Workplace Violence Among Frontline Clinicians in Emergency Departments Amidst the COVID-19 Pandemic

Background: Frontline clinicians working in the emergency department (ED) were at disportionate risk of workplace violence (WPV). This study investigated the prevalence of WPV and its association on quality of life (QOL) among this population in China during the COVID-19 pandemic. Results: The overall prevalence of WPV was 29.2% (95%CI: 26.5%-31.9%). Multiple logistic regression analysis revealed that having family/friends/colleagues infected with COVID-19 (OR=1.81, P=0.01), current smoking status (OR=3.24, P<0.01) and severity of anxiety symptoms (OR=1.13, P<0.01) were positively associated with WPV. Working in inpatient ED units (OR=0.45, P<0.01) was negatively associated with WPV. After controlling for covariates, clinicians experiencing WPV had a lower overall QOL compared to those without (F (1, 1103) =14.2, P<0.01). Conclusions: Prevalence of workplace violence was common among ED clinicians in China during the COVID-19 pandemic. Considering the negative impact of WPV on QOL and care quality, timely preventive measures should be undertaken for ED clinicians.


Introduction
The novel coronavirus disease (COVID-19) has become a major public health concern since early January, 2020 [1]. As of May 2020, over 5.9 million people have been infected with COVID-19 [2]. To contain the rapid transmission of the novel virus, timely identi cation and treatment of COVID-19 is important [3,4]. As such, emergency departments (ED) play a critical role in medical services in early identi cation of infected cases [5,6], provision of timely treatment and referral to other units/hospitals [7,8]. Due to highly stressful and overcrowding clinical environment, heavy workload, limited communication between multidisciplinary team members, inadequate knowledge of the epidemic, lack of personal protective equipment and relevant guidelines on the diagnosis and treatment for patients in early stage of the COVID-19 pandemic, ED clinicians were often exposed to an elevated risk of infection, burnout, mental health problems and even workplace violence (WPV) [9][10][11].
As a global public health challenge, WPV refers to physically and psychologically damaging actions against professionals in the workplace [12]. Verbal and physical violence are common forms of WPV among clinicians [13,14]. Some studies have examined the epidemiology of WPV on ED clinicians. For instance, a meta-analysis revealed that the lifetime prevalence of WPV was 79.8% among ED clinicians in China [13]. Previous studies found that the 1-year prevalence of WPV was 12.1% among ED clinicians in the US [15], the 2-year prevalence was 92.9% among ED clinicians in Taiwan [16], and the 1-year prevalence of WPV was 89.9% among ED clinicians in Beijing, China [17]. A recent study found that the 1-month prevalence of verbal and physical WPV was 15.8% and 3.3%, respectively among ED clinicians, while the corresponding 3-month prevalence was 13.8% and 3.3%, respectively in China [18]. WPV was associated with a diverse range of negative consequences, such as mental health problems, job dissatisfaction, decreased quality of patient care in service provision and medical errors [19,20]. In order to develop preventive measures to mitigate the negative outcomes brought by WPV, it is important to understand the patterns of WPV and its associated factors. In addition, quality of life (QOL) is a comprehensive health outcome which has been widely adopted in clinical practice. To date, no studies have examined the association between WPV and its association with QOL among ED clinicians during the COVID-19 pandemic. This research gap has given us the impetus to examine the prevalence of WPV and its associated factors in the frontline ED clinicians during the COVID-19 pandemic in China, and also explore the association between WPV and QOL.

Setting and sample
This was a cross-sectional, national online survey conducted between March 15 and March 20, 2020 in China. Due to the risk of contagion, traditional face to face assessments and random sampling cannot be not adopted. Similar to other studies [11,21,22], data collection was conducted using the WeChat-based QuestionnaireStar application (Changsha Renxing Science and Technology, Shanghai, China) using snowball sampling method. WeChat is a social communication program with more than 1 billion users in China including all the ED clinicians we invited to participate in this study. To be eligible, participants should be: 1) frontline ED clinicians during the COVID-19 pandemic commencing from January 20 to March 20, 2020; 2) aged 18 years; and 3) able to read/understand Chinese and provide informed consent. This study was approved by the ethics committee of University of Macau, China.

