A cross–sectional study on the prevalence and associated risk factors for workplace violence against Chinese nurses

Objectives The purpose of the present study was to explore the characteristics of workplace violence that Chinese nurses at tertiary and county–level hospitals encountered in the 12 months from December 2014 to January 2016, to identify and analyse risk factors for workplace violence, and to establish the basis for future preventive strategies. Design A cross–sectional study. Setting A total of 44 tertiary hospitals and 90 county–level hospitals in 16 provinces (municipalities or autonomous regions) in China. Methods We used stratified random sampling to collect data from December 2014 to January 2016. We distributed 21 360 questionnaires, and 15 970 participants provided valid data (effective response rate=74.77%). We conducted binary logistic regression analyses on the risk factors for workplace violence among the nurses in our sample and analysed the reasons for aggression. Results The prevalence of workplace violence was 65.8%; of this, 64.9% was verbal violence, and physical violence and sexual harassment accounted for 11.8% and 3.9%, respectively. Frequent workplace violence occurred primarily in emergency and paediatric departments. Respondents reported that patients’ relatives were the main perpetrators in tertiary and county–level hospitals. Logistic regression analysis showed that respondents’ age, department, years of experience and direct contact with patients were common risk factors at different levels of hospitals. Conclusions Workplace violence is frequent in China’s tertiary and county–level hospitals; its occurrence is especially frequent in the emergency and paediatric departments. It is necessary to cope with workplace violence by developing effective control strategies at individual, hospital and national levels.

in page 3 line 24 you said that nurses are more likely to experience WPV but did not explain this information. id think that the range of sexual harassment is in some countries less than 13.02 % in line 29. the statistics you mention in line 39-49 are talking about physician you need to mention nurses statistics related WPV in china and world wide, and if there is previous study about nurses in china? if yes you need to say what is the contribution of your study, if not you need to mention it.
in page 4 line 7 there are more important consequences than you reported, the method paragraph is not clear do you mean by-80 nurses were extracted from department of emergency, neurology, obstetric and gynecology-does it mean 80 from all of these department or 80 from each department? in the discussion part you need to discuss more and compare your result with previous result in more clear way, you need to compare your results with previous result in china and neighbor countries or world wide to make clear the contribution and the uniqueness of your study. you need to give the reader the new information you found. 1. Competing Interests: None declared 2. We carry on the explanation to the "Yi Nao." "Yi Nao" (where people employed by those in dispute with the hospital, together with family members of patients, took various measures to put pressure on the hospital, thereby profiteering). 3. We add the study limitations in the manuscript. The present study has several limitations. First, we collected data about whether nurses had experienced WPV over the past 12 months, so there may be recall bias in the results. Second, we studied tertiary and county-level hospitals, but we did not study specialized hospitals. However, this study might be effective in preventing WPV in general and public hospitals.

REVIEWER
We wish you a happy work. . We add references and change to "Several substantial studies have suggested that nurses have a high risk of experiencing WPV.6-10 " 3. "range of sexual harassment" in page 3 line 29 (Manuscript for the first time). We added references and changed to "During the past 12 months, the incidence rate of physical violence for nurses in Ethiopia,7 South Korea,8 Jordan,9 Germany10 and Iran 3 ranged from 18.22% to 56.0%, verbal abuse from 63.8% to 89.58%, and sexual harassment from 4.7% to 19.7% " 4. "We did not mention nurses statistics related workplace violence in china and world wide" in page 3 line 39-49 (Manuscript for the first time).We add references and change to "Further, the incidence rate of WPV differs among nurses in various countries; for instance, the incidence was 76.0% in Greek, 82% in Pakistan, and 67% in Italy.5-6" ; "Most previous studies of WPV against in China have been conducted in the provinces and the samples are not sufficiently representative; they do not present an accurate picture of the incidence of WPV against nurses in Chinese general hospitals.18-20 " 5. "which may lead to the phenomenon that healthcare workers do not hope their children to be engaged in medical work."in page 4 line 7(Manuscript for the first time). We add references and change to "Moreover, violent incidents have a negative impact on the psychological welfare of the healthcare workers,23 who do not want their children to be engaged in healthcare.24 " 6. We give a detailed description of the sample extraction. "In order to select the same proportion of the workforce from each department, we sought to recruit 120 nurses from the Departments of Internal Medicine and Surgery, 80 nurses from the Departments of Emergency, Neurology, Obstetrics and Gynecology, and Pediatrics, and 40 nurses from the Departments of Stomatology, Ophthalmology, and Ear, Nose and Throat in each tertiary hospital. We distributed 10,560 questionnaires to 44 tertiary hospitals." 7. We compare our result with previous result in China and world wide. "Compared with previous Chinese studies,18-20 our study provides a comprehensive depiction of the incidence of WPV in Chinese comprehensive public hospitals. We have also documented the characteristics of the perpetrators and the coping style of nurses who experience WPV. This study demonstrates that WPV in China is higher than other countries. 34-37 " We wish you a happy work.  5. Authors suggested that training should provide to frontline nurses to prevent WPV. A good example to be utilized is the "Management of Violence" and additionally, authors should critically re-think how to improve the psychological capital of these at risk nurses e.g. improving resilience to mitigate the negative impact brought by WPV. 6. Lots of WPV preventive strategies have little empirical support in the discussion. There are lots of empirical evidence on anti-violence strategies in the literature. Please support your lines of discussion with recent empirical evidence to make your suggestions sound.

