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Workplace violence toward resident doctors in public hospitals of Syria:
prevalence, psychological impact, and prevention strategies: a cross-sectional
study
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* Open Access
* Published: 07 January 2021

WORKPLACE VIOLENCE TOWARD RESIDENT DOCTORS IN PUBLIC HOSPITALS OF SYRIA:
PREVALENCE, PSYCHOLOGICAL IMPACT, AND PREVENTION STRATEGIES: A CROSS-SECTIONAL
STUDY

* Okbah Mohamad1,
* Naseem AlKhoury1,
* Mohammad-Nasan Abdul-Baki ORCID: orcid.org/0000-0002-6551-90872,
* Marah Alsalkini3 &
* …
* Rafea Shaaban4,5

Show authors

Human Resources for Health volume 19, Article number: 8 (2021) Cite this article

* 2768 Accesses

* 9 Citations

* Metrics details

ABSTRACT

INTRODUCTION

Workplace violence (WPV) against healthcare workers is a common and daily
problem in hospitals worldwide. Studies in different countries indicated that
exposure to WPV potentially impacts the psychological status of healthcare
workers. However, there is a paucity of studies approaching this issue in the
Syrian healthcare system.

OBJECTIVES

This study had three objectives: (1) to estimate the prevalence of violence
against resident doctors in Syria, (2) to examine the association between WPV
and resident doctors’ psychological stress, sleep quality, depression, and
general health and (3) to suggest approaches to tackle this problem from the
resident doctors' perspectives.

METHODS

A cross-sectional study was conducted in 8 out of 14 provinces, and covered 17
out of 56 accessible functioning hospitals in Syria. Data were collected using
anonymous, self-administered questionnaires during February 2020. A total of
1226 resident doctors volunteered to participate in the study. Finally, 1127
valid questionnaires were used in the final data analysis. The overall response
rate was 91.92%.

RESULTS

A total of 955 participants (84.74%) reported exposure to WPV in the 12 months
prior to the study. In specific, 84.74% exposed to verbal violence and 19.08% to
physical violence. Patients’ associates were the predominant aggressors in both
verbal and physical violence (n = 856; 89.63%, n = 178; 82.79%, respectively).
Most resident doctors (87.31%) suggested enacting more legislation to protect
doctors as the best solution to reduce WPV. Verbal and physical violence showed
a significant positive correlation with each item of depression and stress, and
a significant negative correlation with both subjective sleep quality and
subjective health.

CONCLUSION

Workplace violence against resident doctors in Syria is highly common.
Therefore, policymakers, hospital managers, and supervisors should work
collaboratively in order to minimize WPV and ensure resident doctors’ safety and
psychophysical stability.

Peer Review reports

INTRODUCTION

Workplace violence (WPV) describes deliberate physical, psychological, sexual,
and other acts against someone at work that may risk his/her health or even
cause death [1]. Regarding this definition, almost all workers are susceptible
to experiencing WPV as part of their job. However, WPV in health settings has
reached an epidemic proportion [2], and healthcare workers face a far higher
risk of being injured during their job than workers in other occupational groups
[2,3,4].

The prevalence rate of WPV differs considerably between countries and
environments of practice [5]. One survey, for instance, by the U.S. Bureau of
Labor Statistics reported that healthcare workers experienced 73% of
violence-related injuries and illnesses in 2018 [6]. A research in China
estimated WPV prevalence towards healthcare workers at 56.4% [7]. Other studies
in the Arabic region can be found too. Namely, a study in Iraq revealed a high
prevalence (more than 85%) of violence toward healthcare workers [8].

In the contexts of wars and crises, violence toward healthcare workers is
expected to escalate due to extreme tension and hostile conditions. This has
been seen in the literature as healthcare workers were subjected to overt
attacks and threats in times of war [8,9,10]. Furthermore, the indirect effects
of war represented by the lack of supplies and human resources could contribute
to violence accidents [8].

The Syrian crisis started in 2011 and has affected Syrians' life in every aspect
[11]. Destruction had entailed a high proportion of health facilities, and many
healthcare workers had left the country, had been injured, or even lost their
lives [12]. Unfortunately, the shortage of medical professionals and the
increased weight of war placed a tremendous burden on the remaining doctors,
requiring them to deal with an increased number of patients and worsening the
quality of care provided, thereby, doctors are becoming more prone to WPV and
its consequences. Also, the lack of medical utilities and medications due to
sanctions imposed on Syria and the indirect effect of war has led to
deterioration of the quality of healthcare, which could lead to patients'
dissatisfaction with health services [13].

