Workplace violence (WPV) is defined as “incidents where staffs are abused, threatened, or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being or health.” [1] Healthcare workers (HCWs) tend to underreport WPV, given the tradition of enduring violence at work as part of their job [2]. In previous studies, HCWs showed a higher risk of being injured via WPV [3-5], up to 16 times higher than other service industry workers for both mental and physical aspects [6]. In South Korea, WPV toward HCWs has been increasing for decades [7]. Incidents such as stabbing a physician to death in a general hospital’s outpatient consulting room, biting a nurse’s finger to the point of amputation during an L-tube procedure, and a diagnosed COVID-19 patient spitting to a medical staff attracted nationwide public attention [8-10].

In addition to depression, anxiety, and burnout, post-traumatic stress disorder (PTSD) is one of the most frequent negative psychological consequences of WPV victims [11]. Rosenthal et al. [12] reported that 34.4% of HCWs experienced verbal or physical violence and among them, over 60% affirmed at least one posttraumatic symptom. A cross-sectional study conducted in UK reported one in 6 physicians screened positive for PTSD, and 2 in 5 for current anxiety and depression [5]. HCWs experience at least one symptom of PTSD, including the feeling of being intruded, having avoidant behavior, and experiencing hyper-arousal status [11,13]. The WPV victims could suffer from the symptoms of burnout, lowered level of motivation, increased intention to leave, and poorer performance at workplace [14-16]. Further, in cases of HCWs, they could also show the reduced empathic attitude for patients due to the lack of energy/affection. One systematic review conducted in UK found a negative association between burnout and empathy in HCWs [17]. As emotional exhaustion, defined as lack of energy and affection, is core dimensions of burnout, empirical evidence supports that HCWs could suffer from the reduced empathic attitude for patients due to the lack of energy and affection. As empathy has been regarded as an elementary affection for therapeutic alliance [18,19], lowered level of empathy in HCWs after experiencing WPV could induce medical mistakes, diagnostic inaccuracy, patients’ undue reports of symptoms, and poorer clinical outcomes [20-22].

Despite these well-known detrimental effects of WPV on mental health, the differential impact of WPV subtypes (physical or verbal) on the empathic capacity of HCW has received little attention [23]. Previous research revealed that association of physical violence with depression and anxiety was not statistically significant, however, verbal violence was strongly associated with anxiety and depression, low self-esteem and avoidance and intrusion in a sample of battered women in Italy [24]. On the contrary, Zafar et al. [5] have also reported that HCWs who experienced physical violence were about 7 times more likely to be screened positive for PTSD than those who experienced verbal violence. Therefore, no consistent conclusion can be drawn from the existing literature in regards to the relationship between the type of WPV and its detrimental psychological impact. Providing prevention programs regarding WPV against HCWs, according to the differential types of violence, would allow HCWs to be equipped with more practical tools of how to deal with violence and its aftermath. Thus, we conducted a survey to investigate the possible differences in psychological outcomes between the verbal and physical violence at workplace by comparing the differences of 1) the empathic capacity, 2) post-traumatic symptoms, and 3) coping skills in HCW, segregated according to the degrees of exposure to the verbal and/or physical violence at workplace.

In our study, victimized HCWs showed a low level of empathy with patients. This finding is similar to previous researches indicating that WPV hinders understanding patients and causes inappropriate care with weakened empathy toward patients [30,31]. Having a high level of empathy is associated with HCWs’ psychological well-being [32]. Establishing immediate WPV interventions are required in order to maintain empathy and work efficiency.

Our study confirms that the impact on HCW’s empathy depends on the types of violence: physical and verbal. Experiences of verbal violence heightened the risk of lowered empathy, whereas physical violence did not show significant effects. This result aligns with previous study in which verbal violence had a significant effect on depression, anxiety, and physical symptoms in comparison with injuries inflicted by physical violence [33]. It is also consistent with other studies suggesting that, different from common sense, verbal violence has a greater impact on mental health and musculoskeletal pain than does physical violence [34]. However, in health care facilities, experience of physical violence is usually one-off thing, while verbal violence can occur in a more persistent and pervasive manner, and victims can be more susceptible to negative health outcomes [35-37]. Verbal violence can be experienced as more personally demeaning and humiliating. Recent network analyses reported that verbal violence which makes individuals feel worthless and damage one’s self-esteem serve as connector in the verbal abuse-depression and anxiety-social interaction features [38]. Statistical back up related to personal implication with verbal assaults demonstrated that verbal aggression which appears targeted, demeaning or humiliating has been significantly associated with higher experienced anger provocation [39] and depression [40]. For this reason, victims may blame themselves for the incident and question their qualifications as medical professionals [41]. Verbal abuse may hurt victims’ self-esteem longer and deeper. Legal interventions are not easily or promptly given for verbal abuse, while overt physical violence is usually punished and compensation for the adversity can be ordered by court. Organizational protection and support from colleagues sometimes underestimate the significance of verbal violence. Many victims of verbal violence may be hurt by the biased judgment of others [42]. Lack of adequate support systems or collegial sympathy and appreciation may discourage the verbally abused and possibly reduce their capacity to be empathetic with patients [43]. Patients who have cognitive deficits, dementia, and other serious psychiatric problems may become verbal abuse perpetrators [44]. They may devalue the quality of the services and project their anger and frustration toward HCWs. Verbal abuse among hospital members or long-term care patients can occur for longer periods of time than episodic physical abuse, which can be more detrimental to mental health, since victims would feel helpless with self-blaming attitudes. While bodily traumas can be noticed and healed with immediate and direct remedies, psychological traumas are often ignored and neglected without clear timeline or boundary between prevailing authoritarian manners and abusive conducts.

