Workplace violence against mental health professionals in AddisAbaba, Ethiopia: a facility-based qualitative study

Workplace violence against mental health professionals in AddisAbaba, Ethiopia: a facility-based qualitative study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Workplace violence against mental health professionals in AddisAbaba, Ethiopia: a facility-based qualitative study Djibril Moussa, Dureti Kassim, Asrat Habtegiorgis This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8632851/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background: Violence is a global public health problem that results in multidimensional negative consequences. Several studies showed that mental health professionals are vulnerable to workplace violence. In addition, there are several studies on workplace violence in psychiatry practice in Ethiopia. Therefore, the present study aimed to explore the knowledge and the perceptions of mental health professionals, particularly psychiatry resident physicians and clinical and psychiatry nurses on workplace violence Method: This study design was a qualitative study design to research about knowledge and perceptions of psychiatry residents, psychiatry nurses and clinical nurses working at St Paul's Hospital Millennium Medical College (SPHMMC), Addis Ababa, Ethiopia. The study had collected six focus group discussions (FGDs) over 2 months’ period and 26 in-depth interviews with those with exposure to workplace violence. Each FGDs had six to eight participants. Data analysis was thematic analysis where the researchers inductively followed data to generate themes and subthemes. The approach was an inductive constructionist approach to extract explicit data from the themes using a semantic or explicit theoretical framework. Results and discussion : The results revealed five thematic areas and several subthemes under each theme. The five themes were knowledge of workplace violence, workplace safety, and response to violent behaviors in the Workplace, structural factors contributing to workplace violence and perceived support and attitudes towards workplace violence. Verbal violence was the most reported form of violence at the workplace by both psychiatry residents and both psychiatry nurses and clinical nurses. The participants agreed that there were structural barriers to working effectively including limited security in the hospital. In addition to this, they felt lonely in the workplace. The participants mentioned that workplace had several other limitations including lack of alarm system and security personnel. They also had a perception that the technical or expert support they received from the facility during work was not enough. Some clinical nurses and psychiatry nurses demonstrated high levels of frustration that reached to consider leaving the job. The present study also found that safety guidelines are lacking and there are important points that need improvement to decrease workplace violence. Conclusion: The authors recommend that future studies to assess mental-wellbeing and satisfaction of mental health professionals in psychiatry facilities in Ethiopia is important. mental health professionals psychiatry and safety psychiatry residents psychiatry nurses clinical nurses workplace violence and Ethiopia Figures Figure 1 Background Violence is a global problem resulting in a wide-spread negative health consequences such as injuries or death [ 1 ], mental health problems [ 2 , 3 and 4 ] and cardiac related risks [ 5 ]. According to the definition of World Health Organization (WHO), violence is “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community that either results in or has with a likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation”. It includes two important components: interpersonal violence such as suicide and self-harm, and collective violence on self and towards the community [6 and 7]. Social scientists consider violence as a subset of aggression but politicians and society separate aggression and violence. Anderson and Bushman defined Violence as an extreme form of aggression that has severe physical harm as its goal [ 8 ]. Rather than conceptualizing aggression (e.g., bullying, pushing or punching) and violence (e.g., homicide or suicide) on dichotomy bases or as separate entities, some studies prefer to describe aggression and violence on severity continuum in which aggression can be of a spectrum ranging from mild to severe forms [ 9 ]. Rutherford and colleagues defined violence types based on three major categories: Self-directed violence, interpersonal violence, and collective violence [ 10 ]. 1) Self-directed violence mainly includes suicide and para-suicide; 2) Interpersonal violence is defined as form of violence between individuals as well as family members, workplace or individuals who spend time together in the same place [ 11 ]. Interpersonal violence is one of the important causes of injuries and death in the USA [ 12 ]; 3) Collective violence is a direct violence towards others to achieve certain objectives that may be political, social or economic achievements. Furthermore, there are four types of violence based on the nature of violence: Physical violence, verbal violence, sexual violence, psychological violence and neglect violence. Physical violence involves harming individuals or groups of people through physical actions, while verbal violence uses words to insult, intimidate, or harm individuals or other groups [ 13 ]. Sexual violence (SV) is a widespread health problem in both high-income nations [14 and 15]. There are examples of SV reported in low-income countries such as Ethiopia [16 and 17]. SV occurs when sexual means are used to commit violence whether physical or by sexual means. SV can be collective, targeting populations during wars, or interpersonal, targeting specific individuals. SV includes any sexual violation terms such as sexual abuse or sexual harassment where there is no consent for any sexual contact [ 18 ]. Psychological violence is deliberate mental, spiritual, moral or social attack on individuals or groups of people which can include harassment, insults, threats and events [ 19 ]. Family violence (FV) is also pervasive across the world [ 20 ] and individuals, particularly childbearing women, can be exposed to psychological, physical or sexual violence at family level (e.g., between partners) [ 21 ]. Various terminologies such as “domestic violence”, “intimate partner violence”, “violence against women and children” or “wife battering”. Infant or child maltreatment, and adolescent or elder abuse are also important elements of FV that can happen across one’s life span [ 22 ], as it has been witnessed during COVID 19 pandemic [ 23 ]. About 10 million children in the USA experience intimate violence annually [ 24 ]. Child neglect occurs when parents do not meet their child's developmental needs despite being capable of doing so [ 25 ]. Workplace violence (WV), particularly in healthcare, is another common type of work-related problem that targets staff and results in various types of negative outcomes worldwide [ 26 , 27 , 28 , 29 , 30 and 31 ]. Although the inconsistencies in the description of WV exist, the International Labor Organization has defined the most recognized definition for WV. International Labor Organization (ILO) defines WV as incidents where staff are abused, threatened or assaulted in circumstances related to their work including commuting to or from work which may affect their health or wellbeing [ 32 ]. The World Health Organization (WHO) estimates that injuries including unintentional and violence related cases claim the lives of 4.4 million people every year and contribute 8% of the global death rates [ 33 ]. The two main types of WV are psychological and physical. For example, studies in the USA identified that homecare workers are exposed to verbal aggression (yelling or insulting), workplace aggression (non-physical aggression), WV (physical assault or physically threatening behavior), sexual harassment (with or without physical contact), and sexual aggression involving physical contact [34 and 35]). A study in Ethiopia showed that women who are working as waitresses experienced every type of WV [ 36 ]. Another study in South Africa also concluded that women working at mining industry were highly vulnerable to sexual harassment and sexual aggression [ 37 ]. Violence in mental health practice is an area of clinical practice that affects delivery of mental health services. Mental health disorders have been associated with relative risk of violence and the disorders with increased violence risk include schizophrenia and other psychotic disorders, bipolar depression, substance misuse including alcohol use and personality disorders [ 38 ]. A review on violence and mental illness noted that various social and economic factors, including substance use, are the causes of violence rather than mental health alone. The study proposed prioritizing the management of substance use disorders as a prevention strategy for WV during mental health disorders treatment [ 39 ]. WV is a long-standing clinical challenge for mental health professionals worldwide. For instance, Psychiatry residents in the United States have a 50% chance of being exposed to violence during their general psychiatry training [ 40 ]. However, the rate of psychiatrist exposure to violence was up to 48% during their lifetime [ 41 ]. Similar studies conducted in Europe reported that psychiatry trainees had higher rates of exposure to verbal, physical and sexual assault during their training. For instance, physical violence was 44% [ 42 ]. Therefore, WV is very important topic in mental health services. The one-year prevalence of verbal and