The effects of WPV have been seen to contribute to declined job performance
[14], higher stress levels [15], depression [16], and impaired sleep quality
[17]. Studies to understand this issue are important in order to provide a safer
work environment, enhance the quality of healthcare services, and for patients
satisfaction.

Most of the resources about WPV against healthcare workers in Syria were news,
editorials or correspondence articles with no major research studies. Therefore,
this study aims to estimate the prevalence of violence against resident doctors
in Syria, investigate the association between exposure to WPV and health-related
outcomes in terms of psychological stress, sleep quality, depression, and the
overall subjective health of Syrian resident doctors, and suggest approaches to
tackle this problem from the resident doctors' perspectives.

METHODS

SAMPLE AND PROCEDURE

A cross-sectional study was conducted within one month duration in February 2020
upon public Syrian hospitals that offer one of the training residency programs
approved by the Syrian Commission of the Medical Specialties: Ministry of Higher
Education (MoHE), Ministry of Health (MoH), and Ministry of Defense (MoD).

The selection was designed to represent all of the country's geographical
regions (north, west, middle, east, and south). Each region was represented by
two provinces with the exception of the north and east, which were represented
by one province owing to war conditions. Hospital selection was mainly based on
accessibility and full functionality. We selected the main MoH hospital in each
province, which is characterized by the highest number of medical specialties
available relative to other hospitals, except for Damascus, where we selected
two hospitals since it is the capital city and has more hospitals than other
cities. MoHE hospitals are only situated in four provinces (Lattakia, Aleppo,
Damascus, and Rural Damascus). Lattakia contained one MoHE hospital. Two main
MoHE hospitals were selected from each of Damascus and Aleppo. Accessible
functioning MoD hospitals are located in three provinces (Homs, Lattakia, and
Damascus); the main hospital was chosen from each province. Ultimately, the
resident doctors were recruited from 17 out of 56 accessible functioning
hospitals (MoH: 9/35, MoHE: 5/12, and MoD: 3/9) located in 8 provinces
(Damascus: 5, Lattakia: 3, Tartous: 1, Hama: 1, Homs: 2, Aleppo: 3, Al-Hasakah:
1, and Al-Sweda: 1). Hence, each residency program was represented by
approximately a third of the overall number of hospitals.

Anonymous and self-administered questionnaires were distributed and collected by
researchers and contributors (resident doctors and senior medical students) who
were trained to understand the study objectives and answer participants’
questions. The sampling criteria of resident doctors were as follows:

* The resident doctor did not help in the questionnaire distribution.

* The resident doctor is in his second year of residency training or more.

* The doctor has not yet finished his residency training.

The resident doctors were approached in the hospital cafeteria, following work
shifts, and on an individual basis.

The contributors informed the participants that filling out the questionnaire
could take up to 5–10 min, reminded them to pay attention to answer all the
questions, and were available to explain any unclear questions to participants.

A total of 1226 resident doctors volunteered to participate in the study. 99
questionnaires were incomplete or poorly answered (for example, selecting
multiple responses to one-response items). Finally, 1127 out of 1226 valid
questionnaires were used in the final data analysis. The overall response rate
was 91.92%.

QUESTIONNAIRE

All questions were administered to resident doctors in Arabic language as Arabic
is the native language of the Syrian resident doctors.

DEMOGRAPHIC QUESTIONNAIRE

The demographic questionnaire gathered data on age, gender, specialty, year of
residency, residency province, residency program, financial income, and marital
status.

WORKPLACE VIOLENCE AGAINST RESIDENT DOCTORS

The questionnaire was built based on review of the Workplace Violence in the
Health Sector Country Case Studies Research Instruments Questionnaire [18] and
questionnaires that had been used in pertinent studies [19, 20].

Participants were asked to report on their experiences over the past 12 months,
including the following items: (1) how often have you suffered from verbal
violence in the past 12 months? (2) How often have you suffered from physical
violence in the past 12 months? The response categories for each item were:
never, rarely (< 12 times in the past 12 months), sometimes (1–3 times per
month), often (1–5 times per week), and always (almost every day). The incidence
of a specific form of violence was dichotomized as yes (ranging from rarely to
always, and it was coded as ‘1′) or no (never, and it was coded as ‘0′).

In our questionnaire, verbal violence was defined as using offensive language,
yelling, or screaming with the intent to offend or frighten. Physical violence
was defined as a physical assault or any attempt at a physical attack. Physical
assaults included behaviors, such as hitting, pulling, pushing, slapping, hair
pulling, or arm twisting with intent to cause bodily harm.

