Abstract
Workplace violence (WPV) in the health sector is a global public health issue. The magnitude of WPV is a particular concern in China’s health system. To examine the potential causes of WPV, we analyzed 3,045 qualitative responses to an open-ended question in a survey with health workers in the Zhejiang province, China. We adapted a four-level socio-ecological framework (societal/systemic, community/organizational, interpersonal, and individual) to thematically analyze the data. Ten sub-themes emerged. Within the societal/systemic level, we identified three sub-themes: (a) lack of legislation against WPV, (b) suboptimal accessibility and affordability of health services due to maldistributed health resources, commercialized health services, and inadequate health insurance, and (c) unregulated mass media reports. Within the community/organizational level, three sub-themes emerged: (a) lack of supportive health facility leadership, (b) inaction by government authorities, and (c) inefficient law enforcement agencies. Within the interpersonal level, two sub-themes were identified: (a) poor provider–patient communication and (b) distrust between health workers and patients. Finally, we identified the personal characteristics of health workers (e.g., competence and professionalism) and patients (e.g., sociodemographic background and expectations/satisfaction) as two individual-level sub-themes.
We recognized interactions among different levels. The weak state of Chinese legislation in this area and lack of high-level political will and guidance (societal/systemic) has left health facilities and law enforcement agencies (community/organizational) unclear about how to address WPV. The maldistribution of quality health resources (societal/systemic) has led to overcrowded outpatient clinics at higher-level care facilities (community/organizational). In light of the insufficient government funding and profit-oriented health services (societal/systemic), health workers were motivated to seek profits by providing unnecessary services, which compromised their professionalism (individual). Provider–patient relationships deteriorated (interpersonal), and patients sometimes held unrealistically high expectations associated with high medical expenses (individual). We propose multisectoral prevention strategies to address WPV in the health sector at all levels using a socio-ecological framework.
Background
Workplace violence (WPV) is a global public health problem (World Health Organization [WHO], 2002). Forms of WPV include verbal violence, physical violence, psychological abuse, sexual harassment, sexual assault, and homicide (Di Martino, 2002). Among industries, the health sector is disproportionally affected by WPV, and health workers are at a high risk of WPV (WHO, 2002). WPV incidents against health workers have been reported in the United States, the United Kingdom, Thailand, Iran, Germany, Jamaica, India, and many other countries (Ambesh, 2016; Bawaskar, 2014; Cooper & Swanson, 2002; Di Martino, 2002; Fallahi-Khoshknab et al., 2016; Franz et al., 2010; Jackson & Ashley, 2005; Kamchuchat et al., 2008; Phillips, 2016). WPV has been increasing in China’s health sector, and 62.4% of the country’s health care workers have reported experiencing WPV, according to a recent systematic review of 44 studies (Lu et al., 2018). China has a low homicide rate overall, compared to other countries, but it has a rather high murder rate in the health sector (Hesketh et al., 2012). Between 2001 and 2018, at least 50 health workers, mostly physicians, were murdered in hospital settings in China (Xiao, 2018). In addition, a unique form of WPV, Yi Nao (an organized criminal group hired by or composed of patients or their families that often uses extreme violence and disruptive behaviors to extort monetary compensation from health facilities), is a particular concern of the Chinese health system (Hesketh et al., 2012; Yang et al., 2019). WPV can lead to physical harm, mental distress, concerns about personal safety at work, reduced productivity, increased burnout, reduced job satisfaction and low morale (Wu et al., 2014; Xing et al., 2016) and brain drain of the health workforce (Wu et al., 2014). However, despite the increasing levels of WPV against health workers and its adverse consequences, few preventive actions have been taken to address these problems in China.
Local evidence is essential for individual countries’ efforts to develop appropriate anti-WPV programs in the health sector and to devise locally appropriate actions and campaigns. The World Health Organization (WHO) has published framework guidelines and relevant research tools for countries to adapt and use to collect local evidence (WHO, 2002). Both quantitative and qualitative data are important for understanding the issue (Richards, 2003), but previous Chinese studies have only focused on the epidemiological component. Potential correlates of WPV in China’s health system reported by earlier cross-sectional survey studies include age, sex, the tier of the health facility, the education, and type of health workers, subspecialty or department, professional ranking or years of practice, work shift, and the organization’s supporting policies (Jiao et al., 2015; Li et al., 2017; Sun, Zhang, et al., 2017; Wu et al., 2012; Yang et al., 2019).