physical WV towards nurses is 84.2% [ 43 ]. This is high rate of violence towards mental health workers. This indicates the important nature of studying the WV among nursing staff in a psychiatry facility in comparison to other health care workers. Research question that study asked was How the mental health professionals perceive about WV in clinical workplace at St Paul’s Hospital Millennium Medical College (SPHMMC) in Addis Ababa, Ethiopia. The American Public Health Organization (APHA) also called violence a public health issue and demanded a public health approach to violence [ 44 ]. A study at Amanuel Hospital in Ethiopia found that 36.8% of mental health professionals experienced physical violence, 62.1% encountered verbal violence, and 21.8% faced sexual violence [ 45 ]. Research into mental health disorders, such as depression, quality of life factors, and work-related outcomes like the intention to leave one's job has been conducted [ 46 ]. Additionally, literature on nurses' perceptions of workplace violence, including their exposure to violence and safety, has seen significant growth in recent years [ 47 ]. General Objective was to explore the knowledge and perceptions of psychiatry residents, clinical nurses and psychiatry nurses at SPHMMC. Specific Objectives were to: Assess what resident physicians, clinical nurses and psychiatry nurses know about WV, determine the kind of perceptions psychiatry nurses and residents (i.e., psychiatry residents) have on WV and lastly identify perceived factors such as safety, guideline or facility issue that might expose professionals to violence. Methodology The study took place at Saint Paul’s Hospital Millennium Medical College in Addis Ababa Ethiopia and Study period was from July 1 to September 1, 2022. The study was qualitative, involving focus group discussions (FGDs) and in-depth interviews (IDI) with individuals who reported workplace assaults. Two groups studied in this study are psychiatry residents, clinical and psychiatry nurses at SPHMCC. Six FGDs that constituted four psychiatry resident groups and two nurse groups. The nurses in the study were two categories namely clinical nurses and psychiatry nurses. Each FGD had six- eight participants. Each session took about 45–60 minutes. Participants with work experience received invitations to an IDIs. All of them agreed to the IDIs. Psychiatry residents’ cohorts were (i.e., year 1 to 3 psychiatry residents), who were being trained as psychiatry trainees while psychiatry nurses and clinical nurses at SPHMMC were employees. Thirty-five participants (23 psychiatry residents and 12 clinical and psychiatry nurses) took part in the study. Selection of psychiatry residents and psychiatry nurses and clinical nurses was with a purposive sampling. Inclusion criteria were any psychiatry nurses, clinical nurses and psychiatry residents in psychiatry working at SPHMMC at the time of the study who was willing to participate at the time of the study. The investigator excluded the other mental health workers including psychologists, social workers, and cleaners as the study aimed to explore the knowledge and perception of psychiatry resident physicians and the clinical nurses and psychiatry nurses on WV. Data generation was through three ways. First, collection of demographic data and filling of surveys after getting the participant’s consent. Second, FGDs were on professional similarity (i. e., either psychiatry residents, psychiatry nurses or clinical nurses) for keeping homogeneity. Third, the investigators allocated participants who had experience of WV to an in- depth interview after giving consent. Based on the choice of the participants, Data collection was both in both English and in Amharic to get detailed information. Quality assurance of Pilot FGDs/IDIs followed. During the data collection and FGDs, two research assistants had training to maintain data quality control. The investigator also listened to audio tapes and checked transcripts for completion and correction. The first author made final coding of the whole transcripts after a familiarization with the data. The investigator recruited two research assistants to help collect data and help translate/transcribe and help code data following data collection with the investigator. The investigator collected data and cleaned it for analysis. The investigators transcribed the data into a word document by verbatim writing of the interview scripts. The Amharic version translations into English followed. The recorded transcripts will be in a safe setting. The research team will destroy data within 2 years of publishing data. The interviews used in this study were developed for this study and English version of the interview guide for both FGDs and IDI is attached as a supplementary file. The first author read the data and coded transcripts by writing the codes of each IDIs or the FGDs. Then, the primary investigator classified data into the themes and subthemes. The investigator reviewed the themes with two co-investigators who re-examined themes and subthemes. The research team agreed on the themes for analysis using thematic analysis approach. The investigator wrote up the thematic points with subthemes. Clinical trial number: N/A Results The psychiatry residents in the study were n = 23 representing 76% of the resident physician population while the nurses n = 12 or 63% of the nurses working in the department of psychiatry at Saint Paul’s Hospital at the time of the study. Table 1 Demographic data Participants who experienced WV agreed to give IDIs and shared their knowledge and perception of the incidents. Out of 27 respondents, a large proportion of them (21) experienced WV at least twice, while six (22.2%) of them experienced one time. Study population Clinical work Nurses Clinical nurses Psychiatry nurses Psychiatry residents Year one residents Year two residents Year three residents SexResidents Male Female Nurses Male Female Age range of participants 25–35 years Table 2 Exposure of violence among psychiatry residents’ physicians and nursing staff at the hospital Exposuretoworkplace Violence Yes 27 No 8 Number of times exposed to violence One time 6 Two times 18 Three times 1 >Four times 2 Types of violence Physical 6 Emotional 0 Sexual 1 Verbal 20 Place of work Inpatient only 2 Outpatient only 2 Both inpatient and outpatient 31 Number of years at the hospital Less than a year 11 One year 6 Two years 12 >Three years 6 Twenty-seven percent reported exposure to violence while only eight out of the 35 participants reported no exposure to violence. The eight people were first year residents who were working at outpatient services for 6 months only. Female nurses and residents had tendency for being victims of sexual violence while male participants had more exposure to physical and emotional violence. For instances n = 18 of the participants had at least 2 times of being assaulted while working at the hospital. The most common type of violence in the mental health facility was verbal aggression n = 20 where twenty out of the 27 participants were exposed to, followed by physical violence n = six. All nurses and resident physicians worked in wide variety of clinical settings ranging from outpatient to inpatient service while n = 31. One third of the participants n = 12 worked in the psychiatry wards for up to three years. The FGDs revealed five thematic areas and 4–5 subthemes under each theme (Fig. 1 ). The five thematic areas identified are as follows: Knowledge of WV Workplace safety Response to violent behaviors in the Workplace Structural factors contributing to WV Perceived support and attitudes towards WV There are two major domains in the themes. The first one is on knowledge of participants on violence. The second domain area is in the workplace itself ranging from safety, structural and managerial issues related to workplace. 5.1Theme 1: Knowledge and gaps in the knowledge of violence in the workplace Psychiatry resident physicians, psychiatry nurses, and clinical nurses expressed good understanding and knowledge of a violent patient. They mentioned in four out of six FGDs that they had gaps at the workplace-based training on violent management. This was mainly on the practical aspects of violence management. In general, regarding the violence knowledge, all of nurses and psychiatry residents agreed that types of violence included physical, sexual, emotional, verbal etc. in all six FGDs and in n = 27 of the IDIs, the participants agreed on types of violence and on reasons of violence and violent behavior. They also discussed the causes and risk factors of violence, which demonstrated their knowledge of work. Discussion WV studies around the world demonstrate high rates of prevalences. Some studies indicate very high rates of workplace violence (WV), with prevalences reaching 97% [ 48 ]. Rates can reach 91.5% in emergency units [ 49 ]and are also elevated in forensic and other mental health settings. Therefore, WV is common in mental health practice. In recent years, the number of nursing studies have been on the rise in comparison to the psychiatry resident exposure to WV. The nurses spend more time in the wards and have more exposure to patients compared to psychiatry residents. Our study supports previous research that pointed out verbal violence as commoner form of violence in the workplace. For example, junior doctors particularly female physicians felt to be less safe compared to male colleagues as reported in Pakistan [ 50 ]. In particular, the study found that nursing staff had higher levels of workload contributing exposure to WV. They demonstrated frustration, shock and lack of support during their working time that can increase their risk of developing burnout or other