We also investigated the following domains related to each type of violence (if
the resident doctor had experienced that type of violence):

* Aggressor sex

* Aggressor

* Accident time

* Accident location

* Causes of the event: ‘Refusing patient’s admission to the hospital’ was
defined as doctors may refuse to admit patients due to non-serious injury,
overloaded sections and priorities, or unavailable services.

STRATEGIES TO PREVENT WORKPLACE VIOLENCE

This section was prepared by reviewing relevant studies [19, 20] and in
consultation with the senior author to make necessary changes according to our
requirements. We used one question: ‘What are the necessary procedures to
minimize the number of violent acts as much as possible?’ including the
following answers: educational lectures to increase the awareness of workplace
violence, training of resident doctors using workplace violence prevention
programs to handle WPV, video recording, enacting more legislation to protect
doctors, increasing security guards, increasing staff number, restricting
visitors' access to hospital departments, and violence reporting system.
Furthermore, participants with no experience of workplace violence were given
the chance to select answers concerning the most effective measures to reduce
workplace violence.

SUBJECTIVE HEALTH AND DEPRESSION

We measured subjective health and depression using the Copenhagen Psychosocial
Questionnaire II (COPSOQ II) [21]. Subjective health was estimated by one global
item (‘In general, would you say your health is (4) excellent, (3) very good,
(2) good, (1) fair, (0) poor). Depression scale had four items. The introduction
asked participants to think about how often in the past 4 weeks they had
experienced each item. The COPSOQ II measure of depression was designed to
measure the level of depressive symptoms experienced by workers rather than to
diagnose clinical depression. An example item is, ‘How often have you had a bad
conscience or felt guilty?’ All items were asked on a scale of 1 (not at all), 2
(a small part of the time), 3 (part of the time), 4 (a large part of the time),
or 5 (all the time).

PSYCHOLOGICAL STRESS

In this study, the 2 single-item measures were used to measure the level of
stress of the participants [22]. The baseline questionnaire included 2 questions
on stress. The first question measured the ability to handle stress, phrased ‘On
a scale of 1 to 6, how would you rate your ability to handle stress?’ (from 1
for ‘I can shake off stress’ to 6 for ‘Stress eats away at me’). The second
question ascertained perceived stress, phrased ‘In the past year, how would you
rate the amount of stress in your life (at home and at work)?’ (from 1 for ‘no
stress’ to 6 for ‘extreme stress’).

SLEEP

Subjective sleep quality was measured by using one item [23] (‘During the past
month, how would you rate your sleep quality overall?’). The response format
ranged from very bad (0) to very good (3).

STATISTICAL ANALYSIS

Our data were entered in Microsoft Excel software and the statistical analysis
was carried out using the Stata software package (version 6; Stata Corp, College
Station, TX, USA). Data were expressed as percentages. The Chi-square test was
used to analyze differences between groups. Spearman’s correlation coefficient
was used for ranked variables to describe the relationship between each type of
violence and psychological outcomes. We considered p value < 0.05 to be
significant.

RESULTS

SOCIO-DEMOGRAPHIC CHARACTERISTICS OF THE PARTICIPANTS

Table 1 presents the socio-demographic characteristics of respondents. Most
participants were male (60.78%), half of them (49.33%) aged 27–29 years, and the
majority of them were from internal medicine (n = 365; 32.39%) followed by
surgery (n = 238; 21.12%). Second and third-year resident doctors formed 63.26%
of the participants. 521 (46.23%) of the participants were related to the
Ministry of Higher Education (MoHE), 467 (41.44%) were related to the Ministry
of Health (MoH), and 139 (12.33%) were related to the Ministry of Defense (MoD).
The majority of participants (65.39%) were single and 40.82% were from Damascus
city. For 32.92% of the participants, their income was from their job salary and
family support, and for 16.95%, the salary was their only income.

Table 1 Socio-demographic characters of resident doctors in Syria, (n = 1127)
Full size table

PERCENTAGES OF EXPOSURE TO VERBAL AND PHYSICAL VIOLENCE BY DEMOGRAPHIC
CHARACTERISTICS

The percentages of exposure to verbal and physical violence by socio-demographic
characteristics are shown in Table 2. A total of 955 participants (84.74%)
reported exposure to at least one type of WPV in the 12 months prior to the
study. In specific, 84.74% of the subjects reported exposure to verbal violence
and 19.08% to physical violence. This shows that all physical violence incidents
were preceded by verbal violence. With regard to age, resident doctors aged
(24–26) were significantly more exposed to verbal violence (p = 0.019). Men
resident doctors were more frequently physically assaulted in comparison with
women, which was statistically significant (p < 0.0001).