VERSION 2 -AUTHOR RESPONSE
Dear Dr Cheung, Thank you very much for your valuable advice. We revised the manuscript according to your suggestion(The traces of change are represented in blue). Modify as follows : 1. Competing Interests: None declared 2. We further refine the abstract, especially the sentence structure. We change to "Objectives: The purpose of the present study was to explore the characteristics of workplace violence that Chinese nurses at tertiary and county-level hospitals encountered in the 12 months from December 2014 to January 2016, to identify and analyze risk factors for workplace violence, and to establish the basis for future preventive strategies. Design: A cross-sectional study. Setting: A total of 44 tertiary hospitals and 90 county-level hospitals in 16 provinces (municipalities or autonomous regions) in China. Methods: We employed stratified random sampling to collect data from December 2014 to January 2016. We distributed 21,360 questionnaires, and 15,970 participants provided valid data (effective response rate = 74.77%). We conducted binary logistic regression analyses on the risk factors for workplace violence among the nurses in our sample and analyzed the reasons for aggression. Results: The prevalence of workplace violence was 65.8%; of this, 64.9% was verbal violence, and physical violence and sexual harassment accounted for 11.8% and 3.9%, respectively. Frequent workplace violence occurred primarily in emergency and pediatric departments. Respondents reported that patients" relatives were the main perpetrators in tertiary and county-level hospitals.
Logistic regression analysis showed that respondents" age, department, years of experience, and direct contact with patients were common risk factors at different levels of hospitals. Conclusions: Workplace violence is frequent in China"s tertiary and county-level hospitals. The frequent occurrence of WPV in emergency and pediatric departments is also remarkable. It is necessary to cope with workplace violence by developing effective control strategies at individual, hospital, and national levels." 3.L37 -"has increased gradually increasing over the few decades" is changed to "In China, WPV in hospitals has increased gradually over the past few decades." L36-47 -We removed the prevalence of WPV towards doctors. We changed to "According to the report from the Chinese Hospital Association, the proportion of hospitals experiencing WPV rose from 90% in 2008 to 96% in 2012 and the prevalence of sexual harassment has increased year by year.16 " 4. We merge all the ethical approval / considerations under the same subtitle named "ethical considerations". ETHICAL CONSIDERATIONS Ethical approval to undertake this study was granted by the Research Ethics Committee of Harbin Medical University in March 2014. We obtained consent from each hospital involved in the research processes. All participants gave informed consent to the researchers or to their head nurses before the survey, and participants' personal information was kept confidential. 5. We add the information about how to improve the psychological capital of these at risk nurses. We changed to "We also suggest improving psychological resilience for at-risk nurses to mitigate the negative impact of WPV and to prevent chronic diseases and reduce the incidence of mental illness.48 " 6.We add some recent empirical evidence on anti-violence strategies in the discussion. We changed to: 1) On the one hand, hospitals can establish a code green response team, comprising a charge nurse, security personnel, and primary nurse to manage the potentially violent situation. Dilman"s study demonstrated that 85% of code green calls resulted in successful resolution of the violent incidents.