Known to be a serious problem in many countries in the industrialised world, new research indicates that violence in the health care workplace is actually a global phenomenon. Crossing borders, cultures, work settings and occupational groups, violence in the health care workplace is an epidemic in all societies, including the developing world.

The new research results from developing and transition countries, where data on this subject was previously either unavailable or scarce^*, shows that more than half of the health sector personnel surveyed had experienced at least one incident of physical or psychological violence in the year previous to the study. In South Africa that figure reached 61%, and in Thailand 54 %. Research was also conducted in Portugal where the sixty percent of the 212 respondents from a large Urban Health Centre indicated that they had been subject to at least one incident of violence in the last 12 months.

In Bulgaria 37% and Lebanon 41% of the respondents reported incidents of verbal violence which is a form of psychological abuse.

The research was commissioned by a joint programme on workplace violence in the health sector realised by the International Labour Office (ILO), the International Council of Nurses (ICN) , the World Health Organization (WHO), and Public Services International (PSI) . The joint programme aims to provide guidance for the development and implementation of international, national and local guidelines or policies to address and eliminate workplace violence in health care settings.

Some research highlights
In many countries the joint violence programme research provided the first opportunity to assess the prevalence and nature of workplace violence in the health sector^**. The results, presented in a recent technical consultation held in Geneva , showed that workplace violence in the health sector is universal, although local characteristics may vary. The data demonstrated that violence is far too high and that interventions and preventative measures are urgently needed.

The high prevalence of psychological violence (in addition to widespread physical violence) was one of the main conclusions of the consultation. Many health workers reported that the violence in the streets is spilling over to the hospital. In addition stress resulting from health systems being restructured is a major contributing factor to the generation of workplace violence.

Who and where
Workplace violence affects all health workers, both women and men, though some are more at risk than others. Ambulance staff exposure to violence is extremely high in all countries investigated. In all the studies, nurses and physicians also report very high levels of exposure.

Consequences
The consultation highlighted the negative consequences of such widespread violence on the delivery of health care services, which can include deterioration of the quality of care provided and the decision by health workers to leave the health care professions. This can result in a reduction in health services available to the general population and an increase in health costs. In developing countries particularly, equal access to primary health care is threatened if health workers, already a scarce resource, abandon their profession because of the threat of violence.

Other findings
In most countries studied, there were no specific workplace policies in place to prevent or respond to workplace violence. This resulted in under-reporting of violent incidents, poor follow-up of reported incidents, no sanction of the perpetrators and dissatisfied victims.

The research also highlighted the key interrelationship between stress and violence. In South Africa a significant number of victims reported their suffering from symptoms of post-traumatic stress disorder (PTSD) after experiencing an incidence of violence. While being the victim of violence in the health sector workplace causes high levels of stress, such stress is also a factor in creating violent behaviour. The data furthermore confirmed that witnesses are often stressed by their exposure to an incident of violence.

The consultation confirmed that the definitions used for workplace violence are universal. The data demonstrated that the health sector is at the forefront as far as workplace violence is concerned. This groundbreaking research gave a unique insight into the situations and professions at major risk and allows for the development of targeted interventions.

Addressing the Problem
The ILO/ICN/WHO/PSI joint programme has drafted guidelines taking a preventive, remedial, participative and systematic approach. Strategies are presented for workplace violence recognition, risk assessment, intervention, monitoring and evaluation. These guidelines are being revised according to the recommendations made and will be available in the coming weeks.

Working Definitions
For the purpose of the research the following definitions were employed:

Workplace Violence
Incidents when staff members are abused, threatened or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being or health.

Physical Violence
The use of physical force against another person or group, that results in physical, sexual or psychological harm. Includes beating, kicking, slapping, stabbing, shooting, pushing, biting, pinching, among others^.

Psychological Violence (emotional Abuse)
The intentional use of power, including threat of physical force, against another person or group that can result in harm to physical, mental, spiritual, moral or social development. Includes verbal abuse, bullying/mobbing, harassment, and threats.

Terms related to violence were also defined as follows:

• Assault/Attack

Intentional behaviour that harms another person physically, including sexual assault (i.e. rape).

• Abuse

Behaviour that humiliates, degrades or otherwise indicates a lack of respect for the dignity and worth of an individual.

• Bullying / Mobbing

Repeated and over time offensive behaviour through vindictive, cruel, or malicious attempts to humiliate or undermine an individual or groups of employees.

• Harassment

Any conduct based on age, disability, HIV status, domestic circumstances, sex, sexual orientation, gender reassignment, race, colour, language, religion, political, trade union or other opinion or belief, national or social origin, association with a minority, property, birth or other status that is unreciprocated or unwanted and which affects the dignity of men and women at work.

• Sexual harassment

Any unwanted, unreciprocated and unwelcome behaviour of a sexual nature that is offensive to the person involved, and causes that person to be threatened, humiliated or embarrassed.

• Racial harassment

Any threatening conduct that is based on race, colour, language, national origin, association with a minority, birth or other status that is unreciprocated or unwanted and which affects the dignity of women and men at work.

• Threat