Violence against physicians and nurses: a systematic literature review

Background Violence against physicians and nurses is a global public health problem. This study explored violence against physicians and nurses using a systematic literature review. Methods Pubmed and Scopus were searched using search words ‘violence’ OR ‘aggression’ ‘against’ ‘physicians’ AND ‘nurses’. Articles published between 2010 and 2020 in the English language, excluding review/systemic review articles, were included in the study. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for literature search and reporting and assessed the quality of the article based on the JBI checklist for analytical cross sectional studies. Results A total of 22 studies were included. The majority of the studies showed that there was a significant violent incident within every setting, often directly involving patients or their relatives. Workers of emergency departments were more likely to be exposed to violence. Verbal abuses were the highest among all settings. Physicians were more likely to face physical violence, while nurses were more prone to sexual harassment. Lack of communication plays a significant role. Fewer reports of violence were noted due to lack of action taken previously. Conclusion Adequate policy making and implementation and operational research are required to further mitigate the episodes of violence.


Background
Violence against physicians and nurses, along with other healthcare personnel, is not a new phenomenon (McKay et al. 2020). Various violent incidents were widely documented worldwide (WHO 2016). An Iranian study indicated that healthcare personnel are 16 times more exposed to violence at their work settings (Najafi et al. 2014). This situation is not only found in middle-income countries, similar incidents happen in high-income countries such as Australia (Hills et al. 2012), the UK (Elston and Gabe 2016), Germany (Vorderwülbecke et al. 2015), and many more. Although every nation has taken a variety of measures to prevent such events, similar incidents continue to occur due to various causes. According to a research paper published from India, some causes of such incidents were low social image of the doctors, the role of media, low health budget constraints and low quality of healthcare. The study also indicated that vulnerability of small and medium private healthcare facilities, lack of faith in the judicial process, low health literacy, huge cost of healthcare and poor service provider-seeker communication trigger the problem (Nagpal 2017). In this Covid-19 context, to prevent workplace violence against healthcare workers, India has passed a new law (Withnall 2020). The patient-physician, along with other healthcare professional relationships, is the keystone of the healthcare delivery system (Agarwal 2017). Therefore, such violent activities are the proxy indicators that a nation has a flawed healthcare delivery system. This review paper provided evidence on the prevalence of different violent activities upon physicians and nurses and their particular characteristics, which will help to devise prevention strategies.

Methods
The current study has used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for literature search and reporting (Moher et al. 2009). One junior researcher and one senior researcher independently searched scientific literature in November 2020 in two databases viz. PubMed and Scopus using search terms, 'violence' OR 'aggression' 'against' 'physicians' AND 'nurses'. Studies published in English during the past ten years (2010-2020) were screened for inclusion. Eligible studies, both quantitative and qualitative, focused on violence or aggression against physicians or nurses or both were included. Studies related to other healthcare workers along with physicians or nurses or both were also included. Systemic reviews and review studies were excluded.
One senior researcher rechecked data and consensus by repetitive meetings to resolve all the disagreements and discrepancies. In total, 66 articles were found based on the search strategy in Pubmed and 1360 in Scopus. Among them, after removing duplicates, only 912 articles were selected. Among those articles, 538 were included after excluding non-English, review/systemic review articles, selecting articles published in the past ten years, and selecting fields social science & medicine. Among them, 516 articles were excluded because those articles did not meet the objectives upon which this review study was conducted. Therefore, finally, 22 articles were included for review. The exclusive screening and acceptance process is described in Fig. (1).
The current study focused on and included the author's name, year of publication, place of study, country, year of study, study type, population, sample size, demographic data, type of violence, prevalence of different types of healthcare workplace violence, vulnerable areas within settings, persons involved in violence and violence initiation, reporting and consequences and suggested strategies.
Three researchers critically assessed the quality of the selected articles based on the JBI checklist for analytical cross sectional studies (Moola et al. 2020). During critical appraisals of the studies, the one junior and one senior researcher independently identified eight broad themes. Another senior researcher rechecked and validated the themes to explore the factors affecting violence against physicians and nurses. All selected articles were presented denoting whether each of them had dealt with those themes.