The number of qualitative studies on WPV in China’s health sector is grossly limited. Only two qualitative studies conducted before 2015 were identified (Cai et al., 2011; Tucker et al., 2015). These highlighted several reasons for patient distrust and WPV, including health providers’ profit-making practices, high medical expenses, insufficient communication, the maldistribution of a quality workforce, poor quality of care, and insufficient medical ethics education (Cai et al., 2011; Tucker et al., 2015). However, these studies have a limited scope, and a more comprehensive understanding of the causes of WPV is warranted.
This study’s purpose was to gain an in-depth understanding of factors contributing to the widespread WPV in China, according to health care workers, using a socio-ecological framework recommended by the WHO Violence Prevention Alliance (Violence Prevention Alliance, 2019). The study analyzed qualitative responses to an open-ended question in a large-scale survey conducted in China’s Zhejiang province. We propose prevention strategies based on the socio-ecological framework to provide potential directions for future interventions.
Methods
This study is a qualitative analysis of participants’ responses to an open-ended question from a questionnaire survey with health workers in Zhejiang, China. This method has been widely accepted and adopted in previous research (Jackson & Trochim, 2002; Mossholder et al., 1995; Popping, 2015; Roberts et al., 2014).
Study Population and Design
We conducted a cross-sectional survey between July 2016 and July 2017 in an eastern province of China that has a population of 56 million people, including 500,000 health sector workers (Health and Family Planning Commission of Zhejiang Province, 2018; Zhejiang Provincial Bureau of Statistics, 2018). China has a three-tiered health service delivery system (Eggleston et al., 2008), and our target population comprised health workers who had patient contact at health facilities from all tiers.
We adopted a proportionate stratified sampling strategy to include health facilities at all three levels in both urban and rural areas. The study methods have been published elsewhere (Yang et al., 2019). We selected primary care facilities that provided primary health care to the population of a district or a town, as well as tertiary and secondary hospitals located in cities and counties that aimed to provide referral care to the populations residing in their administrative areas. Specifically, a total of 45 health facilities were included in the study: five tertiary hospitals; eight secondary hospitals; and 32 primary care health facilities, including 16 urban community health centers and 16 rural township health centers.
We obtained permission from the hospital managers or primary care facility directors to survey the health workers. We invited health workers on duty on surveying days to complete the questionnaire. These workers included doctors, nurses, laboratory staff (who needed to dispense sample containers and collect biological samples from patients), and administrative staff who had patient contact in their daily tasks. The purpose of the study was fully explained to the participants before the survey, and the front page of the questionnaire included a statement of consent. Anonymity and confidentiality were assured. The senior author, who also served as the principal investigator of the project, oversaw the data collection.
Ethics
The ethics committee of our university reviewed and approved this study. We informed participants that the survey was voluntary and obtained verbal consent before the commencement of the survey.
Study Instrument and Data Analysis
The study used the questionnaire survey tools on WPV recommended by the WHO (Di Martino, 2002; Xing et al., 2015). We asked an open-ended question at the end of a questionnaire survey: “What factors or reasons do you think are causing WPV in China’s health sector?” We extracted the text responses to this question, merged them with the respondents’ sociodemographic characteristics, and created a database. Content analysis, a research method for the subjective interpretation of the content of text data through the systematic classification process of coding and identifying themes or patterns, was used to analyze the open-question data (Hsieh & Shannon, 2005). Frequencies of themes and sub-themes, which can enhance internal generalizability of the qualitative research findings within a study (Maxwell, 2010), were calculated and reported. A mixed inductive and deductive coding approach was used to code the data (Hsieh & Shannon, 2005).
We adapted the four-level socio-ecological model to guide the thematic analysis deductively. (Violence Prevention Alliance, 2019). The framework acknowledged the complex interactions that exist both among the different levels and within individual levels. We held two group meetings to develop the four-level social-ecological framework using individual, interpersonal, community/organization, and societal/systemic levels to guide the analysis. Then, two research assistants, master’s degree students majoring in social medicine with qualitative research experience, coded the data independently. Additional new codes were allowed to emerge inductively from the raw data. Coding inconsistencies were resolved through discussions with a third person. Codes were then organized and grouped into themes and sub-themes. NVivo 12, a qualitative data coding and retrieving program, was used to code and group the thematic findings. The frequencies of the themes and sub-themes were then calculated and reported. Descriptive analyses were conducted to summarize the sociodemographic backgrounds of the respondents using Stata 16.0 (StataCorp LP, College Station, TX, United States).
