The Journal of Emergency Medicine, Vol. -, No. -, pp.

1–12, 2015
Copyright Ó 2015 Elsevier Inc.
Printed in the USA. All rights reserved
0736-4679/$ - see front matter

http://dx.doi.org/10.1016/j.jemermed.2015.02.049

Violence: Recognition,
Management and Prevention

WORKPLACE VIOLENCE AND SELF-REPORTED PSYCHOLOGICAL HEALTH:

COPING WITH POST-TRAUMATIC STRESS, MENTAL DISTRESS, AND BURNOUT
AMONG PHYSICIANS WORKING IN THE EMERGENCY DEPARTMENTS COMPARED
TO OTHER SPECIALTIES IN PAKISTAN

Waleed Zafar, MBBS, MSC, MPH, SCD,* Uzma R. Khan, MBBS, MSC,* Shakeel A. Siddiqui, MBBS,*
Seemin Jamali, MBBS,† and Junaid A. Razzak, MD, PHD*
*Department of Emergency Medicine, Aga Khan University, Karachi, Pakistan and †Jinnah Postgraduate Medical Centre, Karachi, Pakistan
Corresponding Address: Waleed Zafar, MBBS, MSC, MPH, SCD, Department of Emergency Medicine, Aga Khan University, Karachi 74800,
Pakistan

, Abstract—Background: Little is known about the
mental health impact of workplace violence (WPV) among
emergency physicians (EPs) working in emergency depart-
ments (EDs) in Pakistan and whether this impact varies
across specialties. Objectives: Our aim was to measure the
prevalence of WPV among EPs in 4 of the largest hospitals
in Karachi, Pakistan; to measure the association between
the experience of WPV and self-report of post-traumatic
stress disorder (PTSD), depression, anxiety, and burnout;
to compare the same factors across medical specialties;
and to explore the coping strategies used by physicians in
dealing with job-related stressors. Methods: A cross-
sectional survey was conducted among 179 physicians
from 5 specialties (response rate, 92.2%) using standard
questionnaires for WPV, PTSD, burnout, current mental
distress, and methods of coping. Results: One in 6 physicians
reported experiencing a physical attack and 3 in 5 verbal
abuse on the job in the previous 12 months. Pathologists
were less likely to report any form of WPV compared to
all other specialties. There was, however, no difference in
experience of WPV between EPs and internists, surgeons,
or pediatricians. One in 6 physicians screened positive for
PTSD, and 2 in 5 for current anxiety and depression. There
was significant comorbidity of mental distress with PTSD.
Those who reported experiencing physical attack were 6.7
times more likely to report PTSD symptoms. We also found
Reprints are not available from the authors.
high rates of burnout (42.4% emotional exhaustion; 72.9%
depersonalization) among physicians. Conclusion: Experi-
ence of WPV was not uniform across specialties but was
generally high among Pakistani physicians. Prevention of
WPV should be a high priority for health care policy mak-
ers. Ó 2015 Elsevier Inc.
, Keywords—anxiety; burnout; coping; depression; emer-
gency department; emergency physician; Karachi; mental
health; Pakistan; post-traumatic stress disorder; workplace
violence
INTRODUCTION
Workplace violence (WPV), verbal abuse and threatened
or actual physical violence in the workplace, is a signifi-
cant challenge faced by physicians worldwide (1–4).
Some studies suggest that emergency physicians (EPs),
because of the front line nature of their jobs, are at an
increased risk of experiencing WPV compared to other
clinical specialties (2,4). However, few studies have
compared experience of WPV across specialties using
uniform methods. Experiencing WPV has been
associated with a higher rate of burnout - defined as ‘‘a
psychological syndrome in response to chronic
interpersonal stressors on the job’’ that is characterized

RECEIVED: 15 August 2014; FINAL SUBMISSION RECEIVED: 17 December 2014;