Results
Included articles were arranged chronologically according to the year of publication shown in Table 1. The main findings of those articles were written down under the 'results' and 'conclusions' columns of Table 1. Among those selected studies, 18 studies were cross-sectional, three were qualitative and one study was from the mixed-method domain. Among 22 studies, 18 studies were conducted with physicians and nurses, three studies with nurses and only one study with physicians. Male participants outnumber female participants, if all studies are take into consideration. All studies support that violence was a common phenomenon in all the settings. The majority of the respondents indicated that they were exposed to at least one type of violence in their hospitals during the previous 12 months. There were mainly two types of violence that occurred in the hospitals, viz. non-physical and physical. Non-physical violence mainly includes verbal abuse and threats and physical violence includes direct physical attacks upon health workers. Men were more exposed to physical violence than women healthcare staff. From the angle of sexual harassment, women were more exposed. One study revealed that verbal abuses were more common against married, unhealthy and older nurses (Honarvar et al. 2019). In every setting, there were fewer reports against violence than the prevalence of violence. Tjhe main findings of the included studies were arranged in a tabular fashion according to the date of publication.
This study has identified eight broad areas where the articles are reporting or focusing. The areas are Types and prevalence of violence, Vulnerable groups, Place of violence in health facilities, Source of violence initiation, Causes of violence, Reporting of violence, Consequences, Mitigation strategies. Table 2 presents the assessment of the quality of the selected articles based on the JBI checklist for cross sectional studies. Our assessment shows that not a sigle study had clearly identified the confounding factors and therefore did not mention strategies to deal with confounding factors. For seven studies, we could not assure that the outcomes were measured in a valid and reliable way. Table 3 presents the conformity of the selected articles with contracted themes. The majority of the selected articles had the following themes, i.e. 'type and prevalence of violence (17 articles)', 'vulnerable groups (13 articles)', 'source of violence initiation (12 articles)' and 'causes of violence (10 articles)'. Less conformed themes were 'reporting of violence (8 articles)', 'consequences (6 articles)', 'place of violence in health facilities (4 articles) and 'mitigation strategies' (3 articles).

