# Workplace violence against female healthcare workers: a systematic review and meta-analysis

May-Elizabeth Pere-Ere Ajuwa, Clair-Antoine Veyrier, Lorraine Cousin

Cabrolier, Olivier Chassany, Fabienne Marcellin, Issifou Yaya, Martin

Duracinsky

► To cite this version:

May-Elizabeth Pere-Ere Ajuwa, Clair-Antoine Veyrier, Lorraine Cousin Cabrolier, Olivier Chassany, Fabienne Marcellin, et al. Workplace violence against female healthcare workers: a systematic review and meta-analysis. BMJ Open, 2024, 14 (8), pp.e079396. 10.1136/bmjopen-2023-079396. inserm-05031209

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# BMJ Open Workplace violence against female healthcare workers: a systematic review and meta-analysis

May-Elizabeth Pere-ere Ajuwa,¹ Clair-Antoine Veyrier ID,¹,²
Lorraine Cousin Cabrolier,¹,² Olivier Chassany,¹,² Fabienne Marcellin ID,³
Issifou Yaya,¹,² Martin Duracinsky¹,²

**To cite:** Ajuwa M-EP, Veyrier C-A, Cousin Cabrolier L, et al. Workplace violence against female healthcare workers: a systematic review and meta-analysis. *BMJ Open* 2024;14:e079396. doi:10.1136/bmjopen-2023-079396

► Prepublication history and additional supplemental material for this paper are available online. To view these files, please visit the journal online (https://doi.org/10.1136/bmjopen-2023-079396).

M-EP-eA and C-AV contributed equally.

Received 30 August 2023
Accepted 01 August 2024

## ABSTRACT

**Background** Workplace violence (WPV) is highly prevalent in the health sector and remains a major occupational issue causing significant harm, ranging from bodily and psychological harm to death. Female healthcare workers (HCWs) are at high risk of WPV.

**Objectives** Identify risk factors of WPV among different professional categories of female HCWs.

**Data sources** PubMed, EMBASE and Web of Science, along with their references lists January 2010 and March 2022.

**Eligibility criteria** English language observational studies focusing on WPV among HCWs evaluating the risk factors, impacts and consequences of WPV in female HCWs.

**Method** Risk of bias was assessed for all studies by Joanna Briggs Institute critical appraisal checklists. We estimated the pooled prevalence of WPV and the associated 95% CI using a random-effects meta-analysis model. We then described the associated factors and effects of WPV.

**Results** 28 reviewed studies (24 quantitative, 4 qualitative and 1 mixed-method) from 20 countries were selected. From the available results of 16 studies, the pooled prevalence of WPV was estimated at 45.0% (95% CI 32% to 58%). Types of violence included verbal abuse, verbal threats, physical assaults, sexual harassment, mobbing, bullying and discrimination. Perpetrators were patients, patients' relatives, colleagues and supervisors. Nurses were the most studied HCWs category. WPV was found to affect both mental and physical health. Age, marital status, lower occupational position, substance abuse, shorter work experience and low support at work were the main socio-demographic and organisational factors associated with higher risk of WPV.

**Conclusion** WPV prevalence is high among female HCWs, warranting a multilevel intervention approach to address and mitigate its impact. This approach should include targeted policies and individual-level strategies to create a safer work environment and prevent adverse effects on both HCWs and the broader healthcare system. Further research is needed to better document WPV in categories of HCWs other than nurses.

**PROSPERO registration number** CRD42022329574.

## STRENGTHS AND LIMITATIONS OF THIS STUDY

⇒ This study is one of the first to focus on the female healthcare workers (HCWs) population and to use cited methods for a systematic review.

⇒ The review included 28 peer-reviewed studies published in reputable databases from 20 countries, providing a broader picture of the subject.

⇒ The review explored a wide range of workplace violence types, in different categories of female HCWs.

⇒ The review highlights not only the prevalence of workplace violence, but also its correlates and consequences.

⇒ The prevalence of workplace violence in female HCWs was not indicated in all studies and there is a need for more studies in different countries on categories of female HCWs other than nurses.

