Violence against medical staff is a deep-rooted problem in different countries. The present study adopted a self-administered web-based questionnaire to analyze medicolegal aspects of violence toward Egyptian physicians. Over three-quarters of the participants were under 40, and more than two-thirds practiced medicine for ten years or less. The participation of a high percentage of new generations could be attributed to their accessibility to online webpages through which the questionnaire was distributed more than seniors31,32.
The majority (88%) of participants reported previous exposure to verbal violence, whereas 44% were exposed to physical violence, and there was a significant association between the occurrence of verbal and physical violence. On the other hand, only 13% of respondents reported exposure to sexual harassment that was not significantly related to physical violence.
A narrative review included published questionnaire-based studies that investigated violence in healthcare sectors since 2000. Table 4 illustrates 25 studies from 15 countries other than the present study, pointing to violence in healthcare institutes as a worldwide problem. The percentages of healthcare providers who reported verbal violence ranged from 8.7 to 94.6%. Whereas the percentages of those exposed to physical violence ranged from 1 to 81%. It was found that verbal violence was more prevailing in relation to physical violence in all studies. Regarding sexual violence, it was investigated by only five studies, other than the present study9,21,28,33,34. The percentages of medical staff who reported sexual harassment ranged from 1.7 to 48.1%.
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It was noticed that the published studies investigated violence in healthcare sectors through perspectives of public health, emergency medicine, critical care, psychiatry, and nursing. Only three out of 25 studies were conducted by researchers affiliated with forensic medicine25,28,30; these forensic articles were concerned with violence in the Egyptian healthcare sector during the COVID-19 pandemic.
The current study concerned analyzing medicolegal aspects of violence regardless of the COVID-19 crisis. This study started by outlining the characteristics of physicians previously exposed to physical violence. It was observed that more than two-thirds of them were males, which agreed with the Egyptian study conducted by Mahmoud and Ezzat23. In other words, In Egypt, female doctors were significantly less exposed to physical violence than their male counterparts, which could be attributed to the local cultural norms that dignified females’ bodies. On the other hand, Assil et al. reported that emergency physicians in Egypt of both sexes were equally exposed to aggression during the COVID-19 crisis28. Elsaid et al. declared that Egyptian female healthcare providers experienced more physical violence than males during the COVID-19 pandemic25. Variations in the included categories of healthcare providers and the circumstances of the COVID-19 crisis might explain the variations in the results regarding the relationship between gender and physical violence.
This study revealed that physicians aged 30 years were more exposed to physical violence than junior physicians who agreed with Abdel-Salam5. Also, it was found that physicians with experience duration from 10 to 20 years were significantly more exposed to physical aggression than others.
It is essential to consider that complicated cases are managed by more senior physicians with relatively long experience duration. Working on risky issues could be associated with undesirable outcomes that provoke anger and attacks of violence toward treating staff38. Also, the more extended period of medical practice and handling many cases increase the likelihood of exposure to violent events. On the other hand, a study conducted by Algwaiz and Alghanim in Saudia Arabia found that less experienced healthcare workers were exposed to physical violence7. Including nursing staff in the Algwaiz and Alghanim study might explain such variations in results.
In the present work, physical violence was significantly higher in specialties that manage critical cases, including surgery and emergency. The severity and life-threatening conditions of the cases admitted to these departments are often associated with poor outcomes. Anger from the patients ‘ families could be transformed into violence toward the physicians. Similarly, several studies pointed to emergency departments as a commonplace of violence toward medical staff8,11,18.
The current study revealed that physicians’ qualifications and job levels did not influence the exposure of physicians to physical violence, which means that increasing scientific degrees or job levels does not protect physicians against physical violence.
Regarding the trend and frequency of violence, the present study pointed to significant increases in physical violence toward physicians in Egypt, particularly after 2011. It is essential to consider that the Arab Spring Revolutions were associated with increased violence and aggressive behavior among Arabian societies in different sectors, including healthcare systems39.
It is worth mentioning that nearly two-thirds of participants stated that increased violence toward medical staff was not influenced by the COVID-19 crisis, which coincides with the results of Salem et al.30. However, a meta-analysis conducted by Ramzi et al. proved that violence significantly increased against nursing staff, not physicians, during the COVID-19 pandemic19.
The present study reported an extremely high frequency of violent incidents, as 30.5% of the physicians had been exposed to physical violence more than five times annually.
Analysis of the circumstances of violence revealed that the most violent events occurred in the hospitals of the Ministry of Health and that of universities. Similarly, Abdellah and Salama; and Mahmoud and Ezzat previously reported that violence toward emergency physicians was more prevailing in Egyptian governmental hospitals6,23. The governmental institutes in Egypt serve most populations, particularly those who cannot afford the cost of treatment in private institutes. Also, tertiary governmental hospitals receive emergency and complicated cases that private hospitals cannot manage31,32. The high workload could stand behind relative medical supply shortages and waiting times that promote violence toward medical staff40. All these factors contribute to increased violence in the governmental health sector in Egypt compared with the private sector.