Discussion
There was a significant violent incident within every setting. Patients and patient relatives were directly involved. Workers of emergency departments were more likely to be exposed to violence. Verbal abuses were the highest in all settings. Physicians were more likely to face physical violence, while nurses were more prone to sexual harassment. Lack of communication plays a significant role. Fewer reports of violence were noted due to lack of action taken previously. Keywords: "violence" OR "aggression" "against" "physicians" AND "nurses".
Preliminary search for relevant arƟcles  • Pearson's chi-square analysis was used to test the differences in exposure to physical and non-physical violence according to respondents' characteristics. Odds ratios and 95% confidence intervals were used to assess potential associations between exposure to violence (yes/no) and the respondents' characteristics using logistic regression model • 80.4% reported exposure to violence; 20.8% physical and 59.6% non-physical.
• No statistical difference in exposure to violence between physicians and nurses was observed.
• Men significantly experienced higher exposure to physical violence in comparison with women.
• Logistic regression analysis indicated that less experience (OR 8.03; 95% CI 3.91-16.47) and a lower level of education (OR 3; 95% CI 1.29-6.67) among respondents meant they were more likely to be victims of workplace violence than their counterparts.
• The assailants were mostly the patients' relatives or visitors, followed by the patients themselves, and co-workers.
• Consequences of both physical and non-physical violence were considerable.
• Only half of victims received any type of treatment.
• Non-reporting of violence was a concern, main reasons were lack of incident reporting policy/procedure and management support, previous experience of no action taken and fear of the consequences • There is a need for intervention to protect health workers and provide safer hospital workplace environments.
• • Nurses were more likely to be exposed to violent incidents than physicians (p < 0.001).
• Men, less experienced, and younger respondents were more likely to encounter violent episodes.
• Excessive waiting time, shortage of staff and unmet patients' demands were the most common reasons for violence.
• Verbal abuse was the most common type encountered.
• The assailants were mostly the patients' relatives or friends, followed by the patients themselves.
• Reasons for not reporting violent events included: feel it is a part of the job, previous experience of no action and fear of consequences • Physicians and nurses are at high risk of violent incidents.
• Health decision makers need to be aware of the potential consequences of such events.
• Appropriate preventive measures are needed to make hospitals safer environments • Verbal abuse (72.5%), physically attacked (16.5%) -(Among those 29.6% reported that the last incident involved a weapon) and in 64% of cases the attacker was a patient's relative.
• The last attack could have been prevented (86%), and 64% said that no action was taken against the attacker (64%).
• Physicians were less likely than nurses to report physical attack (OR 0.46; 95% CI 0.2-1.0), and personnel with greater work experience (OR 4.8; 95% CI 2.0-11.7) and those who said that there were procedures to report WPV in their workplace (OR 3.2; 95% CI 1.6-6.5) were more likely to report verbal abuse.
• WPV was associated with mental health effects in the form of bothersome memories, super-alertness and feelings of avoidance and futility • WPV is an important challenge in the EDs of large hospitals in Karachi.
• A majority of respondents feel that WPV is preventable, but only a minority of attackers face consequences 4.
• 2014 • Public hospitals in two districs (Ma'an in the south region and Al-Mafraq in the north-east region) of Jordan.
• A descriptive exploratory research design -Quantitative study.
• 396 nurses and 125 physicians • 15% of the participants were exposed to physical violence.
• The factors -absence of policies, inadequate staffing and lack of communication skills.
• Only 16.9% of participants indicated that there were specific policies available for dealing with physical workplace violence.
• Strengthening security and providing training were some of the important factors indicated by participants for decreasing violence in the workplace • Workplace violence is a problem in underserved areas that needs attention from administrators.
• Firm policies should be implemented to tackle the problem of workplace violence • Qualitative study using in-depth interviews focused on personal experiences of patient-physician mistrust and trust.
• Between June and September 2013.
• 160 patients, patient family members, physicians, nurses and hospital administrators at seven hospitals varying in type, geography and stages of achieving goals of health reform. These interviews included purposive selection of individuals who had experienced both trustful and mistrustful patient-physician relationships • A patient perception of injustice within the medical sphere, related to profit mongering, knowledge imbalances and physician conflicts of interest.
• Individual physicians, departments and hospitals were explicitly incentivised to generate revenue without evaluation of caregiving.
• Physicians did not receive training in negotiating medical disputes or humanistic principles that underpin caregiving.
• Patient-physician mistrust precipitated medical disputes leading to the following outcomes: non-resolution with patient resentment towards physicians; violent resolution such as physical and verbal attacks against physicians; and non-violent resolution such as hospital-mediated dispute resolution.
• Policy responses to violence included increased hospital security forces, which inadvertently fuelled mistrust.
• Instead of encouraging communication that facilitated resolution, medical disputes sometimes ignited a vicious cycle leading to mob violence.
• However, patient-physician interactions at one hospital that has implemented a primary care model embodying health reform goals showed improved patient-physician trust • Restructuring incentives, reforming medical education and promoting caregiving are pathways towards restoring trust.
• In addition to regulatory and legal, responses are urgently needed to restore trust 6. • The most frequent perpetrators of verbal violence were patients (listed as a source of violence by 39.3% of the respondents) and peers (39.6%), with the most forceful identified as physicians and patients.
• Physical violence against nurses was most often initiated by patients (20.8%) who were also the most forceful source in this category.
• Nurse leaders were found to be the most frequent and forceful sources of violence in terms of leadership level.
• A positive correlation between external (patient and relatives) and internal (physician and nurse) sources of violence was determined • Development of action-oriented violence management strategies required • Physical violence, threats of violence and verbal abuse occurred most frequently in ICUs, whereas sexual harassment and bullying were highest in operating rooms.
• The main perpetrators were patients, followed by physicians and patients' families.
• Nurses perceiving greater work demands and less trust and justice were more likely to have been exposed to violence • Reduction of violence will contribute to creating a better nursing work environment 8. • Fear for safety was common among worker victims (38%). Only 19% of events were reported into official reporting systems • This pervasive occupational safety issue is of great concern and likely extends to patients for whom these workers care for • Verbal abuse (60%) and bullying (19%), sexual harassment (7%), physical violence (3%) and racial harassment (3%).
• Patients emerged as the main perpetrators of violence (64%).
• Significant associations between gender and workplace violence. Women and nurses were more predisposed to experience violent incidents than men and physicians • Female gender being a significant predictor of abuse.
• The first two categories were correlated, in a statistically significant way, with the risk of WPV (p = 0.005, p = 0.004, multiple logistic regression).
• The assailants more frequently were men whereas assaulted professionals more often were women.
Men committed physical violence more frequently than women, in a statistically significant way (p = 0.034, chi-squared test).
• Verbal violence (51%) was often committed by people in a lucid and normal state of consciousness; physical violence (49%) was most often perpetrated by assailants affected by dementia, mental retardation, drug and substance abuse, or other psychiatric disorders.
• • Preventive actions should be taken to reduce the risk of exposure to violence against the staff members working at the locked psychiatric clinics • Preventive actions should be taken to reduce the risk of exposure to violence against the staff members working at the locked psychiatric clinics of the staff responded that paients contributed to the creation of the most severe violent episode, 48% stated that staff behaviour contributed to violent episodes.
• According to physicians and nurses-50% of violence was related to patient dissatisfaction with the quality of service, the degree of staff professionalism, or an unacceptable comment of a staff member.
• Other reasons-lack of understanding of the hospital system on the part of patients, together with poor communication between patients and providers and expectations gaps • Staff and patients share conditions of overload, pressure, fatigue, and frustration. Lack of coping tools to prevent violence.
• Self-conscious awareness regarding potential interacting factors required to coping with hospital violence