## INTRODUCTION

Workplace violence (WPV) is defined by the WHO as 'the intentional use of physical force or power, threatened or actual, against oneself, another person, group, or community, resulting in, or having a high likelihood of resulting in, injury, death and/or psychological or developmental harm or deprivation'.¹ The management of all forms of WPV is a major public health challenge.² Approximately one-third of all healthcare workers (HCWs) have experienced WPV.³ Compared with other working populations in the USA, social support workers and hospital HCWs are second only to taxi drivers in terms of their vulnerability to WPV.⁴ Throughout Europe, a higher risk of third-party violence is reported in the healthcare sector and female HCWs are the most likely to experience violence.⁵

According to the International Labour Organization, International Council of Nurses, WPV may be classified into two types: physical and non-physical violence.² Examples of physical violence include beating, choking, pushing, slapping, kicking, grabbing, shooting, stabbing, sexual assault and

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© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

¹URC ECO, Assistance Publique - Hopitaux de Paris, Paris, France

²ECEVE UMR 1123, INSERM, Paris, France

³UMR912 (SESSTIM), INSERM, Marseille, France

**Correspondence to**
Dr Clair-Antoine Veyrier;
clair-antoine.veyrier@aphp.fr
other types of physical contact intended to injure or harm. Threats, sexual harassment, racial harassment, bullying/mobbing and verbal abuse are examples of non-physical (or psychological) violence that can be perpetrated by a variety of people in the workplace. According to the WHO, verbal abuse (58%) is the most prevalent form of non-physical violence, followed by threats (33%) and sexual harassment (12%) among HCWs.⁶

Female HCWs have a unique status and function in public health and healthcare because they make up a significant part of the healthcare workforce with systematic differences in gender distribution by occupation.⁷ George *et al* have attributed women's susceptibility to WPV to gender power disparities.⁸ In most countries, female health workers are over-represented in the nursing and midwifery professions while male workers make up the majority of physicians, dentists and pharmacists.⁷ Female workers are specifically vulnerable to WPV because of their lower status.⁸,⁹

Many researchers have carried out in-depth investigations of WPV among nurses, and others have explored and compared WPV risk factors among doctors and nurses in healthcare settings.¹⁰ However, these groups of healthcare personnel are not the only ones who can become WPV victims.¹¹ According to the International Classification of Health Workers, HCWs are not limited to health professionals, but also include health associate professionals, personal care workers in health services and health management and support personnel.¹² Nursing homes, home care settings, clinics, pharmacies and other places where HCWs provide any type of service can all be the scene of WPV.

To our knowledge, no systematic review has yet estimated the prevalence of WPV in female HCWs of different occupational categories and analysed associated factors. The objective of this systematic review is to synthesise studies that investigate the factors associated with WPV in different occupational categories of female HCWs and its impact on their health.

# METHODS

## Design

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standard approach 2020 checklist was used to assess the methodological quality of each included study.¹³ ¹⁴ The protocol is registered in the International Prospective Register of Systematic Reviews database (PROSPERO).

## Inclusion and exclusion criteria

This review used the SPIDER (Sample, Phenomena of Interest and Design, Evaluation and Research) framework for its inclusion criteria, which were as follows:

* Sample: The target population was to be female HCWs in all countries (all or specific professional categories, including health professionals, health associate professionals, personal care workers in health services and health management and support personnel).

and health management and support personnel). Female health students were included, based on the Center for Disease Control and Prevention's classification of medical and nursing students as HCWs, as well as the fact that their clinical years in medical, dentistry or nursing school required them to work in a healthcare setting.

* Phenomena of interest: Studies focused on WPV among HCWs with findings about women. WPV included physical violence (such as beating, choking, pushing, slapping, kicking, grabbing, shooting, stABBing, sexual assault and other types of physical contact intended to injure or harm) and non-physical violence (such as threats, sexual harassment, racial harassment, bullying/mobbing and verbal abuse).

* Design: Observational (cross-sectional or cohort studies).

* Evaluation: The study evaluated the associated risks of WPV and its impact on health in female HCWs.

* Research type: Qualitative or mixed-method studies could be included.

Studies had to be published in peer-reviewed journals, with full text available in English and published between 1 January 2010 and 1 March 2022. Any articles that did not meet the above criteria were excluded. The date limitation was intended to focus on more recent evidence.

## Data sources and search strategy

Published studies were retrieved from the following electronic databases: PubMed, Scopus and Web of Science. We retrieved 26 articles from a previous larger scoping review we conducted that focused on the health of HCWs. In this scoping review, we also used social science databases. We found that PubMed, Scopus and Web of Science largely retrieved papers from the scoping review. As detailed in online supplemental file 1, the search used the combination of the following concepts and terms in Medical Subject Headings: 'Occupation', 'Violence' and 'Occupational Health'. The third concept was added to limit results to occupational-related violence, part of occupational health and exclude home-related violence. The reference lists of the obtained papers were manually reviewed to include other studies related to violence among female HCWs.