Table 2 Association between exposure to WPV and demographic variables
Full size table

The frequency of violent episodes was statistically significantly different
among the various specialties (p < 0.0001): psychiatry, pediatrics, emergency
medicine, and obstetrics were the specialties with the highest frequency of
verbal violence, while physical violence was more frequently observed in
resident doctors whose specialty was emergency medicine (p < 0.0001). With
regard to physical violence, resident doctors working in MoH hospitals had the
highest rates (p < 0.001). For the geographical distribution, Damascus had the
highest level of verbal violence (p = 0.009) and Al-Hasakah had the highest
level of physical violence (p < 0.001).

VERBAL AND PHYSICAL VIOLENCE CHARACTERISTICS

Table 3 displays the characteristics of workplace violence.

Table 3 Verbal and physical violence characteristics
Full size table

Generally, violence whether it is verbal or physical was mainly perpetrated by
men and patients’ associates. 81.15% of the verbal violent accidents happened in
the morning, while 50.68% of the physical violent accidents happened at night.
The study has shown that the emergency department was the most common location
for both verbal and physical violence (n = 790; 82.72%, n = 183; 85.12%,
respectively). The respondents indicated that delay in waiting/care time has
been causally implicated in both verbal (80.02%) and physical (62.33%) violent
incidents.

WPV PREVENTION STRATEGIES

Figure 1 shows the resident doctors’ perceptions of strategies to prevent
workplace violence, which reflect a lack of violence prevention and management
measures in the studied hospitals. Most resident doctors (87.31%) in this survey
suggested enacting more legislation to protect doctors as the best solution to
reduce WPV. Restricting visitors' access to hospital departments (73.47%),
violence reporting system (66.90%), increasing security guards (61.85%), video
recording (49.33%), training of resident doctors using workplace violence
prevention programs to handle WPV (34.43%), increasing the number of healthcare
workers (28.22%), and educational lectures about workplace violence to increase
the awareness of this issue (26.00%) were the other solutions named.

Fig. 1

Resident doctors’ perceptions of strategies to prevent workplace violence
(multiple answers)

Full size image

ASSOCIATION BETWEEN WPV AND PSYCHOLOGICAL OUTCOMES

Table 4 shows the correlations among each type of violence and resident doctors’
health outcomes. Verbal and physical violence were significantly positively
correlated with each of the depression and stress scales’ items, and
significantly negatively correlated with subjective sleep quality and subjective
health.

Table 4 Spearman’s correlations among each type of workplace violence and health
variables
Full size table

DISCUSSION

PREVALENCE AND CHARACTERISTICS OF WPV AGAINST RESIDENT DOCTORS IN SYRIA

To the best of our knowledge, this is the first study in Syria to shed light on
WPV, its related factors, and its psychological impact.

Based on the findings of the present study, 84.74% of Syrian resident doctors
had encountered at least one type of violence during their shifts in the last
12 months prior to the survey. This is much more than that reported by previous
studies [14, 24,25,26,27].

The diversity of assessment scales and different geographical location may
explain the discrepancy between these studies. This could also be linked to the
ongoing state of war that has in various ways eroded healthcare services. 57% of
public hospitals are not functioning or are only partially functioning, placing
a mounting burden and crowding on the surviving functioning hospitals.[28]

Training, planning, and monitoring have been impacted by declining numbers of
senior professors, leaving resident doctors with destitute preparation or
guidance and under conditions that force them to work beyond their knowledge and
expertise to fill the shortage of services gap [29], and have less time to build
rapport with patients, deteriorating the doctor–patient relationship.

In addition, incoherence of leadership and loss of validity of healthcare
systems, due to conflict and uncertainty, are seriously undermining health
policy-making frameworks themselves [30].

Furthermore, in our study, all resident doctors were working in public
institutions where long waiting time is prevailing and viewed as the key factor
for violence (80.02% and 62.33%, respectively, for VA and PA). One study
reported that working in a public institution was significantly associated with
exposure to verbal and physical abuse [31].

The findings demonstrated that resident doctors were more likely to experience
verbal violence (84.74%) followed by physical violence (19.08%). This finding is
consistent with studies done elsewhere [19, 32, 33]. Because in intense
situations, patients usually first display rage as verbal violence then switch
to intimidation and eventually show physical violence.