ACCEPTED: 17 February 2015

1
2 W. Zafar et al.
by ‘‘an overwhelming exhaustion, feelings of cynicism
and detachment from the job, and a sense of
ineffectiveness and lack of accomplishment’’ - among
physicians (5,6). WPV, especially in the form of a direct
threat to life, also can result in the development of post-
traumatic stress disorder (PTSD), depression, and anxiety
(7). Physicians’ poor mental health and burnout have in
turn been associated with higher rates of medical errors
and suboptimal patient care (8–11). However, while
considerable attention has been paid to measuring the
experience of WPV among EPs and nurses, there has
been comparatively little work done on measuring the
mental health impact on physicians of experiencing
WPV and whether this impact is uniform across various
clinical specialties.
One factor that is likely to play an important role in
modifying the mental health impact of WPV on physi-
cians is the coping strategies they use. Coping refers to
‘‘constantly changing cognitive and behavioral efforts to
manage specific external and/or internal demands that
are appraised as taxing or exceeding the resources of the
person’’ (12). There is scant information on how physi-
cians, especially in resource-constrained settings in low-
and middle-income countries, cope with stressors like
WPV, what coping strategies they use, and what, if any, as-
sociation exists between coping strategies and the mental
health impact of experiencing stressors like WPV.
The aims of this study were threefold: first, to update
findings of a study reported earlier regarding prevalence
of WPV among EPs in 4 of the largest hospitals in Kara-
chi, Pakistan, and to compare their experience of WPV
with the experience of physicians in other medical spe-
cialties; second, to measure the association between
experience of WPV and symptoms of PTSD, psycholog-
ical morbidity, and burnout among physicians and to
compare these experiences across specialties; and third,
to explore the coping strategies used by physicians in
dealing with job-related stressors (1).
Table 1. Selected Characteristics of the Hospitals Participating in the Study
Authority to
Register
Medicolegal
Hospital* Complaints Status
Aga Khan University No Private nonprofit
hospital
Abbasi Shaheed Yes Public hospital
Jinnah Postgraduate Yes Public hospital
Medical Center
Civil Karachi Yes Public hospital
ED = Emergency department.
* All are full-service tertiary care hospitals with 24-hour emergency departments that work in 3 shifts and are teaching hospitals for affil-
iated medical schools and for postgraduate training. Treatment in the public hospitals is free to patients; in private hospitals, it is mostly out
of pocket.
METHODS
Study Design and Setting
This study was a cross-sectional survey conducted in 4
of the largest tertiary care hospitals in Karachi, Pakistan.
Selected characteristics of these hospitals are presented
in Table 1. We planned to approach all physicians work-
ing in the emergency departments (EDs) of the 4 partici-
pating hospitals and, for comparison, all physicians
working in selected departments in 4 other specialties
within specific hospitals. The specialties (internal med-
icine, surgery, pediatrics, and pathology-hematology)
were chosen to offer a range in physicians’ interaction
with patients and their caregivers. The study was
approved by the ethics review committee of Aga Khan
University Hospital (2447-EM-ERC-13) and the review
boards or departmental chairs of all the participating
hospitals.
Selection of Participants
We obtained a complete duty roster of physicians work-
ing in the EDs of all 4 participating hospitals and in the
departments of internal medicine in Civil Karachi, of sur-
gery in Abbasi Shaheed, of pediatrics in Jinnah postgrad-
uate, and of pathology-hematology in Aga Khan
University at the beginning of February 2013. Trained
research assistants then approached all personnel on the
roster in person to explain the objectives of the study
and to invite them to participate. Participants were
enrolled after they provided written consent and were re-
quested to fill out the paper questionnaire without
providing identifying information and to return the ques-
tionnaires to the research assistants. Participants were
blinded to any specific hypotheses of the study and no
compensation was offered for participation. Data collec-
tion lasted until November 2013.
Approximate
Total No.
No. of Physicians and Nurses in ED No. of Patients seen of Beds in
per day (All Shifts Included) per day in the ED the Hospital
35–45 physicians and 45–55 nurses 200–250 600
25–35 physicians and 50–60 nurses 900–1200 850
25–30 physicians and 20–35 nurses 900–1200 1300
15–25 physicians and 20–30 nurses 900–1200 1900
Workplace Violence and ED Burnout in Pakistan
Methods of Measurement
English is the primary language for medical education
and clinical work in Pakistan, and our survey question-
naire used the original English wording for each of the in-
struments discussed below.
Workplace Violence
To measure the physicians’ experience of WPV, we used a
survey instrument developed by the Joint Programme on
Workplace Violence in the Health Sector of the Interna-
tional Labor Office, the International Council of Nurses,
the World Health Organization, and the Public Services In-
ternational (ILO/ICN/WHO/PSI Joint Programme) (13).
Previously, this questionnaire has been used in several
countries and in Karachi (1,14). The questionnaire has
the following sections: 1) questions regarding personnel
and workplace characteristics; 2) questions about
physical violence in the workplace, defined as use of
‘‘physical force against another person that results in
physical, sexual, or psychological harm and includes
beating, kicking, slapping, stabbing, shooting, pushing,
biting, and pinching, among others’’; and 3) questions
related to verbal abuse, defined as ‘‘bullying, mobbing,
harassment, and verbal abuse that humiliates, degrades,
or otherwise indicates a lack of respect for the dignity
and worth of an individual.’’ The primary question of
interest was whether, in the last 12 months, the
respondent had been physically attacked or verbally
abused in the workplace. Other questions related to the
identity of and the consequences for the attacker.
Post-traumatic Stress Disorder
Post-traumatic stress symptoms were screened using the
civilian version of PTSD Checklist (PCL-C) (15–18).
This is a validated 17-item self-report measure that corre-
sponds to the Diagnostic and Statistical Manual of
Mental Disorders, 4th edition symptoms of PTSD. The
civilian version asks about symptoms in relation to
generic ‘‘stressful experiences.’’ The questionnaire is
scored on a Likert-like scale ranging from 1 (not at all)
to 5 (extremely). Following the standard symptom-
cluster method of scoring PCL, we dichotomized re-
sponses for each item into positive (a score $3) and nega-
tive (a score #2). Respondents were considered to have
screened positive for PTSD if they scored positive on
$1 item among the 5 B items (related to ‘‘re-experi-
encing’’), 3 among the 7 C items (related to ‘‘avoidance
and numbing’’), and 2 among the 5 D items (related to
‘‘altered arousal and reactivity’’). In this study, the PCL
had an internal consistency of 0.93 for all 17 items and
0.83, 0.89, and 0.75 for B, C, and D items, respectively.
3
Burnout
We measured burnout using the Maslach Burnout Inven-