Instruments
A data collection sheet was designed to collect demographic and clinical information including gender, age, education level, marital status, work experience, shift duty, rank (junior/senior), type of hospital (primary /tertiary), working unit (inpatient/outpatient), smoking status, and work experience during the 2003 SARS outbreak. Three additional COVID-19 related questions were also asked: 1) whether they provided direct care for COVID-19 patients; 2) whether they had family members, friends or colleagues infected with COVID-19; and 3) whether they lived in a province with more than 500 con rmed COVID-19 cases throughout the study period.
WPV experienced by the frontline ED clinicians during the COVID-19 pandemic was measured by the Chinese version of the 9-item workplace violence scale [23,24], which covers verbal and physical violence [24]. This scale has satisfactory psychometric properties [25][26][27]. Anxiety symptoms were assessed by the validated Chinese version of the Generalized Anxiety Disorder Scale-7 (GAD-7) [28]. This scale had been widely used in the Chinese populations [29,30]. The total score of the GAD-7 ranged between 0 to 21, with a higher total score indicating more severe anxiety. The sum of the rst two items on the World Health Organization Quality of Life Questionnaire-brief version (WHOQOL-BREF) [31] was used to assess overall QOL. A higher total score indicated higher QOL [32].

Data analysis
Data analyses were performed using SPSS statistical software version 24.0. Categorical variables were compared using Chi-square tests, and continuous variables were compared using two samples independent t-tests, or Mann-Whitney U tests between ED clinicians with WPV and those without. To explore independent correlates of WPV, multiple logistic regression analysis was conducted, with WPV as the dependent variable. All variables with a P value of <0.05 in the univariate analyses were entered as independent variables. Analysis of covariance (ANCOVA) was conducted to compare QOL between ED clinicians with WPV and those without after controlling for variables with signi cant group difference in univariate analyses as covariates. Level of signi cance was set as P<0.05, and all tests were 2-tailed.

Results
A total of 1,103 ED clinicians from all the 32 provinces, municipalities and autonomous regions met the study criteria and participated in this study. Overall prevalence of WPV was 29.2% (95%CI: 26.5%-31.9%; 322/1,103), with verbal violence of 27.5% and physical violence of 5.8% during the COVID-19 pandemic. Table 1 presents the demographic and clinical characteristics of participants between non-violence and violence groups. There were signi cant differences between the two groups in age, years of work experience, living circumstances, rank, clinical work unit, shift work, current smoking status, having family/friends/colleagues infected with COVID-19, direct patient care of COVID-19 patients and GAD-7 total score (all P values <0.05). After controlling for covariates, ED clinicians with WPV had a lower overall QOL compared to those without (F (1, 1103) =14.2, P<0.01).

