Impact of workplace violence on anxiety and sleep disturbances among Egyptian medical residents: a cross

To the best of our knowledge, this is the first study to explore WPV against medical residents in Egypt and to explore the relationship between residents’ mistreatment and the occurrence of sleep disorders and generalized anxiety. In the present study, verbal abuse on daily basis (26.7%) was the most experienced form of violence among study participants, followed by academic misuse of power (12.9%), while the least reported form was physical abuse (1%). These results are in line with the study done in 2013 by Al-Shafaee et al. who reported that the most common type of abuse was verbal abuse (36.8%), followed by academic misuse of power (35%) [1]. A study in Macau documented that healthcare workers had encountered verbal abuse, physical assault, and sexual harassment with a percentage of (53.4%), (16.1%), and (4.6%), respectively [25]. Daily exposure to shouting and yelling was reported by 26.7% of participants in the present study. Ghareeb et al., in 2021 stated that about half of the healthcare workers reported exposure to verbal violence and the most reported verbal violence categories were shouting and threatening with a prevalence of 90.5% and 58.6%, respectively [26]. Offenders prefer using verbal violence more than physical assault, possibly because shouting is the easiest and safest method of disturbing or threatening others. Regarding physical violence, we found that 15.8% of the study population faced harm by throwing objects on them once a month. This finding was in accordance with a study done in two Egyptian public hospitals where the prevalence of physical WPV was 9.6% [27]. The low prevalence of physical violence in the present study might be attributed to the high proportion of female participants (86%) and this result was supported by Al-Shafaee et al. who stated that female experienced verbal abuse rather than physical abuse [1], while male physicians experienced more physical violence than female physicians [25]. In Saudi Arabia, 19% of physicians faced physical WPV in emergency department (ED) hospitals in Dammam [25]. Furthermore, 43% of Iranian emergency residents experienced verbal abuse, 10% experienced physical assault, and 31% experienced sexual harassment [28]. Recently, a multicenter study conducted in the United Arab Emirates and Saudi Arabian Eds revealed that nearly twenty-one percent of the studied group reported being attacked physically and 32.3% reported being beaten by a weapon [29]. The percentage of participants who experienced sexual violence or harassment in the present study was low. This could reflect the underreporting of sexual violence and possibly either a recall bias linked to repressed memories during stressful events [30], or women’s fear of speaking publicly on sexual maltreatment and their fear of retaliation [31]. Indeed, in the current study, participants found that it risky to report sexual harassment. Healthcare workers' refraining from reporting violent actions was documented in previous studies [29, 32]. Fear of reporting a sexual harassment and worry towards reporting violence were in line with the previous literature, where only 30% of physicians reported such incidents to higher authorities and they considered it an inefficient procedure [33]. Such fear and lack of reporting could be attributed to inefficient security measures to protect victims and possibly a lack of publicly announced reporting systems [25] Clearly, healthcare facilities should include mechanisms that allow victims of abuse to voice their problems confidentially without jeopardizing their careers. Sexual harassment is criminalized by the Egyptian law with punishment of the harasser with a minimum sentence of six month in prison, and if the perpetrator has an authority over the victim, the sentence is between two and five years in prison [34]. The WPV penalty for verbal and physical assaults against an official employee is also stated in the Egyptian law as mentioned in articles 136, 137 and 241 of Penal Code No. 58 of 1937 [34]. Unfortunately, fear of retaliation and long legal procedures discourage victims from reporting and taking advantage of these laws.

Senior staff members (59.4%), followed by patient relatives (57.4%), were the main perpetrators in our study. Indeed, a recent study reported that 88.0% of the sources of violence against physicians were attributed to patient relatives [26]. Similarly, patients and their companions were the major causes of abusive behaviors in previous research [25, 28, 31, 35]. Additionally, consultants, specialists and senior medical staff were more likely to commit academic and verbal abuse at 50% and 65.5%, respectively [1]. Unfortunately, the occurrences of unacceptable behavior or violent acts towards junior physicians still occurs, mostly because senior staff demand filial obedience from junior physicians, as a means of expressing power [1].

Workplace PSC was significantly higher among those working morning shift only. There was a significant relation between residents’ specialty and PSC; the highest score was recorded among ER, ICU and Anesthesia residents. In 2015, Baykan et al. found that ER physicians were subjected to more violence than other specialties [36]. Meanwhile, WPV was particularly common in psychiatry and ER physicians in North American and Asian nations [37]. In the ER, physicians deal with critically ill or multiple trauma patients with angry relatives who expect to receive instantaneous care [28]. Also, physicians are at high risk of WPV due to heavy workloads, low physician–patient ratios, unmet expectations of patients and stressful work climate [38, 39]. Moreover, the negative attitudes of institutional managers, the COVID-19 pandemic, inadequate security, dissatisfaction with service, shortage of staff and violence portrayed in the media are important violence precursors, well documented in the literature [26, 27, 29, 40].