Frequencies of physical and verbal violence were higher in male resident
doctors, and this difference was statistically significant in the case of
physical violence. This finding agrees with other studies [8, 26, 34] and with
literature review [35]. This may be attributable to “the cultural norms of
avoiding ‘observed’ violence against females” [8].

A significant association was found between the resident's doctor's young age
and exposure to verbal violence. This finding is in line with a previous report
[36], and could be attributed to the fact that senior resident doctors have
better communication skills and are more professional in dealing with nervous
and agitated clients. Also, this patient-initiated violence might be due to the
lack of medical management skills by junior resident doctors and the respect of
patients for an older doctor. Senior resident doctors were slightly more exposed
to physical violence, but there was no significant association.

In coherence with other studies [19, 20, 37], the results showed that patients’
associates were the most common source of verbal (89.63%) and physical (82.79%)
violence. This seems to be related to that in Syria, as in most Asian countries,
the relatives unnecessarily stay in the patient’s ward close to healthcare
workers interfering with doctors’ decisions and tasks. They might also request
an urge of care delivery or more medical attention.

It is noteworthy that resident doctors encountered verbal violence by their
colleagues (48.27%) more than by patients (35.6%), which was found to be higher
than previous study [27]. This could be attributed to the ‘pyramidal system’ of
residency programs in Syria in which senior resident doctors—with the relative
absence of supervisors in public hospitals—could determine juniors’ roles and
comment on the lack of competency of them, which juniors may perceive as verbal
violence. Besides, understaffing and the impact of stress in this very difficult
working condition may be other possible factors [10].

The level of physical and verbal violence was higher among resident doctors
specialized in hospitals affiliated to the Ministry of Health and this
difference was statistically significant in the case of physical violence. MoH
hospitals are disseminated all around Syria, opposed to MoHE hospitals that are
only located in four provinces. This would generate a disparity in the
allocation of resources. According to WHO report 2018, the number of resident
doctors in MoH hospitals were 3,639 compared to 2,173 at MoHE hospitals [38].
Hence, MoH hospitals could suffer from a low doctor–patient ratio and
insufficient institutional infrastructure compared to MoHE hospitals, which
could increase patient dissatisfaction and set a lower threshold for WPV.

Additionally, there was a significant relationship between verbal violence and
being a resident doctor in Damascus province. Damascus is the capital city of
Syria and has the largest number of well-equipped hospitals which patients from
other cities seek (21% of the overall Syrian health workload during 2018 was in
Damascus) [38] to get better medical management, leading to more crowding and
increasing waiting time in hospital departments, therefore, conflicts arise and
WPV occurs.

THE NEGATIVE EFFECTS OF WPV ON RESIDENT DOCTORS’ PSYCHOLOGICAL STATUS

The medical residency is recognized as one of the most stressful and exhausting
periods in a doctor’s life [39]. Syrian resident doctors have a high baseline of
chronic stress as demonstrated in a recent study [40]. Moreover, due to the
large number of doctors emigrating abroad [29], the remaining ones suffer from
an increased workload and long working hours to compensate for the shortage of
human resources. Prolonged working hours is a known risk factor for stress [41].
In addition, low financial income is another risk factor [42]. In our study,
only 16.95% of participants considered salary as the only income source and many
of them reported having an extra job or required financial support from their
families, which might make them lose their independence. That being said,
workplace violence does nothing but add oil to the fire and pose an additional
threat to mental well-being [43], job performance [44], job satisfaction [24],
and self-esteem of doctors, and they begin to question the worth of their work
and profession while providing medical service.

According to the correlation analysis, both verbal and physical violence
threatened the psychological well-being of resident doctors, which is consistent
with other findings [45,46,47]. Interestingly, verbal violence correlated
stronger than physical violence with all health outcomes variables, possibly
because verbal violence occurs through a frequent basis and its intensity
accumulates to become comparable with or even greater than physical violence,
which occurs less frequently.

WPV also affects job motivation and contributes to less empathy and a decline in
enthusiasm, which further complicates the poor relationship between Syrian
doctors and patients and increases the doctors’ possibility of leaving the job.
Research showed that WPV is a significant predictor of turnover intention [48]
and depressive symptoms [49] in Chinese doctors. More than that, depressed
resident doctors made significantly more medical errors than their non-depressed
peers [49] which put patient’s safety at risk. If violence persists, more
resident doctors will be pressured to abandon their jobs and the safety of the
public will continue to deteriorate.