Results
Sample Characteristics
A total of 4,862 participants responded to the questionnaire, and 3,045 responses to the open-ended question were included in the analysis. Table 1 presents the characteristics of the respondents who answered the open-ended question. Among the 3,045 participants, 40.4% were doctors, 39.5%were nurses, 14.3% were laboratory staff and 3.1% were administrators.
Characteristics of Respondents and Non-respondents of the Open-ended Question.
Factors Contributing to WPV
Table 2 shows the frequencies of sub-themes organized under the four-level socio-ecological analytical framework. In this section, we present factors within each level and interactions within and among the different levels.
Contributing Factors Within a Four-level Socio-ecological Framework (n = Frequency of Mentions).
The Societal and Systemic Levels
Lack of legislation against WPV
Legislation against WPV is absent in China (509 mentions). A 34-year-old primary care physician (Participant ID (PID) 491) mentioned, “There are no policies or laws [against WPV]. Hospitals and physicians end up being the ones who pay monetary compensations [to reconcile conflicts].” Many other participants echoed similar thoughts, including “the country does not have legislation in place to protect health workers’ personal safety” (PID 3526), “Because there is no legislation and patients are always seen as a vulnerable group, it feels like hurting physicians is not hurting human beings” (PID 402); “most relevant laws protect patients’ interests, which in this case becomes a ‘sharp weapon’ with which they can attack us” (PID 1114).
Health system factors.
Accessibility and affordability of health services were relevant systemic factors (430 mentions). Three sub-themes emerged under this category: maldistributed health resources and unmet demand, the commercialization of health services provided by government-owned health facilities, and financial burdens for patients.
Maldistributed health resources and unmet demand.
Limited and maldistributed health resources, such as the workforce, were frequently mentioned as a systemic contributor to WPV against health workers (190 mentions). PID 3152 noted, “We are so understaffed that we can’t provide good quality services,” while PID 1126 commented, “Health resources in the public sector are too limited to meet the increasing demand for health services.” The fragmented health system leads to “good quality health resources being concentrated in higher-level hospitals led to patients flocking to these hospitals. As a result, physicians in these hospitals are routinely overworked” (PID 898). As revealed by one administrator (PID 1091) from a tertiary hospital, “Many patients have to wait in very long queues, which leads to discontent.”
The commercialization of health services provided by government-owned health facilities.
Public facilities depend on revenue generated from patients to maintain their operations, due to insufficient public funding (43 mentions). As PID 1144 mentioned, “It’s not right to commercialize public medical services. Hospitals are defined as ‘public’, but are de facto profit-oriented because public funding is insufficient to maintain normal operations, such as by paying staff salaries.” Some participants mentioned that unnecessary tests and medicines are a problem (PIDs 547, 1144, 1417 and 1511). Hospital staff also “suffer from both physical stress [in seeing patients] and mental stress [in revenue generation],” PID 1688 commented.
Financial burdens for patients.
There were 197 mentions of high medical expenses and inadequate health insurance coverage. PIDs 78, 2865, and 4733 noted that the over-provision of unnecessary services increases medical expenses and financial burdens for patients due to the commercialization of health services. PIDs 2281, 4356, and 4360 revealed that patients’ complaints about limited insurance coverage and high out-of-pocket payments are common. PIDs 1044, 2199, and 2688 mentioned that these have compromised the affordability of medical services in the public sector.
Mass media
The mass media was widely believed to have played a major role in shaping public opinions and increasing WPV against health workers. Distorted or even fabricated media reports were mentioned by 616 participants. For example, PID 1810 shared that “the mass media has been dramatically harming the images of physicians and spreading the message that physicians decide on medications or surgeries based on how much profit they can make.” Some media outlets have even fabricated medical disputes. For example:
Press A reported on a female patient’s anus being sewn up at a women’s hospital in Shenzhen, which turned out to be a false report. To attract eyeballs and earn more clicks, some media articles distorted, exacerbated or reported only part of the true story. (PID 481)
Some widespread media reports have also portrayed health workers in a negative light, leading to sentiments against them. “Some bad media reporting has misled the public, creating hostile public sentiment against physicians,” noted PID 481. PID 521 echoed, “There are too many negative media reports and too few positive vibes surrounding health services.”
