review article

Violence in Health Institutions in Turkey (Medical, Social and Legal Aspects of Events)

Hasan Zafer Acar*, Ruhsan Kaptanoğlu

Girne-American University, Northern Cyprus

*Corresponding author: Hasan Zafer Acar, Girne-American University Medical Faculty Lecturer, Üniversite Caddesi Karmi kampüsü Karaoğlan, Girne, Northern Cyprus. Tel: +90-5428866022; Email(s):;

Received Date: 24 September, 2019; Accepted Date: 18 October, 2019; Published Date: 24 October, 2019

Citation: Acar HZ, Kaptanoğlu R (2019) Violence in Health Institutions in Turkey (Medical, Social and Legal Aspects of Events). Int J Nurs Health Care Res 10: 1119. DOI: 10.29011/2688-9501.101119


There is a significant increase in the morbidity and mortality of violent incidents in health institutions especially in recent years; in the World and also in our country [1-6]. For this reason, medical, social and legal aspects of events; have been evaluated by making a wide assessment, the causes have been examined, the situation in other countries has been reviewed and solutions have been proposed accordingly in this article. Types, causes, reasons of attacks, kinds of attackers, proffessions of victims, places of attacks, kinds of traumas have been reviewed in some studies related with the attacks on health workers in Turkey and compared with data from other countries. According to the results of this study; nurses are the most frequent victims of attacks, the most frequent type of attacks are verbal attacks, the most frequent place of attacks are emercensy services in Turkey. We generally found the same findings when we reviewed the literature.


Doctors; Health institutions; Nurses; Solutions; Violence


Violence in health institutions is defined as; “From patients, relatives, or any individual who pose a risk to the health worker; threat behavior, verbal threat, economic abuse, physical assault, sexual assault state” [1]. The problem of violence against healthcare workers is not only a serious problem in our country but also in the whole world’s “Public Health” problem [1,2,3]. Health service providers are attacked 16 times more than those working in other business areas [4]. Safety is one of the most basic need of the human. People who do not feel safe in the institution; “Efficient Working” is not possible [1]. For this reason, the causes of the attacks in health institutions should be revealed immediately, examined and rational solutions should be determined and implemented by the administrators as soon as possible.

Attacks in Health institutions; Types, Causes, Victims

The Types Of Violence Attacks On Victims in Health Institutions is Generally as Follows [1,2]:

• Verbal attacks,

• Physical attacks (without a tool),

• Sexual attacks,

• Cutting – penetrating tool attacks,

• Attacks by firearms,

• Psychological attacks (mobbing).

The Reasons For Attack in Health Institutions in General Are As Follows [1,2]:

• Excessive patient density in hospitals, especially in emergency room, long time waiting due to organizational disorder,

• Actions under the influence of alcohol, drugs or stimulants,

• Mental or behavioral disorders,

• Populist discourses of politicians towards voters

• According to the high expectations of patients or relatives; low level of infrastructure and quality of services,

• The provocative articles in the press,

• Inadequate security stuffs

• To be alone with the patient and relatives,

• Low educational and cultural level,

• Scientific insufficiency,

• Wrong treatments,

• Neglect of duty,

• Disinterested physician and assistant health personnel,

• Long working hours, overload,

• Payment difficulties,

• Attackers are not sufficiently punished.

Attackers in Health Institutions Are in Order Of Frequency As Follows [1,2]:

• Patients

• Patients’ relatives,

• Patients and their relatives.

Health Personnel Exposed to Violence in Health Institutions Are As Follows [1,2]:

• Nurses,

• Doctors

• Emergency assistance - operating room technicians,

• Patient admissions officers,

• Laboratory staff,

• Accounting personnel,

• Security elements,

• Ambulance drivers.

The Places Where the Attacks Were Made in Health İnstitutions are as Follows [1,2]:

• Emergency services,

• Clinics,

• Patient admission desks,

• Patient rooms,

• Hospital entrances.