In our study, the number of participants with PTSD scores of 14 points or above was higher for those who experienced verbal (without physical) abuse than for those who experienced physical (without verbal) abuse. This result is consistent with previous study in which the percentage of participants with PTSD scores of 14 points or higher was 28% for cases of verbal violence and 19.6% for cases of physical violence [45].

Owing to the urgent nature of medical care, medical workers who endure verbal violence cannot be easily repositioned. HCWs are usually trained be tolerant of verbal abuse resulted from patients’ disease. If the perpetrator is a patient, rejection or eviction of perpetrators is often legally or ethically difficult, owing to medical staff’s beliefs and common sense that “refusal of care is not ethically right.” These factors play a role in aggravating “re-experience” symptoms of PTSD [46].

Physical restraint has no effect on verbal violence [47]; although control over violence is critical for the safety of the abuser and the abused, since loss of psychological autonomy or agency in a traumatic event causes further distress [46]. Thus, the self-efficacy and empowerment to solve a threatening situation is important for HCWs who suffered from verbal violence [48]. Encouraging self-confidence against violence may prevent serious burnout symptoms [49].

Most verbally abused victims in this study reported that they did not take any action or report incidents. Similar trends were found in previous studies conducted in other Asian countries [50,51]. Meanwhile, in Germany, 60.3% of victims reported the incidents through formal procedures, while 97% directly reported the incidents to their supervisors [52]. These results can be partly attributed to cultural differences between Asian and Western countries. In South Korea, there is a particularly strong cultural tendency to suppress the expression of HCW’s personal dissatisfaction or negative affections and to take HCW’s sacrifice for granted [44]. Enduring unfair treatment or unreasonable situations is often attributed as part of the job. Further, previous study presented that the lack of appropriate measures, legal systems, and effective employee training on WPV and WPV prevention could be a fundamental reason why most victims responded that they took no action or pretended as if it never happened [53]. Given this context, workplace harassment prevention law in Korea came into effect in July of 2019. Considering government controlled nationwide insurance system with low payment and high quality service, the workload of HCWs in South Korea is far heavier than in other developed countries [53]. Busy hospital settings with short allotment of consultation and fewer medical professionals may lead patients and their families to be more resentful towards HCWs. Therefore, it is necessary to observe the effects of legal and institutional measures against verbal violence in the future.

In summary, verbal violence impedes HCWs’ ability to be empathetic and leads to a higher risk of PTSD symptoms compared to physical violence. For regulating verbal as well as physical WPV, legal and systemic assistance and well-designed medical literacy plans for the public should be further developed. If medical institutions focus mainly on physical violence, overlooking the negative impact of verbal violence, HCW’s work efficiency will be impeded. The lack of appropriate legal actions and less developed training program related to WPV may be another fundamental reason why most victims take no action or pretend the violence never happened [54]. Refusal to treat patients should strictly follow a lawful protocol by considering the degree of violence, legal appropriateness, and HCWs’ competence [55]. A physician may need to have the right to refer unruly and uncooperative patients to other doctors or safer hospitals after giving notice of the specific reasons for treatmenttermination and providing information regarding substitute treatment facilities [55]. HCWs without legal and practical protection may struggle with demoralizing and dangerous situations, which is simultaneously harmful to the patients’ support systems and countermeasures; policies such as zero-tolerance policies against verbal abuse are strongly demanded. An automatic phone explaining zero-tolerance policies and recording system is needed for the legal evidences and education for the public.

Preventive measures such as public campaigns and teaching of de-escalation at the institutional level also need to be implemented. Considering the heavy workload and irregular work schedules of HCWs, practical intervention including brief intervention or online-based platform for the prevention of WPV is needed. In recent previous study, WPV prevention program using online modules for 2 hours has been demonstrated [56] and a brief intervention with one-session, 3-hour simulation training on WPV revealed improvement of staff’s confidence against WPV [57]. These results suggest that interventions at the institutional level are effective, and practical interventions and prevention programs must be developed and implemented according to the type of violence experienced.

Our study has several limitations. First, the cross-sectional design limits causal inferences concerning WPV and empathy. Second, we used self-reporting questionnaire to measure the exposure of WPV, despite the controversies on the objective evidences in defining WPV. Personal threshold of WPV may be also unalike according to susceptibility of each person and situational differences. However, subjective report is important, especially for managing psychological sequelae, despite lack of objective measuring devices on individual traumatic events. In addition, HCWs are well known to report WPV less than they actually went through since they are afraid of being criticized not to adept to defend themselves and evaluated to be less qualified by their supervisors and hospital managers. WPV is often misinterpreted as a clinical failure for being less empathetic. In our study, self-report procedure using smartphone answering method protecting confidentiality might enhance to report WPV more than person-to-person interview or formal recording using paper. Third, all the respondents in this survey were working in a general training hospital in a metropolitan area where the workload is more diverse and serious than other smaller local hospitals or clinics at rural area. Therefore, the findings of this study regarding WPV cannot be generalized to most healthcare workers. Finally, although physical violence and verbal violence groups are interdependent, we compared two groups using between-group differences tests in order to emphasize the traumatic effect of solitary verbal abuse for several reasons: Public health strategy against violence has focused preventing physical violence rather than verbal violence. Guards and material equipment protecting health care workers from physical violence have been prepared, while overlooking the effect of prevailing verbal abuse in hospitals.

Nevertheless, this study raises important issues as the findings have implications for the health of both patients and medical practitioners. Effective intervention techniques and policies can be developed taking into consideration our findings that healthcare workers who are subjected to verbal violence feel low empathy toward patients and experience stress while providing healthcare services.