Causes and Effects on Workplace Violence in Healthcare Settings.
Ximena Cors-Cepeda1
doi: http://dx.doi.org/ijms.2024.2679
Volume 12, Number 4: 485-488
Received 01 05 2024; Rev-request 09 08 2024; Rev-recd 10 08 2024; Accepted 11 11 2024
“Don't take it personally.”
That's the advice that several senior medical students gave me before I began my clinical rotations. At the time, I often wondered what they meant. Now, a year after completing my clinical phase of medical school, I understand why they emphasized it so much. It seems like something we say to convince ourselves that the system isn't broken. A shield, a coping mechanism, a way to navigate the workplace violence and the hierarchies we encounter daily.
Recently, I befriended a couple of preclinical students. Talking to them, I couldn't help but think, “Was I this excited about life before rotations?”. The truth is, the more I thought about it, the more I remember how enthusiastic I was. Back then, I didn't fully grasp why the older students gave me that advice. I anticipated some workplace stress and occasional outbursts, but I had no idea how common it was going to be. How I was going to feel consistently diminished and underappreciated, simply because I was labeled as “just the student”.
During my rotations, I witnessed students and residents grappling with imposter syndrome and burnout, enduring insults from colleagues, patients, and families. I observed my peers transition from motivated and bright-eyed individuals to cynical, disheartened professionals in a short amount of time. That's when I really started to understand why we tell ourselves that violence in the workplace is something we must endure. Because otherwise, I'm left wondering how every healthcare worker manages not to crumble under the weight of personal attacks layered on top of the inherent stress of the job.
Ultimately, I found comfort in knowing others share my struggles. This inspired me to gather information and explore how to empower future medical professionals to change the current system. With this in mind, I aim to explore the causes and types of violence in healthcare. By doing so, I hope to contribute to changing the culture and preserving the motivation we all initially have as young students entering this field Figure 1.
Figure 1Causes and Effects on Workplace Violence in Healthcare Settings.
Workplace violence (WPV) is “any act or threat of physical violence, harassment, intimidation, or threatening behavior that occurs at the worksite”, and is four times more prevalent in healthcare than other industries.1 This phenomenon is influenced by organizational climate, supervisory style, and interpersonal relationships. Factors linked to increased interpersonal aggression include trait anger, interpersonal and situational conflicts, and job dissatisfaction.2 Healthcare workers are particularly susceptible to various forms of violence, including verbal abuse, sexual harassment, demeaning behaviors, discrimination, and bullying.3
Trainees experiencing mistreatment from healthcare professionals are often overlooked victims, particularly in teaching hospitals.4 This mistreatment ranges from acts of disrespect and humiliation to verbal attacks, reported by up to 83.6% of medical and nursing students during training.5 In a study done in my country, Mexico, 52.3% of medical residents experienced violence during their training, with psychological (44%) being the most frequent.4 These behaviors persist due to ingrained practices in medical culture, where young individuals are expected to “endure” the demands of medical practice. Subtle yet pervasive behaviors like rude comments and aggressive questioning induce shame, perceived as part of the Socratic method.6
Medical education operates within a structured social context where interactions are heavily influenced by power roles and hierarchies.7 While these hierarchies ideally aim to enhance patient care and promote a positive learning environment, they often become dysfunctional, leading to increased workplace stress and mistreatment of learners.8 In these settings, there is resistance to expressing opinions due to fear of challenging authority, with this attitude seen as a “rite of passage.” This dynamic predominantly affects individuals at lower hierarchical levels, including residents, students, and nursing staff, hindering open communication, and negatively impacting work quality and learning in healthcare.9
This level of mistreatment isn't only experienced in clinical environments but also in research and educational settings. These mistreatments include a range of behaviors such as bullying, harassment, discrimination, and the exploitation of junior staff. These issues are often embedded within a hierarchical structure, similar to clinical medicine, where it is almost expected for junior professionals to tolerate mistreatment.10 This contributes to broader issues in medical education because it fosters a culture where abuse and mistreatment are normalized, undermining the well-being and development of trainees. When such behaviors are tolerated or even expected, it erodes trust, hinders collaboration, and stifles open dialogue. Consequently, this toxic culture impacts not only individual trainees but also the overall quality and integrity of medical education, ultimately affecting patient care and professional standards.11,12
The conjunction of the hierarchical nature of medical education and workplace violence contributes to burnout and imposter syndrome among individuals in the field.13 Mistreatment also impacts academic achievement, correlating with poorer learning outcomes, lower self-esteem, and reduced quality of patient care.14 For instance, a study done in Brazil in 2022 showed that 94% of medical students in an academic institution felt affected by violence, with 77% feeling diminished and depressed and more than 50% reporting impaired academic performance.15 Research indicates that students who have experienced violence are more likely to express dissatisfaction with their chosen careers and exhibit reduced confidence in making clinical decisions.16
The effects of structural violence are enduring and can permeate all levels of hierarchy. While it often impacts those in lower positions, such as residents and junior doctors, the toxic environment can influence individuals at all roles and levels, including those in positions of authority like senior doctors/nurses and administrative staff, as well as undergraduate students and non-clinical practitioners.17 This systemic issue doesn't just harm the most vulnerable; it also affects those who might feel compelled to perpetuate these harmful behaviors. As a result, a culture of abuse can persist and impact everyone within the field. Simply put, this is a systemic issue with serious and widespread negative effects on all involved.
