Workplace violence (WPV)can be defined as “Incidents where staff 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”. It includes physical and psychological violence, such as verbal abuse, harassment, bullying/mobbing, and threat [1]. Healthcare workers are specifically vulnerable to WPV as they are in direct contact with people in distress due to economic and emotional burden and having great hope as well as expectation from doctors and hospitalsin taking care of the patients [2]. Indian Medical Association has reported that 75% of doctors have experienced WPV at some point of time during their career [2,3]. Annual incidence of WPV is 8 per 10,000 full time employees, which is 4 times more when compared to all other professionals where the incidence is reported to be 2 per 10,000 [2,3]. Beyond immediate physical harm, WPV has significant psychological consequences. Exposure to workplace violence has been consistently associated with elevated levels of perceived stress, anxiety, depression, burnout, and psychological distress among healthcare workers [4,5]. Persistent exposure can impair emotional well-being, reduce job satisfaction, and negatively affect professional performance and patient care. Despite these consequences, psychological impacts of WPV remain underreported due to stigma, normalization of violence, and inadequate institutional reporting mechanisms, particularly in low- and middle-income countries [6]. Medical interns constitute a particularly vulnerable subgroup within the healthcare workforce as they are in a transitional phase between undergraduate training and independent medical practice, characterised by long duty hours, high workloads, frequent patient interactions, and limited decision-making authority [7]. WPV is a silent epidemic, as there is a lot of underreporting of incidents, despite of an increased incidence of WPV. Many studies have reported the proportions of WPV; however, there is a gap in the literature regarding exposure to WPV and the development of psychiatric disorders, such as anxiety and depression, experienced by healthcare professionals. Hence, the aim of our study was to address this critical gap. Objectives: 1. To assess the prevalence of workplace violence and harassment faced by healthcare workers. 2. To determine the association between exposure to workplace violence and perceived stress, anxiety, and depression. 3. To determine the association between verbal abuse and physical violence and the severity of perceived stress, anxiety, and depression.

This was a cross-sectional study conducted in the department of Psychiatry at Koppal Institute of Medical Sciences, Koppal, from April 2022 to June 2022. The study was approved by the Institutional Ethics Committee. The study was intended to include all interns on the compulsory rotatory internship during the study period at our college. Participation was voluntary, and confidentiality and anonymity were ensured throughout the study. A specially prepared questionnaire, developed after an extensive review of literature, was used. Inclusion criteria: All the interns who have given consent for the study. Exclusion criteria: Incompletely filled questionnaires and interns who have not consented for the study. Tools used: 1. Perceived stress scale-10(PSS-10): It is a 10-item, self-reported questionnaire designed to measure the degree to which situations in one’s life are appraised as stressful. It is rated on a Likert scale of 0-4 with <13 – low perceived stress, 14-26 – moderate, and >27 – severe. 2. Generalised Anxiety Disorder-7(GAD-7) scale: GAD-7 is a self-reported questionnaire rated on a Likert scale of 0-3. Severity is rated with a score of <4 -minimal, 5-9 – mild, 10-14 – moderate, and >15 – severe. 3. Physical health questionnaire-9(PHQ-9): PHQ-9 is a self-rated questionnaire consisting of 9 items rated on a Likert scale of 0-3. Grading represents 0-4 as minimal, 5-9 as mild, 10-14 as moderate, 15-19 as moderately severe, and >20 as severe. The variables collected were age, gender, currently posted department, PSS-10, GAD-7 and PHQ-9 questionnaire and various aspects regarding exposure to workplace violence. Data was collected through google forms, by sharing the link through Whatsapp and Gmail. Participants were instructed to complete the questionnaire and do it independently without any discussion. They were permitted to submit only one response.The collected data was exported to Google Sheets. Data obtained were then checked for completeness, and any forms without consent or with incomplete responses were excluded. The sample included 114 subjects out of 142 interns, after exclusion using consecutive sampling and exclusion criteria. Data analysis was done using IBM SPSS software, version 27. Descriptive statistics were expressed as frequency and percentage. Chi-square test was used to analyse the association between exposure to workplace violence and stress perceived, anxiety and depression. P- value of less than 0.05 was considered statistically significant.