After the Attacks - Except Death - The Physical and Psychological Traumas are [1,2]:

• Different kinds of wounds in the body by attacks with; cutting-penetrating-crushing tools or firearms

• Depression, suicide, emotional disorders (Anger, fears, stress, sadness, anxiety, frustration, guilt,etc.), decreased productivity, and sleep disorders may occur due to mental trauma.

Data sources 1

Potential Sources Of The Various Types Of İnformation İnclude [1]:

• Individuals

• Agency or institutional records

• Local programmes

• Community and government records

• Population-based and other surveys

• Special studies.

A range of research institutes collect and analyse data on the victims of international conflicts and conflicts within a single country. They include the Stockholm International Peace Research Institute (SIPRI), which has developed a detailed, standardized format for its annual reports on the impact of conflicts, and the Correlates of War project at the University of Michigan in the United States, a widely cited source on the magnitude and causes of conflicts from the 19th century to the present day. Data specifically on torture and human rights abuses are gathered by a wide range of national human rights agencies, as well as a growing number of international nongovernmental organizations, including African Rights, Amnesty International and Human Rights Watch. In the Netherlands, the Interdisciplinary Research Programme on Root Causes of Human Rights Violations monitors deaths and other outcomes of abuses worldwide.

Data sources 2

The European Crime and Safety Survey (EU ICS)

The Survey, focused on the European Union inhabitants experience with crime and law enforcement, was conducted by an European consortium comprising Gallup, UNICRI, the Max Planck Institute, CEPS/INSTEAD, and GeoX Ltd.,. The survey compares levels of victimisation across the EU and measures how citizens feel about their security and safety. It analyses the relationships between the EU citizens’ views on their quality of life and the levels of neighbourhood crime across the EU (the EU-15, Estonia, Poland and Hungary) - all independent of actual police records. The survey was carried out in the 15 old member states of the Union plus Poland, Hungary and Estonia. The study was co-funded by the European Commission, DG. European Foundation for the Improvement of Living and Working Conditions, 1997 Sexual harassment in the European Union, 1996, Jenkins, 1996, p. 3. Tables 9 to 12 and figures 6 and 7 are reproduced with permission from the National Institute for Occupational Safety and Health. Cincinnati. Ohio.

Violence Towards Health Care Personnel

Prevalence, risk factors, prevention and relation to quality of care, doctoral dissertation. Stockholm Karolinska Institutet, Department of Public Health Science, Division of Psychosocial Factors and Health.

The situation in Turkey

Turkey also has several detailed studies regarding the attacks seen in health care institutions [5-7]. According to the common findings of these studies, attacks in health institutions in our country; The frequency order of the perpetrators, types, causes, places of attack, victims and the effects of the attacks on the victims is as follows:

Attack Type:

The most common attacks are verbal attacks. The second is physical attacks without the use of an attack tool. The third type is: attacks with sharp-penetrating tools.

The Attackers:

The most frequent attackers are; patient relatives. The second most frequent attackers are; patients with their relatives.

Attack Causes:

In the Studies Conducted in Our Country, the Following were Identified as the Most Common Cause of Attack:

• Excessive patient density in emergency departments,

• Low level of education and culture,

• Provocative news and populist discourses published in the media.

Attack Locations:

The most frequent location of the attacks in Turkey; emergency services. Clinics are in second place and patient admission desks in third place.


The most important occupational groups exposed to violence in health institutions in Turkey respectively: nurses, doctors, and admissions officers.

Problems that Arise in Victims of Violence:

In our country, the most common problems encountered in the health personnel who are subjected to violence are: Psychological problems (emotional disorders, depression, decrease in productivity), injuries, death [8,9].

Situation in Some Other Countries

In a study conducted in the USA, the rate of physical and psychological attacks in health institutions was found to be 15%. (These attacks were found to be the most common attacks against nurses [10]. Violence also differs in various countries and cultures. For example; Violence has been declared an urgent legal situation in the United States [11]. In recent years, the United Kingdom has moved to the agenda of Europe and Australia [12,13]. In Australia, the most serious place of violence is the health sector [13]. According to a study conducted in Finland, psychiatric nurses took the 3rd place and doctors took the 4th place in terms of exposure to violence following the prison guards and police officers [7]. In a study conducted in Canada, 67% of the victims reported violence [14].

