Violence is a major public health issue that continues to grow both worldwide and in our country. Although violence is something we face in every area of life, it is very common in the healthcare field as well. Violence in healthcare, which has become a constant and hot topic lately, seriously affects the physical and mental health of doctors and all healthcare workers. This situation also significantly impacts the quality of healthcare services. The World Health Organization (WHO) considers this issue not just a problem for doctors and healthcare staff, but an urgent health crisis that directly affects the well-being of the entire society. Violence in healthcare has become a massive problem in other countries, just like it is in ours. It is clear that violence in the health sector has increased in our country, especially in recent years, appearing frequently in the media and leading to many legal disputes. Even though these cases have gone to court, it has been observed that the deterrent factor is not at a sufficient level. In this study, the types of violence in healthcare, the current and newly made legal regulations in our country, the rights of healthcare workers against violence, how a victim of violence should manage the process, and suggestions for solving violence are discussed.

Keywords: Violence, violence in healthcare, healthcare personnel

INTRODUCTION

Violence, which is seen as a violation of human rights, is defined as a behavior applied for the purpose of physical coercion or threat—regardless of ethnic origin, class, religion, social status, cultural, economic, or geographical boundaries—directed at oneself or someone else, which may lead to death, injury, mental damage, or developmental disorders [1,2]. Violence has been defined by the World Health Organization as the intentional use of physical or psychological power against oneself, another person, a group, or a community, which results in (or is highly likely to result in) injury, death, psychological harm, developmental delay, or deprivation [3] At the same time, violence is a public health problem that directly affects the well-being of communities [4]. The World Medical Association defines violence in healthcare as an international emergency that shakes the foundations of health systems and critically affects the health of patients [5]. It has also been defined as any behavior that puts a healthcare worker at risk and includes verbal abuse, threatening behavior, or assault by a patient or a member of the community [6]. It is known that violence, which is seen in every field, carries a higher risk for healthcare workers compared to other professional groups [7,8]. Additionally, it should not be forgotten that every single healthcare worker is a potential candidate for violence [9]. From the perspective of the World Health Organization, the concept of “healthcare workers” includes physicians, assistant physicians, multi-tasked health assistants, dentists, dental assistants, pharmacists and pharmacist assistants, veterinarians, animal health assistants, midwives, assistant midwives, assistant nurses, nurse aides, physiotherapists, laboratory technicians and assistants, medical radiology technicians and assistant technicians, as well as administrative staff, technical staff, and other personnel who serve alongside or participate in the service [10]. Accordingly, all administrative or technical personnel working in health institutions and organizations are also included in this scope [11]. This study adopts a narrative review approach and aims to provide a critical and analytical evaluation of violence in healthcare in the Turkish context. Unlike purely descriptive studies, this research offers a comparative and critical synthesis of the literature and identifies key gaps in current legal and institutional frameworks.

Methodology

This study adopts a narrative review methodology to examine the phenomenon of violence in healthcare within the Turkish context. The primary objective is to synthesize existing literature, evaluate legal frameworks, and identify gaps in current research and practice.

A comprehensive literature search was conducted using both international and national academic databases, including PubMed, Scopus, Google Scholar, and ULAKBİM. The search focused on studies published between 2000 and 2025 to ensure both historical perspective and contemporary relevance.

The following keywords were used during the search process: “violence in healthcare,” “healthcare workers,” “occupational safety,” “workplace violence,” “Turkish Penal Code,” and “health law.”

The inclusion criteria were defined as: Peer-reviewed academic articles, legal and policy-related documents, studies focusing on healthcare violence and its legal, social, or institutional dimensions, publications available in English or Turkish. Studies that lacked scientific rigor, were not directly related to healthcare violence, or consisted solely of opinion-based content without empirical or legal grounding were excluded.

Rather than providing a purely descriptive summary, this study applies a thematic and comparative approach. The selected literature was categorized under key themes such as:

Types and causes of violence, legal regulations and enforcement, institutional responses (e.g., White Code system) and preventive strategies.

