The Occupational Stress from Workplace Violence and the 2019-nCoV Pandemic in Chinese Healthcare Professionals: A Mobile App-Based Survey

Objectives: To investigate the medical occupational risk and stress level of workplace violence (WPV) and novel coronavirus 2019 ( 2019-nCoV) pandemic in Chinese healthcare professionals (HPs). Methods: A national questionnaire survey was created to investigate HPs from 21 provinces of China. Seven questions in environment part and eight questions in stress part were used to assess medical occupation risk and stress respectively. Categorical data were statistically analyzed using chi-square tests. Structural equation model was performed to examine the correlations and differences among experiences of WPV, the 2019-nCoVpandemic, and occupational stress. did (Stress with a positive relationship with increasing doctor-patient conicts (E=0.5, P0.000), and a negative correlation with ego-enhancement (E=-0.2, P=0.000) and public concern (E=-0.2, P=0.000). The 2019-nCoV pandemic had a positive correlation with ego-enhancement (E=0.09, P=0.006), the public's concern (E=0.1, P=0.002)


Introduction
The rising violence against healthcare professionals (HPs) is common around the world 1 , which is worse in India and China [2][3][4][5] . According to the statistical data of the National Health Commission, there are about one million medical disputes each year in China, averaging 40 in each medical institution 6 . In mainland China, workplace violence (WPV) from patients and their relatives/friends has increased rapidly in the past 20 years 6 . Cross-sectional studies in different regions of China have documented the prevalence of physical violence in workplace. The rate for WPV nearly doubled from 4.5% in 2008 to 8.3% in 2012. From 2013 to2017, 288 violent incidents against Chinese HPs were publicly reported, and 67.0% -77.6% Chinese HPs faced intimidation, verbal and/or physical violence at work 7 . Another study counted the WPV incidents in China from 2000 to 2020 8 . Total 345 medical incidents occurred, of which 54 resulted in murder. Other forms of violence, such as disrespect or verbal aggression towards HPs, are even more frequent. WPV againstHPs has become increasingly common recent years, making clinical medicine in China to be a high-risk career 9 .
On December 31st, 2019, the rst detected severe acute respiratory syndrome (SARS) case caused by novel coronavirus 2019(2019-nCoV) was reported and con rmed in Wuhan, China. The ongoing 2019-nCoV pandemic has caused anxiety and depression around the world. HPs are on the front line ghting againstthe 2019-nCoV pandemic, facing a highinfection risk and suffering from great psychological stress 10,11 . According to the survey, 38.7% of the HPs had mental stress during the 2019-nCoV pandemic period 12 . This stress not only reduced HPs motivation, increased turnover rates, but also has lasting effected on their physical and mental health. Therefore, a safe and harmonious workplace is vital to HPs' e ciencyand long-term health 2 .
The aims of present study are to explore the risk of medical occupation in China and differences in occupational stress between WPV and the2019-nCoV pandemic, and examine the relationship between the 2019-nCoV pandemic and working enthusiasm among Chinese HPs.

Survey target and structure
We launched an mobile app-based survey from March 1st, 2020 to May 25th, 2020. Chinese HPs were eligible for the study by WeChat (the largest mobile messaging app in China, which has around 1.08 billion monthly active users 13 ). The questionnaire was self-designed on the basis of consulting a large amount of literature and had been revised after a pilot study and experts' evaluation ( Figure 1). The questionnaire is consisted of 35 questions from three parts: general information, medical occupation environment, medicaloccupationstress. Seven questions in environment part, eight questions (4 pairing questions) in stress part were used to assess medical occupation risk and stressrespectively.

Survey procedure
This survey was created on an app called Questionnaire Star (https ://www.wjx.cn/). A uniform resource locator (URL) link of the survey was generated through this app. Next, we applied the snowball sampling method 14 to recruit participants, during which we took advantage of trusted interpersonal relationships among HPs. The voluteeners posted the URL to their working WeChat Groups("Wei XinQun" in Chinese) and WeChat Moments ("Peng You Quan" in Chinese), where all their HPs could easily obtain ( Figure 1).

