ENCOURAGING EMPLOYEES TO REPORT VERBAL VIOLENCE IN PRIMARY 
HEALTH CARE IN SERBIA: A CROSS-SECTIONAL STUDY
Marina B FISEKOVIC KREMIC1*, Zorica J TERZIC-SUPIC1, Milena M SANTRIC-MILICEVIC1,  
Goran Z TRAJKOVIC1
1Primary Health Center New Belgrade, Djordja Cutukovica 48a, Zemun, 11070 Belgrade, Serbia
Received: Jan 25, 2016
Accepted: May 16, 2016
Original scientific article
Introduction. Workplace violence is a serious and multidimensional problem that adversely affects professional 
and personal lives of employees. The aim of this study was to assess the prevalence and characteristics of 
verbal violence as a part of psychological violence among employees in primary health care in Belgrade, and to 
identify contributing factors of verbal violence in the workplace. 
Methods. In this cross-sectional study, the final analysis included 1526 employees, using multi-stage sampling. 
Data were collected using the questionnaire Workplace Violence in the Health Sector Country Case Studies 
Research, developed by ILO/ICN/WHO/PSI. Descriptive statistics and logistic regression analysis were used to 
analyse the data. The general response rate was 86.8% (1526/1757). 
Results. It was found that 47.8% of the participants were subjected to verbal violence. The main source of 
verbal violence was patient/client, 55.6% of employees did not report the incident. Among those who did 
not report the incident, 74.9% believed that reporting violence was useless. The interaction with patients 
(OR, 1.45; 95% CI, 1.02-2.06) and work between 6pm and 7am (OR, 1.27; 95% CI, 1.01-1.60) were significant 
contributing factors of verbal violence. 
Conclusion. The results are indicative of a high prevalence of verbal violence against employees in primary 
health centres, which could have undesirable consequences. Conducting a better organizational measure and 
encouraging employees to report workplace violence could reduce the prevalence of verbal violence.
Uvod. Nasilje na delovnem mestu je zelo resna in večdimenzionalna težava, ki prizadane strokovno in osebno 
življenje zaposlenega. Cilj te študije je ovrednotenje razširjenosti in lastnosti verbalnega nasilja kot del 
psihološkega nasilja med zaposlenimi v osnovnem zdravstvenem varstvu v Beogradu ter prepoznavanje 
dejavnikov, ki prispevajo k verbalnemu nasilju na delovnem mestu. 
Metode. Zaključna analiza presečne študije vključuje 1526 zaposlenih z uporabo vzročenja na več stopnjah. 
Zbiranje podatkov je potekalo z uporabo vprašalnika ‘Raziskava študije primerov držav glede nasilja na 
delovnem mestu v zdravstvenem sektorju’ (Workplace Violence in the Health Sector Country Case Studies 
Research), ki ga je razvil program ILO/ICN/WHO/PSI. Za obdelavo podatkov so bile uporabljene opisne 
statistike in logistično regresijska analiza. Splošna stopnja odzivnosti je bila 86,8% (1526/1757).
Rezultati. Izkazalo se je, da je bilo 47,8% sodelujočih podvrženo verbalnemu nasilju, glavni vir verbalnega 
nasilja pa je bil s strani pacienta/stranke, 55,6% zaposlenih pa dogodka ni prijavilo. Med vsemi, ki dogodka ni 
prijavilo, jih 74,9% verjame, da bi bila prijava odveč. Stik s pacienti (OR, 1,45; 95% CI, 1,02–2,06) in delovni čas 
med 18h in 7h (OR, 1,27; 95% CI, 1,01–1,60) sta dejavnika, ki znatno prispevata k verbalnemu nasilju.
Zaključki. Rezultati nakazujejo visoko razširjenost verbalnega nasilja med zaposlenimi v zdravstvenih centrih, 
kar lahko povzroči neželene posledice. Boljši organizacijski ukrepi ter spodbujanje k prijavi nasilja na delovnem 
mestu bi lahko zmanjšalo razširjenost verbalnega nasilja.