• Rafeea F, Al Ansari A et al. • 2017 • Emergency Department of the Defence Force (BDF)
Hospital, Bahrain.
• Violence against ED workers occurred during night shifts (53%), while physical abuse was reported to occur during all the shifts.
• 40% of the staff in the ED of the hospital were not aware of the policies against workplace violence, and 26% of the staff considered leaving their jobs at the hospital • Focus group discussion and individual interviews using a phenomenological approach.
• 31 participants (9 hospital police officers, 10 nurses, 6 patient care technicians and 6 emergency medicine resident physicians) • Emergency Department's healthcare workers provide high-quality care to a marginalised patient population that concurrently poses safety threats, creating a patient care paradox.
• Teamwork is critical to safely managing this population, but hierarchy and professional silos hinder coordinated care between healthcare professionals.
• Environmental challenges and systems issues both in and outside the ED exacerbate threats to safety • The experience of ED staff members while caring for agitated patients is complex and multidimensional.
• Study identified issues that coalesced into four tiers of healthcare delivery at the individual, team, environment and system levels • Nurses with non-official employment status and non-Farsi ethnicity, having a disease, with non-evening shift work, and those with short or long employment period were more affected.
• Unrealistic expectations by patients' companions and long working hours were the most common attributing factors • Violence against nurses, as a strenuous and healththreatening crisis, should be investigated to shot out the problem • Family members were the main perpetrator for VA (75%) and PA (35%).
• Regarding reporting, the violent incidences were mostly reported to ED security and ED faculty.
• Individuals who are younger, less experience, and male gender were more exposed to abuse both VA and PA at p < 0.05.
• Nurses and junior residents reported more abuse than senior residents (p < 0.05).
• Majority of the participants had reported lack of job satisfaction due to verbal abuse (p = 0.01) • Work place violence is common in Emergency Departments of the current setting. • Qualitative-Semi-structured interviews and hybrid thematic analysis approach was used to determine dominant themes.
• 63 participants (11 attending physicians, 36 resident physicians, 10 nurses, and 5 paramedics, 1 interview participant did not give their job title) • Most events involved verbal abuse, although a significant percentage of responses described some kind of physical violence.
• ED factors such as busy times with high patient volumes or periods of waiting are associated with increased violence, as well as incidents with unanticipated outcomes such as patients with severe illness or death.
• Decreased levels of health literacy among patients often contribute as well as the financial stressors of paying for medical care.
• Providers reported negative consequences of workplace violence on quality of care for patients and their own motivation to work in the ED.
• Communication strategies were frequently proposed as interventions to mitigate violence in the future, including both provider communication as well as public awareness campaigns • Alarming levels of verbal and physical abuse and their impact on patient care are described.
• Indian ED providers that differ from those in more developed settings, including financial stressors, inadequate enforcement of rules governing behaviour in the hospital, and an overwhelming frequency of violence emanating from patient family members and attendants rather than the patients themselves