Ethical considerations
This survey did not involve human specimens, which based on the questionnaire. During this survey, China is in a period of national blockade. Therefore, there was no ethical application.

Data processing and statistical analysis
The collected questionnaires were reviewed manually. All data were clustered into a database, doublechecked, and locked. The Statistical Product and Service Solutions (SPSS) 20.0 was used to analyzed the data. Continuous variations were presented as median and range or as mean ± standard deviation (SD) according to their distribution. Categorical variation were described by percentage and analyzed by chisquare tests. Linear regression model wasused to examine whether gender, age, degree, major, professional title, hospital-level are predictive factorsofmedical occupation environment. The structural equation model was used to examine the correlations among experiences of violence, the 2019-nCoV pandemic, and occupational stress. A P-value of <0.05 was considered statistically signi cant.

Characteristics of medical occupation environment
Most participants thought the current professional environment of Chinese medical occupation was terrible (n = 433, 34.89%), and only 18.77% (n = 223) of them thought it was good ( Table 2). Signi cant differences were observed in the evaluation of Chinese medical professional environment in terms of gender, education associate degree, profession and professional title (P = 0.000, 0.004, 0.000, 0.014) ( Table 1). Chinese medical professional environment was better in the sight of female HPs, professional degree HPs, junior professional title HPs, and the nursing staves than others. Most participants thought medical occupation was at high risk (n = 1082, 81.19%) ( Table 2). The subjective medical occupational risk degrees were different considering different ages, degrees, professional titles, and hospital-level, respectively (P = 0.000, 0.001, 0.000, 0.000) ( Table 1). The risk was higher in HPs between 31-60 years, and with intermediate professional titles (Junior and Bachelor), than others. Work-related stress ranked rst among medical occupational risks (n = 786, 63.34%), followed by security threat from doctor-patient con ict (n = 368, 29.65%), physical injury from medical work (n = 31, 2.5%), and legal liability (n = 56, 4.51%) ( Table 2). Medical occupational risk was various among different professionals, and hospitallevels (P = 0.005, 0.001) HPs (Table 1). *Choose "wore" (n=23) or "better" (n=389) of social status to answer this question.
After the outbreak of 2019-nCoV pneumonia, most of the participants thought the social status of HPs was not changed (n = 829, 66.8%). Among participants who thought their social status was improved (n = 389, 31.35%) during this special period, 57.28% (n = 236) thought the change would not last for more than 3 years (Table 2).  (Table 3).

