hard-to-schedule, rotating hospital workforce. Participants completed a "Workplace Violence in Healthcare Setting" questionnaire designed to capture the frequency and type of violence experienced, along with the Trauma Screening Questionnaire (TSQ), a validated tool used to screen for symptoms consistent with traumatic stress reactions. Using a standardized screening tool for trauma symptoms, rather than just asking people if they "felt stressed," allows the study to speak more precisely about the psychological toll of violence, not only its frequency.

The sample was drawn from a range of hospital roles, not just nurses. About 46% of participants were between 30 and 39 years old. Nursing officers made up the largest group at 53.4%, followed by sanitary attendants (17%), hospital attendants (12%), doctors (8.7%), security guards (7.7%), and lab technicians (1.02%). Because nursing officers formed the majority of respondents, the findings speak especially directly to the nursing workforce, though the study captures a broader picture of the emergency department team.

The results were striking: the large majority of participants, 92.5%, reported experiencing verbal violence, and about one in four (25.71%) reported experiencing physical violence. These numbers align with what other Indian and international emergency department studies have found, where verbal abuse is nearly universal and physical violence, while less common, is far from rare. Importantly, the study also looked at reporting behavior and found that staff often chose not to report incidents to their seniors. The reasons given were a perceived belief that nothing would change (inaction), concerns about the time it would take to file a report, and fear that reporting could hurt their career. This gap between how often violence happens and how often it gets formally reported is a recurring theme in workplace violence research and helps explain why the true scale of the problem can be underestimated by hospital administrators.

When asked what they believed caused this violence, participants pointed to a cluster of related factors: patients and families having unrealistic expectations about what care could achieve, gaps in the public's basic knowledge about diseases and treatment, shortages of resources, overcrowding in the emergency department, and long waiting times before being seen. These are largely systemic and environmental factors, not simply a matter of individual "difficult" patients, which is an important distinction for how solutions should be designed.

Participants themselves suggested several preventive strategies: educating the public about healthcare processes and realistic expectations, and improving healthcare facilities and infrastructure so that overcrowding and delays are reduced. The study's conclusion draws these threads together: workplace violence in hospitals is linked to overcrowding, long waits, inadequate public knowledge, and the absence of effective systems for handling complaints, and it can damage both the quality of patient care and staff morale. The authors recommend a multi-pronged response, including better resource management, stronger communication skills training for staff, public education campaigns, infrastructure improvements, self-defense training, legislative measures to protect healthcare workers, and effective, trusted complaint systems.

For nursing students, this study is a useful reminder that workplace violence is rarely just about one "difficult" encounter. It is shaped by the conditions around care delivery, including wait times, staffing, and how well patients understand their own care. It also highlights that fear of career consequences can silence reporting, which is something nursing programs and hospital leadership need to actively counter with safe, supported reporting pathways.

For educators

Teaching and appraisal notes

This is a cross-sectional survey study conducted at a tertiary care hospital in North India (author affiliations indicate the National Institute of Nursing Education, PGIMER, Chandigarh, with one co-author from the Department of Hospital Administration, PGIMER). The study addresses a well-established but persistently under-addressed problem: workplace violence directed at healthcare staff, with a particular focus on the emergency department, which the literature consistently identifies as a high-risk clinical area due to time pressure, overcrowding, and high-acuity, high-anxiety patient encounters.

Methodologically, the study used consecutive, non-probability enrollment of 389 participants following informed consent, which is a pragmatic approach for capturing a rotating, shift-based hospital workforce but limits generalizability compared to random sampling. Two instruments were used: a "Workplace Violence in Healthcare Setting" questionnaire to characterize exposure and type of violence, and the Trauma Screening Questionnaire (TSQ), a validated brief screening tool for post-traumatic stress symptomatology. Combining an exposure questionnaire with a validated psychological screening instrument is a methodological strength, as it allows the study to move beyond simple prevalence counting toward documenting potential psychological sequelae, though the abstract as available does not report the TSQ score distributions or cut-off-based prevalence of probable PTSD, only that the tool was used to "evaluate an individual's responses to traumatic events."

The sample was multidisciplinary: nursing officers were the largest occupational group (53.4%), with sanitary attendants (17%), hospital attendants (12%), doctors (8.7%), security guards (7.7%), and lab technicians (1.02%) also represented. This is a notable strength for faculty discussion, since much of the workplace violence literature in India and internationally has focused narrowly on nurses or doctors; this study's inclusion of support staff (sanitary and hospital attendants, security) broadens the picture of who is exposed to violence in the ED ecosystem, and who may need to be included in any institutional response.

Key findings were a very high rate of verbal violence exposure (92.5%) and a substantial rate of physical violence exposure (25.71%), a verbal-greater-than-physical pattern broadly consistent with the wider Indian and international ED literature, even though direct numerical comparison is limited by differing instruments, denominators, and recall windows across studies. A particularly instructive finding for discussion is the underreporting phenomenon: participants avoided reporting incidents to seniors due to perceived futility (belief that nothing would change), time burden, and fear of career repercussions. This is a well-documented barrier in the broader Indian workplace-violence-in-healthcare literature and is worth using as a discussion anchor for why prevalence figures based on self-report surveys, rather than institutional incident reports, are likely closer to the true scale of the problem.

The authors' conclusions link violence to systemic and environmental drivers, overcrowding, long waits, inadequate resources, and gaps in public health literacy, rather than framing it primarily as a matter of individual patient behavior. This framing supports a systems-level, rather than purely individual-resilience-based, approach to prevention. The recommended interventions span multiple levels: operational (resource management, reducing wait times and overcrowding), educational (public health literacy campaigns, staff communication skills training, self-defense training), structural (infrastructure improvements), and policy/legal (legislative protections, functional complaint and redressal systems).

For teaching purposes, this study offers a compact case for discussing survey design trade-offs (consecutive convenience sampling versus random sampling), the value of pairing exposure surveys with validated psychological screening tools, and the gap between violence incidence and institutional reporting. It also invites comparison with the broader South Asian and Western Pacific literature on nurse-directed workplace violence, and can anchor discussion of a systems-based prevention bundle for Canadian acute-care settings facing similar overcrowding pressures.