Another important characteristic of the widely reported WPV incidents against health workers is that there were no follow-up reports about the consequences to perpetrators, or the very slight penalties they faced. PIDs 558 and 2069 revealed that negative media reports did not include information about the consequences to perpetrators. This makes perpetrators even more aggressive. A false message that violent behaviors occurred without severe consequences might lead to copycat behaviors. “Such media reports just enlighten some illegal gangs that they can make money by beating up physicians,” and “they think that perpetrators do not need to bear any ill consequences for hurting physicians,” said PIDs 2069 and 2155, respectively.
The Community/Organizational Level
Many respondents suggested that tolerance of WPV by multiple types of organizations contributes to WPV in the health sector. These included a lack of supportive health facility leadership, inaction from governmental authorities, and inefficient law enforcement agencies.
Health facilities.
A lack of support and action from health facility leadership in preventing and dealing with WPV was frequently reported (186 mentions). PIDs 40 and 486, respectively, mentioned that “hospital regulations require our staff not to respond when we are attacked. There are insufficient protections for staff in the hospital,” and “hospital directors are tolerant of patient perpetrators without any principles. They just want to bring it down and do not want to report it to higher levels of authority. This only compromises our benefits. Such blind tolerance only makes this worse!”
One female primary care physician (PID 491) commented, “We do not feel secure at work because even after a violent incident occurs, there are no sick leaves or further protections implemented in the facility.”
One important reason for hospitals’ tolerant attitudes towards WPV was the potential negative impact of the violent events on the hospitals’ reputation. PID 4762 said:
It’s because of the impact [of the incident] on the hospital’s image and reputation. No matter who should be responsible for the incident, if it has occurred, outsiders will blame the hospital. This really reduced doctors’ morale, and we do not want to take care of patients with severe conditions [due to higher mortality rates among them]. It’s very frustrating.
Government authorities.
Some respondents believe that government authorities have tolerant attitudes and take no action towards WPV (269 mentions). There were frequent mentions of “no action,” “tolerance,” and “no or insufficient attention to WPV by relevant authorities.” For example, PID 1070 expressed that the “government pays little attention to health workers and is tolerant of violent behaviors against health workers. Workers in the health sector become a vulnerable group.” Another respondent mentioned:
Governments make little effort to deal with violence in the health sector. They always try to reconcile by compromising victims’ interests, leading to Yi Nao groups who aim to obtain monetary compensation from hospitals through using violent behaviours. The more violent you are, the more compensation you get. (PID 1213)
Law enforcement agencies.
Some believed law enforcement agencies downplay WPV incidents against health workers (255 mentions). Impunity or a lack of consequences to WPV perpetrators were mentioned by 251 participants. “There are no consequences to patient perpetrators, making them believe that nobody can do anything to them, even when they violate [health workers],” PID 355 commented. Others revealed that “some perpetrators can just get around punishments by pulling some strings” (PID 2024), and “there are few consequences to such crimes. Some even get monetary compensation by doing so” (PID 4068). PID 351 commented, “Law enforcement agencies make a big problem smaller and trivialize it into nothing. They are afraid that it’s too cumbersome.” PID 724 echoed, “Law enforcement agencies pay little attention, and they often regard WPV incidents as ‘doctor–patient conflicts’ as an excuse for not taking any actions, which fuels more of these crimes.”
The Interpersonal Level
Poor provider–patient communication.
Fifty-four respondents acknowledged an information asymmetry between patients and physicians; however, insufficient communication and poor attitudes were also frequently mentioned (474 times). Fifty-eight respondents mentioned that some health workers had poor or impatient attitudes towards patients. These problems led to inadequate communication. The most direct consequences of miscommunication were patient dissatisfaction and compromised individual patient–physician relationships. “Patients are already anxious and annoyed by their illnesses and the health-seeking process. Poor communication owing to constrained consultation time immediately upsets patients and leads to patient discontent,” said PID 1114.
Distrust between health workers and patients.
Patients’ distrust of health providers or a lack of reciprocal trust between providers and patients was common, with a total of 519 mentions. The deteriorating health provider–patient relationship was believed to be closely related to patient distrust. As commented by PIDs 1069 and 1161, there is a tense provider–patient relationship and decreased patient trust in medical professionals.