To effectively address workplace violence and create a safer workplace, it is imperative to implement interventions at both the organizational and individual levels. This approach acknowledges that workplace violence is a systemic problem requiring systemic change while also recognizing that change is often motivated by increased awareness and open discussion of the issue.
Negative Acts Questionnaire.
| Factors | Items |
|---|---|
| Work bullying | Someone withholding information which affects your performance. Being ordered to do work below your level of competence. Having key areas of responsibility removed or replaced with more trivial or unpleasant tasks. Being given tasks with unreasonable or impossible targets or deadlines. Excessive monitoring of your work. Being exposed to an unmanageable workload. |
| Personal bullying | Being humiliated or ridiculed in connection with your work. Spreading of gossip and rumors about you. Being ignored or excluded. Having insulting or offensive remarks made about your person, attitudes, or your private life. Being shouted at or being the target of spontaneous anger. Intimidating behavior such as finger-pointing, invasion of personal space, shoving, blocking/barring the way. Hints or signals from others that you should quit your job. Being ignored or facing a hostile reaction when you approach. Persistent criticism of your errors and mistakes. Having your opinions and views ignored. Practical jokes carried out by people you don't get on with. Having allegations made against you. |
Observed Horizontal Violence in Clinical Settings.
| Behavior | Possible Manifestations |
|---|---|
| Nonverbal cues, nonverbal innuendo | Eye rolling, making faces in response to questions. |
| Verbal remarks, verbal affront | Snide, rude, demeaning comments, shouting, using a condescending, or patronizing tone of voice. |
| Actions/inactions | Refusing assistance, allocating unrealistic workloads, hoarding, or hiding supplies. |
| Withholding information | Deliberately withholding information. |
| Sabotage | Deliberately setting up another worker for failure. |
| Infighting | Excluding members of staff from communication. |
| Scapegoating | Blaming negative outcomes on one identified nurse without regard to his or her actual responsibility for those outcomes. |
| Passive aggressive behavior | Backstabbing, complaining to others about a person but not speaking to that person directly. |
| Broken confidences | Gossiping, sharing information that is meant to be private. |
Medical education represents a journey of self-discovery and adaptation to a distinct subculture within clinical environments. The challenges related to hierarchies and workplace violence encountered during our early training stages can significantly impact our motivation, self-esteem, and mental health. No student, resident, attending physician, nurse, or any other healthcare professional should ever feel diminished or undervalued. Looking back, I wish I had understood this before starting my clinical training; perhaps then, I wouldn't have felt so isolated. If I could rephrase the advice given to me by senior colleagues, I would tell myself: “Recognize what applies to you and do not tolerate mistreatment to appease others' comfort.” I now understand that I have the ability to speak out against these issues, and that these experiences have equipped me to identify opportunities for change within the system. It is crucial to address not only individual changes but also the broader systemic issues that contribute to workplace violence and hierarchical challenges in medical education. The goal is to foster a more respectful and supportive environment in the medical field. By advocating for systemic change and supporting one another, we can advance in our careers without allowing anyone to dim our lights.
I would like to thank Dr. Pilar González Amarante for her continued support during this year.
The Authors have no funding, financial relationships or conflicts of interest to disclose.
Conceptualization & Writing - Original Draft: XCC.
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Ximena Cors-Cepeda, 1 Final year Medical Student, Tecnológico de Monterrey, Monterrey, Mexico.
About the Author: Ximena is currently a Medical Intern in Social Service Year (Year 7/7: MD program) at Tecnológico de Monterrey, Mx. She aspires to specialize in Psychiatry.
Correspondence: Ximena Cors-Cepeda. Address: Av. Eugenio Garza Sada 2501 Sur, Tecnológico, 64700 Monterrey, N.L., Mx. Email: ximecors@gmail.com
Editor: Francisco J. Bonilla-Escobar; Student Editors: Juan Pablo Medina-Gaona; Copyeditor: Richard Christian Suteja; Proofreader: Amy Phelan; Layout Editor: Julian A. Zapata-Rios; Process: Peer-reviewed
Cite as Cors-Cepeda X. From Hope to Hardship: Understanding the Impact of Hierarchies and Violence in Medicine. Int J Med Stud. 2024 Oct-Dec;12(4):485-488.
Copyright © 2024 Ximena Cors-Cepeda
This work is licensed under a Creative Commons Attribution 4.0 International License.
International Journal of Medical Students, VOLUME 12, NUMBER 4, December 2024