ABSTRACT
Keywords: 
verbal workplace 
violence,  
contributing factors, 
health workers
IZVLEČEK
Ključne besede: 
verbalno nasilje na 
delovnem mestu, 
dejavniki spodbujanja, 
zdravstveni delavci
*Corresponding author: E-mail: marinaf@sezampro.rs
10.1515/sjph-2017-0002 Zdr Varst 2017; 56(1): 11-17
11
SPODBUJANJE ZAPOSLENIH K PRIJAVI VERBALNEGA NASILJA V OSNOVNEM 
ZDRAVSTVENEM VARSTVU V SRBIJI: PRESEČNA ŠTUDIJA
Fisekovic Kremic MB, Terzic-Supic ZJ, Santric-Milicevic MM, Trajkovic GZ. Encouraging employees to report verbal violence in primary health care in Serbia:  
a cross-sectional study. Zdr Varst 2017; 56(1): 11-17
© Nacionalni inštitut za javno zdravje, Slovenija. 
1 INTRODUCTION 
Workplace violence is a serious and multidimensional 
problem that adversely affects professional and personal 
lives of employees (1, 2). Violence appears as physical 
violence or as psychological violence in different forms. 
Psychological violence (Emotional abuse) is “Intentional 
use of power, including threat of physical force, against 
another person or group, that can result in harm to 
physical, mental, spiritual, moral or social development” 
(3, 4). It includes verbal abuse, bullying/mobbing, 
harassment and threats. Verbal violence is behaviour 
that humiliates, degrades or otherwise indicates the lack 
of respect for the dignity and worth of an individual. 
Psychological violence should be considered more deeply, 
because results of studies indicate a high prevalence of 
this kind of violence (5-7).
Psychological workplace violence can lead to a decrease 
in job satisfaction, quality of life and productivity (8, 9). It 
might, consequently, lead to an increase in medical errors, 
the reduction of patient care quality, and it might have 
negative effects on the employee-patient communication 
(10, 11). Employees in health care institutions are at the 
top of the list of occupations with a high level of stress 
and the risk of workplace violence (12). 
Studies from twenty years ago showed that verbal 
violence was the most frequent type of violence, but the 
true prevalence of it is unknown and varies from country 
to country (4, 13, 14). Verbal violence against healthcare 
workers ranges from 23.2% to 97.8% (7, 15, 16). 
Globalization and intense transition are expected 
to increase the number of victims of violence in the 
workplace (4, 17). In the last two decades, Serbia faced 
different challenges. It was a period of transition and 
reforms in all social and economic areas, including health 
care system. In the period from 2005 to 2010, an increase 
of workplace violence from 48.7% to 64.2% was recorded, 
which was reported by non-governmental organizations 
or trade unions (18). In Serbia, there is a legal basis for 
the prevention of abuse at work, which should provide 
greater security for employees: The Constitution of the 
Republic of Serbia, Labour Law, Law on the Prevention 
of Workplace Harassment, Discrimination Law, Law on 
Safety and Health at Work (19). In spite of this, there 
is no sufficient social and media attention given to this 
problem because of the lack of information about the 
types of assistance available, the procedures to report 
violence, and the lack of strategies which might reduce 
or prevent verbal violence. 
The aim of this study was to assess the prevalence and 
characteristics of verbal violence as a part of psychological 
violence among employees in primary health care in 
Belgrade, and to identify contributing factors of verbal 
violence in the workplace.
2 MATERIALS AND METHODS
2.1 The Study Design and Participants
This cross-sectional study was conducted among employees 
in primary healthcare in Belgrade, conducted between 
October 2012 and July 2013. The study population was 
medical (1320 (86.6%)) and non-medical employees (205 
(13.4%)). Multistage random sampling was conducted in 
three phases. Details of the study design, population and 
sampling procedures are described in another article (20). 
2.2 Data Collection 
Data were collected using the questionnaire Workplace 
Violence in the Health Sector Country Case Studies 
Research, developed by ILO/ICN/WHO/PSI (3, 21). 