## Selection of articles

The retrieved articles were first selected by two independent review authors (M-EPA and C-AV) based on abstracts and titles, after duplicates were removed. A second selection was realised based on the full text. Where there were conflicts, a meeting with the reviewers was held to reach a consensus.

## Extraction grid

A Google Form extraction grid was created to collect data systematically. It included the following sections:
* The article: digital object identifiers, year of study, first author surname, journal of publication, full study title and country of study.

* The study details: design of the study, and objectives.

* The descriptive results:

Population studied: Both men and women or women only, sample size and percentage of women.

Professional categories: detailed according to the International Classification of Health.¹²

Characteristics of WPV: types, perpetrators (including gender, if reported), risk factors.

Prevalence of WPV: by professional category (including specialty, if reported) and workplace (hospital, clinics, etc, including departments, if reported).

The two primary reviewers (M-EPA and C-AV). A third reviewer (LCC) double-checked and any notable differences were resolved by discussion.

## Risk of bias in individual studies

The risk of bias of each study included in this systematic review was assessed independently by the two primary reviewers using the Joanna Briggs Institute critical appraisal checklists¹⁵ for analytical cross-sectional studies, qualitative studies and cohort studies. If the two reviewers

could not agree on whether a study should be included, a third reviewer was consulted to reach a consensus. The overall risk of bias for each included study was categorised as low risk of bias, some concern of bias or high risk of bias. The risk of publication bias was assessed by visual interpretation of funnel plots if at least 10 studies reporting the outcome could be identified.

## Data synthesis

Each data outcome was synthesised, summarised and reported in a narrative way using tables and texts. This was done in accordance with the PRISMA statement (online supplemental file 2).

Besides, a meta-analysis was conducted using the Stata V.15.0 software. The meta-analysis was performed on the studies where prevalence of WPV for female HCWs was available. Data on the prevalence of WPV were represented as a proportion with 95% CIs. A random-effects model was used, and statistical significance was set at p<0.05 for all analyses. Heterogeneity was estimated visually in forest plots and statistically using I² tests, as recommended by the Cochrane collaboration.¹⁶ We considered heterogeneity low if I² was <25%, moderate if 25–50% and

<figure><img src="image_3.png" /><figcaption>**Figure 1** Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow chart for selection of articles to include in the systematic review. WPV, workplace violence.</figcaption></figure>
substantial if >50%. To examine heterogeneity, subgroup analysis was performed.

## Patient and public involvement

There was no direct patient or public involvement in this review.

## RESULTS

### Selection of articles

A total of 561 articles were retrieved from the search strategies. There were 163 in PubMed, 185 in Scopus and 187 in Web of Science. To enhance comprehensiveness, we included 23 articles from a previous scoping review and 3 additional references from a meta-analysis obtained through a primary search that were not present in the initial database. After removing duplicates and excluding articles that did not meet the inclusion criteria, 28 articles were included for extraction. The exclusive screening and acceptance process is detailed in the flow chart figure 1.

### Critical appraisal and quality assessment of articles

We have annexed the quality score of all included studies in online supplemental file 3. All qualitative studies fulfilled the checklist with a low risk of bias. Two cross-sectional studies presented moderate scores. None article was excluded based on quality score. This ensures that all selected studies, regardless of their quality score, contribute to the comprehensiveness and robustness of the analysis.

### Characteristics of included studies

Through the 28 studies included in this review, sample sizes varied from 7 to 12 944 participants and study locations covered 20 countries (see detailed characteristics in table 1).

### Overview

This review identified the prevalence of WPV (globally and according to the professional category of female HCWs) and focus on different factors associated with WPV against female HCWs: (1) socio-demographic factors, (2) organisational climate, and (3) workstation, (4) perpetrators of WPV and (5) impact on health.

