‘That’s Enough’ - Workplace Violence Against Physicians, Pharmacists, and Nurses in Saudi Arabia: A Systematic Review of Prevalence, Causes, and Consequences

Introduction

Workplace violence (WPV) among healthcare providers (HCPs) is a growing concern for both developed and developing nations, including Saudi Arabia.^1–47 WPV is defined by the World Health Organization (WHO) as

incidents where staff are abused, threatened, or assaulted in circumstances related to their work, involving an explicit or implicit challenge to their safety, well-being, or health.⁴⁸

Violence can take many forms in the workplace, including physical violence and/or psychological violence. Physical violence involves actions such as beating, kicking, slapping, stabbing, pushing, biting, and pinching.⁴⁸ Psychological violence includes forms of verbal aggression (eg, shouting, insults, humiliation, threats, and the use of offensive language), harassment based on race or gender, and workplace bullying.⁴⁸ Over one-third of all WPV incidents worldwide currently occur within the healthcare sector.⁴³

While nurses and physicians are often the primary focus of WPV studies due to their frontline roles, pharmacists in Saudi Arabia also frequently serve as frontline healthcare providers, particularly in community pharmacies,¹⁹ and hospital settings.^20,25,31 Their direct interaction with patients and families, including addressing medication concerns and managing disputes over prescriptions, places them at risk of WPV. However, existing research often underrepresents pharmacists, leaving gaps in understanding the unique factors contributing to their experiences of WPV.¹⁹ By including pharmacists in addition to nurses and physicians, this review aims to provide a more comprehensive understanding of WPV across multiple professional roles and healthcare settings.

The Australian Institute of Criminology has identified the healthcare sector as the most violent industry globally, highlighting the severity of WPV in this field.⁴⁹ The prevalence of WPV varies significantly across studies due to differences in the types of violence examined, employment sectors, healthcare providers, countries, and the definitions and measurement tools used. In the United States (U.S.), HCPs are at risk for WPV, being five times more likely to experience violence at work than other workers. They account for 73% of all nonfatal workplace injuries from violence.⁵⁰ In Europe, it is reported that HCPs are 16 times more at risk of violence than other professionals.⁵¹ In Canada, it is reported that 71.4% of Canadian workers experienced at least one form of harassment or violence in the workplace.⁵² According to the systematic review and meta-analysis by Liu et al (2019), 61.9% (95% CI: 56.1% to 67.6%) of HCPs reported exposure to any form of WPV. The study analyzed WPV prevalence across various regions, including Asia, Europe, North America, Australasia, Africa, and Latin America, highlighting the global nature of this occupational hazard.⁴⁵

WPV significantly affects the safety, dignity, and overall well-being of HCPs physically, mentally, and socially.^2,7,10,23 It impacts organizations through absenteeism, reduced productivity, loss of skilled professionals, work morale, compensation costs, job dissatisfaction, and high employer burnout and turnover rates.^1,3,4,7,10 It is the leading cause of occupational fatalities worldwide, with an estimated 1.5 million workers dying annually due to WPV.⁵³ While quantifying the financial impact of WPV can be challenging, research indicates that it contributes to approximately 30% of the overall society’s costs of violence.^54,55 It also contributes to a higher rate of medical and medication errors, leading to adverse outcomes and limiting the level of care provided to patients.^1,10,16,23

While nurses are often the primary victims,^{1,16,17,20,25,32} WPV affects all occupational groups in healthcare, including physicians and pharmacists.^{3,12,17,18,21,33} These incidents are frequently underreported because many HCPs view violence as an expected aspect of their work.^{1,2,10,15,16,23} Additionally, they may hesitate to report such incidents due to concerns about the reactions or consequences they might face.^{1,2,10,15,16,23} Physicians, pharmacists, and nurses face high rates of WPV due to the nature of their work.^1,2,5,7,16 They frequently interact with patients and families in emotionally charged situations involving illness, pain, or death, where frustrations over delays or unmet expectations can escalate.^1,2,10,16,19 High-stress environments like emergency departments, long working hours, and fatigue increase the risk.^{4,5,10,12,15,22,29,31,33} Pharmacists often encounter disputes over prescriptions,¹⁹ while nurses and physicians provide hands-on care, exposing them to violent behavior from patients with medical, psychiatric, or substance abuse issues.^1,2,15,23,26 Additionally, insufficient reporting mechanisms leave these professionals more vulnerable to WPV.^1,2,16 The reliance on a diverse workforce, including expatriate workers, introduces language and cultural barriers that may exacerbate misunderstandings and conflicts.^{5,7,13,17,34,37,41}

Currently, no systematic review exists that comprehensively evaluates the prevalence of workplace violence across all three professions—physicians, pharmacists, and nurses—and in various healthcare settings in Saudi Arabia. Furthermore, there is a lack of research addressing the contributing factors, types, sources, and potential causes of WPV, as well as the reactions and impact on HCPs. Additionally, existing measures to address and manage WPV across various sectors in the country still need to be explored. Thus, this systematic review aims to synthesize existing evidence on WPV among physicians, pharmacists, and nurses in Saudi Arabia by examining the prevalence, contributing factors, types, sources, potential causes, reactions, and impact of WPV in this context. The review seeks to identify literature gaps and provide policy and practice recommendations to prevent and reduce violence in healthcare settings. This study is essential to inform strategies that protect healthcare workers, enhance workplace safety, and ultimately improve the quality of healthcare delivery in Saudi Arabia.