This approach enables a critical synthesis of findings, highlighting consistencies, contradictions, and gaps in the literature. The methodology aims to enhance the analytical depth of the study and provide a foundation for evidence-based recommendations.

Types and Causes of Violence in Healthcare

Violence is evaluated as physical and psychological according to how it occurs [8]; however, some studies show that types of violence consist of verbal violence, physical violence, and sexual harassment. In different cultures, racism is also included among the types of violence [12]. It has been stated that violence covers a wide range from verbal abuse to physical intervention, and it is impossible for healthcare personnel to predict or intervene in violence beforehand [13].

According to various studies, there are many reasons for the violence occurring between healthcare workers and patients and/or their relatives, and these acts of violence can cause psychological, physical, economic, and social harm [14]. These reasons can be listed as: lack of communication between healthcare personnel and the patient/patient’s relative, inadequacy of security measures, excessive working hours for healthcare personnel [15], inability to show sufficient attention to the patient due to an insufficient number of staff, high number of patients, incorrect messages delivered in print, visual, and social media, the death of a patient, dissatisfaction with the treatment, and healthcare personnel experiencing burnout syndrome due to long working hours and working conditions [13,16].

The Legal and Forensic Analysis of Violence in Healthcare (Türkiye)

The right to health, accepted as the right to have the highest possible standard of physical and mental health, is one of the most fundamental rights to life for all people. It is described by the World Health Organization as the right to access and use the facilities and conditions necessary to reach the goal of healthy individuals and society [17]. In Article 25 of the Universal Declaration of Human Rights, the right to health is organized as a guarantee right that everyone should have, stating: “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing, medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.” In Article 56 Constitution of The Republic Türkiye, it is regulated that everyone has the right to live in a healthy and balanced environment, and the state has the obligation to ensure that everyone maintains their life in physical and mental health; and to plan and provide services from health institutions through a single hand. The same article also regulates that the state performs this duty by utilizing and auditing health and social institutions in the public and private sectors, and that general health insurance can be established by law to ensure that health services are carried out widely.

Parallel to the technological and scientific developments in recent years, while the expectations from healthcare workers have increased, groups profiting from physician-patient relationships have multiplied, and changes in the health system have brought the concept of patient rights to the forefront, it is observed that the rights of healthcare workers, who are under serious responsibility, are being ignored [8]. Today, although incidents of violence against healthcare workers are increasing, since there is no special legal regulation regarding the responsibilities of healthcare workers, the unfair practices they are exposed to, and violence, cases of violence in healthcare are evaluated according to general regulations [18].

As stated, although there is no separate provision in the Turkish Penal Code to prevent violence in healthcare, some regulations include specific features for healthcare workers. The issues to be evaluated here should be whether the actions taken against the healthcare worker constitute a crime and the punishability of third parties being deprived of health services as a result of these acts. The Turkish Penal Code No. 5237 regulates certain crimes that we can characterize as violent towards healthcare workers; in terms of our subject, it is possible for crimes such as threat, insult, slander, blackmail, deprivation of liberty, intentional killing, intentional/negligent injury, sexual harassment, sexual assault, damage to property, damage to public property, preventing the benefit of public services, violation of workplace immunity, and resisting to prevent the performance of duty to be committed against healthcare workers. In the healthcare sector, where communication with people is high and two critical issues such as health and the right to life are at the central point, communication problems, insults, threats, injuries, and killing constitute the most common types of crimes we encounter.