114 interns have consented to the study and were included in the analysis. Age and gender distributionare represented in Table 1, with all of them between 18 and 32 years. They were posted in different departments in the tertiary care center associated with our college during the study period. Table 1: Age and Gender Distribution. Age Variable Frequency Percentage 18-22 12 10.53 23-25 97 85.08 26-32 05 4.39 Gender Variable Frequency Percentage Female 56 49.12 Male 58 50.88 Table 2: Frequency of exposure to violence Frequency of exposure to violence Frequency(n) Once 9 Twice or thrice 10 >3 times 8 PSS-10 questionnaire result: Data from the PSS-10 questionnaire depict that the subjects who were exposed to workplace violence were at risk of developing stress. The severity was graded, and the percentage of interns developing different grades is shown in Figure 4. Chi square test showed significant association between stress perceived by the subjects at workplace and exposure to work place violence, with p-value of 0.001 (Table 3). Table 3: Association between exposure to workplace violence and perceived stress Variable Exposure to workplace violence p-value Chi-square dF Yes No Low perceived stress 2 68 0.001 95.2 2 Moderate perceived stress 23 13 Severe perceived stress 7 1 Total 32 82 GAD-7 questionnaire result: GAD-7 questionnaire responses show that subjects exposed to workplace violence developed minimal to severe anxiety and the percentage of interns developing anxiety of different grades is presented in Figure 4. The association between anxiety developed and exposure to workplace violence was statistically significant and the p-value is 0.001 (Table 4). Table 4: Association between exposure to workplace violence and anxiety Variable Exposure to workplace violence p-value Chi-square dF Yes No Minimal 20 62 0.001 12.4 3 Mild 3 10 Moderate 7 9 Severe 2 1 Total 32 82 PHQ-9 questionnaire result: PHQ-9 questionnaire results reveal that interns developed minimal to severe depressive symptoms. 34.38% of them developed minimal depressive symptoms and an even distribution of 15% each was observed in mild, moderate, moderately severe and severe depressive grades (Figure 4). Statistically significant association was found between depressive symptoms developed by subjects and the exposure to workplace violence. The p-value was 0.001 (Table 5). Table 5: Association between exposure to workplace violence and depression Variable Exposure to workplace violence p-value Chi-square dF Yes No Minimal 11 61 0.001 48.7 4 Mild 5 17 Moderate 6 3 Moderately severe 5 1 Severe 5 0 Total 32 82 Table 6 represents the association between the type of violence exposed and perceived stress, anxiety, and depression, showing clinically and statistically significant results with p-values of 0.018, 0.006, and 0.021, respectively. Table 6: Association between Type of violence and PSS-10, GAD-7 & PHQ-9 Variable Verbal Abuse/threat(n) Physical violence(n) Both(n) p-value PSS-10 0.018 Low perceived stress 7 0 0 Moderate - severe perceived stress 20 3 2 GAD-7 0.006 Minimal 20 0 0 Mild – severe 7 3 2 PHQ-9 0.021 Minimal 16 1 0 Mild – severe 11 2 2 Multivariate logistic regression analysis shows subjects exposed to physical violence or both verbal abuse and physical violence had higher odds of developing psychiatric disorders (PSS-10 – 4.38,0.036, GAD-7 – 5.92, 0.020, PHQ-9 – 3.88, 0.048). In contrast, female gender, age >25 years, and working in clinical departments were not significantly associated with workplace violence or psychiatric outcomes (Table 7). Table 7: Multivariate logistic regression analysis Variable Adjusted Odds ratio (AOR) 95% CI p-value PSS-10 Physical +/- both violence 4.38 1.10 – 17.42 0.036 Age>25 years 1.21 0.46 – 3.21 0.69 Female 1.09 0.38 – 3.14 0.87 Clinical department 1.42 0.52 – 3.91 0.49 Hosmer–Lemeshow p = 0.61 GAD-7 Physical +/- both violence 5.92 1.32 – 26.48 0.020 Female gender 1.34 0.52 – 3.47 0.55 Age>25 years 0.94 0.31 – 2.86 0.92 Clinical department 1.58 0.56 – 4.46 0.39 Hosmer–Lemeshow p = 0.73 PHQ-9 Physical +/- both violence 3.88 1.01 – 14.89 0.048 Female gender 1.27 0.49 – 3.28 0.62 Age>25 years 1.11 0.37 – 3.36 0.85 Clinical department 1.36 0.50 – 3.74 0.55 Hosmer–Lemeshow p = 0.66