Discussion
To the best of our knowledge, this is the rst study to investigate the differences in occupational stress between WPV and the 2019-nCoV pandemic among Chinese HPs. Compared with WPV, the 2019-nCoV pandemic posed more personal risks and less psychological stress to HPs. WPV weakened working enthusiasm and signi cantly intensi ed doctor-patient con ict. The 2019-nCoV pandemic increased the practicing enthusiasm and was unrelated to doctor-patient con ict. Our ndings also indicated that most HPs believed that the current practice environment for Chinese medical workers was poor. Work-related stress account for the rst place of occupation risk. Most participants regard their social status as the middle level and the social status of HPs has not changed after the outbreak .
Compared with WPV, the 2019-nCoV pandemic posed more physical risks to HPs. Jia, H. et al. 15 indicated that the prevalence rate of psychological violence in WPV was 34.6%-62.03%, while that of physical violence was 3.77%-4.73%. High infectivity of the 2019-nCoV, obscure diagnosis and treatment plan, and the shortage of protective materials increased the infection risk of HPs. Korth, J. et al. 16 con rmed that the front-line workers (nurses and allied clinical services, 28%) had a signi cantly higher 2019-nCoV prevalence rate than administrative workers did (19%).
This study found that WPVsigni cantly increased the psychological stress of HPs, weakened the practicing enthusiasm, and intensi ed the doctor-patient con ict. Once WPV occurs, HPs may face the risk of being abused or assaulted by patients 9,17,18 . Verbal and physical violence can signi cantly increase HP's anxiety and depression. There is evidence that HPs are at the highest risk of threatsand physically abuses at workplace 19,20 . WPV can signi cantly increase absenteeism, tension the working atmosphere, and lower staff morale.These not only weaken practicing con dence and enthusiasm but also aggravate negative emotions of both doctors and patients.
The 2019-nCoV pandemic brought less psychological stress compared with WPV did. Meanwhile, it increased the practicing enthusiasm, and was unrelated to doctor-patient con ict. During the 2019-nCoV pandemic, HPs rushed to the frontline regardless of personal safety and took risks in spite of di culties.Their sel ess actions were widely praised and shared by Chinese public on social media 21 .
HPs received widespread social support. Xiao, H. et al. 22 indicated that social support reduced anxiety and stress, improved mood and self-e cacy, and let to more understanding, respect, encouragement, courage, and a sense of professional achievement to HPs 23 . In our study, the 2019-nCoV pandemic didn't weaken HPs' enthusiasm and con dence in clinical work. On the contrary, most HPs showed a sense of collective honor, and they also believed that the 2019 -nCoV pandemic might be bene cial for the medical system to reform..Wang, W. et al 12 indicated that during the 2019-nCoV period, the prevalence of WPV was relatively lower (20.4%) 12 than it used to bein previous studies in China (59.64% -76.2%) 24,25 . The 2019-nCoV pandemic improves the mutual consideration between doctors and patients. During the 2003 SARS outbreak, promoted relationships between patients and HPs were also noted but was temporary.
This crisis can provide an opportunity for the public to regaintheir trust in HPs.
This study found that the current environment for Chinese medical occupation wasnot good and at high risk. This may be related to frequent occurrence of physical con icts, long-term overloaded work, poor treatment and so on 26 . In this study, doctors thought that their environment was worse than that of nurses. Fa iora, E. etal. 27 showed that nurses weremore likely to experience verbal violence than doctors.
Anand, T.et al. 28 showed that doctors were more often victims of physical violence. The possible reason is that the most serious harm may be resulted from physical violence which is primarily related to doctors. In our study, HPs between 31-60 years old, with low educational background (junior and bachelor), or with a junior professional title thought that the occupational risk was higher. A study from the University of Oslo 29 also pointed out that young doctors are more vulnerable than senior doctors under WPV. J. Sun's indicated that the older, lower-educated physicians with lower titles often have more psychological pressure, less self-con dence, and fewer social support 30 .
Work-related stress ranked the rst of occupational risk. The possible reason is that HPs are mostly dealing with di cult tasks and heavy pressure. Meanwhile, competition for a promotion is erce. The frequent occurrences of discourteous behaviors such as medical disputes, insults and physical harm, bring much stress to HPs.Furthermore, in Chinese healthcare reform, doctors and nurses are under heavier stress to cure more patients, meet with more administrative requirements, and comply with more government regulations.
In China, the labor shortage of HPs is becoming more and more serious 31,32 . In a survey, only 4.5% physicians wanted their children to be medical doctors in the future (in 2014) 33 . In our study, the proportion was 12.25%, which was higher than that in previous studies, possibly on account of the reduction of WPV against HPs in China since the institution of new laws and policies with stricter enforcement in 2015 (Chinese Medical Doctor Association (CMDA), 2015) 34 . The trust between doctors and patients has been improved through continous medical reform, equitable diagnosis and treatment and positive media portrayal 33,35 .
The middle and temporarily stable social status of HPs was concluded from this study. This may also be the result of increasing negative medical events in recent years, selective coverages of the media as for This study has limitations. Most of the participants are not on the front line against the 2019-nCoV pandemic, which limits generalizability. Future studies should attempt to increase this population.

Conclusions
Most HPs believe that the current practice environment for Chinese medical workers is abominable and at high risk. The primary occupation risk factor is work-related stress. In HPs' opinion, their social status is at the middle level and has not changed after the outbreak. Compared with WPV, the 2019-nCoV pandemic posed more personal risks and less psychological stress to HPs. WPV weakened working enthusiasm and signi cantly intensi ed doctor-patient con ict. The 2019-nCoV pandemic increased the practicing enthusiasm and was unrelated to the doctor-patient con ict.