tory (MBI) for human services (Mind Garden, Inc, Menlo
Park, CA). The MBI is a validated and widely used 22-
item questionnaire with 3 scales: emotional exhaustion
(9 items), depersonalization (5 items), and reduced per-
sonal accomplishment (8 items) (19,20). All items are
scored on a 7-point Likert-like scale ranging from
0 (never) to 6 (everyday). There is no overall burnout
score, and each scale is scored separately. Following
standard methods, we dichotomized respondents into
positive if they had high burnout ($30 for emotional
exhaustion, $12 for depersonalization, and #33 for
reduced personal accomplishment) or negative if they
had moderate or low burnout (<30 for emotional exhaus-
tion, <12 for depersonalization, and >33 for reduced per-
sonal accomplishment). In this study, the internal
consistency of the emotional exhaustion scale was 0.85
and the depersonalization scale was 0.68. We decided
not to use the responses for reduced personal accomplish-
ment scale because of high response instability in our
sample.
Mental Distress
We screened for symptoms of mental distress, anxiety,
and depression using the General Health Questionnaire-
12 (GHQ-12; GL Assessment, London, United
Kingdom). This is a widely used 12-item questionnaire
with well-established psychometric properties that is
scored on a 4-point Likert-like scale ranging from 0 to
3 (21). Following standard methods, we dichotomized
the scores on each item into categories of: 1 (a score of
2 or 3) and 0 (a score of 0 or 1) (21). An overall score
$4 was considered positive for current mental distress.
The GHQ-12 has been validated for use in a Pakistani
population: when compared with the diagnosis made us-
ing the Psychiatric Assessment Schedule (PAS) it was
found to have a sensitivity of 93% and specificity of
88% (22). The GHQ-12 had an internal consistency of
0.85 for all 12 items.
Coping Strategies
We measured how physicians in our study coped with
job-related stressors using the Ways of Coping question-
naire (23–25). This is a 66-item questionnaire with 8
distinct scales. Each item is scored on a 4-point Likert-
like scale ranging from 0 (does not apply or not used)
to 3 (used a great deal). There is no overall coping score,
and each scale is scored separately. The internal consis-
tency of the 8 scales in this study ranged from 0.67 to
0.85.
4 W. Zafar et al.
Statistical Analysis
We hypothesized that the average prevalence of experi-
encing a physical attack in the last 12 months as reported
by EPs would be approximately 25%, and for other spe-
cialties would be 10%, while the prevalence of verbal
abuse was hypothesized to be approximately 75% for
EPs and 55% for other specialties (1,2). Given our
overall study goal of estimating the difference between
the proportions within 6 5 percentage points of true
population difference at a = 0.05, our estimated sample
size was 180 (26).
Standard descriptive summary statistics were used to
characterize the sample of physicians and their experi-
ences of WPV stratified by specialty. Associations be-
tween variables were evaluated using nonparametric
tests after ruling out normality in the data (using the Sha-
piro–Wilk test among other steps): Kruskal–Wallis test
and the Fisher’s exact test as appropriate (27–30). All
tests were 2-sided, with a type I error level of 0.05.
Multivariate logistic regression (MLR) analyses were
used to test the association with outcomes identified a
priori. The final models for estimation of adjusted
odds ratios (aORs) were developed based on the theoret-
ical model of the study and through forward selection
using Akaike Information Criterion (31). Following rec-
ommendations in the literature, we based the analyses on
our a priori theoretical model and did not perform Bon-
ferroni adjustment for multiple comparisons (32–34).
All statistical analyses were performed with Stata
software (version 12.0; StataCorp LP, College Station,
TX) (35).
RESULTS
One hundred ninety-four physicians from 5 specialties
were approached to participate in the study; 179 agreed
to participate and returned completed (n = 165) and
almost completed (n = 14) questionnaires (a response
rate of 92.2%). Table 2 shows the demographic character-
istics of the sample that included 52 (29%) EPs, 29
(16.2%) internists, 35 (19.6%) pediatricians, 28 (15.6%)
general surgeons, and 35 (19.6%) pathologists from the
4 participating hospitals. Internists and surgeons were
significantly more likely to be <30 years of age, and pa-
thologists were more likely to be married, compared to
the EPs. Most respondents had between 1 and 5 years
of total clinical experience and were employed full-
time in their current jobs. On a scale of 1 (not worried
at all) to 5 (very worried), pathologists (mean, 2.1)
were significantly less worried about WPV in their cur-
rent workplace compared to all other specialties (range,
3.8–4.0). There was a significant difference among
specialties regarding their knowledge of procedures for
reporting WPV but no difference in their feeling of
encouragement to report WPV.
Prevalence of WPV
Overall, 28 (15.6%) respondents reported experiencing a
physical attack, 94 (52.8%) reported witnessing a phys-
ical attack, and 109 (60.9%) reported experiencing verbal
abuse in the last 12 months (Table 3). Pathologists were
significantly less likely to report any form of WPV
compared to all other specialties. However, EPs were
no more likely than internists, pediatricians, and surgeons
to report physical attack or verbal abuse.
Of the 28 respondents who reported experiencing a
physical attack, 6 (21.4%) said that the last attack
involved a weapon, 19 (67.8%) said that the perpetrator
of physical attack was someone accompanying the pa-
tient, and 4 (14.3%) said that the attacker was a patient.
Significantly, 22 (78.6%) of those who reported physical
attack thought that the last attack was preventable, and
only 2 (7.1%) said that the incident was reported to the
police or the attacker prosecuted. Excluding pathologists,
reported experience of verbal abuse was common across
specialties (range, 65–80%). As with physical attacks, 77
(70.6%) of those who reported verbal abuse said that the
perpetrator was someone accompanying the patient, and
22 (20.2%) said the abuser was the patient. Of those
who reported verbal abuse, 74 (67.9%) thought that the
last incident was preventable, but only 19 (17.4%) said
any action (mostly issuance of verbal warning) was taken
against the perpetrator.
Post-traumatic Stress Disorder
Overall, 26 (15.4%) respondents screened positive for
PTSD (Table 4). In the MLR analyses (model 3 in
Table 5), there was no association of age or sex with
screening positive for PTSD. After controlling for con-
founding variables, experience of physical attack
(aOR = 6.72 [95% confidence interval {CI}, 1.8–25.2])
(but not verbal abuse) and current mental distress
(aOR = 5.64 [95% CI, 1.6–19.7]) were strongly and
significantly associated with screening positive for
PTSD.
Burnout
Overall, 70 (42.4%) respondents screened positive for
emotional exhaustion and 124 (72.9%) for depersonaliza-
tion (Table 4). In the MLR analyses (models 4 and 5
in Table 5), EPs were significantly more likely
(aOR = 2.48 [95% CI, 1.1–5.4]) to report emotional
exhaustion and less likely to report depersonalization
(aOR = 0.32 [95% CI, 0.1–0.7]) compared to other
Workplace Violence and ED Burnout in Pakistan 5