Material and Methods

Design

A systematic literature review was conducted to research workplace violence against healthcare providers (ie, physicians, nurses, and pharmacists). This review followed the guidelines of the preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA).⁵⁶ All the methods employed in this review were conducted in complete alignment with the guidelines outlined in the Cochrane Handbook for Systematic Reviews of Interventions.⁵⁷

Inclusion/Exclusion Criteria

Studies were included if they met the following criteria:

1. Original research articles that were peer-reviewed,
2. Research focused specifically on workplace violence against healthcare workers (ie, physicians, nurses, and/or pharmacists),
3. Studies that assessed at least one type of workplace violence (eg, physical and/or psychological), reported prevalence rates, and included enough data on possible causes and contributing factors of WPV,
4. Quantitative studies (ie, cross-sectional studies),
5. Publications were in English,
6. Research conducted in Saudi Arabia between 2010 and 2024.

The studies were excluded based on the following criteria:

1. Studies categorized as reviews, qualitative studies, conference abstracts, letters, commentaries, or editorials.
2. Studies for which the full text was unavailable.
3. Research focusing on violence against healthcare students, fellows, interns, residents, or veterinarians.

Data Sources, Search Terms, and Search Strategy

Searches were conducted using the electronic databases PubMed and Web of Science. Search terms were drawn from four main keywords: “healthcare worker”, “violence”, “work”, and “Saudi Arabia”. Search term lists related to each keyword were created using MeSH (Medical Subject Headings) terms from PubMed. Additional relevant terms were manually selected from the literature throughout the review process.^1–42 Table 1 displays the various keywords used to search for relevant articles in this review. Keywords not available as MeSH terms were searched as phrases using free-text mode. Reference lists of the retrieved and related review articles were manually reviewed to identify additional relevant studies. Consultation with experts or colleagues in the field was also conducted to ensure the comprehensiveness of the search terms. The search for all articles on WPV across the mentioned databases was conducted from January 2010 to November 2024.

Table 1 A List of Search Terms Used for This Review (PubMed and Web of Science)

Data Extraction

Two reviewers independently screened the titles and abstracts to assess eligibility based on the study inclusion criteria. Articles not meeting these criteria were excluded during the initial review. Full texts were obtained electronically and reassessed for inclusion in potentially eligible articles. Any disagreements were resolved through group discussion. All studies that met the inclusion criteria were included and evaluated.

Quality Assessment of the Included Studies

The selected studies were evaluated using the AXIS tool for cross-sectional studies⁵⁸ alongside international standards for survey studies. The AXIS tool includes 20 questions grouped into areas that assess key aspects of a cross-sectional study’s design, execution, and reporting quality. The AXIS tool uses a “yes”, “no”, or “do not know” response format for each question. Two reviewers assessed each item independently to determine potential areas of bias and whether the study meets quality standards. Any disagreements were resolved through discussion. Studies with more “yes” responses are generally considered to have higher methodological quality.

Results

Search Outcome

After removing duplicates, the initial electronic and manual search of reference lists from included articles yielded 463 articles. Four-hundred fifteen studies were excluded after title and abstract review for the following reasons: irrelevant studies (n = 340), not conducted in Saudi Arabia (n = 14), qualitative study (n = 1), review articles (n = 51), inability to retrieve full text (n = 2), studies on violence against healthcare students, fellows, interns, residents and veterinarians (n = 7). The full texts of the remaining 48 studies were thoroughly reviewed. Six studies were excluded as they did not meet the inclusion criteria, resulting in 42 studies in the systematic review (Figure 1).

Figure 1 Flowchart of identification and selection procedure.

Quality Assessment of the Included Studies

All the studies meet most of the AXIS quality criteria, particularly in areas of clear aim, ethical standards, appropriate sample and methods, and transparent and comprehensive reporting of results. Limitations include potential response bias and generalizability due to sampling limitations. Areas that could be improved include a deeper analysis of non-respondents. Overall, all the studies provide valuable insight into workplace violence among healthcare professionals in Saudi Arabia. See Table 2.

Table 2 Quality Assessment of the Included Studies

Characteristics of the Reviewed Studies

The key characteristics of the 42 studies published between 2010 and 2024 are presented in Table 3. ^1–19 The majority of the studies were conducted in the Western (ie, Jeddah, Mecca, Al-Madinah, Taif) (n = 12)^{14,15,22–24,26,28,31,32,37,38,41} and Central (ie, Riyadh, Buraidah) (n = 10)^{1–4,6,7,25,27,30,36} Provinces, followed by the Eastern Provinces (n = 7) (ie, Al Khobar, Dammam, Jubail, Qatif, Al-Hassa),^{8–11,21,29,42} with fewer studies in the Northern (ie, Tabuk, Arar) (n = 2),^12,13 and Southern (ie, Abha) (n = 2) Provinces.^16,33 Nine studies were Nationwide (ie, data were collected across various provinces in Saudi Arabia).^{5,17–20,34,35,39,40} The sample sizes of the studies varied, with participants ranging from 96 (small-scale studies) to 7398 (large-scale studies) (median = 359; IQR: 213–437), with a total of 29,826 participants. All studies used cross-sectional survey designs, lasting 0.5 to 12 months.^1–42