mental health disorders. A study conducted in Nigeria reported increased instances of workplace frustration [ 51 ]. This study took place in setting up a higher number of staff in the hospital compared to our study where nursing workers are smaller. Healthcare workers at mental health facilities need mental health screening and follow-up for their own wellbeing. A study on nurses in Australia [ 52 ] has shown potential workplace trauma among nurses. In a recent study on mental health workers' responses to violent incidents, anger was the primary emotion expressed by nurses. Additionally, frustration and shock were reported alongside anger, which may reflect cultural differences in emotional expression [ 53 ]. Psychiatry residents in our study had strategic outlook on how to improve the services when asked about how they would have changed things. This included safety guideline development and training to improve capacity to handle a violent incident. Violence exposure can be stressful for health care workers. It affects their satisfaction with work environment. One nurse in this study wanted to leave hospital work due to a lack of support and safety. In a similar study on Korean nurses, researchers reported intention to depart their work when they felt that they were under threat or had been exposure to physical injury. This was correlated with female gender and job satisfaction which is the same as the factors raised by our study participants [ 54 ]. In our study, the nurses felt loneliness and frustration at the quality of the workplace which affects their quality of life [ 55 ]. Our study the psychiatry residents reported loneliness and nurses’ frustration with hospital work. These factors could affect the mental wellbeing of nursing staff and psychiatry residents in the event of WV. They attributed their feelings to the exposure of violence in the workplace. Psychiatry residents and nurses also reported low rate of reporting about exposure to violence. They also had same level of low reporting in case of violence in the workplace [ 56 ]. Again, the European psychiatry residents in 39 countries stated that 92% rate of verbal aggression during their work that is close to finding in this study. Verbal aggression was the most common form of violence that both nurses and residents report. At the same time, European psychiatry residents expressed the feeling of having training gaps in addressing violent behavior, which is like the finding of our study. Nurses in particular reported lack of support during workplace activities. The psychiatry residents also had also reported lack of debrief in case WV happens. Workplace risk factors study conducted by [ 57 ] reported that environmental factors related to the workplace infrastructure were risk factors associated with risk of violence as a potential risk. Another meta-analysis on the links between genetics and violence did not show relationships between them [ 58 ] downplaying if violence tendencies were related to multiple factors. As main risk factors are mainly patient or mental health related, recent studies considered environmental/occupational factors in the risks towards WV violence [ 59 ]. In our study, the structure of mental health ward seems to be a factor that the psychiatry residents agreed upon as infrastructure contributor to WV. This includes lack of alarm systems, limited number of escape doors etc. In a recent study mental health professionals reported trauma because of being exposed to violence [ 60 ]. They reported lack of support in the workplace was a factor in the trauma they endured because of working in mental health facility. Woods indicated in a systematic review on the association between violence risk factors and aggression in clinical psychiatry practice as contradictory [ 61 ]. Another study on WV incident cases showed that there was no standardized reporting system on violence experiences and workplace conditions designed for dealing with violence cases [ 62 ]. This study promotes understanding on how mental health workers understand about violence in psychiatric practice. The study also explored how psychiatry residents in different stages of their training addressed violence in the workplace and how it affected them physically and emotionally. Lastly, it investigated if there are gaps in clinical psychiatry training regarding violence in mental health and if they were aware of the connection between human rights and managing violent patients. This study has important significance in addressing violence in the clinical setting. Although a previous study demonstrated that residents regarded SPHMMC as a suitable place for training it did not address the case of violence in the workplace [ 63 ]. The study of psychiatry residents did not take part in it. Although resident supervision and mentorship addresses support the trainees during residency, the workplace safety issues are an area of critical gap in the resident-supervisor relationship. The residents demonstrated they do not seek assistance with experiences related specifically to the working environment. Nurses reported similar situation. Nevertheless, as nurses as being employees rather than trainees in the psychiatry department, their knowledge was very much the same as the residents, but they had more feeling of being unsafe in the workplace. This was very marked among female nursing team. Further studies are necessary to explore the workplace environment and the safety of the psychiatry residents and nurses in the hospital and nationally in Ethiopia. Areas of focus can be mental health distress, burnout and dissatisfaction among psychiatry resident physicians and nurses. Conclusion The present findings showed that there is high prevalence of WV against mental health professionals, which agrees with previous reports regarding workplace violence in psychiatry practice in many parts of the world. The most common types of WV in male are verbal while Sexual violence is common in females. Our findings also showed that mental health professionals perceived that there is limited workplace safety. The findings also indicate that safety guidelines are lacking and there are important points to improving working conditions to decrease WV at facility levels. Future studies need to assess mental well-being and satisfactions of mental health professionals in psychiatry facilities in Ethiopia. Key recommendations are to consider training of psychiatry residents and nurses for hand-on skills in addressing violence in the workplace and development of facility-based safety guidelines in psychiatry wards. Psychiatry practice safety guideline at Ethiopian Psychiatry Association (EPA) for all mental health facilities in line with recommendations from FMOH of Ethiopia. There is a need to consider the workforce wellbeing both physically and mentally and conduct studies on state of mental health of psychiatry residents and nurses working in mental health services. The study’s main strength is that it explored the knowledge and perceptions of psychiatry residents and nursing staff on violence in the workplace. Key limitation of the study of the study is that it addressed psychiatry residents and nurses in one tertiary hospital facility. The study would have been stronger if the study on psychiatry residents and nursing staff in wide areas of practice in both urban and rural areas where burden of clinical work may have been different. Another limitation focuses on trainees and nurses and did not involve other mental health workers including psychologists and attending psychiatrist as a WV through the hospital facility. Abbreviations AA Addis Ababa FGD Focus Group Discussions FV Family Violence ILO International Labor Organization II In-depth Interviews SPHMMC Saint Paul’s Hospital Millennium Medical College SV Sexual Violence WHO World Health Organization WV Workplace Violence Declarations Ethics approval and consent to participate The study was in part a thesis work for psychiatry residency training at SPHMMC in Addis Ababa Ethiopia. Ethics review was submitted to institutional review board at SPHMMC, and it was accepted for data collection. The research conducted on study participants and the materials collected through focus group discussions and in-depth interviews followed the Helsinki declaration. Study proposal was sent to SPHMMC ethics review committee and containing consent to participate in the study in English and Amharic, study questionnaires and clear study plan. All participants signed consent forms to take part in the study. Consent for publication All authors and supervisors consented to this publication. Participants signed consent forms. Competing interests There are no competing interests among research teams. Authors' contributions DM proposed, designed and collected data. DM analyzed data and wrote this study. DK and AHG were supervisors who assisted the principal investigator in applying proposal, securing grant application and assisted DM to complete with this study and present. During publication, both DK and AHG read, reviewed and agreed to format of the paper for submission. Authors’ information Author is a consultant general psychiatrist with special interest in community psychiatry, addiction mental health and geriatric psychiatry. Authors’ information Author is a consultant general psychiatrist with special interest in community psychiatry, addiction mental health and geriatric psychiatry. Funding This study received funding from research directorate of SPHMMC. The funding supported data collection and analysis. Author Contribution DM proposed, designed and collected data. DM analyzed data and wrote this study. DK and AHG were supervisors who assisted the principal investigator in applying proposal, securing grant application and assisted DM to complete with this study and present. During publication, both DK and AHG read, reviewed and agreed to format of the paper for submission. Acknowledgement First, I am thankful to my psychiatry residency training at the department of psychiatry at Saint Paul’s Hospital Millennium Medical College in Addis Ababa Ethiopia support during my residency and support of this research project. The primary investigator appreciated the supporting roles of my supervisors. Dr. Dureti Kassim for mentorship and supervision, Dr. Asrat Habte Giorgis for supervision and mentorship on thesis and during the final year of my residency training, and Dr. Faiz Mohamed Kassim for kindly offer to join the supervisors’ team during data collection, analysis and write up, and for giving valuable feedback and mentorship throughout the process. Data Availability Primary data is available after a reasonable request from readers from corresponding author. References Petrosky E. Surveillance for violent deaths—National violent death reporting system, 34 States, four California Counties, the District of Columbia, and Puerto Rico, 2017. MMWR Surveillance Summaries. 