Workplace violence is defined as any event that results in harm caused by work-related assaults, threats and abuse, whose impact on the victim may lead to a deterioration in health, safety and well-being (1).Workplace violence (WPV) is often associated with the type of occupation, with higher incidence among professions involving interactions with many individuals; therefore WPV is a matter of considerable concern for the health sector.
A US report notes that on average, 20 workers are murdered and 18,000 are assaulted each week while at work (2); similar figures are provided by European reports (3). Forty-eight per cent of non-fatal workplace violence incidents take place in the healthcare sector (4). About 50% of healthcare workers experience workplace violence in the course of their career (5, 6). Healthcare workers have a 16 times greater risk of suffering workplace violence than workers in other sectors (7). Nurses are more at risk (8, 9) and female workers, both nurses and doctors, are at even higher risk (10). In a sample of 1826 health professionals, about 11% had suffered physical assault, 5% on more than one occasion, while 64% had received threats or verbal abuse (11). Saeki et al (12) report a prevalence of 15%.
Data from the US National Crime Victimization Survey for the period 2005–2009 show a rate of workplace violence of 5.1/1000 for all occupations, 10.1/1000 for physicians and 8.1/1000 for nurses. For mental health workers the violent victimisation rate was 20.5/1000, second only to the rate of law enforcement officers (47.7/1000) (13).
In Belgium, a study on patient-physician aggressions (14) conducted by means of an online questionnaire which was completed by 4930 participants, found that, in the preceding 12 months, 37% had been the victim of aggression: 33% verbal aggression, 30% psychological, 14% physical and 10% sexual. Psychiatric and emergency departments were the settings where violence most commonly occurred.
In Israel, Carmi-Illuz (15) compared the risk of violence between a sample of hospital-based physicians and a sample of community-based physicians, finding a substantially comparable risk.
With regard to the authors of violent acts in the workplace, Rippon (16) identifies several categories: patients, family members, visitors and co-workers. In Turkey, a study found that 64.5% of the attacks were carried out by the patients’ family members (17)
A particular form of violence, homicide, is infrequent but extremely disturbing.
In 2006, a leading schizophrenia specialist, W. S. Fenton, was killed at his office by one of his patients (18).
In the healthcare professions, homicide is a malicious and intentional event and is a very rare violent circumstance.
A study in the USA found that between 1980 and 1990, 106 healthcare workers were killed at work (19). Of these, 26 were physicians. The US BLS (Bureau of Labour Statistics) (OSHA 4) reported that 69 HCWs were killed between 1996 and 2000. In Italy, in the period between 1988 and 2010, 17 physicians (20) were killed at work.
Nielssen and Large (21) have analysed homicides by psychiatric patients in psychiatric hospitals and proposed a classification into three patient categories: acute psychiatric patients soon after hospital admission, patients not receiving medication with a history of serious violence, and patients with dementia or intellectual disability, held in low-security inpatient settings in contact with vulnerable patients (victims of the homicide). In this study, the victims were both healthcare workers and fellow patients.
A study by Knable (22) describes a sample of mental health workers who were killed by patients in the US. The study highlights the low frequency of these events (about one case per year) and describes the characteristics of victims and perpetrators. The victims were most likely young female caseworkers, with little work experience, killed during unaccompanied visits to residential treatment facilities. The perpetrators were mostly male, diagnosed with schizophrenia, with poor adherence to medication.
We have carried out a retrospective analysis, to explore the main features of all the reported cases of work-related homicides of physicians in Italy over the past 32 years.