The review found that non-physical violence was the most common type of WPV, with verbal abuse being the most prevalent form, reported in 52–98.3%. Other forms of violence identified included threats, physical assaults, sexual harassment, mobbing, bullying and discrimination. Some studies reported a higher prevalence of sexual violence compared with physical violence,¹⁷ while contradictory findings were reported elsewhere.¹⁸ Inappropriate sexual behaviours, including sexual harassment and sexism/gender inequality, were also reported by chiropractors.¹⁹

### Prevalence of WPV

Using a random-effects meta-analysis of 16 studies, the pooled prevalence of WPV among female HCWs was

<table><caption>**Table 1** Characteristics of the 28 studies included in the literature review</caption><thead><tr><th>Study characteristics</th><th>No. of studies</th></tr></thead><tbody><tr><td>Design</td><td>Cross-sectional=27<br>Cohort=1</td></tr><tr><td>Type</td><td>Quantitative=24<br>Qualitative=4</td></tr><tr><td>Healthcare workers category included</td><td>Nurses=13<br>HCWs in general=8<br>Physicians=3<br>Pharmacists=1<br>Paramedics=1<br>Elder-care workers=1<br>Chiropractors=1<br>Medical students=1<br>Doctors and medical students combined=1</td></tr><tr><td>Location</td><td>China=5<br>USA=2<br>Australia=3<br>Brazil=2<br>Turkey=2<br>Italy=3<br>Austria=1<br>Denmark=1<br>Ethiopia=1<br>Germany=1<br>Ghana=1<br>Greece=1<br>Mexico=1<br>Norway=1<br>Portugal=1<br>Saudi Arabia=1<br>Sri Lanka=1<br>Switzerland=1<br>Taiwan=1</td></tr><tr><td>Types of workplace violence</td><td>Physical: physical violence in general (no specific type was analysed).<br>Non-physical: verbal abuse, threats, sexual harassment, bullying.</td></tr><tr><td></td><td>HCW, healthcare workers.</td></tr></tbody></table>

estimated at 45.0% (95% CI 32% to 58%), varying widely between 9.0% (95% CI 6% to 11%) in Portugal²⁰ and 92.0% (95% CI 87% to 95%) in Italy.²¹ These results are visualised in a forest plot (figure 2). For heterogeneity, we see that I²=99.8%, demonstrating severe heterogeneity among the included studies. To evaluate publication bias related to the meta-analysis of WPV, a funnel plot was created (figure 3). Egger's test for a regression intercept resulted in a p value of 0.175, indicating no evidence of publication bias.

### Prevalence of WPV according to the professional category of female HCWs

Across studies included in this analysis, five categories of female HCWs were identified, including nurses, doctors,
Pooled prevalence of WPV

<figure><img src="image_4.png" /><figcaption>**Figure 2 Random effect model forest plot for WPV among female healthcare workers. WPV, workplace violence.**</figcaption></figure>

pharmacists, allied health professionals (such as paramedics, elder-care workers, medical technologists and nursing technicians), as well as other roles including administrative staff, security staff and medical students. Within these groups, the prevalence of WPV varied significantly. Among doctors, WPV the prevalence ranged from 31.8% to 81.1%, as reported in two studies.¹⁸ ²² Among nurses, the prevalence ranged from 25.45% to 100%, based on different studies¹⁰ ¹⁸ ²³⁻²⁸ while for pharmacists, it was reported at 35%.²⁹ The reported prevalence for allied health professionals ranged from 2.7% to 72.1% for nursing technicians, 35% to 42% for paramedics, 11.9% among elder-care workers³⁰ and 62.8% for medical technologists.¹⁸ Among other staff categories, the prevalence was reported at 36.3% among students,³¹ 43.4% among administrative staff¹⁸ and 41.8% among security staff.¹⁷

## Factors associated with WPV against female HCWs

### Socio-demographic factors

Most included quantitative studies (13/25 (52%)) reported an association between being a female HCW and an increased risk of WPV.¹⁷ ²¹⁻²³ ²⁹ ³¹⁻³⁷ Young age (<40

years) was associated with an increased risk of physical violence, verbal abuse and sexual harassment in female nurses.²³ ²⁷ ³⁶ On the conversely, older nurses (≥56 years) in Australia were more likely to report occupational violence and aggression.¹⁰ Marital status (being single, separated or widowed) was associated with sexual harassment (53.9%) and verbal abuse (75%) among nurses in Ghana.²³ However, bullying and mobbing were common among married operating room nurses in China.³³