Table 2. Demographic Characteristics of the Survey Respondents

Specialty

Emergency Internal
Medicine Medicine Pediatrics Surgery Pathology
Characteristics (n = 52) (n = 29) (n = 35) (n = 28) (n = 35) p value

Sex, n (%)
Female 25 (48.1) 16 (55.2) 24 (68.6) 17 (60.7) 23 (65.7) 0.33
Male 27 (51.9) 13 (44.8) 11 (31.4) 11 (39.3) 12 (34.3)
Age, n (%)
<30 years 25 (48.1) 25 (86.2)* 23 (65.7) 23 (82.1)* 21 (60.0) <0.01
$30 years 27 (51.9) 4 (13.8) 12(34.3) 5 (17.9) 14 (40.0)
Hospital, n (%)
Aga Khan University 27 (51.9) 0 0 0 35 (100) N/A
Abbasi Shaheed 7 (13.5) 0 0 28 (100) 0
Jinnah Postgraduate Medical 10 (19.2) 0 35 (100) 0 0
Civil Karachi 8 (15.4) 29 (100) 0 0 0
Marital status, n (%) *
Married 24 (46.1) 11 (37.9) 22 (62.9) 12 (42.9) 25 (71.4) 0.03
Not married 28 (53.9) 18 (62.1) 13 (37.1) 16 (57.1) 10 (28.6)
Total work experience, n (%) * * *
<1 year 5 (9.6) 3 (10.3) 3 (8.8) 0 2 (5.7) <0.01
1–5 years 20 (38.5) 24 (82.8) 24 (70.6) 22 (78.6) 22 (62.9)
6–10 years 11 (21.1) 2 (6.9) 5 (14.7) 6 (21.4) 8 (22.9)
>10 years 16 (30.8) 0 2 (5.9) 0 3 (8.6)
Months worked in the current 33.0 (47.9) 19.9 (18.3) 25.3 (41.8) 25.1 (17.4) 30.9 (19.9) 0.11
department, mean (SD)
Employment status, n (%)
Full-time 42 (80.8) 27 (93.1) 34 (97.1) 26 (92.9) 34 (97.1) 0.06
Part-time/temporary 10 (19.2) 2 (6.9) 1 (2.9) 2 (7.1) 1 (2.9)
How worried about WPV in 3.9 (1.0) 3.8 (1.2) 4.0 (1.2) 3.8 (1.2) 2.1 (1.0)* <0.01
current workplace,† mean (SD)
Procedures for reporting violence 32 (61.5) 7 (24.1)* 19 (54.3) 8 (28.6)* 20 (57.1) <0.01
in current workplace, n (%) saying yes
Encouragement to report WPV, n (%) saying yes 25 (49.0) 11 (45.8) 15 (42.9) 8 (28.6) 12 (37.5) 0.48

SD = standard deviation; N/A = not applicable; WPV = workplace violence.

* Significantly different from emergency medicine in pairwise comparisons at p = 0.05.
† 1 = Not worried at all to 5 = very worried.

specialties. Age, sex, experience of physical attack or ver-
bal abuse, and current mental distress were not signifi-
cantly associated with burnout.
Current Mental Distress
Overall, 66 (39.3%) respondents reported feeling
currently mentally distressed (Table 4). In the MLR ana-
lyses (model 6 in Table 5), after controlling for con-
founders, the only factor significantly associated with
current mental distress was screening positive for PTSD
(aOR = 3.81 [95% CI, 1.3–11.1]).
Coping Strategies
Table S1 shows the mean values for each of the 8 coping
strategies reportedly used by the respondents in dealing
with work-related stressors. Those who experienced
physical attack in the last 12 months made significantly
greater use of confrontive coping, seeking social support,
and escape and avoidance compared to those who did not
experience physical attack. Respondents who screened
positive for PTSD used significantly more of all of the
coping strategies except confrontive coping and planful
problem solving, compared to those who screened nega-
tive for PTSD. There was no difference in the coping
behavior of those with and without current mental distress
except in the use of escape and avoidance. Finally, pathol-
ogists made significantly less use of coping strategies
compared to other specialties (results not shown).
DISCUSSION
This study compares the self-reported experience of
physical and verbal workplace violence during the previ-
ous 12 months among physicians working in the EDs with
those working in other clinical specialties in 4 of the
largest hospitals in the most populous city of Pakistan.
Using validated and widely used methods, we measured
the prevalence of PTSD, burnout, and psychiatric
morbidity among a sample of Pakistani physicians and
the association of these negative mental health outcomes
6 W. Zafar et al.

