Workplace violence against security personnel at a university hospital in Egypt: a cross-sectional study

Introduction

Workplace violence (WPV) is well-defined as any act or danger of physical violence, harassment, bullying, or other disruptive activities at the workplace that may result in physical or emotional problems¹. The literature and news show that violence is common globally and occurs every day in various public spheres, including the health system².

Healthcare violence reflects violence in society in general. However, violence contradictory to social expectations that hospitals are sites that denote security, care, sympathy, and lifesaving. It is hard to acknowledge that violent incidents occur commonly in hospitals and in some situations physical violence in hospitals can be exceedingly dangerous³.

Healthcare WPV is an underestimated and constant problem that has been widely overlooked. Many healthcare organizations and institutions that are considered safe resorts are now facing “steadily growing rates of crime, including violent criminalities such as stabbing, rape, and homicide” as stated by Phillips⁴. According to the US Agency of Labor Statistics 2007 report, violence occurs more habitually in healthcare and social support organizations than in any other labor force segment and is responsible for 60% of all nonfatal assaults within this segment⁵.

The majority of research studies have revealed that following an incident of WPV, there are high rates of lost working days, burnout, and dissatisfaction, in addition to decreased feelings of wellbeing among staff members^6,7. In return, fright at work has even driven some healthcare personnel to protect themselves by carrying weapons, mostly firearms or knives⁸.

Hospital security officers are required to protect the safety of healthcare workers, hospital guests, and patients. They are asked to assist in control of violent situations and are consequently at an elevated risk to tolerate violence-associated incidences and are therefore recognized as a group at high risk of being attacked⁹. They are often disregarded in the literature concerning healthcare violence-related incidences. The comparatively few studies that do involve hospital security staff demonstrate that these workers are among groups with the highest rates of violence-related incidences within the healthcare setting^10–12.

The significance of policies and security staff training has been accepted and various hospitals offer limitation tools and weapons to security personnel. Such establishment, chiefly of non-lethal intermediary weapons (e.g. conducted electrical weapons) or lethal weapons (e.g. handguns) has been conflicted owing to the moral, legal, and financial issues related to the well-being and safety of patients and staff in hospitals^13,14.

WPV directed towards hospital security staff has seldom been studied in developing countries including Egypt; thus, the actual magnitude of the problem is unknown. The purposes of this study are to estimate the prevalence and associated issues of different types of violence against hospital security personnel, conditions of violence, category of perpetrators, and victims’ reaction in a university hospital setting.

Methods

Results

The questionnaire was completed by 150 out of 170 legible security personnel (response rate 88.2%) who reported a total number of 553 workplace events in the past year.

The majority (87.3%) of security personnel reported exposure to violence in the past year. Being a woman and working for over 5 years were independent predictors of violence exposure (adjusted odds ratio (AOR) = 7.7 and 10.1, respectively; Table 1).

Table 2 shows that the commonest suggestions from participants to prevent violence were training (73.3%) and assigning a large number of personnel (62.7%), while Table 3 shows that the commonest forms of physical violence reported by personnel were pushing (24.8%), beating (18.6%) and throwing objects (12.3%). The threat of physical force and verbal abuse were the commonest emotional violence experienced by participants (23.7% and 20.4%; respectively). Patients’ relatives/friends and patients themselves were the commonest perpetrators of violent events (72.5% and 23.3%; respectively).

Table 4 shows that security personnel were alone in more than one-third of WPV events. In addition, more than two-fifths and more than one-third of violent events occurred during evening shifts and official vacation other than Friday, respectively. More than one-fifth of violent events were reported to the hospital administration. Only 3.8% of perpetrators received a verbal warning from the directors and only 2% of 553 reported events resulted in a lawsuit against the perpetrator.

Table 5 shows that participants reported that the commonest effect of violence was being bothered (80.9%), being fearful (69.5%), and having work dissatisfaction (61.8%) and anger/anxiety (47.3%). The commonest coping mechanisms were reporting to directors/supervisors (94.7%), telling family/friends (92.4%), pretending the event did not occur (77.1%) and replying to perpetrators themselves at the time of the event (74.0%).

Discussion

Hospital security workers, who are trained to offer tertiary prevention on escalation of an event, have also been acknowledged as a group at an increased risk of being assaulted^12,16 and in need of tools to identify, alleviate, and avoid violent events in hospitals¹⁷.

In this study, the majority (87.3%) of security personnel reported exposure to violence in the past year. A similarly high prevalence (63.8%) of type II violence, which is perpetrated by a client receiving services from an organization, such as a patient or guest, was reported among security guards and police officers in a study of six US hospitals¹⁶. This high prevalence could be attributed to the nature of the work of security personnel, who repeatedly interfere in efforts to protect both staff and patient safety and are frequently injured in occurrences with violent patients¹⁸. It has been previously acknowledged that hospital safety and security employees are often ignored in the healthcare violence-related injury literature⁹. There are relatively few studies involving hospital security workers and these have revealed that these employees have some of the highest rates of violence-related incidences within hospitals, anywhere from 2 to 5 times as many incidences as nurses^{10–12,19–21}. However, almost no studies have been carried out to discuss the risk and protective factors for hospital security employees⁹.