In the current study, the calculated abuse index was significantly higher among unmarried residents and those working both morning and night shifts than those working morning shift only. Harthi et al. reported similar results, where violence was significantly more prevalent among unmarried compared to married physicians [25]. Additionally, Eyasu and Taa affirmed that single women were four times more likely to encounter workplace violence than married women [41]. Marital status indeed affects workplace violence [41]. Single female workers could be more likely to face sexual harassment and verbal violence because they are generally younger than married women. Harthi et al. stated that verbal and physical abuse occurred with the same prevalence of 39.4% in both the morning and night shifts [25]. Similarly, Alzahrani et al. stated that 58% of violent attacks occur during night shifts [42]. About 74.4% of participants were exposed to bullying in the morning, which could be attributed to the presence of nearly all administrative staff in the day shifts and the high possibility of conflict with managers and other members of the healthcare team [25].

Continuous exposure to the stressful climate caused by WPV has been shown to increase the risk of short and long-term physical, social, and psychological illness [43]. It is documented in the literature that physicians exposed to WPV suffer from anxiety and sleep disorders [44, 45]. In the current study, 86% of participants were classified as poor sleepers, while 59.4% had generalized anxiety disorder (GAD). Moreover, unmarried physicians working both the morning and night shifts for a 12-h duration in public hospitals had higher insufficient sleep and GAD. Workplace violence was shown to be associated with severe anxiety [46, 47]. The relationship between GAD and WPV was reported in recent study by Yang et al. who found that in Chinese clinicians, more anxiety, insomnia and depression symptoms were linked to WPV exposure [46]. Severe anxiety and WPV have a bi-directional effect as WPV might adversely influence work interest, decrease job satisfaction, and lead to anxiety and burnout. Anxiety, on the other hand, might compromise the resident’s performance and lead to more patient conflicts, potentially increasing the risk of WPV [39]. Reduction of the quality of sleep was observed more among unmarried physicians who were exposed to WPV, and this finding was in line with Hacimusalar et al., who also reported that 72.4% of the physicians had poor sleep quality and 74.6% worked night shifts while 67.2% worked day shifts [48]. Furthermore, there was a direct correlation between both GAD and Global PSQI score with the abuse index, while Global PSQI score showed a moderate direct correlation to GAD. In agreement with previous studies, exposure to WPV had an adverse effect on healthcare subjective sleep quality and stress management [45, 49, 50]. Namely, WPV decreased subjective sleep quality by lifting the work stress of healthcare workers [51]. A recent study found that physicians who experienced verbal violence had a 2.6 times higher risk of deteriorating sleep quality than those not exposed [48]. Likewise, it was documented that verbal abuse and sexual harassment led to sleep disturbances and that higher incidences of violence resulted in increased odds for sleep disorders [52]. Nurses who encountered WPV have increased anxiety, emotional instabilities, and recurrent waking up at night, which affected their sleep quality [51, 53]. Several studies have proved the strong association between stress or anxiety and violence since violence generates stress and stressed physicians are more susceptible to violence [50, 54]. Moreover, stress and sleep disorders have a mutual relationship with a bidirectional pattern. As stress caused by violence increases, the risk of long-term ineffective sleep also increases [48, 55]. Furthermore, long-term stress is associated with activation of the “sympatho-adreno-medullary and the hypothalamo-pituitary-adrenocortical systems” which are known to affect sleep adversely [56, 57]. In addition, impaired sleep quality and sleep time have been linked to reduced learning ability, concentration, memory capacity, and ineffective coping with daily problems [58].

The study has several limitations. Our study is based on self-reported violent exposures, which predisposes our results to recall bias. As with other such surveys, the questionnaire was self-administered, and recall bias could not be ruled out. In addition, the means of collecting the sample via an online survey on social media renders it hard to ensure that our sample is representative of all medical residents in Egypt. Moreover, the responses consisted of residents who opted-in to fill the survey. This might explain why more female physicians filled the questionnaire. A possible explanation is that females are more prone to violence, thus are more eager to respond to the questionnaire. We thus recognize the possibility of a sampling bias that might limit the generalizability of our results.

The cause-effect relationship between WPV and anxiety and sleep quality could not be guaranteed since the study is cross-sectional. The sleep quality of the participants was assessed with verbal reporting by PSQI alone. However, adding biological parameters might have aided in assessing sleep quality objectively.