Table 3 Summary of Included Studies on Workplace Violence Against Healthcare Providers in Saudi Arabia

The participants’ age groups ranged from 20 years to over 60. The settings for these studies included diverse healthcare environments, such as hospitals,^{1,2,8,11,13,16,30,31,34,35,37,38,40–42} tertiary medical cities,^6,24 primary healthcare centers,^{3,9,13,14,16,21,32,37} psychiatric hospitals,^7,23,26,28 emergency departments,^{4,5,12,15,19,22,29,33,36,39} community pharmacies,¹⁹ and home healthcare services provided by government sectors in Saudi Arabia (eg, Ministry of Health, Ministry of Defense, Ministry of National Guard, etc).²⁵ The study participants in the reviewed articles covered diverse healthcare providers, including nurses, physicians, and pharmacists. Among these, studies focusing specifically on nurses^{2,4,7,8,23,24,26–28,30,39,41} were more frequently reported compared to other professions. In contrast, physicians^15,22,35,42 and pharmacists¹⁹ were rarely the primary focus of studies, typically being included as part of broader categories of healthcare providers.^{1,3,5,6,9–14,16–18,20,21,25,29,31–34,36–38,40}

The Prevalence of Workplace Violence Against Healthcare Workers in the Province

The literature reveals varying prevalences of WPV in different Provinces. The Central Province (ie, Riyadh, Buraidah) experienced 41.2%–89.3% of at least one form of WPV.^{1–4,6,7,25,27,30,36} In the Eastern Province (ie, Al Khobar, Dammam, Jubail, Qatif, Al-Hassa), 27.7%–82.4% of cases had WPV witnessed violence.^{8–11,21,29,42} In the Western Province (ie, Taif), WPV stood at 26%– 90.3%.^{14,15,22–24,26,28,31,32,37,38,41} The Northern Province (ie, Tabuk, Arar) had about 48.6% to 90.7% cases of WPV.^12,13 The Southern Province (ie, Abha) reported a prevalence between 45.7% and 57.5% of WPV.^16,33 The prevalence of WPV among cases in nationwide studies was 4%– 81%.^{5,17–20,34,35,39,40} Based on the maximum and minimum prevalence values reported, the Northern Province had the highest prevalence of workplace violence, with a maximum prevalence of 90.7%.¹² In contrast, the Western Province had the lowest prevalence of workplace violence, with a minimum prevalence of 26%.⁴¹ Local cultural norms, existing legal and policy frameworks, and the extent of awareness and training on WPV may shape these variations.

Across most studies, the gender of the attacker in WPV incidents was predominantly male.^{3,7–10,21,27,29,32,33,36,42} The analysis of WPV incidents revealed a notable difference between male and female attackers. The average percentage of male attackers was 56.85% (range: 39.42% to 65.9%), significantly higher than that of female attackers, who accounted for an average of 27.63% (range: 14.7% to 40.8%). See Table 4.

Table 4 The 6 to 12-month Prevalence and Contributing Factors of Workplace Violence Against Healthcare Workers in Different Provinces

The Contributing Factors of WPV Against HCPs

The commonly reported contributing factors of WPV were gender, age, years of work experience, profession, workload, shift patterns, nationality, department, and lack of training and knowledge of violence reporting systems. The analysis revealed that 11 studies^{4,5,20,25,31,32,34,36,37,41,42} identified female HCPs as being more likely to be targeted in WPV incidents, whereas seven studies^{1,8,10,14,17,30,33} highlighted male HCPs as being at higher risk. This reflects variability in the influence of gender as a contributing factor across different studies and contexts. Multiple studies reported that younger age (eg, individuals under 35) was the most frequently reported contributing factor of WPV.^{1,11,17,18,25,30,32,34,40,42} Working evening and night shifts,^{3,4,6,11,13,16–20,23,26,42} multiple shifts,^3,7,32,38 in the emergency departments,^{6,8,12,13,21,37,38} non-Saudi HCPs^{5,7,13,17,34,37,41} and less experienced staff (eg, those with fewer than 5–10 years of experience)^{1,10,15,20,25,30,32,41,42} are commonly reported as at-risk groups. Nurses were frequently identified as at higher risk of WPV across multiple studies.^{1,16,17,20,25,32} Physicians^12,18,21,33 and pharmacists^3,17,18 were less frequently highlighted than nurses. Insufficient training and lack of awareness of violence reporting systems and prevention measures^2,9,14,15,40 were also common contributing factors of WPV. See Table 4.

