workplace violence ( wpv ) is referred to any incident or situation in which a person in his workplace or work - related circumstances is subjected to mistreatment , threats , or aggression . according to the international council of nurses , the likelihood of health care workers ' exposure to violence is even higher than prison guards or police officers . although all types of violence are destructive , physical violence can hurt victims physically and psychologically more than other forms . physical violence involves use of physical force against an individual or a group , and can lead to physical , psychological , or sexual harm and includes punching , kicking , slapping , shouting , pushing , biting , pinching , and wounding using sharp objects . in 2007 , nearly 15% of work facilities were assigned to violent and threatening acts in usa . results of a study conducted during 20092010 in italy showed that 13.4% of nurses reported at least one physical attack during the past year . in taiwan , 19.6% reported physical violence . in iran , the results of a systematic review study indicated that the prevalence of physical violence was between 9.1 and 71.6% and the most common types of physical violence were pushing or pitching , as experienced by 43% of participants . pointed out that the prevalence of physical violence against emergency medical workers in east azerbaijan was 37.7% . the outcomes of wpv include physical consequences such as increasing low back pain , symptoms of somatic and musculoskeletal disorders , and psychological consequences such as posttraumatic stress disorder , anxiety , fear , depression , substance abuse , and poor quality of patient care . furthermore , health care workers suffer from job dissatisfaction , poor quality of life , and low self - esteem . although several studies have been carried out regarding wpv in iran , there is no overall feature about physical violence against health care workers . the aim of this study was to investigate the frequency of workplace physical violence among iranian health care providers working in some teaching hospitals , their response to such violence , as well as the contributing factors to physical violence . this cross - sectional study was conducted in 2011 in some teaching hospitals across iran . study population comprised all health care workers including physicians , nurses , midwives , nurse aids , and paramedical personnel that numbered 57,000 according to the latest ministry of health and medical education statistics in 2011 . inclusion criteria included : ( i ) working in a teaching hospital and ( ii ) having at least 1 year of experience . the participants were selected by multistage random sampling in three phases . in the first phase , all the provinces were included in this study ( four provinces excluded due to administrative issues ) . sample size of each province was calculated according to the proportion of health care professionals . in the second phase , thus , 135 teaching hospitals were selected . in the third phase , samples were selected by random sampling based on samples ' size in each hospital . sample size was estimated by the following formula and with a confidence interval of 1.96 , power of 0.80 , and d = 0.01 : m = ( z1  /2/d)(p)(1  p ) m = ( 1.96/0.01)(0.75)(0.25 ) = 7203 n = ( m)(total)/m + total n = ( 7203)(65,000)/7203 + 65,000 = 6485 data were collected using the international questionnaire of  workplace violence in the health sector  developed by the international labor organization ( ilo ) , the world health organization ( who ) , the international nurse council ( icn ) , and the public services international ( psi ) . the questionnaire contains five sections : ( a ) 21 items about personal and workplace data ; ( b ) 17 items about physical violence ; ( c ) 37 items about psychological violence ( emotional abuse ) , which involves verbal violence , bullying / mobbing , and sexual harassments ; ( d ) 8 items about the health sector ; and ( e ) 3 open - ended questions on participants ' views on wpv . the questionnaire was translated from english to persian by a bilingual person and then back - translated from persian to english by another person who was also proficient in both languages . then , after matching with the other existing persian version , the content validity of the questionnaire items was assessed by a committee including 11 experts who were interested in the research topic . finally , the items were modified according to the experts ' opinions . moreover , the reliability of the questionnaire was confirmed by test - retest ( r = 0.71 ) through completion by 180 health care workers employed in one of the teaching hospitals of tehran . in this paper , only relevant findings to workplace physical violence are presented because of the extensive amount of data involved . this study was approved by the ethics committee of university of social welfare and rehabilitation sciences ( ethics committee approval number : 14/86 ) . informed consent was obtained from the health workers who agreed to participate in this study . this study was approved by the ethics committee of university of social welfare and rehabilitation sciences ( ethics committee approval number : 14/86 ) . informed consent was obtained from the health workers who agreed to participate in this study . the mean age of the participants was 34  8.5 years , and 78.5% of the participants were nurses . the majority of participants ( 85.1% ) indicated that they had not received training program for dealing with workplace physical violence . demographic and work characteristics of the participants ( n=5874 ) about 23.5% of the participants reported that they had been physically abused in the past year , and all of them happened without use of any weapons . pushing ( 59.9% ) , kicking ( 36.2% ) , and punching ( 32.7% ) were reported as the most frequent forms of workplace physical violence . among the victims , 118 participants received serious injuries ( 8.8% ) . moreover , 36.5% of physical violence occurred on the night shift . the majority of the physical incidents occurred inside the hospitals ( 90.1% ) , against female health workers ( 67.5% ) , and between the ages of 30 and 40 years ( 39.5% ) . frequency of physical violence ( n=1333 ) the most common reaction of victims to physical violence was asking the aggressor to stop violence ( 45% ) . six hundred and fifty - two participants ( 60.5% ) did not report violence and the most common reason for not reporting physical violence was they considered reporting it useless ( 52% ) [ table 3 ] . lack of people 's knowledge of employees ' tasks ( 49.2% ) was the most common contributing factor to physical violence [ table 4 ] . reactions of health personnel to physical violence ( n=1333 ) contributing factors to physical