Even though there is no separate provision for increasing sentences specifically when these crimes are committed against healthcare workers, for healthcare workers who are public officials, the sentences for crimes of insult, injury, deprivation of liberty, and damage to property are evaluated as “qualified versions” in the relevant law articles, leading to an increase in the penalty amount. In this regard, according to the regulation in the last paragraph of Additional Article 12 of the Basic Law on Türkiye Healthcare Services No. 3359, healthcare workers in private health institutions and organizations are also considered public officials regarding crimes committed in connection with their duties, without any distinction between public or private hospital employees. Thus, the qualified version of the crime will also apply in cases where a healthcare worker in a private health institution is the victim of a crime. The reason for introducing this regulation is that healthcare personnel become victims of violence because they are not sufficiently protected by laws, and healthcare services, which are among the most important services for society, are interrupted. Therefore, the legislator has introduced these regulations for intentionally committed crimes against all healthcare workers, regardless of the private-public sector distinction [19].

Prevention and Management Strategies

While there were no special regulations regarding healthcare workers in the law, with the impact of the pandemic process that affected the entire world, additions were made to Additional Article 12 of the Basic Law on Türkiye Healthcare Services No. 3359 to prevent violence against healthcare workers. It has been ruled that for crimes of intentional injury (Article 86), threat (Article 106), insult (Article 125), and resisting to prevent the performance of duty (Article 265) found in the Turkish Penal Code No. 5237, committed against health personnel and auxiliary health personnel working in both public and private health institutions due to their duties, the penalties to be given shall be increased by half, and the provisions for the postponement of prison sentences regulated in Article 51 of the Türkiye Penal Code shall not be applied.

Furthermore, it is stated in the continuation of the article that if there is another health professional in the institution where the violence occurred who can perform the service provided by the victim, the other personnel will ensure the continuation of the service. Of course, in addition to legal regulations, the determination of healthcare workers to report the violence they experience and the identification and follow-up process of the perpetrator by law enforcement after the crime is committed are very important at the point of preventing the recurrence of crimes.

As a matter of fact, in Additional Article 12 of the Basic Law on Türkiye Healthcare Services, it is regulated that for those suspected of crimes intentionally committed against personnel working in health institutions and organizations due to their duties, the statements of the healthcare personnel to be heard as complainants, victims, and witnesses shall be taken directly at their workplaces, thus providing convenience for healthcare workers and making a regulation for the rapid resolution of the incident.

The existence of violence prevents not only the healthcare workers who are subjected to it but also third parties from benefiting from healthcare services.

Furthermore, in accordance with the Ministry of Health Circular on Employee Safety, a “White Code Unit” has been established to monitor incidents of violence against healthcare workers. It is regulated that anyone subjected to violence can report it to the White Code Unit, and this unit operates 24 hours a day.

When we look at it from the perspective of private law, since the violence experienced constitutes a “tort” (wrongful act), the personnel exposed to violence have the right to file a lawsuit for material and moral damages. Even if the violence occurs as a result of malpractice or the loss of a patient’s relative, there is no “legal justification” for the person who carries out the attack on the healthcare worker in this sense.

Discussion

The findings of this study indicate that violence in healthcare should not be viewed solely as an individual or behavioral issue, but rather as a complex and multidimensional problem shaped by systemic, institutional, and socio-cultural factors. Previous studies have consistently identified communication breakdown, excessive workload, and patient dissatisfaction as major contributing factors to violence [4,15,16].

Comparative evidence suggests that healthcare systems with stronger organizational structures and more balanced patient distribution tend to experience lower levels of workplace violence. In many European countries and in the United States, workplace violence is addressed through a combination of preventive strategies, institutional support mechanisms, and workforce planning. These systems often benefit from relatively lower patient-to-provider ratios, stronger primary care structures, and more balanced patient distribution [20,21].

In contrast, the Turkish healthcare system continues to face challenges such as overcrowding, high patient demand, and limited time allocated per patient, which may increase the risk of aggressive behavior [7, 8]. In the United States, studies emphasize the importance of workplace violence prevention programs, staff training, and organizational policies aimed at early identification and de-escalation of violent situations [22]. Similarly, European healthcare systems tend to implement structured preventive measures, including risk assessment protocols and institutional reporting systems [21].

In contrast, the Turkish healthcare system is characterized by high patient demand, overcrowded emergency departments, and limited time allocated per patient. These structural differences may contribute to a higher risk of violence in healthcare settings [7,8].