Types, Sources, Possible Causes, and Impact of Workplace Violence Against Healthcare Providers Across Studies

The most reported type of workplace violence across studies is verbal violence, with an average prevalence of approximately 63.7%, ranging from 19.7% to 98.2%.^{1–16,18,19,21–23,25–29,31–39,41,42} Physical violence is the second most frequently reported type, followed by threats and sexual violence, which are less frequently reported. Interestingly, the average prevalence of threats (36%, ranging from 12% to 74.4%)^{2,3,9,21,24,25,28,30,33} is higher than that of physical violence (18.8%, ranging from 3% to 79%)^{1–7,9–17,19,21–29,31–35,37–39,41} and sexual violence (14%, ranging from 1.9% to 76.5%).^{2,4,6,7,10,14,19,20,25,28,30,34,39} See more details on Table 5. Patients (45.5%, ranging from 7.1% to 99.3%), patients’ relatives or friends (45.1%, ranging from 6.6% to 91%), and other healthcare staff, including colleagues, supervisors, and managers (35.7%, ranging from 2.2% to 86%) were the most commonly reported sources of violence against healthcare providers.^1–42

Table 5 Types, Source, Possible Causes and Impact of Workplace Violence Against Healthcare Providers Across Studies

The causes of workplace violence identified in the studies included lack of penalty for offenders (63.7%, ranging from 43.5% to 90.6%),^{2,3,9,10,12,21,23,34,37} inadequate security measures (52.3%, ranging from 31.9% to 86.7%),^2,4,10,12,21 shortage of staff (49%, ranging from 7.4% to 92.5%),^{1,2,4,10,12,13,16,23,26,28,31,35,39} overcrowding (43%, ranging from 9.7% to 93.7%),^{1,3,9,10,12,16,21,23,26,35–37,39} miscommunication and misunderstanding (42%, ranging from 31.5% to 54.6%),^{2–4,9,28,31,34} long waiting time to receive care (33.25%, ranging from 5.6% to 51.6%),^{1–4,9,10,13,16,23,26,31,36,37} unmet patient and service demands (33%, ranging from 6.1% to 69.3%),^{1,3,4,9,13,21,23,25,26,36} and lack of staff training on how to deal with violence (19%, ranging from 15.5% to 22.5%).^2,9,28 See more details on Table 5.

Healthcare providers reported a range of actions after experiencing workplace violence. The most common response was reporting the incident mainly to a senior staff member (average prevalence of 83.3%, ranging from 1.7% to 74.8%).^{1,3,4,7,9,10,12–15,17–21,23,25–29,31,34–36,39,40} This was followed by taking no action after a violent incident (average prevalence of 66%, ranging from 8.1% to 84%).^{3,4,6,9,10,14,15,17,18,20,21,23,25–29,31–36,39,42} Some healthcare providers reported instructing the perpetrator to stop (30.3%, ranging from 4.5% to 36.2%),^{4,17,18,20,26,31,32,34} while others chose to inform a colleague (average prevalence of 29.7%, ranging from 6.1% to 66.6%).^{1,3,4,9,10,15,21,23,25,26,32,34,35} The last reported action was reporting the incident to the police (average prevalence of 12.3%, ranging from 4.9% to 23.8%).^{1,3,9,10,15,35,39}

Following a violent incident, many HCPs reported emotional distress, including symptoms such as hyper-alertness, feelings of unease, fear, sadness, anxiety, and stress (average prevalence of 60.4%, ranging from 4.9% to 96.7%).^{5,7,13,20,21,23,26,28,29,31,32,35,39} A proportion of participants reported experiencing no change in workplace behavior due to the incident (average prevalence of 59%, ranging from 46.5% to 73.8%).^3,8,9 Additionally, reduced work performance was observed among some healthcare providers (average prevalence of 30%, ranging from 11.4% to 78.2%),^{3,7,9,10,21,35,36,39} and consideration of resignation (average prevalence of 25%, ranging from 3% to 48.9%).^{5,21,26,32,35,37} For further details, refer to Table 5.

Existing Measures to Deal with WPV and Recommendations Made by HCPs to Reduce WPV Across Studies

Only six studies reported existing workplace measures to deal with violence. The most frequently reported measures are the presence of security personnel and the use of surveillance cameras,^14,31 incident reporting and documentation systems,^25,31,34,38 and training HCPs on WPV safety procedures.^14,25,31,33 See Table 6.

Table 6 The Existing Measures to Deal with WPV, and Recommendations Made by HCPs to Reduce WPV Across Studies

Only ten studies reported recommendations from HCPs to reduce WPV.^{4,7,12,13,21–24,31,38} The most recommended measures by healthcare providers to reduce workplace violence include implementing strict penalties for offenders,^{4,7,12,21,22,31} increasing staffing levels to meet patient demand,^{7,13,21,23,24,31,38} providing training on violence prevention and management,^{4,7,13,14,21–24,31} establishing transparent reporting systems and policies^{7,12,22,23,31} to handle incidents effectively, increasing security personnel and installing surveillance cameras,^{7,13,21–24,31,38} liaison with police and local authorities,^13,21,23 strict control of visitor numbers and visiting hours and access to sensitive areas,^4,22–24,31 and support systems for affected HCPs.^4,33,34 See Table 6.