SUGGESTED STRATEGIES FOR TACKLING WPV

Efforts to limit WPV should be collaboratively built on different levels. First,
at the healthcare system level, policymakers should enact more and reinforce
existing legislation to protect doctors from aggressors’ behaviors, which has
been the most proposed solution by resident doctors in our study (87.31%).
Increasing healthcare workers’ numbers could also reduce the workload and lessen
WPV. Second, at the hospital administrative level, respondents in this study
articulated a desire of limiting visitors' access, the existence of a management
system for reporting and controlling violence, and better security coverage such
as video recording and increasing security guards inside the hospital. These
solutions may reflect the personal satisfaction of resident doctors by the
presence of additional security measurements inside the workplace environment.

Resident doctors depend largely on their own knowledge and skills to keep them
safe. Therefore, we recommend that managers, supervisors, and coworkers should
incorporate violence management educational programs as part of the Syrian
residency training program. One study showed that such programs have measurable
outcomes for a less violent workplace environment and better awareness of how to
deal with aggressors [50]. In addition, training in conflict management,
communication skills, and de-escalating during an aggressive event is strongly
recommended and need to be integrated in a structured violence prevention
program, as reported in a systematic review [51].

Third, regarding colleague-initiated violence, we strongly recommend senior
resident doctors to properly use the pyramidal system to maintain its prime
objective in producing well-trained junior resident doctors rather than abusing
it and taking an opportunity to practice WPV against juniors. That could be
strengthened if supervisors spent more time tracking the tutorial process in
hospitals. Finally, since the deteriorating doctor–patient relationship is one
of the key triggers of aggression towards doctors, they should devote more
attention to improve their communication skills to create a more harmonious work
environment [52].

All efforts against workplace violence should be developed with the prime goal
of improving patient care without compromising staff safety.

STRENGTHS AND LIMITATIONS

The major strengths of this study include its large sample size in relation to
the number of Syrian resident doctors. The annual Health Resources and Services
Availability Monitoring System (HeRAMS) report for 2018 showed that the total
number of resident doctors in MoH and MoHE hospitals from the 8 approached
provinces was 5468 [38]. Thus, we assume that our sample approximately
represented 18.07% (988/5468) of the resident doctors working in MoH and MoHE
hospitals. However, we could not afford reliable data regarding the number of
resident doctors in MoD hospitals. Also, this is the first study in Syria to
investigate workplace violence and spot a light on this issue, which may help
explain the high response rate and show the interest of resident doctors in this
issue. Our findings will help strengthen the Syrian health profile and offer a
good guide for hospital management and policy-making, so that regulations can be
adopted in this regard. Furthermore, this study investigated the association
between workplace violence, and resident doctors’ health status in terms of
stress, depressive symptoms, general health, and sleep quality, which has
important implementations in medical training and research. However, this study
also has various limitations. First, the survey used to assess WPV in this study
is not a validated tool and was based on literature review. The methods of
measurement of sleep quality and general health were also poor. Second,
according to this study design, which was an adequate and efficient way to
assess the prevalence, but restrains our ability to establish a true cause and
effect relationship between variables. Third, this survey is based on
self-reported data, which may have led to recall and report bias. Fourth, sexual
violence was not addressed in this analysis due to cultural reasons and
priorities. Hence, it avoids unrealistic data and focuses on other types of
violence. Fifth, we were not able to reach all of the Syrian provinces at the
time of the study due to war circumstances. Finally, despite the large sample
size of participants from multiple provinces, any convenient sample is
vulnerable to sampling bias that may impact the generalizability of research
outcomes.

CONCLUSION

To the best of our knowledge, this is the first study to examine WPV among
resident doctors in war-torn Syria. Syrian doctors work in an environment
affected directly and indirectly by the war. The shortage of medical equipment
and drugs due to restrictions and low socioeconomic status, and the emigration
of well-qualified physicians made it difficult for remaining doctors to respond
to the growing public needs that compromised the doctor–patient relationship and
the standard of treatment given, making doctors more vulnerable to WPV and its
adverse effects. The findings indicate 84.7% of participants reported that they
had experienced at least one type of verbal or physical violence during their
shifts in the last 12 months prior to the survey. This study also showed that
WPV was positively associated with psychological stress and depressive symptoms,
and negatively associated with sleep quality and overall general health of
Syrian resident doctors. Therefore, in order to prevent WPV and ensure resident
doctors’ psychophysical stability, it is necessary to implement legislation,
develop a violence reporting system, and provide violence prevention training
for resident doctors.