In the study conducted in Switzerland, 2800 public health workers were surveyed and 51% of them were verbally or physically attacked [8]. In studies conducted in the UK, Hong Kong and China, the rates reported for physical violence are 5.3-21% on average, and 43-73% for verbal violence. WHO, ILO and ICN ”workplace violence in health care institutions” 2002 reports that on average 3-17% of healthcare workers in many different countries suffer physical and 27-67% verbal violence [7,13,15]. In a comprehensive study conducted in Sweden, physically and psychologically in the health sector. It has been stated that violence incidents increase gradually [16].

Legal Aspect

An article by Honsell on “American Legal Culture” notes that the American political authorities excessively cover consumer rights and prefer punitive damages to win elections rather than protecting producer and service provider. For instance; an individual claiming to lose prophecy skills due to chemotherapy received a million dollar damages from hospital. “Medical Malpractices Act” was adopted in the United States of America. In other words, the damages aspect of doctors on health matters has increasingly become a perfect liability in this country. This article also states that there are also bumper stickers as “call your lawyer if you are sick” in America. The author emphasizes that one of the reasons behind this is to support the insurance companies [17]. But it does not look very well. No doubt, patients must be protected as they are humans, hence “Patients’ Rights Regulation” was adopted accordingly (Date of Official Gazette: 01.08.1998, No. of Official Gazette: 23420). Pursuant to this Regulation; The patient shall be informed about:

• Possible reasons and course of disease,

• How the medical intervention to be performed, by whom and where, and the estimated duration?

• Alternative diagnosis and treatment options and their associated benefits and risks, and the potential impact of patient’s health,

• Possible drawbacks,

• Possible benefits and risks if the treatment is rejected,

• Important features of medications,

• Lifestyle recommendations critical for the health,

• When necessary, how to access medical assistance [15].

The provision of such information (informed consent) would protect the doctors against some damages [18]. Since our topic is not patients’ rights but the protection of health personnel against violence; we believe that in addition to criminal and public law, thinking outside of general rules on damages for the attacks towards this profession, which is challenging and requires devotion, may prevent violence and make the healthcare personnel feel more secure. As known, the damage determines the upper limit of ruled compensation. The aim of compensation is to eliminate the damage [19]. However, the victim may be provided with the opportunity to demand a compensation excessing the damage from the perpetrator by adopting some private responsibility clauses to deter the perpetrators from acting against the law; thus Turkish Civil Code Articles 25/3 and 995/1 may be considered accordingly.Similarly, punitive damages may be possible in the violence against healthcare personnel.Through placing the security cameras in the way of not breaching the patient rights, it would be easier to prove such actions [20].

Data Analysis

Data was analyzed using the Statistical Package for Social Science (SPSS), version 24.0 after coding.

First level analysis consisted of summarizing sample characteristics, exposure to and types of violence and MBI burnout subscales.

The second level of analysis looked at the factor associations with exposure to violence, verbal and physical separately, using the Pearson chi-square.

The third level of analysis consisted of the multivariate model whereby exposure to verbal and physical violence were the dependent variables and factors identified to be statistically significant in the bivariate analysis were included to control for their potential confounding factor.


According to the results of this study; nurses are the most frequent victims of attacks, the most frequent type of attacks are verbal attacks, the most frequent place of attacks are emercensy services in Turkey. We generally found the same findings when we reviewed the literature. But unlike other countries; the most frequently attackers are the relatives of the patients in the Turkey. Although the most common cause of attack is the excessive patient density and inadequacy of waiting rooms as in other countries, the second most common cause of attack is economic and cultural insufficiency and the third reason is provocative news and populist discourses of politicians published in the media. Therefore, we think that these problems should be given priority when searching for solutions in our country.