Discussion

This study represents the first comprehensive literature review on WPV in Saudi Arabia. It utilizes extensively sourced evidence from reliable databases. Our results were derived from a synthesis of 42 peer-reviewed studies encompassing various healthcare sectors, professional groups, and cities. The review reported a wide but consistently high prevalence of WPV, ranging from 26% to 90.7%. Compared to global data, the prevalence of WPV shows similar high, wide-ranging patterns. For example, an international review by Liu et al (2019)⁴⁵ reported WPV prevalence ranging from 4% to 81%, while an African review noted an even broader range, from 9% to 100%.⁴³

In a global review,⁵⁹ regions, such as Europe (26.38%) and the Americas (23.61%), predominantly consist of high-income countries. Stricter reporting systems, better safety protocols, and comprehensive staff training may contribute to comparatively higher WPV prevalence reporting rates.⁵⁹ In contrast, regions like the Eastern Mediterranean (17.09%) and the Western Pacific (14.53%) include a mix of middle- and high-income countries. These countries may face lower WPV prevalence reporting rates due to resource constraints, understaffing, and limited enforcement of workplace safety policies.⁵⁹ Regions such as Africa (20.71%) and South Asia (5.6%) are predominantly composed of low—and middle-income countries. Workplace violence is often exacerbated by inadequate healthcare infrastructure, higher patient-to-staff ratios, and weaker enforcement of policies to protect healthcare workers.⁵⁹ These socioeconomic factors likely contribute to the significant burden of WPV observed in these regions. These findings highlight that WPV is not only an essential issue in Saudi Arabia but also a global epidemic affecting HCPs across all continents.

Our review found that the majority of attackers in WPV incidents were male, aligning with the findings of Nikathil et al (2017),⁴⁷ Binmadi and Alblowi (2019),⁴⁶ and Liu et al (2019),⁴⁵ which similarly identified the predominance of male perpetrators. Several sociocultural and systemic factors may explain this phenomenon. Saudi Arabia’s healthcare workforce, particularly in supervisory and administrative roles, is often male-dominated, creating more opportunities for males to be in positions of authority. This power may sometimes result in inappropriate or abusive behavior toward juniors.^60,61 Additionally, cultural norms and traditional gender roles may contribute to the prevalence of male perpetrators, as societal expectations and power imbalances may discourage women from reporting violence, especially when the perpetrator is male.^60,61 Addressing these underlying factors requires targeted interventions that consider the sociocultural context and workplace dynamics unique to the region.

Importantly, despite the predominance of male attackers, our findings demonstrate that both male and female healthcare workers are equally vulnerable to WPV, emphasizing the widespread nature of the issue. Previous reviews have similarly noted no significant difference in risk between genders.^45,47,59 These findings underline the importance of implementing universal safety measures and comprehensive strategies to protect all healthcare professionals, regardless of gender.

This review identifies key contributing factors of WPV against healthcare workers, including demographic, professional, and organizational factors. Younger and less experienced workers were found to be at a higher risk of violence compared to their older and more experienced counterparts, emphasizing the need for targeted interventions aimed at early-career professionals. These individuals may lack the skills to manage violent situations and are often more accessible to potential perpetrators.^43,45 A critical factor contributing to WPV is the lack of sufficient training and awareness regarding violence reporting systems, highlighting the necessity for organizations to implement comprehensive training programs and promote reporting mechanisms.

Nurses consistently emerged as the most vulnerable group to WPV, primarily due to their extensive patient interactions and caregiving responsibilities, which increase their exposure to potentially violent situations.^{1,16,17,20,25,32} As the primary point of contact for patients and visitors, nurses are often the first targets of violence, making them more susceptible compared to other healthcare workers.⁴³ Additionally, research on WPV has predominantly focused on nurses, followed by physicians, with pharmacists receiving considerably less attention.^1–42 While physicians and pharmacists face lower reported rates of WPV, they remain at significant risk, particularly in high-stress environments such as emergency departments and community pharmacies, where direct patient interactions are frequent.^{6,8,12,13,21,37,38} These findings align with global reviews that also highlight the heightened vulnerability of nurses to WPV.^45,47,59

Certain settings and work conditions, such as emergency departments, psychiatric units, evening and night shifts, and rotating or extended shifts, were consistently identified as high-risk environments for WPV. Factors contributing to this risk include reduced staff presence, increased patient volume, heightened stress, fatigue, diminished vigilance, disrupted routines, and the intense, unpredictable nature of interactions during these times. These findings are consistent with global reviews that emphasize the critical role of these factors in WPV incidents.^47,59 Targeted interventions are essential to address these risks. Measures such as increasing staff security, implementing de-escalation training, and improving resource availability during high-risk shifts and in vulnerable settings are crucial to mitigating the occurrence of WPV. These actions can help create a safer work environment for all healthcare professionals and reduce the impact of WPV across various healthcare contexts.