The present study examined the prevalence of workplace violence and its association with perceived stress, anxiety, and depression among medical interns in a tertiary care centre in South India. Prevalence of WPV observed in our study was 28.07% and is comparable to that reported by Anand et al and Kumar et al [10,11] and less compared to Kaur et al, Singh et al and Ori et al [2,8,9]. Variations in reported prevalence across studies may be attributed to differences in study populations, definitions of violence, and reporting practices. Verbal abuse/ threat is the most common reported form, 84.38% of the interns exposed to WPV have reported it as verbal abuse in our study.Studies by Ori et al, Singh et al, Anand et al and Kumar et al, have also shown that verbal abuse is the most frequently reported form[8-11]. Our study has shown that 62.5% of times the aggressors being patients’ relatives and patients’ themselves are perpetrators 12.5% of times.Patients and their relatives being the common perpetrators of violence has also been reported by several studies [2, 8-11]. Perceived stress levels, assessed using the PSS-10, were notably higher among interns exposed to workplace violence. Similar findings have been reported in studies among healthcare workers, where exposure to violence was associated with elevated stress levels and emotional exhaustion [5,6,12,13]. In our study, subjects reported having symptoms of anxiety, especially moderate in 21.87% and severe in 6.25%. These findings are corroborative with a study by Anand T et al., which suggested that workplace violence and harassment of healthcare workers, especially interns and residents, can lead to anxiety and depression, resulting in burnout and decreased work proficiency [10]. Depressive symptoms assessed using the PHQ-9 were significantly more common among interns who reported exposure to workplace violence. Comparable associations between workplace violence and depression have been documented among healthcare workers in both developed and developing countries [6,14]. Strengths and limitations: A major strength of this study is its focus on medical interns, an under-researched yet vulnerable population, and the use of validated instruments (PSS-10, GAD-7, and PHQ-9) to assess psychological outcomes. Limitations of the study are that, its cross-sectional design limits causal inference; self-reported data may be subject to recall and social desirability bias, potentially leading to underreporting of WPV or mental health symptoms; as a single-centre study, the findings may have limited generalizability. Further research directions: Multicentric and longitudinal study designs and studies including experienced doctors and other healthcare professionals including nurses, technicians of various investigative departments and other support staff are required to be conducted in future to further establish relationship between WPV and mental health outcomes. Impact of WPV on health care system: Persistent stress, anxiety, and depression among health care professionals may also have an impact on patient care[2].The current rise in the violence against healthcare professionals has affected the future plans of of interns forcing them to work overseas, join private/corporate hospitals or choose non-clinical courses or administration or some may even quit and opt for career change [3]. This can further reduce number of doctors in public sector and can create a vicious cycle of overburdened public hospitals and increased WPV. Measures to be incorporated to prevent WPV against doctors include incorporating communication skills training, conflict resolution strategies, and stress-management programs into curricula, to improve resilience. Regular mental health screening and access to counselling services may facilitate early identification and management of psychological distress. Institutionalmeasures such as clear and strict anti-violence policies, effective reporting mechanisms, stringent security measures to screen the potential perpetrators, prompt administrative action and appointing grievance counsellors are essential [3, 15].

This study demonstrates that workplace violence is prevalent among medical interns and is significantly associated with increased levels of perceived stress, anxiety, and depression. Addressing workplace violence and supporting the mental well-being of interns as well as doctors and other health care professionals is essential for fostering a safe learning environment, ensuring quality patient care, and sustaining the healthcare workforce.

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