The questionnaire was translated into Serbian by a 
multidisciplinary team, following standard methods of 
translating, and adapted to the context of Serbian PHCs 
to improve clarity and appropriateness of our situation 
(22). The high test-retest reliability was achieved; 
Spearman was 0.91 and kappa coefficients were ≥ 0.90. 
A pilot questionnaire was tested in a group of 20 health 
workers at the beginning of the study and two weeks after 
it (20). This questionnaire contains four sections to assess 
personal and workplace information (27 items), physical 
violence (25 items), psychological workplace violence 
(emotional abuse), including verbal abuse, mobbing, 
sexual harassment and racial harassment (57 items), 
the health sector (5 items). In this study, our results are 
associated only with verbal violence, because of the 
extensive amount of data involved. 
2.3 Data Analysis
Descriptive statistics were used to analyse the data 
(the prevalence of exposure to verbal violence and the 
frequency of socio-demographic and work characteristics, 
the reaction of employees to verbal violence), using 
the SPSS software version 20. Univariate analyses were 
conducted to assess the association between each 
independent variable (socio-demographic and work 
characteristics) and the outcome variable, verbal violence 
[yes/no]. All variables which were significantly associated 
with the outcome measure (p < 0.05) were entered into 
a multiple logistic regression model. The odds ratio (OR) 
and confidence intervals (95% CIs) were calculated. The 
Hosmer-Lemeshow goodness-of-fit test was used to assess 
the validity of the logistic models. (23). 
3 RESULTS
A general response rate was 86.8% (1526/1757). The final 
analysis included 1526 employees, 243 men (15.9%) and 
1280 women (83.9%). There was no significant association 
between the exposure to workplace verbal violence 
10.1515/sjph-2017-0002 Zdr Varst 2017; 56(1): 11-17
12
10.1515/sjph-2017-0002 Zdr Varst 2017; 56(1): 11-17
13
and 7am (P<0.001; see Table 1). Furthermore, verbal 
violence was more prevalent among employees who had 
more education (Table 1). 
and gender, age, marital status and years of work 
experience. However, the prevalence of verbal violence 
was significantly higher among employees who interacted 
with patients, worked in shifts, and worked between 6pm 
Table 1. Socio-demographic and work characteristics of participants (n=1526)a.
Gender 
Male 
Female 
Age 
≤29
30-49
≥50
Marital status 
Married/Permanent relationship
Single 
Education level
Primary
Secondary 
College 
Faculty 
Professional group 
Physician 
Nurse
Other 
Years of work experience
≤10
11-20
>20
Working in shifts 
No
Yes 
Working between 6pm and 7am
No 
Yes 
Interacting with patients during work 
No 
Yes 
The age group of patients 
Preschool children
School children 
Adults 
Elderly 
The number of staff in the same work 
setting 
> 20
≤ 20
An encouragement to report 
workplace violence 
No 
Yes 
103 (14.1)
626 (85.9)
55 (7.6)
454 (62.4)
219 (30.1)
509 (70.2)
216 (29.8)
9 (1.2)
369 (50.6)
80 (11)
271 (37.2)
208 (28.5)
462 (63.4)
59 (8.1)
155 (21.3)
246 (33.8)
327 (44.9)
117 (16.0)
612 (84.0)
441 (60.5)
288 (39.5)
79 (10.8)
650 (89.2)
49 (6.8)
87 (12.1)
391 (54.3)
193 (26.8)
598 (82.0)
131 (18.0)
379 (52.0)
350 (48.0)
140 (17.6)
654 (82.4)
64 (8.1)
422 (53.2)
307 (38.7)
586 (73.6)
210 (26.4)
25 (3.1)
397 (49.9)
85 (10.7)
289 (36.3)
230 (28.9)
420 (52.8)
146 (18.3)
152 (19.1)
236 (29.6)
408 (51.3)
210 (26.3)
587 (73.7)
556 (69.9)
239 (30.1)
176 (22.1)
621 (77.9)
34 (4.7)
98 (13.5)
436 (60.0)
159 (21.9)
607 (76.2)
190 (23.8)
332 (41.8)
463 (58.2)
1.00 (Reference) 
1.30 (0.99-1.72)
1.00 (Reference) 
1.25 (0.85-1.84)
0.83 (0.56-1.24)
1.00 (Reference) 
1.18 (0.95-1.48)
1.00 (Reference) 
2.58 (1.19-5.60)
2.61 (1.15-5.94)
2.60 (1.19-5.68)