The Individual Level (Patients and Health Workers)
Health workers.
Participants’ answers reflected the provider perspective (59 mentions). Fifty suggested there was still room for improvement in clinical skills and professionalism among some health practitioners. “Some health staff do not master the complete set of clinical skills,” and “nursing staff do not have proficient skills,” said PIDs 1372 and 1974, respectively. Some physicians lacked professionalism and overprescribed, according to PIDs 1417 and 1676. There were nine mentions of workers’ insufficient awareness of how to protect their personal safety in the workplace (PIDs 1459, 2754, 4476, and 4822) and claims that they were “unwilling to face such issues and chose to ignore them because of the impunity of WPV” (PID 1639).
Patients.
Patient factors (450 mentions) considered relevant to the occurrence of WPV included patients’ sociodemographic characteristics (education, income, or payment capacity) and patients’ expectations and satisfaction. A total of 276 participants attributed patient aggression to their lower levels of education or poor manners. Another important attribute was related to patients’ high expectations for and dissatisfaction with treatment outcomes and health services (174), which were thought to be affected by high out-of-pocket payments (PIDs 182, 252 308 and 1953), poor health literacy (PIDs 595, 1317 and 1753), and information asymmetry. Some mentioned that patients had unrealistically high expectations for treatment outcomes and health services. Patient disappointment, doubts, discontent, complaints, anger, and abuse against health workers might follow unmet expectations (PIDs 52, 889, 928, 1076, and 1317).
Interactions
Interactions existed among levels and within single levels. The weak legislation and lack of high-level political will and guidance left health facilities and law enforcement agencies unclear about how to deal with WPV. “There is a lack of rigid legislation and effective enforcement strategies. Enforcement agencies are too tolerant of violent behaviors against health workers,” PID 87 said.
The maldistribution of quality health resources led to overcrowded clinics in outpatient services at higher-level care facilities. Health workers in these hospitals were overwhelmed by seeing too many patients each day and had insufficient time for proper communication with each patient. PIDs 1194 and 2158, respectively, commented that “physicians have to deal with so many patients [each day]. We have no time or energy to pay really careful attention to all [if we want to finish the queue within a day],” and “the consultation time for each patient is literally too little. Doctors also get impatient [seeing so many patients a day].”
In light of the insufficient government funding and health services’ profit-orientation, health facilities have prioritized revenue generation over patient benefits and staff safety. Health workers were motivated to boost profits by providing unnecessary services, compromising their professionalism. As a result of the commercialization of health services, patients have commonly felt exploited by public facilities. Patient trust eroded, provider–patient relationship deteriorated and patients often began to hold unrealistically high expectations. Participant 1857 revealed that “patients believe that doctors are just making huge profits from them. So, they already hold a hostile attitude towards us before seeing a doctor.” Also, health services gradually became a commercial service, in the eyes of the public, rather than a public good. Some patients and their families “just see us doctors as servants” (PID 1189) or “waiters” (PIC 519) and believe that “we should treat them as gods. As long as they pay our hospital, they expect to be cured, ignoring the limitations of medicine itself” (PID 2894).
Unregulated media reports also played an undesirable role in poor provider–patient relationships and the declining patient trust in health providers. “Patients have really poor trust in health facilities, doctors, and nurses. Due to the leading negative tones by media reports, patients immediately become suspicious and irritated that the hospital staff has made a mistake once they feel uncertain,” PID 963 mentioned. PID 912 echoed, “To attract eyeballs, the mass media fueled the fire and made the physician–patient, as well as the nurse–patient relationship worse.”
Discussion
Qualitative research examining the causes of WPV in China is sparse. The present study’s findings have added to our understanding by applying the socio-ecological model to examine the causes of WPV in Chinese hospital setting. The study identified a total of 10 factors in four levels: the societal and systemic level (lack of legislation against WPV, poor accessibility and affordability in the health system, and unregulated mass media), the community and organizational level (insufficient support from health facility leadership, inaction by government authorities and inefficient law enforcement agencies), the interpersonal level (inadequate provider–patient communication, distrust between health workers and patients) and the individual level (health workers’ poor clinical competence and skills; lack of professionalism, and insufficient awareness of protective measures; and patients’ sociodemographic backgrounds, expectations, and satisfaction). As factors within and among different levels interact closely with each other, we have interpreted the results in a holistic way, rather than within separate levels.