Table 3. Self-reported Experience of Physicians of Workplace Physical Violence and Verbal Abuse

Specialty

Emergency Internal
Medicine Medicine Pediatrics Surgery Pathology
Characteristics of Workplace Violence (n = 52) (n = 29) (n = 35) (n = 28) (n = 35) p value

Experienced physical attack in last 12 months, n (%) 12 (23.1) 4 (13.8) 3 (8.6) 8 (28.6) 1 (2.9)* 0.02
Last physical attack involved a weapon† 4 (33.3) 0 1 (33.3) 0 1 (100)
Identity of attacker†
Patient 2 (16.7) 0 0 2 (25.0) 0
Relatives of patients 9 (75.0) 3 (75.0) 3 (100) 4 (50.0) 0
Coworker 0 1 (25.0) 0 0 1 (100)
Others 1 (8.3) 0 0 2 (25.0) 0
Last attack was preventable† 9 (75.0) 4 (100) 2 (66.7) 7 (87.5) 0
Action was taken against attacker† 4 (33.3) 0 1 (33.3) 2 (25.0) 0
Consequences for the attacker
Verbal warning issued 4 0 1 0 0
Reported to police/prosecution 0 0 0 2 0
Witnessed physical violence in last 12 months, n (%) 34 (65.4) 21 (72.4) 18 (51.4) 19 (67.9) 2 (5.9)* <0.01
How often witnessed†
Once 6 (17.6) 7 (33.3) 5 (27.8) 2 (10.5) 2 (100)
2–4 times 14 (41.2) 9 (42.9) 7 (38.9) 7 (36.9) 0
5–10 times 7 (20.6) 4 (19.0) 3 (16.7) 2 (10.5) 0
Several times a month or more 7 (20.6) 1 (4.8) 3 (16.7) 8 (42.1) 0
Experienced verbal abuse in last 12 months, n (%) 37 (71.1) 19 (65.5) 28 (80.0) 19 (67.9) 6 (17.1)* <0.01
How often experienced†
Once 2 (5.4) 4 (21.0) 2 (7.1) 0 1 (16.7)
Sometimes 29 (78.4) 12 (63.1) 20 (71.4) 17 (89.5) 2 (33.3)
All the time 6 (16.2) 3 (15.8) 6 (21.4) 2 (10.5) 3 (50.0)
Identity of abuser†
Patient 12 (32.4) 4 (21.0) 4 (14.3) 1 (5.9) 1 (20.0)
Relatives of patients 25 (67.6) 14 (73.7) 24 (85.7) 12 (70.6) 2 (40.0)
Coworker 0 1 (5.3) 0 3 (17.6) 2 (40.0)
Last attack was preventable† 25 (67.6) 13 (68.4) 18 (64.3) 15 (78.9) 3 (50.0)
Action was taken against attacker† 5 (13.5) 8 (42.1) 5 (17.9) 1 (5.3) 0
Consequences for the attacker
Verbal warning issued 5 7 5 0 0
Reported to police/prosecution 0 1 0 1 0

* Significantly different from emergency medicine in pairwise comparisons at p = 0.05.

† n (%) of only those who experienced the corresponding form of workplace violence in last 12 months.

with the experience of WPV. We also looked at the com-
mon coping strategies used by physicians in dealing with
job-related stressors. We found WPV to be a common
experience: approximately 1 in 6 physicians reported
experiencing a physical attack and 3 in 5 reported experi-
encing verbal abuse on the job in the last 12 months. Pa-
thologists were significantly less worried about WPV and
were less likely to report any form of WPV compared to
all other specialties. However, there was no difference in
experience of WPV between EPs and internists, pediatri-
cians, or surgeons. One in 6 physicians also screened pos-
itive for PTSD, and those who experienced physical WPV
were almost 7 times more likely to screen positive
compared to those who did not experience WPV. We
found relatively high rates of burnout among physicians.
Compared to other specialties, EPs were more likely to
feel emotionally exhausted but less likely to feel deper-
sonalization. Every 2 in 5 physicians reported currently
experiencing symptoms of anxiety, depression and
mental distress. Compared to those who did not experi-
ence WPV, those who experienced physical WPV used
more coping strategies, especially confrontive coping,
escape or avoidance, and seeking social support.
In a previous study, we documented that 13.6% of EPs
in Karachi reported experiencing physical attack and
68% reported verbal abuse in the previous 12 months,
rates that are broadly in line with our findings in this study
(respectively, 15.6% and 60.9% overall, and 23.1% and
71.1% among EPs) (1). Over the 5 years between data
collection for the 2 studies, the reported prevalence of
physical WPV has increased (by 10 percentage points)
in the EDs of Karachi, while the prevalence of reported
verbal abuse has shown little change. Experience of
WPV is high not just for EPs but also for general surgeons
and internists, and somewhat less for pediatricians. Only
pathologists-hematologists—specialties that feature less
interaction with both patients and their caregivers, the
main sources of WPV in both this and our earlier
study—reported significantly lower rates of experiencing
WPV.
Workplace Violence and ED Burnout in Pakistan 7