AVAILABILITY OF DATA AND MATERIALS

The data analyzed during the current study are available from the corresponding
author on reasonable request.

ABBREVIATIONS

WPV:

Workplace violence

MoHE:

Ministry of Higher Education

MoH:

Ministry of Health

MoD:

Ministry of Defense

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Download references

ACKNOWLEDGEMENTS

This research wouldn’t have been done without all the help of resident doctors
and medical students. We would like to thank Rula Ghossen (PhD), Dr. Mahmmoud
Swij, Naya Hassan, Hassan Mayya, Sara Deeb, Sally Hasan, Leen Askar, Mohammed
Amr Knifaty, Hala Al-Rakkad, Ahmad Samir, Dr. Ali Hammed, Dr. Fener Mahmoud
Alhussein, Dr. Ali Sabbour, Maysa Jaddah, Abed ulazeiz Jneid, Nour Hassoun
Alnajjar, Rema Tomeh, Ayman Taji, Dr. Ahmad Al-Khawam, Hussein Ahmad.

FUNDING

There is no funding.

AUTHOR INFORMATION

AUTHORS AND AFFILIATIONS

1. Faculty of Medicine, Tishreen University, Latakia, Syria

Okbah Mohamad & Naseem AlKhoury

2. University of Hama College of Human Medicine, Hama, Syria

Mohammad-Nasan Abdul-Baki

3. Faculty of Medicine, Albaath University, Homs, Syria

Marah Alsalkini

4. Faculty of Medicine, Al-Andalus University for Medical Sciences, Tartus,
Syria

Rafea Shaaban

5. Faculty of Medicine, Tartus University, Tartus, Syria

Rafea Shaaban

Authors
1. Okbah Mohamad
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2. Naseem AlKhoury
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3. Mohammad-Nasan Abdul-Baki
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4. Marah Alsalkini
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5. Rafea Shaaban
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CONTRIBUTIONS

OM and NK designed the study. OM, NK, M-NA-B, and MA contributed to data
collection. RS analyzed the data and supervised the study. OM, M-N A-B, and MA
drafted the manuscript. NK coordinated the research team. All the authors read
and approved the final manuscript.

CORRESPONDING AUTHOR

Correspondence to Mohammad-Nasan Abdul-Baki.

ETHICS DECLARATIONS

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

Participation was voluntary, all participants received a thorough explanation
about the research, and that all information being anonymous, confidential, and
used for research purposes only. This study presented minimal risk of harm to
resident doctors, no medical intervention was performed, or personal information
was disclosed. During questionnaires' distribution, each resident doctor was
informed that completing the questionnaire was considered as consent to
participate.

CONSENT FOR PUBLICATION

Not applicable.

COMPETING INTERESTS

The authors declare no conflict of interest.

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Mohamad, O., AlKhoury, N., Abdul-Baki, MN. et al. Workplace violence toward
resident doctors in public hospitals of Syria: prevalence, psychological impact,
and prevention strategies: a cross-sectional study. Hum Resour Health 19, 8
(2021). https://doi.org/10.1186/s12960-020-00548-x

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* Accepted: 15 December 2020

* Published: 07 January 2021

* DOI: https://doi.org/10.1186/s12960-020-00548-x

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KEYWORDS

* Workplace violence (WPV)
* Resident doctors
* Public hospitals
* Syria

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1. World Health Organization. World report on violence and health.
https://www.who.int/violence_injury_prevention/violence/world_report/en/full_en.pdf.

2. Gates DM. The epidemic of violence against healthcare workers. Occup
Environ Med. 2004;61:649–50. https://doi.org/10.1136/oem.2004.014548.

CAS Article PubMed PubMed Central Google Scholar

3. Alkorashy HAE, Al Moalad FB. Workplace violence against nursing staff in a
Saudi university hospital. Int Nurs Rev. 2016;63:226–32.
https://doi.org/10.1111/inr.12242.

Article PubMed Google Scholar

PubMed PubMed Central Google Scholar

Article PubMed Google Scholar

Article PubMed PubMed Central Google Scholar

8. Lafta RK, Falah N. Violence against health-care workers in a conflict
affected city. Med Confl Surviv. 2019;35:65–79.
https://doi.org/10.1080/13623699.2018.1540095.

Article PubMed Google Scholar

Article PubMed PubMed Central Google Scholar

11. Ben Taleb Z, Bahelah R, Fouad FM, et al. Syria: health in a country
undergoing tragic transition. Int J Public Health. 2015;60(Suppl 1):S63-72.
https://doi.org/10.1007/s00038-014-0586-2.