violence ( n=1333 ) this study was performed in different cities of iran in order to determine the frequency of physical wpv toward health professionals . the result of a study in jordan showed that 22.5% of hospital nurses were exposed to physical wpv . reported that 15.93% of emergency staff were exposed to physical violence during the past 3 months . the incidence of physical violence in another study was 21% , which is similar to the frequency obtained in the present study . but in some other studies , between 46 and 70% of participants were exposed to physical violence , which exceeds the results of the present study . this may be due to cultural differences between countries or underreporting . in the present study , rahmani et al . indicated that the frequency of pushing and punching was 71.4% and 20.4% , respectively . noted that hitting , kicking , and scratching were the most frequent types of physical violence . pointed out that hitting , pushing , or shoving was reported by 73.9% of victims , which is consistent with the result of the present study . the main source of violence was patient 's family , which is consistent with the findings of other studies . however , merecz et al . showed that above 64% of psychiatric nurses and more than 16% of other nurses had frequently been subjected to patients ' physical violence . in another study , patients were the main cause of physical violence and threats to attack . the difference could be attributed to cultural differences , and the constant presence of patient 's family during hospitalization and coming into contact with medical staff and nurses in iran . the results showed that female health workers , especially between 30 and 40 years of age , were exposed to physical violence more than other workers , which is consistent with many reviewed studies . in all these studies , wpv against female workers , who were often younger , was more than that of others . so , managers and health personnel , especially nurses , should identify these risk factors in order to prevent and manage such violence . moreover , in the current study , nurses were the main victims of physical violence . this is thought to be due to their close contact with patients and/or their families . the present study results also reveal that more than half of the participants did not report exposure to violence , and considered reporting useless . furthermore , more than 60% of participants stated that there was no guideline for reporting violence in their workplace , and more than half of them said that no action has yet been taken to pursue the incidence of violence . moreover , the most participants indicated that no specific policy had been thought up for dealing with violence . this is congruent with the findings of another study which showed that only 23.6% of participants reported the physical violence . the most important reasons for not reporting included considering reporting useless and fear of being stigmatized as a troublesome and incompetent person . in other studies , almost all of the participants stated that no guidelines existed in their workplace for preventing and control of violence . these findings indicate lack of proper staff training programs for preventing and managing violence , and also , lack of appropriate legislation and policy for pursuing received reports and managing violence in health care settings . however , results of a study in australia showed that nearly 70% of health workers were satisfied with wpv control policies and reporting mechanisms , which is inconsistent with the finding of the present study . it may be due to existence of transparent policies , appropriate legislation , and reporting mechanisms in developed countries . in the present study , more than half of the participants believed that  lack of people 's knowledge about staff tasks was among factors associated with violence , which is in agreement with the results obtained by rahmani et al . so , lack of awareness can cause the patients and/or their relatives to have unrealistic expectations of health professionals and , consequently , unmet expectations lead to violence . second , due to the large sample size and self - reported method for data collection , missing data for each item was relatively significant . finally , regarding the cultural sensitivities or the related stigma of violence victims , it is probable that participants might not have expressed all their experiences . many participants were concerned about incidence of violence in their workplace and most disinclined to report violence due to lack of appropriate support and follow - up mechanisms by managers . provision of appropriate training programs to prevent and manage violence , development of a documenting and reporting system , and identifying and supporting workers - at - risk can lead to minimizing the violence . moreover , increase of people ' awareness about the responsibilities of health care workers should be considered . this article is part of a research project commissioned by the ministry of health and medical education ( moh ) no . this article is part of a research project commissioned by the ministry of health and medical education ( moh ) no .
background : workplace violence is a serious and problematic phenomenon in health care settings . 
 research shows that health care workers are at the highest risk of such violence . 
 the aim of this study was to address the frequency of physical violence against iranian health personnel , their response to such violence , as well as the contributing factors to physical violence.materials and methods : a cross - sectional study was conducted in 2011 , in which 6500 out of 57,000 health personnel working in some teaching hospitals were selected using multi - stage random sampling 
 . data were collected using the questionnaire of  workplace violence in the health sector  developed by the international labor organization , the international council of nurses , the world health organization , and the public services international.results:the findings revealed that 23.5% of the participants were exposed to physical violence in the 12 months prior to the study . 
 nurses were the main victims of physical violence ( 78% ) and patients ' families were the main perpetrators of violence ( 56% ) . 
 the most common reaction of victims to physical violence was asking the aggressor to stop violence ( 45% ) . 
 lack of people 's knowledge of employees ' tasks was the most common contributing factor to physical violence ( 49.2%).conclusions : based on the results , legislating appropriate laws in order to prevent and control violence in the workplace is necessary . 
 moreover , developing educational programs to manage the incidence of physical violence should be on health centers ' agenda .