1.00 (Reference) 
1.22 (0.97-1.53)
0.45 (0.31-0.64)
1.00 (Reference) 
1.02 (0.77-1.36)
0.79 (0.60-1.03)
1.00 (Reference) 
1.87 (1.45-2.41)
1.00 (Reference) 
1.52 (1.23-1.88)
1.00 (Reference) 
2.33 (1.75-3.11)
1.00 (Reference) 
0.62 (0.36-1.04)
0.62 (0.39-0.98)
0.84 (0.52-1.37)
1.00 (Reference) 
0.70 (0.55-0.90)
1.00 (Reference) 
0.66 (0.54-0.81)
0.062
0.252
0.361
0.139
0.016
0.022
0.016
0.094
<0.001
0.881
0.077
0.070
0.042
0.488
<0.001
<0.001
<0.001
<0.001
0.005
Variable, n (%) Yes (729) OR (95% CI) p-value No (797)
Verbal violence 
a The sum may be less than the total number of participants because of the missing data 
10.1515/sjph-2017-0002 Zdr Varst 2017; 56(1): 11-17
14
48% of employees reported that they had been subjected 
to verbal violence at the workplace. Verbal attacks 
occurred most often sometimes (82.0%) and inside health 
organizations (97.4%). The main source of verbal violence 
was the patient/client (52.1%) (Table 2).
Many of employees who have experienced verbal violence 
had disturbing memories, thoughts, or images of the 
abuse (69.3%) (Table 4). 
Table 2.
Table 3.
Table 4.
Characteristics of verbal violence in the workplace 
(n=729).
Reactions of employees to verbal violence (n=729).
Reac Problems and complaints that employees 
experienced after verbal violence (n=729). tions of 
employees to verbal violence (n=729).
The exposure to verbal violence 
   No
   Yes 
How often 
   All the time 
   Sometimes 
   Once 
Who verbally abused 
   A patient/client 
   Relatives of a patient/client
   A staff member 
   The management 
   An external colleague/worker 
   The general pubic 
The place of verbal violence 
occurrence 
   Inside health organizations 
   At a patient’s home 
   Outside (on one’s way to work) 
Reactions of participants toward 
violence 
   Told a colleague 
   Told the person to stop 
   Told friends/family 
   Took no action 
   Tried to pretend it never happened 
   Sought help from the union 
   Completed the incident form
   Sought counselling 
   Tried to defend themselves 
Reporting the incident 
   No 
   Yes 
Action taken with regard to the 
incident occurred 
   No 
   Yes
   Do not know 
The source for taking the action 
   The management  
   An employer 
   The union
   The association
   The police 
Satisfaction with the manner in 
which the incident was handled 
   Very dissatisfied 
   Dissatisfied 
   Moderately satisfied
   Satisfied 
   Very satisfied 
The reason for not reporting the 
incident 
   It was not important
   Felt ashamed 
   Felt guilty 
   Afraid of negative consequences 
   Useless 
   Did not know whom to report 
Disturbing memories, thoughts, or 
images of the abuse 
   No 
   Yes 
Avoiding thinking or talking about the 
abuse
   No 
   Yes 
Being watchful and on guard
   No 
   Yes 
Feeling like everything you had done 
was an effort 
   No 
   Yes 
797(52.2)
729(47.8)
54(7.4)
598(82.0)
77(10.6)
380(52.1)
104(14.3)
156(21.4)
79(10.8)
4(0.5)
4(0.5)
710(97.4)
10(1.4)
7(1.0)
333(45.7)
313(42.9)
197(27.0)
183(25.1)
148(20.3)
33(4.5)
32(4.4)
12(1.6)
5(0.7)
406(55.6)
323(44.3)
510(70.1)
93(12.8)
125(17.2)
65(67.7)
23(24.0)
0
0
4(4.2)
301(44.6)
189(28.0)
121(17.9)
24(3.6)
37(5.5)
60(14.8)
10(2.5)
0
78(19.2)
304(74.9)
61(15.0)
223 (30.6)
506 (69.3)
319 (43.8)
410 (56.1)
254 (34.8)
475 (65.2)
313 (43.0)
416 (47.0)
Variables 
Variables 
Variables 
Variables 
Values, n(%)
Values, n(%)
Values, n(%)
Values, n(%)
Out of all participants who experienced verbal violence, 
45,7% told to a colleague and 55.6% of employees did 
not report the incident. Among those who did not report 
the incident, 74.9% believed that reporting violence was 
useless (Table 3). Participants could mark more than one 
answer to questions related to reactions toward violence 
and reasons for not reporting the incident.
