Workplace violence against medical students- A Turkish perspective

Background: Workplace violence against healthcare providers including the medical students being an important issue all over the World. The aim of this study is to survey the medical students about exposure to workplace violence (WPV) while they are doing their medical training in private tertiary hospitals. Methods: This was a cross-sectional study carried out among all medical students (4th, 5th, and 6th class) attending a teaching hospital at Bezmialem Vakif University (BVU), Istanbul, Turkey. A total of 150 students in the 2017-2018 academic year were recruited in this study. Data were collected using a modified questionnaire through a face to face interview. Data were analyzed using SPSS 16. Results: About one-third of the surveyed students (54, 36.0%) exposed to violence and 71.3% of them witnessed incidents of violence against healthcare providers at the workplace. The prevalence of physical violence and verbal abuse among medical students was reported at 5.5% and 92.6% respectively. About 81.5% were females compared to 18.5% of their counterparts. Patients (38.9%) and their relatives (61.1%) were the main sources of the violence respectively. More than half (57.0%) of students exposed to violence at outpatient services and 25.9% at the emergency room and 16.7% at inpatient wards. Few of them (22, 14.7%) thought that they will get support if they make a complaint. Conclusion: Being a medical student and has direct contact with patients and their relative is not always safe practice. Our results suggested a high prevalence of verbal and physical abuse against medical students. Health sector authorities should adopt a restrictive and clear strategy to protect medical students and other healthcare providers.


Background
Violence continues to manifest itself in the field of health as well as in every field of society. Incidents of abuse against the health personnel emerged as a severe public problem that taking part in everyday health practice [1,2]. Many cases of violence in health reduce the motivation of the health personnel, prevent the provision of quality health services to the patient, and sometimes cause mental and physical injuries or end up with death [2,3]. More than half of the employees exposed to violence stated that they felt high levels of "anxiety and restlessness after the event" [4]. Whatever the source of violence, motives are often similar among different societies most common factors contributing to the stimulation of aggression were the death of patients, the lack of educational background among the patient's relatives and the weakness of the health organization's security facilities [5,6 Although, health workers, especially physicians and nurses, are at high risk of being exposed to workplace violence [1][2][3][4], however, the possibility to face violence increases when the intern students meet patients frequently. At the level of the intern, medical students need to be actively involved in health presentation.
Lack of experience and the skills of communication with patients, relatives, and other health personnel may raise the likelihood of unintentional professional errors among intern students. Xie et al. [6] reported that insufficient communication was behind about 27.2% of the incidence of violence among medical students of West China [6]. The author also reported that mental abuse was the highest percent (20.3%) followed by 14.6% offensive threat (14.6%), sexual harassment (9.9%) and physical violence (8.9%) respectively [6]. In their studies about Iranian medical students, Sahraian et al. [7] indicated that medical students exposed to various forms of violence including the verbal (85.5%), physical (24.9%), and sexual harassment (26.1%). Most of the works of literature examining workplace violence in health were about the healthcare personnel [1]. However, minimal literature that explores the violence against ___________________________________________________ drsaadalezzi@gmail.com 1 Department of Public Health, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey Full list of author information is available at the end of the article the medical students when they are undergoing a regular training programme in hospital. Exposure to or witnessing the violence at the workplace negatively reflected on medical students' choices for their future career. Sood et al. [8] reported that about 60.8% of the medical students ranked certain specialties as riskier such as surgical branches. The author also referred to a high awareness (96.0%) developed among medical students toward the increased prevalence of violence against the medical staff [8]. Al-Samarraie and Ali Jadoo [9] concluded that violence and work-related variables contributed significantly to the consolidation of the idea of migration among medical students. Moreover, medical students may expose to abuse and mistreatment in the form of verbal, power, physical, ethnic and sexual harassment. Chung et al. [10] found that 63.0% of medical students involved in focus group discussion declared that they experienced mistreatment at least once during the clerkships. The author also reported that the source of mistreatment included residents, attendings, nurses and the faculty [10]. In this study, the authors tried to draw public attention to the seriousness of workplace violence against healthcare providers by focusing on future doctors (medical students). This study aimed (1) to assess the prevalence of workplace violence against the medical students who are attending clinical training in a busiest tertiary private hospital, (2) to assess their knowledge on how to report the incident of violence, (3) to evaluate their attitude toward the possible support that they will have when they encounter the incident of violence, (4) to evaluate their opinion toward the role of media in preventing the violence, and (5) to assess the expectation of medical students about the possibility to expose to different types of violence for the first ten years of their professional life or not.

Methods
A cross-sectional descriptive study was conducted to explore the workplace violence against medical students at a private tertiary hospital. A universal sampling technique was recruited to survey all medical students in 4th, 5th and 6th classes who were attending clinical training at the teaching hospital, Bezmialem Vakif University, Istanbul, Turkey. Data was collected over the period (months and year) in the academic year of 2017-2018 using a modified questionnaire through a face to face interview. Table 1 presents the main inclusion and exclusion criteria.

Statistical analysis
Data was analyzed using SPSS 16.0 for Windows (SPSS Inc., Chicago IL, USA). All descriptive statistics were presented in percentages, mean and standard deviation. The significance limit in all tests will be assumed to be less than 0.05.