### Organisational climate

Organisational climate or contextual factors that contribute to various types of WPV experienced by female HCWs encompass several dimensions. These include: low occupational position,²³ night-shift work (67.1%),²⁵ extended waiting time (98.5%),³⁸ patients' current health status.²³ ²⁵ ²⁷ ³³ ³⁶ ³⁸ Up to 10 years of professional experience in nursing and contract employment type (73.5%), and low social support at work (83.1%) were also identified to be associated with WPV.²³ ²⁷ Physical violence, threats, micro-aggression, gender discrimination and sexual harassment faced by female doctors were all
<figure><img src="image_5.png" /><figcaption>**Figure 3** Publication bias funnel plot for workplace violence among female healthcare workers.</figcaption></figure>

associated with,³⁵ as well as a medical culture in which medicine is perceived to be a man's job.²² In the USA Bakken *et al* highlighted marital status (6.0%) as a basis for higher incidences of discrimination and harassment for pharmacists.²⁹ Other factors included long working hours, the state of patients and call volume among paramedics in Australia³⁷ and low occupational position for students in Germany.³¹

## Workstation

For nurses working in the emergency units, WPV prevalence ranged from 40.6% to 53.9%.³⁶ ³⁸ According to Fute *et al*, the odds of violence against nurses in the emergency department in Southern Ethiopia were roughly four times higher than in the outpatient department (OPD) (Adjusted Odds-Ratio (AOR)=4.3, 95% CI (2.44 to 7.50)).³⁶ WPV prevalence was 40.6% in general inpatient wards in Greece³⁸ and twice as high compared with outpatient nurses (AOR=2.1, 95% CI (1.98 to 3.42)).³⁶ The prevalence range of reported verbal and sexual harassment was 16.7–17.9% in critical care units, 18.1–20.5% in OPD, 35.9–44.4% in medical-surgical units and 20.8–25.6% in special units.²³ Regarding hospital characteristics, WPV were frequently reported in tertiary hospitals³³ and in public hospitals (29.9–47.8%).¹⁷ ³⁶ No workstation variable was identified as a risk factor for doctors, emergency unit among paramedics in Australia.³⁷

## Perpetrators of WPV

Patient relatives (12.0–70.5 %),²³ ²⁵ ³⁸ patients (26.6–47.5 %)²³ ³⁶ ³⁸ and colleagues and supervisors (2.4–54.9%) were reported as WPV perpetrators in nurses.²⁵ ³⁸ Sexual harassment²³ against nurses was perpetrated by physicians

(54.9%). WPV in elder-care workers were mostly colleagues (71.7%), followed by direct supervisor/manager (19.7%), clients (9.4%), top management (7.6%), subordinates (5.0%), relatives of clients (4.7%) and colleagues from a different ward (2.5%).³⁰ The source of harassment for female students already in their clinical year was mostly male superiors (supervisors, teachers), only 12% were patients. Perpetrators in the included studies were (40–70%) men.

## Impact on health

Most nurses reported that WPV had impacted their mental health in various ways. As a result of WPV, nurses experienced anger (76%), psychological stress (72%), disappointment (69%), loss of job satisfaction (60%), fear (50%), depression (22%), loss of self-esteem (16%),³⁸ anxiety, shame, emotional and sleep disorders and overall poor mental health.²³ ²⁵ ²⁷ Female doctors reported heightened stress responses, erosion of the recipients' sense of confidence and long-term health deficits.³⁹ Physical injuries such as traumatic joint/ligaments and muscle/tendon injury (43%), wounds, laceration and amputations (27%), musculoskeletal (5%), fracture (5%) and mental disorders (11%) were reported due to the high rates of physical assaults on paramedics.³⁷ WPV in elder-care workers resulted in major depressive episodes.³⁰

More findings are detailed in online supplemental files 4 and 5.
DISCUSSION

To our knowledge, this is the first comprehensive system-
atic assessment of WPV that has examined the prevalence,
associated factors and consequences of WPV among
female HCWs. This review included 28 peer-reviewed
studies and used the most widely sourced evidence from
reputable databases. Violence against female HCWs has
been documented at alarmingly high rates across studies,
ranging from 2% to 98.3%. A global systematic review
conducted on WPV against physician and nurses that
included 22 peer-reviewed articles found that physicians
were more likely to face physical violence, while nurses
were more likely to experience sexual harassment.⁴⁰ This
review highlights the variability in WPV prevalence across
different professional categories of female HCWs, under-
scoring the need for targeted interventions tailored to
specific roles within the healthcare sector.