2020;69. Bentivegna F, Patalay P. The impact of sexual violence in mid-adolescence on mental health: a UK population-based longitudinal study. Lancet Psychiatry. 2022;9(11):874–83. Bunston W, Franich-Ray C, Tatlow S. 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Sari H, Yildiz İ, Çağla Baloğlu S, Özel M, Tekalp R. The frequency of workplace violence against healthcare workers and affecting factors. PLoS ONE. 2023;18(7):e0289363. American Public Health Association. Violence is a public health issue: public health is essential to understanding and treating violence in the US American Public Health Association [Internet]. 2018 Nov 13. Abate A, Abebaw D, Birhanu A, Zerihun A, Assefa D. Prevalence and associated factors of violence against hospital staff at Amanuel Mental Specialized Hospital in Addis Ababa, Ethiopia. Psychiatry J. 2019;2019(1):3642408. Jang SJ, Son YJ, Lee H. Prevalence, associated factors and adverse outcomes of workplace violence towards nurses in psychiatric settings: A systematic review. Int J Ment Health Nurs. 2022;31(3):450–68. Riahi S, Thomson G, Duxbury J. An integrative review exploring decision-making factors influencing mental health nurses in the use of restraint. J Psychiatr Ment Health Nurs. 2016;23(2):116–28. Itzhaki M, Peles-Bortz A, Kostistky H, Barnoy D, Filshtinsky V, Bluvstein I. Exposure of mental health nurses to violence associated with job stress, life satisfaction, staff resilience, and post‐traumatic growth. Int J Ment Health Nurs. 2015;24(5):403–12. Ridenour M, Lanza M, Hendricks S, Hartley D, Rierdan J, Zeiss R, Amandus H. Incidence and risk factors of workplace violence on psychiatric staff. Work. 2015;51(1):19–28. Ahmed F, Memon MK, Memon S. Violence against doctors, a serious concern for healthcare organizations to ponder about. Annals Med Surg. 2018;25:3–5. Seun-Fadipe CT, Akinsulore AA, Oginni OA. Workplace violence and risk for psychiatric morbidity among health workers in a tertiary health care setting in Nigeria: Prevalence and correlates. Psychiatry Res. 2019;272:730–6. Beattie J, Griffiths D, Innes K, Morphet J. Workplace violence perpetrated by clients of health care: A need for safety and trauma-informed care. J Clin Nurs. 2019;28(1–2):116–24. Jalil R, Huber JW, Sixsmith J, Dickens GL. Mental health nurses’ emotions, exposure to patient aggression, attitudes to and use of coercive measures: Cross sectional questionnaire survey. Int J Nurs Stud. 2017;75:130–8. Jeong IY, Kim JS. The relationship between intention to leave the hospital and coping methods of emergency nurses after workplace violence. J Clin Nurs. 2018;27(7–8):1692–701. Liang Y, Wang H, Tao X. Quality of life of young clinical doctors in public hospitals in China’s developed cities as measured by the Nottingham Health Profile (NHP). Int J Equity Health. 2015;14(1):85. Pereira-Sanchez V, Gürcan A, Gnanavel S, Vieira J, Asztalos M, Rai Y, Erzin G, Fontaine A, Pinto da Costa, Szczegielniak M. A. Violence against psychiatric trainees: findings of a European survey. Academic psychiatry. 2022;46(2):233-7. Gillespie GL, Gates DM, Miller M, Howard PK. Workplace violence in healthcare settings: risk factors and protective strategies. Rehabilitation Nurs J. 2010;35(5):177–84. Vassos E, Collier DA, Fazel S. Systematic meta-analyses and field synopsis of genetic association studies of violence and aggression. Mol Psychiatry. 2014;19(4):471–7. Jang SJ, Son YJ, Lee H. Prevalence, associated factors and adverse outcomes of workplace violence towards nurses in psychiatric settings: A systematic review. Int J Ment Health Nurs. 2022;31(3):450–68. Ham E, Ricciardelli R, Rodrigues NC, Hilton NZ, Seto MC. Beyond workplace violence: Direct and vicarious trauma among psychiatric hospital workers. A qualitative study. J Nurs Adm Manag. 2022;30(6):1482–9. Woods P, Ashley C. Violence and aggression: A literature review. J Psychiatr Ment Health Nurs. 2007;14(7):652–60. Campbell CL, Burg MA, Gammonley D. Measures for incident reporting of patient violence and aggression towards healthcare providers: A systematic review. Aggress Violent Beh. 2015;25:314–22. Abate A, Abebaw D, Birhanu A, Zerihun A, Assefa D. Prevalence and associated factors of violence against hospital staff at Amanuel Mental Specialized Hospital in Addis Ababa, Ethiopia. Psychiatry J. 2019;2019(1):3642408. Additional Declarations No competing interests reported. Supplementary Files Supplementaryfile.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 17 Apr, 2026 Reviewers agreed at journal 09 Apr, 2026 Reviewers agreed at journal 09 Apr, 2026 Reviewers invited by journal 29 Jan, 2026 Editor assigned by journal 29 Jan, 2026 Editor invited by journal 23 Jan, 2026 Submission checks completed at journal 22 Jan, 2026 First submitted to journal 22 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8632851","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":587965696,"identity":"89e3f300-448d-4d20-b8ac-069b9550d06f","order_by":0,"name":"Djibril Moussa","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1klEQVRIiWNgGAWjYDCCAwfbGBgMLOTAHB4GBsYGIrVIGJOihYENSEokNhCthe/g4bbHFQUS6f3TDh+TeMNgI7vhAPvDB/i0SB442G54xkAid8bttDTJOQxpxhsO8Bgb4NNiAPSLZANQS8PtHDNpHobDiUAtbBLEaEmXh2j5D9TC/owoLQkGEC0HgFoYzPBqAfsFqMVw4+20ZMs5BsnGMw8T8AvfjePPHjb8sZGXu5188MabCjvZvuPt+EOMQeIAijuBmBmveiDgbyCkYhSMglEwCkY8AAD7IU8/6/W42AAAAABJRU5ErkJggg==","orcid":"","institution":"Amoud University","correspondingAuthor":true,"prefix":"","firstName":"Djibril","middleName":"","lastName":"Moussa","suffix":""},{"id":587965697,"identity":"24487d94-8967-4bff-bfa5-8e8ecdaac05b","order_by":1,"name":"Dureti Kassim","email":"","orcid":"","institution":"Saint Paul’s Hospital Millennium Medical College","correspondingAuthor":false,"prefix":"","firstName":"Dureti","middleName":"","lastName":"Kassim","suffix":""},{"id":587965698,"identity":"9b31bdcf-41e9-4737-a94c-0fc5b68aa4bb","order_by":2,"name":"Asrat Habtegiorgis","email":"","orcid":"","institution":"Saint Paul’s Hospital Millennium Medical College","correspondingAuthor":false,"prefix":"","firstName":"Asrat","middleName":"","lastName":"Habtegiorgis","suffix":""}],"badges":[],"createdAt":"2026-01-18 17:23:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8632851/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8632851/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102375355,"identity":"fa53c120-69b7-456d-9158-f229d234df6e","added_by":"auto","created_at":"2026-02-11 05:19:12","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":103205,"visible":true,"origin":"","legend":"\u003cp\u003eMapping of the emerging Themes and subthemes\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8632851/v1/98298cfaa4ec3c509f312d6c.jpg"},{"id":102375356,"identity":"cd26641c-5a53-4237-a3b6-5f1b66dea699","added_by":"auto","created_at":"2026-02-11 05:19:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":678480,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8632851/v1/8d063758-a5e7-4546-9c87-25b8d69cff25.pdf"},{"id":102375354,"identity":"25321f6c-9106-45fa-b26e-0df9ac6bbd01","added_by":"auto","created_at":"2026-02-11 05:19:12","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":21490,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile.docx","url":"https://assets-eu.researchsquare.com/files/rs-8632851/v1/4d168e4b28150888780c6201.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Workplace violence against mental health professionals in AddisAbaba, Ethiopia: a facility-based qualitative study","fulltext":[{"header":"Background","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eViolence is a global problem resulting in a wide-spread negative health consequences such as injuries or death [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], mental health problems [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e and \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] and cardiac related risks [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. According to the definition of World Health Organization (WHO), violence is \u0026ldquo;the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community that either results in or has with a likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation\u0026rdquo;. It includes two important components: interpersonal violence such as suicide and self-harm, and collective violence on self and towards the community [6 and 7].