In this study, being a woman and working for more than 5 years are independent predictors of violence exposure (AOR=7.7 and 10.1; respectively). Several studies reported that younger and less experienced security officers have elevated rates of violence-related incidences^8,12,22–25.

In contrast to these findings, a study conducted in the Midwest US, showed that both age and gender were not associated with verbal violence, although, while healthcare workers more than 60 years old were less exposed to physical violence (odds ratio (OR) = 0.31, p<0.05)²⁶. In another study of US hospitals, the higher prevalence of WPV across all sub-types in workers of a younger age suggested that younger workers are more prone to be victims¹⁶. Older workers may be more tolerant of these events resulting in their under reporting²⁷ or they may be more skilful at event de-escalation.

Most studies that investigated gender of recipients of violence-related incidences in healthcare reported that men are more liable to experience these injuries more than women^{11,12,23,28–30}, while others have not found difference in rates based on victims’ gender^31,32.

The commonest suggestions to prevent violence in the current study were training (73.3%) and assigning a larger number of personnel (62.7%). The results of a survey of healthcare specialists from 19 hospitals in six cities of Heilongjiang Province, China are in agreement with our results, where the respondents exposed to WPV expected to obtain organizational and social support. Those exposed to psychological violence had a strong opinion of the need for targeted training to support their proficiency in responding to violence (OR = 1.319, 95% CI: 1.034–1.658) and endorsing WPV legislation (OR = 1.968, 95% CI: 1.523–2.543). Those exposed to physical violence incidences thought it might be helpful to strengthen staff with back-up support (OR = 3.101, 95% CI: 1.085–8.860)³³.

The commonest forms of physical violence in this study were pushing (24.8%), beating (18.6%) and throwing objects (12.3%). The threat of physical force and verbal abuse were the commonest emotional violence experienced (23.7% and 20.4%; respectively). Patients’ relatives/friends and patients themselves were the commonest perpetrators of violent events (72.5% and 23.3%; respectively). Similarly, verbal abuse (32.8%) was the most prevalent subtype of type II violence among security guards and police officers in the US followed by physical threat (24.1%), then finally physical assault (6.9%)¹⁶.

Also, in the Emergency Department (ED) in Ankara, Turkey, regarding frequency of physical violence, security officers (75%) described higher rates than other professions working in the ED (p<0.0001); exposure to any form of verbal abuse was highest among housekeepers (90.9%) and security officers (90.6%). In that study, self-reported verbal threat and sexual harassment among security officers was 75% and 15.6%, respectively. Relatives or friends accompanying patients were most frequently responsible for the violence, and this confirms what was concluded in a previous study³⁴.

In a study within a large hospital system in Midwest US, nurses (OR = 1.87, p≤0.01) and security personnel (OR = 4.71, p≤0.01) reported verbal violent events in the past year more than any other job groups. Also, security staff (OR = 30.79, p≤0.001), registered nurses (OR = 2.72, p≤0.05), and mental health specialists (OR = 18.71, p≤0.01) were at a higher risk for physical violence²⁶. These findings concerning physical violence consolidate other previous studies that have documented security personnel, mental health specialists, and nurses as being at higher risk^11,16.

In this study, security personnel were alone in more than one-third of events. Additionally, more than two-fifths and more than one-third of violent events occurred during evening shifts and official vacation other than Friday, respectively. More than one-fifth of violent events were reported to the hospital administration. Only 3.8% of perpetrator received a verbal warning from the directors and only 2% had a lawsuit against the perpetrator. In a study from Israel, security employees emphasized the contribution of the behaviour of physicians and nurses to the development of a violent incident, especially verbal interaction, and delayed response time. A previous study reported that clinical staff had a negative attitude towards security personnel and considered that calling them to situations is a contributing factor to the development of a violent episode, which can escalate the situation and should be avoided if not necessary².

In the present study, the commonest effects of violence were being bothered (80.9%), being fearful (69.5%), and having work dissatisfaction (61.8%) and anger/anxiety (47.3%). The commonest coping mechanisms were reporting to directors/supervisors (94.7%), telling family/friends (92.4%), pretending the event did not occur (77.1%) and replying to perpetrators (74.0%). Similarly, the most commonly reported reaction of ED staff in Turkey was sadness for sexual harassment (86%), physical assault (82.9%) and verbal threats (82%). The other reactions were anger for physical assault (83.8%), disappointment for verbal threat (79.3%) and disgust for physical assaults (69.3%). However, the most common coping method was “Doing nothing and keeping silent” (37.2–59.5%), followed by reporting to a manager (56.8%) for physical assaults, but this method is the least commonly used among participants experiencing verbal abuse (35.8%), verbal threat (34.7%) and sexual harassment (34.9%)³⁴.

Data availability