The analysis revealed that verbal violence is the most prevalent type of WPV, reported by approximately 63.7% of HCPs across studies, with a wide prevalence range (19.7%–98.2%). This highlights the widespread prevalence of verbal aggression in healthcare settings. Verbal abuse was consistently identified as the most common form of WPV, aligning with findings from all reviews.^43–45,59 Threats (36%) ranked second, followed by physical violence (18.8%) and sexual violence (14%). The higher prevalence of verbal violence and threats compared to physical and sexual violence suggests that non-physical forms of aggression are more common in Saudi Arabia. This finding aligns with the results reported by Binmadi and Alblowi (2019)⁵⁹ and Liu et al (2019),⁴⁵ who also observed lower prevalence rates for these forms of WPV in their review studies. However, it contrasts with the findings of Njaka et al (2020)⁴³ in the African context, where both physical and sexual violence were reported to be significantly higher, highlighting notable regional differences in the prevalence and dynamics of WPV. Verbal violence was the most common type of WPV reported in this study; this is possibly due to the high frequency of interactions between healthcare providers and patients.^45,59 It could also be perceived as less severe and is culturally normalized in some contexts, leading to more frequent occurrences and reporting. Additionally, physical and sexual violence are often underreported possibly because of stigma and fear of retaliation, which makes verbal violence seem more common in comparison.

The large variability in the reported prevalence of sexual violence in our study (ranging from 1.9% to 76.5%) highlights a significant challenge in interpreting the findings. This variability may be due to differences in how sexual violence is defined and measured across studies. Some studies provide clear definitions and standardized methodologies, while others lack detailed descriptions, leading to inconsistencies in reported rates. Additionally, cultural and organizational differences in reporting practices, workers’ sensitivity to violence, and the stigma associated with sexual violence may further contribute to underreporting or variability in prevalence estimates.^43–46 Future research should aim to address these differences and explore the underlying factors contributing to the variability in sexual violence prevalence.

Among the general causes of WPV identified in this study—such as staff shortages, overcrowding, long waiting times, miscommunication, unmet patient demands, and inadequate security measures—miscommunication plays an important role. Factors such as unclear instructions, language barriers, cultural differences, and unmet expectations may escalate tensions between healthcare providers and patients or their families. These misunderstandings may cause frustration and anger, which can lead to verbal or physical violence.

Moreover, some of these causes may indirectly contribute to sexual violence in healthcare settings. For instance, inadequate security measures can result in unmonitored or unsupervised interactions, creating opportunities for inappropriate behaviors. Similarly, overcrowding and miscommunication may exacerbate tensions and interactions, increasing the risk of sexual violence. Addressing these issues requires targeted interventions, such as improving communication training programs, implementing standardized communication protocols, and ensuring adequate security measures to protect healthcare providers, particularly in high-risk environments. Future research should explore these connections further to develop effective strategies for mitigating WPV in all its forms.

Patients and their relatives or friends were identified as the most common perpetrators of WPV, highlighting the central role of patient–caregiver interactions in these incidents. These findings align with the reviews by Njaka et al (2020)⁴³ and Liu et al (2019),⁴⁵ which similarly emphasize the predominance of patients and their close contacts as primary sources of violence in healthcare settings. Several strategies can be implemented to address this issue:

1. Healthcare workers should receive comprehensive training in communication and conflict resolution to effectively manage interactions with patients and their families, and reduce the potential for escalating tensions.
2. Healthcare facilities should consider environmental design modifications, such as creating secure areas for staff and limiting unrestricted access to sensitive spaces, to minimize patient-staff conflicts.
3. Educating patients and their families about appropriate behavior and the consequences of violent actions is crucial in fostering a culture of mutual respect toward healthcare providers.

These combined efforts can create safer healthcare environments for staff and patients.

While reporting incidents of WPV to senior management was a common response among HCPs, underreporting remains a significant issue. Factors that may contribute to underreporting include fear of negative consequences, lack of institutional support, inadequate policy enforcement, and a sense of resignation or normalization of violence within healthcare settings. The reporting process is often lengthy and time-consuming, discouraging workers from reporting incidents. Additionally, insufficient support from supervisors or coworkers, fear of retaliation or being blamed, and the perception that reporting will not lead to meaningful change all contribute to underreporting. These observations align with previous international reviews,^43–45,47 which have similarly identified these barriers to reporting WPV.

Following a violent incident, many HCPs reported experiencing emotional distress. This observation is supported by the systematic review conducted by Lanctôt and Guay (2014),⁴⁴ which found that WPV is predominantly linked to psychological impacts, such as symptoms of post-traumatic stress disorder, depression, and anxiety, as well as negative emotional responses, including anger, fear, and sadness. Prospective studies are essential for advancing knowledge in this field. Most research heavily depended on retrospective data and self-reported information. A proper understanding of the incidence and short- and long-term effects of WPV on healthcare workers can only be achieved through longitudinal cohort studies involving population-based samples. Further research into the long-term psychological and physical impacts of WPV on healthcare workers would be highly beneficial. This could expand knowledge about the relationships between WPV and adverse outcomes, such as post-traumatic stress disorder, depression, anxiety, burnout, and turnover.

