MWV: prevalence and related laws in China

In Mainland China, MWV appears to be rising, but current and accurate statistics are lacking. A cross-sectional study among 2464 medical professionals in Fujian and Henan Province found that 11% had experienced physical assault, 26% emotional abuse, 12% were threatened with assault, 3% were sexually harassed and 1% were sexually assaulted.6 One representative study showed that 92.75% of 1656 physicians in Shanghai, Hubei and Gansu Province reported verbal abuse, 88.1% experienced threats of assault and 81.04% experienced physical assault.7 In another study, 106 of 840 general practitioners and nurses in Heilongjiang province (Northeast China) reported physical assault in the past 12 months, with 62.3% of the perpetrators being the patients’ relatives and 22.6% being the patients themselves.8 A most recent cross-sectional study with nurses (n=15, 970) in 44 tertiary hospitals and 90 county-level hospitals from 16 provinces in China reported that the prevalence of MWV was 65.8%, which including verbal violence (64.9%), physical violence (11.8%) and sexual harassment (3.9%).9 One study conducted in Macau in 2014 showed that 18.1%, 56%, 14.5% and 4.7% of nurses (n=613) and 3.7%, 38.3%, 12.1% and 3.7% of doctors (n=107) experienced physical assault, verbal abuse, bullying, and sexual harassment in the preceding year, respectively.10 A large study of nurses in Hong Kong (n=850) showed that 39.2% experienced verbal abuse, 22.7% experienced physical assault and 1.1% experienced sexual harassment.11 In Taiwan, 19.6% of 521 nurses indicated that they experienced physical violence, 51.4% experienced verbal abuse, 29.8% experienced bullying/mobbing and 12.9% experienced sexual harassment in the past 12 months.12 In China, a particular form of MWV is perpetrated by criminal gangs targeting hospitals and healthcare staff is Yi Nao (医 闹), literally stated as ‘healthcare disturbance’. This form of MWV is motivated by financial benefit and dissatisfaction with treatment outcomes rather than miscommunication.13 14 When entering these as keywords ‘医闹’ in the Chinese search engine Baidu, one can retrieve more than 8 million related links and pictures. Despite the high percentage of MWV exposure, training on how to avoid or respond to these incidents appears to be lacking.8 WPV is an emergent crisis in China and research is needed to better quantify the prevalence of these occupational exposures to characterise the underlying processes that are driving this phenomenon, the consequences for hospital staff well-being and to develop and evaluate interventions that can improve these conditions.

In Mainland China, several criminal laws (Security administration punishment act of the People’s Republic of China (Presidential decree—38), Notice of maintenance of the order in medical institutions (2012–2017), Amendment of criminal law of the People’s Republic of China (nine)) were passed to enhance workplace protection for health workers in recent years. These laws specifically state: (1) no unit or individual can disturb the normal medical treatment order in medical institutions by any means, (2) the police department should enhance the safety of patients and healthcare workers (HCW) in medical institutions and (3) the people involved in the perpetrating or organising MWV would be imprisoned for 3–7 years. However, inadequate surveillance and insufficient reporting measures undermines the potential impact of these laws.

The impact of MWV in China

The consequences of MWV in China are far reaching. Physicians and HCW in China are already experiencing diminished professional prestige and MWV decreases the number of adequately trained HCW. The popularity of studying medicine and nursing among youth is decreasing due to fears of unsafe working environments, which can increase the turnover rate of current registered clinical doctors and nurses. For example, the labour shortage of paediatric care specialists is becoming more and more serious in China as the frequency of MWV increases.9 In a survey of physicians in 2014, only 4.5% wanted their children to be medical doctors in the future,15 which is a notable decrease from 11% in 2001 and 7% in 2011.16 Inadequate hospital staff will increase the workload of existing medical professionals, thus reducing the quality of care and patient safety, which may increase patient mortality and perpetuate the cycle of violence against medical professionals. A shortage of HCW in China also undermines the potential for utilising nurses and non-specialists in task-shifting innovations for mental health.17 18 Higher rates of MWV occur within psychiatry, emergency and paediatric departments.6 19

Physician–patient trust and mistrust is related to MWV and often appears in media reports in China. Mistrust creates a negative social environment for healthcare work. From the patient perspective, mistrust is driven by unexpected treatment and care, lack of respect and low-quality service, medicine rebate from pharmaceutical companies and red packets (monetary gifts to ensure proper care to doctors).20 21 This negative relationship quality continues a vicious cycle of MWV, which further exacerbates poor patient health outcomes. Repairing physician–patient trust in China is urgently needed.

MWV affects the mental health and well-being of HCW. It not only predicts HCW’s quality of life but also severely impacts psychological health and may lead to suicide. Recent studies report HCW who experienced MWV suffered from anxiety (25.67%), depression (28.13%), post-traumatic stress disorder symptoms (28%),22 23 poor sleep hygiene and fatigue symptoms.24

Secondary and tertiary interventions among HCWs in China

Preventative interventions are needed to reduce the incidence of MWV and to ameliorate the consequences of these incidents if they occur.25 Primary prevention could focus on the structural and social issues that underlie medical violence in China.21 For example, improving patient-hospital staff communication may be a key strategy to bolster trust in medical providers and reduce misunderstandings about required medical treatments.26 Secondary interventions involve early actions such as surveillance efforts to identify people who may develop mental health issues following exposure to MWV and intervene at this stage to prevent the onset or worsening of symptoms.27 Tertiary prevention strategies ensure that injured employees receive timely and proper care to report the incident to relative authorities, to inform managers about the incident, to secure any evidence during the post-incident response process, to record details about the incident and addressing any need of victimised employees that caused by physical or psychological factors. However, there are few studies that gave a comprehensive perspective of post-incident actions and its effectiveness to reduce distress following MWV.

We conducted a systematic literature review of the global literature to identify secondary or tertiary preventative interventions for MWV among HCWs in medical settings from the English databases of PubMed, PsychInfo, EMBASE, CINAHL, ERIC and Chinese databases of WANFANG, CNKI from the start of these databases to January 2017. Keyword searches consisted of three parts: intervention (‘treatment’, ‘therapy’, ‘intervention’ or ‘prevention’); workplace violence (‘medical workplace violence’, ‘aggression’, ‘harassment’, ‘assault’, ‘mobbing’ ‘violence,’ and ‘incivility’) and healthcare workers (‘doctor’, ‘physician’, ‘nurse’, ‘nursery’, ‘clinician’, ‘healthcare workers’ and ‘healthcare professionals’). A total of 8148 records were identified, 143 full-text papers were searched for eligibility and 10 publications were selected that addressed MWV prevention. The earliest tertiary prevention study was published in 1988, and the most recent one was published in 2011. These interventions included incident debriefing,28 consultation,29 individual or group psychotherapy30 and ongoing social support.31 Among these studies, only one paper was conducted in China. In this controlled trial with 122 head nurses studied in a hospital by Gao et al,32 a hospital intervention after MWV was evaluated. The intervention group (n=72) received psychological evaluation by psychiatrists after exposure to medical violence, timely psychological consultation, short vacations and financial compensation due to suffering MWV. The control group (n=52) had no psychological evaluation or intervention. The trial results showed that head nurses in the intervention group reported statistically higher levels of sense of emotional belonging (P<0.05) and lower turnover intention than the control group (P<0.01).