This study contributes knowledge regarding the issue of violence against healthcare staff, particularly in district Peshawar, Khyber Pakhtunkhwa, where little qualitative research on this subject has been done previously. This study aimed to explore the views of hospital stakeholders regarding incidents of violence. The three main themes that emerged from the qualitative analysis reflected the stakeholders' overall view of workplace violence as a health and safety issue for the hospital employees.
Most of the stakeholders described the violence as any form of verbal, physical, and psychological abuse. The first theme reflected that not all the wounds are visible and reiterated that most of these violent events are not reported and noticed in the hospital settings and are considered as routine events with the job. Almost all the stakeholders regarded verbal abuse as a weapon of choice and the most common form of violence. Incidents of verbal, emotional, and psychological violence are not reported and are far more common in comparison with physical violence. This finding is supported by literature from national and international settings where verbal abuse was said to be the predominant form of violence (13, 17–19). This does not mean that physical violence is not a problem in hospitals settings and does not require any attention. Physical violence is recently reported in the local healthcare settings of Peshawar (13) and Karachi (20) in Pakistan. On the contrary, there should be no room for physical violence in hospital settings and could not be justified on any ground.
Additionally, the healthcare professionals were finding themselves as a victim of violence. They described that such situations were unavoidable, and most of the time, they felt scared and emotionally drained. They perceived emotional or psychological abuse as a hidden form of violence being practiced routinely and highlighted that personal violence is more damaging than the one targeted against the system. Similar findings were reported in a review, where it was stated that reported incidents of violence represent only the tip of the iceberg, being under-reported because of the perception that it comes with the job. The resulting consequences to the victim included psychological burnout (21).
The second theme elaborated that there could be many reasons and causes of violence in the healthcare settings, but it is never the answer. The healthcare professionals shared their negative experiences regarding the behavior of people towards them. They believed most of the time people wanted self-directed care, and any disagreement with them provides an excuse for reverting violence. Low literacy, overburdened health facilities leading to delayed attention, and long waiting times are some of the reasons at the public level. Lack of education based on the views of the participants is the most important cause of violence in healthcare settings. This view is supported by literature from the local settings where illiteracy and lack of awareness among the public were considered as an important cause of violence (13). Furthermore, the lack of implementation of security acts and political involvement were found to be the most important reasons for violence that should be addressed at the level of government. These findings are consistent with previous studies (13, 22–23). Most of the victims of physical abuse were those who tried to stop the perpetrators. This issue was highlighted in a cross-sectional study from Iran, where it was reported that most of the victims of physical violence were those who were trying to stop the aggressors and lack of people's knowledge about employees' tasks was the contributing factor (24).
Different stakeholders were of different opinions regarding the causes and contributing factors of violence, such as, "there are many causes that provoke violence such as lack of facilities or malfunctioning of equipment, long waiting times, intolerance or illiteracy of the public, but does that give anyone the right to abuse the service provider?". Moreover, they believed that policy vacuum, inadequate management of administration, and lack of collaboration and security system at institutes create a chaotic workplace environment that results in improper service delivery and frequent incidents of violence. Staff were desensitized to incidents of violence and considered them as a part of their daily routine. The healthcare workers desensitize due to the daily nature of these incidents, as reported in a mixed-method study from Gambia (22).
The current study also found that such incidents of violence harmed individuals` health and institutions. Victims passed through psychological stress and remained silent most of the time. They described that such incidents negatively affected their lives and patient care. To further add to their anxiety, there was a lack of coping mechanisms at the institutions. Similar findings were also reported that there is a relationship between stress and workplace violence. The tension generated due to violence can take the most extreme forms, such as burnout or suicide (25).
The participants reported that most of the time, patients' attendants, family members, or sometimes the patients themselves were the perpetrators of violence. They were directly involved in such incidents. These people were either uneducated or politically spoiled. However, in some situations, the colleagues, hospital staff, and the administration were indirectly involved by practicing personal, psychological, or power harassment. This kind of violence, as reported, is another significant area needing further exploration in future research. Such findings are reported in the literature in other countries as well (13, 26).
The third important theme described various strategies for the prevention of violence at the governmental and institute levels. Among the many prevention strategies, promoting education is the key to prevent violence as reported by the participants. Similarly, creating awareness among the public regarding avoidance of violence can make a big difference. Advocacy for violence prevention and implementation of policies regarding the security of healthcare institutes were found to be essential steps towards a safe working environment. Making hospitals "zero-tolerance zones" for violence was identified as a necessary factor in averting violence. The importance of education and violence prevention programs for a safe working environment is supported through literature (27).
In the present study, it was found that staff education, collaboration, and skill development were necessary for conveying care and averting violence. Good communication skills and fostering resilience was found essential for preventing and handling situational triggers. De-escalation training of hospital staff has shown promising results in the local context (28, 29). Facilitating hospital processes and managing attendants were identified as essential factors in preventing violence (30).
Our study findings also suggested the establishment of effective emergency response and security system for crisis de-escalation and protection. The participants said that there should be a 24-hours security surveillance system including scanners, cameras, security surveillance officers, and a security center at all hospitals. It was also identified that there should be a rehabilitation center and the development of a compensation system for the victims of violence, which is consistent with the results of a previous study (31).
Our study has holistically addressed the issue of violence against healthcare workers from a conservative culture. Some of the reasons for violence against healthcare workers have already been addressed previously from other cultures. Our study further adds to the existing literature and also provides a structured approach to avoid violence against healthcare workers.
The study is limited in that it did not include the experiences of healthcare staff in small and remote areas' health facilities. The study did not have the perspectives of patients and their attendants. The findings also did not thoroughly differentiate the risks for violence by specific occupation or type of facility. Despite these limitations, the study was informative. It revealed that, in the experience of healthcare workers interviewed, violence in the Khyber Pakhtunkhwa healthcare system has become normalized or as an unavoidable risk.