Themes
The current study identified eight significant themes based on the review articles. Themes were arranged systematically as type and prevalence of violence, vulnerable group, area of violence, source of violence, causes of violence, reporting of violence, consequences of violence and mitigation strategies.

Type and prevalence of violence
The majority of the participants in different studies agreed that they faced at least one kind of violent attack in the past 12 months. Significant violence were non-physical assaults, followed by physical assaults. Studies showed that according to prevalence, the most common type of violence was verbal abuse, as indicated in various study settings. Other types of violence were verbal threats, physical assaults, sexual abuse, ethnical harassment, reputation smearing, mobbing behaviour, bullying, intimidation behaviour and racial harassment. Some studies showed that sexual violence was higher than physical violence (Abed et al. 2016), and some showed the opposite (Sun et al. 2017). According to one study, patient's and staff's perceptions and emotions regarding violence episodes were similar (Shafran-Tikva et al. 2017). A systemic review and meta-analysis conducted by Liu et al. (2019) showed that 61.9% reported exposure to any form of work place violence such as exposure to non-physical violence was 42.5% and 24.4% experienced physical violence during the previous 12 months. The most common form of nonphysical violence was verbal abuse, followed by threats and sexual harassment (Liu et al. 2019). A systemic review and meta-analysis showed similar results that the prevalence of verbal abuse against the emergency department nurses was 89.7% and physical violence was 21.0% (Azami et al. 2018).

Vulnerable groups
Studies showed that direct care providers were at significant risk (Pompeii et al. 2015). The majority of the studies showed that nurses and women were more likely to be exposed to violence than physicians and men (Algwaiz and Alghanim 2012;Park et al. 2015;Abed et al. 2016;Ferri et al. 2016;Alsaleem et al. 2018;Honarvar et al. 2019;Demirci and Uğurluoğlu 2020). However, another study observed no significant difference between physicians and nurses regarding the episodes of violence (Kitaneh and Hamdan 2012). Physicians and men were more likely to be exposed to physical violence (Kitaneh and Hamdan 2012;Abed et al. 2016;Wang et al. 2018). Nurses and women were more likely to be exposed to sexual harassments (Demirci and Uğurluoğlu 2020). Though one study said physicians were less likely to be exposed to physical attack than nurses (Zafar et al. 2013). Younger and less experienced groups were more exposed to violence than seniors (Kitaneh and Hamdan 2012;Hamdan and Abu Hamra 2015;Sachdeva et al. 2019). However, one study indicated healthcare personnel with more significant work experience were more likely to report verbal abuses (Zafar et al. 2013). Commonly, emergency workers faced violence during the night shift, but workers faced violence in all shifts in other departments (Rafeea et al. 2017). Vulnerable groups were exposed to violence more due to having less experience regarding better handling the situation, while seniors said their political influence and respect from patients and relatives because of their long years of experience play a significant role (Anand et al. 2016;Kumar et al. 2016;Phillips 2016).