Article PubMed Google Scholar

12. World Health Organization. World Health Organization Syrian Arab Republic
annual report 2013.
https://www.who.int/hac/crises/syr/syria_annual_report_2103.pdf?ua=1.

13. Al Faisal W, Al Saleh Y, Sen K. Syria: public health achievements and
sanctions. Lancet. 2012;379:2241.
https://doi.org/10.1016/S0140-6736(12)60871-X.

Article PubMed Google Scholar

Article PubMed PubMed Central Google Scholar

18. World Health Organization. Workplace Violence in the Health Sector.
https://www.who.int/violence_injury_prevention/violence/interpersonal/en/WVquestionnaire.pdf.

Google Scholar

20. Wang P-Y, Fang P-H, Wu C-L, et al. Workplace violence in Asian emergency
medical services: a pilot study. Int J Environ Res Public Health. 2019.
https://doi.org/10.3390/ijerph16203936.

Article PubMed PubMed Central Google Scholar

21. Pejtersen JH, Kristensen TS, Borg V, et al. The second version of the
Copenhagen Psychosocial Questionnaire. Scand J Public Health. 2010;38:8–24.
https://doi.org/10.1177/1403494809349858.

Article PubMed Google Scholar

CAS Article PubMed Google Scholar

Article PubMed PubMed Central Google Scholar

Article PubMed Google Scholar

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medical speciality training in Turkey. Occup Med. 2008;58:361–6.
https://doi.org/10.1093/occmed/kqn045.

Article Google Scholar

27. Anand T, Grover S, Kumar R, Kumar M, Ingle GK. Workplace violence against
resident doctors in a tertiary care hospital in Delhi. Natl Med J India.
2016;29(6):344–8.

PubMed Google Scholar

28. Pham PN, Vinck P. Technology, conflict early warning systems, public
health, and human rights. Health Hum Rights. 2012;14:106–17.

PubMed Google Scholar

Article PubMed Google Scholar

Chapter Google Scholar

31. Farrell GA, Bobrowski C, Bobrowski P. Scoping workplace aggression in
nursing: findings from an Australian study. J Adv Nurs. 2006;55:778–87.
https://doi.org/10.1111/j.1365-2648.2006.03956.x.

Article PubMed Google Scholar

Article Google Scholar

CAS Article PubMed PubMed Central Google Scholar

Article Google Scholar

Article PubMed Google Scholar

37. Ayranci U. Violence toward health care workers in emergency departments in
west Turkey. J Emerg Med. 2005;28:361–5.
https://doi.org/10.1016/j.jemermed.2004.11.018.

Article PubMed Google Scholar

38. World Health Organization. Public Hospitals in the Syrian Arab Republic.
https://applications.emro.who.int/docs/syr/CoPub_HeRAMS_annual_rep_public_Hospitals_2019_EN.pdf?ua=1&ua=1.

39. Thomas NK. Resident burnout. JAMA. 2004;292:2880–9.
https://doi.org/10.1001/jama.292.23.2880.

CAS Article PubMed Google Scholar

40. Alhaffar BA, Abbas G, Alhaffar AA. The prevalence of burnout syndrome among
resident physicians in Syria. J Occup Med Toxicol. 2019;14:31.
https://doi.org/10.1186/s12995-019-0250-0.

Article PubMed PubMed Central Google Scholar

41. Ebrahimi S, Kargar Z. Occupational stress among medical residents in
educational hospitals. Ann Occup Environ Med. 2018;30:51.
https://doi.org/10.1186/s40557-018-0262-8.

Article PubMed PubMed Central Google Scholar

CAS Article PubMed Google Scholar

Article PubMed PubMed Central Google Scholar

44. Kowalenko T, Gates D, Gillespie GL, et al. Prospective study of violence
against ED workers. Am J Emerg Med. 2013;31:197–205.
https://doi.org/10.1016/j.ajem.2012.07.010.

Article PubMed Google Scholar

Article PubMed PubMed Central Google Scholar

CAS Article PubMed Google Scholar

51. Raveel A. Schoenmakers BInterventions to prevent aggression against
doctors: a systematic review. BMJ Open. 2019;9:e028465.
https://doi.org/10.1136/bmjopen-2018-028465.

Article PubMed PubMed Central Google Scholar

52. Rew M, Ferns T. A balanced approach to dealing with violence and aggression
at work. Br J Nurs. 2005;14:227–32.
https://doi.org/10.12968/bjon.2005.14.4.17609.

Article PubMed Google Scholar

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