A Socio-ecological Framework for Understanding Workplace Violence in China’s Health Sector: A Qualitative Analysis of Health Workers' Responses to an Open-ended Survey Question

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.

Workplace violence against COVID-19 front-line healthcare workers versus non-front-line in Hangzhou, China: a cross-sectional study

“…In our study, inconsistent with previous studies, 2 8 we found that both front-line/non-front-line HCWs with higher professional titles were more likely to suffer from WPV. The association between professional titles and WPV may be triggered by the differences in the patients they treated.…”

“I didn’t come into nursing to be attacked and constantly abused”: A qualitative study of exposure to violence for nurses across ethnic groups in the United Kingdom

“…In the UK, over a decade of austerity and vast public spending cuts to health and social care services have led to an overburdened health system and chronic staff shortages [29, 30]. Other societal factors include social and cultural norms that condone violence such as accepting workplace violence in healthcare as being an unfortunate but inevitable “part of the job” [31, 32].…”

“…Risk factors for violence exposure at the institutional level include insufficient support from organisational leaders and a lack of violence prevention policy, education and program evaluation [31]. At the interpersonal level, personal relationships and social interactions influence the risks of becoming a victim or perpetrator of violence and include poor communication and distrust between healthcare practitioners and patients, and bullying behaviours between colleagues [31].…”

“…Risk factors for violence exposure at the institutional level include insufficient support from organisational leaders and a lack of violence prevention policy, education and program evaluation [31]. At the interpersonal level, personal relationships and social interactions influence the risks of becoming a victim or perpetrator of violence and include poor communication and distrust between healthcare practitioners and patients, and bullying behaviours between colleagues [31]. Finally, at the individual level, risk factors for violence exposure include insufficient awareness of prevention measures, underreporting violent incidents to prevent future occurrences and patients’ sociodemographic characteristics, expectations and satisfaction [31].…”

Criminal Litigation of Workplace Violence in Chinese Hospitals and Legal Effort to Deescalate Crimes

“… 4 , 18 , 19 Specifically, Chinese legislation about workplace violence has weakness, like the absence of legislation on workplace violence and the ineffective enforcement authorities. 20 - 22 The continuance of workplace violence in the hospitals has violated the Chinese law. Therefore, the effectiveness of China’s health legislation and policy needs to be assessed.…”