Many respondents believed that government authorities have adopted tolerant attitudes towards WPV in the health sector and that high-level legislation and policies against WPV in the health sector are lacking. Law enforcement’s response to WPV incidents was frequently reported to be poor, and impunity was common. Our finding of insufficient support from health facility leadership is consistent with a quantitative study that found that more than 40% of 4,862 health workers reported a lack of a WPV reporting mechanism within their facilities (Yang et al., 2019).
Due to the vulnerability of patients and imbalanced power relationship between patients and providers, patient violence against health workers has long been regarded as a health system or societal problem, rather than a legal issue. From a legal and human rights perspective, however, each individual has the right to be free from violence and to work in a safe environment. Legislation to protect health workers’ personal safety and dignity at work was lacking until a female chief physician was killed in late 2019, after which, for the first time, a high-level legal document was issued explicitly forbidding any groups or individuals from harming health workers’ safety and dignity in China (The National People’s Congress of the People’s Republic of China, 2020). Violators are subject to potential criminal consequences, but the implementation and effects of such legislation need to be evaluated.
Creating evidence-based policies and ensuring effective law enforcement efforts require multisectoral cooperation. The participation of key stakeholders, including service users, health workers, health organizations, policymakers, legislative authorities, law enforcement agencies, media agencies, and labor unions, is essential. Additionally, striking a reasonable balance between service users’ and providers’ obligations and liabilities in the health care setting, and precisely defining “intentional violence,” are core to avoiding compromising interests of patients who are medically incapable of controlling their violent behaviors while condemning intolerable purposeful violence (Ryan, 2016).
The accessibility and affordability of health services were deemed suboptimal due to insufficient government funding, profit-oriented health services, and inadequate insurance coverage (Liu, 2004), which are believed to be important contributors to WPV. This is consistent with previous studies suggesting that China’s widespread profit-generating medical practices have eroded patient trust, with poor provider–patient relationship being the key influencing factor (Hesketh et al., 2012; Phillips, 2016; Tucker et al., 2015; Wu et al., 2014; Yang et al., 2019). Quality workforces are generally concentrated in secondary and tertiary care facilities, due to China’s hospital-oriented health care system (Wu & Lam, 2016). For this reason, many patients bypass primary care and seek outpatient services at higher-level care facilities without a referral for simple common conditions (Wu et al., 2017). WPV occurs significantly more frequently in secondary and tertiary facilities (Yang et al., 2019).
Directing more quality workers to primary care settings and retaining them there are the foremost health reform directions for improving accessibility and affordability of health care in a systemic approach to addressing WPV. Additionally, intensive provider payment reforms (Ma et al., 2019) and nationwide zero-profit drug policies (Li et al., 2018), to eliminate entrenched profit-focused medical practices, have been iteratively implemented since 2009, but a realignment between the incentive system and patients’ interests has not yet been achieved (Yi et al., 2015); continuing effort in this regard is still needed. Insurance coverage has reached more than 95% of the Chinese population, yet more efforts are warranted to improve the depth of coverage and to reduce co-payments and medical impoverishment (Xu et al., 2019).
Provider–patient trust and communication were revealed to be the key interpersonal-level contributing factors. Patient trust, the foundation of clinical medicine, is a multi-dimensional concept that encompasses trust in individual physicians, medical institutions, and the health system in general, and these dimensions closely influence each other (Hall et al., 2001). Public trust in health providers in China has substantially eroded due to the widespread nature of profit-oriented medical practices and adverse media reports. These findings are consistent with previous reports that adverse media reports negatively impact perceptions of doctor–patient relationship among both patients and doctors (Sun, Wang, et al., 2017). Restoring patient trust requires multisectoral efforts (Tucker et al., 2016). The mass media also plays an important role in shaping social norms (Arias, 2018), and this double-edged sword can be leveraged to restore patient trust. Patient trust restoration campaigns are scarce in medical systems, and none exist in China. Innovative strategies, such as crowdsourcing, that engage the public in co-creating communication messages may improve patient trust in mass media campaigns (WHO/TDR, 2018). Additionally, humanistic care and communication skills education have not been strong components of the Chinese medical education curriculum and should be strengthened (Tucker et al., 2015; Tucker et al., 2016). Periodic training of individual health workers who have direct patient contact to improve communication skills and professionalism is necessary. Existing legal channels for suing for malpractice when patients have grievances regarding their treatment that operate through medical associations are known to be ineffective (Hesketh et al., 2012; Jiang et al., 2014). More effective and neutral patient complaints or conflict resolution mechanisms are desirable. Other measures include better assessment and management of patient satisfaction and expectations.