Descriptive analyses (univariate analysis)
Because of the inclusion and exclusion criteria, the total number of participants was 150 (response rate 82.9%). Most of our sample were females (109, 72.7%) compared to (41, 27.3%) males. The highest percent (77, 51.3%) were from 5th class, then (53, 35,3%) from 4th class and the lowest percent (20, 13.3%) were from 6th class. About one third of surveyed students (54, 36.0%) exposed to workplace violence, however, the vast majority (107, 71.3%) of them witnessed accident of violence against healthcare providers at workplace. Patients were the source of violence in about 38.9% of cases, compare to 61.1% were from the patient's relatives ( Figure 1).
More than half (57%) of students exposed to violence at outpatient services and, 25.9% at the emergency room and, 16.7% of violence happened at inpatient wards ( Figure 2).
Among the 54 students who were exposed to violence, about 50, 94 % of violence was verbal compare to 4, 6% was physical violence (Figure 3).
The surveyed students were asked about their knowledge regarding the white Code (1111): The number allocated for urgent communication in the event of violence against employees in hospitals of Turkey. About 65, 43.35% of them described their knowledge as "quite insufficient", and only one third (38, 38.0%) of students were able to recognize the right Code: "1111". Moreover, very few students (22, 14.7%) thought that they will get enough support when they made a complaint ( Table 1). Most of the surveyed students (106, 70.7%) disagreed with idea of frequent news of violence in the news will often contribute to a reduction in violence by raising awareness in society. Moreover, most of them (140, 93.3%) expected that they will expose to verbal violence in the next ten years compare to 56, 37.3% expected to face physical violence. Furthermore, about two third (103, 68.7%) expected that the incidence of violence against health workers will increase in the next 10 years (Table 2).

Discussion
In this research, the prevalence of workplace violence incidents against medical students was 36.0% which inconsistent with the results of previous research in China [6] and Iran [7]. Moreover, the medical students witnessed [71.3%] incidents of violence against medical personnel more than they have suffered. Such findings reinforce previous research findings indicating a significant increase in the rate of violence against health personnel in Turkey [5,12]. In 2015, Both Karakas et al. [5] and Bayram et al. [12] reported a prevalence of workplace violence incidents of 74.4% and 78.1% against Turkish nurses and physicians, respectively. Previous studies have discussed the causes of violence against healthcare givers [13][14][15]. The patient and his relatives are the primary sources of violence against health personnel, followed by other colleagues and supervisors. As in the current study, Karakas et al. [5] found that the patient's relatives contributed to more violence than their patients [5]. The severity and rate of violence vary depending on the severity of the cases and the efficiency of the service provided, therefore, the prevalence of workplace violence increases in the less qualified emergency departments (ED), the busiest outpatient clinics and where the intensive, recovery or lifesaving services are needed. Unlike previous studies [7,12,16] where the WPV more reported in the emergency rooms and inpatient services, most of the medical students (57.5%) experienced WPV at the OP services. The reason is that the hospital of BVU is one of the oldest and busiest private OP clinics in the heart of the European side of Istanbul city. However, the BVU also provides emergency services free of charge for twenty-four hours. Like previous studies [6,7] the highest percent (50.94%) of violent incidents was verbal compared to 4.6% incidents of physical violence. Most of the medical students who exposed to violence were hesitated to make a complaint (figure 2). Indeed, students found a difficulty to decide because either they lack knowledge about how to make the complaint in the right way, or they had doubts about obtaining adequate support when filing a complaint. Results of this study showed that 38.0% of students had enough knowledge enabled them to recognize the right code (1111) allocated to use in case of violence incident against healthcare personnel in Turkey. Ayrancı et al. [4] found that most of the victims could not get help during the incident; however, the inexperienced young age group working in the emergency services tend to report violence more than their colleagues. Chung et al. [10] indicated that medical students refrain from reporting the incident of violence because they thought it is not vital and may lead to damage the student-supervisor relationship and often sympathize with the source of the violence at the expense of the student. The author also attributed the factors preventing medical students from reporting incidents of violence or mistreatment to various and deeply embedded factors in the culture of medicine, as well as the negative connotations associated with reporting" [10]. Most of the students dissatisfied with the role of media in the subject of violence against healthcare providers. Students did not accept the frequent presentation of incidents of violence in the media. This trend was reflected in the students' expectations as they would be exposed to workplace violence during the first ten years of their profession with a suspected high prevalence rate of violent incidents to occur in the future. The students believe that raising people's awareness about the seriousness of the violence is not only done through the media. Whenever the news about violence against healthcare givers is repeated without a radical solution, the more likely it is to accept the idea than to reject it altogether. Although this study shed light on the violent incidents against medical students who were under clinical training in a private tertiary hospital of medical college, however, because of the cross-sectional design the causal relationship was not possible. Moreover, the results cannot be generalized because of the sample collection was from one center. Further research among students from a public hospital is recommended.

Conclusion
In conclusion, this study showed that the prevalence of violence incidents (36.0%) is high among medical students. About seventy percent of the students were witnesses to workplace violence incidents against other health personnel. There is an apparent ignorance of how to deal with violent incidents. Most of the surveyed students do not know the correct number allocated to call and ask for support when the abuse occurs. However, few of them believed in the usefulness of requesting support. The majority of students had a pessimistic view of the future of the medical profession and believed that the abuse would increase in the future. Students have not accepted the role of media on how to present the problem. The need for awareness and training programs to counteract workplace violence has become more necessary than ever and may be more useful if it was in the curriculum.

Declarations Acknowledgement
We render our special thanks to all medical students for their patience and help during the study.

Funding
The author (s) received no financial support for the research, authorship, and/or publication of this article. study concept, design, writing, reviewing, editing and approving the manuscript in its final form. AI and PT contributed in the study design, analysis and interpretation of data, drafting the work, writing the manuscript and reviewed and approved the manuscript. All authors read and approved the final manuscript.

Ethics approval and consent to participate
We conducted the research following the Declaration of Helsinki, and the protocol was approved by the Ethic Committee of Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey (Ref: 54022451-050.05.04/27.03.2018). Moreover, written informed consent was obtained from each included student who were willing to participate after explanation of the study objectives and guarantee of secrecy.

Consent for publication
Not applicable