\u003c/p\u003e\u003cp\u003eSocial scientists consider violence as a subset of aggression but politicians and society separate aggression and violence. Anderson and Bushman defined Violence as an extreme form of aggression that has severe physical harm as its goal [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Rather than conceptualizing aggression (e.g., bullying, pushing or punching) and violence (e.g., homicide or suicide) on dichotomy bases or as separate entities, some studies prefer to describe aggression and violence on severity continuum in which aggression can be of a spectrum ranging from mild to severe forms [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Rutherford and colleagues defined violence types based on three major categories: Self-directed violence, interpersonal violence, and collective violence [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. 1) Self-directed violence mainly includes suicide and para-suicide; 2) Interpersonal violence is defined as form of violence between individuals as well as family members, workplace or individuals who spend time together in the same place [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Interpersonal violence is one of the important causes of injuries and death in the USA [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]; 3) Collective violence is a direct violence towards others to achieve certain objectives that may be political, social or economic achievements.\u003c/p\u003e\u003cp\u003eFurthermore, there are four types of violence based on the nature of violence: Physical violence, verbal violence, sexual violence, psychological violence and neglect violence. Physical violence involves harming individuals or groups of people through physical actions, while verbal violence uses words to insult, intimidate, or harm individuals or other groups [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Sexual violence (SV) is a widespread health problem in both high-income nations [14 and 15]. There are examples of SV reported in low-income countries such as Ethiopia [16 and 17]. SV occurs when sexual means are used to commit violence whether physical or by sexual means. SV can be collective, targeting populations during wars, or interpersonal, targeting specific individuals. SV includes any sexual violation terms such as sexual abuse or sexual harassment where there is no consent for any sexual contact [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Psychological violence is deliberate mental, spiritual, moral or social attack on individuals or groups of people which can include harassment, insults, threats and events [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFamily violence (FV) is also pervasive across the world [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] and individuals, particularly childbearing women, can be exposed to psychological, physical or sexual violence at family level (e.g., between partners) [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Various terminologies such as \u0026ldquo;domestic violence\u0026rdquo;, \u0026ldquo;intimate partner violence\u0026rdquo;, \u0026ldquo;violence against women and children\u0026rdquo; or \u0026ldquo;wife battering\u0026rdquo;. Infant or child maltreatment, and adolescent or elder abuse are also important elements of FV that can happen across one\u0026rsquo;s life span [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], as it has been witnessed during COVID 19 pandemic [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. About 10\u0026nbsp;million children in the USA experience intimate violence annually [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Child neglect occurs when parents do not meet their child's developmental needs despite being capable of doing so [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWorkplace violence (WV), particularly in healthcare, is another common type of work-related problem that targets staff and results in various types of negative outcomes worldwide [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e and \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Although the inconsistencies in the description of WV exist, the International Labor Organization has defined the most recognized definition for WV. International Labor Organization (ILO) defines WV as incidents where staff are abused, threatened or assaulted in circumstances related to their work including commuting to or from work which may affect their health or wellbeing [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe World Health Organization (WHO) estimates that injuries including unintentional and violence related cases claim the lives of 4.4\u0026nbsp;million people every year and contribute 8% of the global death rates [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe two main types of WV are psychological and physical. For example, studies in the USA identified that homecare workers are exposed to verbal aggression (yelling or insulting), workplace aggression (non-physical aggression), WV (physical assault or physically threatening behavior), sexual harassment (with or without physical contact), and sexual aggression involving physical contact [34 and 35]). A study in Ethiopia showed that women who are working as waitresses experienced every type of WV [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Another study in South Africa also concluded that women working at mining industry were highly vulnerable to sexual harassment and sexual aggression [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eViolence in mental health practice is an area of clinical practice that affects delivery of mental health services. Mental health disorders have been associated with relative risk of violence and the disorders with increased violence risk include schizophrenia and other psychotic disorders, bipolar depression, substance misuse including alcohol use and personality disorders [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eA review on violence and mental illness noted that various social and economic factors, including substance use, are the causes of violence rather than mental health alone. The study proposed prioritizing the management of substance use disorders as a prevention strategy for WV during mental health disorders treatment [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. WV is a long-standing clinical challenge for mental health professionals worldwide. For instance, Psychiatry residents in the United States have a 50% chance of being exposed to violence during their general psychiatry training [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. However, the rate of psychiatrist exposure to violence was up to 48% during their lifetime [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Similar studies conducted in Europe reported that psychiatry trainees had higher rates of exposure to verbal, physical and sexual assault during their training. For instance, physical violence was 44% [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Therefore, WV is very important topic in mental health services. The one-year prevalence of verbal and physical WV towards nurses is 84.2% [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. This is high rate of violence towards mental health workers. This indicates the important nature of studying the WV among nursing staff in a psychiatry facility in comparison to other health care workers. Research question that study asked was How the mental health professionals perceive about WV in clinical workplace at St Paul\u0026rsquo;s Hospital Millennium Medical College (SPHMMC) in Addis Ababa, Ethiopia.\u003c/p\u003e\u003cp\u003eThe American Public Health Organization (APHA) also called violence a public health issue and demanded a public health approach to violence [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eA study at Amanuel Hospital in Ethiopia found that 36.8% of mental health professionals experienced physical violence, 62.1% encountered verbal violence, and 21.8% faced sexual violence [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eResearch into mental health disorders, such as depression, quality of life factors, and work-related outcomes like the intention to leave one's job has been conducted [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Additionally, literature on nurses' perceptions of workplace violence, including their exposure to violence and safety, has seen significant growth in recent years [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGeneral Objective was to explore the knowledge and perceptions of psychiatry residents, clinical nurses and psychiatry nurses at SPHMMC. Specific Objectives were to: Assess what resident physicians, clinical nurses and psychiatry nurses know about WV, determine the kind of perceptions psychiatry nurses and residents (i.e., psychiatry residents) have on WV and lastly identify perceived factors such as safety, guideline or facility issue that might expose professionals to violence.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe study took place at Saint Paul\u0026rsquo;s Hospital Millennium Medical College in Addis Ababa Ethiopia and Study period was from July 1 to September 1, 2022. The study was qualitative, involving focus group discussions (FGDs) and in-depth interviews (IDI) with individuals who reported workplace assaults. Two groups studied in this study are psychiatry residents, clinical and psychiatry nurses at SPHMCC. Six FGDs that constituted four psychiatry resident groups and two nurse groups. The nurses in the study were two categories namely clinical nurses and psychiatry nurses. Each FGD had six- eight participants. Each session took about 45\u0026ndash;60 minutes. Participants with work experience received invitations to an IDIs. All of them agreed to the IDIs.