Pursuant to the common view of researchers, the violence at the healthcare institutions is more when compared with other workplaces. Hence, as the report by WHO suggests, the problem must be solved immediately [1]. In our country, the number of violence cases is more at the healthcare institutions than other institutions, yet its prevalence has been rapidly increasing in recent years. The higher frequency of violence in public healthcare institutions than private institutions may be explained with the following reasons:

• Higher number of patients at public healthcare institutions than private sector, and consequent lack of attention and organization,

• Lower education and culture level among patients and their relatives at public institutions,

• Higher number of violence leading factors (i.e. noise, comfortless areas) at public institutions,

• Insufficient security measures.

The violence incidents at healthcare institutions do not only affected the victims but also significantly deteriorate public order and rapidly diminish the quality and quantity of service production. Successful students graduated from the medical faculties do not particularly prefer the most important specialties like gynecology, general surgery, neurosurgery and pediatrics where violence mainly occurs. Therefore, the students with lower success levels choose such specialties, which bring lower quality, higher malpractice cases and associated more reactions among citizens - “A vicious cycle is created”. Hence this problem must be urgently analyzed by the public institutions, academicians and other civil society organizations in order to take the necessary measures.

Solution Proposals:

Social and Physical Measures:

Measures to be Taken by The Government:

• Prevention of violence at healthcare institutions is actually a component of local, regional and national, health, safety, economic sustainability and human right related state policies, and is among the priority duties of government.

• All political parties should develop a state policy together with government, and urgently implement it accordingly.

• All related applicable laws should be reviewed and new laws should be adopted.

• Awareness raising activities should be organized on the violence against healthcare personnel, and the result should be disseminated in media.

• The preventive effectiveness should be enhanced with civil society organizations.

• Politicians should avoid populist discourse for the prevention of violence at healthcare institutions.

Institutional Measures:

• The number of doctors and allied healthcare personnel should be sufficient at emergency services where the attacks mainly occur in consideration with patient numbers. The administration should satisfy them at the workplace.

• The number of security guards should be sufficient where they would be assigned at appropriate location to prevent such attacks. They should be informed and exercised of their actions in case of any attack. The nearest police station should be contacted, and contingency plans should be prepared.

• Potential attackers (people that may be under the influence of alcohol, drug-stimulants, psychopath looking people etc.) and people that want to enter with any possible attack tool should be turned down by the security; healthcare personnel should be warned accordingly.

• Be listed to do in case of attack and to prevent attacks by the administration, should be schematized, and all health personel should be taught.

• In the emergency room the triage method must be used.

Health Personnel-Related Measures:

• In every case as a priority, the medical staff must learn to be friendly and kind, they should be learn how acts to patients and their relatives.

• Periodically physicians and other allied health personnel, attacks concerning in-service training should be given and the exercise should be done.

• For the reduction of incidents of malpratice in the health institutions should be given in-service training and internal audits should be conducted.

• With training related to triage in the emergency room should be provided and should be checked.

• Staff assignments should be precisely defined and is open to conducted in health institutions.

Special Recommendations:

• In Health institutions; emergency rooms, clinics, hospital admissions of benches, seats can be design for the people, they should be relaxed.

• Relaxing and attractive paint colors should be used in this place,

• Relaxing music should be playing

• It should be enough seating in standby section.

• Escape routes should be created in any case of attack.

• In the appropriate places should be equipped with cameras and alarm systems.

• The lighting in the venue should be sufficient.

• Ambient temperature and humidity must be of the ideal size.

• Enough free car parking spaces should be include.

• At the first bathroom and whole pace should be clean and hygienic.

• Patients and their relatives to eliminate their needs it should be included canteen and free water dispenser.

• Especially in the highest risk areas should be include barries that may escape protected from attacks.


The incidence of violence in health institutions in our country is increasing. In order to prevent these incidents, the measures should be taken quickly by the relevant institutions and social research studies should be done more universities.