As mentioned by study respondents, more than two-thirds of the physical violence occurred during the night shifts, followed by evening shifts, which is in agreement with Abdel-Salam5. The increased physical violence in night and evening shifts could be attributed to the relative shortage of medical staff and security personnel. Also, night and evening shifts are often covered by junior physicians with limited experience in the absence of seniors, which increases liability for medical errors.
Regarding violent perpetrators, the current study revealed that patients’ relatives were responsible for more than three-quarters of the violent events against physicians, which coincides with the results of previous Egyptian studies23,25. In Egyptian society, solid social relationships usually motivate family members and friends to attend to their patients41. Thus, the patient’s relatives and friends might break their anger through violence toward medical staff.
A tiny fraction of the participating physicians pointed to the patients as violent perpetrators, which could be explained by the inability of patients incapacitated with their illness to exert physical aggression.
Nearly three-quarters of the participating physicians claimed that violence perpetrators were of low educational standards. In addition, almost half of all the respondents attributed hostile behaviors to the poor communication skills of the offenders. The association between violence toward healthcare providers and limited communication was proved by Ghiasee and Sağsan42.
The participating physicians stated that outbreaks of violence were triggered by a shortage of medical equipment/supplies, worrying regarding the patient’s condition, and long waits to receive care, as mentioned by 49.5%, 45.7%, and 42.9% of participants, respectively. It is worth noting that the Egyptian healthcare sector services in a country with more than 100 million population in 2023,26,27which explains the overloaded healthcare system with a relative shortage of services. Additionally, the continuous emigration of Egyptian physicians to more developed countries further contributes to patients-physicians mis-proportion43.
Regarding the instruments used in aggression, three-quarters of the respondents declared that the offenders used their bodies to attack the physicians, whereas 29.5% of participants mentioned that blunt instruments were used. Most seriously, 7.6% and 1.9% of the participants were attacked by sharp and firearm weapons, respectively, which might reflect intense aggression and the associated grave risk.
The commonly reported attacks were pushing, pulling, throwing objects and fists. The traumas were mainly directed toward accessible areas in the upper half of the body. Similarly, Salem et al. 2022 reported that physicians’ heads, chests, and upper limbs were the most typical target areas for traumas30. Most seriously, some participating physicians reported attempts of stabbing and slashing with sharp weapons.
Regarding the physical consequences of the violence, three-quarters of participants experienced pain. Whereas simple wounds, including contusions, abrasions, and cut wounds, were mentioned by 22.9%, 16.2%, and 1.9% of participants, respectively. Most seriously, 4.8%, 3.8%, 2.9%, and 1.9% of violent attacks result in serious injuries, including firearm injuries, internal organs injuries, fractures, and burns. The previously reported physical outcome of violence toward Egyptian physicians during the COVID-19 crisis was much milder than that described in the current study. Salem et al. 2022 said that 4.5% of physicians had abrasions or contusions, and 0.6% of physicians reported simple wounds, whereas no serious injuries were reported30.
Complete healing is the usual outcome of violence-induced injuries, as reported by the current study participants. Nevertheless, a small fraction of them reported residual scars or even infirmities as a consequence of violence.
Regarding the immediate responses of attacked physicians, only 59% of them asked the security personnel for help, and only 34.3% called the police to handle the violent events. Similarly, in Egypt, Abdellah and Salama and Salem et al. mentioned that 76.2% of emergency medical staff and 75% of physicians did not report their exposure to violence6,30. Also, in Iraq, Lafta et al. declared that 69% of physicians did not report violence to the police44.
Considering the legal outcome of violence, only 14.3% of the physicians took legal and judicial actions. In contrast, no legal steps were taken by more than half of physicians in response to physical violence. Also, many physicians forgave the attackers and did not proceed with litigation procedures. The reluctance of physicians in this context could be attributed to dissatisfaction with legal responses to previous notifications and a lack of trust that appropriate action will be conducted30,44. Non-taking appropriate legal actions as a response to violence contributes to further violation of the rights of healthcare providers in the future.
The participating physicians believed that adopting rigorous legislation and strengthening the security issues are the most important preventive actions to protect medical staff. Also, participants recommended raising public awareness regarding the judicial penalties for violence against healthcare providers. In addition, it is necessary to improve medical service and decrease the workload by increasing the number of healthcare providers in Egypt.
Strengths and limitations
The present study provided a comprehensive medicolegal analysis of physical violence toward physicians in Egypt. This research elucidates escalating and alarming violence toward Egyptian physicians, even after ending the COVID-19 crisis. The current results could govern future protective measures in the Egyptian healthcare sector. Also, the narrative review denoted that violence toward healthcare providers is a worldwide problem that was not adequately investigated from a medicolegal perspective.
The main limitation of the current study is a relatively small number of participants which could be attributed to the tendency of non-disclosure of work-related issues. Also, the narrative review of relevant studies has an inherited limitation of being less rigorous than a systematic review.
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