Furthermore, while many countries emphasize preventive and system-oriented strategies, the approach in Türkiye has been more focused on legal deterrence. This difference suggests that preventive approaches and institutional strategies may be more effective in reducing violence than relying solely on punitive measures [22,23].

This suggests that the limited effectiveness of legal reforms in Türkiye is not solely related to the content of the law, but rather to weaknesses in implementation and enforcement mechanisms. Although recent legal amendments have strengthened penalties, studies indicate that legal measures alone are not sufficient to prevent violence without effective institutional support [18,19].

Another important issue is the role of institutional mechanisms such as the White Code system. Although this system represents an important step toward protecting healthcare workers, its effectiveness remains limited due to the lack of transparency and restricted access to data. This issue has also been discussed in the literature in terms of implementation challenges and legal limitations [9,18].

Furthermore, the findings highlight that systemic factors—such as staff shortages, long working hours, and high patient density—play a critical role in the emergence of violence. Previous studies emphasize that emergency departments, where patient intensity is high, are among the most risky units in terms of violence exposure [8,24].

Therefore, violence in healthcare should be understood not merely as an individual behavioral problem, but as a systemic failure rooted in structural inefficiencies within the healthcare system.

Overall, the results suggest that addressing violence in healthcare requires a comprehensive and integrated approach. In line with previous research, effective solutions should include not only legal regulations but also structural reforms, improved working conditions, and enhanced communication strategies [13,15].

These findings provide a basis for the recommendations presented in the following section.

CONCLUSION

Violence in healthcare remains a critical and persistent challenge that undermines both the efficiency of health systems and the well-being of healthcare professionals, as widely reported in the literature [7,8,13]. The findings of this study demonstrate that, despite recent legal reforms in Türkiye, violence has not decreased proportionally, indicating that legal deterrence alone is insufficient to address the problem [18,19].

This study highlights that violence in healthcare should not be interpreted solely as an issue of individual behavior or criminal intent. Instead, it is a multifactorial phenomenon shaped by systemic deficiencies, institutional practices, and socio-cultural dynamics. High patient density, excessive workload, communication gaps, and unrealistic expectations have been identified as contributing factors in previous studies [4,15,16], collectively creating an environment in which violence becomes more likely.

One of the key contributions of this study is the identification of a critical gap between legal regulation and practical implementation. While healthcare workers are legally recognized as public officials and protected by enhanced penalties, the lack of effective enforcement mechanisms and institutional transparency limits the impact of these regulations. In particular, the restricted accessibility of White Code data prevents comprehensive analysis and evidence-based policymaking, as also discussed in the literature [9,18].

Based on the analytical synthesis of the literature, this study proposes that addressing violence in healthcare requires a holistic and integrated approach. The following strategic recommendations are emphasized:

Enhancing Institutional Transparency

Public access to detailed and anonymized White Code data should be ensured to support scientific research and policy development.

Strengthening Structural Conditions

Reducing patient-to-provider ratios, improving working conditions, and addressing workforce shortages have been emphasized as essential measures in previous studies [13,15].

Improving Communication and Training

Healthcare workers should receive structured training in conflict management and de-escalation techniques, while public awareness campaigns should aim to align patient expectations with medical realities, as suggested in the literature [13,16].

Developing Preventive Policies

Rather than relying solely on punitive legal measures, proactive strategies—such as risk assessment in high-violence units (e.g., emergency departments)—should be implemented, as highlighted in prior research [8,24].

Ensuring Legal and Ethical Balance

Any proposed measures must remain consistent with fundamental human rights, particularly the right to health, and avoid exclusionary practices that may create further inequalities [12,14].

In conclusion, sustainable solutions to violence in healthcare depend on the integration of legal, administrative, and social interventions. Only through a comprehensive reform framework that addresses both the root causes and systemic dimensions of violence can a safer working environment for healthcare professionals—and a more effective healthcare system—be achieved [12,14].

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