Table 4. Characteristics of Respondents who Screened Positive for Post-traumatic Stress Disorder, Burnout, and Mental
Distress

Attribute for Which physician Received a Positive Screen, n (%)

PTSD, 26 Emotional Depersonalization, Current Mental

Characteristics (15.4)* Exhaustion, 70 (42.4)* 124 (72.9)* Distress, 66 (39.3)*

Sex, n (%)*
Male 15 (15.6) 36 (36.7) 76 (74.5) 44 (43.6)
Female 11 (15.1) 34 (50.7) 48 (70.6) 22 (32.8)
Age, n (%)*
<30 years 18 (16.5) 46 (43.0) 84 (75.7) 45 (40.9)
$30 years 8 (13.3) 24 (41.4) 40 (67.8) 21 (36.2)
Specialty, n (%)*
Emergency medicine 4 (7.7) 28 (57.1) 29 (56.9) 19 (39.6)
Internal medicine 3 (11.5) 9 (36.0) 21 (77.8) 6 (24.0)
Pediatrics 5 (15.1) 13 (37.1) 29 (85.3) 13 (40.6)
Surgery 8 (28.6) 10 (37.0) 21 (75.0) 14 (50.0)
Pathology 6 (20.0) 10 (34.5) 24 (80.0) 14 (40.0)
Experienced physical attack, n (%)*
Yes 7 (26.9) 14 (51.8) 18 (66.7) 11 (40.7)
No 19 (13.3) 56 (40.6) 106 (74.1) 55 (39.0)
Experienced verbal abuse, n (%)*
Yes 19 (18.1) 44 (41.5) 78 (73.6) 45 (45.0)
No 7 (10.9) 26 (44.1) 46 (71.9) 21 (30.9)

PTSD = Post-traumatic stress disorder.

* Percentage of the total respondents that screened positive. Percentages should not add to 100 in rows or columns.

To our knowledge, no previous study has measured
rates of PTSD among Pakistani physicians. Various
studies have reported the prevalence of PTSD symptoms
among ED personnel to range from 10% to 25% (36–38).
In this study, we showed that there is significant
comorbidity of depression and anxiety symptoms with
PTSD symptoms, and that those who reported
experiencing physical attack were much more likely to
report PTSD symptoms even after we controlled for
comorbid depression and anxiety. In the wake of a
WPV experience, individual response will be influenced
by several factors, including personal resilience and
coping strategies (39,40). The identification of
personnel who are at greater risk of developing PTSD,
and providing early evidence-based interventions like
cognitive behavioral therapy with a trauma focus, are
likely to reduce the prevalence of PTSD symptoms
among physicians who have experienced a violent inci-
dent (41–43).
We also found high rates of burnout among physicians
in Karachi. While to our knowledge no previous study has
measured burnout among physicians or medical students
in Pakistan, international reviews have put the rates some-
where between 30% and 60% (44–46). Using the same
instrument and cutoff values as our report, a recent
study among 7288 U.S. physicians found that 37.9%
reported emotional exhaustion and 29.4% reported
depersonalization (47). Higher rates of burnout among
EPs have also been reported elsewhere (48). In this
context, our finding that EPs were 2.5 times more likely
to report emotional exhaustion compared to physicians
in other specialties is in line with earlier findings. Burnout
has been associated with poor psychological and physical
health, impaired job performance, marital difficulties,
and drug abuse among physicians (44–48). While the
causes of burnout are complex, prospective studies have
linked the experience of WPV with higher rates of
burnout (49). Prevention of WPV and enhancing physi-
cians’ resilience through the use of evidence-based relax-
ation techniques, such as mindfulness, are likely to
reduce the experience of burnout among physicians
(50,51).
The prevalence of depression, anxiety, and mental
distress among Pakistani physicians is unknown. Studies
in other countries that have used GHQ-12 among physi-
cians have reported rates of psychological morbidity
ranging from 10% to 30% (52–56). The sample of
physicians in this study reported somewhat higher rates
of mental distress. Coping refers to actions used to
minimize stress. In this study, we sought to explore
differences in coping strategies used by those who
experienced WPV versus those who did not. Our
findings indicate that those who experience WPV and
PTSD symptoms often use significantly more coping
strategies that could be maladaptive under certain
circumstances, such as confrontive, distancing, and
escape or avoidance coping (57). More work is needed
to determine whether providers can be trained to use
8 W. Zafar et al.

Screen Positive for

healthier strategies, such as planful problem-solving, pos-

Mental Distress
Table 5. Factors Associated with experiencing Physical Attack and Verbal Abuse, and Screening Positive for Post-traumatic Stress Disorder, Burnout, and Mental Distress:

3.81* (1.3–11.1)
0.70 (0.3–1.5)
1.12 (0.5–2.7)
1.10 (0.5–2.4)

0.84 (0.3–2.4)
1.73 (0.8–3.8)

0.88 (0.4–1.9)
0.90 (0.3–2.3)
itive reappraisal, and seeking social support, and whether
Model 6:

Current
the use of these strategies has any role in reducing the

N/A

N/A
experience of adverse mental health symptoms among
physicians.