Our study has implications for WPV prevention both within and outside of China. We propose prevention strategies using a socio-ecological framework that attempts to address WPV at all levels (Figure 1). The prevention framework focuses on prevention strategies, rather than on the post-hoc management of WPV incidents, which will not solve the underlying problem. However, this framework can serve as a guide for efforts to reduce WPV in the health sector at all levels and has important policy and public health implications for countries facing this issue. The dynamic interplay of interventions within single levels or among different levels should be recognized and changing one aspect may generate a multi-faceted impact, as indicated by overlapping rings in the model.
Socio-ecological prevention framework for addressing workplace violence in the health sector.
Societal level preventions include strategies for improving accessibility and affordability in China’s health system, reforming provider payment mechanisms, tackling profit-oriented medical practices, restoring eroded patient trust, setting up legislation against WPV, and regulating the ethics and principles of media reports. Humanistic care education should also be improved. The government has an essential responsibility to develop national and provincial policies on occupational health and human rights protection to reduce and eliminate WPV. We call for more labor law revision and the introduction of special legislation against well-defined types of WPV in the health care setting and more rigid regulations for media reports (e.g., accuracy, neutrality, objectivity) related to medical practices and WPV. At the community level, organizational responsibility and duties need to be articulated to guide actions, and employers are strongly recommended to establish effective anti-violence mechanisms within their facilities.
At the interpersonal level, introducing an effective appointment system to allow minimal waiting and sufficient consultation times, promoting humanistic care, and improving employees’ communication skills may improve relationships between service users and providers. Additional efforts to improve provider–patient relationships include establishing more effective patient complaint or conflict resolution mechanisms. Restoring provider–patient trust is important.
Finally, individual-focused interventions are needed to enhance the practices of individual providers and patients to prevent WPV. Periodic training for all health workers who have direct patient contact is necessary. Training content can include workshops to improve the recognition of irritating attitudes and clinical behaviors among health providers; patient communication skills; WPV awareness; professionalism; risk assessment reporting; self-defense; and the ability to predict, prevent and respond to violent behaviors. Potential public interventions include environmental improvements to reduce distress or irritation when long waits are involved, educational campaigns to improve health literacy and awareness of complaint systems, assessment, and management of patient satisfaction and expectations, and timely information provision to individual patients regarding their health issues or complaints. The consequences of initiating violence against health workers or health facilities should be made known to service users.
This study has limitations. First, the study was conducted in a developed eastern province in China. Respondents’ views may have limited representativeness of health workers in other areas of the country. However, the large sample size and coverage of a wide range of sub-specialties from three levels of the health care system in various socio-economic contexts may complement to a certain degree and provide some generalizability. Second, responses solicited through an open-ended question in a questionnaire may present a limited depth of understanding. The comments, nevertheless, were easily understandable and covered a broad range of topics. The lack of a defined framework and the informal nature of the survey allowed participants to express their thoughts and concerns, which led to the generation of a series of themes. Third, the study only solicited views from health workers. Future research with other key stakeholders, such as health authorities, service users, hospital managers, law enforcement agencies, media agencies, and legislators and policymakers, should be conducted to refine the framework.
Conclusions
The study adopted a socio-ecological model to examine contributors to WPV in the health sector in China using qualitative data from health workers’ perspective. Ten factors within four socio-ecological levels were identified: societal/systemic (legislation, health system factors and mass media), community/organizational (employer health facilities, governmental health authorities and law enforcement agencies), interpersonal (communication and trust), and individual (providers and patients). We proposed WPV prevention strategies using the socio-ecological model that can serve as a starting point for addressing WPV in all health sector levels.
Footnotes
Acknowledgment
We thank Ms. Weiqi Han from the London School of Hygiene and Tropical Medicine for carefully reviewing and editing the English language of this article.
Authors’ Note
The funders of the study had no role in the study design, data collection, data analysis, data interpretation, or writing of the article.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by Zijin Talent Programme and Academy of Medical Sciences and the Newton Fund (Grant number NIF\R1\181020).