\u003c/p\u003e\u003cp\u003ePsychiatry residents\u0026rsquo; cohorts were (i.e., year 1 to 3 psychiatry residents), who were being trained as psychiatry trainees while psychiatry nurses and clinical nurses at SPHMMC were employees. Thirty-five participants (23 psychiatry residents and 12 clinical and psychiatry nurses) took part in the study.\u003c/p\u003e\u003cp\u003eSelection of psychiatry residents and psychiatry nurses and clinical nurses was with a purposive sampling. Inclusion criteria were any psychiatry nurses, clinical nurses and psychiatry residents in psychiatry working at SPHMMC at the time of the study who was willing to participate at the time of the study. The investigator excluded the other mental health workers including psychologists, social workers, and cleaners as the study aimed to explore the knowledge and perception of psychiatry resident physicians and the clinical nurses and psychiatry nurses on WV.\u003c/p\u003e\u003cp\u003eData generation was through three ways. First, collection of demographic data and filling of surveys after getting the participant\u0026rsquo;s consent. Second, FGDs were on professional similarity (i. e., either psychiatry residents, psychiatry nurses or clinical nurses) for keeping homogeneity. Third, the investigators allocated participants who had experience of WV to an in- depth interview after giving consent. Based on the choice of the participants, Data collection was both in both English and in Amharic to get detailed information.\u003c/p\u003e\u003cp\u003eQuality assurance of Pilot FGDs/IDIs followed. During the data collection and FGDs, two research assistants had training to maintain data quality control. The investigator also listened to audio tapes and checked transcripts for completion and correction. The first author made final coding of the whole transcripts after a familiarization with the data.\u003c/p\u003e\u003cp\u003eThe investigator recruited two research assistants to help collect data and help translate/transcribe and help code data following data collection with the investigator.\u003c/p\u003e\u003cp\u003eThe investigator collected data and cleaned it for analysis. The investigators transcribed the data into a word document by verbatim writing of the interview scripts. The Amharic version translations into English followed. The recorded transcripts will be in a safe setting. The research team will destroy data within 2 years of publishing data.\u003c/p\u003e\u003cp\u003eThe interviews used in this study were developed for this study and English version of the interview guide for both FGDs and IDI is attached as a supplementary file.\u003c/p\u003e\u003cp\u003eThe first author read the data and coded transcripts by writing the codes of each IDIs or the FGDs. Then, the primary investigator classified data into the themes and subthemes. The investigator reviewed the themes with two co-investigators who re-examined themes and subthemes. The research team agreed on the themes for analysis using thematic analysis approach. The investigator wrote up the thematic points with subthemes.\u003c/p\u003e\u003cp\u003eClinical trial number: N/A\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe psychiatry residents in the study were n\u0026thinsp;=\u0026thinsp;23 representing 76% of the resident physician population while the nurses n\u0026thinsp;=\u0026thinsp;12 or 63% of the nurses working in the department of psychiatry at Saint Paul\u0026rsquo;s Hospital at the time of the study.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic data Participants who experienced WV agreed to give IDIs and shared their knowledge and perception of the incidents. Out of 27 respondents, a large proportion of them (21) experienced WV at least twice, while six (22.2%) of them experienced one time.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy population\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical work\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNurses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical nurses\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePsychiatry nurses\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ePsychiatry residents\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYear one residents\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYear two residents\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYear three residents\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSexResidents\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNurses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge range of participants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u0026ndash;35 years\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eExposure of violence among psychiatry residents\u0026rsquo; physicians and nursing staff at the hospital\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eExposuretoworkplace\u003c/p\u003e \u003cp\u003eViolence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eNumber of times exposed to violence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOne time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTwo times\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThree times\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;Four times\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eTypes of violence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmotional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSexual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVerbal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ePlace of work\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInpatient only\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOutpatient only\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBoth inpatient and outpatient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eNumber of years at the hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLess than a year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOne year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTwo years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;Three years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eTwenty-seven percent reported exposure to violence while only eight out of the 35 participants reported no exposure to violence. The eight people were first year residents who were working at outpatient services for 6 months only. Female nurses and residents had tendency for\u003c/p\u003e\u003cp\u003ebeing victims of sexual violence while male participants had more exposure to physical and emotional violence. For instances n\u0026thinsp;=\u0026thinsp;18 of the participants had at least 2 times of being assaulted while working at the hospital.\u003c/p\u003e\u003cp\u003e The most common type of violence in the mental health facility was verbal aggression n\u0026thinsp;=\u0026thinsp;20 where twenty out of the 27 participants were exposed to, followed by physical violence n\u0026thinsp;=\u0026thinsp;six. All nurses and resident physicians worked in wide variety of clinical settings ranging from outpatient to inpatient service while n\u0026thinsp;=\u0026thinsp;31. One third of the participants n\u0026thinsp;=\u0026thinsp;12 worked in the psychiatry wards for up to three years.\u003c/p\u003e\u003cp\u003eThe FGDs revealed five thematic areas and 4\u0026ndash;5 subthemes under each theme (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The five thematic areas identified are as follows:\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eKnowledge of WV\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWorkplace safety\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eResponse to violent behaviors in the Workplace\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eStructural factors contributing to WV\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePerceived support and attitudes towards WV\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThere are two major domains in the themes. The first one is on knowledge of participants on violence. The second domain area is in the workplace itself ranging from safety, structural and managerial issues related to workplace.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u003cb\u003e5.1Theme 1: Knowledge and gaps in the knowledge of violence in the workplace\u003c/b\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003ePsychiatry resident physicians, psychiatry nurses, and clinical nurses expressed good understanding and knowledge of a violent patient. They mentioned in four out of six FGDs that they had gaps at the workplace-based training on violent management. This was mainly on the practical aspects of violence management. In general, regarding the violence knowledge, all of nurses and psychiatry residents agreed that types of violence included physical, sexual, emotional, verbal etc. in all six FGDs and in n\u0026thinsp;=\u0026thinsp;27 of the IDIs, the participants agreed on types of violence and on reasons of violence and violent behavior. They also discussed the causes and risk factors of violence, which demonstrated their knowledge of work.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWV studies around the world demonstrate high rates of prevalences. Some studies indicate very high rates of workplace violence (WV), with prevalences reaching 97% [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. Rates can reach 91.5% in emergency units [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]and are also elevated in forensic and other mental health settings.\u003c/p\u003e\u003cp\u003eTherefore, WV is common in mental health practice. In recent years, the number of nursing studies have been on the rise in comparison to the psychiatry resident exposure to WV. The nurses spend more time in the wards and have more exposure to patients compared to psychiatry residents.