Our findings align with and expand upon prior reviews in the field:

1. Aljohani KA (2022)⁶² conducted a narrative review on WPV against nurses in Saudi Arabia, analyzing 15 studies from 2011–2021. Our study broadens this scope by systematically reviewing WPV across multiple healthcare professions, including physicians, pharmacists, and nurses, analyzing 42 studies from 2010–2024. Both studies identify nurses as the most frequent victims, patients and families as primary perpetrators, and verbal abuse as the most common form of violence. Both studies also identify overcrowding, miscommunication, and unmet patient needs as significant contributors to WPV. Aljohani’s review focuses exclusively on hospital settings, while our research explores a broader range of settings, including hospitals, primary care environments, and community pharmacies. Additionally, our study provides a more in-depth analysis of contributing factors such as gender, age, shift patterns, nationality, and profession-specific risks, offering a more comprehensive understanding of WPV.
2. Aljohani B et al (2021)⁶³ conducted a systematic review and meta-analysis on WPV in emergency departments from 22 USA, Australia, Canada, and South Africa studies. Their findings indicate that WPV is frequent in emergency department settings (36 incidents in every 10,000 patients) and that a significant proportion of violent incidents are associated with drug and alcohol use. While they focus specifically on emergency departments, our research examined WPV across diverse healthcare settings, enabling a comprehensive comparison across sectors. In our systematic review, the prevalence of WPV in emergency departments (EDs) in Saudi Arabia ranged from 45% to 91%,^{4,5,12,15,19,22,29,33,36,39} indicating that a significant proportion of healthcare professionals in this setting are exposed to violence. In contrast, Aljohani et al (2021)⁶³ reported an incidence of 36 violent incidents per 10,000 patient presentations in EDs, which represents a considerably lower figure. The differences in reported WPV prevalence may arise from variations in study scope, methodology, and data sources. The current review captures broader settings, and timeframes, while Aljohani’s study uses narrower settings and official reports, which could lead to underestimation.

Study Strengths and Limitations

This study represents the first comprehensive systematic review of WPV targeting HCPs, including physicians, nurses, and pharmacists in different settings. It examines the prevalence, contributing factors, types, sources, potential causes, reactions, and impacts of WPV, offering valuable insights for understanding and preventing this universal issue. The strength of this review lies in its comprehensiveness, incorporating a wide range of studies, and its use of a robust systematic review methodology, which enhances the reliability of its findings.

Despite its contributions, this review has several limitations. Many of the included studies relied on self-administered questionnaires and self-reported data, often covering recall periods of 12 months, which could introduce recall bias. Furthermore, the lack of a standardized tool and definition for assessing WPV posed challenges for comparing results across studies. This highlights the need to develop a widely applicable and standardized assessment instrument for future research.

The cross-sectional design of the included studies also limits the ability to establish causal relationships. Moreover, the exclusion of qualitative research restricts the review’s ability to provide a deeper understanding of WPV from the perspective of healthcare providers. Qualitative studies could offer richer insights into the nature and context of violence that are often missing in quantitative studies. Additionally, the restriction of the review to studies published between 2010 and 2024 may have excluded earlier work on the topic. Therefore, future research should incorporate qualitative approaches, and longitudinal designs to enhance understanding and interventions targeting WPV.

Another limitation of this review is the variability in methodologies used by the included studies to assess WPV. Detection methods varied, with some studies relying on officially reported cases and others on self-reported data collected through surveys or interviews. While some studies employed standardized questionnaires, self-reported surveys, or incident reporting systems, not all explicitly reported the specific instruments or approaches used. This lack of detailed methodological information and consistent reporting introduces variability in the reported prevalence rates, limiting the ability to assess the reliability and comparability of findings across studies fully.

Additionally, differences in methodological factors such as recall periods and population samples may have influenced the reported magnitude of WPV. These differences may make it challenging to synthesize and interpret prevalence data comprehensively. Prevalence comparisons between provinces or regions may lack validity if studies employed differing methods, making it difficult to draw meaningful conclusions about regional differences in WPV prevalence.

One key limitation of this study is the inability to perform a meta-analysis due to the significant heterogeneity across the included studies. The variability in definitions of workplace violence, study designs, data collection instruments, and population characteristics made statistical synthesis inappropriate. Future research should address these limitations by adopting standardized tools and methodologies for measuring WPV. This would enhance the consistency and reliability of findings, enabling better comparisons across studies and providing robust evidence to inform interventions and policy development. Additionally, standardized methodologies and consistent definitions would facilitate meta-analytical synthesis, improving the comparability and applicability of findings.

Another limitation of this review is the lack of gender-disaggregated data in the included studies. While gender differences in WPV are a critical area of concern, many of the studies reviewed either did not stratify their findings by gender or provided limited information on how gender intersects with different types of WPV (eg, verbal, physical, or sexual violence). This gap in reporting made it challenging to conduct a detailed analysis of gender-specific experiences and their implications. Future research should aim to collect and report more detailed, gender-stratified data to understand better how gender influences WPV and to inform the development of gender-sensitive interventions and policies.

