To the best of our knowledge, this was the first 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 findings 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 . Results of these existing studies were lower than our findings. Of particular note was that our findings were even higher than the 1-year prevalence of WPV among ED clinicians in the US (12.1%) , but lower than the 2-year prevalence (92.9%) in Taiwan , and the 1-year prevalence (89.9%) in Beijing, China . Our findings were also lower than the lifetime prevalence (79.8%) among ED clinicians in China reported in a meta-analysis .
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 efficiency and quality of care, which undeniably increase patients’ and their families’ dissatisfaction and irritability, and eventually lead to WPV . 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 conflicts with patients / family members . 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 sufficient 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 . Besides, emergency psychological response services established for inpatients in many hospitals could help alleviate patients’ mental distress and other mental health problems [42-44], 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 . 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 . 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 confirmed in this study. Smoking behaviors could be associated with high level of work-related stress  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 findings [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 conflicts with others, resulting in aggression and WPV . 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 . 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 findings [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.