  1. Krug E (2002) World Report on Violence and Health. Geneva: World Health Organization.
  2. Chappell D, Di Martino V (2000) Violence at Work, (2nd Edition) Geneva: International Labour Office.
  3. Di Martino V (2002) Workplace Violence in the Health Sector - Country Case Studies Brazil, Bulgaria, Lebanon, Portugal, South Africa, Thailand, plus an additional Australian Study: Synthesis Report; Geneva: ILO/ICN/WHO/PSI Joint Programme on Workplace Violence in the Health Sector, forthcoming working paper.
  4. Kingma M (2001) Workplace violence in the health sector: a problem of epidemic proportion. Int Nurs Rev 48:129-30.
  5. Cenger C, Börtlüoğlu A, Tüzün B, Göktepe M, Sezgin A, et al. (2018) Sağlık Çalışanlarına Yönelik Şiddet: Olgu Serisi. Adli Tıp Bülteni 23:133-137.
  6. TurkanS (2013) Özel Kastamonu Anadolu Hastanesi. Üroloji Kliniği 55: 254-255
  7. Tekin İ (2006) Acil Hekimlerine Yönelik Ş Türkiye Klinikleri J Surg Med Sci 2: 68-73.
  8. Menckel E, Viitasara E (2002) Threats and violence in Swedish care and welfare -Magnitude of the problem and impact on municipal personnel. Scand J CaringSci 16: 376-385.
  9. Gerberich SG, Church TR, McGovern PM, Hansen H, Nachreiner N, et al. (2004) An epidemiological study of the magnitude and consequences of work related violence: the Minnesota Nurses’ Study. Occup Environ Med 61: 496-503.
  10. Lanza ML(1992) Nurses as patient assault victims: an update, synthesis, and recommendations. Arch Psychiatr Nurs 6: 163-171.
  11. Joint Programme on Workplace Violence in the Health Sector Geneva (2002) International Labour Office ILOInternational Council of Nurses ICNWorld Health Organization WHOPublic Services International PSI. Joint Programme on Workplace Violence in the Health Sector Geneva.
  12. Hoel H, Sparks K, Cooper C (2000) The cost of violence and stress at work and the benefits of a violence and stress- free working environment, University of Manchester Institute of Science and Technology.
  13. Farrell GA, Bobrowski C, Bobrowski P (2006) Scoping workplace aggression in nursing: findingsfrom an Australian study. J Adv Nurs 55: 778-787.
  14. Fernandes C, Bouthillette F, Raboud JM, Bullock L, Moore C, et al. (1999) Violence in the emergency department: a survey of health care workers. CMAJ 16: 1245-1248.
  15. Chen WC, Hwu HG, Kung SM, Chiu HJ, WangJD (2008)Prevalenceanddeterminantsofworkplace violence of health care workers in a psychiatric hospital in Taiwan. J Occup Health 50: 288-293.
  16. Nordin H (1995) Fakta om vaold och hot I arbetet, Solna, Occupational Injury Information System, Swedish Board of Occupational Safety and Health.
  17. Honsell H (2016) “Amerikan Hukuk Kültürü”. ÇM.Topuz Mühfhad C 16: S3-S4.
  18. Ersoy N, Özcan MS, Aydıner R (2010) “Acil tıp’ta aydınlatılmış onam”. Ulus Travma Acil Cerrahi Dergisi 16: 1-8.
  19. FikretE (2019) Borçlar Hukuku C.II s.324; Oğuzman, Kemal -Öz,Vedat Borçlar Hukuku II s.111.
  20. Gates D, Fitzwater E, Telintelo S (2002) Preventing assaults by nursing home residents: caregivers’ knowledge and confidencea pilot study. Journal of the American Medical Directors’ Association 3:366-370.

© by the Authors & Gavin Publishers. This is an Open Access Journal Article Published Under Attribution-Share Alike CC BY-SA: Creative Commons Attribution-Share Alike 4.0 International License. With this license, readers can share, distribute, download, even commercially, as long as the original source is properly cited. Read More.

International Journal of Nursing and Health Care Research