\u003c/p\u003e\u003cp\u003e Our study supports previous research that pointed out verbal violence as commoner form of violence in the workplace. For example, junior doctors particularly female physicians felt to be less safe compared to male colleagues as reported in Pakistan [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn particular, the study found that nursing staff had higher levels of workload contributing exposure to WV. They demonstrated frustration, shock and lack of support during their working time that can increase their risk of developing burnout or other mental health disorders. A study conducted in Nigeria reported increased instances of workplace frustration [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. This study took place in setting up a higher number of staff in the hospital compared to our study where nursing workers are smaller.\u003c/p\u003e\u003cp\u003eHealthcare workers at mental health facilities need mental health screening and follow-up for their own wellbeing. A study on nurses in Australia [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e] has shown potential workplace trauma among nurses. In a recent study on mental health workers' responses to violent incidents, anger was the primary emotion expressed by nurses. Additionally, frustration and shock were reported alongside anger, which may reflect cultural differences in emotional expression [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePsychiatry residents in our study had strategic outlook on how to improve the services when asked about how they would have changed things. This included safety guideline development and training to improve capacity to handle a violent incident.\u003c/p\u003e\u003cp\u003eViolence exposure can be stressful for health care workers. It affects their satisfaction with work environment. One nurse in this study wanted to leave hospital work due to a lack of support and safety. In a similar study on Korean nurses, researchers reported intention to depart their work when they felt that they were under threat or had been exposure to physical injury. This was correlated with female gender and job satisfaction which is the same as the factors raised by our study participants [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. In our study, the nurses felt loneliness and frustration at the quality of the workplace which affects their quality of life [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. Our study the psychiatry residents reported loneliness and nurses\u0026rsquo; frustration with hospital work. These factors could affect the mental wellbeing of nursing staff and psychiatry residents in the event of WV. They attributed their feelings to the exposure of violence in the workplace.\u003c/p\u003e\u003cp\u003ePsychiatry residents and nurses also reported low rate of reporting about exposure to violence. They also had same level of low reporting in case of violence in the workplace [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. Again, the European psychiatry residents in 39 countries stated that 92% rate of verbal\u003c/p\u003e\u003cp\u003eaggression during their work that is close to finding in this study. Verbal aggression was the most common form of violence that both nurses and residents report. At the same time, European psychiatry residents expressed the feeling of having training gaps in addressing violent behavior, which is like the finding of our study. Nurses in particular reported lack of support during workplace activities. The psychiatry residents also had also reported lack of debrief in case WV happens.\u003c/p\u003e\u003cp\u003eWorkplace risk factors study conducted by [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e] reported that environmental factors related to the workplace infrastructure were risk factors associated with risk of violence as a potential risk. Another meta-analysis on the links between genetics and violence did not show relationships between them [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e] downplaying if violence tendencies were related to multiple factors. As main risk factors are mainly patient or mental health related, recent studies considered environmental/occupational factors in the risks towards WV violence [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e In our study, the structure of mental health ward seems to be a factor that the psychiatry residents agreed upon as infrastructure contributor to WV. This includes lack of alarm systems, limited number of escape doors etc. In a recent study mental health professionals reported trauma because of being exposed to violence [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. They reported lack of support in the workplace was a factor in the trauma they endured because of working in mental health facility.\u003c/p\u003e\u003cp\u003eWoods indicated in a systematic review on the association between violence risk factors and aggression in clinical psychiatry practice as contradictory [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAnother study on WV incident cases showed that there was no standardized reporting system on violence experiences and workplace conditions designed for dealing with violence cases [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]. This study promotes understanding on how mental health workers understand about violence in psychiatric practice. The study also explored how psychiatry residents in different stages of their training addressed violence in the workplace and how it affected them physically and emotionally.\u003c/p\u003e\u003cp\u003eLastly, it investigated if there are gaps in clinical psychiatry training regarding violence in mental health and if they were aware of the connection between human rights and managing violent patients. This study has important significance in addressing violence in the clinical setting.\u003c/p\u003e\u003cp\u003eAlthough a previous study demonstrated that residents regarded SPHMMC as a suitable place for training it did not address the case of violence in the workplace [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]. The study of psychiatry residents did not take part in it.\u003c/p\u003e\u003cp\u003eAlthough resident supervision and mentorship addresses support the trainees during residency, the workplace safety issues are an area of critical gap in the resident-supervisor relationship. The residents demonstrated they do not seek assistance with experiences related specifically to the working environment.\u003c/p\u003e\u003cp\u003eNurses reported similar situation. Nevertheless, as nurses as being employees rather than trainees in the psychiatry department, their knowledge was very much the same as the residents, but they had more feeling of being unsafe in the workplace. This was very marked among female nursing team.\u003c/p\u003e\u003cp\u003eFurther studies are necessary to explore the workplace environment and the safety of the psychiatry residents and nurses in the hospital and nationally in Ethiopia. Areas of focus can be mental health distress, burnout and dissatisfaction among psychiatry resident physicians and nurses.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe present findings showed that there is high prevalence of WV against mental health professionals, which agrees with previous reports regarding workplace violence in psychiatry practice in many parts of the world. The most common types of WV in male are verbal while Sexual violence is common in females. Our findings also showed that mental health professionals perceived that there is limited workplace safety. The findings also indicate that safety guidelines are lacking and there are important points to improving working conditions to decrease WV at facility levels. Future studies need to assess mental well-being and satisfactions of mental health professionals in psychiatry facilities in Ethiopia.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Key recommendations are to consider training of psychiatry residents and nurses for hand-on skills in addressing violence in the workplace and development of facility-based safety guidelines in psychiatry wards.\u003c/p\u003e \u003cp\u003e Psychiatry practice safety guideline at Ethiopian Psychiatry Association (EPA) for all mental health facilities in line with recommendations from FMOH of Ethiopia. There is a need to consider the workforce wellbeing both physically and mentally and conduct studies on state of mental health of psychiatry residents and nurses working in mental health services.\u003c/p\u003e \u003cp\u003eThe study\u0026rsquo;s main strength is that it explored the knowledge and perceptions of psychiatry residents and nursing staff on violence in the workplace.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eKey limitation of the study of the study is that it addressed psychiatry residents and nurses in one tertiary hospital facility. The study would have been stronger if the study on psychiatry residents and nursing staff in wide areas of practice in both urban and rural areas where burden of clinical work may have been different.\u003c/p\u003e\u003cp\u003eAnother limitation focuses on trainees and nurses and did not involve other mental health workers including psychologists and attending psychiatrist as a WV through the hospital facility.