Place of violence in health facilities
Studies showed that verbal abuse, threats of violence and physical violence most frequently occurred in ICUs, whereas reported highest cases of sexual harassment and bullying were in operating rooms (Demirci and Uğurluoğlu 2020). Those who worked in psychiatry departments, emergency departments, i.e. those who provide a high quality of medical care, and geriatric departments were more likely to be exposed to physical violence (Ferri et al. 2016;Wong et al. 2017;Alsaleem et al. 2018). A systemic review and meta-analysis showed that psychiatry and emergency departments were the most common workplace violence areas (Liu et al. 2019). Another review study supports that emergency departments had a possible chance of becoming a place of violence because of various environmental risk factors of violence such as poor staffing, lack of privacy, overcrowding and availability of nonsecured equipment types that can be used as a weapon (Stowell et al. 2016).
The number of beds in the department in which the critical patients are admitted is usually fewer. Explanation of the patient's particular situation is not always possible by doctors and nurses in those departments due to time constraints and many more related factors. Owing to this, there is more misunderstanding between patient parties and service providers in those departments. The majority of the outcome of those departments' cases were low due to the patient's critical condition leading to more violence in those departments.

Source of violence initiation
The majority of the studies showed that patients, patient relatives, peers and family members were the main perpetrators of violence (Algwaiz and Alghanim 2012;Kitaneh and Hamdan 2012;Hamdan and Abu Hamra 2015;Kvas and Seljak 2015;Park et al. 2015;Abed et al. 2016;Sachdeva et al. 2019). One of the studies revealed the main perpetrators of violence against nurses were the patient and higher authority and a positive correlation between external, i.e. patient and relatives, and internal, i.e. physician and nurse sources of violence (Kvas and Seljak 2015). Along with the above, physicians also identified as a source of violence among other healthcare providers (Honarvar et al. 2019;Demirci and Uğurluoğlu 2020). Staff behaviours also contributed as a source of violence (Shafran-Tikva et al. 2017). Violence was associated with mental health effects as bothersome memories, super-alertness, feelings of avoidance and futility, etc. Patients affected by dementia, mental retardation, drug and substance abuse, or other psychiatric disorders were more involved with violence (Zafar et al. 2013;Ferri et al. 2016).

Causes of violence
Most of the studies showed that excessive waiting time was the most common attributor of violence against healthcare staff (Algwaiz and Alghanim 2012;Hamdan and Abu Hamra 2015;Shafran-Tikva et al. 2017;Davey et al. 2020). Other factors were unrealistic expectations from patient parties (Hamdan and Abu Hamra 2015;Shafran-Tikva et al. 2017;Honarvar et al. 2019;Davey et al. 2020), poor understanding by the patients and their families of the healthcare system, poor communication between patients and service-providers (Hamdan and Abu Hamra 2015;Tucker et al. 2015;Shafran-Tikva et al. 2017), lack of communication skills among healthcare providers (AbuAlRub and Al Khawaldeh 2014; Hamdan and Abu Hamra 201515;Tucker et al. 2015), behaviour (Pompeii et al. 2015;Shafran-Tikva et al. 2017), condition of a hospital setting (Shafran-Tikva et al. 2017;Wong et al. 2017), staff professionalism, including their unacceptable comments and clients dissatisfaction about the quality of services (Pompeii et al. 2015;Shafran-Tikva et al. 2017), absence of policies, inadequate staff (Algwaiz and Alghanim 2012;Bilici et al. 2016) and long working hours (Honarvar et al. 2019). Another systemic review found a similar result that major risk factors of violence were long waiting times, the discrepancy between patients' expectations and services, substance abuse by the patient and their psychiatric conditions (Raveel and Schoenmakers 2019). Another review study indicated that patients' psychological health, including anxiety, acute stress reaction, alcohol and drug intoxication and dementia, were predictors of physical violence against healthcare workers perpetrated by patients (D'Ettorre et al. 2018).