Implication to Practice and Policy

1. Staff training and education: To manage WPV effectively, HCPs in Saudi Arabia must receive training in conflict resolution, de-escalation techniques, and reporting protocols. These training programs can be integrated into mandatory continuing medical education (CME) requirements for healthcare professionals. Public awareness campaigns, led by the Ministry of Health (MoH) and supported by community leaders, should promote respect for healthcare workers and highlight the legal and social consequences of violent behavior.
2. Improved reporting systems: Establishing a centralized, confidential, and accessible reporting platform through the MoH would ensure transparency and encourage incident reporting. This system should be supported by clear protocols to protect healthcare workers from retaliation and reduce the stigma associated with reporting WPV. Regular feedback on actions taken in response to reports can build trust in the system.
3. Strengthened security measures: In high-risk areas such as emergency departments and psychiatric units, enhanced security measures can include hiring additional trained security personnel, installing advanced surveillance systems, and making environmental modifications such as secure staff areas, improved lighting, and controlled access points. The MoH can mandate these measures in public and private healthcare facilities as part of accreditation standards.
4. Workforce and system improvements: Addressing systemic issues such as staff shortages is critical to reducing worker fatigue and improving patient satisfaction. Increasing staffing levels, particularly in high-demand departments, can be achieved by incentivizing healthcare careers through scholarships, competitive salaries, and benefits for Saudi nationals. Additionally, implementing standardized communication protocols can help alleviate patient frustrations and reduce misunderstandings.
5. Zero-tolerance policies: Implementing strict zero-tolerance policies, with clearly defined penalties for offenders, should be enforced at both institutional and national levels. The MoH can collaborate with legal authorities to ensure judicial protections for healthcare workers and publicize these policies to deter potential perpetrators. Legal awareness campaigns could emphasize the consequences of violence against healthcare providers under Saudi law.
6. Collaborative efforts: Collaboration between healthcare organizations, professional societies, policymakers, and community leaders is essential for creating and enforcing region-specific WPV prevention guidelines. Saudi Arabia’s Vision 2030 initiatives can serve as a framework for aligning these efforts with national goals of improving healthcare quality and safety.

Suggestion for Future Work

Future studies should explore longitudinal trends in WPV and evaluate the effectiveness of interventions across different healthcare settings. Furthermore, qualitative research is needed to gain deeper insights into the experiences of HCPs facing WPV and to understand cultural and organizational factors unique to Saudi Arabia. Future research should examine gender differences, occupational variations, and time trends in WPV against HCPs. Studies are required to investigate the impact of awareness and education on enhancing the detection and reporting of abuse.

Conclusion

This review makes a unique contribution to the literature by comprehensively examining WPV across multiple healthcare professions and settings in Saudi Arabia, filling significant gaps in understanding its prevalence, contributing factors, sources, types, and causes. The findings reveal alarmingly high rates of WPV against HCPs between 2010 and 2024. Key contributing factors include gender, age, years of experience, workload, shift patterns, nationality, and inadequate training. Among the healthcare workforce, nurses reported the highest rates of violence, with verbal abuse being the most common form, primarily perpetrated by patients and their relatives. Contributing factors identified include inadequate security measures, staff shortages, overcrowding, and miscommunication, highlighting critical areas for targeted intervention.

Failing to address WPV may exacerbate existing challenges in the healthcare sector. This includes increased staff burnout, reduced job satisfaction, and higher turnover rates, which may contribute to a critical shortage of skilled professionals.^{1,3,4,7,10,24,29} Additionally, the psychological and emotional stress caused by WPV may impair healthcare providers’ ability to deliver safe, high-quality care, leading to poor patient outcomes and undermining the overall efficiency of healthcare systems.⁴⁴

Addressing the root causes of WPV—such as improving staffing levels, implementing robust security measures, enhancing staff training, and mitigating miscommunication—can transform the healthcare environment. Increasing staffing levels may help reduce worker fatigue and patient frustrations, alleviating tension and potential conflict.^{43–47,54,61} Enhanced security measures, including trained personnel and surveillance systems, can deter violent behavior and ensure timely incident response.^{43–47,54,61} Comprehensive training programs for healthcare providers in conflict resolution and de-escalation techniques are critical to equipping staff with the skills to manage violence effectively. These efforts can also improve healthcare worker satisfaction, reduce burnout, better staff retention, and enhance patient care quality.^{43–47,54,61}

Lessons from countries with similar WPV challenges offer valuable insights for Saudi Arabia. For example, successful strategies implemented in the United States, Australia, Asia, and South Africa include mandatory staff training, robust reporting mechanisms, zero-tolerance policies, and enhanced security measures. These interventions have demonstrated success in reducing WPV and could be adapted to align with the cultural and organizational context of Saudi Arabia.^44–47,61

The successful implementation of these strategies requires coordinated efforts from key stakeholders:

1. Government agencies should establish and enforce comprehensive national policies, such as mandatory reporting systems, zero-tolerance policies, and legal protections for healthcare workers. They should also allocate funding for WPV prevention programs and ensure adequate staffing across healthcare facilities.
2. Healthcare institutions should implement robust training programs, strengthen security measures, develop efficient reporting systems, and provide ongoing support for WPV victims.
3. Professional societies are vital in raising awareness about WPV, developing best practice guidelines, and fostering stakeholder collaboration. They can also facilitate education, training, and research initiatives to address WPV.

By integrating evidence-based strategies and clearly defining the roles of stakeholders, Saudi healthcare systems can create safer and more supportive environments for healthcare professionals and patients. These interventions are critical to reducing WPV prevalence, improving healthcare worker well-being, and ensuring the delivery of high-quality care. Efforts to enhance staff training, streamline reporting processes, and enforce strict penalties for violent behavior are essential steps toward fostering a sustainable and secure healthcare environment.