Previous reviews highlighted gender as a predictor of
WPV and nurses as being at a higher risk of WPV.⁴¹ ⁴²
Medical workers were more vulnerable to WPV than non-
medical staff, still vulnerable to physical violence.⁴² This
review added to the knowledge by highlighting the prev-
alence of the WPV in understudied categories of female
HCWs such as doctors, pharmacists, allied health profes-
sionals (paramedics, elder-care workers, chiropractors,
medical technologists and nursing technicians) and
others (administrative, clerical, security and medical
students) across five continents.

Verbal violence is usually the first stage, that can either
progress to physical violence or be contained. This may
explain why verbal violence was the most common form of
violence in this review and is also consistent with previous
studies. ⁴³ ⁴⁴ Nurses have received more attention in the
study of WPV than the other workers mentioned above
(43.3%).¹⁰ ²³⁻²⁸ ³³ ³⁶ ³⁸ ⁴⁵⁻⁴⁷ In addition, nurses consistently
reported the highest incidence of WPV events in the
reviewed studies, both in those focusing just on nurses
and those involving the entire healthcare workforce. This
could be because nurses are generally accessible to both
patients and visitors. They are also the first contact point
for patients, making them potential victims. This is also
supported by other studies. ⁴³ ⁴⁸ ⁴⁹ On the contrary, one of
the included studies found that physicians had a higher
rate of WPV than any other group of female HCWs.¹⁷ This
may be due to the fact that doctors generally work alone,
whereas nurses work in groups, an important factor in the
development of aggression.¹⁸

Nursing technicians were another category of female
HCWs with a high prevalence of WPV,³² although they
were mostly grouped with nurses and, to the best of our
knowledge, not separately studied. Another group of
HCWs at risk for WPV were female medical technologists
and paramedics. The female HCWs with the lowest prev-
alence of WPV were elder-care workers and pharmacists.
The explanation for the low prevalence among pharma-
cists is unclear, but it could be hypothesised that have
limited contact with patients and there may be less and

indirect emotional interaction between them (delivering
treatment) compared with nurses and other HCWs.

In this systematic review, a wide range of WPV experi-
enced by female HCWs was identified, including physical,
verbal, bullying, physical assault, threats, sexual harass-
ment and psychological violence. These forms of violence
can have significant impacts on the well-being and profes-
sional satisfaction of female HCWs. They contribute to
stress, anxiety, depression and physical injuries, leading
to absenteeism, decreased job satisfaction and reduced
quality of patient care. Verbal violence was the most
commonly reported type of WPV across studies, followed
by sexual harassment, bullying and psychological violence.
This is consistent with the findings of Liu *et al* that verbal
abuse was the most common type of violence against
female HCWs.⁴⁴ Sexual harassment has been reported
among female nurses and medical students,⁵⁰ which is
extremely harmful and requires immediate attention. In
our review, physical violence was examined as a group of
acts of violence, with no special attention given to any
type and it was as common as sexual harassment. This
may be important for future studies as WHO reports that
more than one-third of HCWs experience physical abuse
at some point in their careers.³

This systematic review identified several factors asso-
ciated with WPV against female HCWs, categorised into
socio-demographic, organisational and workstation
correlates of WPV. In terms of socio-demographics, age
and marital status were consistently reported by most
studies. This is consistent with a previous systematic
review.⁴⁹ Although a study in China observed a higher
tendency among married women,³³ single or separated
female HCWs had more incidence on WPV.²³ Further-
more, younger nurses also reported a higher incidence
of WPV than older ones, which could be due to the
longer work experience of older nurses (and better
training in the management of difficult situations with
patients). Regarding the organisational climate, among
several recurring factors, low occupational position/
power imbalance, which exists in the healthcare setting,
was widely connected to many incidences of non-physical
violence; as well as years of experience, long waiting times,
overcrowding, shifts, lack of security, medical culture in
which medicine is perceived male-dominated environ-
ment among others. In terms of the workstation, studies
have consistently associated emergency departments with
WPV, followed by psychiatric settings and outpatient facil-
ities. This is similar to

previous studies.⁴⁴ ⁵¹ This could be due to the critical
need for treatment and the current condition of the
patients, but also to a shortage of HCW in emergency
departments—coupled with overcrowding of these units,
which become entry care points even for non-urgent
cases. The psychiatric unit admits persons in a condi-
tion of impaired mental well-being; this could explain
the high occurrence of violence. Adequate male/female
ratios and increased security should be ensured in these
high-risk units.
Patients and their relatives or friends were the common perpetrators of violence.²³ ²⁵ ³⁶ ³⁸ This is in line with one study conducted by Alsaleem *et al*.⁵² On the other hand, superiors and physicians were frequently identified as perpetrators of sexual harassment. In most cases, the perpetrators were men. As a result, these factors need to be taken into account when establishing rules and regulations on the behaviour of patients, families or colleagues. These measures would provide female HCWs with a sense of security and psychological support.