Discussion
To the best of our knowledge, this was the rst study that examined WPV among ED clinicians during the COVID-19 pandemic (from January 20 to March 20, 2020). The overall prevalence of WPV was 29.2% (95%CI: 26.5%-31.9%) among ED clinicians in this study. Since no studies have used similar timeframe in the past, direct comparison with our study ndings was not plausible. Nonetheless, a previous study found that the 1-month prevalence of verbal and physical WPV among ED clinicians was 15.8% and 3.3%, respectively, while the corresponding 3-month prevalence was 13.8% and 3.3%, respectively [18]. Results of these existing studies were lower than our ndings. Of particular note was that our ndings were even higher than the 1-year prevalence of WPV among ED clinicians in the US (12.1%) [15], but lower than the 2year prevalence (92.9%) in Taiwan [16], and the 1-year prevalence (89.9%) in Beijing, China [17]. Our ndings were also lower than the lifetime prevalence (79.8%) among ED clinicians in China reported in a meta-analysis [13].
Apart from different measures on WPV, sampling methods and timeframe between studies, we speculated some reasons that could possibly explain the common WPV among ED clinicians during the COVID-19 pandemic. First, many ED clinicians, especially those experienced physicians/nurses, joined the crisis response teams, they volunteered to work in infectious hospitals which increased insurmountable pressure on existing scant health resources in China. In addition, low clinician-to-patient ratio, alongside with many cases suffering from life-threatening illnesses in ED that required immediate attention [33,34], may affect the e ciency and quality of care, which undeniably increase patients' and their families' dissatisfaction and irritability, and eventually lead to WPV [34]. Second, ED clinicians encountered enormous pressure and heavy workload from multi-party during the pandemic. Excessive mental stress and physical exhaustion may easily trigger mental health problems [35,36], together with use of personal protective equipment, deter effective communication with patients, or stir up con icts with patients / family members [17]. Miscommunication or ineffective communication was a known factor causing WPV in clinical settings. Third, some urgent contingent measures in ED were adopted to prevent the rapid disease transmission. For example, all patients and their families must wear face masks with temperature check on entry, and thus, the number of ED entrances and exits were reduced, which could lead to patient dissatisfaction, increased disputes between hospitals administrators, physicians/nurses and patients, on top of long waiting time and high medical expenses. All these human and structural factors may trigger WPV [37,38].
Our study found that ED clinicians working in inpatient units had lower likelihood of reporting WPV. In inpatient units, ED clinicians usually had su cient time to communication with patients about their illnesses and adjust treatment plans [39,40]. Effective communication could improve the relationship between clinicians and care recipients. Furthermore, most family visits were suspended during the COVID-19 pandemic. This suspension could largely reduce the likelihood of face-to-face WPV originated from patients' families [41]. Besides, emergency psychological response services established for inpatients in many hospitals could help alleviate patients' mental distress and other mental health problems [42][43][44], which proportionally reduce the risk of WPV in ED settings.
In this study, ED clinicians who had family/friends/colleagues infected with COVID-19 reported more WPV than those without. Frontline clinicians with infected family/friends/colleagues usually suffered from fear of contagion and other negative mood symptoms, such as high level of stress, depressive and anxiety symptoms and psychological trauma [45]. Past research had also reported that psychological trauma was common among healthcare workers with infected family/friends/colleagues during the Severe Acute Respiratory Syndrome (SARS) outbreak [46]. Clinicians inherited with negativity could affect the overall quality of service delivery and deter effective communication with patients and their families, and even lead toWPV.
Previous studies found that clinicians with smoking behavour reported more WPV than non-smokers [47,48], which was also con rmed in this study. Smoking behaviors could be associated with high level of work-related stress [49] and burnout [49,50]. High level of stress and burnout could impair concentration, inattention to patients which highly increase the risk of medical errors, resulting in poor relationship with patients and high risk of WPV. Similar with previous ndings [14,51], ED clinicians suffering from severe anxiety symptoms were associated with higher risks of WPV. The relationship between anxiety and WPV was bidirectional. On the one hand, ED clinicians with anxiety symptoms were more likely to stir up con icts with others, resulting in aggression and WPV [51]. On the other hand, anxiety may affect the quality of care in clinical practice, which triggered WPV perpetrated by patients and/ their family members [52,53].
QOL is determined by the interaction of distressing (e.g. adverse events and anxiety) and protective factor (e.g. good social support and economic status) according to the distress/protection QOL model [54]. Previous studies found that health professionals may suffer from short-and long-term adverse consequences following WPV incidents such as lower quality of care, physical injuries and emotional problems [55,56]. Therefore, it is reasonable to assume that ED clinicians who experienced WPV were more likely to have lower QOL than those without. As expected, our study found that ED clinicians with WPV had lower QOL than those without, which echoled previous ndings [13,19,57].
The merits of this study included the large sample size and use of standardized instruments on WPV. There were several limitations that needed to be addressed. First, the cross-sectional study design implied that causal relationship between WPV and other variables cannot be established. Second, due to logistical reasons, pre-existing mental health conditions of participants were not measured. Third, most of ED clinicians were predominantly females, which may subject to gender bias to a certain extent.

Conclusions
WPV was common among ED clinicians during the COVID-19 pandemic in China. Due to the negative detrimental impact of WPV and QOL, effective preventive measures on WPV should be developed, and timely psychological assistance should be provided to those victimized by WPV.

Declarations
Ethics approval and consent to participate This study was approved by the ethics committee of University of Macau, China. All participants provide informed consent in the study.

Consent for publication
Not applicable.

Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author upon request.

Competing interests
The authors declare that they have no competing interests.   Bolded values: P<0.05; CI: con dential interval; GAD: Generalized Anxiety Disorder; OR: odds ratio