Reporting of violence
Violence was most often reported by security personnel and emergency department staff (Sachdeva et al. 2019). Lack of violence reporting was present in every setting. One study showed that only 19% of violent incidents were reported (Pompeii et al. 2015). The review revealed that physicians and nurses were not interested in reporting violence due to various reasons such as the previous experience of no action taken and fear of the consequences and lack of management support (Algwaiz and Alghanim 2012;Zafar et al. 2013;AbuAlRub and Al Khawaldeh 2014;Hamdan and Abu Hamra 2015). They were not aware of reporting policy & procedures (Kitaneh and Hamdan 2012;Rafeea et al. 2017).

Consequences
Owing to consequences of violence, healthcare providers reported lack of job satisfaction. According to one study, 26% of the staff considered leaving their job at the hospital (Rafeea et al. 2017;Sachdeva et al. 2019). Workplace violence significantly affected the psychological stress, sleep quality and health worker-patient relationship significantly, ultimately affecting the quality of patient care services (Hamdan and Abu Hamra 2015;Tucker et al. 2015;Sun et al. 2017;Davey et al. 2020). Similar findings were shown in a systemic review and meta-analysis conducted by Binmadi and Alblowi (2019) that the impact of violence on workers manifested as impaired quality of work, psychological problems, and, although rare, quitting the job. Another review study conducted by Baydin and Erenler (2014) showed a similar result that workplace violence victims' most common psychological effects were reduced job satisfaction and fear.

Mitigation strategies
Prevention strategies should be taken to reduce the violent attacks against physicians and nurses and other healthcare providers, mainly those who work in emergency departments (Bilici et al. 2016). Strengthening security personnel and training to mitigate workplace violence among providers is required (Tucker et al. 2015). Communication strategies should be devised as well as public campaigns required to nullify the communication gaps (Davey et al. 2020). Similar mitigation strategies were expressed by the findings of a systemic review and meta-analysis that governments, policymakers and health institutions need to take actions to address work place violence towards healthcare professionals globally (Liu et al. 2019). However, another systemic review and meta-analysis showed no hard evidence on the effectiveness of that (Raveel and Schoenmakers 2019). A qualitative metaanalysis conducted by Ashton et al. (2018) recommended similar findings to reduce workplace violence staff training in understanding violence and aggression and clinical supervision needed. Along with the above, another review study conducted by Gillespie et al. (2010) suggested other   protective strategies to combat the negative consequences of violence such as carrying a telephone, practising selfdefence, instructing perpetrators to stop being violent, self and social support, and limiting interactions with potential or known perpetrators of violence.

Limitations
There were many publications related to our topic on other sites. However, we selected only Pubmed and Scopus indexed journals to conduct this review because Pubmed is a free accessed website and Scopus for its popularity in medicine and social science. Another limitation of our review study is that we did not include those studies conducted on health workers other than doctors and nurses. Because doctors and nurses are directly involved in service delivery and are primary victims of healthcare workplace violence, most of the studies concerned about such a topic had taken samples from the doctor and nurse communities. However, to explain the ground reality and context, much more inclusion of other healthcare providers' studies are necessary. The study findings address patient and family as sources of violence, but does not address co-worker or non-client violence (Phillips 2016). Also, types of violence varies across countries. Different countries have different cultures and contexts of violence against physicians and nurses. Therefore, more context-based exploration of the causes of violence against physicians and nurses are warranted, especially in the low and middle income countries.

Proposed checklist for scientific research on violence against physicians and nurses (VPNCheck)
From our search strategy in the two most widely used databases and most appropriate search words, based on study objectives, we have initially critically assessed the selected articles. During the review, we explored specific gaps among included articles. We propose a checklist (Table 4) for scientific research on violence against physicians and nurses (VPNCheck).

Conclusion
Reduction of violence provides a better working environment for healthcare workers leading to a better healthcare delivery. Internal system-related factors should be considered first. Emergency departments prone to violent attacks should intervene first. Context-based research guiding strategies and policies are needed to reduce workplace violence against physicians and nurses.
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