10.1515/sjph-2017-0002 Zdr Varst 2017; 56(1): 11-17
15
Table 5. Multiple logistic regression model with verbal 
violence as the dependent variable. 
A professional group
   A physician
   A nurse 
   Other
Working in shifts
   No 
   Yes 
Working between 
6pm and 7am
   No 
   Yes 
An interaction with 
patients during work
   No 
   Yes 
The level of education
   Primary
   Secondary 
   College
   Faculty 
The number of staff in 
the same work setting
   ≤20
   >20
An encouragement 
to report workplace 
violence
   Yes
   No 
1.00 (Reference)
2.57 (1.59-4.13)
0.97 (0.60-1.57)
1.00 (Reference)
1.30 (0.97-1.74)
1.00 (Reference)
1.34 (1.07-1.68)
1.00 (Reference)
1.77 (1.26-2.47)
1.00 (Reference)
0.73 (0.30-1.75)
0.81 (0.32-2.04)
1.52 (0.62-3.70)
1.00 (Reference)
1.43 (1.10-1.85)
1.00 (Reference)
1.56 (1.28-1.96)
Independent 
variables
Values, n(%)
Multiple logistic regression analyses (Table 5) indicated 
that nurses, as a professional group (OR=2.57, 95% CI: 1.59-
4.13), who work between 6pm and 7am (OR=1.34, 95% CI: 
1.07-1.68), interact with patients during work (OR=1.77, 
95% CI: 1.26-2.47), with less than 20 employees in the 
same work setting (OR=1.43, 95% CI: 1.10-1.85) and with 
no encouragement to report workplace violence (OR=1.56, 
95% CI: 1.28-1.96), were predictors of verbal violence.
4 DISCUSSION
The results indicated that 47.8% of employees had been 
exposed to verbal violence. Workplace violence has 
increased in countries worldwide (4, 24). The prevalence 
rates of verbal violence were from 29.8% to over 82% in 
the previous studies (15, 25). According to our knowledge, 
there is not a lot of research on workplace violence and 
mobbing conducted in Bosnia and Herzegovina, and 76% 
of physicians self-reported one or more types of mobbing 
<0.001
0.897
0.083
0.011
0.001
0.480
0.657
0.355
<0.001
0.008
behaviour (26). In Slovenia, the study was conducted on 
health care workers in emergency departments in primary 
and secondary health care, and it showed that 74.2% of 
them experienced verbal or other forms of indirect verbal 
violence at the workplace (27). These results confirm that 
verbal violence against healthcare workers is a serious 
problem (7, 16, 28). 
Our study showed that patients were the main source 
of verbal violence. In most other studies, patients are 
attackers, followed by their relatives or employees (25, 
29). In our study, verbal violence is 1.5 times more common 
among employees who interact with patients during work. 