Limitations
Screen Positive for
Depersonalization
Dependent Variables, Adjusted Odds Ratios (95% Confidence Intervals)

1.04 (0.5–2.2)
0.32† (0.1–0.7)
0.78 (0.3–1.7)

0.96 (0.3–2.6)
1.52 (0.7–3.4)
0.75 (0.3–1.6)
Model 5:

This study has several limitations. First, it was based on

N/A
N/A
N/A
N/A
self-reported data. We tried to minimize recall bias by
limiting the recall window to the last 12 months and the
last remembered event, a previously adopted and recom-
mended approach (1,14,58,59). Using self-report ques-
Emotional Exhaustion

tionnaires to measure psychological health and coping

Screen Positive for

1.91 (0.9–3.8)
2.48* (1.1–5.4)
0.62 (0.3–1.3)

1.47 (0.6–3.6)
0.87 (0.4–1.8)
0.74 (0.4–1.4)

strategies is also well-established. Prospective observa-

Model 4:

tion to measure the incidence of WPV in the hospitals

N/A
N/A
N/A
N/A

N/A = Predictors not included in the final multivariate model; PTSD = post-traumatic stress disorder; WPV = workplace violence.

participating in this study was not feasible because of

the time and resource constraints, and would likely
have led to serious underestimation of the true prevalence
of WPV because of weak reporting mechanisms. Second,
the survey questionnaire was long, requiring an average
0.22 (0.04–1.3)

6.72† (1.8–25.2)

5.64† (1.6–19.7)
Screen Positive

1.07 (0.3–3.4)
0.71 (0.2–2.5)

0.81 (0.5–1.2)

1.58 (0.5–5.0)

of 35 min to complete. However, we reduced the risk of

for PTSD
Model 3:

N/A
N/A
N/A

incomplete submissions by using trained data collectors,

who explained to the respondents different parts of the
questionnaire and the importance of answering all ques-
tions, and ensured that the questionnaires were thor-
0.56 (0.3–1.2)
1.25 (0.6–2.7)
3.46† (1.6–7.5)

2.26† (1.7–3.0)
Verbal Abuse

oughly completed. Consequently, a small proportion of

Experienced
Model 2:

questionnaires had incomplete information. We were

N/A
N/A

N/A
N/A
N/A
N/A

also able to approach most EPs working during the study

period in the 4 main EDs of Karachi.
Among the strengths of this study is the use of stan-
Physical attack

0.89 (0.4–2.1)
1.79 (0.7–4.2)
1.00 (0.4–2.3)

1.73† (1.2–2.5)

dardized and previously validated instruments, which al-

Experienced
Model 1:

lows for comparison of this study with others that have

N/A
N/A

N/A
N/A
N/A
N/A

used the same instruments. Second, we were able to

Results from Multivariate Logistic Regression Analyses

achieve a high response rate with little missing informa-

tion by using trained data collectors, publicizing the
study, and gaining the cooperation of hospital leaders.
Believe there are procedures to report WPV in the hospital

Third, this is one of the first studies to measure rates of

Emergency medicine (compared to other specialties)

PTSD, burnout, and mental distress among Pakistani phy-

sicians and to compare them across specialties.
Age ($30 years of age compared to younger)

Screen positive for current mental distress

CONCLUSION
Screen positive for emotional exhaustion
Screen positive for depersonalization

Given the high rates of WPV experience in Karachi hos-

Predictors

pitals and its impact on the mental health of the physi-

Males (compared to females)

cians, it is important to place a high priority on

Experienced physical attack
Experienced verbal abuse

prevention of WPV. Some strategies that might be adop-

Screen positive for PTSD

† Significant at p = 0.01.
* Significant at p = 0.05.

ted for primary prevention of WPV include a well-

publicized adoption of zero-tolerance policies toward
perpetrators of WPV, improving the efficiency of the
ED, training staff in effective communication skills and
conflict resolution skills, and training in defusing or de-
escalating potentially violent situations (60–65). Future
work should focus on understanding the prevalence of
Workplace Violence and ED Burnout in Pakistan
WPV elsewhere in Pakistani health care institutions,
understanding the impact of WPV on physicians’ mental
health and performance, implementing and assessing the
effectiveness of WPV prevention strategies in the local
working environment, and longitudinally evaluating the
mental health of health care personnel.
Acknowledgments—The authors acknowledge the help of Mr.
Mustafa Abidi, Ms. Tahira Begum, Ms. Rubaba Naeem, Ms.
Shumaila Rupani, Ms. Muniba Shah, Dr. Nishi Shakil, and
Mr. Ali Zia in data collection, and of Mr. Asher Feroze in crea-
tion of the database. We also thank Drs. Naseem Ahmed, Tariq
Ayubi, Muhammad Baqir, Shereen Z. Bhutta, and Muhammad
Saeed Quraishy for facilitating data collection in their respec-
tive hospitals. For bravely continuing to work under difficult cir-
cumstances, we express our deepest gratitude to the physicians
who participated in this study and to all their colleagues.
Partially supported through the Johns Hopkins-Pakistan Interna-
tional Collaborative Trauma and Injury Research Training pro-
gram grant number 2D43-TW007-292 (U.R.K. and J.R.) from
the Fogarty International Center of the United States National
Institutes of Health. The content is solely the responsibility of
the authors and do not represent the views of the Aga Khan Uni-
versity and Hospital, the Fogarty Center, or the National Insti-
tutes of Health.
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Workplace Violence and ED Burnout in Pakistan 11