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAddis Ababa\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFGD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFocus Group Discussions\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFamily Violence\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eILO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInternational Labor Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eII\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIn-depth Interviews\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSPHMMC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSaint Paul\u0026rsquo;s Hospital Millennium Medical College\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSexual Violence\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorkplace Violence\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe study was in part a thesis work for psychiatry residency training at SPHMMC in Addis Ababa Ethiopia. Ethics review was submitted to institutional review board at SPHMMC, and it was accepted for data collection. The research conducted on study participants and the materials collected through focus group discussions and in-depth interviews followed the Helsinki declaration. Study proposal was sent to SPHMMC ethics review committee and containing consent to participate in the study in English and Amharic, study questionnaires and clear study plan. All participants signed consent forms to take part in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors and supervisors consented to this publication. Participants signed consent forms.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThere are no competing interests among research teams.\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026apos; contributions\u003c/h2\u003e\n\u003cp\u003eDM proposed, designed and collected data. DM analyzed data and wrote this study. DK and AHG were supervisors who assisted the principal investigator in applying proposal, securing grant application and assisted DM to complete with this study and present. During publication, both DK and AHG read, reviewed and agreed to format of the paper for submission.\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026rsquo; information\u003c/h2\u003e\n\u003cp\u003eAuthor is a consultant general psychiatrist with special interest in community psychiatry, addiction mental health and geriatric psychiatry.\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026rsquo; information\u003c/h2\u003e\n\u003cp\u003eAuthor is a consultant general psychiatrist with special interest in community psychiatry, addiction mental health and geriatric psychiatry.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis study received funding from research directorate of SPHMMC. The funding supported data collection and analysis.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eDM proposed, designed and collected data. DM analyzed data and wrote this study. DK and AHG were supervisors who assisted the principal investigator in applying proposal, securing grant application and assisted DM to complete with this study and present. During publication, both DK and AHG read, reviewed and agreed to format of the paper for submission.\u003c/p\u003e\n\u003ch2\u003eAcknowledgement\u003c/h2\u003e\n\u003cp\u003eFirst, I am thankful to my psychiatry residency training at the department of psychiatry at Saint Paul\u0026rsquo;s Hospital Millennium Medical College in Addis Ababa Ethiopia support during my residency and support of this research project. The primary investigator appreciated the supporting roles of my supervisors. Dr. Dureti Kassim for mentorship and supervision, Dr. Asrat Habte Giorgis for supervision and mentorship on thesis and during the final year of my residency training, and Dr. Faiz Mohamed Kassim for kindly offer to join the supervisors\u0026rsquo; team during data collection, analysis and write up, and for giving valuable feedback and mentorship throughout the process.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003ePrimary data is available after a reasonable request from readers from corresponding author.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePetrosky E. Surveillance for violent deaths\u0026mdash;National violent death reporting system, 34 States, four California Counties, the District of Columbia, and Puerto Rico, 2017. MMWR Surveillance Summaries. 2020;69.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBentivegna F, Patalay P. 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Prevalence, associated factors and adverse outcomes of workplace violence towards nurses in psychiatric settings: A systematic review. Int J Ment Health Nurs. 2022;31(3):450\u0026ndash;68.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHam E, Ricciardelli R, Rodrigues NC, Hilton NZ, Seto MC. Beyond workplace violence: Direct and vicarious trauma among psychiatric hospital workers. A qualitative study. J Nurs Adm Manag. 2022;30(6):1482\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWoods P, Ashley C. Violence and aggression: A literature review. J Psychiatr Ment Health Nurs. 2007;14(7):652\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCampbell CL, Burg MA, Gammonley D. Measures for incident reporting of patient violence and aggression towards healthcare providers: A systematic review. Aggress Violent Beh. 2015;25:314\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbate A, Abebaw D, Birhanu A, Zerihun A, Assefa D. Prevalence and associated factors of violence against hospital staff at Amanuel Mental Specialized Hospital in Addis Ababa, Ethiopia. Psychiatry J. 2019;2019(1):3642408.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"mental health professionals, psychiatry and safety, psychiatry residents, psychiatry nurses, clinical nurses, workplace violence, and Ethiopia","lastPublishedDoi":"10.21203/rs.3.rs-8632851/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8632851/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eViolence is a global public health problem that results in multidimensional negative consequences. Several studies showed that mental health professionals are vulnerable to workplace violence. In addition, there are several studies on workplace violence in psychiatry practice in Ethiopia. Therefore, the present study aimed to explore the knowledge and the perceptions of mental health professionals, particularly psychiatry resident physicians and clinical and psychiatry nurses on workplace violence\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod: \u003c/strong\u003eThis study design was a qualitative study design to research about knowledge and perceptions of psychiatry residents, psychiatry nurses and clinical nurses working at St Paul's Hospital Millennium Medical College (SPHMMC), Addis Ababa, Ethiopia. The study had collected six focus group discussions (FGDs) over 2 months’ period and 26 in-depth interviews with those with exposure to workplace violence. Each FGDs had six to eight participants. Data analysis was thematic analysis where the researchers inductively followed data to generate themes and subthemes. The approach was an inductive constructionist approach to extract explicit data from the themes using a semantic or explicit theoretical framework.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults and discussion\u003c/strong\u003e: The results revealed five thematic areas and several subthemes under each theme. The five themes were knowledge of workplace violence, workplace safety, and response to violent behaviors in the Workplace, structural factors contributing to workplace violence and perceived support and attitudes towards workplace violence.\u003c/p\u003e\n\u003cp\u003eVerbal violence was the most reported form of violence at the workplace by both psychiatry residents and both psychiatry nurses and clinical nurses. The participants agreed that there were structural barriers to working effectively including limited security in the hospital. In addition to this, they felt lonely in the workplace. The participants mentioned that workplace had several other limitations including lack of alarm system and security personnel. They also had a perception that the technical or expert support they received from the facility during work was not enough. Some clinical nurses and psychiatry nurses demonstrated high levels of frustration that reached to consider leaving the job. The present study also found that safety guidelines are lacking and there are important points that need improvement to decrease workplace violence.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eThe authors recommend that future studies to assess mental-wellbeing and satisfaction of mental health professionals in psychiatry facilities in Ethiopia is important.\u003c/p\u003e","manuscriptTitle":"Workplace violence against mental health professionals in AddisAbaba, Ethiopia: a facility-based qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-11 05:19:07","doi":"10.21203/rs.3.rs-8632851/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-17T22:11:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"291855676147194495494443671453439827472","date":"2026-04-10T01:03:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"244346535614127648756316213246235433346","date":"2026-04-09T15:16:25+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-29T05:56:45+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-29T05:55:58+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-23T09:57:28+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-22T20:14:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychiatry","date":"2026-01-22T20:08:26+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"136b988e-2174-4225-8b26-5356e5a0508d","owner":[],"postedDate":"February 11th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-11T05:19:07+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-11 05:19:07","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8632851","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8632851","identity":"rs-8632851","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}