This finding might indicate the miscommunication between 
patients and healthcare workers, especially nurses. Nurses 
are the group of health professionals who are at risk for 
workplace violence in our study and most other studies 
(9-11, 29). The studies showed that workplace violence 
among nurses, compared to other professional groups, is 
a frequent problem, and has negative effects on nurses’ 
health, work, and therefore on the quality of care (1, 10, 
11, 30). Nurses are the first to come into contact with 
patients and their relatives. It is necessary to improve the 
quantity and quality of their communication with patients 
(14). Patients my either feel that they did not receive an 
appropriate treatment or what they deserved, or that 
they did not receive the treatment in time (16, 31). It is 
possible that patients are impatient because of the nature 
of a disease or because of a crowd. Besides illness, it is 
possible that many of them are under the influence of 
alcohol, drugs, or possessing weapons (4, 25). 
Working in night shifts is considered to be a high-risk factor 
for the exposure to violence, which is confirmed by other 
and our research findings, while working between 6pm 
and 7am, according to our study, is about 1.3 times more 
frequent to be a risk factor for the exposure to violence 
among employees. Higher rates of violence during night 
shifts can be attributed to personnel who are required to 
work alone, and are under stress caused by patients’ self-
assessment that the need for care was urgent, long waiting 
times for procedures, the failure to obtain necessary 
services promptly, or poor work and working conditions 
(25, 32). In our study, the exposure to verbal violence 
occurred more often in the work settings with 20 and more 
employees. It is known that workers in medium- and large-
sized organisations experienced workplace violence more 
often than those in small-sized organisations (33).
In the current study, more than half of the participants 
did not report violence. In other studies, despite a high 
prevalence of verbal violence, participants also did 
not report violence (7, 28, 30). The encouragement to 
report workplace violence and increased awareness and 
information on the occurrence of workplace violence are 
measures that contribute to better reporting and combating 
10.1515/sjph-2017-0002 Zdr Varst 2017; 56(1): 11-17
16
violence (29, 34, 36). In our study, the encouragement to 
report workplace violence was 53.3%. 
In this study, participants considered reporting useless 
(74.9%), because they were concerned that they may 
suffer another assault by reporting it, or feared losing 
their jobs (36). The lack of reporting could be due to the 
lack of proper feedback from officials and the lack of 
proper guidelines for violence reporting. Moreover, this 
might indicate that health care workers do not trust legal 
institutions (37, 38). 
The strength of this study is a better understanding of 
workplace violence, because the real size of the problem 
is still unknown, and this study provides the data about it. 
One of strengths is that the prevalence of workplace verbal 
violence is determined. Another strength of this study is 
that it explains the relationship between predictors of 
verbal violence and verbal violence itself, and provides 
the ability for planning measures against workplace 
violence as well as the basis for future research. 
There were some limitations in the present study. First, the 
data were collected retrospectively, and self-reports may 
cause recall bias and underreporting. Second, the findings 
of this study cannot be generalized and are limited to the 
workplaces in the study. Also, the results may suffer from 
a misunderstanding of the workplace violence definition 
or the lack of willingness to share private information.
5 CONCLUSION
In conclusion, the results are indicative of a high 
prevalence of verbal violence against employees in 
primary health centres, which could have undesirable 
consequences. Contributing factors of verbal violence 
include the interaction with patients during work, a large 
number of staff in the same work setting, and working 
between 6pm and 7am. The majority of the participants 
were not inclined to report verbal violence because they 
thought it would have been useless and due to the lack of 
encouragement to do so. Conducting better organizational 
measures and encouraging reporting workplace violence 
could reduce the prevalence of verbal violence. 
CONFLICTS OF INTEREST
The authors declare that no conflicts of interest exist.
FUNDING
None. 
ETHICAL APPROVAL
The study was approved by the Secretariat of Health of 
Belgrade and by the Ethics Committee at the University 
of Belgrade, the Faculty of Medicine. The participation 
in the research was voluntary. Anonymity, confidentiality 
and privacy of data were explained and guaranteed. 
Before research, in order to obtain verbal consent, 
every employee received relevant details regarding the 
background and objectives of the survey. 
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