ARTICLE SUMMARY
1. Why is this topic important?
Workplace violence (WPV) in the emergency depart-
ment (ED) has been well documented; however, few re-
ports have compared the experience of WPV among
emergency physicians to that in other specialties, espe-
cially in low- and middle-income countries. While there
is evidence to suggest a substantial mental health impact
of WPV on physicians, few studies have documented
this impact using standardized methods. There is also
limited information on whether WPV is associated with
physician burnout and on coping mechanisms used to
deal with WPV. A better understanding of WPV, its
impact on psychological health and burnout, and the
role of coping strategies will help researchers and policy-
makers develop effective interventions to reduce WPV
and its impact on the well-being of health care personnel.
2. What does this study attempt to show?
This study compares the experience of self-reported
physical and verbal WPV in the last 12 months among phy-
sicians working in EDs with those working in other clinical
specialties in 4 of the largest hospitals in the most populous
city of Pakistan. Using validated and widely used methods,
this study measured the prevalence of post-traumatic stress
disorder (PTSD), burnout, and psychiatric morbidity
among a sample of Pakistani physicians. The study also
looked at the common coping strategies used by physi-
cians in dealing with job-related stressors.
3. What are the key findings?
One in 6 physicians reported experiencing physical attack
and 3 in 5 verbal abuse on the job in the last 12 months. Pa-
thologists were less likely to report any form of WPV
compared to all other specialties. However, there was no dif-
ference in experience of WPV between emergency physi-
cians and internists, surgeons, or pediatricians. One in 6
physicians screened positive for PTSD, and 2 in 5 for current
anxiety and depression. There was significant comorbidity
of mental distress with PTSD. Those who reported experi-
encing physical attack were 6.7 times more likely to report
PTSD symptoms. We also found high rates of burnout
(42.4% emotional exhaustion; 72.9% depersonalization)
among physicians that were not related to experience of
WPV. Those who experienced WPV used more coping stra-
tegies (especially confrontive coping, seeking social sup-
port, and escape or avoidance) than those who did not.
4. How is patient care impacted?
A high prevalence of WPV, symptoms of PTSD, burnout,
depression, and anxiety among Pakistani physicians are ex-
pected to adversely affect the quality of patient care.
Comprehensive policies to reduce WPV in the EDs of Kar-
achi are needed. There is also a need to train physicians in
using coping strategies that are not maladaptive.
11.e1 W. Zafar et al.

Supplementary Table 1. Comparison of Coping Strategies (Mean Values) used by Physicians, Stratified by Experiences of
Physical Violence, Verbal Abuse, and whether the Respondent Screened Positive for Post-traumatic
Stress Disorder or Mental Distress

Experienced Physical Experienced Verbal

Violence, Mean (SD) Abuse, Mean (SD) PTSD, Mean (SD) Mental Distress, Mean (SD)

Coping Strategy Used Yes No Yes No Yes No Yes No

Confrontive (range, 0–24) 7.3 (3.7) 5.2 (3.7) 6.1 (3.6) 4.6 (3.9) 6.6 (4.0) 5.4 (3.7) 5.3 (3.4) 5.7 (4.0)
Distancing (range, 0–24) 7.6 (4.1) 5.8 (3.8) 6.8 (3.7) 5.0 (4.0) 8.1 (4.2) 5.8 (3.9) 6.9 (3.8) 5.7 (4.0)
Self-controlling (range, 0–28) 8.8 (4.8) 7.0 (4.5) 7.9 (4.4) 6.3 (4.6) 9.6 (4.8) 6.8 (4.3) 7.9 (4.1) 6.9 (4.8)
Seeking social support (range, 0–24) 8.2 (3.5) 6.4 (4.2) 7.2 (3.9) 5.9 (4.4) 8.3 (3.8) 6.4 (4.1) 6.8 (3.6) 6.6 (4.4)
Accepting responsibility (range, 0–16) 4.0 (2.8) 3.3 (2.6) 3.5 (2.4) 3.3 (2.9) 4.6 (2.8) 3.2 (2.6) 3.5 (2.4) 3.4 (2.8)
Escape avoidance (range, 0–32) 7.3 (4.6) 5.3 (4.6) 5.6 (4.6) 5.4 (4.7) 9.3 (5.4) 4.8 (4.2) 6.8 (4.6) 4.8 (4.5)
Planful problem solving (range, 0–24) 7.5 (3.4) 6.5 (4.3) 7.4 (4.0) 5.5 (4.2) 8.1 (4.3) 6.5 (4.1) 6.6 (3.8) 6.7 (4.3)
Positive reappraisal (range, 0–28) 9.9 (5.4) 7.5 (5.1) 8.5 (4.9) 6.7 (5.5) 10.1 (5.2) 7.5 (5.2) 7.6 (4.7) 8.1 (5.5)

PTSD = Post-traumatic stress disorder; SD = standard deviation.