The health impacts of WPV on female HCWs are significant and multifaceted, discussed in this review. Physical and mental impacts have been documented, with the latter being more prevalent. Physical injuries were reported among various categories of HCWs, including paramedics,³⁷ nurses, security personnel and other HCWs.³⁴ ⁴⁶ Mental impacts include psychological stress, anxiety due to perceptions of promiscuity attached to the nursing profession, shame, depression and post-traumatic stress disorder (PTSD); some affected workers stated that they sought medical treatment. Consequently, some HCWs reported reduced work productivity, lack of motivation and hyper-vigilance. Increased use of sick leave and time off work, as well as consideration of giving up their careers or eventually quitting were reported as a result of WPV. Given that WPV has a significant impact on the lives of HCWs, it is obvious that the quality of service provided by HCWs will suffer as well; thus, health management must pay close attention to factors that make the workplace hostile to HCWs.

It is also worth noting how only a few HCWs reported WPV. This was largely attributable to an ineffective system for handling complaints, so HCWs chose to ignore and accept it as part of their job. Training on WPV de-escalation, evidence-based mitigation strategies, effective workplace reporting systems and psychological support would be beneficial to HCWs.

## Limitations

This review has several limitations. It exclusively focused on female HCWs experiences of WPV. The prevalence of WPV in female HCWs was not indicated in all studies. The use of occupation health concept in the search strategy was meant to exclude home-related violence but could have excluded some studies still related to WPV. We only included large and general databases and we did not include specialised qualitative databases. Qualitative studies were few in the review and may have failed to thoroughly explore the nature of the violence from the HCWs' perspective, an issue that quantitative studies typically do not allow for extensive analysis. Furthermore, most studies were cross-sectional, and longitudinal studies are also needed to describe changes with time of WPV, and to better understand its consequences for individuals affected. Lastly, there is a need for more studies in different countries on categories of female HCWs other than nurses.

## CONCLUSION

This systematic review found a high prevalence of WPV among female HCWs. It also advances our comprehension of the extent to which female HCWs experienced WPV at their workplace. WPV was documented to have a detrimental impact on female HCWs' mental and physical health, resulting in sick leave, absenteeism and decreased productivity. Immediate actions such as targeted policy development, WPV de-escalation training, as well as management communication and support, must be implemented to address WPV in the health sector and prevent its negative impact on both HCWs and the whole healthcare system. More research is also needed to better document the prevalence of WPV among other groups of female HCWs other than nurses.

**Acknowledgements** We thank the MNH Foundation for their support of this project, especially Philippe Denormandie and Julia Fernandez.

**Contributors** M-EP-eA: Data Curation; Formal Analysis, Investigation, Methodology, Software, Writing—Original Draft. C-AV: Guarantor, Conceptualisation, Data Curation, Formal Analysis, Methodology, Supervision, Writing—Review and Editing. LCC: Data Curation, Writing—Review and Editing. OC: Project Administration, Writing—Review and Editing. FM: Data Curation, Writing—review and Editing. IV: Data Curation; Writing—Original Draft, Writing—Review and Editing. MD: Project Administration, Supervision, Writing—Review and Editing.

**Funding** This study was funded by MNH foundation (Grant no: NA).

**Competing interests** None declared.

**Patient and public involvement** Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

**Patient consent for publication** Not applicable.

**Ethics approval** This study uses scientific articles to conduct a systematic review. Following the Helsinki declarations, no human or animal species was involved in this review; hence this work did not require ethical approval.

**Provenance and peer review** Not commissioned; externally peer reviewed.

**Data availability statement** Data are available upon reasonable request. Extracted data are available on request to the corresponding author. Search strategy and key finding tables are available in appendices.

**Supplemental material** This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

**Open access** This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

## ORCID iDs

Clair-Antoine Veyrier http://orcid.org/0000-0003-3497-0382
Fabienne Marcellin http://orcid.org/0000-0001-8853-3829

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